Individual at Wayland

INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING THE
DEATH OF A MAN AT HMP WAYLAND IN AUGUST 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2008
This is the report of an investigation into the death of a man in August 2007 in HMP
Wayland. The man was 56 years old and died of natural causes.
I offer the family my sincere condolences on their loss and apologise for the delay in
issuing this report.
This investigation was undertaken by one of my colleagues. Both he and I would like
to thank the Governor and staff of Wayland for their participation. A medical
practitioner was identified by Norfolk Primary Care Trust to undertake a review of the
man’s clinical care and she was assisted in doing so by another officer. I also
appreciate their assistance.
Indeed, in a case such as this, where someone has died from natural causes, the
findings of the clinical review play a large part in my report. In this case, the
reviewers find that he generally received a good standard of care whilst in prison.
I conducted another investigation into a death at Wayland some months before this
man’s death and made a number of recommendations on my subsequent report.
Some of the concerns uncovered in this investigation were the same as I had
identified previously. The Prison Service did not have the benefit of seeing my
previous report before the man died, but later accepted the recommendations I
made. I therefore only make two recommendations to the Governor in this report.
However, I draw his attention to the issues common to both investigations so he can
assure himself that they have indeed been addressed.
I understand that the man who died was noted for his commitment to health and
fitness. He was often described as a ‘fitness fanatic’. It is particularly sad that he
should have died of a heart attack immediately after exercising, something that he
particularly enjoyed.
This report has been anonymised for publication on my website.
Stephen Shaw CBE
Prisons and Probation Ombudsman May 2008
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CONTENTS
Summary
The investigation process
HMP Wayland
Key findings
Issues
Recommendations
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SUMMARY
The man who died was a 56 year old man who was serving a life sentence. He had
been released on licence in 2001 but recalled to prison after being arrested for a
further offence in the summer of 2002.
On recall, he was taken first to HMP Woodhill but transferred to HMP Wayland in
September 2002. He seemed to settle well there and it was continually noted in his
records that he was hard-working, polite and respectful. He had a good attitude on
the wing and good relationships with staff and other prisoners alike.
The man suffered from angina and prison healthcare services were aware of his
condition. His blood pressure was frequently monitored and blood tests were carried
out. In November 2005, he complained of chest pain that was not relieved by taking
his medication. His heart was checked and he was admitted to hospital for
treatment.
The man had a strong interest in health and fitness and was a gym orderly. He was
widely regarded as being a ‘fitness fanatic’ and was often found to be exercising. It
was after exercising on the morning of his death that he collapsed while returning to
his cell and stopped breathing. Staff tried to resuscitate him and were briefly
successful. However, the man stopped breathing again and despite continued staff
efforts and the attendance of paramedics, he passed away.
The man’s sister, who was his listed next of kin, told my investigator how helpful the
prison staff were after her brother’s death. She was also moved by the memorial
service they held, which she was invited to attend.
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THE INVESTIGATION PROCESS
1. My investigator visited Wayland and spoke to staff who worked with the man
during his imprisonment. He interviewed seven members of staff and one
prisoner. These interviews were conducted with one or both of the clinical
review team present. Transcripts were sent to the interviewees, who signed
and confirmed their content.
2. Notices were posted to staff and prisoners about the investigation, inviting any
contributions. None were received.
3. The investigator studied all relevant prison records relating to the man who
died. These included his main prison record, medical records and statements
made by staff. The investigator also visited the wing where the man was
housed and the wing where he died.
4. The Norfolk Primary Care Trust (PCT) identified a medical practitioner to carry
out a review of the man’s clinical care. She was assisted by another colleague.
I am grateful to both of them for undertaking this review.
5. 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.
Having seen a draft copy of my report, the Coroner decided to proceed with the
inquest. My investigator attended and gave evidence. The jury returned a
verdict of death by natural causes.
6. One of my family liaison officers spoke to the man’s sister, who raised some
concerns she wanted our investigation to consider. These are addressed in
this report, which I hope also answers any further questions she may have.
She made a point of saying that she was grateful for how helpful staff at
Wayland had been. She had been moved by the memorial service held in
Wayland for her brother, to which she had been invited.
7. My investigator discussed aspects of the man’s treatment with both healthcare
staff at Wayland and the clinical reviewers. He also attended the panel that the
Norfolk PCT held to discuss the clinical review.
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HMP WAYLAND
8. Wayland is a category C adult male training prison with an operational capacity
(maximum crowded capacity) of 709. It opened in 1985 and since then the
buildings have been extended three times. It now comprises eight residential
units, mainly with single cell accommodation.
Healthcare
9. Healthcare at Wayland is available from 8.00am to 8.30pm Tuesdays to
Fridays. Saturday to Monday cover is from 8.00am to 5.30pm. A visiting
doctor attends on Monday mornings, Wednesday afternoons and Friday
afternoons. If a doctor is required outside of these hours, the on-call service is
used.
E and F wings
10. E and F wings are adjacent to each other. The door out to the exercise yard is
at the end of E wing furthest away from F wing. To move between the exercise
yard and their own wing, F wing prisoners are therefore required to pass
through E wing. Furthermore, lunch is served in E wing, so F wing prisoners
pass between the two to collect their meals. Although the doors in and out of
the wings are supervised, there is obviously an element of freedom of
movement between the two wings and the exercise yard at certain times.
11. The man’s cell was at the end of F wing nearest to E wing. It was his habit to
exercise and either to bring his plate and cutlery with him, or pass through E
wing to get back to his cell, quickly collect his plate and cutlery, and hurry back
through to E wing to collect his meal.
Previous deaths at Wayland
12. This is only the third death in Wayland that my office has investigated since I
became responsible for investigating all deaths in custody in April 2004. In the
two previous reports I made a number of recommendations, including ones
about medical record-keeping, support for healthcare staff involved in a death
in custody, inclusion of healthcare staff in hot debriefs (debriefs for staff on the
actual day that they have had to deal with a death), and the guidance for
breaking the news of a death to a prisoner’s family. However, the
recommendations that are relevant to the man’s death were contained in a
report published in December 2007 so the prison would not have had the
opportunity to read them before this man died.
Her Majesty’s Inspectorate of Prisons
13. The most recent inspection of Wayland by HM Chief Inspector of Prisons was
an announced inspection in June 2006. Her subsequent report did not identify
any issues particularly pertinent to this investigation.
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Independent Monitoring Board (IMB)
14. The most recent IMB report covers the period June 2006 to May 2007. It does
not contain any issues relevant here.
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KEY FINDINGS
15. The man was sentenced to life imprisonment in December 1980. He moved
through the prison system until he was released on life licence in October 2001.
In early 2002, the man lost three close family members. His son, his sister and
his nephew all died within a few weeks of each other.
16. On 1 June 2002, the man was arrested following an incident that had occurred
after he had been drinking. His licence was revoked and he was recalled to
prison to continue serving his life sentence. He arrived at HMP Woodhill on 3
June. He was subsequently sentenced to an additional two months’
imprisonment for the offence for which he had been arrested.
17. The man remained in Woodhill for approximately three months. His health
screening on reception identified that he was deaf in one ear and that he had
angina. Staff seemed to keep this under consideration when dealing with him.
There is a note on his file from the physical education department that he
should be assessed for remedial gym due to his history of angina. There is a
further note from the medical officer to the kitchen requesting that the man
receive a low fat diet.
18. The man was transferred to Wayland on 10 September 2002 and allocated to E
wing. His reception screening noted his angina and that he had an outstanding
appointment for a cardiac clinic from before his recall. He signed the compact
agreeing to abide by the rules about holding his own medication.
19. Towards the end of that month, the man asked to see the doctor, saying that he
was using his GTN spray (used to relieve the symptoms of angina) more
frequently and that his blood pressure was slightly raised. His file contains a
handwritten note indicating that he was due to be seen two days later, but there
is no note of this consultation having occurred.
20. The man was moved to F wing on 24 December. The following May, he was
placed on a disciplinary report for being in possession of a stereo that was not
on his property card. In the light of this adjudication, he subsequently refused a
lifer day out of the prison saying he wanted to complete an offending behaviour
course instead.
21. Still in May 2003, when requesting some medication for hayfever, he again
mentioned that he had been using his GTN spray more frequently than usual.
It is unclear whether any action was taken in response to this comment.
22. In October, the man once more asked to see the doctor, saying that he was
suffering from severe chest pain. There is a note on his file giving a date, but
once again it is not clear whether the note referred to a consultation, if the
consultation occurred and, if so, what happened.
23. Later that month the man lost a tooth filling and asked to see the dentist. There
is no note on his file as to whether he had an appointment and in March 2004
there was another request to see the dentist for a lost filling. Again there is no
8
indication on file as to what happened and in early June yet another similar
request was recorded. In March 2005, he made another request to see the
dentist for a missing filling and his record shows that on this occasion he was
treated for a dental abscess.
24. The man’s medical record indicates that in May 2005 he had had an angiogram
six months previously, although there is nothing in the chronological notes to
show this. The recommendation was that he should continue to be observed
and monitored.
25. The Parole Board considered his case and reported that May. They
recommended that the man should remain in closed conditions to develop
insight into risk situations and coping with difficult emotional upsets. They also
said that he needed to undertake additional work on cognitive skills and drug
and alcohol relapse prevention.
26. In November 2005, the man complained of chest pain during exercise. He was
referred to the Emergency Assessment Unit Medical (where a doctor may refer
a patient instead of them going to a hospital accident and emergency
department). He was again given an angiogram and prison healthcare staff
contacted the hospital before his return to Wayland to clarify whether any
further specific needs had been identified.
27. The man was due to attend a cardiology clinic as an outpatient on 7 February
2006. However, he was concerned about the possibility of being readmitted to
hospital and refused to attend. Healthcare staff contacted the hospital to
arrange a further appointment.
28. The man had been prescribed statin to help his cholesterol level. However it
was discontinued in July due to concerns over the effect it might have on his
wider health. His cholesterol level continued to be measured on a regular
basis. The clinical reviewers judge that discontinuing the medication was
appropriate.
29. An escorted town visit was arranged for him on 12 September 2006, and no
problems were reported. That same month a mandatory lifer panel of the
Parole Board adjourned consideration of the man’s case, requesting
psychology and medical reports.
30. On 15 December, the man complained of chest pain at 2.00am. It disappeared
after he used his GTN spray. The pain returned in the morning, but went away
after the man went for a walk. On 20 December, he was given an
electrocardiogram (ECG, an electrical recording of the heart used in the
investigation of heart disease). He was seen again on 22 December and his
blood pressure was checked.
31. The adjourned mandatory lifer panel of the Parole Board met again on 12
March 2007. However, the reports previously requested had not been carried
out. His case was once again adjourned to 4 July. Although not relevant to the
9
man’s death, I would draw the Governor’s attention to this delay, which strikes
me as unacceptable.
31 August
32. On the morning of 31 August 2007, the man had been running in the exercise
yard. After exercising he walked through E wing and, shortly before midday,
was waiting in the corridor for the door allowing prisoners back into F wing to be
unlocked. One of the cells by this door was occupied by prisoner A with whom
the man was acquainted. Prisoner A was watching athletics on television and
the man stood in the doorway and the two chatted about sport. As he paced up
and down, the man was moving and stretching his left arm. Prisoner A thought
that he might be suffering from cramp as he had just been exercising. He
walked away, prisoner A began to eat his lunch but heard a sudden heavy
noise. He put his food down, went to his door and saw the man slumped in the
corner of the corridor.
33. Prisoner A went to the man and lifted him up. The man was very rigid, shaking,
and sweating profusely. Prisoner A called the man’s name, but he did not
respond. He shouted for help.
34. A prison officer was on E wing at that time, having been supervising the
exercise yard. He remembers seeing the man come back in from his
customary run, and that there had been nothing unusual in his appearance or
demeanour at that time. On hearing prisoner A’s shout for help, the officer
went across and was the first to arrive where the man had collapsed. He asked
prisoner A to stand aside while he also tried to get a verbal response from the
man. Within another minute, the wing senior officer (SO) and a second prison
officer arrived. Realising the seriousness of the situation, the second prison
officer radioed through to the Communications Centre a Code Blue call for
urgent medical assistance. (Code Blue indicates that a prisoner is either not
breathing or has seriously restricted breathing.) At this point at least one of the
officers also asked Communications to ensure that an ambulance was
summoned. The time was now 11.56am. Prisoner A was asked to return to his
cell as prisoners were being locked up to allow staff to concentrate on the man.
35. An agency nurse working in Wayland at that time and a pharmacy assistant,
were on E wing distributing medication. As soon as they heard the call for help,
the nurse ran to where the man had collapsed. The pharmacy assistant
collected the emergency grab bag, locked the treatment room and followed.
They both reached the man within three minutes of him collapsing.
36. At this point the man was breathing but not responding. The agency nurse and
the pharmacy assistant put the man into the recovery position. However,
despite this, he stopped breathing. The nurse and the pharmacy assistant
immediately began to perform cardio-pulmonary resuscitation (CPR) and after
four or five minutes the man began to breathe. However, he very quickly
stopped breathing once more. Staff continued to perform CPR, and
Communications were asked to update the Ambulance Service accordingly.
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37. A staff nurse was working in the healthcare centre when she heard the Code
Blue call over the radio. She contacted Communications and told them that
there were medical staff, including a nurse, on E wing at the time. She asked if
her attendance was also necessary. However, when she did not receive a
response within a minute she decided to take the emergency grab bag and go
to E wing. While she was on her way across, Communications responded to
her earlier question and advised that she should attend.
38. The staff nurse’s emergency grab bag differed from the one the pharmacy
assistant had taken from the treatment room. Previously, ‘live active bags’ had
been located on wings in the prison. However, maintenance had proved to be
a problem - for example, the oxygen cylinders would deplete. Defibrillators
(machines that apply electrical impulses to the heart) had previously been
available on the wings, but there had been problems with maintenance and
they had been withdrawn. As a result, a decision had been taken that all
emergency equipment would be supplied from the healthcare centre.
39. The staff nurse arrived on E wing and the pharmacy assistant briefed her as to
what had happened. The staff nurse confirmed that an ambulance had been
called. There were no defibrillator machines on E wing. The only defibrillator
available was in healthcare. The staff nurse asked one of the officers in
attendance to go to healthcare and collect it. The staff nurse, the agency nurse
and the pharmacy assistant continued to perform CPR on the man.
40. A Principal Officer (PO) was the orderly officer that day and therefore
responsible, with the duty governor, for the operational running of the prison.
On hearing the Code Blue call, he quickly made his way to E wing, arriving at
12.00 noon. The PO took control of the staff responses and deployment, and
satisfied himself that all necessary actions had been undertaken. He ensured
that updates were fed back to Communications for onward transmission to the
Ambulance Service. The staff nurse asked him to ensure that passage was
clear for ambulance/paramedic staff to get through prison security and to E
wing as quickly as possible. At some point, the agency nurse went back to the
healthcare centre and collected the man’s notes in case the paramedic team
needed them.
41. When emergency calls are received by the Ambulance Service, staff dealing
with the call may despatch a First Response Paramedic who will be able to
reach an emergency scene more quickly than an ambulance crew. The
Ambulance Service had done so on this occasion, and at 12.17pm a paramedic
from the First Response Unit arrived on E wing. He administered adrenaline to
the man. The officer sent to collect a defibrillator from the healthcare centre
had not yet returned, but the paramedic had brought one with him and applied it
to the man. At this point the pharmacy assistant left the area and the first
prison officer was replaced by a third prison officer.
42. At approximately 12.26pm, the ambulance crew arrived on the wing and began
to try to resuscitate the man. Unfortunately, despite the medical assistance
already provided by a number of people, they were unable to revive him. At
12.34pm it was agreed by those present that the man had died. The area was
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sealed off until the police arrived at 1.35pm and gave permission for the man to
be moved. He was taken from the wing into a healthcare room, where the
chaplain arrived and prayed over his body.
43. As the man had collapsed outside his cell, prisoner A had been able to hear
everything that happened. By the time the man’s body was moved he had
become quite upset. An officer remained outside his cell to provide support,
and they spoke together. Prisoner A had been trying to give up smoking, but
asked the officer if he could get him a cigarette. The prisoner in the cell next
door was a smoker and provided a few cigarettes. Later on a Listener came to
see him. (Listeners are fellow prisoners who have been trained by The
Samaritans to provide support.) Prisoner A asked medical staff if he could
have medication to help him sleep. They did not provide anything the first
night, but on the subsequent two nights they did provide a sleeping tablet.
Healthcare staff who had been involved in trying to resuscitate the man later
spoke with prisoner A and reassured him that he did the best he could have
done. Prisoner A told my investigator that he was not offered any further
counselling or support beyond this.
44. Other prisoners on the wing remained locked in their cells. Staff arranged for a
letter to be distributed to prisoners explaining why they had been locked in their
cells. They were also informed of various methods of support available. Staff
also reassessed any prisoners who were thought to be at risk of self-harm.
45. The pharmacy assistant had become upset by the man’s collapse, and was
supported by a member of the prison’s care team at the time. Once she
returned to the healthcare centre, further visits were made to ensure that she
had recovered. She was also given telephone numbers for use over the
weekend if she felt she needed them. The staff nurse commented that there
was some support for healthcare staff, but that it might not have been
adequate. The healthcare staff returned to the healthcare centre straight after
the man had been pronounced dead. They were provided with telephone
numbers to contact if they felt they needed to talk to someone. A member of
the chaplaincy team came to the healthcare centre that afternoon, but arrived
during a clinic and so staff were not able to properly engage with her.
46. Uniformed staff were offered support by the care team on E wing at the time.
They were also taken for a hot debrief. However, healthcare staff were not
involved and continued to work. Healthcare staff did have a post-incident
meeting at a later date. A round-up meeting was also held for staff some
weeks after the event.
47. The man’s sister was his next of kin. Because of the distance between her
address and Wayland, staff contacted HMP Bullingdon (the establishment
nearest to where she lives) to request assistance in breaking the news. This
call was made at 2.12pm. However, Bullingdon telephoned Wayland at 2.55pm
and said they were unable to assist. Wayland then contacted the police, by fax
and by telephone, to ask for assistance in informing the sister and to give her a
telephone number to contact at the prison. They asked for confirmation that
this had been done. The man’s sister contacted Wayland at 6.25pm.
12
ISSUES
Clinical care
48. There were elements of good practice in the man’s care, but these were not
always evident from the poor records. Not only did this make reading the
records difficult, but there were times when it could have affected his medical
care. On one occasion, for example, the man was waiting for a dental
appointment for a considerable period of time. When he was finally given an
appointment, it turned out to be for someone else with the same surname. The
man’s records also included documents for other prisoners with the same
surname. Moreover, both written and electronic records seemed to be kept in
parallel which is confusing. Medical record-keeping was a subject on which I
made a recommendation in my earlier report and the prison accepted it. I will
not repeat it here, but remind the Governor of the importance I attach to this
issue.
49. Overall, the clinical reviewers consider that the man received good care in
prison. Prison staff were aware of his heart condition and his health was
regularly monitored. The main issue of concern is the delay of five days in
December 2006 between him complaining of chest pain and being given an
ECG. His records do not show if this delay was deliberate, and if so, why. This
did not have any effect on his death, but such a delay could have had serious
consequences at the time.
The Governor should ensure that any episodes of chest pain are
addressed as a matter of urgency.
50. The man’s angina was noted on his reception into Woodhill, and he was
regularly monitored while he was in prison. However, a clear care pathway
does not seem to have been put into place. It is the clinical reviewers’ opinion
that a care plan should have been drawn up.
The Governor should ensure that care plans are in place for prisoners
with cardiac health problems.
Response to the man’s collapse
51. Staff responded to the man’s collapse very quickly. By good fortune,
healthcare staff were on E wing at the time, so the agency nurse was able to
reach him with minimal delay.
52. In view of the distance from healthcare to E wing, I am a little concerned at the
status of the emergency grab bags and defibrillators on the wings.
Defibrillators and full emergency bags had previously been kept on E wing, but
had been removed - apparently pending a review of their maintenance. Sadly,
it does not appear that this would have made any difference in this man’s case.
Nonetheless, if equipment is to be replaced, it would be sensible if the new
equipment could be in place before the old is removed. I understand that the
provision of equipment has been reviewed and I am pleased to learn that there
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should now be an adequate number of defibrillators and emergency medical
provisions available around the prison.
Support
53. The care team appear to have provided good support for uniformed staff and
they attended E wing very quickly. However, healthcare staff had differing
views on the support made available to them. Due to staff numbers, they had
to return straight to work and were unable to take advantage of support in the
immediate aftermath of dealing with the man’s collapse. They were made
aware of the support available to them, but they would have benefited if the
care team had been able to offer them support at the time.
54. Healthcare staff were also not involved in the hot debrief. This could have not
only assisted the purpose of the debrief itself, but could have been valuable to
those who had just dealt with a traumatic incident.
55. Recommendations about support for healthcare staff and their involvement in
hot debriefs were made and accepted in a recent report and I will not repeat
them here. But I would draw the Governor’s attention to these matters so he
can reassure himself that these issues have been addressed.
Informing next of kin
56. It was unfortunate that there was a delay in the man’s sister being informed of
her brother’s death. The Prison Service Order that deals with contacting next
of kin in such a situation recommends that such news should be broken to
families face-to-face, but recognises that there are a number of factors that
mean that each occasion must be assessed individually. The man was
pronounced dead at 12.34pm. Staff at Wayland wanted to ensure that his
family were informed as soon as possible.
57. Because of the distance between Wayland and the man’s sister’s home, they
contacted Bullingdon to ask if someone would be able to visit to break the
news. This telephone call was made at 2.12pm. Staff at Bullingdon telephoned
Wayland at 2.55pm to say that they were unable to help. At 3.12pm, staff at
Wayland contacted the police by telephone and by fax asking for assistance in
informing the man’s sister. The police were also given contact details at the
prison for the man’s sister to use, and asked to let the prison know when she
had been informed. The sister contacted Wayland at 6.25pm. The police did
not make any further contact with Wayland.
58. It seems to me that staff at Wayland did make proper efforts to ensure that the
man’s sister was informed personally of her brother’s death as soon as
possible. However, this did not prevent a significant delay, just short of six
hours, from occurring. It was regrettable that staff at Bullingdon were unable to
help. However, staff at Wayland should not have left the impetus with the
police for so long without following it up
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59. As mentioned earlier, I made a similar recommendation in a report that was
published in December 2007. The Prison Service accepted that it would review
contingency plans to ensure that guidance on how to inform next of kin was
included. In those circumstances I will not repeat the formal recommendation
here, but I again draw the matter to the Governor’s attention. I attach great
importance to ensuring next of kin are contacted in as sensitive and as timely a
manner as possible.
60. The man’s sister was very grateful for the help and support she received from
staff at Wayland in the light of her brother’s death. She was particularly moved
by the memorial service held for him. She asked us to reflect this in my report
and I am pleased to be able to do so. I would also like to commend staff at
Wayland for the way this was handled.
Issues raised by the man’s family
61. As mentioned above, my investigator and family liaison officer spoke to and
visited the man’s sister. In addition to other issues addressed above, she
raised the questions in the paragraphs below.
62. The man did not seem to have many possessions, and his sister asked if there
was anything else of his in storage. My investigator asked the prison to check
their own and central storage areas. They did so, under both names by which
the man had been known, and assured him that there was no further property.
63. The sister was told that her brother had said to another prisoner that he was
experiencing pain in his arm and chest, and that he still went running despite
the pain. She wondered whether it was possible that he was depressed and
that he went running while aware of the possible consequences. My
investigator was unable to identify who this prisoner may have been. There
were no other indications that the man was depressed or was reckless in
regard to his health.
64. The man’s sister asked what medication her brother was on and whether he
had his own supply or had to collect it each day. The man kept his medication
in his own possession, collecting it monthly.
65. The man had gone to hospital for some tests, where it was determined that the
medication he was taking for his cholesterol was having an adverse affect on
his wider health. He was then taken off this medication and not prescribed
anything in its place. His sister asked whether this was an oversight. As
mentioned above, his statin was discontinued due to concerns over the effect it
might have had on his wider health. His cholesterol level continued to be
monitored and the clinical reviewers judge that discontinuing the medication
was appropriate.
66. The man’s sister was keen that the investigation considered whether the
emergency response was timely and carried out appropriately following the
man’s collapse. The 999 call for an ambulance was made at approximately
11.56am. The Ambulance Service despatched a First Response Unit who
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arrived on E wing at 12.17pm. The ambulance arrived at the prison at
approximately 12.23pm, with the paramedics arriving on E wing at
approximately 12.26pm. The staff nurse asked the PO to ensure in advance
that prison gate staff were expecting the emergency responders. She told my
investigator that in the three years she had worked in the prison this was
probably the fastest transfer of emergency service staff through the prison she
had witnessed.
67. The sister asked about the daily regime within the prison. Unlock takes place
at 8.00am Monday to Friday and 8.30am at weekends. The man was on an
enhanced wing and would not have been locked up as other prisoners would
be on the main wings. All prisoners on F wing have free access to other
prisoners’ rooms until midnight (when they would be expected to be in and
remain in their own rooms until unlock the following morning). Prisoners on the
enhanced wings have keys to their own rooms allowing free access outside of
the curfew times.
68. The sister also asked whether her brother had a television and DVD player in
his cell, as several DVDs were among his possessions. The man had a prison
issue television in his cell, for which he paid £1 per week. No prisoners in
Wayland have DVD players in their cells, but there is a DVD player available for
prisoners’ use in the main association room.
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RECOMMENDATIONS
As I mentioned in my introduction to this report, I have recently made a number of
recommendations to Wayland in a report that was not available prior to the man’s
death. These included the recommendations stressing the importance of medical
record-keeping, providing support for healthcare staff, and covering how news is
broken to next of kin. The Prison Service accepted these recommendations and I
hope that the changes promised have been implemented. In these circumstances I
will not make the same recommendations again.
The two separate recommendations emerging from this report are as follows:
The Governor should ensure that any episodes of chest pain are addressed as
a matter of urgency.
The Prison Service have accepted this recommendation. A Governor’s Notice to
Staff is to be issued stating that any prisoner complaining of chest pain should be
reported immediately to Healthcare. Healthcare staff will respond in accordance with
the National Service Framework cardiac pathway direction.
The Governor should ensure that care plans are in place for prisoners with
cardiac health problems.
The Prison Service have accepted this recommendation. National Service
Framework cardiac pathways are to be obtained and formulated into patient care
plans.
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