Individual at Whitemoor

The death in custody of a prisoner
at HMP Whitemoor in May 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2005
This is the report of an investigation into the circumstances of the death of a
prisoner at HMP Whitemoor in May 2004.
All deaths of prisoners in custody are investigated, including those due to
natural causes. The responsibility for carrying out these investigations
traditionally fell to the Prison Service itself, but has now been passed to the
Prisons and Probation Ombudsman (PPO) to bring independence and greater
consistency to the task.
In this case, the investigation has been carried out by the Deputy
Ombudsman, Assistant Ombudsman and an Investigator. An independent
clinical review was conducted by the Deputy Ombudsman.
My colleagues and I would like to extend our condolences to the man’s family
for their loss. We would also like to thank the Governor in charge of
Whitemoor Prison at the time of our visit, and the other members of his staff
who assisted us for their help. We found staff helpful and co­operative.
Stephen Shaw
Prisons and Probation Ombudsman
2
Contents
Summary 4
The events leading up to the man's death 6
The man's healthcare needs 8
The management of the crisis situation 9
Consideration 11
Conclusions 13
Recommendations 14
3
Summary
The man was 59 years old when he died from an apparent asthma attack in
the early hours of the morning in May 2004 whilst in the care and custody of
HMP Whitemoor.
This was the man’s only custodial sentence; he was sentenced to life
imprisonment in 1994 and was appealing against his conviction. At the time of
his death he remained a Category A prisoner which affected timely access to
himduring the early hours of the morning he died.
The man who died was well known to staff at Whitemoor Prison as a result of
the length of time he had been there, and particularly to the healthcare staff
who had dealt with many of his health problems.
The man was in poor health and had been for some time. He suffered from
ischaemic heart disease, bronchial asthma and chronic obstructive airway
disease (COAD) and was frequently seen for chest and bronchial infections.
On the evening before he died the man was seen by a health care worker
following a message received from residential staff that he had chest pain. In
the early hours of the morning he died, the man rang his cell bell requesting
medical assistance. He subsequently collapsed and was pronounced dead.
The primary cause of death was later given by the pathologist as acute
asthma, with a secondary cause as ischaemic heart disease.
The Deputy Governor wrote to the man’s wife offering his condolences and
attended the funeral. She was contacted by one of our Family Liaison Officers
and discussion was had about the report. She had no questions or particular
concerns at that time.
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Background
HMP Whitemoor is a high secure prison and as such there are various
security measures that are undertaken before a prisoner of category A status
can be unlocked at night. The procedures for unlocking a category A prisoner
in case of serious self harm or injury in HMP Whitemoor state that staff may
enter a cell alone to save a life, but are reminded that they must ensure their
own safety and ensure keys and radio’s are safe.
The man who died was known to staff as being of good behaviour and not
causing any problems. This was documented in his wing file by his personal
officer, and in a review of his category A status on in May 2004. The man
remained a category A status prisoner due to his denial of offence and
difficulties in assessing the risk he may pose outside of prison conditions. He
had no security incident reports written about him and no adjudications.
All the indications are that this was a death from natural causes. The
Ombudsman’s Terms of Reference permit in these circumstances, that it may
be sufficient for a clinical review to be carried out by an independent health
care professional, rather than a full investigation. My approach in cases of
apparent natural cause deaths has been to conduct an initial review to
determine if a full investigation is justified. In the man’s case, I decided that the
circumstances did require a full investigation.
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Chronology of events in the weeks leading up to the man's death
The man who died was a regular visitor to healthcare and had several
overnight stays leading up to May 2004.
x May 01:30 Healthcare called to his cell. The man thought he was
having an asthma attack. He was using his nebuliser in
his cell, and said he panicked when he couldn't breathe.
x May He was seen by healthcare staff after another attack.
x May Entry in IMR
x May He was seen by healthcare staff because he had a tight
chest.
x May The man was seen twice on this day. He was seen on
the wing by healthcare as special sick due to having
chest pain, and was using his nebuliser
Chronology of events during the incident on the day he died
02:02 The man rang his cell bell
02:03 The cell bell was cleared
02:12 From 02:12 to 02:25 Category A prisoner checks were
conducted by wing staff
02:16 He was visited for a category A check
02:18 The man’s personal officer informs a nurse and principal
officer that he needs medical attention.
02:22 The officer contacts Healthcare again to inform of
renewed seriousness of the man's condition.
02:23 The officer contacts the principal officer regarding
renewed seriousness of situation.
02:25 The principal officer contacts a senior officer.
02:27 Ambulance is requested. Dog Handler is requested.
02:28 The principal officer, senior officer, the man’s personal
officer, a Dog Handler and a nurse enter the man's cell.
The nurse commences resusitation.
02:30 A Doctor is called.
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02:45 The Doctor and ambulance arrive at prison.
02:55 The Doctor and ambulance arrive on wing.
03:00 The man is pronounced dead.
7
The man's healthcare needs
The man who died suffered from ischaemic heart disease, Chronic Obstructive
Airways Disease (COAD) and bronchial asthma. Over his time in custody he
had attended several outside hospital appointments over the years. The last,
and only outside hospital appointment in 2004 was on 28 April which included
an overnight stay.
From the beginning of April 2004 till the day of his death, there were 14 entries
in his Inmate Medical Record (IMR). Most of these were due to the man’s
shortness of breath and chest problems. He was seen as special sick in
healthcare, and on the wing and stayed on the healthcare centre for two nights
from 12­14 April 2004. There is no doubt that medical staff were well aware of
the man’s health needs.
Amongst other visits, healthcare staff visited himin his cell early in May 01:30
as the man felt he was having an asthma attack and could not breathe so
understandably was anxious. He used the nebuliser he had in cell and staff
reassured him thus helping him to calm down. One healthcare officer
commented that he often needed his nebuliser and reassurance.
In the week before the man’s death he was seen three times by healthcare
staff. The prison doctor saw himduring that time and was concerned about
him and asked him if he wanted to stay the night in the healthcare centre but
he declined. Unfortunately this information was not recorded in the Inmate
Medical Record (IMR). Two prisoners, interviewed subsequently commented
that the man had been upset in healthcare on the day prior to his death.
In the weeks prior to the man's death the prisoners in neighbouring cells
collected his meals for him as he struggled to climb stairs without getting
breathless and was having difficulties walking.
During the evening before he died health care staff received a message that
the man was complaining of chest pain. A member of the health care team
attended the wing and saw the man and noted that he was using his nebuliser,
but denied any chest pain. He felt the problem was with gastric reflux and so
a single dose of gaviscon was administered.
At approximately 02:16 the man’s personal officer noted that the man was
using his nebuliser and looked unwell and therefore returned to the office to
call health care. A nurse attended the wing accompanied by the principal
officer and waited in the office until sufficient staff were available to enter the
cell. It does not appear that the nurse attended the cell to assess the clinical
condition of the man until sufficient staff were on the wing to facilitate the
unlocking of his cell door due to his Category A status.
8
Management of the crisis situation
At 02:02, the cell­bell call log shows the man rang his bell. My investigators
checked with a security systems engineer that the times on the cell bell log
were accurate, and the engineer confirmed that they were accurate to within
two seconds of Greenwich Mean Time. The bell, according to the cell bell log
was deactivated at 02:03. One of the man’s neighbouring prisoners recalled
hearing noise from the man’s cell at around this time. To deactivate the bell
an officer must go to the cell door. The officer on duty, does not recall this
incident, neither does the OSG.
The officer was performing the check of all category A prisoners when at 02:16
he attended the man’s cell. It becomes slightly unclear as to what happened
next. In the officer’s statement to the police, he stated that at this time the
man was using his nebuliser but indicated he was alright, then a minute later
pressed his cell bell. There is no evidence of the cell bell in the man’s cell
being activated after 02:03 on the cell bell log.
The officer then ran along the wing and down a flight of stairs back to the wing
office and phoned healthcare and spoke to a nurse at 02:18 and explained the
situation. It was usual procedure to use the phone and not the radio at night.
The officer then phoned Oscar one – a principal officer and again explained
the situation. The officer then returned to the man’s cell looked through the
door flap where he saw that the man was now on the floor, laying on his side,
but could see his chest moving. The officer returned to the office and
contacted healthcare and the principal officer again to reappraise them of the
situation.
The officer said he was aware of night procedures from the night folder. He
also said that he is not expected to enter the cell of his own accord and to wait
for additional help to arrive. This was confirmed during interview by the
principal officer.
Once the principal officer received the call, he and a senior officer went to the
wing via healthcare to collect the nurse, as only the principal officer and the
senior officer hold keys, except for those in individual officers sealed pouches
for emergency access to cells. The nurse was waiting for them with his
medical bag that weighs 11 kilograms. The three of them went to the wing. It
was a journey that involved the unlocking and relocking of doors over quite a
distance.
The principal officer, the senior officer and the nurse arrived at the wing office,
and waited a few minutes for a dog handler to arrive, then along with an officer
they entered the cell at 02:28. There is no evidence that any further checks
were made on the man who died by the staff of the wing or the staff arriving on
the wing, including the nurse, from the time the second call was made to
health care and the Orderly Officer and the time they entered the cell, a
period of some 10 minutes. On entering the cell the man was found in a
collapsed state and the nurse immediately commenced resusitation, and the
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officer left to contact the control room to ask them to call paramedics and the
duty governor.
The control room phoned for an ambulance, the duty governor and the prison
doctor. A senior officer went to the prison gate to wait for the ambulance.
The control room log sheet records that the ambulance and duty governor
arrived at 02:45. The process for allowing the ambulance to gain entry is that
when the ambulance is called they are given a code, which on arrival at the
prison they quote. This allows entry, and a senior officer and dog handler then
escort the ambulance to the nearest vacinity of the incident.
The prison Doctor stated he arrived before the ambulance. By the time he
was allowed through the gate and waited for an officer with keys to escort him
it was eight to ten minutes from his arrival at the prison till he arrived on the
wing.
The ambulance crew arrived at the wing at 02:56. The ambulance staff
attempted to revive the man using a defiblerator but to no avail and he was
pronounced dead by the doctor at 03:00.
Once the man had been pronounced dead, the cell was sealed and all
contingency plans were correctly followed. All relevant paperwork provided by
the prison was to a high standard and level of detail.
10
Consideration
There are several points worthy of further discussion.
Healthcare provision
My investigators considered whether the man may have been more
appropriately situated in the healthcare unit given his chronic medical
condition. The prison doctor states he offered this to himbut he declined,
unfortunately there is no record of this. There would have been a bed
available to him had he wanted one. Healthcare staff are instructed that to
open the cell if the man was in distress would still have needed the same
amount of staff as was needed on normal wing location. We therefore do not
know if any time would have been saved had the man been situated in
healthcare.
The man’s prison medical records indicate that while in prison before the night
of his death, that he was being given an appropriate level of medical care.
However, there was no formal provision made to assist him in meeting the
activities of daily living whilst on the wing, as a result of his poor mobility and
chronic chest condition. For example through providing prisoner aides who
would act as a paid helper to assist with day to day activities such as fetching
meals and helping clean his cell.
In response to emergencies, health care professionals are required to carry a
heavy medical bag over a considerable distance to reach the wing. A trolley
for the bag had been provided but is difficult to use when the journey involves
stairs. Consideration should be given to the provision of some emergency
medical equipment being located on the residential units.
Furthermore, one of the nurses conducted resuscitation techniques alone for
approximately 25 minutes. It would be advisable for night staff to be trained in
basic Cardio Pulmonary Resuscitation techniques, as 25 minutes of CPR
alone is physically exhausting and emotionally difficult.
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Timeliness of response and unlocking prisoners of category A status prisoners
at night
The officer was also the man’s personal officer. The man was known to staff,
as being “no problem” and they were aware of his chronic medical condition.
The officer knows the cell bell only rang once, but is unaware of the time of
this bell. This was the first incident of this nature that the officer had had to
face and it was clear that he had found it a particularly difficult situation at the
time, and it had affected him deeply.
The officer was under clear instructions from the night orderly officer, the
principal officer not to enter the cell alone. Once the officer became aware of
the man’s distress he acted entirely appropriately given his instructions. The
officer stayed with the man who died after raising the alarm until he heard gate
keys and he then returned to the wing office while they waited for the dog
handler. It would be desirable for someone to have remained with the man
monitoring his condition until entry of his cell, given the OSG was also in the
office and could attend to the arrival of other officers.
The distance the principal officer and the senior officer had to travel to reach
the wing via healthcare is quite lengthy, and they covered the distance quickly.
However, it is quite possible that they may not have been situated in the night
orderlies' office they could have been conducting security checks elsewhere in
the prison, which would have meant it would have taken longer to reach the
wing. This could prove problematic in future serious incidents.
Different high security prisons operate different practice in terms of unlocking
category A prisoners at night. There is continuity on advice of who should be
present which includes the night orderly officers and the dog handler, but
ambiguity over opening a cell door alone.
Given the fact that the man was a category A prisoner, and the officer’s
instruction from the principal officer, it is understandable why he did not enter
the cell on his own. However, once support had arrived, given the officer’s
and the nurse’s knowledge of the man it is difficult to understand why it was
necessary to wait for the dog handler.
The issue of unlocking prisoners at night is complex, full of ambiguity and also has
implications for nursing staff. The nurse explained to my investigators how it is
difficult when you are relying on others to open the cell door, when as a clinician your
judgement is to get into the cell immediately. Furthermore, by saying an individual
officer can make that judgement, but having other procedures in place can be
confusing, and forces a large decision to be made usually by junior staff.
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Conclusions
The man died of an asthma attack and ischaemic heart disease. The medical
treatment leading up to his death was satisfactory. However, more could have
been put in place in terms of provision for his needs on the wing.
There are some concerns over the length of time taken to enter the man’s cell.
Whilst I understand and appreciate the security concerns surrounding
unlocking prisoners of category A status at night, he was known to be an ill
man, in need of regular medical attention, and known to not have caused staff
any security concerns. This concern is amplified when we consider the
potential delay could be 26 minutes from the time the man pressed his cell call
bell to the time his cell was entered.
Once, the officer was aware of the man’s distress he acted quickly and
appropriately. It is however, concerning once more, that once a Principal
Officer, Senior Officer, Officer and a Nurse were present they still waited,
albeit for a short time, for a dog handler before they entered the cell. The
OSG was in the wing office and could have allowed entry of the Dog Handler
onto the wing when he arrived.
The weight of the medical bag, carried over a significant distance was not an
easy feat for the nurse. He then entered the cell and carried out resusitation
unaided for approximately 25 minutes. He should be commended for his
efforts.
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Recommendations
Unlocking of prisoners in life threatening situations
A review of the policy for unlocking prisoners during patrol states should be
undertaken to ensure that there is timely access in life threatening situations.
Records and record keeping
Record keeping is an integral part of clinical practice. It is a tool of
professional practice that should inform the care pathway. It is not an optional
extra to be fitted in if circumstances allow.
Staff must be reminded of their professional responsibilities for appropriate,
accurate and contemporaneous records.
Location of equipment
Consideration should be given to reviewing the location of emergency medical
equipment to ensure that staff are able to access it in a timely manner.
CPR training
All permanent night duty staff should be trained in basic life support to ensure
that the medical practitioner attending an incident has appropriate and
effective support.
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