Individual at Whitemoor

Investigation into the circumstances surrounding the
death of a man
at HMP Whitemoor in January 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2009
This is a report of an investigation into the circumstances of the sudden death of
a prisoner at HMP Whitemoor, on 13 January 2008. The man was found collapsed
in his cell at 8.24am. Tragically, efforts to resuscitate the man by prison staff and
paramedics failed and he was pronounced dead shortly afterwards. I would like to
offer my sincere condolences to all those who knew the man and were affected by
his death.
My colleague conducted the investigation on my behalf. Although my office usually
makes every effort to include families in our investigations, this was not possible
because the man had no next of kin who wished to be involved.
An independent review of the man’s medical care was undertaken by the Chair of
the Clinical Care Review panel for Cambridgeshire Primary Care Trust (PCT). The
Professional Performance Manager at Cambridgeshire Primary Care Trust,
conducted staff interviews at Whitemoor on behalf of the Clinical Care Review panel.
I am very grateful to the panel for their valuable contribution.
I would also like to thank the Governor of Whitemoor and his staff for their
cooperation with the investigation. I am particularly grateful to the Senior Officer who
provided a very high standard of prison liaison. A member of the Independent
Monitoring Board, also made a valuable contribution to my investigation.
I conclude that the man’s care at Whitemoor and the response to his collapse was
generally satisfactory, but I make two recommendations in my report. The first
relates to a review of the policy and distribution of radios. My recommendation is
that all staff working on the prison wings should carry radios to ensure immediate
response to medical emergencies. The other recommendation asks that all staff are
issued with pocket masks to aid mouth to mouth resuscitation in emergencies. In
this case the standard of record keeping in the Inmate Medical Records was poor. I
make no recommendation because the Head of Healthcare informed my investigator
that a new computerised patient record system was due to be implemented.
The issue I raised within my report regarding the responsibility for disposal of the
remains of a prisoner without next of kin is currently being researched by the Prison
Service. They have told my office that they are happy for the final draft of this report
to be issued and I am grateful to them.
Jane Webb
Deputy Prisons and Probation Ombudsman January 2009
2
CONTENTS
Summary 4
The investigation process 5
HMP Whitemoor 8
Key findings 9
Issues 13
Recommendations 15
Annexes
3
SUMMARY
The man was convicted of serious offences for which he received a life sentence.
He was familiar with prison life as he had served a previous sentence for similar
convictions. He was a category ‘A’ prisoner and served most of his sentence at
Whitemoor. Due to the nature of his offences, the man was located on the
vulnerable prisoner wing where he worked as a cleaner until he died.
Following a minor heart attack in 1993, the man had been diagnosed with coronary
heart disease in November 1994. In 2006, he felt chest pain following exercise for
which he was sent to hospital and released the same day. The man’s medical
record showed that he attended healthcare for a variety of ailments, not necessarily
for heart problems. With regard to his heart condition, it is difficult to tell whether the
man was regularly monitored as the clinical review panel found that healthcare
record keeping fell below the standard expected.
On the morning of 13 January, the man’s cell was unlocked at around 8.12am. The
officer who unlocked him did not recall seeing anything wrong, neither did he recall
getting a response from the man at that time. At around 8.24am a prisoner and
friend of the man, shouted that he could not wake him up. Staff attempted cardio
pulmonary resuscitation (CPR) and called an ambulance. Sadly, despite every
effort, the man was pronounced dead by the ambulance paramedics a short time
later.
The clinical reviewer noted that there had been a delay communicating with nursing
staff as they did not carry radios. My investigation found that the only member of
healthcare staff who carried a radio was Hotel 1, who was the person expected to
respond to medical emergencies sent over the radio net. The lack of radios for other
healthcare staff meant a delay in treating the man as the nurse had to be collected
from the treatment room on the first floor.
The prison made lengthy enquiries regarding next of kin but no family who wished to
be involved were found. My investigator found that the prison does not have a clear
policy regarding what is to be done with the property and remains of a prisoner in
these circumstances. She spoke with both the governing Governor and the
chaplaincy in order to both highlight and resolve the issue between them.
The investigation also concluded that all staff, including healthcare staff should be
provided with pocket masks and training in their use. In this case, the outcome
would not have been different if mouth to mouth resuscitation had been used at first,
but it could well have a bearing on the outcome of emergency situations in the future.
My recommendations aside, I judge that the care the man received before his
collapse and subsequently was appropriate.
The standard of medical record keeping in this case was poor. The Head of
Healthcare told my investigator that a new system of patient record keeping was due
to be implemented (SYSTEM 1) and this would reduce this problem.
4
THE INVESTIGATION PROCESS
1. I was notified of the man’s death on 14 January 2008. Terms of Reference
and Notices were issued to staff and prisoners at Whitemoor telling them that
an investigation would be taking place, and inviting those who wished to see
the investigator to make themselves known. My investigator requested copies
of the man’s core record, medical record, and other records relevant to his
time in custody and to his death. She also received a note of the events
following the man’s death from a member of the Independent Monitoring
Board (IMB).
2. My investigator also contacted the Coroner to inform him of the nature and
scope of the investigation and to request a copy of the Post Mortem Report.
The report concludes that the man died of:
1a. Myocardial infarction
1b. Hypertensive ischaemic heart disease
1c Atherosclerosis.
The Coroner has requested a copy of my report upon completion and I am
happy to comply.
3. My investigator visited Whitemoor on 28 and 29 May 2008. She met the
Governor, Head of Healthcare, a member of the IMB and the chaplain. My
investigator visited the healthcare department and met the staff. She also met
informally with staff and prisoners on the wing where the man was located
and subsequently died. When my investigator visited, the vulnerable prisoner
unit was closing and only a small number of prisoners remained.
4. The clinical review of the man’s medical care at Whitemoor was
commissioned from Cambridgeshire Primary Care Trust (PCT). The clinical
review is an annex to this report.
5. My investigator has consulted investigation reports relating to the deaths of
prisoners at Whitemoor since 2004, but there were no similarities in the
circumstances of this case. My investigator has also read the report of an
announced inspection of Whitemoor in 2006 by Ms Anne Owers, HM Chief
Inspector of Prisons. In her report, Ms Owers highlighted the impact of
chronic staff shortages in healthcare on prisoners. Ms Owers concluded that
it meant that prisoners such as the man who suffered from a chronic disease
had “only a basic level of care, with very little chronic disease management.”
A report prepared by the Independent Monitoring Board (IMB) in 2006 – 2007
has found that the prison is functioning reasonably well in most areas.
5
HMP WHITEMOOR
11. HMP Whitemoor is part of the Prison Service High Security Estate. It accepts
Category A and B prisoners and those serving a sentence of over four years.
The maximum prison capacity is 458 men.
12. Healthcare provision is the responsibility of Cambridgeshire Primary Care
Trust. The healthcare centre is located on two floors. The lower floor
provides a treatment room and nine in-patient beds. The upper level contains
offices and further treatment rooms for clinics such as dentistry, opticians, and
diabetic, podiatry and x-ray facilities. Nurse-led clinics include diabetic and
well-man. A cardiac clinic is a recent addition. The healthcare centre
employs one full time doctor and provides 24 hour nursing care. An out of
hours service is provided to the prison by Suffolk doctors on call (SUFDOC).
13. The man was located on ‘C’ wing which was designated for vulnerable
prisoners. When my investigator visited the prison, only a very few prisoners
remained on the wing. This was because it was being re-roled to a main wing
for prisoners on normal location and would no longer cater for vulnerable
prisoners.
14. My investigator was informed that the healthcare department is currently
transferring to a new system for holding patient records and updating
information. This is called System 1 and means that in the future, patient
notes will be computerised. My investigator noted that when it is
implemented, it will meet a recommendation by HM Chief Inspector of
Prisons, Ms Anne Owers, that “an electronic patient record system should be
installed”.
15. My office had received a complaint regarding the impact on prisoners of the
wind turbine at Whitemoor. The complaint raised concerns regarding the
negative effects of the noise of the turbine which research had linked with
depression. My investigator spoke with the Governor, his staff and prisoners
about the turbine. My investigator was told that the local newspaper had
voiced concerns initially over the noise of the turbine and the impact upon the
landscape when it was installed. To date, staff and prisoners were not aware
of any complaints of any nature from staff or prisoners regarding either noise
or the turbine. Neither had any effects been linked to health matters in the
prison.
6
KEY FINDINGS
20. The man was remanded into custody and located in the segregation unit at
HMP Gloucester on 17 December 1993. He had been convicted of serious
offences following a trial at a Crown Court. On 25 February 1994, a life
sentence with a tariff of ten years was imposed.
21. The man transferred to HMP Wakefield on 7 March 1994. He was
unsuccessful in his appeal against his life sentence in February 1995. After a
period in HMP Full Sutton, he transferred to Whitemoor on 1 December 1999,
where he remained until his death on 13 January 2008.
22. There is a documented medical history of the man’s period in custody and this
has been examined more fully in the clinical review. The man had a mild
heart attack on 14 March 1993 while at Gloucester prison. An entry in the
man’s personal records on that day says he was admitted to Gloucester Royal
Infirmary. He was discharged from hospital on 18 March 1993.
23. Following a referral by the prison, the man was seen at Pinderfields General
Hospital, Wakefield on 28 November 1994 by a Senior Lecturer in Cardiology.
The doctor wrote to the Medical Officer at Wakefield, on 28 November 1994 to
say that “The diagnosis of coronary disease is not in doubt and I think the
indication for further investigation would be progressive shortness of breath or
more significant pain on exertion”. The doctor suggested that the man’s
condition should be managed by medication and a reduction in his
prescription of atenolol could be considered. (Atenolol is a drug to help lower
blood pressure.)
24. Between the end of 1994 and September 1996, the man attended healthcare
for medical ailments other than for his heart condition but his health appeared
stable. An entry in his medical record dated 3 September 2006 says
healthcare staff had been asked to see the man as he had complained of
chest pain while exercising the day before. The following day, his condition
had not improved and he was sent to Pinderfields General Hospital for
investigation. The man returned to the prison the same day. My investigator
noted that, although the record gave detailed reasons for the man going to
hospital, the outcome had not been recorded. It is also a concern that the
next entry is dated 18 January 2007. If the IMR is an accurate record of
patient contact, it would indicate that the man had not been seen by
healthcare between his discharge from hospital to his appointment with the
prison doctor, on 18 January some four months later.
25. The clinical reviewer and my investigator found the standard of record
keeping was poor. The Inmate Medical Record (IMR) was difficult to follow at
times as entries were not always made in chronological order and some staff
handwriting was difficult to read. The Head of Healthcare acknowledged that
this was a problem. She informed my investigator that a new computerised
patient record system called SYSTEM 1 was due to be implemented. It would
require medical staff to record appointments and medical treatments onto a
7
Events of 13 January 2008
26. An officer on C wing said that he unlocked the cells on ‘C’ wing at around
8.15am and did so in accordance with the policies and procedures he learnt in
training. He said that he looked through the flap in the cell door. (This was to
ensure that the door was not blocked and that there was nothing of concern
with the prisoner in the cell.) Then he unlocked the man’s cell. He could not
recall whether or not he received a response from the man, but he did not
recall anything wrong at the time. He said that it was a Sunday morning and
prisoners sometimes sleep late on a Sunday.
27. My investigator obtained and read prison service basic training protocols
regarding cell unlock procedures. The protocol is very clear that a response
should be received from the prisoner. The hot debrief notes stated that
responses were obtained from prisoners on the day that the man died. The
implication is that this would have included a response from the man,
suggesting he was alive when the cell was unlocked. However, as the officer
cannot recall if he received a response or not, it is difficult to be clear as to
whether the man was alive when the cell was unlocked or if it was assumed
he was sleeping.
28. At around 8.24am, a second officer said he heard a prisoner, and friend of the
man, calling to him from behind the locked gate to ‘C’ wing where the man
was located. The officer said that the other prisoner was ‘in a distraught state’
saying that he could not rouse the man. The officer immediately went to the
centre wing office to ask for assistance from a third officer. Both the third
officer and the other prisoner went to cell B3-26 where they found the man
collapsed. They described finding the man as being half on and half off the
bed. His head and upper body was positioned between the bed and a chair
next to his bed. His lower body was fully on his bed.
29. On checking the man for signs of life, neither the officer nor the other prisoner
could find a pulse. They said that they commenced cardio pulmonary
resuscitation (CPR) at that point.
30. Around the time the man was discovered, a senior officer was overseeing the
movement of prisoners from ‘C’ wing down to the servery to collect their
breakfast. A nurse was in the treatment room on her own dispensing
medicines to prisoners. The senior officer said he overheard the third officer,
who was outside the man’s cell, asking for assistance from staff. The senior
officer said he went to the man’s cell but two officers together with the nurse
were already there. He said there appeared little he could do to assist within
the cell. However, he instructed wing staff who were not involved in the
incident to secure all prisoners in their cells and to carry out a roll check. He
instructed the wing collator, (a wing collator is responsible for the
administrative tasks on the wing) to tell healthcare, the control room and
Oscar 1. (Oscar 1 is the person who is in charge of the operational running of
8
31. The wing collator said she carried out the senior officer’s instructions. She
telephoned healthcare, informed them of the emergency, and asked them to
bring a defibrillator.
32. At the time the man was found, prisoners were unlocked and waiting at the
servery on the ground floor to collect their breakfast. The servery is located
near to the treatment room on the first floor.
33. In her statement, the nurse said that an officer came to the treatment room
and asked her to see the man as he was ‘suffering from chest pain’. To my
investigator, this has suggested that the man had been able to speak to staff.
However, in interview, the nurse made it clear that she thought the officer said
this because she did not want to alarm prisoners who would have overheard
her.
34. The two officers did not call for healthcare assistance over the radio net
because neither officer was carrying a radio. A fourth officer did not have a
radio either and so she ran from the central office to the ground floor and then
to the treatment room. She wanted assistance from the nurse, who also had
no radio and had been called verbally by the fourth officer who ran to alert
her.
35. At interview with my investigator, the nurse said that when she arrived at the
man’s cell at 8.28am, she was disappointed to find that the officers had not
started CPR. The man was face down on the bed “with his head hanging
down between the bed and the chair”. The nurse said that she rolled the man
on to his front and checked for a pulse for around ten seconds. She told my
investigator that pocket masks for giving mouth to mouth resuscitation were
not carried by all staff. There was one available on the wing and healthcare
staff had been issued with them but the nurse did not have one. Therefore
she started CPR with chest compressions only, assisted by two officers, until
a mask was provided. The second officer began the task of logging the
incident with action taken and movements by various members of staff
entering and leaving the cell.
36. The nurse said that she asked for healthcare staff to be contacted
immediately and to bring emergency equipment. The third officer called to the
wing collator who was in the central office to ask for assistance. The wing
collator said that she contacted healthcare and stated that there was an
emergency and asked staff to bring the defibrillator.
37. A few minutes later, a second nurse arrived with the defibrillator. When
attached to the man, the defibrillator showed that he had a non-shockable
9
38. At approximately 8.35am, the wing collator telephoned the control room and
asked Oscar 1 to call for an ambulance to attend the wing. The control room
log sheet shows that an ambulance was called and arrived at the gate at
8.39am. The first paramedic crew had difficulty in inserting a canula (a tube
which puts essential liquid medication directly into a vein) into the man. The
nurse said she continued CPR until the second paramedic crew arrived at
8.50am. The two nurses and the forth officer left the cell in order to allow the
paramedics space to care for the man.
39. In the East of England Ambulance Service report, it is recorded that
paramedics took over administering CPR at 8.50am. They conducted an
electrocardiogram (ECG) test to measure the electrical activity of the man’s
heart and administered adrenaline through an intravenous line. Unfortunately,
all attempts at resuscitation by both staff and paramedics were unsuccessful
and the man was pronounced dead at 9.15am by the paramedic crew.
40. The other prisoner was taken to healthcare by staff to be cared for and
monitored while he adjusted to the loss of his great friend. The prisoner
informed the Reverend that ”staff have been brilliant”. The Reverend
informed my investigator that, on the same day, he went to each cell on ‘C’
wing to inform every man personally of the man’s death.
41. At 10.15am, the IMB member said that she arrived on ‘C’ wing with Oscar 1.
She saw the right hand side of the landing was screened off and also noted
that the staff involved were calm.
42. The Deputy Governor, arrived to chair a hot debrief at 10.26am. The IMB
member’s report states that “the hot debrief was calm and well balanced with
both the deputy governor and Oscar 1 ensuring staff welfare was known to be
of equal importance as ensuring the regime continued as smoothly as
possible”. The Staff Support & Care Team member reiterated his and the
team’s availability at any time.
43. The duty doctor from the SUFDOC out of hours service, attended the cell,
accompanied by Oscar 1 to examine the man. He confirmed death at
11.00am. Other members of staff, including the Governing Governor
attended the cell and spoke to the other prisoner later that morning. The man
was removed from his cell by the undertaker at 11.52am and the cell sealed.
10
44. The following Thursday, a memorial service for the man was held at the
prison. It was well attended by prisoners and staff and was conducted with
the aim of possible closure regarding the man’s death, which the Reverend
considered important.
45. The IMB member told my investigator and the clinical reviewer that, in her
view, the prison had learnt lessons from previous deaths. She said that the
prison had a “real desire to deal with it [the man’s death] professionally”.
11
ISSUES
The clinical review
46. The clinical review was undertaken by the Chair of the Clinical Care Review
Panel for Cambridgeshire Primary Care Trust (PCT) and the Professional
Performance Manager at Cambridgeshire Primary Care Trust. Interviews with
medical staff and officers at Whitemoor were conducted on behalf of the
Clinical Care Review panel. Although the panel acknowledged that the
clinical records were poor, they were able to conclude that the care the man
received was reasonable and equitable with that he would have received
outside prison.
47. In 1993 the man had been diagnosed with chronic heart disease. The panel
found that, due to poor recording keeping, it was difficult to tell whether the
man had attended the cardiac clinic or if he had been identified as a prisoner
who would benefit from chronic disease management. It may have been the
case that the man did not wish to avail himself of the cardiac clinic. However,
there is no evidence in his medical records that the man was aware that the
clinic was available to him. I have made no recommendations regarding
recording keeping as improvements are in hand via the computerisation of
medical records at Whitemoor.
The provision of equipment
48. The panel concluded that there had been a delay in communication on the
day the man died. I agree that there are issues regarding communication
which should be addressed. My investigator understood that healthcare staff
generally had access to two radios. However, on the day the man died,
healthcare staff only had access to one radio. This had been issued to the
member of healthcare staff who was Hotel 1 and responsible for responding
to emergencies. Neither the nurse nor the staff unlocking prisoners had
radios. This meant that when the man was discovered, an officer had to run
downstairs to fetch the nurse. The nurse lost time in attending as she had to
secure the medicines and lock the treatment room. She would have been
alerted to the emergency sooner via the radio net if she had carried a radio.
In the man’s case, healthcare staff not having a radio would not have altered
the outcome, but it might be a crucial factor in another emergency in the
future.
The Governor should review the policy for the distribution of radios to
staff. He should ensure that sufficient healthcare staff and a greater
number of wing staff carry radios to enable an immediate response to
medical and other emergencies.
12
49. The nurse said that she had not been issued with a pocket mask since
beginning her work at the prison. While acknowledging this did not delay
matters, this should be rectified and all staff should be issued with pocket
masks with appropriate training in their use.
The healthcare manager should ensure that all staff are issued with a
pocket mask and are given appropriate training in its use.
The man’s ashes
50. The prison does not have a clear policy regarding what is to be done with the
property and remains of a prisoner without next of kin. To her great credit, the
family liaison officer made every effort to find the man’s next of kin, without
success. The family liaison officer acted in the best interests of decency and
with the greatest of respect for the man when she assumed responsibility for
scattering his ashes without the benefit of such policy or guidance. However,
the question of how the remains of a prisoner without family are disposed of
remains the responsibility of the Governor. My investigator alerted both the
Governor and the Reverend to the problem and they will develop a policy to
deal with the issue.
Conclusion
51. The man was a well respected prisoner whose death was sudden and
unexpected. When he was found collapsed in his cell, staff and ambulance
paramedics made every effort to save his life, but were unsuccessful.
52. Although I have made recommendations relating to the issue of pocket masks
and the distribution of radios, the investigation found that the quality of care
that the man received was reasonable and equated to that which he would
have received in the community.
13
RECOMMENDATIONS
1. The Governor should review the policy for the distribution of radios to staff.
He should ensure that all healthcare staff working on the prison wings
should carry radios to enable immediate response to medical emergencies.
‘Accepted. A review of the policy relating to the distribution of radios will be
undertaken. In addition to this, HMP Whitemoor will also examine an alternative
paging system (similar to hospitals) to be used by the Health Care Centre for
their nurses on duty to complement existing systems of communication.’ A target
date has been set for [28] February 2009.
2. The Governor should ensure that all staff are issued with a pocket mask
and are given appropriate training in its use.
‘Accepted. All staff with direct prisoner contact will be issued with a pocket mask.
As part of the rolling training programme 2009/10 training will be delivered on the
use of pocket masks.’
14