Individual at Winchester

Investigation into the circumstances surrounding
the death of a man at the a local hospital, whilst in the
custody of
HMP Winchester, in March 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2010
This is the report of an investigation into the circumstances of the death of
a male prisoner at HMP Winchester on 24 March 2010. The man had a long history of
chronic obstructive pulmonary disease (COPD) and had undergone a tracheotomy in
2008 as part of treatment for the condition. A post mortem found that the main cause of
death was broncho pneumonia and COPD. I would like to offer my sincere condolences
to the man’s family and all those who knew him and were affected by his death.
An investigator from my office conducted the investigation. An independent review of
the man’s medical care was undertaken by a panel led by a doctor who is an Associate
Clinical Director at NHS Hampshire, together with two colleagues. I am grateful for their
contribution. I am also indebted to the Clinical Manager from National Patient Safety
Agency, for her Root Cause Analysis Investigation Report which contributed to the
review.
I would also like to thank the Governor of Winchester, his staff and prisoners on D wing
where the man lived, for their assistance. I am particularly grateful to the liaison officer
for a very high standard of liaison with my office.
One of my family liaison officers contacted the family. The man’s daughter did not wish
to raise any issues regarding her father’s care at Winchester.
I judge that the man’s death could not have been anticipated or prevented. However,
nursing and clinical staff were not proactive in his care. This may not have affected the
circumstances of the man’s death, but may prove critical in the future. I make five
recommendations. The majority relate to clinical issues highlighted by the clinical
review panel such as the need for better clinical record keeping and the provision of a
specialist respiratory nurse. There is a need for a protocol on the admission and
discharge of prisoners to hospital and prison healthcare staff should provide a full
medical history to ambulance staff. My report will be drawn to the attention of the South
Central Ambulance Service Trust. I have also asked for consideration of a multi-agency
action plan to manage imminent deaths events. I hope that the necessary changes in
practice identified in the clinical review and this report are adopted.
I am pleased to commend the actions of a nurse who, in the face of resistance,
steadfastly insisted that the man be taken to hospital when his condition deteriorated a
few months before his death. I also acknowledge the foresight and planning of the duty
governor when the man died, in respect of support for staff and the man’s next of kin.
The family’s response to the report is documented on page 20 of the report. The
National Offender Management Service has accepted the recommendations and
commendation and their response can also be found on page 20 of my report.
Jane Webb
Acting Prisons and Probation Ombudsman November 2010
2
CONTENTS
Summary 4
The investigation process 5
HMP Winchester 6
Key findings 7
Issues 13
Recommendations and commendation 20
3
SUMMARY
The man had served five months of a 16 month prison sentence when he died on 24
March 2010. He had a long history of lung disease and had been unable to work since
2003.
When he arrived at Winchester on 2 October 2009, the man gave nursing staff a past
history of gastrointestinal disease1 and palpitations on breathing. He had suffered from
chronic obstructive pulmonary disease (COPD)2 and had undergone a tracheotomy3 in
an intensive care unit. The investigation found that, despite giving this history, he did
not see a prison doctor until 12 October. The man was initially accommodated in the
healthcare centre, but later moved to a residential wing.
On 30 December, the man’s condition deteriorated and an ambulance was called. The
paramedics thought that he was suffering from a chest infection and initially refused to
take him to hospital. However, the duty nurse insisted that a prison doctor give a
second opinion and they were then persuaded of the seriousness of his condition. I
have commended the nurse for her actions. The man was discharged from hospital
three weeks later. He was sent to the wing as a bed was not available in the healthcare
centre. The Clinical review panel were critical of the lack of communication between the
prison and the hospital and I have therefore made a recommendation in this regard.
The man’s condition deteriorated again on 20 March, and he was admitted to hospital
as an emergency. The following day it became clear to prison staff that he was
terminally ill. In light of his condition, a risk assessment was carried out and his
restraints were removed on 22 March. During the final days of the man’s life, the prison
contacted HMP Liverpool who agreed to send family liaison officers to give the man’s
daughter the news of his death. This was good practice. The man died on 24 March.
The family liaison officers from HMP Liverpool visited the man’s daughter to break the
news of his death. Two members of staff from Winchester visited her the following day.
The clinical review panel has judged that, while not affecting the outcome, some
aspects of the man’s care fell short of the standard expected and was not proactive. I
make five recommendations regarding record keeping, the admission and discharge of
prisoners from hospital, the provision of relevant information to the ambulance service
and increasing the healthcare department’s expertise in managing prisoners with
chronic respiratory conditions. During the hot debrief, staff suggested an action plan to
manage the imminent death of a prisoner. I have also made a recommendation in this
regard.
1
Gastrointestinal disease is disease of the stomach, colon, bowels, or rectum.
2
Chronic obstructive pulmonary disease is a non reversible lung disease that is a combination of emphysema and chronic
bronchitis; usually patients have been heavy cigarette smokers.
3
Atracheotomy is a surgical operation that creates an opening in the windpipe to assist breathing.
4
INVESTIGATION PROCESS
1. The man died on 24 March 2010. I was notified of his death later the same day.
Terms of reference and notices were issued to staff and prisoners at Winchester
telling them that an investigation would be taking place, and inviting those who
wished to see the investigator, to make themselves known. The investigator
requested copies of the man’s core record, clinical record, and other records
relevant to his time in custody and his death.
2. My investigator also contacted HM Coroner to inform him of the nature and scope of
my investigation. The coroner’s officer told her that a post mortem found that the
man died of:
1a Broncho pneumonia
1b Chronic end stage obstructive pulmonary disease.
3. A panel led by a General Practitioner and Associate Clinical Director from NHS
Hampshire conducted a clinical review. The panel comprised of a Registered
General Nurse and Head of Patient Safety from NHS Hampshire and a Primary
Care Integrated Governance Development Manager. They focussed on the clinical
care given to the man at Winchester. A Root Cause Analysis Investigation Report
undertaken by a Clinical Manager from the National Patient Safety Agency, was
used during the review. A third report completed by a Associate Medical Director
Patient Safety WEHCT reviews the man’s care in hospital.
4. The Investigator and the clinical reviewer visited Winchester on 11 May 2010. They
met, a governor, who acted as prison liaison for my office and was duty governor at
the time of the man’s death. The Investigator and the clinical reviewer visited the
healthcare centre and spoke with staff. They also toured the wing in which the
man’s cell was located before his death and spoke with prisoners and staff who
knew him. The investigator wrote to the Governor, on 10 June 2010 updating him
on the status of the investigation.
5. My family liaison officer wrote to the man’s daughter to explain the investigation
process and invite her to contact my office with any concerns or issues regarding
her father’s care. There was no response to this letter at the time of writing the
report, but she will be given an opportunity to have sight of this investigation report.
5
HMP WINCHESTER
11. HMP Winchester is a category B4 local male training prison located outside
Winchester city centre. It has a maximum capacity of 707 prisoners following the
extensive refurbishment of C wing. It has four residential and one administrative
wing5. The West Hill unit is a separate resettlement unit for category C men.
12. Healthcare at Winchester is provided by Solent Healthcare. The in-patient unit has
18 beds, with the majority of prisoners suffering from mental health problems. A
member of healthcare staff is allocated to work on each wing, including the West Hill
unit. At the time of this investigation, there were two chronic disease registers with
120 prisoners on the asthma register and six on the register for chronic obstructive
pulmonary disease. Dental and Pharmacy services are provided. At the time the
investigator visited, the role of Head of Healthcare was divided between two
members of staff who shared the role.
13. The prison has 24 hour healthcare facilities. Doctors are not on site during the night
or after midday on Saturday. The local out of hours medical service is available for
medical emergencies when doctors are not on duty.
14. The Independent Monitoring Board (IMB) is a voluntary body comprised of
individuals drawn from the community. They monitor all aspects of prison life and
produce an annual report. The IMB report for 2008/2009 is positive in a number of
areas including healthcare, although the Board has some concerns regarding low
staffing levels.
15. The most recent inspection by HM Inspectorate of Prisons, was carried out in 2007.
The resulting report described Winchester as remaining a reasonably well-
performing prison as a whole.
16. There have been 15 deaths at Winchester since my office began investigating all
deaths in prison custody in 2004. Record keeping and chronic disease
management have been a concern in past investigations and the clinical review
panel found that they continue to remain so.
4
When they enter prison, prisoners are risk assessed and given a category based on their offence and the risk that they pose to the
public should they escape. There are four categories: A, B, C and D, with category A being the most dangerous. Category B are
prisoners for whom the highest security conditions are not necessary but for whom escape must be made very difficult. Category C
are those who cannot be trusted in open prison conditions, but would not have the ability or resources to make a determined
escape.
5
An administrative wing is where the governors office is located, together with all the other administraive staff necessary to the
everyday working of the prison such as finance, security, activities.
6
KEY FINDINGS
17. The man was convicted and sentenced to 16 months imprisonment at a local Crown
Court on 2 October 2009. He was sent to HMP Winchester on the same day and
had served around five months of his sentence when he died on 24 March 2010.
18. A first reception healthcare screen was carried out when the man arrived at
Winchester. Although the clinical records do not say when the required second
healthscreen was carried out, a registered mental health nurse, told the investigator
and the clinical reviewer that the second healthscreen has to be completed within 72
hours of arrival into the prison. She said that it was likely that the healthcare
professional who carried out the first healthscreen, may have had time to do the
second one immediately afterwards. This was common practice if reception was not
too busy. She described the second healthscreen as focussing on whether the
prisoner had hepatitis B and taking a family history. As the clinical record has
entries for 2 October relating to a family history, it can be assumed that the member
of staff that did the initial screening did both health screens at the time and the
registered mental health nurse, confirmed this was the case.
19. The clinical record shows that the man gave a past history of gastrointestinal
disease (acid reflux), palpitations on breathing, chronic obstructive pulmonary
disease (COPD) and cervical spondilosis6. The man’s refusal to stop smoking
despite his COPD condition is notable and there is no evidence that he was offered
support or practical help in dealing with it. Importantly, the clinical reviewer saw that
the man told the member of staff that carried out the screening that he had
undergone a tracheotomy7 and the doctor referred to both respiratory failure and the
tracheotomy in his report.
20. There is no evidence that the concerns set out in the pre-sentence report regarding
the man’s health and disability needs were picked up by reception staff at
Winchester and passed to the healthcare department. Equally, there is no evidence
that the court or probation staff at the local Crown Court passed the concerns on to
the prison.
21. The man was accommodated in the healthcare unit because of his poor mobility.
Entries in the clinical record show that healthcare staff observed him twice a day.
His refusal to stop smoking was also noted but as mentioned previously there is no
evidence that the man was offered practical help to stop smoking at this point.
22. The clinical record shows that the man was prescribed medication but did not see a
doctor until 12 October. This appointment was made because he asked for a
nebuliser8 to be prescribed to help his lung condition as he had used one in the
community prior to his imprisonment.
6
Cervical spondylosis is a degenerative disease of the neck vertebrae
7atracheotomy is a surgical operation that creates an opening into the windpipe with a tube inserted to provide a passage for air;
performed when the pharynx is obstructed by oedema or cancer or other causes
8anebuliser is a device that produces a fine spray or mist often used for breathing treatments in patients with COPD.
7
23. A prison doctor, assessed the man on 12 October. He noted that the man had
swollen ankles, shortness of breath and advised him to stop smoking. He did not
prescribe medication for the man to use with his nebuliser. From mid October to
early December, the man was seen twice a day by healthcare staff and there did not
appear to be any major concerns.
24. On 8 December, healthcare staff assessed the man as fit for transfer to another
prison. No other information was provided and it is not clear whether the
assessment was routine or because the man had been selected to transfer. It is
also not clear from the records when the man was assessed as fit to move from the
healthcare unit to a cell on a residential wing. From the clinical record, it appears
likely he moved to a wing before 29 December as on that date, the record shows
that a nurse was called to the man because he had breathing difficulties. When he
went to the cell, the nurse, saw that the cell was “humid and smokey” and the man’s
cellmate opened the window. The nurse gave the man oxygen and an appointment
was made for the prison doctor to review him.
25. In the early hours of 30 December, the man’s health deteriorated again. The nurse
went to the cell at 4.00am and again at 4.30am and noted the man’s shortness of
breath on each occasion. An entry in the offender contact log made by a member of
the wing staff, at 5.37am confirms that the man was given oxygen in his cell in the
early hours of the morning because he was struggling to breathe. The log shows
that the man was also given a nebuliser to help with his breathing. He was told that
smoking was not helping his condition and he was advised to either cut down or
stop. His cellmate was also a heavy smoker who was told not to smoke as the man
was “gasping to breath”. The member of wing staff suggested that a cell move for
health reasons might be beneficial to the man. The nurse decided to send the man
to hospital to stabilise his condition but this information did not reach wing staff.
26. In interview with the investigator and the clinical reviewer, a nurse said that she was
allocated to work on ‘D’ wing during the day on 30 December. Before she started
her duty, night nursing staff had told her that the man might need to go to hospital.
Therefore, when she arrived on the wing, she was already aware that the prison had
previously made arrangements for the man to go to hospital. Healthcare staff and
the Orderly Officer (Oscar 1)9 knew of the arrangement but wing staff did not. The
nurse told the investigator and the clinical reviewer that she thought that the man
had already gone to hospital when she arrived on the wing. She was surprised to
find he had not.
27. The South Central Ambulance Service Trust Patient Clinical Record shows that an
ambulance was called at 10.23am. It arrived at the prison at 10.28am. The
paramedic’s comment on the record shows that prison nursing staff treated the man
but they did not have salbutamol to nebulise him. Ambulance staff noted on their
9The Orderly Officer (Oscar 1) is the discipline officer with overall responsibility for the running of the prison
wings.
8
record that the man’s salbutamol inhalers had run out and should have been
replaced. In the circumstances the paramedics were reluctant to take the man to
hospital as their assessment of the situation was that the man appeared to have run
out of medication.
28. In interview with the investigator and the clinical reviewer, the nurse said that the
paramedics told her that they were not prepared to take the man to hospital on the
basis that he may have a chest infection. The paramedics told the nurse to ask the
prison doctor to write a prescription for the medication that he needed. According to
the nurse, valuable time was lost while they discussed the matter. She said that the
paramedics did not understand that prison healthcare doctors had to write a
prescription and then the medication was ordered from Lloyd’s Pharmacy in the high
street.
29. The matter was resolved through the nurse’s insistence that the man’s condition was
unstable and that he should be taken to the prison doctor in healthcare to confirm
this. The man was wheeled to healthcare and the prison doctor confirmed the
seriousness of his condition. The man left the prison at 11.25am arriving at the local
Hospital at 11.31am.
30. The man remained in hospital for three weeks. The clinical reviewer obtained
copies of the man’s hospital records. They showed he had a chest X-ray, a
computerised tomography (CT ) scan (an x-ray which provides detailed images) and
a bronchoscopy.10 Tests for cancer of the windpipe were negative. He received
treatment for his lung condition including the use of positive pressure masks. He
found the mask difficult to tolerate and asked for this treatment to stop. He allowed
oxygen treatment and nebulised medicines to continue.
31. On 21 January, the man returned to the prison. There is no evidence in the clinical
record that the prison and the hospital communicated to arrange the man’s
discharge back to the prison. There were no available beds in healthcare when the
man returned so the duty governor found the man an available cell on a wing. The
investigator asked the nurse that confirmed she thought the same member of staff
would have completed both screenings if the hospital contacted the prison to warn
that a prisoner was to be discharged back to the care of the prison. The nurse
replied that, in her experience, the prison “have to do the running” in finding
information from the hospital. I address this matter later in the report.
32. A prisoner and friend of the man spoke with the investigator and clinical reviewer.
He recalled that the man was admitted to hospital at the end of December. When
the man returned to the prison, he remembered that he was placed with a cellmate
whose cell hygiene was poor. The man was given help if he needed it as officers
and prisoners knew that he could not collect his meals or clean the cell himself. He
told him that he thought he had around six to nine months to live. The friend did not
10 A Bronchoscopy is a procedure used to look at a patient’s lungs, airways and voice box
9
know who had given the man this information. He commented that, despite his poor
health, the man did not complain.
33. A review by a prison doctor was arranged for 23 January. The clinical reviewer
noted that the man had been prescribed a high dose course of steroids at the
hospital to help to reduce his symptoms with the dosage to gradually reduce until
finished.
34. The clinical record shows that the man remained on the wing and continued to
receive regular visits from healthcare nursing staff. The clinical reviewer has noted
that observations on the man were not recorded in the medical record. On 5 March,
the man was admitted again to the hospital for treatment of his COPD condition. He
returned to the prison on 7 March, with antibiotic and steroid medication and without
further planned appointments to monitor his condition. He was allowed to keep all
his medication in his cell and an appointment was made for a review with the prison
doctor.
35. On 13 March, the clinical record shows that the man ran out of prednisolone11 and
the prison doctor was asked to prescribe more. He received this two days later.
Events on 20 March 2010
36. On 20 March, the man’s condition deteriorated further and wing staff called
healthcare staff to see him. A nurse responded to the call and found the man
struggling to breathe. She gave him oxygen and then handed his care to day staff
when she went off duty.
37. The investigator and the clinical reviewer spoke with a prison doctor. The doctor
had not met the man before 20 March but was told by nursing staff that he had
“given up”. She said that he was on the maximum amount of medication that the
prison could give and it was clear to her that he needed to be admitted to hospital.
The man told the prison doctor that he had been ill like this before. The prison
doctor was aware that using oxygen was a problem as the man was a heavy
smoker. She told the clinical reviewer and investigator that there is new NICE 12
guidance which says that despite smoking, a patient cannot be denied oxygen. The
prison doctor took a brief history from the man and examined him. She arranged for
admission to hospital for assessment because of his worsening COPD.
38. The clinical reviewer reviewed the hospital notes. The hospital assessed the man
as having end stage respiratory failure. Treatment was withdrawn with the man’s
consent and he was kept comfortable on a syringe driver13.
11
Prednisolone is used to treat inflammatory conditions
12 NICE stands for the National Institute of Health and Clinical Excellence
13 A syringe driver is a small, portable battery-driver infusion pump, used to give medication subcutaneously via a syringe usually
over a 24 hours period.
10
39. The form for assessing the man’s risk at hospital was completed by the duty
governor on 20 March. The man was restrained by double handcuffs linked to a
chain and attached to a prison officer. The risk assessment noted that if a
defibrillator14 had to be used, restraints with a single handcuff should be used so that
they could be swiftly removed in an emergency.
21 and 22 March 2010
40. The bedwatch log completed by the escort officers records that the restraints were
removed on 21 March at the doctor’s request for treatment and replaced afterwards.
(The bedwatch log is a history of time and events which take place while a prisoner
is out of the prison as an inpatient at hospital.) The risk assessment was reviewed
and the restraints removed on 22 March because of the man’s serious condition. A
Officer recorded in the bedwatch log that a governor should attend the hospital to
undertake a risk assessment and update the paperwork. The entry on the risk
assessment shows that this was done.
41. The bedwatch log entry for 21 March shows that, on at least two occasions, nursing
staff asked the man if he wished his next of kin to be contacted. He said he did not.
The man’s condition continued to deteriorate and he was aware that he was dying.
He accepted morphine and nebulisers but found the oxygen mask too difficult to
tolerate despite repeated encouragement by nursing staff that it would help.
42. The duty governor visited the hospital on 22 March after escort staff told the prison
that the man had a very short time left to live. He arranged for the chaplain, to visit
and he did so later that day.
23 March 2010
43. In his statement an officer and member of the Care Team15, said that the duty
governor telephoned him at 7.15pm and asked him if he was willing to be ready in
his role as staff care team member to help staff if the man died.
44. The duty governor log for deaths in custody recorded by the duty governor showed
he visited the hospital at 8.00pm. Nursing staff told him that the man was dying. A
statement made by one of the escort officers, said that when the duty governor
arrived at the hospital, he checked that the officers felt able to deal with the man’s
death if it happened while they were on duty. The officer and the other escort
officer, said that the duty governor talked them through the procedures to be
followed when the man died.
14
adefibrillator is a machine that gives an electric shock of preset voltage to the heart through the chest wall in an attempt to
restore the normal rhythm.
15
The Care Team is made up of members of prison staff who are able to deal with concerns and look after staff’s emotional well
being following a difficult or distressing event in the prison.
11
24 March 2010
45. The man continued to deteriorate and he died on 24 March at 5.15am. One of the
escort officers said he received a telephone call at 5.17am to confirm this. He then
went to the hospital to support the escort officers, arriving at 6.05am.
46. An entry in the duty governor’s log says that at 6.55 am, the duty governor returned
to the prison and spoke to the Governor . Details of the man’s next of kin were held
in the Governor’s safe. This revealed that the man’s next of kin was his daughter
who lived in Liverpool, a considerable distance from the prison. The duty governor
telephoned HMP Liverpool and spoke to the deputy governor. (The log suggested
that Liverpool had been forewarned of the situation the day before.) Liverpool
arranged for two family liaison officers, to visit the man’s daughter later that morning
to break the news.
47. A hot debrief was held at 8.30am led by the duty governor, with the officer from the
care team in attendance. (A hot debrief is a meeting for staff to discuss emotive
issues and any lessons learned following serious events such as deaths in custody.)
Prisoners who knew the man well were told the news personally by duty governor
and the chaplain. The support and listener scheme16 was offered.
48. The man’s daughter was told of his death at around 11.30am. She told the family
liaison officers that she had known her father was ill and his death was expected.
She said she was not close to him and asked that his prison property and money be
given to charity. The prison asked that she review this as they had found evidence
that the man had owned a property and she might wish to deal with this. She
agreed to do so.
49. A prison chaplain, and a senior officer and family liaison officer, visited the man’s
daughter and offered her his prison property the day after his death. The prison paid
for his funeral.
16 Listeners are prisoners vetted and trained by the Samaritans to provide confidential emotional support to fellow
prisoners in distress.
12
ISSUES
Clinical care
50. The clinical review was undertaken by a panel led by a doctor from NHS Hampshire.
They reviewed the man’s medical records as well as records from the Royal
Hampshire County Hospital and South Central Ambulance Service. The
investigation has also benefited from a Root Cause Analysis Investigation Report17
conducted by a Clinical Manager which makes a number of recommendations on
clinical matters. A third report was submitted to my office from a colleague of the
clinical reviewer who is an Associate Medical Director of Patient Safety.
51. The panel identified a number of areas of concern. They judged that the man clearly
had severe lung disease with a significant reduction in his life expectancy. This
would have been evident when he arrived at the prison and gave his medical history
to nursing staff. The panel considered his care at Winchester was reactive, rather
than the proactive care expected in the best NHS general practice. The man was
not given flu injections, COPD monitoring, pre-emptive medical or specialist nurse
reviews. He was not referred to a local specialist and information was not sought
from his previous consultant doctor. It would have been appropriate to have done
this and the lack of disease management is a concern.
52. The panel also commented that on 30 December, the man’s inhaler ran out and he
could not take medication in a nebuliser as it had not been prescribed. He was
found to have a chest infection. While the lack of inhalers would not have prevented
the problem, their absence increased his cough and other symptoms. The panel
acknowledged difficulties in supplying medication to prisoners on the wings. The
man would have found attending a “hatch” window difficult because of his poor
mobility and there is a reliance on the prisoner to take responsibility for ordering
medication in good time. The panel found that the 72 hours for replacement
medication compares well with the community general practice given security and
supply issues.
53. The man was discharged from the hospital and went to a residential wing because
there were no beds available in the healthcare unit. The review panel judged that
this could have been avoided with prior planning between the prison and the
hospital. No formal discharge arrangements were made and communication
between the hospital and prison healthcare staff appears to be poor. In her review,
the colleague of the clinical reviewer has acknowledged that:
“We do realise, however, that there may be some educational work to be done
around discharge back to prison care and recognising that this is not the same as
discharge home.”
17
ARoot Cause Analysis is an analytic tool used to review critical incidents. It includes the identification of root and contributory
factors, identification of risk reduction strategies and development of action plans.
13
The actions of the hospital do not fall within the remit of this office, but it is clear that
prison staff could be more proactive about seeking and following through information
about the management of prisoners admitted to hospital.
The Primary Care Trust, the Head of Healthcare and the Governor should
establish a joint protocol regarding the admission and discharge of prisoners
from outside hospitals. Timely and accurate information should be obtained
and provided to both discipline and prison healthcare teams by nominated
staff. Also, healthcare staff should ensure that they receive appropriate
discharge plans, with an action plan for any ongoing care by the prison. In the
event that these are not provided by the hospital, the healthcare department
should actively request this.
54. Record keeping at Winchester falls short of the standards set by the Nursing and
Midwifery Council. Entries are dated but not timed and are often without any key
clinical observations or findings. In addition, the professional status of the member
of staff making the entry is not always clear. The panel acknowledged that a prison
using a computer system meant for a general practice setting causes difficulties as
the coding arrangements are not always appropriate. The panel said that “record
keeping is a consistent weakness found in other Death in Custody reviews at HMP
Winchester”. The review also described inconsistent use of the computer system,
citing a number of instances in which incorrect codes had been entered, leading to
inaccurate information being recorded. In conference with the Governor, the clinical
reviewer and the investigator were told that a new computer system is due to be
installed but a date had not been agreed.
The Head of Healthcare should remind healthcare staff of the necessity of
accurate and timely recording in accordance with standards set by the
Nursing and Midwifery Council in Principles of Good Record Keeping.
55. The reluctance of ambulance staff to take the man to hospital is a concern and is
raised by both the panel in their review and the Clinical Manager in her Root Cause
Analysis Investigation Report. She points out that a more timely removal might have
reduced the man’s discomfort and prevented further deterioration of his condition.
This incident has highlighted a possible training issue for paramedics responding to
emergency calls at the prison as they might be unaware of the structure and
management of a prison healthcare department. This is outside the remit of my
investigation. However, the failure of healthcare staff to tell the paramedics that the
man had undergone a tracheotomy previously may have given the paramedics the
impression that the man had simply run out of medication and was not as seriously
ill as evident. The investigator and the clinical reviewer discussed this issue with the
Governor. He has agreed that it may be appropriate for the ambulance service to
consider visiting the prison healthcare department as part of their training.
The Governor and Head of Healthcare should ensure that healthcare staff
provide all relevant clinical history to staff in the ambulance service if a
14
prisoner has to be taken to hospital as an emergency. This will prevent delay
in treating acutely ill prisoners. The Governor should also contribute, as
required to the review of the protocol between the ambulance service and the
Primary Care Trust.
56. The clinical review panel have taken action on a number of issues with the Primary
Care Trust and other stakeholders following their review of the man’s clinical care.
These include reviewing the provision for specialist healthcare for prisoners with
chronic long term conditions and improving communication between members of the
prison healthcare team. The South Central Ambulance are reviewing the protocol
for ambulance staff and I hope that the recommendation above enables the prison to
be actively involved.
Root Cause Analysis Investigation Report
57. The author has identified lessons learned from the man’s death and has made a
number of recommendations in her report which also support the findings of the
clinical review panel. I am pleased to endorse her recommendations where they fall
within the remit of my office. Other recommendations made by her are outside my
remit, but can only improve practice. Notably, the recruitment and training of nursing
staff in the management of long term conditions is being addressed and funding is
available for two nurses in 2010. Also, meetings giving opportunities for shared
learning are to be implemented.
58. During their visit, the investigator and the clinical reviewer noted the lack of
communication between the healthcare staff and prison doctor. The clinical review
found that despite being in the healthcare centre when he first arrived, the man was
not assessed by a doctor until ten days after his arrival. Thereafter, he was not
examined by a doctor unless nurses made an appointment or specific request in
spite of his severe, ongoing medical condition. The doctors have little involvement
in the day to day running of the healthcare inpatient centre despite the doctors’ office
being located down the corridor from this facility. The clinical manager has
recommended joint assessments and care planning between the prison and
healthcare staff for prisoners resident in the healthcare unit, as well as weekly
reviews between healthcare staff including prison doctors. While not relevant to the
man’s death, if implemented, the clinical manager’s recommendations are
necessary to improve practice and communication within healthcare and the prison.
59. The clinical review panel and the clinical manager have identified a need for greater
links with a respiratory specialist nurse in order to increase the expertise in the
healthcare team in managing prisoners with medical conditions similar to those of
the man. The review found that Solent Healthcare, who provide healthcare services
for the prison, are reviewing the provision of specialist nurse care to prisoners with
long term condition such as COPD. Given the high number of prisoners at
Winchester with respiratory conditions, I am pleased to endorse the clinical
manager’s recommendation.
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The Head of Healthcare should engage the services of a respiratory specialist
nurse in order to provide increased expertise and support nursing staff in
managing prisoners with chronic respiratory conditions.
Use of restraints
60. The man transferred to hospital under restraint. While his death was not expected, it
was evident that he was very unwell. A risk assessment was carried out and it was
decided that he should be restrained by handcuffs, with a chain attached to an
officer. When the man deteriorated on 21 March, a hospital doctor asked for the
restraints to be removed in case electrical equipment needed to be applied. When
the man improved, the doctor said that the restraints could then be reapplied. A
decision was taken later that day for the restraints to be permanently removed when
his condition deteriorated further. I am pleased that the prison was responsive in
conducting a review and showed compassion in removing the restraints.
Advice on smoking
61. The clinical manager identified smoking as a contributory factor to the man’s
condition. The clinical reviewer considered that stopping smoking would have been
the most significant way of reducing his risk of death and he found that staff had
given the man advice on this. I acknowledge that he chose not to give up, but there
is no evidence that the man was offered alternatives to smoking such as nicotine
replacement therapy or the opportunity to attend relevant clinics at the prison. I
make no formal recommendation on this point. However, I encourage the Head of
Healthcare to take steps to ensure that healthcare staff are aware of the role of the
smoking cessation lead nurse and the referral process for clinics. Also, that
prisoners who suffer from illness where smoking is an aggravating feature are
actively targeted and staff record referrals in the clinical record.
Debrief on 1 April
62. Minutes of a death in custody debrief held on 1 April show that a number of issues
arose. Prison staff felt that when they have advance knowledge of a possible death
in custody, it would be helpful to have a multi-agency meeting with healthcare,
chaplaincy, family liaison officer and police liaison officer so that an action plan can
be created. This would form part of the bedwatch folder of information for staff. This
would be a proactive response and good practice. I therefore make the following
recommendation.
When the expected or imminent death of a prisoner is notified to the prison,
the Head of Healthcare should inform the Governor at the earliest opportunity.
This will enable the Governor to convene a multi-agency meeting with all
relevant staff with the aim of creating an action plan for staff to manage
events.
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63. Paramedics initially refused to take the man to hospital on 30 December. Through
the insistence of a nurse, the man was taken to the healthcare centre. A doctor then
confirmed the nurse’s assessment that the man’s condition was unstable and he
needed urgent treatment. The nurse is to be commended for her tenacity and
actions which enabled an urgent and appropriate transfer to hospital.
The Governor should write to the nurse regarding her challenge to the initial
refusal to take the man to hospital. I commend her sound professional
judgement and insistence that the man be taken to hospital urgently by the
paramedics.
64. The duty governor during the last few days of the man’s life, assumed the
responsibility for telling the family that the man was terminally ill. The man’s next of
kin live a great distance from the prison. The duty governor arranged for family
liaison officers from nearby HMP Liverpool to go to the man’s daughter’s home and
personally deliver the news of his death. Staff from Winchester visited the family the
following day to return his property. This was sensitive to the family.
65. The duty governor also put in place support for the escort staff from the care team
once it became clear that the man’s death was imminent. This demonstrated good
practice, consideration and support for staff, as well as an understanding of the
difficulties staff would potentially face.
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CONCLUSION
66. The man had served over five months of a 16 month prison sentence when he died
of broncho pneumonia and end stage COPD on 24 March 2010. He had been
diagnosed with a chronic lung disease a number of years before and gave a history
of ill health when he arrived at the prison. Despite his incapacity and the immobility
arising from his condition, his death was sudden and unexpected.
67. The clinical review panel were critical of aspects of the man’s care and I have made
recommendations on relevant issues. However, the review concludes that the
failings identified did not materially alter the outcome for the man.
68. The nurse is to be commended for taking a firm and positive stance in ensuring the
man was sent to hospital. I am also pleased to note the proactive and sensitive
arrangements by the duty governor in respect of liaising with the man’s next of kin
and early provision of support for the prison staff who escorted him in his last hours.
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RECOMMENDATIONS AND COMMENDATION
1. The Primary Care Trust, the Head of Healthcare and the Governor should establish
a joint protocol regarding the admission and discharge of prisoners from outside
hospitals. Timely and accurate information should be obtained and provided to both
discipline and prison healthcare teams by a nominated staff. Also, healthcare staff
should ensure that they receive appropriate discharge plans, with an action plan for
any ongoing care by the prison. In the event that these are not provided by the
hospital, the healthcare department should actively request this.
Accepted. Head of Health Care to liaise with Clinical Services Manager for
Solent Healthcare and establish a joint protocol for outside hospital admission
/ discharge.
2. The Head of Healthcare should remind healthcare staff of the necessity of accurate
and timely recording in accordance with standards set down by the Nursing and
Midwifery Council in Principles of Good Record Keeping.
Accepted. Head of Health care to brief all nursing staff of the importance of
accurate and timely recording on Vision system. This to be added as an SPDR
objective and management checks to ensure compliance.
3. The Governor and Head of Healthcare should ensure that healthcare staff provide
all relevant clinical history to staff in the ambulance service if a prisoner has to be
taken to hospital as an emergency. This will prevent delay in treating acutely ill
prisoners. The Governor should also contribute, as required to the review of the
protocol between the ambulance service and the Primary Care Trust.
Accepted. Head of Health Care to liaise with Solent Heath Care Head of
Clinical Services and arrange for ‘quick glance’ medical records to be held in
HCC for those prisoners who are deemed ‘at risk’ of hospital escorts due to ill
health or medical complications. The list of prisoner’s names that require this
measure should be checked and updated daily.
4. The Head of Healthcare should engage the services of a respiratory specialist nurse
in order to provide increased expertise and support nursing staff in managing
prisoners with chronic respiratory conditions.
Accepted. Some nurses have undergone respiratory training already, and
others are pencilled in for future training. Head of Health Care to provide a list
of those trained in managing chronic respiratory conditions.
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5. When the expected or imminent death of a prisoner is notified to the prison, the
Head of Healthcare should inform the Governor at the earliest opportunity. This will
enable the Governor to convene a multi-agency meeting with all relevant staff with
the aim of creating an action plan for staff to manage events.
Accepted. Head of Health Care to put in place procedures that will inform the
Governor immediately of any expected / imminent death of a prisoner
.Governor to appoint an Inquest Liaison Officer and put in place a protocol is
to guide the ILO through the process.
Commendation
The Governor should write to the nurse regarding her challenge to the initial refusal to
take the man to hospital. I commend her professional judgement and insistence that
the man be taken to hospital urgently by the paramedics.
The nurse has already received her Commendation from the Governor.
The family’s response
The family have thanked my office for the report. They do not wish to add anything
other than to ask that their thanks be passed to the nurse who insisted that the man was
taken to hospital. The Investigator will write separately to the governor to ask if he
could pass the family’s thanks to the nurse on their behalf. The family are pleased to
see that, since the man’s death, ‘steps have been taken’ to improve the care and
conditions for other prisoners with chronic breathing conditions. The family have said
that they are happy for their comments to be included in the final report.
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