Individual at Winchester

Investigation into the circumstances surrounding the death of
a man at HMP Winchester on 27 October 2004
Report by the Prisons and Probation Ombudsman for England and Wales
June 2005
This is the report of an investigation into the circumstances of the death of a
man at HM Prison Winchester on 27 October 2004. He died from a heart
attack almost certainly brought on from sudden exercise.
I extend my sincere condolences to the man’s family and friends for their loss.
I would like to thank the Governor at Winchester Prison at the time of our
investigation. I would also like to thank the members of her staff who assisted
us, in particular the then head of healthcare.
This was the first time the man had been in prison; it was as a result of his first
offence. He was a quiet man who did not like to make a fuss, and was looking
forward to his release.
The man's heart attack could not have been predicted. However, the
symptoms he presented were not correctly identified. Whilst it is impossible to
know whether his death could have been prevented, I believe he should have
been transferred to a hospital outside of prison. This would have given him
the greatest chance of survival. I have taken advice from the clinical reviewer.
Having done so, I have concluded that the Prison Service should consider
whether the circumstances are such that disciplinary action be taken in
respect of the action of two members of staff, or whether further training is
required.
I have also criticised aspects of the prison's family liaison. The man's widow
has not been treated respectfully.
I make 10 recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2005
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Contents
Summary 4
Investigation Process 5
Background 6
The events leading up to the man's death 7
Findings and Conclusions 10
List of recommendations 14
3
Summary
The man was sentenced to four months in prison on 8 October 2004. This
was as a result of his first offence and was his first time in prison. He was a
quiet man, who wanted his sentence to pass quickly. It was said he did not
like to make a fuss.
The man shared a cell with his co-defendant. He worked in workshops and
spent a lot of time in the Chapel.
On 27 October, the man visited the gym. He had not exercised properly for
15 years. After a while, the man started feeling unwell. He showered and
returned to the wing. Here, he experienced chest pain, and tingling in his left
hand. The man's cellmate and a wing officer were concerned and called
healthcare; convinced he was having a heart attack. The Healthcare Officer
(HCO) did not feel that the man had all the symptoms of a heart attack, and
felt that the man might have strained a muscle.
A second HCO visited the man a short while later. His pulse and blood
pressure had increased. The man was taken to the healthcare centre for
observation at about 8.30pm. However, the man was not checked on until
approximately 9.55pm, at which point he had lost consciousness. Despite
resuscitation efforts, he was pronounced dead at 10.15pm.
I conclude that several errors of judgement were made by healthcare staff.
The first HCO did not recognise that the man was suffering a heart attack.
The second HCO did not consult a doctor or paramedic when it was found
that the man's blood pressure and pulse had risen significantly in a short
period of time. Two nurses did not carry out their own assessments of the
man and accepted the HCO's diagnosis. Furthermore, the man was not
transferred to outside hospital even though regular checks could not be made
on his condition.
Aspects of family liaison by the prison have also caused me concern. The
man's wife has never received a letter of condolence and, at the time of
writing, has not received the man's possessions.
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Investigation process
My investigator, Ms Thea Walton, visited Winchester accompanied by an
Independent Clinical Reviewer employed by my office, Ms Tracey Campbell.
They met with the then head of healthcare. They were able to visit the cell
where the man had died and the wing where he had lived. They also visited
the gym and spoke to gym staff.
Ms Walton and Ms Campbell issued notices to staff and prisoners informing
them of the investigation and inviting comment.
Ms Walton offered to meet with representatives from the Independent
Monitoring Board (IMB) and the Prison Officers' Association (POA).
Access to the man’s prison records, including his medical records, were
readily provided to the investigation. The Coroner also provided Ms Walton
with the post mortem report and statements from the police.
Following the initial visit, Ms Campbell interviewed two nurses and two
healthcare officers. She took notes of the interviews and sent them to the
relevant staff to sign and return.
Ms Walton spoke with the man’s cellmate at Winchester. Ms Walton also
returned to Winchester with another investigator, Mr David Cameron, in order
to speak further to staff and formally interview one of the officers.
One of my family liaison officers, Ms Lucy Phelan, contacted the man’s wife.
Ms Phelan and Ms Walton went to visit the man’s wife to discuss the
investigation. The man’s wife was concerned about the level of healthcare her
husband had received. Ms Phelan kept her updated on the investigation and
report.
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Background
The man was born on 1 September 1958 in Maltby, where he was raised by his
parents with his sister and stepbrother. The man had two children, and had been
married to his current wife for seven years.
The man had 28 years experience working with heavy goods vehicles. He worked
hard and long hours. His pre sentence report refers to references from employers
being exceptional, commenting on his loyalty and hard work. The man committed his
first and only offence in 2002. He volunteered information to the police and was
remorseful for his involvement in the crime. During the two years before the man
was sentenced, he found it progressively stressful. He suffered anxiety attacks and
was depressed. His doctor had prescribed antidepressants.
The pre sentence report that was prepared for him notes: “(The man) seems
genuinely fearful of a custodial sentence...I have grave concerns that he would not
recover from such a sentence. His health has clearly declined since the offence and
I doubt that mentally he could cope in a custodial setting”. The report goes on to
recommend a Community Punishment and Rehabilitation Order.
The man was sentenced to four months imprisonment and taken to Winchester
prison on 8 October 2004.
6
The events leading up to the man's death
The man arrived at Winchester prison on 8 October. He underwent an initial
healthcare reception screening conducted by a nurse where it was identified
that he had suffered depression and was on antidepressants. The man did
not disclose that he had recently suffered an anxiety attack for which he had
had to attend hospital. The following day, the man saw the medical officer. It
was noted that his general heath was good, and he was described as stout
and strong. The doctor prescribed the man his antidepressants, and some
other medication for a continuing minor medical problem. The man later
decided he wanted to try not taking the antidepressants, and the medical
officer agreed.
Over the next two weeks, the man was described by staff as quiet. He spent
a lot of time at the Chapel and was employed in a workshop with his cellmate,
who was also his co defendant and whom he had known through work for a
couple of years. Over this period of time, staff were working towards
transferring the man to a prison closer to his home, and the possibility of his
being released on a Home Detention Curfew.
On 27 October, the man had gone to work with his cellmate. That evening
they went to the gym at about 6.15pm. The man had not been to the gym for
about 15 years. The cellmate reported that the man had been working out for
about 20 minutes when he started to feel unwell. The man stopped exercising
and went to have a shower. After the class had finished they walked back to
the wing together. The cellmate said that the man told him he was in pain and
felt dizzy, and asked him to stay with him to “keep an eye on him” until they
got back to the wing.
When they returned to their cell, the man was feeling cold so the cellmate put
some blankets over him. The cellmate reported that the man was obviously in
pain. He was groaning and bending over, and is reported to have said, “I
think I am having a heart attack or stroke or something", so the cellmate
alerted an officer.
The officer who attended reported that she remembered the evening clearly.
They had been short staffed on the wing and had borrowed an officer from
another wing. It was approximately 6.45pm to 7pm when the prisoners who
had been at gym came back and she noticed that the man looked unwell.
Shortly after, the man’s cellmate approached her and asked her to come and
see the man. She went to his cell, where the man told her he had been to the
gym and was feeling very cold and tired. The officer asked the cellmate to
close the window and tried to make the man feel more comfortable. The man
told her that he had pains in his chest, arm and hand. The officer reported
that she was very concerned and thought the man was having a heart attack.
She left the cell and spoke to the senior officer on the wing, who radioed
healthcare for assistance, and she then returned to the man's cell. The
cellmate fetched a drink of water, and they tried to keep him comfortable and
calm. At this point, the officer noticed the man was having some involuntary
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face movement. She was worried as to what this might be, and went out to
the senior officer who reassured her that healthcare staff were on their way.
The first HCO arrived at the man's cell at about 7.15pm. The first HCO said
that the man was complaining of chest pain and tingling in his left hand. He
was not short of breath; he had good colour and complexion and was not cold
or clammy. The first HCO took his blood pressure and pulse. The man's
pulse was strong and regular at 66 beats per minute, and his blood pressure
was 117/86, which is not worryingly high.
The man told the first HCO that he had been performing bench presses in the
gym, and had not previously exercised in about 15 years. He had also been
feeling anxious about waiting for a transfer and it was his wife's birthday. He
reported that he had not been sleeping well. The man stood up, and walked
around the cell. When he did this, the pain worsened, so the first HCO asked
the man to stay resting. The first HCO decided that the pain was most likely
to be muscular or nerve related.
The man had requested pain relief so the first HCO went to the treatment
room to collect some Ibruprofen. Whilst there, he telephoned the nurse based
on reception to check his decision. She agreed that the first HCO had made
the correct decision.
In interview, the nurse based on reception said she had received the call from
the first HCO at a time when she was very busy. She recalled the first HCO
saying that the man was suffering from muscular pain having overdone it at
the gym, and had a bit of chest pain. She agreed she would review the man
later before the shift was over.
The prison officer was very concerned about the man and told the
investigation that she specifically asked the first HCO if he was sure that it
was not a heart attack. She said that the man was quite calm, but obviously
in a great deal of pain.
The man wanted to phone his wife, as it was her birthday. The officer said he
could use the office phone. This meant he could sit down. Whilst there, a
second HCO came to the wing to check how the man was feeling. It was
about 8.10pm when he arrived at the wing. The second HCO noted that the
man was not breathless, but he was still complaining of pain in his left arm.
The second HCO retook his observations. The man's pulse had risen to 100
beats per minute and his blood pressure had reached 150/100. The second
HCO decided that, due to this change in his observations, the man should be
admitted to the healthcare centre. The man was reluctant to go, but collected
some things from his cell and walked to healthcare unaided.
At about 8.30pm, the man and the second HCO arrived at the healthcare
centre. The second HCO said that he verbally handed over to the nurse
based in healthcare, and suggested hourly observations. The nurse based on
reception was also present and agreed on this course of action. However,
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she commented in her interview that it is difficult to conduct observations at
night because they do not hold keys, so it is up to the discretion of the nurses.
The nurse based in the healthcare centre said she received a verbal handover
before the other staff went off duty. Although she could not remember exactly
what was said, she recalled that the man's main problem was thought to be
anxiety and he had been brought over to the healthcare centre as a
precaution. The nurse based in the healthcare centre then wrote the care
plans for patients in healthcare. She had identified the problem as being
chest pain associated with raised blood pressure following a gym session.
The short-term goal was to exclude a cardiac cause, although it is not
documented how this would be achieved, and to eliminate chest pain.
Interventions were documented as giving medication as prescribed, give
analgesia, monitor vital signs as required, and refer to hospital as necessary.
The man was sharing a cell in the healthcare centre. In his police statement,
the man’s healthcare cellmate reports that the man came into his cell around
9pm. The man told him he had pains in his arm and he thought he had
overdone it in the gym. The man was unable to make his own bed so the
healthcare cellmate helped him, and they spoke for a short while. The
healthcare cellmate reported that after a while the man started to breathe
heavily. Thinking that he was trying to sleep, he stopped talking and started
reading his book.
The nurse based in the healthcare centre started her drug round between
9.30 and 9.45pm. She approached the cell the man was in at approximately
9.55pm to give the healthcare cellmate his medication. The nurse based in
the healthcare centre saw that the man's hands looked waxy and was
concerned. She asked the healthcare cellmate to shake the man's shoulders,
and when he did the man was lifeless. The healthcare cellmate then checked
for a pulse and could not feel one. The nurse based in the healthcare centre
called for the Night Orderly Officer. Once he had arrived, they entered the
cell.
The nurse based in the healthcare centre commenced CPR until the
paramedics arrived but to no avail. The man was pronounced dead at
10.15pm.
All contingency plans were followed. Officers broke the news to the man’s
cellmate the following morning. They were supportive and compassionate,
and the prison facilitated a move to a prison closer to his family.
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Findings and Conclusions
The man visited the gym on 27 October. He had not visited a gymnasium for about
15 years. He was inducted into the gym and signed a compact, part of which stated
that all injuries should be reported immediately to gym staff.
The man returned from the gym with chest pain following strenuous exercise, and
reported he had not exercised in 15 years. The officer who attended to the man
acted appropriately and compassionately when alerted to the man’s ill health.
The first HCO, who visited the man on the wing, appears to have confused the
signs and symptoms of a Myocardial Infarction (MI) with muscle strain and
possible nerve involvement. Although the man’s observations were recorded
as being within normal limits, the other signs, such as the increased pain on
exertion and decreased pain when resting, chest pain and tingling in left
fingers, should have alerted the first HCO to the potential cardiac involvement.
Ibuprofen was recorded in the IMR as administered; this was not documented
in the prescription chart.
The first HCO contacted the nurse based in reception. Without having seen
the man, she appeared to make the decision that he was not at risk.
The second HCO, who attended to the man did not seek assistance, despite
his recent history of chest pain, the increase in his pulse rate and blood
pressure, along with the ongoing complaints of pain in his left arm. Although
he admitted the man to healthcare for overnight observation, he did not
document how often the observations should be.
In medical emergencies, there is a term called the "golden hour". This refers
to the 60 minutes following the trauma, or pain when it is crucial a victim
receives medical treatment for any chance of survival. In a prison, the rules
governing the golden hour are just the same as anywhere else. A medical
team has 60 minutes to get a victim from incident site to the operating table.
In this case, the emergency situation was not identified.
I must make a judgement as to how reasonable the HCOs' actions were. To
this end, I must consider whether other HCOs would have acted the same
way, and whether the man received the same level of healthcare as he would
if he were not in prison. I am surprised that the advice of a doctor was not
sought when the first HCO, attended to the man, especially when confronted
by wing staff who were extremely concerned that the man was suffering from
a heart attack. Furthermore, I am surprised that an ambulance was not called
when the second HCO attended, and the man’s blood pressure and pulse
were substantially raised. The fact that neither HCO identified the potential
that the man was having a heart attack informed the decision making by the
nurses. Having taken advice from the independent clinical reviewer:
I recommend that the Prison Service consider whether the
circumstances are such that disciplinary action be taken in respect of
the actions of the two HCOs.
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I recommend that the Governor of Winchester reminds healthcare staff
that, when a pulse rate and blood pressure is significantly raised in a
patient with a very recent history of chest and left arm pain, the
emergency services should be called.
The second HCO stated that, on arriving in healthcare at 8.30pm with the
man, he gave the nurse based on the healthcare centre a verbal handover
and suggested hourly observations. The man does not appear as an entry in
the ‘Hand Over Observation' log.
The nurse based in the healthcare centre, having received a verbal handover
regarding the man at approximately 8.30pm in which hourly observations were
suggested, did not visit the cell until 9.55pm. She states that she went to the
cell to issue night time medication (this is the routine on healthcare). Prior to
starting the drug round, she completed a nursing care plan. The care plan
does not include basic observations of pulse and blood pressure. She had
identified the problem as being chest pain associated with raised blood
pressure, following a gym session. The short-term goal was to exclude
cardiac cause (it is not documented how she intended to do this), and
eliminate chest pain. Interventions were documented as: 1. Give meds as
prescribed (the only prescription on the man’s drug chart was Amitriptyline); 2.
Give analgesia PRN; 3. Monitor vital signs as required (no indication as to
how often this was required); 4. Refer to hospital as necessary. It is of great
concern that no observations were conducted in order to exclude a cardiac
cause.
The nurse based in the healthcare centre stated that the making of
observations is not practical at night as she is only on duty with an operational
support grade (OSG). The then head of healthcare, stated that if observations
were needed, an officer with keys would visit to facilitate this. The nurse
based in the healthcare centre did not seem aware of this, and I question the
practicality given staffing levels at night. The nurse based in the healthcare
centre certainly appeared to view her evening round to be for issuing
medication rather than performing observations. Given that proper
observation could not or was not given to the man, it is difficult to understand
why consideration was not given to the man being taken to a hospital outside
the prison.
Nursing observations require the nurse to have physical contact with the
patient, for example to measure the pulse. If these observations are needed,
either staffing levels need to be provided to facilitate such measures, or the
patient needs to be transferred to hospital. Where a clinical judgement is
made that observations are necessary, these must be facilitated.
The nurse based in the healthcare centre did not enter the cell until the Night
Orderly Officer arrived, despite having access to the emergency key pack.
Instructions to nurses are given not to open the cell at night without the Night
Orderly Officer present. She stated during the telephone interview that she
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did not think it was worth risking entering the cell, as it was obvious that the
man was not alive.
Both nurses involved appear to have taken the HCOs' word for what was
wrong with the man, without investigating thoroughly themselves. It may be
that there is a de facto reliance on healthcare officers to make clinical
judgements. The independent clinical reviewer concluded that the actions
and lack of action by the four members of staff involved in the care of the man
during the episode of chest pain had a direct impact on his chances of
survival. I therefore make the following recommendations, drawing from the
independent clinical review.
I recommend that the healthcare manager, in conjunction with the local
Primary Care Trust, should ensure that all members of healthcare staff
are aware of their different roles and responsibilities to ensure
accountability and high levels of care.
I recommend that nurses should be reminded to protect their
professional registration and remember their responsibility for the duty
of care of patients, by satisfying themselves that care recommended by
HCOs is appropriate and any diagnosis accurate.
I recommend that HCOs and nurses should take into account all
observations and information the patient is giving and err on the side of
caution. A doctor should be called to attend patients complaining of
chest pain, particularly when there is left arm pain as well, even in the
absence of abnormal pulse and BP observations.
I recommend that the frequency of required observations should be
clearly documented in the IMR and nursing care plan, to facilitate
continuity of suitable care.
I recommend that handovers should then be documented in the IMR or
nursing notes and in the Hand Over Observation log. The staff giving
and receiving hand over should sign and print their names on the log.
I recommend that the nursing care plans should be completed
accurately, carefully and thoroughly. Basic observations should be
taken and documented on all patients admitted to healthcare.
The prison's contact with the man’s wife
The man’s wife was contacted by the police to inform her of her husband's
death. They gave her a phone number to call for more information. The
man’s wife phoned the number at the prison. Nobody knew anything about
the death. Finally she was told that he had died in the hospital and was given
the number. When she phoned the hospital, the sister she spoke to said they
knew nothing about her husband. The man’s wife was finally told that he had
died at the prison. The man’s wife set off for Winchester not knowing what
had happened.
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Where the next of kin lives far from a particular prison, it is best practice if a
Governor from a jail closer to the next of kin's home is approached and asked
to break the news in person.
The man’s cell was still sealed at the time of the man’s wife's visit and she
was told that staff would notify her when she would be able to visit. She has
heard nothing further. The man’s wife did not receive a letter of condolence
from the Governor and, at the time of writing this report, she still had not
received her husband’s possessions. This is wholly unacceptable.
I recommend that the man's possessions are delivered to his wife as a
matter of urgency.
I recommend that Winchester's contingency plans are amended such
that the appointed prison family liaison officer ensures that a
condolence letter is sent to the bereaved family from the Governor at the
earliest opportunity, and possessions are gathered and returned to
family members in a timely and sensitive manner.
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List of Recommendations
I recommend that the Prison Service consider whether the circumstances are
such that disciplinary action be taken in respect of the actions of the two
HCOs.
The Prison Service considered this recommendation and felt this was a
training issue for the nurses involved, with advice and guidance.
I recommend that the Governor of Winchester reminds healthcare staff that,
when a pulse rate and blood pressure is significantly raised in a patient with a
very recent history of chest and left arm pain, the emergency services should
be called.
I recommend that the healthcare manager, in conjunction with the local
Primary Care Trust, should ensure that all members of healthcare staff are
aware of their different roles and responsibilities to ensure accountability and
high levels of care.
I recommend that nurses should be reminded to protect their professional
registration and remember their responsibility for the duty of care of patients,
by satisfying themselves that care recommended by HCOs is appropriate and
any diagnosis accurate.
I recommend that HCOs and nurses should take into account all observations
and information the patient is giving and err on the side of caution. A doctor
should be called to attend patients complaining of chest pain, particularly
when there is left arm pain as well, even in the absence of abnormal pulse
and BP observations.
I recommend that the frequency of required observations should be clearly
documented in the IMR and nursing care plan, to facilitate continuity of
suitable care.
I recommend that handovers should then be documented in the IMR or
nursing notes and in the Hand Over Observation log. The staff giving and
receiving hand over should sign and print their names on the log.
I recommend that the nursing care plans should be completed accurately,
carefully and thoroughly. Basic observations should be taken and
documented on all patients admitted to healthcare.
I recommend that the man's possessions are delivered to the man’s wife as a
matter of urgency.
The Prison Service have returned the man’s possessions to the man’s wife
I recommend that Winchester's contingency plans are amended such that the
appointed prison family liaison officer ensures that a condolence letter is sent
to the bereaved family from the Governor at the earliest opportunity, and
14
possessions are gathered and returned to family members in a timely and
sensitive manner.
The Prison Service has drawn up an action plan to address the issues
highlighted in the report.
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