Individual at Winchester

Investigation into the circumstances surrounding the death
of a prisoner at HMP Winchester
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2006
This is the report of an investigation into the circumstances of the death of a man at
HMP Winchester. Following post mortem examination, his cause of death was
recorded as sudden unexpected death in epilepsy.
I extend my sincere condolences to those who knew this man.
He had spent the vast majority of his life in care and in psychiatric units, and was
remanded to HMP Winchester, following an alleged assault on a member of staff at
the residential home where he lived. It was clear to the judge at the time that prison
was not the most appropriate location for the man. No reader of this report will doubt
otherwise.
I would like to thank the Governor of Winchester at the time of our investigation. I am
also grateful to those members of his staff who assisted us, particularly the duty
governor on the night of the prisoner’s death, who acted as a liaison officer for the
investigation team. At the time of death, this man was not in contact with any
members of his family. I have found the prison’s efforts to locate his family and their
subsequent contact with his brother to have been both sensitive and respectful.
I am grateful to Mid Hants Primary Care Trust for their clinical review of this man’s
medical care whist he was at Winchester, the findings of which have informed this
report.
I make seven recommendations and draw one other matter to the Governor’s
attention.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2006
2
Contents
Summary 5
The investigation process 7
The man who died 8
HMP Winchester 9
The events leading up to the man’s death 10
The day the man died 16
Discussion of the issues 20
Findings and conclusions 25
List of recommendations 28
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Summary
1. The man was 34 years old when he arrived at Winchester. He had been
remanded into custody at Southampton Crown Court, following an alleged
assault on a member of staff at the residential home where he lived. He had
suffered from a form of epilepsy and mild to moderate learning difficulties from
an early age. He had spent time in custody some 15 years earlier when he
had been charged with Grievous Bodily Harm.
2. At the time of remanding him into custody, the judge hearing the case
expressed his reservations in doing so. He asked the prosecuting barrister to
contact Winchester to explain his vulnerabilities and to ensure that efforts
were made to seek alternative accommodation for him. The barrister duly sent
a fax, asking the duty governor to contact him. The fax was received by the
prison and sent to the Healthcare Centre. The duty governor at the time has
no recollection of seeing it.
3. Shortly after his arrival in Winchester, the man was located in a single cell in
the Healthcare Centre. A first reception health screen was eventually carried
out for him four days after his arrival at the prison. It was only following his
reception health screen that he was prescribed anti-psychotic tranquillisers
and medication to control his epilepsy.
4. Throughout the months that followed, considerable efforts were made by the
prison Community Mental Health Team (CMHT) to find alternative
accommodation for the man. Indeed, the CMHT had managed to locate a
place for him, and were in the process of making arrangements for his
transfer, when he died. He therefore remained in a single cell in the
Healthcare Centre until his death.
5. The man had difficulties comprehending the reasons for his imprisonment and
was, at times, a challenging person for staff to care for. He spent much of his
time on “three man unlock” (meaning that three officers needed to be present
if his door was opened) whilst in the prison and so did not often engage in the
normal regime in the Healthcare Centre. He suffered several epileptic fits
during his time at Winchester and would not consistently take his medication.
6. At approximately 05.40am on the day of his death, the man was seen by the
Night Duty Nurse to be lying on a strange position. She and the Night Duty
Officer Support Grade (OSG) were unable to rouse him and the nurse
suspected that he had died in his sleep. Neither the OSG nor the nurse held
keys to open the cell door and, given that the man was on “three man unlock”,
the nurse requested that the Night Orderly Officer send three officers to unlock
the cell. The three officers arrived in the Healthcare Centre approximately six
minutes later and entered the cell along with the nurse. The man had no
pulse and was cold to the touch, and the nurse believed he was dead. The
officers and the nurse left the cell and the door was locked and sealed.
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7. The nurse had some difficulty in getting a doctor to attend to certify the man’s
death and this was finally done at 08.40am by a prison doctor.
8. The man was not in contact with any members of his family. His brother, who
had never met him, was located by Buckinghamshire Constabulary and was
told of his death and how to contact the prison.
9. A post mortem report into the man’s death recorded the cause as sudden
unexpected death in epilepsy and the inquest into his death concluded that he
died of natural causes. The clinical review of his care has been conducted by
Mid Hants Primary Care Trust, the findings of which are included in this report.
I make seven recommendations.
5
Investigation process
10. One of my investigators visited Winchester and met with a member of the
Independent Monitoring Board and a representative of the Prison Officers’
Association (POA). She also visited the Healthcare Centre, where the man
had spent his time since he arrived at Winchester.
11. The investigator issued notices to staff and prisoners informing them of the
investigation and inviting comment.
12. Access to the man’s prison records, including his medical records, was
provided to my investigator. A copy of the post mortem report into his death
was provided by HM Coroner.
13. Formal and informal interviews were conducted with several officers and
members of healthcare staff.
14. One of my family liaison officers wrote to the man’s brother to explain the
purpose of the Ombudsman's investigation and to discuss any questions the
family might have had. His brother did raise any concerns with my Family
Liaison Officer and has not expressed any wish to meet with either her or the
investigator.
15. The Prison Service has been given an opportunity to comment on a draft of
this report and, where appropriate, their responses to recommendations have
been included.
6
The man who died
16. The man was born in 1970 and was placed into care by his natural mother when he
was a baby. She subsequently returned to her birthplace in the Caribbean, and had
no further contact with her son. He had an aunt and uncle with whom he was no
longer in touch. The man also had a brother whom, sadly, he had never met. When
the man was eleven, he developed herpetic meningo encephalitis (an infection of the
brain), an illness which left him with a form of epilepsy and mild to moderate learning
difficulties. He had difficulties with speech and comprehension and attended special
schools from an early age.
17. The man was described by those who knew him as a likeable, but
unpredictable man. His relationship with staff at the prison was variable. He
had formed positive relationships with some members of staff, but his
condition caused his mood to fluctuate. He would occasionally react
aggressively to certain members of staff or if he felt he was being treated in a
negative way.
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HMP Winchester
18. Winchester is a category B local prison, with a category C resettlement unit, West
Hill. The prison was last inspected by HM Chief Inspector of Prisons in November
2004, when a short unannounced inspection was carried out. Acknowledging that
Winchester was, like many other local prisons, around 50 per cent overcrowded, the
Chief Inspector found Winchester to be a prison with a number of improvements still
to make. However, the Chief Inspector also commented upon the vision and
commitment of managers and many staff and welcomed improvements in certain
areas including healthcare.
19. The man spent all of his time located in the Healthcare Centre whilst he was at
Winchester. The prison has a 22 bed patient healthcare facility and medical
cover 24 hours a day. From Monday to Saturday, two locum GPs work in the
prison, covering approximately half of the shifts each. There is also a senior
healthcare officer, healthcare officers and a mixture of general nurses and
psychiatric nurses. During the night, the prison’s healthcare cover is provided
by a nurse who is based in the Healthcare Centre. In addition to the nurse,
there is always an Officer Support Grade (OSG) on duty overnight in the
Healthcare Centre. An out of hours service is provided by Primecare Forensic
(who provide advice and call out doctors from 5.00pm until 9.00am, Sundays
and bank holidays).
20. Two other prisoners have died at Winchester since April 2004. Both of those
deaths were due to natural causes. The investigations into the deaths
highlighted issues of concern regarding the delivery of healthcare at
Winchester.
8
The events leading up to the man’s death
9 June 2005
21. The man appeared at Southampton Crown Court charged with two counts of
assault on members of staff at the care home where he lived. His defence
barrister presented the court with a psychiatric report which suggested that the
man was unfit to plead and was not suitable to remain long term in a voluntary
care home setting. The prosecution team requested that the case be
adjourned until 4 August, in order for them to obtain their own psychiatric
assessment. The man was remanded into the custody of Winchester prison
until this date.
22. On the morning of 9 June the barrister for the prosecution team sent a fax to
the duty governor at Winchester to which he attached a copy of the man’s
psychiatric report. The fax outlined the details of his case and highlighted
some concerns expressed by the judge, who had remanded him into prison
custody. The investigation team spoke to the barrister for the prosecution,
who reiterated the contents of the fax and explained what he could remember
of the man’s court appearance. The man had appeared at court accompanied
by staff from the care home where he lived. The staff informed the judge that,
due to the man’s assaults on staff at the care home, he could no longer be
offered a bed there. The judge had agreed that a second psychiatric report
was needed and that the most likely (and desirable) outcome was for the man
to be found a bed in a medium secure mental health unit. The judge
remanded the man to custody, but asked the barrister for the prosecution to
contact the prison to urge them to do all that was possible to transfer the man
to a more suitable setting than prison. The barrister’s fax highlighted that the
man’s psychiatric assessment stated that his mental health was likely to be
adversely affected by the stress of being in prison. This fax went on to provide
his contact details and to ask for the duty governor to contact him. The
barrister explained to my investigator that he had never been contacted by any
member of staff from the prison.
23. The duty governor on 9 June told my investigator he had no recollection of
receiving the prosecution barrister’s fax. The fax found its way to the
Healthcare Centre, but it is not clear how or when this happened. It appears
that the first person to read the fax was a Senior Officer in the Healthcare
Centre on the morning of 13 June.
24. The man’s Prisoner Escort Record (PER) indicated that he arrived at
Winchester at 13.00 on 9 June and his name appears on the Reception List at
13.46. Boxes on the PER form were ticked to indicate he had a medical
condition, a mental condition, could be violent and was vulnerable. A note
was also made in the section headed “further information about risk” which
indicated that the man had epilepsy.
9
25. Ordinarily, when prisoners arrive in reception at Winchester their warrant is
checked by officers, their property is taken from them and they are searched.
They then speak to a number of people who each check and collect
information about them. One of the people they see is a nurse, who carries
out an initial assessment of their health needs. If they need to see a doctor,
this is usually arranged for the next day. This prisoner had his photographs
taken in reception, but no initial health screen was carried out for him and no
cell share risk assessment was completed.
26. The prisoner was sent to the Healthcare Centre and located in a single cell.
10 to 12 June 2005
27. An entry about the man was made on a daily record of nursing care on 10
June. It noted that there was very little information available about him and
that he was not very communicative. He had been placed in a safer cell in the
Healthcare Centre. However, the investigator was told by the prison doctor
that this was not because there were concerns that he might harm himself, but
simply because there are a number of safer cells in the Healthcare Centre and
they are used as normal accommodation, due to pressures on space.
28. Two separate entries were made in the record on 11 June, the first noting
inappropriate behaviour and the second noting that the prisoner was still
uncommunicative. The second entry also records that a full assessment was
still needed.
29. Similarly, two entries were made in the record on 12 June. The first note
refers to the prisoner’s behaviour as being markedly mentally unstable and on
the difficulty of persuading him to return to his cell. The second entry refers to
his lack of understanding of the reasons for his imprisonment.
30. A nursing care plan was completed for the man on 12 June in which his
identified problems were recorded as:
• memory lapse - unable to give full account of events leading to
imprisonment
• poor hygiene
• poor diet taken.
The interventions identified to address the prisoner’s problems were:
• to give time and listen as he was remembering a little more every time
• encourage personal hygiene
• make contact with Community Mental Health Team (CMHT) as soon as
possible.
•
It was also noted that a short term goal in the man’s care was to encourage him
to eat the meals he was served.
10
13 June 2005
31. On Monday 13 June a Senior Officer (SO) completed an initial health screen
for the prisoner. In interview, the SO explained that he had not been on duty
between 9 and 12 June. He explained that, from what he could remember, he
had completed the man’s health screen on the morning of 13 June, because it
had been picked up by another member of staff that it was still not completed.
The SO believed that the man had been very uncommunicative and thought
that might have been an explanation why the assessment had not been
completed up to that point.
32. A copy of the prisoner’s prescription was obtained and this was faxed through
to the prison. The SO could not remember whether this information came
directly from the prisoner’s GP or was obtained from his Community
Psychiatric Nurse (CPN). The address of his GP is not recorded on his initial
health screen, but there is note of the CPN’s telephone number. It appears
that the prisoner’s GP records were never requested.
33. Many sections of the initial health screen were not completed. Two out of the
eight pages were not completed at all. The SO explained in interview that he
completed the man’s health assessment both by asking him questions and
through use of the information contained in the fax sent by the barrister for the
prosecution. The SO described the prisoner as having difficulties with his
speech and as being very uncommunicative.
34. Following his initial health screen, the prisoner was referred to see a doctor.
He was seen by the prison doctor at some point during 13 June. The second
health screen was never completed for the prisoner, so no details were taken
of his weight, height or blood pressure. The doctor made notes referring to
the details contained in the barrister’s fax and also commented that the
prisoner was hesitant in his speech and had a stutter. A prescription chart
was started for the prisoner, prescribing the following medication:
Cetirizine, 10 mgs daily
Clobazam, 10mgs in the morning, 20mgs at night
Procyclidine, 5mgs three times daily
Risperidone, 1mg twice daily
Sodium Valproate Chrono, 1g twice daily
14 June to 7 October 2005
35. On 14 June the prison doctor attended his weekly meeting with the
Community Mental Health Team (CMHT), a meeting which is known as the
Joint Liaison Ward Round. A note was made in the prisoner’s medical record
by this doctor, indicating that the prisoner needed a psychiatric assessment.
36. The man was seen by a consultant psychiatrist for the prison CMHT, on 21
June. The psychiatrist completed an Outpatient Care Plan for the man, in
which he stated that he did not feel any change needed to be made to the
11
man’s medication as he was not presently depressed or psychotic. The
Psychiatrist indicated that, as part of the man’s care plan, the prison CMHT
would liaise with the prisoner’s local CMHT to establish what steps had been
taken to find alternative accommodation for him.
37. The man was seen again by the consultant psychiatrist on 12 July. He told
him that he had been stressed and had been getting angry at times. The
consultant psychiatrist assessed his patient as being unfit to plead. His
situation was discussed at the prison CMHT’s team meeting later that day. A
number of alternative placements for him were discussed including a specialist
care home for clients with acquired brain injury and a care home where he
would be under the care of a psychiatrist with a specialism in brain injury.
38. The man was seen by a nurse from the first care home on 28 July. On 2
August, the prison CMHT were advised that they would be unable to accept
the man due to his unpredictable behaviour.
39. Nursing staff and discipline officers told the investigator that the man would
not always return to his cell when requested to do so and would occasionally
become aggressive and confrontational. The Head of Healthcare told the
investigator that the man’s unpredictable behaviour and occasional aggression
meant that he spent much of his time at Winchester on “three man unlock”.
(This means that, due to the behaviour or attitude of a prisoner, they have
been assessed as needed to have three officers present when they are
released from their cell.) The Head of Healthcare explained that, as the man’s
temperament was changeable, a daily review was undertaken as to whether
he needed to have three officers present to unlock his cell.
40. Due to his condition, the man was not always able to participate in the daily
regime in the Healthcare Centre and did not receive any visits during his time
in the prison. He struggled to understand the reasons for his imprisonment
and often expressed his frustrations to members of staff at the prison and to
the prison CMHT staff. He was a keen cricket fan and was avidly following the
Ashes test series during his time in Winchester. He also wrote poetry, some
of which has been published.
41. On 4 August, the man appeared at Southampton Crown Court, despite the
consultant psychiatrist’s assessment of 12 July when he was found unfit to
plead. His case was again adjourned.
42. On 16 August, the man was assessed by the consultant psychiatrist as unfit to
plead. On 30 August, he refused to speak to this psychiatrist, who noted in a
letter to the prison doctor that a neuro-psychiatric report was still awaited from
a doctor at the other care home.
43. The consultant psychiatrist assessed the man again on 6 September. He
considered that he seemed more settled than on his previous meeting with
him, but that he had stated he was frustrated in healthcare.
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44. On 15 September, the man attended Southampton Crown Court. Despite
having been recommended as unfit to plead, the evidence against him was
heard and he was found guilty of assault. Sentencing was adjourned until 27
September to await a further psychiatric report.
45. The man appeared at Southampton Crown Court again on 27 September
when sentence was adjourned for another month.
46. On 4 October, the consultant psychiatrist was advised by a doctor from the
other care home that it might be possible to admit the man to the unit under
Section 48 of the Mental Health Act 1983. The necessary paperwork was
prepared by the prison CMHT. On the following day, 5 October, an
arrangement was made between the care home and the prison CMHT that a
care planning meeting would take place on 27 October to manage the man’s
transfer and future care.
47. The clinical review carried out by Mid Hants PCT noted a number of points
relating to the man’s care during this time:
a) The history of medicines administration is incomplete. This is because
administration was not always recorded with clarity. Codes used to
indicate refusal of medicine varied and were sometimes recorded over
a signature suggesting that the medicines were signed as given but
then refused by the prisoner.
b) Nursing notes indicate that the prisoner required considerable
encouragement to take his medicines on many occasions. With this
support he remained compliant for much of his time in Healthcare.
There were occasional days when he took some or none of his
medication and there appears to be no obvious pattern to this
behaviour. In addition to these occasional days, there were two longer
periods of time when he refused all or most his medicines for several
days. The first occasion occurred in mid July, and the second just prior
to his death on 8 October.
Even when non-compliant with most of his medicines, the man tended
to take his Sodium Valproate to help control his epilepsy.
Respiridone is an atypical antipsychotic drug which reduces the efficacy
of Sodium Valproate. An increase in the dose of the Respiridone would
have had the effect of reducing the effect of Sodium Valproate in
controlling seizures. The man’s dose of Respiridone was increased
from 1mg twice a day to 2mg twice a day on 18 July. This issue is
explored further in the discussion section of this report.
c) Circumstances surrounding refusal of medicines in July. On 21 June,
the consultant psychiatrist reported no evidence of depression or
psychosis and indicated to continue with current medication. On 11
July, another doctor reported that the man remained psychotic. On 12
July, the consultant psychiatrist reported that he did not believe that the
13
man was psychotic and that there was no evidence of depression or
psychosis. He advised to continue with the current medication.
Nursing notes on 17 July reported the man to be compliant with
medication, but on 18 July he refused his lunchtime medication
(Procyclidine).
From 19 to 26 July, the man refused all medications except for Sodium
Valproate. From 26 July, he began to refuse less medication, returning
to reasonable compliance (with continued encouragement) on 4
August. The refusal of medications became pronounced on 19 July
and coincided with the increase of Respiridone.
d) Circumstances surrounding refusal of medicines in October. Until 4
October, the man had – with encouragement – been taking his
medicines on the majority of occasions. For reasons that are unclear,
he refused most of his medications on 6 and 7 October. It appears that
he continued to take his Sodium Valproate on the evening of 6 October
and both doses on 7 October, although the recording for the morning of
6 October is unclear.
14
8 October 2005
48. During the night of 7 October and morning of 8 October, the prison’s
healthcare cover was provided by an agency nurse who had been working
night shifts at the prison for about two years. On the night of 7 October she
was accompanied by an OSG.
49. The OSG told the investigation team that part of his role during a night shift is
to carry out “pegging”, which means patrolling the landings and clicking a
mechanical device at designated points around the Healthcare Centre. The
OSG said that, as he is carrying out this pegging, he will often check on
prisoners by looking through the observation panels in their cell doors. In this
prisoner’s case, the OSG explained that he would not look into his cell every
time he went past it (which was every 20 minutes), as the man tended to be
very sensitive to the noise of opening the panel, and would be annoyed if it
woke him up. The OSG said he would usually check the man once after he
seemed to have turned his TV off and to be asleep, and then once or twice
more through the night. On the morning of 8 October, the OSG remembered
checking on the man through the observation hatch at about 3.00am. He
seemed to be sleeping and was lying in a normal position.
50. The OSG told the investigator that, on 7 October, there had been several
prisoners who had been identified as being at risk of suicide or self harm and
were therefore being monitored at regular intervals under the Assessment,
Care in Custody Teamwork (ACCT) scheme. As was normal when there were
prisoners on ACCT to check, he and the agency nurse carried out the
necessary checks between them throughout the night. Similarly, whilst
“pegging” was the OSG’s responsibility, the agency nurse would often check
on prisoners periodically throughout the night.
51. The agency nurse told the investigator that, at about 5.40am on 8 October,
she was checking on prisoners through the observation hatches on their cell
doors. When she looked in on the man he was lying in a strange position.
She described his legs as hanging off the bed and him being in an unnatural
sleeping position. She called out his name, but got no response. The OSG
was in the process of carrying out his pegging and heard the agency nurse
calling to the prisoner. He asked the agency nurse if she thought the man was
okay and she replied that she thought he had passed away. The OSG looked
into the cell and saw the prisoner lying in a strange position. He explained
that he and the agency nurse put the man’s light on and continued calling to
him, but that he did not respond in any way.
52. The OSG told the investigator that at the time he had thought he could see the
man breathing. While he was still looking through the observation panel into
the cell, he was aware then that the agency nurse had returned to the nurses’
station (located only metres away) and was making a phone call to the main
prison requesting officers to come over and open the man’s cell door.
15
53. Neither the OSG nor the agency nurse hold keys during their night shifts. A
sealed pouch containing a set of keys is kept in the Healthcare Centre, but this
is only to be used in an urgent situation. Although there needed to be three
officers present to unlock the prisoner, even if a prisoner was not on three
man unlock, the nurse and OSG on duty would have to ask for two officers to
attend if they needed to open a cell door during the night. In the man’s case,
the agency nurse telephoned through to the Night Orderly Officer (NOO), and
requested that three officers make their way to healthcare. The agency nurse
explained to the investigation team that she could not remember exactly what
she had said to the NOO during the telephone conversation. She thought she
had explained that she thought the prisoner had died, but that the OSG
believed he was still breathing.
54. The NOO told my investigator that, at approximately 5.42am, he received a
telephone call from the agency nurse explaining that she could not rouse one
of the prisoners and that she needed to get into their cell. The NOO sent
three officers to the Healthcare Centre to open this prisoner’s cell. The NOO
told the investigation team that the three officers arrived approximately six
minutes after he had received the agency nurse’s telephone call. The nurse
estimated that the officers took about ten minutes to arrive and the OSG
thought it took about fifteen minutes. The three officers also noted in their
incident reports that they were requested to go to healthcare at approximately
5.45am, but did not record the time that they arrived there. One of these
officers told the investigator that he estimated it took him and the other officers
about six minutes to make their way from the prison centre office to the
prisoner’s cell. This officer told the investigator that, once at the cell door, he
asked why the prisoner was on three man unlock, looked through the
observation hatch and then unlocked the door.
55. The above officer entered the cell first, immediately followed by the agency
nurse and the other two officers. He stated that he believed the man was
dead and the agency nurse said that he felt cold to the touch and she could
find no pulse. She and one of three officers turned the man on to his back and
she checked his pupils, which were unresponsive.
56. The agency nurse explained that she attempted to put the man’s socks back
on him, but one of the officers told her not to touch anything and that they
must leave the cell. She and the three officers then left the cell and the door
was sealed.
57. The NOO was informed that the man had died and so contacted the duty
governor. The NOO then, together a further Officer, began to work through
the death in custody contingency plans. Hampshire Constabulary were
contacted and two police officers arrived at the prison at 6.30am.
58. The agency nurse was asked to arrange for a doctor to attend the prison in
order to certify the man’s death. She contacted the company which provides
the prison’s out of hours medical cover and was told that they were not able to
16
certify death and that a police doctor would have to be contacted. The man
was eventually pronounced dead by a police doctor, at 8.40am.
59. At approximately 7.30am, a hot debrief was held in the Healthcare Centre. This
debrief was attended by the duty governor, the head of healthcare, the duty nurse,
the OSG and the three officers who attended the scene.
Events following 8 October
60. The duty governor explained that, following the man’s death, he went through his
prison record to identify next of kin to inform them of his death. The man had given
his next of kin details as that of his solicitor and the Community Psychiatric Nurse
(CPN) from the residential care home where he had lived before his imprisonment.
The duty governor contacted the telephone number given for the care home, but was
not able to get through to anyone from the mental health team. He informed the
member of staff on duty that the man had died and asked for a message to be
passed on to the mental health team.
61. The duty governor also telephoned the number given for the man’s solicitor. As it
was a Saturday morning, he spoke to the duty solicitor who advised that she would
get a message to the man’s solicitor, but that it was unlikely to be before Monday.
62. At approximately 9.00am, the duty governor contacted Hampshire Constabulary to
request their assistance in tracing the man’s next of kin. At 4.20pm, he was informed
that the police had not had any success in tracing anyone and were now dealing with
a major incident so could offer no further assistance until after the weekend. The
duty governor checked whether the man had ever had any visits and found he had
not. A check of the prisoner’s medical records had shown that he had an aunt and
brother, but no names or addresses were recorded.
63. On Monday 10 October, the duty governor contacted the man’s CPN again and was
able to get through to him. The CPN explained that he had known the man only in his
professional capacity and that, whilst he was very sorry to hear of his death, it was
not appropriate for him to act as the man’s next of kin. The CPN also referred to the
man’s brother and aunt, but did not have addresses for either of them and only knew
the town they had lived in. The duty governor contacted the man’s solicitor again, but
was told he was unavailable and so left a message for him to return his call. By
approximately 2.00pm, Hampshire Constabulary had located a possible address for
the man’s brother and this had been passed to Buckinghamshire Constabulary. The
duty governor attempted to contact the man’s solicitor again, but was told that he had
gone home sick.
64. The duty governor spoke to the man’s solicitor on 12 October and advised him of the
man’s death. The solicitor advised that he would make the necessary arrangements
to close the man’s case, but that he wanted no further involvement and did not want
to act as a next of kin.
65. Some weeks after his death, Buckinghamshire Constabulary successfully located the
man’s brother and, after confirming that he was related to the man, they advised him
of his death and provided contact details for the prison. The brother advised that he
17
and the man had never met. The brother did get in contact with the prison and
arranged to receive a photograph of him. At the time of writing, he has not met staff
from the prison and is seeking legal advice about acting as the prisoner’s official next
of kin. The duty governor wrote to the prisoner’s brother on 31 October confirming
that, as requested, the prisoner’s property was being retained by the prison. The
letter also advised that Hampshire Constabulary were in possession of some
jewellery belonging to the prisoner.
18
Discussion of the issues
The man’s care from 9-13 June
66. The PER form completed for the man on 9 June, indicated a number of factors
to staff. The senior officer on duty in reception on 9 June explained to the
investigator that it was not unusual to see indicators of problems such as
mental health or medical issues. He could not remember this man specifically.
67. The nurse on reception on 9 June explained to the investigator that medical
staff do not routinely have access to documentation about prisoners and so
would not know if certain risks had been highlighted. She described the
system for reception staff passing information to healthcare staff as being “ad
hoc”.
68. The SO confirmed that he had written “straight to healthcare” on the front of
the prisoner’s core prison record. He explained that this decision would have
been taken by a member of healthcare staff. The SO could not remember
discussing it with any member of healthcare. He explained that there is no
nurse based on reception during the lunch time period so, ordinarily, if he
wanted to discuss a prisoner with a nurse he would have waited for the nurse
to return from lunch and then seek their advice.
69. The man’s PER form indicated that he arrived at the prison at 1.00pm His
name then appeared on the reception list timed at 1.46pm. The SO explained
to the investigator that the Prison Service’s computer system, the Local Inmate
Data System (LIDS), is updated over the lunch time period and it is therefore
not possible to enter data onto it. If officers need to add data to the system
during this period, they have to wait until the update is complete and then
enter the information retrospectively. This means that it is not possible to
know whether the man waited outside on the escort van for 45 minutes or
whether he came straight into reception. Either way, his details were not
entered until some time afterwards.
70. The nurse told the investigator that she had been based in reception for all of
that day, apart from an appointment from approximately 9.00am until 10.30am
and a lunch break from 12.30pm until 1.30pm. Another nurse took over from
her at 5.00pm. The nurse could not remember seeing the man in reception
and explained that it was quite possible that she was at lunch for the time that
he spent there. She made an entry in the medical reception register reading
“not seen- straight to healthcare”. She explained that, even if a prisoner was
acting in a way which made it difficult to carry out a formal assessment, she
would still observe them as much as possible and would open a medical
record. The nurse told the investigator that she believed her entry in the
medical reception register meant that she literally had not seen the man in
reception.
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71. Another nurse was on duty in the Healthcare Centre on 9 June. She told my
investigator that she had no recollection of the man arriving in healthcare, or of
being told that he had not had a healthcare reception screen carried out.
72. One of the prison doctors explained to the investigator that he had no
recollection of being asked to see the man on 9 June. He confirmed that two
doctors were on duty at the time: the first doctor was responsible for problems
arising in reception and for issues in the main prison, whilst the second was
responsible for Healthcare Centre (and any problems arising in West Hill - the
Category C unit attached to HMP Winchester).
73. The prison doctor explained that he had checked the healthcare diary to
confirm which doctors were on duty on 9, 10 and 11 June. On 9 and 10 June,
the he was responsible for reception and the main prison and a second doctor
was responsible for the Healthcare Centre. The first prison doctor explained
that, in June 2005, he believed (although could not be certain) that every new
prisoner was being seen by a doctor. This would ordinarily happen the
morning after their arrival at the prison and would take place on BETA unit
(Benefits, Education, Training and Accommodation). This unit is near to A
wing (induction) and the assessment by the doctor would take place as part of
induction. However, if someone in reception needed to be seen by a doctor
on the afternoon of their arrival, this would be arranged. The prison doctor
said this is relatively rare and happens maybe once every two weeks.
74. The first prison doctor went on to explain that, as in this man’s case, if a
prisoner arrived in the prison at 1.00pm and was sent straight to the
Healthcare Centre, the priority would be to get him located in a cell.
Arrangements could then be made for the doctor on duty on the Centre to
assess him. The doctor added that, on Thursday afternoon, he would have
been running a surgery at West Hill, so it might have been easier to have the
prisoner assessed in the Healthcare Centre, rather than getting him to come
over from the other side of the prison.
75. The second doctor told the investigator that he could remember the man, but
had no recollection of him arriving into the Healthcare Centre or of being
asked to assess him. He explained that, when a patient is admitted into the
Healthcare Centre, he would expect them to be identified to him on a ward
round. He also said that, in view of the communication difficulties the man
suffered, he was surprised to learn that he had not been drawn to his
attention, either on his ward round on the Thursday afternoon or during the
day on Friday.
76. The man was a individual who presented as having a number of problems.
The decision to quickly transfer him to the Healthcare Centre was no doubt the
right one. However, given his epilepsy and need for prescribed medication,
the failure to complete a thorough healthcare assessment for him for four days
is worrying. At the time of the man’s arrival at Winchester, there appears to
have been no particular member of staff with responsibility for overseeing
admissions to the Healthcare Centre and ensuring that the necessary health
assessments had been carried out.
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77. My investigator wrote to the Governor on 29 November, to express concern
that a first reception health screen had not been carried out for the prisoner for
four days. The Governor wrote back to the investigator on 1 December,
confirming that the issue was receiving immediate attention.
78. In addition, the Head of Healthcare told the investigator that she had written a
protocol to improve the admissions and discharge procedures in the
healthcare department and that this had now been approved by management
at the prison. She felt that the protocol would reduce the likelihood of
prisoners failing to be properly assessed.
79. It has not been possible to establish why the fax from the barrister for the
prosecution did not come to the attention of anyone until the morning of 13
June. In the event, the fact that the fax was not seen until then does not
appear to have had any effect on the man’s wellbeing. However, it is
surprising that such important information was not viewed with more urgency.
80. It is also of concern that no cell share risk assessments were carried out for
prisoners at the time of this man’s arrival at Winchester. I acknowledge,
however, that the SO on duty in reception on 9 June told the investigator that
these assessments are now being undertaken.
81. The first prison doctor also stated that he has a vague recollection that, when
he was asked to assess the man on Monday 13 June, it was mentioned to him
that “he’s been here a while, we need to get him sorted out”. He does not
recall who said this.
82. During the man’s first four days at Winchester, it appears that members of the
nursing staff had attempted to engage with him and a care plan was
formulated.
First reception health screen
83. When the man’s reception healthcare screen was carried out on 13 June,
many sections of the form were not completed and the information about him
therefore remained vague. The SO who completed the healthcare screen,
explained that this was due to the man’s unwillingness or inability to
communicate. No secondary health assessment was completed, so key
information about the man, such as his height, weight, and blood pressure,
was not recorded.
The man’s care after 13 June
84. Aside from the delay in assessing the man during his first four days in prison,
efforts appear to have been made by healthcare staff to care for him, and
commendably by the prison CMHT to seek alternative accommodation for him.
However, Mid Hants PCT’s clinical review does raise some concerns about
the prescription and administration of medicines:
21
a) No reason for the increase in Respiridone could be found in the
prisoner’s medical notes. The PCT interviewed the prison’s second
doctor, who is a locum, in an attempt to establish the circumstances
leading to the change in medication and to learn any lessons as
appropriate. The second doctor described the prisoner’s compliance
with medication as poor, but agreed that it improved with the
encouragement provided on the many occasions when he had initially
refused medication.
The second doctor agreed that he had increased the Respiridone dose
on 18 July, but could not remember the circumstances surrounding this.
He said that medication changes for this type of patient would only be
instigated on the recommendation of a specialist. The clinical reviewer
could find no evidence that this is the case and, subsequent to their
interview with this doctor, the PCT has confirmed with Prison
Healthcare Service and Hampshire Partnership Trust that, whilst it is
desirable for significant medication changes to be undertaken on the
advice of a psychiatrist, in practice GPs do on occasion instigate
changes without such advice.
The second doctor fully acknowledged that he had not recorded the
reason for his decision to increase the dose of Respiridone. He
described the chaotic circumstances that occur within prison that can
result in a lack of adequate record keeping. The clinical reviewer
provided advice on appropriate action in future.
b) The need to review and possibly modify the dose of Sodium Valproate
in the light of the change to the Respiridone dose. The second doctor
told the clinical reviewer that, due the short stay of most of the prisoners
at Winchester, it was not common practice to make changes to
medications used to treat long term conditions. He indicated that the
management of the man’s epilepsy had never been an issue in his
care. The prisoner did have occasional fits and when these occurred
they would be brought to the attention of the duty doctor. It has been
established that there is no mechanism to manage long term conditions
in Winchester prison. As a result, no change was made to the man’s
epilepsy medication throughout his time at the prison, despite periodic
reports of seizures. This lack of proactive review is a weakness in the
health care offered and has already been highlighted by the clinical
reviewer.
The need for a review of the man’s epilepsy medication in the event of
change to his antipsychotic medication, was highlighted in a report from
the consultant psychiatrist following an assessment of the prisoner on
21 June. In addition, a psychiatric report prepared for the courts
describes a change of medication in August 2004 where an increase in
antipsychotic medication appears to have contributed to an increase in
the man’s epilepsy. The clinical reviewer goes on to state that,
although there were varying views regarding the control of this epilepsy
in August and September 2005, the consistent opinion was that there
22
should be no change to medication pending the opinion of a psychiatrist
who would be further assessing him.
The clinical reviewer considered that the reasons for the increase in the
man’s medication may be documented in the minutes of one of the
case reviews undertaken every morning by the psychiatrist and the
locum doctors. However, the reviewer was able to establish that any
written records of these case reviews would have been made in the
man’s medical records.
The response to the man’s death on 8 October
85. After the agency nurse had called the NOO, it appears that – although the
timings are inexact – the three officers arrived at the Healthcare Centre
reasonably speedily. Once the officers arrived, they took the necessary steps
to ensure that there was no risk to staff, opened the cell door and quickly
entered the man’s cell. Whilst the officers attended the Healthcare Centre
without delay, if any other incidents had been occurring in the prison at that
time it might have proved very difficult to get three officers to attend so swiftly.
If there is an urgent need to unlock the cell of someone on “three man unlock”,
there could be implications for the remainder of the prison were there to be
other incidents.
86. Following the discovery of the man’s death, the prison’s death in custody
contingency plans were appropriately followed and the necessary individuals
contacted. However, the difficulties experienced by the agency nurse in
getting a doctor to certify the man’s death are not acceptable. She told my
investigator that the duty doctor explained that they could not certify the death,
because they were not “forensically trained”. The refusal of the doctor to
attend is surprising and resulted in a delay in certifying the man’s death of
approximately three hours.
87. The duty governor made efforts to trace members of the man’s family and was
saddened by the difficulties he encountered in contacting people who had
known him. Once the man’s brother was traced, the duty governor’s contact
with him has been considerate and timely.
23
Findings and Conclusions
88. The judge who remanded the man to Winchester did so with some reluctance.
The prosecuting barrister’s efforts to convey information to the prison about
the man’s vulnerability were commendable.
89. The man did not understand why he was in custody and the complexity of his
problems made him a challenging person to care for. As is the case all too
often, it is questionable whether prison represented an appropriate location for
a man with such significant disability.
90. When the man arrived at Winchester, a certain amount of information was
available about him. A fax was sent by the prosecuting barrister, detailing
concerns about the prisoner’s vulnerability and urging the prison to contact
him. His PER form noted his epilepsy, vulnerability, potential violence and
medical and mental health issues. However, while the nurse on reception on
9 June did not in fact see the man in reception, she told the investigator that it
is not routine for PER forms to be available to the member of healthcare staff
who completes the first reception health screen.
91. PER forms can contain crucial information and it is important that they are
available for healthcare staff to have sight of this when carrying out a health
assessment for a prisoner.
I recommend that a review is undertaken of how information about
prisoners is communicated to members of healthcare staff who are
required to carry out initial assessments.
The Prison Service have accepted this recommendation, commenting that the
following steps were to be taken by May 2006: “Review to be conducted by
the Head of Operations with the Head of Health Care to ensure an effective
system is in place to make sure any necessary information that comes into the
prison on Reception is communicated from Reception Staff to Health Care
Staff”.
92. The staff who dealt with the man when he first arrived at Winchester
recognised his vulnerabilities and, quite rightly, sent him directly to the
Healthcare Centre. Regrettably, the man’s medical needs were not assessed
and his medication was not prescribed for four days. Given that he was
epileptic, was taking anti-psychotic medication, the implications of this could
have been very serious. The lack of accountability for admissions to
healthcare seems to have contributed to the prisoner being overlooked. When
the man’s health screen assessment was carried out, numerous sections of
the assessment form were not completed.
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I recommend that an urgent review of the admission to healthcare
procedures is undertaken and that all staff are reminded of the
importance of a adhering to any protocol which is in place.
The Prison Service accepted this recommendation: “Healthcare Inpatient
Policy written and signed off by Head of Health Care and Governor in
December 2005. Disseminated to all staff. Admissions & discharge protocol
displayed on notice board in nursing station.”
93. When the man’s first reception health screen was completed, the information
gleaned from him was very brief. I acknowledge that the SO at the Healthcare
Centre found him to be very uncommunicative, however several sections of
the form were not completed at all. No record was made of the man’s GP’s
details and no attempt appears to have been made to request his medical
records.
I recommend that staff are reminded of the importance of completing
thorough healthcare assessments, and an audit of the timeliness and
quality of reception healthcare screens should be carried out.
Again, the Prison Service accepted the recommendation and made the
following comment: “All relevant staff have been reminded; Head of Health
Care has put management checks in place to review all new reception
screens.”
94. After the man’s initial four days at Winchester, it appears that he was
appropriately cared for and considerable efforts were made by the prison
CMHT to locate a bed in a more suitable setting. There are examples of good
practice in the form of the agency nurse’s efforts to encourage the man’s
compliance with his medication, and by members of the CMHT keeping
thorough and comprehensive records of their attempts to find alternative
accommodation for him. However, a number of areas of potential
improvement have been identified by the clinical reviewer. Based upon the
findings of that review, I make the following recommendations:
I recommend that nurses are reminded of the importance of using the
correct annotation to indicate refusal of medication and that doctors
(including locums) are reminded of the importance of recording the
reasons for medication changes clearly in the drug chart.
The Prison Service accepted this recommendation and confirmed that a memo
has been issued to staff.
I recommend that procedures are put in place to ensure appropriate
clinical management of long term conditions such as epilepsy, asthma
and diabetes where the failure to do so could put the patient at
significant risk of injury or death.
Accepting the recommendation, the Prison Service made the following
comment:
25
“Nurse qualified in CDM has now joined bank and is carrying out regular
clinics. IT is also essential to enable monitoring and to set reviews. Plans in
place to install IT system within the prison.”
I recommend that all clinical decisions taken by General Practitioners in
the absence of specialist advice are considered to be “exceptional” and
are reviewed at the next case meeting. Further to this, I suggest that
consideration be given to reinstating the weekly case meetings between
doctors and psychiatrist.
In response to this recommendation, the Prison Service said the following:
“GPs should ensure that any clinical decisions are passed onto specialists as
appropriate. This (and all) recommendations to be shared with provider
practice, and taken through clinical governance arrangements. Weekly case
meetings are not currently possible due to the high number, and therefore lack
of continuity, of doctors (currently 9 on rotation). This recommendation could
only work in practice with 1 or 2 regular doctors.”
I recommend that guidance is provided to clinical staff on appropriate
management and reporting of non compliance of medication where this
could be critical to the patient’s well being.
The Prison Service accepted this recommendation and made the following
comment:
“ ‘Lack of Capacity to Consent’ policy is in place and will be reviewed.
Guidance on non-compliance to be issued to staff.”
95. The response to the discovery of the man’s apparent death was well handled,
with staff acting swiftly and following the prison’s contingency plans
appropriately. However, the failure of the duty doctor to attend and certify
death is surprising and the Governor may wish to consider consulting the
Service Level Agreement and take this forward with the out of hours medical
service accordingly.
96. I consider that the attempts to locate the man’s family were timely and well
handled and that the duty governor’s efforts to trace and correspond with the
man’s brother have been sensitive and appropriate.
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List of Recommendations
1. I recommend that a review is undertaken of how information about
prisoners is communicated to members of healthcare staff who are
required to carry out initial assessments.
2. I recommend that an urgent review of the admission to healthcare
procedures is undertaken and that all staff are reminded of the
importance of adhering to any protocol which is in place.
3. I recommend that staff are reminded of the importance of completing
thorough healthcare assessments, and an audit of the timeliness and
quality of reception healthcare screens should be carried out.
4. I recommend that nurses are reminded of the importance of using the
correct annotation to indicate refusal of medication and that doctors
(including locums) are reminded of the importance of recording the
reasons for medication changes clearly in the drug chart.
5. I recommend that procedures are put in place to ensure appropriate
clinical management of long term conditions such as epilepsy, asthma
and diabetes where the failure to do so could put the patient at
significant risk of injury or death.
6. I recommend that all clinical decisions taken by General Practitioners in
the absence of specialist advice are considered to be “exceptional” and
are reviewed at the next case meeting. Further to this, I suggest that
consideration be given to reinstating the weekly case meetings between
doctors and psychiatrist.
7. I recommend that guidance is provided to clinical staff on appropriate
management and reporting of non compliance of medication where this
could be critical to the patient’s well being.
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