Individual at Wormwood Scrubs

Circumstances surrounding the death of a prisoner
at HMP Wormwood Scrubs, in May 2006
Prisons and Probation Ombudsman for England and Wales
October 2006
This is the report of an investigation into the death a prisoner at HMP Wormwood
Scrubs. On 19 April 2006, blood tests indicated an unusually high level of
paracetamol in the man’s blood, and he was immediately admitted to hospital. He
was later moved to another hospital. Having spent 16 days in hospital, the man died
on 5 May 2006, at the age of 37.
I offer my sincere condolences to the man’s family. The man had suffered from poor
mental health and was a known drug user, but had retained their love, loyalty and
support.
One of my staff conducted the investigation. His report focuses on the man’s time in
prison custody, and evaluates the systems in place to establish whether they were
(and are) fully effective.
I am grateful for the assistance my investigator received from the staff and
management at HMP Wormwood Scrubs. I wish to acknowledge too the help of the
Metropolitan Police who carried out their own enquiry into the man’s death and
willingly shared information. My thanks also go to the Clinical Audit Manager from
Hammersmith and Fulham Primary Care Trust, who was the lead investigator for the
clinical review.
This is a short report because the means by which the man came by his death are a
mystery. It is possible he injected a solution of paracetamol believing it to be an illicit
substance, although I have found no direct evidence to determine the matter one
way or the other.
I make no recommendations of my own in this report, but draw attention to those in
the clinical review. These concern, amongst other matters, the number of nurses
available when prisoners arrive at Reception and the importance of recording and
monitoring physical health.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2006
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CONTENTS
SUMMARY
INVESTIGATION OUTLINE5
BACKGROUND
EVENTS
FINDINGS AND CONCLUSIONS
RECOMMENDATIONS
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SUMMARY
This is the report of an investigation into the death of a man. Until 19 April, the man
was a prisoner at HMP Wormwood Scrubs. He died in hospital on 5 May, with his
family at his bedside. He was 37 years old.
The man had been at Wormwood Scrubs since 1 March 2006. On reception, he
disclosed his drug misuse and history of schizophrenia. Otherwise, he said he was
physically fit. He was prescribed a methadone detoxification programme and located
in the Conibeere Unit, a specialist unit designed to help prisoners during the
detoxification period.
Apart from a short period of time, the man remained in the Conibeere Unit. On 19
April, the prison doctor noticed that he was jaundiced and ordered urgent blood
tests. Later the same day the tests revealed an elevated liver function. He was
admitted to hospital that evening, on the hospitals request. Later, blood test results
revealed an unusually high level of paracetamol in his blood.
On 1 May, the man’s condition deteriorated and he was moved to the intensive care
unit at another hospital. At the time of submitting this report, the post mortem report
is not available. However, it is though that the man died from liver failure.
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INVESTIGATION OUTLINE
1. The investigation into the man’s death was led by one of my investigators. He
visited the prison and was shown the areas where the man had been,
including the healthcare centre and the wing on which the man had been
located. The investigator reviewed the man’s prison records and spoke
informally to both prison staff and prisoners. He issued a notice to staff and
prisoners inviting anyone with information relating to the man’s death to make
them known to the investigator.
2. My investigator also spoke to the Chair of the Independent Monitoring Board
(IMB), the Prison Officers’ Association (POA), one of the prison chaplains,
and various other members of staff, including the Safer Custody Manager.
My investigator spoke informally to prison staff and prisoners who knew the
man and were involved in the events surrounding his death.
3. The prison gave my investigator full access to all the documentation
surrounding the man’s time in prison. The police also provided copies of the
documents and statements in their possession. My investigator obtained
some further information from probation and court services.
4. One of my Family Liaison Officers spoke to the man’s mother and one of his
brothers to discuss their concerns about what had happened to the man. The
man’s mother believed that it was possible for her son to have injected himself
with paracetamol, thinking it was an illicit drug. She thought this was feasible,
following a conversation she had had with a doctor. (She could not remember
the doctor’s name, but was sure it was at the hospital.)
5. Hammersmith and Fulham Primary Care Trust convened a panel to conduct a
clinical audit of the man’s care while in prison.
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BACKGROUND
HMP Wormwood Scrubs
6. Wormwood Scrubs was built between 1875 and 1891. It has a maximum
population of 1,229 prisoners, mostly held in single cells. The population is a
mixture of adult male convicted and unconvicted prisoners, the average ratio
being nine to five respectively. The prison serves West London courts and
has a high reception and discharge rate, averaging around 40 new prisoners
each weekday.
7. The overall establishment rating at the time was three (four being the highest
and one the lowest). The current rating is four. This rating is established from
a number of factors, including performance against area targets, Prison
Service National Standards and independent inspection by Her Majesty’s
Chief Inspector of Prisons (HMCIP). In relation to Prison Service National
Standards, the establishment attained a rating of ‘Good’ for both non-security
and security, which were both marked as above 80% during the most recent
audit in March 2004. Suicide awareness and self-harm procedures were
rated as ‘Good’, achieving a mark of 94%.
8. Following the previous HMCIP inspection in November 2003, HM Chief
Inspector wrote that, nearly two years on from the last inspection, she found a
greatly improved prison, gradually implementing and consolidating
fundamental changes, with senior managers who were actively managing
staff and wings. In areas such as the first night centre, the resettlement unit
and drug strategy, there was evidence of real and sustained improvement.
9. Regarding anti-bullying, HMCIP commented that progress had been made
since her last inspection, but there remained considerable work to do. The
policy was widely publicised and understood. However, communication and
sharing of information about incidents on residential wings was poor. The
completion of anti-bullying documentation was inadequate and there were no
structured interventions to help and support identified bullies or victims.
The Conibeere Unit
10. The Conibeere Unit (Detoxification Unit) is a residential area within the prison,
accommodating prisoners referred for drug or substance detoxification. There
are 51 beds, 46 of which are allocated to prisoners who are detoxifying.
Attendance is voluntary. There are strict guidelines for compliance in place
and all prisoners are required to sign a compact. A subutex detoxification
regime lasts for 12 days, methadone for ten to 15 days and codiazeproxide
withdrawal from alcohol for up to nine days.
Healthcare Centre
11. The Healthcare Centre is located on two floors (H2 and H3). The out-patient
and day centre are located on H2. The in-patient unit is located on H3, and
has 17 beds, 12 of which are single cells. It includes a gymnasium and
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relaxation room. Healthcare provision is primary care centred, with access to
a doctor 24-hours a day. Prisoners with more serious condition or clinical
needs are referred to the local hospital.
12. For emergencies, the prison operates the “Hotel One” system. If emergency
medical assistance is required, then the member of staff detailed as Hotel
One responds, assesses the situation and commences any treatment before
deciding on the next course of action. Hotel One is available 24-hours a day
and is contactable from the communications room, via the UHF radio.
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KEY EVENTS
1 March 2006 to 19 April 2006
13. On arrival at Wormwood Scrubs on 1 March 2006, the man told staff that his
home address was a hostel in Covent Garden, and named his mother as his
next of kin.
14. During his reception health screening, the man said that he had no concerns
about his physical health. He told staff that he had a history of drug misuse
and mental illness. The man said that he received a Haloperidol Decanoate
(depot) injection every 14 days to control his schizophrenia. He said that the
last one he received was on 20 February, and the next was due on 6 March.
Confirmation of the medication was requested from a psychiatrist at a
hospital. An immediate referral was made to the doctor, Community
Psychiatric Nurse (CPN) and the substance misuse nurse. He was also
prescribed a methadone maintenance regime.
15. The man then completed the first night induction, where his immediate needs
were discussed, including an explanation of how to access the Listeners
(prisoners trained to offer support to others) and Samaritans. There is and
was no personal officer scheme in operation at Wormwood Scrubs, and so
the man was told to contact the nearest member of staff should he have a
problem. He was then located in the Conibeere Unit for his detoxification.
16. The following day, 2 March, confirmation was received from the hospital, that
the man was given his depot injection on 23 February (not 20 February as the
man had thought). This meant that his next injection was due on 9 March.
17. On 9 March, the man appeared at Crown Court where he was sentenced to
three years for burglary. That evening, the man was given a depot injection.
He was given a further injection on 23 March. The next one was due on 6
April.
18. On 26 March, the man was involved in a fight with his cellmate. It appears
that the man would not let the other prisoner sleep and, following an
argument, they were found fighting in the cell. They were separated and the
man was moved to the Healthcare Centre, purely as a ‘lodger’, due to lack of
space elsewhere in the prison. The fight was the subject of a Governor’s
Adjudication (disciplinary hearing), and there appear to have been no further
problems between the man and this or any other prisoner.
19. On 27 March, after spending a night in Healthcare, the man was moved onto
B-wing. From 2 April, he attended the Conibeere Unit on a daily basis.
20. Although not written in the Clinical Record, the prescription chart confirms that
the man was given the depot injection on 6 April. The next injection was due
on 20 April.
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21. According to an RMN, on 11 April, the man had smartened himself up, had a
hair-cut and was generally cleaner and tidier than before. Three days later he
returned to the Conibeere Unit, as he was not coping with B-wing. He was
apparently not sleeping and was observed to be shaking in the mornings.
Following his move, the man seemed to be stable and coping well in the
Conibeere Unit.
19 April 2006
22. On 19 April, at 10.00am, staff referred the man to a doctor. He appeared to
be jaundiced, with no other physical symptoms, but the doctor was concerned
and ordered urgent blood tests from the local hospital. At this time, the man
told the doctor that in 1989 he had been diagnosed with Hepatitis C.
23. At 4.47pm, the prison received the results which revealed elevated liver
function. At 5.00pm, the hospital said that the man should be taken to the
Accident and Emergency Department, as an emergency. He was escorted
immediately and admitted to a ward, with two prison officers at his bedside
(he was handcuffed to one of the officers). Blood tests later an abnormally
high amount of paracetamol in the man’s blood.
20 April 2006 – 5 May 2006
24. The hospital continued to monitor and perform tests on the man. When it
became clear that he would remain there, the prison notified his mother at
12.10pm on 20 April, and she visited her son later that afternoon.
25. The man was due to be given a depot injection on 20 April, but the information
was not communicated to the hospital. There do not appear to have been any
adverse effects from the omission.
26. The next day, 21 April, the RMN confirmed to the hospital that the man had
not been prescribed paracetamol whilst in the prison. Additionally, his cell
was searched and no medication was found. The hospital confirmed that the
man had Hepatitis B and C, but did not think it was the cause of his current
condition.
27. By 3.50pm on 30 April, the man had gradually deteriorated to a point that he
was very weak. The handcuffs were removed, although two staff remained at
the bedside. Two days later, on 1 May, the man was moved to the Intensive
Care Unit (ICU) at another hospital. Whilst in the ICU, the two officers
remained, but at the end of the ward rather than at the man’s bedside. He
received regular visits from his family. While he was physically able to do so,
the officers escorted the man to the smoking and TV areas of the hospital.
28. When my Family Liasion Officer spoke to the man’s mother, she said that
when he was in hospital one of the doctors had speculated that the reason for
the high level of paracetamol in his blood was that he might have injected
himself with it. The rationale for the theory was that the man might have
acquired a substance, which he believed was an illicit drug, but was actually
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paracetamol. His mother said that the doctor could not confirm this
explanation, but it was just his professional speculation. It is not recorded in
any of the medical records.
29. Sadly, the man continued to deteriorate and at 11.25pm on 5 May he died in
the ICU. The post mortem report is not yet available, but it is thought that the
man died from liver failure.
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FINDINGS AND CONCLUSIONS
Clinical care
30. The Clinical Audit Manager of the Hammersmith and Fulham Primary Care
Trust, was the lead investigator for the clinical review. The review panel
noted that, during the reception process, time is very tight. A large number of
prisoners are interviewed quickly and moved to a residential area of the
prison. Staff are under considerable pressure to complete the assessments.
The panel also felt that there is a need for the development of staff and the
services on offer, including the planning of these services. Additionally,
improvements should be made to clinical communication and record keeping.
31. The review also noted that there was evidence that the man was not coping
well with prison life, resulting in his being transferred back to the Conibeere
Unit. At no time was there any evidence that the man spoke of a desire to
end his life by suicide.
32. During a medical review on 19 April, it was noted that the man was profoundly
jaundiced. the man’s clinical record does not document whether he had had
previous liver function tests, either in the community or at Wormwood Scrubs,
but they were carried out that day.
33. The prompt medical investigations revealed that there was significant liver
failure and high levels of paracetamol in the man’s blood. He was initially
treated for this at local hospital, before transfer to another hospital’s ICU,
where he was to die.
34. After reviewing the evidence, the panel concluded that the man received the
best quality of care available to him. It was noted that this was a sad and
tragic case but that, even if questions regarding his hepatitis status had been
asked, it is unlikely in the panel’s opinion that a more positive outcome would
have followed. It appears that the man was not ready to stop using illicit
substances and that this was the likely cause of his physical deterioration and
death.
35. The clinical review has made a number of observations regarding healthcare
services at Wormwood Scrubs. Whilst these do not directly relate to the man’
care, the prison health partnership may wish to consider how best to address
the identified learning.
Bullying
36. The man had a fight with another prisoner on B-wing. There is no evidence
that this was connected to bullying.
37. The fight and the possibility of bullying were properly dealt with by the
adjudicating governor.
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Conclusion
38. In conclusion, the man had a long history of intravenous substance misuse.
This lifestyle inevitably has serious effects on the body, and we know that the
man had Hepatitis B and C. It appears that, when in prison, the man
struggled to cope without illicit drugs.
39. I have been unable to establish where the man obtained the paracetamol
from, and how he had such a high level in his blood. The version put forward
by the family may well be feasible, and the man may have unknowingly
injected himself with paracetamol believing it to have been something else.
40. I believe the decisions taken in regard to the man’s handcuffing and bedwatch
were appropriate.
41. The appropriate procedures were also followed in line with the prison’s
contingency plans for dealing with the death of a prisoner.
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RECOMMENDATIONS
Healthcare
The clinical review team make the following recommendations, although they do not
expressly relate to the man’s care, they are more general observations on healthcare
delivery at Wormwood Scrubs. The PCT in partnership with the prison may wish to
consider these learning points to further develop local health services.
1. Nurse staffing levels
The pressure on staff working in reception is highlighted in the clinical review. An
audit to identify and quantify whether there are enough staff to complete this
process accurately and safely is required, with a subsequent review of reception
nurse staffing levels to allow capacity to perform this important task.
2. Assessment
There should be targeted education pertaining to physical assessment and the
requirement for performing tests, in order to ensure that plans for implementing
blood testing (including full blood counts, urea and electrolytes, liver function
tests, and clotting profiles) take into account:
(cid:1) training needs of staff (skill and interpretation)
(cid:1) risk issues, including insurance and reporting arrangements.
3. Action planning
There should also be targeted education pertaining to the assessment process
and action planning to ensure these important processes are optimally
performed.
4. Record keeping
Education regarding the importance of record keeping as an adjunct to physical
assessment is a priority. Of particular importance is the use of free text fields as
a means of capturing important assessment information not recordable using tick
boxes.
5. Communication.
The sharing of information between colleagues within the prison and external
organisations is a priority. Professional courtesy would dictate the provision of
follow-up and closure. His social worker stated that she was shocked when she
inadvertently learned of the man’s death, as she had a rapport with her client that
took a long period of time to cultivate. It is regrettable that she was not notified
formally of his death.
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