Individual at Wormwood Scrubs

Investigation into the circumstances surrounding
the death of a man at HMP Wormwood Scrubs
in January 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2009
This is the report of an investigation into the sudden death of a man at HMP Wormwood
Scrubs, in January 2009. The man was discovered by his cellmate in their shared cell
on B wing at 7.50am. It was clear that the man had passed away earlier in the night
and no efforts were made to resuscitate him.
The man’s history and family circumstances are not known, but he was in his mid-50s. I
would like to offer my sincere condolences to all those who knew him and have been
affected by his death. This includes those prison staff who I know were saddened by
the man’s passing.
An investigator conducted the investigation on my behalf. An independent review of the
man’s medical care was undertaken by a panel, chaired by a doctor, on behalf of the
local Primary Care Trust. I am very grateful to the panel for their contribution.
I would also like to thank the Governor of Wormwood Scrubs and his staff for their
cooperation. I am particularly grateful to the prison liaison officer who, as in the past,
provided a high standard of prison liaison and ensured the documentation was in
exceptional order. The prison’s Family Liaison Officer also made a very valuable
contribution to my investigation.
The man did not have a known history of heart or other serious health problems.
Neither had he complained of feeling unwell to healthcare staff, officers or to his
cellmate. I make two recommendations in my report. The first relates to the need for
staff completing the reception healthcare assessments to ensure that arrangements are
made for prisoners who have raised blood pressure to have regular reviews. The
second asks the Head of Healthcare to remind all healthcare staff of the requirement to
keep legible and accurate records.
The prison’s attempts to find the man’s next of kin reflect very well both on Wormwood
Scrubs and on the Prison Service as a whole. To date, these efforts have been
unsuccessful and the man remains a mystery. Indeed, it is entirely possible that the
name he used was not his real name at all.
The Prison Service has responded to and accepted my recommendations and their
response is on pages 16 and 17 of this report.
This version of my report, published on my website, has been amended to remove the
names of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2009
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CONTENTS
Summary
The investigation process
HMP Wormwood Scrubs
Key findings
Issues
Recommendations and commendation
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SUMMARY
On 9 December 2008, the man was remanded into custody at HMP Wormwood Scrubs.
At his First Reception Healthscreen interview, he told healthcare staff that he did not
have a family history of any serious illness, but was receiving medication in the
community for glaucoma, asthma and gout. The man contacted healthcare on three
occasions for these and other minor illnesses between 9 December and his death on 23
January 2009.
The man’s cellmate recalls that on the evening of 22 January, they both watched a film
on the television beginning at 9.00pm. He said he fell asleep before the man and he did
not hear or see anything unusual during the night.
The man’s cellmate woke at around 7.47am. It was clear from the man’s physical
condition that he had died. He raised the alarm and staff responded immediately. The
officers contacted the communications room using the radio net and asked for
healthcare staff to attend and for an ambulance to be called. Given that the man had
clearly passed away earlier in the night, they judged that it was not appropriate to start
cardio pulmonary resuscitation. At 8.04am, the prison duty doctor, arrived on the wing
at the same time as the paramedic ambulance crew and confirmed the man’s death.
A ‘hot debrief’ was held at 9.00am on the same day at which staff were given an
opportunity to discuss and share initial thoughts and feelings on the man’s death. It was
acknowledged that some staff would be upset as he had routine contact with them
every day in his role as tea orderly. Staff were told that a meeting would be held at
2.30pm that afternoon and the Care Team Leader would be attending to offer support to
staff.
The prison made an extensive search for next of kin of the man, but sadly without
success. With the help of colleagues in the police, National Health Service and
probation, every address, contact detail, or telephone number found for the man was
explored. They were either found not to exist or he was not known. The prison noted
that the man spoke with what was thought to be a South African accent but the South
African High Commission was unable to provide any information. The prison’s Family
Liaison Officer (FLO) explored every possible avenue but to no avail. He subsequently
made arrangements for the man’s funeral.
I make two recommendations in my report. I am also pleased to commend the prison’s
FLO for his tenacious efforts to find next of kin for the man.
The man’s death was sudden and unexpected. My investigation found that the prison
had no reason to suppose he was at risk and responded appropriately to his passing.
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THE INVESTIGATION PROCESS
1. I was notified of the man’s death on 23 January 2009. Terms of reference and
notices were issued to staff and prisoners at Wormwood Scrubs telling them that an
investigation would be taking place, and inviting those who wished to see the
investigator to make themselves known. My investigator requested copies of the
man’s core record, clinical record, and other records relevant to his time in custody
and his death.
2. My investigator also contacted HM Coroner to inform her of the nature and scope of
my investigation. The Coroner has requested a copy of my report and I am happy to
comply. A copy of a post mortem report was not available to my investigator at the
time of writing this draft report. However, she has seen a copy of the man’s death
certificate. While the cause of death is to be established at inquest, the man is
believed to have died from natural causes.
3. The investigator visited Wormwood Scrubs in April 2009. She met and spoke at
length with staff on B wing who knew the man and with the prison’s FLO. She also
toured the wing and saw the cell where the man died.
4. A clinical review of the man’s medical care was commissioned from the local
Primary Care Trust (PCT). The clinical review panel was led by a doctor and
focused on the medical care the man received at Wormwood Scrubs. The review
appears as an annex to this report.
5. The man gave next of kin details to the reception officer when he was received into
the prison in December 2008. Very shortly after his death, the prison, assisted by
the police, attempted to contact the man’s next of kin through the details he had
given to the reception officer. The addresses and telephone numbers he had
offered did not exist. The prison then searched their records of past sentences the
man had served for next of kin details but again without success. The man had told
staff and his cellmate that he had made telephone calls to family. However, a
search of the pinphone records showed that he had made no such calls. He did not
receive visits. The email address and telephone contact number he gave his
cellmate were not valid and he was found not to have lived at the address claimed
prior to imprisonment. Staff noted the man spoke with a possibly South African
accent, and the prison therefore made enquiries of the South African High
Commission and the United Kingdom Border Agency (UKBA), but once more
without success. Staff questioned whether his given name was in fact his real
name. The man had served previous sentences under this name, but all other
personal information he had given to the prison proved unhelpful and his previous
convictions listed four aliases.
6. My investigator telephoned the police officer assisting the prison in finding the man’s
next of kin. He told her that he had passed the case to a specialist financial
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HMP WORMWOOD SCRUBS
7. HMP Wormwood Scrubs is a local category B prison, principally serving the courts of
West London. It has a maximum capacity of 1,277 prisoners and holds remand and
convicted adult males. The prison holds a high number of foreign nationals as
Heathrow falls within the catchment area.
8. There are five main residential wings. The man was located on B wing. This wing
has a capacity for 176 prisoners and is situated near to the healthcare centre.
9. HM Chief Inspector of Prisons made a full unannounced inspection of Wormwood
Scrubs in June 2008. HM Chief Inspector of Prisons subsequent report judged that
progress that the prison had made since her previous inspection had halted, and
there had been “an appreciable drift” in all the key areas namely safety, respect,
purposeful activity and resettlement. However, HM Chief Inspector of Prisons
acknowledged the difficulties the prison faced in coping with constant daily pressure.
10. A report by the prison’s Independent Monitoring Board (IMB) for the period 1 June
2007 to 31 May 2008 mirrored the concerns raised in HM Chief Inspector of Prisons’
report. The IMB also highlighted problems resulting from a shortage of staff. The
IMB report said that they had seen positive signs of improvement in healthcare
services, but these had come at a cost in the cancellation of clinics and longer
waiting lists while the department underwent necessary refurbishment.
11. In September 2007, the prison’s healthcare department was placed under special
measures as part of the Primary Care Trust’s improvement plan.
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KEY FINDINGS
12. The man served a number of sentences at Wormwood Scrubs for offences of fraud
and dishonesty. While serving part of his sentences on licence in the community, he
repeatedly re-offended and was recalled to prison on a number of occasions.
13. In December 2008, the man went to Wembley police station and surrendered
himself to the police. Again, he had breached his licence and said he had
committed further offences.
14. At the police station, the man asked to see a doctor about his asthma. The police
Detained Person’s Medical form was completed by the police doctor at 5.08pm. At
the man’s request, the doctor left a salbutamol inhaler with the instruction to staff
that it was to be given to the man every four to six hours if necessary. (Salbutamol
is a generic inhaler used to treat severe breathing problems in people with lung
disease.) The medical advice to staff was that the man was to be observed on
CCTV at half hourly intervals.
15. In December, the man was remanded into custody. The Prisoner Escort Record
completed by staff driving the man from the court to the prison showed that he had
an (unspecified) medical condition. The boxes indicating the man was at risk of self-
harm or suicide and was vulnerable were also ticked.
16. The First Reception Health screen document was completed by a healthcare worker
in December. The man gave the name and address of his doctor at a medical
centre and said he had been prescribed medication for an eye condition and
asthma. He said he did not have any of the conditions listed on the form including
chest pain. The man said he did not smoke, drink or misuse drugs but indicated he
suffered from depression. He revealed to the healthcare worker that he had cut his
wrists in January 2008 and had been admitted to a hospital for two weeks for
psychiatric treatment.
17. The healthcare worker recorded an impression of the man as: “mental health issues,
states he would not harm himself, co-operative, settled in mood.” The man said he
did not need to see a doctor but the healthcare worker noted that a referral to a
doctor for mental health matters should be made. He was judged fit to live on the
normal wings and in a shared cell.
18. My investigator noted that in a separate interview on the same day, the man gave
different information to an officer who completed a Personal Summary form. The
Personal Summary form contained personal details including next of kin. The man
told the officer that he was allergic to yeast. However, he had told the healthcare
worker completing the First Reception Healthscreen that he did not have any
allergies.
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19. On the second, undated, General Health Assessment completed by a nurse, the
nurse said there was no history of illness in his family. He refused a referral to the
Asthma or Well Man clinic but said he might want to see a doctor in the future for his
eye problem. The clinical review panel has identified two risk factors in the
assessment that in isolation are not a problem, but together are associated with
heart attack and were not acted upon. These were that the man’s blood pressure
was 157/77 and his weight was 88.8kg, indicating that his blood pressure was high
and he was slightly overweight.
20. The man’s medical record suggests that during the six weeks he was at the prison,
he had contact with healthcare on two occasions. He had a consultation with a
medical professional on the day he arrived. The signature to the entry is illegible
and, although likely, it cannot be assumed that the person he saw was a doctor. At
that appointment the man said he had a history of glaucoma and was prescribed
Trusopt (a brand of eye drops to treat glaucoma and raised pressure in the eye). He
described suffering from gout for which he took Ibuprofen for pain relief (he had not
mentioned this condition during his first health screen interview). He relieved his
asthma with a Ventolin inhaler.
21. The next entry on the medical record says that the man was not seen but was “okay
at the moment”. It is not clear whether this meant he had not been seen by a doctor
and had given this information to a member of healthcare staff, or whether it was an
assumption by the member of staff who made the entry and had observed or spoken
with him at some point.
22. The man was located on B Wing. He moved to A wing for a short time and returned
to B wing in January 2009. In January, he returned to court and was sentenced for
committing further offences while on licence.
23. The man’s cellmate said that at around 9.00pm in January, they both decided to
watch a film on television. The man was in the top bunk, lying with his head towards
the cell door in order to watch it. The cellmate said that he fell asleep during the film
and awoke around 1.00am. He recalled that the television was off. My investigator
confirmed with wing staff that, because the cells are small, it is possible to reach the
television controls from the top bunk. The man’s cellmate said that he did not hear
anything during the night.
Events of 23 January
24. My investigator spoke with the Senior Officer (SO) on B wing, regarding
observations carried out on the wing during the night patrol state. The SO said that
prisoners were observed through the flap in the door at 10.00pm, 2.00am and
6.00am. This was simply a count of prisoners confirming that two remained in the
cell during the night and nothing was obviously wrong. Officers did not routinely
unlock cell doors and physically check prisoners for movement during the night. The
SO told my investigator that, if a prisoner was subject to monitoring under the
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25. The SO recalled that the man would normally be dressed and ready in his cell by
7.00am. On this occasion it was unusual that he was not.
26. The wing observation book records that a special cell search was to be carried out at
7.30am on a specific cell on B wing. The noise of the search woke the man’s
cellmate at 7.47am. He noticed that the man showed obvious signs of having died
and raised the alarm.
27. The first Officer went to the cell and opened the door. He attended with a second
Officer, a Principal Officer (PO), and the Governor. The PO’s role was Oscar 1 on
that morning. (Oscar 1 is the operational officer in charge of the day to day regime
of the prison.) The communications room incident log shows that at 7.52am the first
Officer asked healthcare to attend B wing immediately as a prisoner had died. He
also requested an ambulance. The log confirms that an ambulance was called at
7.53am. In line with policies and procedures regarding a death in custody, the police
were asked to attend.
28. At the same time and on arrival at the prison duty doctor, received an urgent
message to go to B wing immediately. He later recalled that he arrived at the man’s
cell at the same time as the paramedic ambulance crew at 8.04am.
29. In his statement the prison duty doctor said that when he arrived at the man’s cell it
was being “guarded” by officers, and a wing governor was already on the scene. He
saw the man lying on his left side on the upper bunk bed with his head towards the
cell door. He said the man faced the room as the bed was on the left side of the cell.
His left foot was hanging over the edge of the bed. The prison duty doctor saw clear
signs of death. He said he felt rigor mortis in the man’s left foot and saw post
mortem staining. (Post mortem staining means the blood has begun to settle in
areas of the body.) He said he talked to the ambulance crew about the man’s
condition and it was decided that, given confirmation of death, no attempt to
resuscitate the man should be made.
30. The prison duty doctor said he spoke with the man’s cellmate. He confirmed that,
during the time they shared a cell, the man was a non smoker. The cellmate said
that he did not see him using his inhaler but was aware that he used eye drops. The
cellmate confirmed that the man did not complain about chest pain or any other
symptoms. He was calm and a well regarded prisoner. He recalled that the man
used to meditate twice a day, did yoga and was vegetarian. He told the prison duty
doctor that he recognised from the man’s physical condition that he had died.
31. A “hot debrief” was held by the Governor that morning. Staff were given the
opportunity to offer their views and express any concerns regarding the man’s death.
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32. Before his death, the man had told his cellmate that he was considering visiting his
son in Florida after his release in March 2009. The prison’s FLO told my investigator
that the man’s cellmate had mentioned to him that the man had given him an email
address and a mobile telephone number so they could keep in touch after they were
released. The prison’s FLO said that the email address was inactive and the
telephone number was unobtainable.
33. The prison’s FLO made extensive efforts to find the man’s next of kin. An entry
(inaccurately dated 20/7/08) in the family liaison log highlighted problems at an early
stage when the next of kin information the man had given proved inaccurate. The
prison’s FLO sought information from the man’s probation officer. The probation
officer said that he had completed a pre-sentence report on the man in January
2009. He described the man as a very reserved individual who did not wish to
discuss his family in any great depth. The probation officer said he did not have next
of kin details and was unable to give any further information, although he would
continue to make enquiries to assist the prison.
34. In January, the police told the prison that they were no nearer finding the man’s next
of kin and enquiries were ongoing. The prison’s FLO spoke to a member of the
Community Mental Health Team (CMHT). He was told that in late September 2008
the man had been detained under Section 2 of the Mental Health Act. The CMHT
had noted that the man did not wish to disclose family details other than he had
three children, two of whom lived outside the United Kingdom.
35. Staff noted that the man spoke with an accent that was possibly South African. In
January, an immigration officer with the United Kingdom Borders Agency, was asked
to carry out an immigration search. On that day, the prison’s FLO log recorded that
enquiries with the South African High Commission were also ongoing.
36. A number of other enquiries were made. The prison’s FLO checked the religious
registration card held in the chaplaincy department but to no avail. The man’s
property was searched for correspondence or any other documentation giving any
information. Prison optician records were searched for any next of kin information
but once more without success. The prison’s FLO contacted the Health Centre
where the man had said he was registered to his GP. He was told by staff that the
GP had left the practice seven years before, and a search of their records found that
the man had not been registered at the practice and they had no records for him.
37. In February, the prison’s FLO contacted the Client Affairs Team at Hammersmith
and Fulham Council. The Client Affairs Team deals with deaths where no next of kin
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ISSUES
The clinical review
38. The clinical review was undertaken by a panel chaired by a doctor on behalf of
Hammersmith & Fulham Primary Care Trust (PCT). Their review is based on prison
clinical and non-clinical records. The panel concludes that they could not identify
any acts or omissions by healthcare staff directly related to the man’s cause of
death. There were no documented signs of ill treatment or abuse but they note the
results of a post mortem were not available to the panel at the time of the review. In
this case, the man died suddenly and without warning. The panel judges that, as the
man had “exhibiting advanced signs of death”, efforts to resuscitate were not
appropriate. I entirely agree.
39. The panel also attempted to follow up contact details the man gave the prison
regarding his family doctor in order to find helpful background medical information.
They found that the King Street Medical Centre does not exist. Among other
enquiries, the panel tried to find a doctor the man was registered with but were
unsuccessful. A review of his Mental Health Trust notes, followed by a telephone
conversation with staff where the man received inpatient care, could not provide an
updated address for his doctor.
Record keeping
40. An entry dated December 2008 in the man’s clinical record is unclear. It says that
the man was “not seen” but was “okay at the moment”. The entry does not say
whether the man said he was okay or a member of staff judged he was or why he
was not seen. The panel has recommended that all clinical records are to be
created, maintained and stored in line with national best practice and guidance
issued by the Prison Service and Royal Colleges. As I have said repeatedly in the
past, proper entries in the clinical record are not an optional extra but a key
component of delivering effective medical care. I therefore repeat a
recommendation I have made many times before:
The Head of Healthcare should ensure that all healthcare staff are reminded of
the requirements to keep accurate and legible records.
Healthcare risk management
41. The panel has recommended that prisoners who are identified with slightly raised
blood pressure, a possible risk indicator for heart and other disorders, should be
offered the opportunity to have it rechecked within four weeks. Treatment should be
offered as appropriate, with the clinical record reflecting the outcomes of the review.
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The Head of Healthcare should ensure that prisoners identified with raised
blood pressure are regularly reviewed and the outcome recorded in their
clinical record.
Commendation
42. On behalf of the prison, the prison’s FLO exhausted every avenue in his search for
the man’s next of kin. His tenacity in keeping to the task and exploring every option
despite the lack of success is highly creditable. The prison’s FLO also showed
sensitivity in negotiating the arrangements for the man’s funeral with Hammersmith
and Fulham Council. I believe he is to be commended for his role as prison’s Family
Liaison Officer.
The Governor should commend the prison’s FLO for his commitment to the
role of Family Liaison Officer. In particular, for ensuring that every avenue
was explored to find the man’s next of kin and that he was treated with dignity.
Conclusion
43. The man’s death was sudden and unexpected. He did not have a documented
history of serious illness and had not complained to staff or fellow prisoners about
sudden ill health or chest pain. He had been a tea orderly for staff on B wing and
many staff to whom my investigator spoke were saddened by his passing.
44. It was clear that the man had died in the night and had been dead for some hours
before he was discovered by his cellmate in the morning. In those circumstances,
there was little staff could do and it was entirely appropriate that they did not attempt
cardiac pulmonary resuscitation (CPR). The greatest difficulty for the prison has
been that the sustained attempts to find next of kin for the man have proved fruitless
as he had successfully kept personal information to himself.
45. My recommendations aside, I judge that the medical care the man received for the
conditions he disclosed to healthcare staff was comparable to that which he would
have received in the community.
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RECOMMENDATIONS AND COMMENDATION
1. The Head of Healthcare should ensure that all healthcare staff are reminded of
the requirements to keep accurate and legible records.
Accepted. 1.Reinforce Nursing and Midwifery Council (N.M.C.) guidelines
2.Remind GP’s of their responsibilities around record keeping
3. Written information re both of the above to be distributed to every staff
member and placed on intranet .
1,2,3: Guidelines and information is freely available to all healthcare staff
on the Shared Drive and instructions are circulated regularly to remind
staff of the importance of this
From Oct 07, the IT workstream will be established with a specific remit for
placing computers in all clinical areas so that all staff have immediate
access to records which should eradicate the issue of having to return to
the registry to collect records, often after the event
4. Audit of records to assess understanding and compliance with national
legislation
Audits have been conducted to identify the extent of issues to b e
addressed – one prior to training: the other three months post. 100%
improvement noted in the Don Gruben
5. Identification of training needs
6. Focussed training around completion of Don Gruben Screening
5,6: Training needs analysis completed. Training needs are being
identified via the following routes (i) the Wormwood Scrubs Male
Establishment (W.S.B.M.) Clinical Governance Forum; (ii) post adoption of
PCT policies; (iii) through the PCT training guide; (iv) following the prison
needs assessment; (v) recommendations from the PCT; and (vi) post
serious untoward incidents and clinical incident reviews. Programme now
in place. One record keeping/management session given. Awaiting dates
for rolling programme.
Training ongoing as new staff appointed.
7. PCT policy adopted. Record keeping standards and records
management policy updated in line with National Health Service Litigation
Authority (NHSLA) requirements. Once reviewed will be launched.
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2. The Head of Healthcare should ensure that prisoners identified with raised
blood pressure are regularly reviewed and the outcome recorded in their
clinical record.
Accepted. Patient group Directives are in the process of being developed and
implemented. Practice changes are also being developed to address this
recommendation.
Commendation
The Governor should commend the prison’s FLO for his commitment to the role
of Family Liaison Officer. In particular, for ensuring that every avenue was
explored to find the man’s next of kin and that he was treated with dignity.
Accepted. The Governor will personally commend the prison’s FLO.
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