Individual at Wymott

Investigation into the circumstances surrounding
the death of a man in hospital
whilst in the custody of HMP Wymott
in October 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2009
This is the report of an investigation into the death of a man who died at the Royal
Preston Hospital on 5 October 2008, whilst he was in the custody of HMP Wymott.
The man had been admitted to hospital after collapsing in his cell earlier that same
day. The cause of death was recorded as an intracerebral haemorrhage as a result
of acute myeloid leukaemia. The man was 48 years old.
My colleagues and I would like to extend our condolences to the man’s family for
their loss. Losing a relative whilst they are held in custody can make it even harder
for both family and friends to come to terms with their bereavement.
This investigation was led by one of my investigators. He was assisted by another of
my colleagues. One of my Family Liaison Officers contacted the man’s mother to
inform her of my investigation and discuss her questions and concerns about her
son’s death.
A clinical review of the medical care and treatment the man received in custody was
undertaken by the Healthcare Manager at HMP Altcourse. The clinical reviewer was
asked to assess whether the medical care the man received in custody was
comparable to that which he might have experienced had he been in the community.
I am most grateful for her assistance. Similarly, I would like to extend my thanks to
another healthcare professional, who completed an independent medical report in
relation to the circumstances of the man’s death and the adequacy of the primary
care delivered to prisoners at Wymott.
I am also grateful to the Governor, staff and prisoners at Wymott for their full
cooperation during the course of my investigation. In particular, I would like to thank
the officer who liaised with my investigators and facilitated the interviews conducted
at the prison.
The man had entered custody on 3 July 2008 and, after an initial stay at HMP
Preston, was transferred on 19 September to Wymott, where he remained until his
collapse on 5 October. A post mortem established that undiagnosed leukaemia had
spread throughout the man’s body. As his mother told my Family Liaison Officer, her
son’s death was sudden and unexpected. My investigator has tried to reflect the
family’s concerns in the course of this report.
I make no formal recommendations of my own, but I endorse one recommendation
made in the independent medical report.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2009
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CONTENTS
Summary 4
The Investigation Process 6
HMP Wymott 8
Key Findings 10
Issues 18
Recommendation 23
3
SUMMARY
The man entered custody on 3 July 2008 after receiving an extended sentence for
public protection at Preston Crown Court. He was initially held at HMP Preston,
where he was considered by staff to be a mature and polite prisoner. The man did
not report any significant health problems during his initial health screening upon
arrival at Preston and did not ask to see the doctor prior to his transfer to HMP
Wymott on 19 September.
At his reception health screening at Wymott, the man advised a nurse that he tended
to bruise easily. She advised him to book an appointment with the doctor. On 1
October, the man was assessed by another nurse and reported bleeding gums and
sores on his penis. The nurse booked an appointment with the doctor for the
following day.
The man was examined by the doctor on 2 October. He did not report any other
symptoms aside from those he had already told the nurse about. The doctor
prescribed medication to address both of the man’s complaints, and ordered blood
tests as a matter of routine due to the number of days that the man’s gums had been
bleeding.
A second nurse was asked to assess the man on the evening of 3 October as he
was experiencing stomach pain. The nurse assessed that this pain was a side effect
of the medication that the doctor had prescribed the day before. He advised the man
to stop taking the medication for the time being. He also advised the man to take in
fluids, as he appeared dehydrated. The man told the nurse that he had stopped
drinking the water at Wymott because he was ‘allergic’ to it.
The second nurse handed over to another nurse on the morning of 4 October, and
asked her to review the man’s health. This nurse did so, and found the man’s
condition to be improved. She also observed that the man appeared less
dehydrated. She advised him to rest. The following morning (5 October), this nurse
checked on the man again as a matter of routine and found him to be feeling better.
However, she did observe spontaneous bruising around the man’s left eye and, out
of concern, ensured that he was listed for blood tests.
The man was locked in his cell at about 12.20pm that day. His cell was unlocked
after the lunch period at about 2.05pm by an officer. A few minutes later, one of the
man’s fellow prisoners found him collapsed on the floor of his cell. He was bleeding
from a cut to his head. The prisoner summoned staff, who in turn radioed for
healthcare staff to attend. They also requested that an ambulance be called.
Several nurses and prison officers attended to the man in his cell. The ambulance
arrived at just after 2.30pm, and the paramedics arrived on the wing within minutes.
Healthcare staff handed over to the paramedics and the man was transferred to the
ambulance. A different nurse travelled with the escorting officers to offer medical
assistance. The ambulance left Wymott shortly after 3.00pm but had to stop on the
way to hospital to allow the man to be treated.
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The ambulance arrived at the Royal Preston Hospital at 3.40pm. The man was
subsequently taken for a computed axial tomography (CT) scan in order to diagnose
his condition. In the meanwhile, his next of kin had been informed of the emergency,
and his mother and sister arrived at the hospital shortly after 6.00pm. The man’s
relatives gave permission for his life support machine to be switched off later that
night. He died at 11.05pm.
The post mortem report recorded the cause of death as an intracerebral
haemorrhage as a result of acute myeloid leukaemia. Essentially, the man died as a
result of spontaneous bleeding into his brain tissue. This in turn had been caused by
the leukaemia, which is a cancer of either the blood or bone marrow.
Although I make no formal recommendations as a result of my investigation, I
endorse one recommendation made in the independent medical report in relation to
the delivery of healthcare at Wymott.
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THE INVESTIGATION PROCESS
1. My investigator was formally notified of the man’s death on 20 October
2008, fifteen days after his passing. Notices were subsequently issued to
both staff and prisoners at Wymott informing them of the investigation
process, and giving them the opportunity to contact my investigator if they
felt that they could assist in providing relevant information. No responses
were received as a result of these notices.
2. My investigator formally opened the investigation on 28 October when he
visited Wymott. He met the prison’s liaison officer and was given full access
to all of the prison records relating to the man. He familiarised himself with
the prison’s healthcare centre and the wing on which the man had lived. He
also visited the cell where the man had been housed whilst at Wymott and
where he was found following his collapse.
3. On 27 November, having examined all of the relevant documentation, my
investigator returned to Wymott and conducted six interviews. Four
interviews were with healthcare staff, one with a senior prison officer and
one with the prisoner who had found the man collapsed. My investigator
also subsequently interviewed a prison officer by telephone on 12
December, as the officer had been unavailable during the initial interviewing
process.
4. My investigator wrote to HM Coroner to inform him of the nature and scope
of my investigation, and to request a copy of the post mortem report. The
Coroner will also receive a copy of my report.
5. My investigator contacted Central Lancashire Primary Care Trust (PCT) and
requested that a clinical review be carried out into the care the man received
whilst in custody. The purpose of the review is to assess whether the
medical care and treatment that the man received in prison was comparable
to that which he would have received had he been living in the community.
The Head of Healthcare at HMP Altcourse, was commissioned to carry out
this review. Her review is annexed to this report.
6. On 14 November, one of my Family Liaison Officers contacted the man’s
mother as his listed next of kin. She gave the man’s mother the opportunity
to discuss the purpose of the investigation and raise any concerns or
questions the family wished us to explore during the investigation. The
man’s mother said her son’s death had come as a complete shock. She told
my Family Liaison Officer that she was aware that her son had visited the
prison’s healthcare centre. She wanted to know why blood tests, which
would have highlighted her son’s extensive leukaemia, were not carried out.
I trust I have addressed the family’s concerns within my report. I hope it
gives them a better understanding of the events leading up to the man’s
death.
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HMP WYMOTT
7. Wymott is a category C training prison for adult male prisoners serving
sentences longer than six months. It is situated close to the town of Leyland
in Lancashire. It has dedicated facilities for vulnerable prisoners, most of
whom will have committed a sexual offence. These vulnerable prisoners
make up approximately half of the prison’s population. The maximum
operational capacity of the establishment is just over 1,040 prisoners.
8. Since my office took responsibility for investigating deaths in prison custody
in April 2004, I have investigated 18 previous deaths at Wymott. Of these,
14 were attributable to natural causes, and four were apparently self-
inflicted. As a result of my previous investigations, I have made a number of
recommendations relating to the delivery of healthcare at Wymott. One of
these, relating to the introduction of electronic record keeping, is reflected in
my current recommendations resulting from the death of the man.
9. The commissioning of healthcare within Wymott is the responsibility of the
Central Lancashire Primary Care Trust (PCT). The prison does not have
inpatient facilities and prisoners who need inpatient care are referred to
HMP Preston or to the local hospital. There is a general practitioner (GP)
surgery within the prison which prisoners can access five days a week.
Overnight and weekend services are covered by a local GP who is on call in
the event that they are required. There is also a clinically qualified member
of healthcare staff on duty within the prison during these periods.
10. An unannounced inspection of Wymott was carried out by Dame Anne
Owers, HM Chief Inspector of Prisons, between 30 October and 1
November 2006. Following her inspection, Dame Anne wrote:
‘This inspection confirmed that Wymott continued to perform
reasonably well and managers and staff deserve credit for the
improvements achieved since our last inspection – and for putting in
hand further improvements.’
11. The Independent Monitoring Board (IMB) at Wymott has recently published
its annual report, covering the year from 1 June 2007 to 31 May 2008. (The
IMB at each prison is made up of members of the public who are both
independent and unpaid. They monitor the day-to-day life in their prison and
ensure that proper standards of care and decency are maintained.) With
regard to the provision of healthcare at Wymott, the IMB commented in their
report:
‘The full transfer to the Primary Care Trust of responsibility for both
healthcare service commissioning and provision is to be welcomed …
the Board wishes to acknowledge the professional and committed
approach of the healthcare staff …’
However, the IMB also noted:
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‘… a significant reduction in the provision of GP services, mirroring the
ratios in community provision …’
8
KEY FINDINGS
From 3 July 2008 until the man transferred to HMP Wymott
12. The man entered custody at HMP Preston on 3 July 2008 after receiving an
extended sentence for public protection at Preston Crown Court. This
sentence was to be made up of a four year period spent in prison, followed
by a four year period spent on licence in the community under the
supervision of the Probation Service.
13. Upon arrival at Preston, the man completed a Well Man Assessment and a
First Reception Health Screening. In neither document did he identify any
significant health problems. The man did mention a history of depression
when he completed the forms, but indicated that he had not previously
sought either medication or counselling in this regard. He told staff that he
had never intentionally harmed himself, nor had he had any suicidal
thoughts.
14. During his initial health screening, the man was assessed as being
physically fit and suitable to perform manual work. At the point of entering
custody the man applied for, and was granted, status as a vulnerable
prisoner as a result of his offence. He named his mother as his next of kin.
15. The man returned to Preston Crown Court on 15 July, where, due to a legal
problem, his original sentence was reviewed. At this hearing, an identical
sentence, comprising four years spent in custody and four years
subsequently on licence, was imposed in place of the original. This
sentence ran from 15 July 2008.
16. On 26 July, staff made an entry in the man’s wing history document. They
commented that he was a ‘mature, polite and tidy’ prisoner who was
complying with the prison regime. During the weeks that followed, prior to
his transfer to HMP Wymott, the man seems to have complied with all that
was asked of him.
From 19 September until 4 October
17. The man was transferred from Preston to Wymott on 19 September. He
was placed in a cell on the ground floor landing on G wing. A new
healthcare reception screening was completed upon his arrival at Wymott by
the reception nurse. The only significant issue raised was that the man
tended to ‘bruise easily’. He was advised by the reception nurse to apply to
see the prison doctor, but no actual appointment was made.
18. The reception nurse told my investigator that there was no actual bruising
evident to her on 19 September, and that the man did not complain unduly
about this issue during the screening. He did not appear unwell, and she
did not therefore make an immediate referral to a doctor. She expected
that, having advised the man to see a doctor, he would obtain an
appointment within the next two weeks, should he make such an application.
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19. The man’s weight was recorded at the screening, and had decreased from
72.6kg upon his admission to custody on 3 July to 70kg on 19 September. It
was noted by staff that the man was pleased to have been transferred to
Wymott, as he had been held there during an earlier prison sentence in
2001.
20. On 1 October, the man was assessed by another nurse. He complained of
bleeding gums and sores on his penis. He did not mention any other
concerns with regard to his health. The nurse arranged for the man to be
examined by the doctor the next day.
21. The man visited the doctor the following day (2 October). He told the doctor
about his bleeding gums and also reported that his ‘glands were up’. He
informed the doctor that he had felt like this for the past two weeks. The
doctor proceeded to examine the man, checking his glands, his gums, and
the sores on his penis. She looked through his medical records and
confirmed that he had not previously seen a doctor since he entered
custody, either at Preston or Wymott. The doctor noted that the man’s
glands were slightly enlarged, which was consistent with bleeding gums and
a mouth infection, and also that he had two ulcers on his penis.
22. The doctor told my investigator that she did not make comprehensive notes
relating to her assessment of the man at the time because she had felt that
it was an entirely routine examination. She subsequently confirmed in a
statement to the Governor that, on 2 October, the man had a clear chest, did
not have a raised temperature, had not lost his appetite and showed no
signs of any significant weight loss. The doctor told my investigator that
there was no significant difference in the man’s weight in comparison with
his previous period in custody.
23. Following her assessment of the man, the doctor prescribed a week’s supply
of Erythromycin and Metronidiazole to address his gingivitis (inflammation of
the gums) and Fucidin to treat his penile ulcers. The doctor also ordered full
blood tests (this is normal practice in prison and had not yet been carried out
in the man’s case). She was also concerned that the man had reported
bleeding gums over a ten day period, which was unusual, and she hoped
that the blood tests might provide an explanation. (The post mortem report
confirms that bleeding gums and ulcers are both classic signs of advanced
leukaemia.)
24. The blood tests were booked for 10 October. The tests were not expedited
because the doctor did not consider that the man presented with any
symptoms which required urgent attention. The doctor checked with the
man if anything else was the matter. The man did not tell the doctor about
any other symptoms, such as headaches or dizziness. There was no sign of
any bruising upon examination. The doctor told my investigator that she
thought that ordering routine blood tests was appropriate to the observations
she made during her examination of the man.
10
25. In a letter to his mother dated 3 October, which she sadly received after his
death, the man complained of feeling unwell. He wrote that he had
struggled to get to the healthcare centre, because he was feeling weak.
26. During the evening of 3 October, a nurse who had been attending another
prisoner on C and D wings, was asked to attend the man’s cell. The nurse
estimates that he arrived on G wing between 8.40pm and 9.00pm. Prior to
examining the man, he contacted staff back in the healthcare centre and
ascertained from the man’s Inmate Medical Record (IMR) that the doctor
had assessed him the previous day, and had prescribed two types of
medication.
27. When he was asked to attend G wing, the nurse was informed that the man
had collapsed. During interview, he told my investigator that, when he
entered the cell, the man was in fact kneeling down against the bed, facing
down onto the mattress. He had done this to achieve a more comfortable
position, as he was complaining of abdominal pain. The nurse helped the
man up onto the bed, and discussed the medication that he had been
prescribed the day before.
28. The nurse said that the man had been sick, but that the vomit contained no
trace of either bile or blood. He also noticed that the man’s lips were dry
and cracked. The man told the nurse that he had not been drinking liquids
because he believed himself to be allergic to the water at Wymott. He was
encouraged by the nurse to resume drinking water. The nurse remembered
subsequently that it was unusual for a patient to say that they were allergic
to water. There was no history of the man being dehydrated in Preston, and
the nurse considered that this was something which began in his last few
days at Wymott. The man had also told his friend and fellow prisoner about
his reluctance to drink the water at Wymott.
29. Upon examining the man, the nurse noted a slight tenderness to his
abdomen. He then verified the medication which the man had collected at
lunchtime that day. He ascribed the stomach pain that the man was
experiencing to the new medication which the doctor had prescribed the day
before, as both types are known to have the potential to cause gastric upset.
The nurse advised the man to stop taking the medications for the time
being. He told the man that healthcare staff would review his condition in
the morning with a view to referring him to a doctor if his stomach pain had
not receded.
30. The following morning (Saturday 4 October), the nurse handed over to a
colleague and asked that the man’s condition be reviewed before the doctor
arrived in case he required further examination. The nurse who checked the
man the night before did not see him again, but checked on his condition
with other staff when he returned to duty on the evening of 4 October. Aside
from the stomach pain and dehydration which the man reported, and the
gingivitis and penile ulcers which the doctor had addressed during her
examination, the nurse who checked the man the night before had no further
concerns about the man’s health at this stage.
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31. The nurse’s colleague reviewed the man’s condition in his cell between
9.15am and 9.30am on 4 October. She ascertained that indicators such as
blood pressure and pulse were within normal limits. She found that his
temperature was slightly raised. The man told her that he was feeling
better, that he was no longer vomiting, and that he was drinking a little more
water. The nurse observed that the man was less dehydrated in
appearance than her colleague had described during their handover.
32. The nurse advised the man to rest in bed and to call healthcare staff if he
felt unwell again. She considered his presentation to be improved from the
night before, and consequently did not refer him to the doctor. She was
unaware that her colleague had associated the man’s abdominal pain with
the new medication he was taking, and she was unable to recall in interview
if the man had started to take this medication again over the weekend prior
to his collapse.
The events of 5 October
33. The man was again examined by the same nurse as part of a routine visit to
G wing at 10.20am on Sunday 5 October, approximately 24 hours after her
earlier assessment. He had not asked to see a member of the healthcare
team, but the nurse had decided to check on him as a matter of courtesy, to
follow up on his previous poor presentation.
34. The man confirmed that he was no longer vomiting, was drinking and eating
again, and was feeling better. The nurse considered that the man appeared
brighter and observed no visible deterioration between 4 and 5 October.
However, she did observe bruising around the man’s eye which he could not
explain. This was the first time that a member of healthcare staff had
noticed any bruising. The man told the nurse that he had neither recently
fallen, nor been assaulted. He was unaware of the bruising until the nurse
pointed it out to him.
35. When my investigator spoke with the man’s friend and fellow prisoner he
said that the man had told him that he had fallen over, banged his head and
sustained a black eye a couple of days prior to his death. Whether this
relates to the report of a collapse which one of the nurses received on the
evening of 3 October is unclear. On that occasion, the nurse arrived in the
man’s cell to find him kneeling deliberately on the floor as a result of
stomach pain. However, the original call over the radio had related to an
apparent collapse.
36. Although the man’s friend seemed to believe that the bruising around the
man’s eye was the result of a fall, the man did not inform either nurse of any
such fall over the weekend. Additionally, the post mortem report establishes
that the bruising around the man’s left eye was spontaneous, and that there
was no evidence of an external trauma to the head from either a fall or an
assault which would have accounted for it. The author of the independent
medical report comments that the appearance of the spontaneous bruising
12
37. The nurse who checked the man on 5 October told my investigator that,
when she returned to the healthcare centre, she listed the man for blood
tests as the doctor said she had also done on 2 October. The nurse was
unable to say during interview whether she had noticed if the man was
already listed as a result of the doctor’s actions. She requested the tests
because she was concerned that the man could not explain the bruising
around his eye. The blood tests were scheduled for 10 October. In the
nurse’s opinion, this was a realistic and standard timeframe for tests to take
place. Following the results of the tests, the man would have been referred
to the doctor as appropriate. No other medical staff assessed the man
again before he collapsed later that day.
38. The man was locked in his cell at about 12.25pm. One of the required daily
roll calls to account for all prisoners was taken at approximately 12.30pm. It
is unclear exactly when the man collapsed after this check. No routine
checks of cells were carried out over the lunchtime period and the man did
not press his in-cell alarm at any time.
39. At approximately 2.05pm, the man’s cell was unlocked by an officer after the
lunch period. Cells would normally be unlocked at about 1.45pm but, as the
officer had to escort some of the prisoners to the visiting area, the regular
unlock was delayed by 20 minutes. All landings have to be unlocked
simultaneously, so the officers on other landings waited for each other
before starting to release the prisoners from their cells.
40. The officer did not look into the man’s cell when he unlocked it, and
therefore did not notice that he was in any distress. He was unaware that
the man had had any interaction with healthcare staff in recent days. Both a
Senior Officer and the officer told my investigator that the unlock after the
lunch period is not one of the occasions during the day when staff are
required to count prisoners. Wymott’s Local Security Strategy confirms this.
The officer also indicated that the man was neither considered to be at risk
of self-harm or suicide, nor to be an especially vulnerable or volatile
prisoner, and there was therefore no particular reason to check him.
41. At 2.10pm, a prisoner who was a friend of the man went to his cell to give
him some water. The prisoner was concerned about his friend’s health
because the man had been telling him that he had been feeling unwell for
just over a week. The prisoner looked through the observation flap of the
man’s cell to check if he was asleep, and saw him lying on the floor. At first,
because the room was quite dimly lit, he assumed that the man was looking
for something he had dropped under the bed. The prisoner stepped inside,
and found the man lying by his bed with his eyes shut. Realising that
something was wrong, the prisoner then went to call two officers who were
standing on the far staircase on G wing.
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42. A minute later, the two officers entered the man’s cell (the prisoner was
asked to remain outside). They found the man lying on the floor. He was
bleeding from a fresh cut above his left eye. The officers also noticed the
bruising around his eye, something already recorded by the nurse earlier
that morning. The officers found that the man’s breathing was laboured and
that he was unable to respond to them verbally. The officer relayed this
information by radio to healthcare staff, who were summoned, as were the
prison’s operational manager and the Duty Governor.
43. The situation was correctly identified by staff at this stage as a ‘code blue’
emergency. During interview, the nurse who checked the man that morning
confirmed that the use of the term ‘code blue’ indicated that the man had
been found in a state of collapse. She said that she was therefore
appropriately prepared for dealing with the emergency when she arrived on
G wing.
44. The prison’s Control Room Daily Log Sheet confirms that an officer made
the initial call on his radio at 2.12pm. Prison records show that two nurses
proceeded towards G wing upon receiving the call. The Duty Governor was
informed of what had happened at the same time. He instructed that the
man’s cell should initially be treated as a ‘scene of crime’, because there
was a possibility, from the evidence available at that stage, that the man had
been assaulted. The subsequent post mortem report makes it clear that
there was no evidence of an assault. Spontaneous bruising appeared on
the man’s face as a result of the leukaemia, and he sustained a cut to his
head as he collapsed in his cell.
45. Very shortly after he had been alerted on his radio to the unfolding situation,
another officer went to the man’s cell, followed almost immediately by a
colleague who was close by on H wing. Two of the officers placed the man
in the recovery position to make sure that his airway remained unobstructed.
One officer applied pressure to the man’s head injury in order to stem the
flow of blood from the wound above his left eye.
46. At 2.14pm, an officer contacted the prison’s Control Room to request that an
ambulance be called. A minute later, at 2.15pm, a Senior Officer attended
the man’s cell and instructed an officer to begin recording a log of events
relating to the man’s collapse. The Head of Wymott’s Offender
Management Unit also arrived on G wing at the same time.
47. Two officers continued to maintain the man in the recovery position on his
left side for approximately seven minutes. Two nurses then arrived on G
wing at 2.19pm and took over the man’s treatment. Another nurse had
collected an emergency bag from the treatment room on the wing en route.
This bag contained the equipment necessary to initially treat a prisoner who
had collapsed. Two officers remained in the cell to assist the nurses.
48. The man’s breathing was laboured, irregular and noisy. His pulse was also
irregular. He remained unconscious throughout, and an airway was
inserted. To allow this procedure to take place, the man was moved out of
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49. The man was given oxygen and staff continued to manage his airway and
assist his breathing with an ambu-bag until the ambulance arrived. (An
ambu-bag is a hand held device with a mask attached, which is used to help
patients who are having trouble breathing.) A towel was placed under his
head, and defibrillator pads were prepared but in the event they were not
required. The nurses contacted the Nursing Supervisor and asked her to
bring the man’s medical records and prescription chart from the healthcare
centre to G wing. She arrived with a colleague at 2.27pm.
50. At the same time, the Control Room was informed by staff working with the
man in the cell that his condition had deteriorated, and that an ambulance
was required urgently. Control Room staff then called for an ambulance for
a second time, and were informed that paramedics were two minutes away
from Wymott. Prison records indicate that the ambulance arrived at the
gates of Wymott at 2.31pm, and that paramedics reached the man’s cell on
G wing three minutes later.
51. The paramedics, with the assistance of two officers, then transferred the
man from his cell to the waiting ambulance. The prison’s healthcare staff
handed over to the paramedics at this stage.
52. As the man was being transferred to the ambulance, the Duty Governor
instructed the Nursing Supervisor to accompany the paramedics to the
Royal Preston Hospital in order to assist them. The Control Room recorded
that the man was still breathing but remained unconscious as he left Wymott
in the ambulance at approximately 3.06pm. The Duty Governor notes in his
statement that there was no delay in the escort leaving the prison.
53. During the journey to hospital, the ambulance stopped en route to allow
emergency treatment to be administered. The Nursing Supervisor was
required to work under the direction of a paramedic on several occasions as
a result of the man’s deteriorating condition. Two prison officers also
travelled in the ambulance as escorts, along with the Nursing Supervisor
and the paramedics.
54. The man’s Prisoner Escort Record (PER) indicates that no handcuffs were
used to restrain him during the transfer from Wymott to the hospital because
it was evident that he was in a critical condition. The hospital’s own risk
assessment confirms that no handcuffs were evident upon arrival at the
Royal Preston Hospital.
55. The man arrived at the hospital’s Accident and Emergency Department at
3.40pm and was transferred into the care of hospital staff. The PER
indicates that he was taken to the resuscitation room where he received
emergency treatment. At 3.50pm, the prison’s bedwatch log, which is
completed by the escorting officers when a prisoner is taken to hospital,
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56. The escorting officers at the hospital then spoke with the Head of the
Offender Management Unit, to advise her that the man’s next of kin should
be called. They also told her that the man had sustained a significant head
injury, and that hospital staff were concerned at this stage that there was a
possibility that he had been assaulted.
57. The Head of the Offender Management Unit consequently arranged for the
clothes which the man’s friend was wearing when he found him to be
secured, and she reported the incident to the police. The man’s cell had
already been sealed with a padlock. (Although prison staff took these
precautions, and the police conducted an investigation later that evening, it
was established that it was the man’s ill health that had resulted in him
falling and injuring his head.)
58. At 4.40pm, the escorting officers at the hospital were informed by nursing
staff that the man was very unwell. The bedwatch log indicates that the man
was taken for a CAT scan at 4.50pm, from which he returned an hour later.
This procedure assists medical staff in diagnosing tumours.
59. A short while later, at 6.10pm, having been notified by prison staff, the man’s
mother and sister arrived at the hospital. At 6.20pm, the escorting officers
were informed by nursing staff that the man had been diagnosed with
advanced stage leukaemia that may well have caused him to collapse in his
cell and hit his head as he fell.
60. At 7.10pm, the man was moved to the Intensive Care Unit at the Royal
Preston Hospital. Within the hour, the escorting officers were told that it was
likely that treatment would be withdrawn that night due to the severity of the
man’s condition. At the request of the man’s family, his life support machine
was switched off at 10.26pm. The man was declared dead a short while
later, at 11.05pm.
Events following the man’s death
61. On the following day, the Head of the Offender Management Unit
telephoned the man’s mother on behalf of the prison to express her
condolences. The man’s funeral was held on 24 October. Wymott’s family
liaison officer attended on behalf of his colleagues. The prison subsequently
met the costs of the funeral.
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ISSUES
62. A clinical review of the care the man received in custody has been carried
out. The purpose of the review was to establish whether the treatment the
man received in custody was equivalent to that which he would have
enjoyed had he been living in the community.
63. Additionally, an independent medical report has been completed at the
request of the local Primary Care Trust by an independent medical advisor.
The purpose of his report was to review the circumstances surrounding the
man’s death and the treatment he received during his time in custody. More
generally, his report also looked at the adequacy of current procedures in
place for delivering healthcare to prisoners at Wymott.
64. When the man’s mother spoke with my family liaison officer, she said that
her son’s death had come as a complete shock. Her son had visited the
prison’s healthcare centre, and she wanted to know why blood tests, which
would have highlighted his extensive leukaemia, were not carried out. In the
following section of this report, my investigator has explored this
understandable area of concern.
Given the symptoms with which the man presented, could his illness
realistically have been diagnosed before his collapse on 5 October?
65. Useful context has been provided by the prisoner and friend of the man who
discovered him collapsed in his cell. In interview, he commented that,
because of his height, slight build and pale complexion, people often thought
the man looked unwell. However, the prisoner said that the man had
enjoyed exercise and using the gym.
66. The prisoner had been acquainted with the man at Preston, and did not
observe any visible change or deterioration in the man’s condition when he
met him again at Wymott. He did say that the man seemed a little more
withdrawn at Wymott, but he also pointed out that the man tended to be
quite a self-contained person who often spent time alone in his cell. The
officers to whom my investigator spoke said that the man had been a
compliant prisoner who had not come to their attention.
67. The prisoner said that, shortly after arriving at Wymott, the man began to
complain of feeling tired and nauseous. He indicated that these symptoms
had become somewhat more marked in the days before the man died. He
also said that he had looked in on the man in the early evening on two or
three occasions, and had found him sleeping. However, the prisoner also
confirmed that he had not observed any sudden or visible deterioration in
the man’s health during the last few days of his life.
68. The man entered custody in Preston on 3 July 2008, and did not ask to be
assessed by their healthcare team at any stage prior to his transfer to
Wymott. He was subsequently assessed by four different members of the
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69. My investigator, the clinical reviewer and the author of the independent
medical report have all established that, during each examination, the
professionals involved took the appropriate course of action given the
symptoms with which the man presented at that time. Both the doctor and a
nurse did order blood tests, which would indeed have revealed the fact that
the man had leukaemia. Unfortunately, the symptoms which caused them
to order these tests only became apparent a few days prior to the man’s
death. Consequently, the tests never took place.
70. The clinical reviewer has concluded that there was no significant oversight
on the part of staff caring for the man at either Wymott or Preston which
might have contributed to his eventual death. Because the man had
previously spent time in custody, the clinical reviewer assumes that he was
familiar with the procedure for reporting ill health, and that he would have
reported additional symptoms if they had caused him discomfort. On the
evidence available, she concludes that the man only began to experience
these more pronounced symptoms in the last few days of his life.
71. The independent medical report similarly concludes that the healthcare staff
who assessed the man at Wymott made appropriate decisions on the basis
of the evidence available to them at the time. He comments that record
keeping amongst healthcare staff was of a good standard, and that all
members of the team were appropriately trained to carry out their duties.
72. The author of the independent medical report has found no evidence from
the medical records held by the man’s GP to indicate that he had reported
experiencing any chronic health problems such as leukaemia before he
entered custody in July.
73. With regard to the doctor’s assessment of the man on 2 October, the author
of the independent medical report agrees that she acted reasonably in
prescribing antibiotic medication to treat what was presumed to be a simple
bleeding of the gums. With the benefit of hindsight, he confirms that it is
possible to link the symptom of bleeding gums with the leukaemia which we
now know caused the man’s death. However, he is of the opinion that the
doctor’s decision on treatment at the time, without the benefit of hindsight,
‘was entirely reasonable’. Similarly, the clinical reviewer is of the opinion
that the doctor acted appropriately in light of the symptoms which the man
reported to her.
74. As regards the nurse’s actions on 3 October, the author of the independent
medical report believes these to have been reasonable and appropriate
given the symptoms with which the man presented. He endorses the
nurse’s presumption that the man’s stomach pains were most likely a side
effect of the antibiotics prescribed the day before.
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75. The author of the independent medical report considers that another nurse
made an appropriate decision in listing the man for blood tests after she
noticed spontaneous bruising around his right eye on 5 October. This nurse
had checked on the man that day as a matter of courtesy. He had not
asked to see a member of the healthcare team, but she wished to follow up
on her examination of him during the previous day.
76. With the benefit of hindsight, the author of the independent medical report
does highlight that a link between spontaneous bruising and bleeding gums
could have been made on 5 October. Making this link would have led staff
to consider the possibility of a diagnosis such as leukaemia. Had they done
so, they might then have ordered emergency blood tests on the same day.
However, a potential delay ordering blood tests would not have made any
difference to the eventual outcome. The man’s leukaemia was far too
widespread at this stage, and he collapsed in his cell just a few hours later.
77. The author of the independent medical report suggests that the link between
bleeding gums and the appearance of spontaneous bruising in the man’s
case provides a learning opportunity for the staff at Wymott. He
recommends that the Head of Healthcare should ensure that the man’s case
is reviewed, something which has not happened thus far. He suggests an
increased emphasis on these types of case reviews, or learning
opportunities, within the healthcare team at Wymott, so that lessons can be
learnt for the future. I endorse his recommendation.
78. Wymott’s healthcare centre is currently undergoing some renovation.
Consequently, the working environment is under some pressure. The
author of the independent medical report points out that these changes have
delayed appointments offered to prisoners. However, he does not consider
that the changes affected the treatment which the man received.
79. Nonetheless, the author of the independent medical report is of the opinion
that the completion of alterations to the clinical accommodation at Wymott,
the full installation of electronic patient record keeping, and the reduction of
GP waiting times, remain a priority. He recommends that these issues are
addressed within the next three months. I note that my earlier investigation
into the death of another prisoner at Wymott, completed in June 2008,
raised some of the same matters. At the time, the electronic patient record
keeping system was scheduled to be completed in September 2008.
The Governor of Wymott should review the progress made in relation
to the ongoing improvements to the healthcare centre at Wymott. He
should work with the Head of Healthcare to ensure that changes and
works are completed as soon as possible and do not impact negatively
on the levels of patient care.
80. In the longer term, the author of the independent medical report
recommends that Wymott should ensure that the prisoners within its care
have access to a chronic disease management clinic. He suggests that all
healthcare staff should receive the relevant training to run these clinics.
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Why did staff not discover that the man had already collapsed in his cell when
they unlocked on G wing after lunch on 5 October?
81. The man was locked in his cell on G wing over the lunchtime period on 5
October, as were all the other prisoners. An officer has confirmed that he
unlocked the man’s cell at about 2.05pm. The officer told my investigator
that unlock would normally take place at approximately 1.45pm, but that he
was delayed because he was taking prisoners to the visiting area. When he
unlocked the cell, the officer said that he did not look through the
observation flap which is built into the cell door, and therefore did not see
the man in a collapsed state on the floor.
82. Wymott has developed its own Local Security Strategy, which is based upon
the Prison Service’s National Security Framework. Within this document, it
is clearly stated how often and when all prisoners must be accounted for.
(In other words, the number of times a roll call is to be conducted during
each 24 hour period is clearly laid out for all staff.) These regular checks
both ensure security and allow staff to confirm that each prisoner is safe.
On this occasion, Wymott’s Local Security Strategy was correctly
implemented. It instructs that prisoners must be accounted for six times
each day, at approximately 6.00am, 7.45am, 12.15pm (at the lock up for
lunch), 5.00pm, 8.15pm and 9.15pm.
83. There is therefore no requirement to make a visual check on a prisoner
during the unlocking of cells after the lunch period. For this reason, the
officer did not look through the observation flap when he unlocked the man’s
cell. He simply went on to unlock the other cells. Within a few minutes, a
fellow prisoner had found the man. Given the man’s eventual diagnosis of
widespread leukaemia, the minutes during which he lay undiscovered in his
cell were not pivotal to his subsequent death. Additionally, whilst the short
delay in finding the man after the unlock was most unfortunate, there was no
actual obligation for a member of staff to check on him at that time and there
should be no criticism that they did not do so.
84. That said, the Senior Officer did tell my investigator that he always looks
briefly through the observation flap when he unlocks, as he was used to
doing so as a matter of habit when he worked on another wing with more
volatile, higher risk prisoners. He suggested that it would be a workable and
realistic aim for staff to observe prisoners very briefly during the unlock after
lunch. He pointed out that each observation would take a matter of
seconds. Although such a policy would not have changed the outcome so
far as the man was concerned, there may be situations when a few minutes
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The response to the man’s collapse on 5 October
85. Having spoken with healthcare staff who assessed and treated the man both
in the days before he collapsed and during the emergency on the afternoon
of 5 October, my investigator is satisfied that all concerned acted
appropriately in addressing the man’s symptoms, and subsequently his
collapse. The clinical reviewer says that healthcare staff at Wymott should
be commended for their assessments and the follow up care administered to
the man between 1 and 5 October. She also notes that both healthcare staff
and prison staff demonstrated a high degree of professionalism and
excellent teamwork in dealing with the man’s collapse and his subsequent
transfer to hospital.
86. Given the man’s very poor health upon leaving Wymott in the ambulance,
the decision was made that he should not be cuffed. This was an
appropriate decision, respectful to the man. It also ensured that, when his
relatives arrived at the hospital later that day, they were not unnecessarily
distressed. I also note that staff at Wymott notified the man’s next of kin
promptly, allowing them to travel to the hospital immediately and to be with
him.
Staff support
87. As I have reported, my investigator conducted interviews with four members
of Wymott’s healthcare staff, two prison officers, and the prisoner who
discovered the man collapsed in his cell. I am satisfied that they have all
been properly supported since 5 October. Staff thought they had been
adequately debriefed, and were offered access to the local care team. All
considered that their needs had been met. The prisoner who was the man’s
friend felt unable to continue on G wing because he was reminded of his
involvement in discovering the man. Staff accommodated his wish and
moved him to another wing straightaway.
Conclusion
88. The death of the man was sudden and unexpected. However, while my
investigation has pointed up a number of matters that both the Governor and
Head of Healthcare at Wymott may wish to take forward, I do not believe
that there were any failures in the care offered to the man while he was in
custody.
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RECOMMENDATION
The Governor of Wymott should review the progress made in relation to the
ongoing improvements to the healthcare centre at Wymott. He should work
with the Head of Healthcare to ensure that changes and works are completed
as soon as possible and do not impact negatively on the levels of patient care.
The prison accepted this recommendation at draft report stage and
responded,
‘Alterations to clinical accommodation are now complete.
The cabling for electronic patient record keeping is in progress. Several areas
have already been cabled and the wings are currently being cabled. The
estimated date for completion of these works is June 2009.
GP waiting times have significantly reduced since the report was published
and waiting time is now less than a week.’
THE RESPONSE OF THE FAMILY TO THE DRAFT REPORT
The man’s mother has responded to the draft report, for which I thank her. In
her letter, she raised several concerns. She expressed her belief that her son
was prescribed the wrong medication before his death, causing him to
collapse in his cell and sustain a head injury from which he did not recover.
The medication the man was prescribed appropriately in the days
before he died were intended to address relatively minor complaints,
namely penile ulcers and gum disease. These medications can have
side effects, causing nausea and such like. The man was advised to
stop taking them for the time being when he felt unwell on 3 October.
These medications had no bearing on the cause of his death. The post
mortem report confirms that the man collapsed in his cell as a result of
a brain haemorrhage, caused by extensive and undiagnosed
leukaemia. He sustained an injury to his head when he fell, but the
cause of death was the haemorrhage in his brain resulting from the
leukaemia.
The man’s mother feels that her son should have undergone blood tests,
which would have identified his leukaemia and allowed treatment to begin at a
much earlier stage. She considers that a blood test would have saved his life.
The man died as a result of undiagnosed and advanced leukaemia.
Blood tests had been ordered which would have revealed this form of
cancer, but had not yet taken place when the man collapsed. The man
was very unwell at this point, but had only started to present with
symptoms in the last few days before he died, which was why no blood
tests had been ordered at an earlier stage.
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The man’s mother believes that when her son arrived at Wymott in July, he
was a fit man.
It is impossible to speculate about the length of time the man had been
living with leukaemia, or how far advanced his condition was when he
arrived at Wymott. Given the extensive spread of the illness by the
time he died, it seems probable that it had been progressing for some
considerable time, but remained undiagnosed. I have found no
evidence of any causal relationship between the man’s illness and his
time in custody.
The man’s mother believes that the filthy state of her son’s cell and the poor
quality of the tap water caused him to acquire a serious blood infection.
There is no evidence in any of the reports prepared by medical
professionals that the man had a blood infection. He had a form of
cancer, which would not have been related to either the quality of the
tap water or the hygiene in his cell. My investigator visited the cell
where the man stayed. It was of a comparable standard to other prison
accommodation of the same build and age.
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