Individual at Peterborough

Investigation into the circumstances surrounding the
death of a man at HMP Peterborough
in December 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2010
This is the report of an investigation into the circumstances of the death of the man
in December 2009. During the morning, he complained of feeling unwell when he
was unlocked to attend court. About an hour later, at 7.40am, staff discovered him
unconscious. Cardio pulmonary resuscitation was carried out by staff but, sadly, he
was pronounced dead by paramedics at 8.16am.
The post-mortem report indicated that the man died from bronchopneumonia (an
infection of the lungs). He was found to have enlargement and scarring of the heart
thought to be due to previous cocaine use which made him more susceptible to an
abnormal heart rhythm, especially once his health was compromised by the
pneumonia. He was 30 years old.
I would like to offer this public expression of condolences to the man’s family on their
loss. A key objective of all my investigations is to ensure that the bereaved family
has the opportunity to raise any concerns and contribute to my inquiries. His mother
raised a number of matters with one of my family liaison officers. I hope my
investigation begins to offer answers to their questions. I am sorry that it has been
delayed.
The investigation was carried out by my colleague. I am grateful to the clinical
reviewer of the local Primary Care Trust (PCT) who carried out the clinical review. I
would also like to thank staff at HMP Peterborough and, in particular, the liaison
officer for their co-operation with this investigation.
The man was in Peterborough for six weeks from 15 October until 24 November and,
upon reception on that occasion, presented with an alcohol problem. However, he
was not viewed to be in need of a detoxification. This was his first time in prison.
Having been released on 24 November, he returned again to Peterborough on 3
December. During his time out of prison, he said he had started to use heroin. He
was given an opiate substitute while he was in police custody. Upon reception at
Peterborough on 3 December, he began a methadone programme as a result of
what appeared to be withdrawal symptoms, and a positive drug test. Staff were
unaware of any underlying illness. He reported feeling unwell on the morning of 8
December but this was not treated with any sense of urgency. He was found
unconscious an hour later.
My report contains six recommendations, many of which echo those in the clinical
review. They concern placing detoxing prisoners on ordinary location and the
subsequent limited monitoring they receive as well as the requirement for discipline
staff to contact medical staff if a prisoner is unwell.
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
investigations.
Jane Webb
Acting Prisons and Probation Ombudsman November 2010
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CONTENTS
Summary
The investigation process
HMP Peterborough
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was in HMP Peterborough from 15 October until 24 November 2009. This
was his first time in prison and, during the reception health screen, he was identified
as having an alcohol problem. It was noted that he was concerned about chest
pains and palpitations related to previous cocaine use but that he had not used the
drug for 18 months. He was released on 24 November having had only routine
entries on his clinical record during his time in custody.
On 1 December, he was arrested for being drunk and disorderly and spent the night
in the police station before being released on bail in the morning. Later that day, he
was arrested again for the breach of a restraining order at his mother’s house. He
saw a health care professional during the evening and admitted taking heroin and
drinking a considerable amount. The following morning, 3 December at 8.35am, he
saw another health care professional, and was given Dihydrocodeine (60mg),
diazepam (10mg), and Citalopram (60mg). He later appeared at court and was
remanded to Peterborough prison until 8 December.
On 3 December, during his reception health screen, the man told the nurse he was
struggling with drug withdrawal symptoms. He was drug tested and gave a positive
test for opiates and benzodiazepine. He was then seen by Prison Doctor A (who
had previously seen him on 16 October and identified alcohol abuse), and told him
he had started to use heroin during the past few days. A methadone stabilisation
programme was put in place and he was given 15mls of methadone. He was not
taken to the stabilisation wing but instead was taken to an ordinary wing where he
shared a cell with a cellmate.
Over the next few days, the man’s methadone was increased daily by 5mls reaching
30 mls on 7 December, which is a standard prescription. There are no additional
entries on the clinical record and he does not seem to have come to the attention of
medical staff in any other way. One member of the discipline staff recalled him
appearing unwell and told him to go to the medication hatch to see a nurse. This is
not recorded anywhere and it is not known whether he followed the advice. The
cellmate described him as being unwell throughout the entire time, which he thought
was due to drug withdrawal.
At 6:35am on 8 December, the day the man was due in court, he was heard crying
out for help. He was seen by an officer (new to Peterborough and first day on the
wing) and said he felt very unwell and had never felt like it before. The officer spoke
to more experienced and senior staff, one of whom went to see him 15 minutes later.
He groaned at him and the officer went away and took no further action. He was
seen again when staff went to collect prisoners for work about 7.45am. He was
found unconscious and cardio pulmonary resuscitation was performed by discipline
and healthcare staff. Paramedics arrived at 7.55am but he was pronounced dead at
8.16am.
Six recommendations have been made including monitoring prisoners on ordinary
location when they are stabilising/detoxifying and the requirement for wing staff to
contact medical staff if a prisoner presents as unwell.
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THE INVESTIGATION PROCESS
1. Initially, the documentation in relation to the man was sent to my investigator.
She visited HMP Peterborough on 21 January and was shown the cell where
he had died. She interviewed four staff and the prisoner who had shared the
man’s cell. On another occasion, she interviewed one member of staff at his
home as he was off sick at the time.
2. During the initial visit, telephone contact was made with the Independent
Monitoring Board (IMB) and my colleague gave them the opportunity to meet
her to discuss any issues of relevance they may have had. The chairman
said he would discuss with his colleagues but no further contact was made
with my investigator.
3. The investigator spoke with the man’s solicitor who represented him in the
past as well as the solicitor who was presented in court on 3 December. She
also contacted the man’s probation officer who provided a copy of his Pre-
Sentence Report. All three provided useful background information.
4. My investigator made contact with the police officer investigating the death.
He provided her with copies of the police custody records for both 1 and 2
December.
5. The clinical review was carried out by a clinical reviewer on behalf of the local
Primary Care Trust and joint interviews of a number of medical staff were
carried out on 23 February. At that stage of the investigation, the cause of the
man’s death was not known and it was not clear which aspects of his care
would be most relevant to his death. Consequently, two staff from the
Integrated Drug Treatment Service (the clinical lead and lead nurse) were
interviewed as he had been prescribed methadone in Peterborough as part of
the policy. Neither had had any personal contact with him but were able to
provide an overview of the service. My investigator and the clinical reviewer
met with the (former) Director to provide feedback.
6. The investigator spoke with the coroner and the pathologist who conducted
the post mortem with regard to further questions from herself and the clinical
reviewer. As part of his review, and with the support of the coroner, the
reviewer interviewed, by telephone, two health care providers (HCP) who
treated the man in police custody. They were able to provide extra
information that they had not recorded on the medical forms (Detained
Persons Medical Form). He also spoke with the pathologist.
7. One of my (former) family liaison officers contacted the man’s mother offering
the opportunity to meet herself and the investigator. His mother declined the
invitation but telephone contact was maintained. Specifically, she said that
her son was not a heroin user and wanted to know why he had been
prescribed methadone.
8. A draft version of this report was sent to the Prison Service and their response
to the recommendations has been repeated verbatim in section. The man’s
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mother provided some additional information after she received the draft and
this is included on page 7.
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HMP PETERBOROUGH
9. HMP/YOI Peterborough opened in spring 2005 and is the only prison that
holds both men and women, though they are held wholly separately. It is
privately run by Kalyx, who also run HMP Bronzefield and Forest Bank in
England, on a 25 year contract. The male side of the prison can hold 624
prisoners.
10. The male residency unit has two house blocks made up of four wings of two
landings, each wing being self-contained. Each block has a central hub from
which officers can respond directly to the ringing of cell bells via a speaker.
11. The first inspection of the male side of the prison at Peterborough by the
former Majesty’s Chief Inspector of Prisons took place in October 2006 and
was followed up in July 2008. The second inspection found that staff-prisoner
relationships remained the prison’s weakest link.
12. At the time of the initial inspection, the Chief Inspector found that the provision
of healthcare was amongst the worst the inspection team had seen for some
considerable time. However, by the time of the follow up inspection, they
found that healthcare had improved “but there remained much to be done.”
13. Since 2008, the responsibility for the provision of primary health services
transferred to Kalyx. Greater Peterborough PCT Partnership (now NHS
Peterborough) had commissioning responsibility for some health care
services. It was also the provider of primary nursing and associated
administration until February 2008 when Kalyx took over these services.
Commissioning mental health in-reach and secondary care remain the
responsibility of NHS Peterborough.
14. In late 2009, the Integrated Drug Treatment Service (IDTS) was set up in
Peterborough. The ITDS is a national programme designed to increase
volume and quality of drug treatment available to prisoners.
15. Prisoners with a heroin problem who need to be stabilised are generally
placed on wing, X1, where they usually remain for at least five days, known as
stage 1. As outlined in the guidance Clinical Management of Drug
Dependence in the Adult Prison Setting (Department of Health 2006)
prisoners:
“should initially be accommodated on a unit that offers access to
unrestricted 24-hour observation, utilising open healthcare hatches where
they have been installed. When new-builds or refurbishments are
undertaken, these facilities should be created.”
16. Following the five day stabilisation, prisoners are able to move cell location
where they continue to be monitored but not as closely. The stabilisation unit
monitors withdrawal and the prisoner’s response to treatment, for example
that they are not over medicated indicated by being over sedated.
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Additionally, “ongoing clinical monitoring is valuable as the early symptoms of
drug withdrawal may mask a separate underlying physiological condition”.
17. By February 2010 when staff were interviewed for this investigation, the
clinical lead stated that the IDTS at Peterborough was only 75 percent
towards being fully set up. Therefore, in December 2009 when the man was
there, the service was even less developed.
18. There were four other deaths at Peterborough in 2009. Only one of which has
been to inquest. The reports into the circumstances of the remaining three
deaths are awaiting the inclusion of clinical reviews which have yet to be
completed by the PCT.
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KEY FINDINGS
19. The man had previously been remanded to HMP Peterborough on 15 October
2009. On that occasion, he was identified by Prison Doctor A as having an
alcohol problem although this was not identified as severe enough to need
treatment for withdrawal. He was, however, prescribed a short night time
course of Zopiclone to help him sleep. It was confirmed with his community
General Practitioner (GP) that he had been prescribed Citalopram (60mg), an
anti-depressant, and this was continued whilst in custody. It was noted that
he was concerned about chest pains and palpitations related to cocaine use,
but that he had been drug free for 18 months.
20. He was released on 24 November 2009 having had only routine entries on his
clinical record during his time in custody. In his wing history sheet, he was
described as having:
“exceptional behaviour on the landing, respectful and polite to the wing
staff, interacting very well with the staff and adherence very well to the
regime, no issues at all”.
21. In the early hours of 2 December, the man was arrested for being drunk and
disorderly at a hospital. He was later taken back to hospital by the police but
discharged into their care within a couple of hours so he could “sober up”
under regular and frequent observations. He was bailed to appear at court at
a later date and released that morning at 9.00am from the police station.
22. Later that day, at 7.25pm, the man was arrested at his mother’s house for
breaching an injunction and was described by arresting officers as being
intoxicated. He told officers he had drunk a large amount of alcohol and was
a user of heroin and cocaine and that he had a heart condition. At 9.10pm, he
was seen by a health care professional (HCP) who recorded that “DP
[detained person] is clearly under the influence of something, admits to using
heroin today and drinking heavily today”. No medication was prescribed and
the HCP recommended a review the following morning. He was not drug
tested as his alleged offence was not one which automatically prompts a test.
23. In Cambridgeshire Police Constabulary the healthcare staff attending their
police stations are from the G4S Forensic and Medical Services Ltd (known
previously as EMFS). They are referred to as health care professionals
(HCPs) and are used as a substitute service for forensic medical examiners
(FMEs - previously known as police surgeons and general practitioners).
Their website says:
“There are over 100 paramedics working with us providing cover on shifts
in their off duty from the ambulance service. They work under the direct
supervision of experienced FMEs until they have a prescribed level of
experience at which point they manage specified cases independently
under strict protocols. Until then they call every job through the FME for a
decision on management, fitness to detain and so on. Paramedics are
local to their patch and usually know their local custody staff well and this
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has greatly improved relations between forensic medical teams and the
police.
24. The clinical reviewer spoke to the HCP who saw the man that evening. The
HCP said that in addition to the notes he made on the Detained Persons
Medical Form (DPMF) he also made other notes which he referred to when
speaking with the reviewer. The HCP told him that the man said that for the
previous nine days, since being released from prison, he had started to use
intravenous (injected) heroin bought from the streets as well as large
quantities of alcohol. He admitted using crack cocaine and heroin on 2
December, but previously had just used heroin and alcohol. His heroin use
was recorded to be one to two bags (£10-20) on most days. He had
occasionally smoked it but usually injected it.
25. During the medical review, the man was alert and compliant but complained
of shivering and being cold but had no other symptoms of opiate withdrawal
such as anxiety, itching, abdominal cramps or diarrhoea. The HCP examined
him and noted that he had needle marks on his arms suggesting intravenous
drug use. He also examined his chest in detail and found nothing of concern.
His condition was considered safe to allow detention, with instructions that he
should be reviewed again by a HCP after six hours.
26. The following morning, 3 December, the custody record shows that at
6.32am, the man said that he was starting to suffer from withdrawal symptoms
but was happy to wait until he got to prison before seeing the doctor. At
7.13am, it is again recorded that he declined to see the doctor for his
withdrawal symptoms. However, at 7.18am, it is recorded that:
“EMFS call centre contacted due to the effects the DP is suffering from.
G4S [the company that escorts prisoners to court] have been notified to
delay transportation to court”.
There is no explanation of why he was to be seen by medical staff when he
said he was well enough to wait until he reached Peterborough.
27. At 8.24am, the man was seen by the HCP who concluded he was suffering
from withdrawal and prescribed three medications. They were:
 60mg Dihydrocodeine (an opiate drug used for routine pain relief in
moderate pain but with heroin like effects on the heroin receptors of the
brain)
 10mg Diazepam (an anti-anxiety treatment for alcohol and opiate
withdrawal states)
 60mg Citalopram (anti-depressant).
Again, the clinical reviewer spoke with this HCP who had also seen the man
36 hours earlier. He said that by this time he had begun vomiting which he
suspected was the result of drug withdrawal. The man again said that he had
used heroin over the last few days. On examination by the HCP, he was
alert, but yawning, had goose bumps on his skin, a runny nose and eyes, a
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raised pulse rate. His chest was examined and found to be clear. Medical
advice was sought from the FME by telephone who concurred with the
diagnosis of opiate withdrawal.
28. The man later appeared at court and was remanded until 8 December. The
solicitor representing the man said he saw him at about 2.30pm at court. He
said that he appeared ‘chipper’ and did not complain about feeling ill. He said
that drug use was not mentioned either to him by the man or during his court
appearance. The solicitor thought that only alcohol had been mentioned as a
factor in his arrest by the prosecution. He said that the man did not want to
apply for bail and understood that his mother could not accommodate him any
more.
29. The man arrived at Peterborough at 5.10pm. The Prisoner Escort Record
(known as the PER, which is use to communicate any areas of risk between
the different criminal justice agencies) identified him as having drugs/alcohol
issues. It did not mention that he was given medication at the police station
and it did not indicate whether the DPMF was attached to the PER as it
should have been. In reception, he went through the routine paperwork,
describing himself as a butcher and providing his mother’s details as his next
of kin.
30. A Cell Sharing Risk Assessment (CSRA - used to assess whether a prisoner
is suitable to share a cell) was completed and the man was assessed as a
medium risk to others. It is recorded that he had concerns about sharing a
cell. The officer recorded that the man said he “got angry/frustrated quickly”,
suffered from depression and was “rattling” (a term used to describe the
effects of withdrawing). The CSRA was also ticked to confirm that he said he
had previously been on ACCT monitoring (Assessment, Care in Custody and
Teamwork – used to identify and support those at risk of self-harm and
suicide). (However, there is no evidence from his previous time at
Peterborough to suggest he had been on an ACCT. He had told the
probation officer that he had been banging his head against the police cell
wall after being arrested in October which is confirmed in the police custody
records.)
31. Nurse B was on duty in reception and she completed some routine paperwork
about the man. As part of her duties she completed section 3 of the CSRA,
assessing him as a low risk to others and with no concerns about self-harm.
Not all of the form was completed and section 4, which should be completed
by the officer who allocates the prisoner into a cell was not filled in.
32. In interview, the nurse, although unable to recall him in any detail, explained
that for a person returning to prison after a brief period in the community, she
would not undertake a full reception health screen. Instead, she would ask
whether there had been in changes from the time when they were in before.
She recorded in his clinical record that:
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“returned after 1 week struggling with drug withdrawal, drug screen re
done, physical general health good but scarred heart from drug use.
Mental health depression but normally copes well until drug use”.
His urine drug test was positive for opiate and benzodiazepine and she
referred him to the doctor.
33. Nurse B completed a Mental Health Reception Assessment and the man said
he felt he had mental health problems. He said he was depressed but not
suicidal although he had attempted suicide five years before. She did not
refer him for a mental health assessment because he had been referred for
an assessment on 15 October. However, the previous medical records do not
show that this assessment was carried out.
34. Later that evening, Prison Doctor A saw the man (who he had previously seen
on 16 October and identified alcohol abuse). (The clinical record records that
the doctor saw him on 4 December. However, in interview he explained that
he had not had access to a computer at the time and so had written his notes
up the next morning which the system recorded as taking place at that time.)
The note in the clinical record reads:
“patient was released from this prison on 24/11/09 which was 9/7 [nine
weeks] ago. Patient stared to use heroin £10-20 worth daily, injecting,
also started to drink again about 0.7 litres of vodka and 2-4 litres of cider.
Patient presented severe withdrawal symptoms yesterday: very shaky,
abdominal cramps etc. Methadone titration was started yesterday and his
received methadone 15mls last night. In addition Zopiclone for 5/7 [five
days] and supportive meds [medication] for 7/7 [seven weeks].”
35. The man was prescribed Zopiclone, supportive medication and Citalopram.
He was given 15mls of methadone in line with their IDTS policy.
36. In interview, Prison Doctor A remembered the man very well and recalled
having a conversation with him regarding his declared use of heroin. The
man said he used heroin for the first time whilst he had been out of prison for
nine days. He said that he had been depressed, had started to drink again
and had used heroin for the first time. The doctor said that he stood out in his
memory because his presentation was unusual in that he had not previously
used heroin, but had started within the last nine days and was already
experiencing withdrawal symptoms.
37. Again at the time of my investigator’s interview with Prison Doctor A, the post-
mortem results and the cause of death were unknown. The doctor said that
the man was shaky and not looking well but he did not present with any pain
or any physical problems. He said that the man told him he was injecting
heroin but could not recall whether he had checked his arms for evidence of
needle sites. Neither the doctor or nurse recalled seeing the DPMF from the
police and so they did not know that he had been given medication which
might have caused the prison drug test to be positive.
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38. The man was not located to the detoxification/stabilisation wing, known as X1.
In interview, neither the doctor nor nurse were aware of any system which
meant that they could direct where in the prison to house a drug user. Instead
he went to W1-15. His wing history sheet was stamped to say that he was
detoxifying.
39. The man’s mother told my family liaison officer that he telephoned her on
Thursday 3 December. She said he sounded very drowsy and told her he did
not feel well.
40. On 4 December, it is recorded in the man’s history sheet that he did not
require an induction as he had been in prison before and he had no issues.
He was moved into cell Y1-14 and his cellmate was already there. This was
the last cell on the first floor and the one furthest away from the wing office
and the hub. The cellmate recalled having seen the man around the wing
previously but did not know him. In interview, he said that the man was
suffering with hot and cold sweats during his time there and he thought he felt
at his worst in the mornings. He also said that the man told him that he used
heroin for the first time when he had been released.
41. Later that day, 4 December, the man was given 20mls of methadone.
Medication is given out in the morning and prisoners have to go to a
medication hatch to collect it. Over the next few days, he was given an
increasing dose of 5mls of methadone per day reaching the standard
maintenance dose of 30mls daily on 6 December.
42. The following day, 5 December, PCO (Prison Custody Officer) A introduced
himself to the man as his personal officer. He recorded that he knew him
from his last stay on the wing. He was described as polite and respectful, and
no issues were raised.
43. At some point over the weekend, PCO A recalled seeing the man and stated
“he was a little bit shaky, he was trying to hold his water and he was making
some funny noises”. The PCO said he told him to go straight to the front of
the medication hatch. He said the man came back but did not say anything
so the PCO assumed that he had been dealt with by medical staff.
44. Cell bell records show that on 7 December the cell bell was rung at 7.10am
and 8.48am. The cellmate remembered the man ringing the cell bell the first
time and complaining that his medication was not working and he needed
something to help him. He said that the man was told he would have to wait
for the medication round. He went to work before the man rang the bell the
second time. In Peterborough, the cell bell can be answered from a central
hub from where staff can speak to prisoners without going to the cell to see
and speak with the prisoner.
45. The man saw a member of the CARAT team later on 7 December with
reference to trying to arrange a methadone prescription should he be released
from court the following day. She recorded that she explained what he
needed to do the following day and he was happy with the arrangements.
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The same day he wrote to his mother asking for money to buy cigarettes,
saying that taking methadone increased his smoking habits.
46. Later that evening, PCO B said he recalled seeing the man in the cell sitting in
his bed talking to his cell mate when he did the roll count at approximately
7.25pm.
47. The man was due to appear at court the next day, 8 December. PCO C, who
had recently started at Peterborough and was on his first morning on duty on
the wing, was responsible for conducting a roll count on the wing before
unlocking prisoners for court that day. He described that at about 6.35am, he
heard someone crying out for help as he walked down the wing so he went to
unlock the cell. He went into the cell and turned on the light and the man told
him he felt very unwell. He gave him a glass of water and asked him to sit up
which he did, although he had to lie back down again as he said he was dizzy.
The cellmate, who was sleeping on the bottom bunk, told him that the man
was detoxifying. Given that the man was due in court that day, the PCO
asked him if he would be going to which he replied that he did not feel right
and had never felt like that before.
48. The cellmate told the investigator that the man said he could see in black and
white and needed help. He got him a couple of bottles of water as he could
not get out of bed. He said that he repeatedly asked for help and had been in
a similar state on other mornings. However, on those occasions he could get
out of bed and did not describe seeing everything in black and white. He
asked him if he was going to get his medication and he said no.
49. PCO C did not know whether it was appropriate for him to telephone Hotel 3
(the medical emergency nurse in the prison) so he spoke to two more
experienced and senior staff, SPCO (Senior Prison Custody Officer) A and
PCO D, on the wing. He explained that the man said that he did not feel right
although without making a specific complaint, and said that he was not going
to court. PCO D said that he would go and see him, which he did at
approximately 6.50am. He was familiar with the man as the officer in charge
of the wing. In interview, PCO D said that he asked him why he was refusing
to go to court. In response, he groaned at him and he left the cell and
continued with the morning duties.
50. In interview, PCO D said that prisoners regularly refused to attend court.
Rather than interrupt the rest of the morning regime, he said that staff deal
with them later in the morning and often prisoners decide to go on their own
accord at unlocking time. The court is contacted by reception staff to see if
the prisoner has to attend and “in the worse case scenario” they could be
taken under restraint. He said that because he had not been told anything
specific about how the man was feeling, such as having chest pains, and he
did not tell him anything, he did not consider radioing for medical staff to
assess him. The PCO explained that medical staff come to the wing every
morning at approximately 8.00am to give medication and they might assess a
prisoner at the request of staff.
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51. At 7.15am, when all the cells were unlocked, the cellmate left the cell. PCO A
was the officer responsible for unlocking the man’s cell that morning but said
in interview that this does not require the staff to look in the cell.
52. PCO B was responsible for collecting prisoners to go to work that morning.
He spent some of the early morning in the office dealing with queries and
paperwork. The cellmate had approached him saying that he wanted another
cellmate as the man was keeping him awake in the night because he was
detoxifying. In interview, the PCO said that he believed that the man was on
the work list which was why he went to his cell (my investigator has been
unable to confirm whether this was the case or not). He arrived at the cell at
about 7.45am. PCO B shouted his name a couple of times, hit his clipboard
against the door and kicked the door. The man, who was in the top bunk, did
not respond. He went into the cell and touched the man’s lower leg, which
was sticking out. It was cold to touch, and the PCO stepped forward to look at
his face as he was lying on his front. He was pale and did not look well and
the PCO realised that something was wrong.
53. PCO B said he shouted down the landing to PCO A to “get SPCO A”. PCO A
ran to the hub and knocked on the window for the SPCO and they both ran to
the cell. Meanwhile, PCO B pressed his personal alarm and called for
medical assistance over his radio. He turned the man on to his back and,
within seconds, he said that the SPCO was there beside him. He started
mouth to mouth breaths and the SPCO did compressions as they stood on
the bottom bunk.
54. Very quickly the orderly officer (the most senior member of the discipline staff)
entered the cell and saw the officers carrying out CPR on the man. He
immediately called for an ambulance over the radio at 7.50am, and asked
staff to move the man on to the floor, which they did.
55. At this point, the emergency nurse and health care assistant (HCA) arrived.
Nurse C took over from the officer giving breaths and tried to get an airway
into his mouth. Unfortunately, the man’s jaw was tightly shut and she was
unable to do so. Instead, she gave oxygen using a normal mask using a jaw
trust to keep the airway as open as possible. The emergency bag, which was
kept in the hub, about 50 yards away, was collected by the HCA. The HCA
arrived and started to use an Ambu bag. She also used the defibrillator which
advised not to administer an electric shock and continue with CPR.
56. The paramedics arrived at 7.55am and continued to treat the man. Sadly, he
was pronounced dead at 8.16am.
57. The Director of the prison and a prison family liaison officer went to break the
news of the man’s death to his mother that morning. She lives with her
elderly mother. Over the next few days, she said that she would prefer all
contact with the prison to be carried out by her son as she found it upsetting.
The prison paid for the funeral and three members of staff attended including
the Director.
15
ISSUES
The man’s time in police custody
58. The man was released from Peterborough on 24 November. He was at
liberty until the night of 1 December which he spent in police custody and was
released in the morning of 2 December. Later that same evening, he was
arrested again and spent the night in police custody. On this second
occasion, he declared using heroin over the past nine days and saw a health
care professional at 7.25pm that evening. He was reported to be alert and
compliant and no medication was prescribed. At 7.13am, he declined the
offer of seeing a doctor until he got to prison but custody staff did call the
Forensic Medical Service. The HCP prescribed Dihydrocodeine when he saw
the man an hour later. Given that he expressed the wish to wait to see the
prison doctor, the decision to prescribe medication to relieve withdrawal
symptoms at that time, appears surprising. However, the actions of the staff
at the police station are beyond the remit of this investigation. A copy of this
report will be shared with Cambridgeshire Police Constabulary.
59. The HCP completed a Detained Persons Medical Form which should have
been attached to the PER which accompanied the man to Peterborough.
Usually the report comes within an envelope marked “medical in confidence”
and its purpose is to outline any medical concerns and actions taken by
medical staff at the police station. In interview, the prison nurse, Nurse B,
could not recall seeing the form (albeit she could not recall him in any detail)
and it was not given to my investigator as part of the documents received from
the prison following his death. Either the form did not travel to Peterborough
or, upon arrival, it was misplaced.
Medical records should always accompany prisoners from police
detention to prison admission and be given to the medical staff upon
arrival.
Were appropriate decisions taken as to where the man should be located?
60. Nurse B completed a shortened version of the first reception health screen on
3 December as the man had only been released a few days earlier. She
referred him to Prison Doctor A who interviewed him. Having given a positive
drug test for opiates, appearing to be withdrawing and saying that he had
used heroin over the past few days, he was assessed as appropriate for
methadone stabilisation.
61. Peterborough has a wing, X1, dedicated for prisoners undergoing treatment
for substance misuse problems as part of the IDTS. Clearly, there will be
times when that wing is full and prisoners will have to be located on an
ordinary wing. However, this has not been suggested as a reason why the
man did not go to X1 but was placed on Y1. Neither the nurse or doctor were
aware that they played a crucial role in informing discipline staff where it was
most appropriate to place the man because of his medical needs. The
prison’s IDTS clinical lead told the investigator that the reception nurse should
16
be proactive in this process. Nurse B was not a regular reception nurse and
in interview believed that this responsibility rested with the doctor.
62. At the time of interviewing staff, in February 2010, the clinical lead described
being 75 percent of the way towards a fully set up ITDS at Peterborough.
Clearly, in December 2009, when the man was there the service was less fully
organised. He said that movement from reception to the stabilisation wing
was working more effectively (although this was not completely clear from
Prison Doctor A and the nurse’s interviews in February 2010).
The head of healthcare, and clinical lead in IDTS, should clarify the
responsibilities of health care staff to recommend the appropriate wing
to which prisoners should be admitted, especially those who require
additional monitoring.
63. The 2006 Department of Health guidance states that when methadone is
administered (by a registered nurse), the nurse should ensure that the
prisoner is fully alert and responds appropriately, and that there are no signs
of drowsiness or collapse, slurred speech, droopy eyelids or lowering of blood
pressure.
64. There are numerous opportunities for health care staff to observe detoxifying
prisoners on wing X1 in Peterborough. However, those on ordinary location
will only be seen when they collect their medication at the hatch which, by its
nature, is a busy place and does not lend itself to significant monitoring of
prisoners medical needs. There is no allocated space on the methadone
medical record to note the prisoner’s appearance as the record only requires
signatures by the prisoner, the nurse administering the drug and a witness. It
is unclear under these circumstances what degree or quality of observation
would take place. PCO A said that he told the man to go to the medication
hatch because he was unwell. If the man did do this, there is no record
anywhere from medical staff. The clinical reviewer noted that no medical staff
recorded that the man was over sedated. However, it is unclear whether staff
made any observations at all as nothing is recorded and, except for the main
medical record, there is no place to record anything. I do not suggest that the
nurses’ observations were inadequate but simply that there is nowhere to
record any issues. It would seem that guidance or protocols do not exist for
staff in respect of detoxifying prisoners who are not located on a dedicated
detoxification/stabilisation wing.
The head of healthcare, and clinical lead in IDTS, should provide
guidance concerning the monitoring and recording of prisoners being
prescribed methadone on an ordinary wing.
Doubts regarding the man’s heroin habit
65. The clinical reviewer conducted a clinical review of the care the man received
in Peterborough. He describes the evidence about his heroin use as
conflicting. He reported use of one to two bags per day whilst out of prison for
a very short period of time, together with his apparent ability to effectively
17
deliver the drug to a vein in his forearm, was unusual. The clinical reviewer
comments that the dose is high for a new user and significant skill would be
needed to inject. However, the man showed withdrawal symptoms at the
police station which led to substitute medicine being given to him. Medical
staff at Peterborough were not aware that he had been given any medication
and took the positive drug test on face value. They accepted his account of a
newly acquired dependence on heroin. He was prescribed methadone in the
standard way for any detoxifying prisoner. The increased dose of methadone
given to him during the last days of his life is considered a significant dosage
for a new heroin user and it would be expected to cause significant sedation.
66. However, the clinical reviewer says that staff did not notice that the man was
sedated. He also noted that the cellmate described him feeling worse in the
morning and asking for medication. He continued:
“Methadone works for over 24 hours and an early wearing off of effect
could suggest that the initial, cautious and entirely appropriate doses of
methadone and his convincing symptoms of withdrawal in police custody,
all suggest that the man had used heroin for some time.”
67. However, this does not take account of the man’s repeated account that he
used heroin for a very short period of time and his consistent self-declared
report of heavy use of other drugs in the past but not heroin. In addition, the
absence of ongoing clinical monitoring, as outlined in the guidance for those
being stabilised on methadone, did not take place. Without this monitoring,
an assessment did not take place which may well have been “valuable as the
early symptoms of drug withdrawal may mask a separate underlying
physiological condition”. (Clinical Management of Drug Dependence in the
Adult Prison Setting, Department of Health 2006.)
Did staff act appropriately when the man reported feeling unwell?
68. PCO C was working his first day on duty as a wing officer and understandably
was a little unsure about procedures. He responded to the man’s calls for
help and went to see him. He realised that he was unwell and considered
calling for the emergency nurse. Correctly, he spoke to two senior staff
members and was told that the situation would be dealt with by one of them.
69. Fifteen minutes later, PCO D went to see the man. In interview, he could not
recall PCO C telling him any specific details about his health. Having seen
the man, PCO D did not judge him to be sufficiently unwell to call for
healthcare staff,despite him groaning at him. In interview, he said that if he
had known the whole picture he would have acted differently. However, PCO
C told the investigator that he did tell his more experienced colleagues what
the man had said to him.
70. It is impossible to know whether earlier medical intervention would have made
a difference to the man, but nonetheless I believe that staff should have
contacted healthcare and asked them to attend as soon as possible. They
18
may not have been able to respond as quickly as they would have done in an
emergency. However, they should have been called.
The Director of HMP Peterborough should remind staff of their
obligation to contact healthcare when a prisoner presents as unwell.
Mouth to mouth resuscitation
71. Without regard to his own health, PCO B gave the man mouth to mouth
resuscitation although he did not have a mask to form a barrier between his
mouth and the man’s. The PCO had been trained outside of the Prison
Service but was confident about his capabilities. The clinical reviewer wrote
in his clinical review that:
“it would be preferable for the safety of staff for standard resuscitation
to be used. In modern CPR, chest compression is the most significant
intervention with mouth to mouth or other ventilation of the chest taking
a secondary role.”
72. Prison staff who have been trained in CPR should be issued with a ventilation
mask as a matter of course as they are the staff most likely to be involved.
However, even for those who are not trained, it would be sensible to make
masks available for staff to carry and use in any situation which might arise.
Protective face pieces for mouth to mouth resuscitation should be
available to all staff.
Cause of death
73. The post mortem report includes the following amongst its concluding
comments:
“The pneumonia present would have taken many hours to develop to
the degree seen. This may raise questions about the deceased’s
status in the last 24 hours or so, including whether he sought any
medical treatment. Further this is not the first case of fatal pneumonia
that I have dealt with from HMP Peterborough and I raise as a possible
concern whether there is some common factor. I trust for instance that
adequate measures are in place to mitigate against the development of
Legionella bacteria in the air conditioning systems at the prison.”
74. In response, the clinical reviewer wrote in his clinical review:
“At the end of the report the pathologist notes that this is not the first
fatal pneumonia that he has seen at HMP Peterborough. He raises the
concern about possible sources of Legionella. This bacterium causes
pneumonia and can be caught from spread via air conditioning systems
as these provide good conditions for the bacterium to grow. It does not
respond to the normal antibiotics used for chest infections. It is often
diagnosed with difficulty as it is an unusual organism that is not easy to
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culture under normal laboratory circumstances and is not routinely
looked for but bacteriologists. It tends to be diagnosed by more
specialist tests after initial treatment with ordinary antibiotics has failed.
HMP Peterborough was included in a public health investigation of a
suspected Legionella outbreak in north-west Peterborough but no
evidence of contamination was found in the prison environment
systems in August 2009. Unfortunately no specimens of sputum
before death or of lung tissue from the post mortem are available or
suitable for culturing the causative organism.”
75. The clinical reviewer made the following recommendation which I endorse.
The prison should review their policies and management of potential
Legionella infection. Prison medical staff should have heightened
awareness of the potential for Legionella to be a cause of chest
infection in staff and prisoners.
Other issues
76. I would like to draw the Director’s attention to the PER form which had been
completed for the man’s court appearance on 8 December. It is entirely
appropriate for considerable sections of this document to be completed in
advance of the journey thereby leaving only relevant sections to be completed
once the prisoner is in reception. In this case, my investigator was surprised
to see that the form had already been signed by a senior officer to indicate
that prior to leaving the prison for court, the man had been searched, correctly
identified and a verbal handover given to escort staff. Clearly, this was not
the case. Under no circumstances should this section have been completed
without the prisoner present and having been searched. I trust that the
Director of Peterborough will speak with the officer involved.
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CONCLUSION
77. Having been released from prison on 24 November, just nine days later, the
man said that he had started to use heroin. Upon arrest, his presentation and
self-declared heroin use led police medical staff to prescribe an opiate
substitute which may have resulted in the positive drug test result in
Peterborough. Having been identified as a heroin user, he was given
methadone but was not located on the stabilisation wing and so he did not
receive an enhanced level of monitoring. According to his cellmate, the man
felt unwell for the duration of his time in Peterborough. On the morning of his
court appearance, he told staff that he felt very poorly but this was not acted
upon with any degree of urgency. It is not possible to know whether earlier
medical intervention either through enhanced monitoring or any action taken
that morning, could have prevented his death.
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RECOMMENDATIONS
All recommendations, with the exception of number 1, were accepted. Number 1
was partially accepted. The proposed action is written in italics following each
recommendation.
1. Medical records should always accompany prisoners from police detention to
prison admission and be given to the medical staff upon arrival.
We accept the principle of this recommendation and will discuss this with our
colleagues from the local Constabulary.
2. The head of healthcare, and clinical lead in IDTS, should clarify the
responsibilities of health care staff to recommend the appropriate wing to
which prisoners should be admitted, especially those who require additional
monitoring.
We will address this issue at the next IDTS meeting to ensure that correct
protocols and Standard Operating Procedures are in place and followed by all
staff in relation to the location of prisoners onto the most appropriate wing.
3. The head of healthcare, and clinical lead in IDTS, should provide guidance
concerning the monitoring and recording of prisoners being prescribed
methadone on an ordinary wing.
Initially a Notice to Staff will be issued to provide staff with the necessary
guidance. This will then be captured in the induction training for new staff.
4. The Director of HMP Peterborough should remind staff of their obligation to
contact healthcare when a prisoner presents as unwell.
Notice to staff issued reminding staff of their obligations. Notice to be re-
issued on a monthly basis.
5. Protective face pieces for mouth to mouth resuscitation should be available to
all staff.
Face pieces will be made available to staff for this purpose as part of the
resuscitation packs on the houseblocks. Nurses will also be provided with
individual face pieces.
6. The prison should review their policies and management of potential
Legionella infection. Prison medical staff should have heightened awareness
of the potential for Legionella to be a cause of chest infection in staff and
prisoners.
HMP Peterborough have confirmed that they have reviewed their
arrangements in relation to Legionella and are confident that procedures are
sufficiently robust to identify ant such potential infections before they become
problematic.
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