Individual at Wakefield

Investigation into the death of a man
at HMP Wakefield, who died in
July 2010 at Pinderfields Hospital, Wakefield
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2013
The man died in July 2010, at Pinderfields Hospital, Wakefield. He had been
transferred to hospital from HMP Wakefield on 6 July 2010 after becoming
unwell. I offer my condolences to his family and friends for their sad loss.
The investigation was undertaken by a senior investigator supported by one of
our family liaison officers. I apologise for the severe delays in the production
of this report.
After a road traffic accident in 1971, the man’s right arm and leg were
amputated. By the time he entered the prison estate in 2000 he not only
faced physical difficulties but also struggled to cope with prison. He
threatened to harm himself several times but staff ensured that he remained
safe.
The man also made several allegations that he was being bullied or abused
by other prisoners. Several of these allegations occurred in 2006. When the
allegations were investigated, staff were either unable to identify who was
responsible or did not have enough information to resolve the matter.
In July 2010, the man became ill. He was taken to hospital, but his condition
continued to deteriorate. He was diagnosed with pneumonia and septicaemia
and although he was given antibiotics he died after several days in hospital.
A clinical reviewer was commissioned. The clinical reviewer included four
recommendations in her report, and an action plan to address these
recommendations has already been developed by the prison. As a result, the
recommendations have not been repeated in this report. However, two
recommendations for improvement are made regarding how to achieve a
proper balance between security and dignity when using escort chains on a
severely disabled prisoner and on the importance of thorough recording of
bedwatch logs.
This version of my report, published on my website, has been amended to
remove the names of the man who died and those of staff and prisoners
involved in my investigation.
Nigel Newcomen CBE January 2013
Prisons and Probation Ombudsman
CONTENTS
Summary
The investigation process
HMP Wakefield
Key Events
Issues
Conclusion
Recommendations
SUMMARY
1. The man had a number of medical needs. After a road traffic accident
in 1971, he had a double amputation. Doctors removed the man’s right
leg to above the knee and right arm to above the elbow. In that same
accident the man also suffered significant chest injuries. The man
used an electric wheelchair to enable him to be mobile.
2. In October 2001, the man was found guilty of serious offences and
given an indeterminate public protection sentence (IPP) with a
recommendation that he serve a minimum of five years. (An IPP
sentence is one where the prisoner has to, at the end of their tariff,
satisfy the Parole Board that the risk they pose to the public is
acceptable, a prisoner with an IPP sentence has no automatic right to
be released.)
3. The man was initially in custody at HMP Winchester before being
transferred to HMP Bristol in February 2002. He was then transferred
to HMP Wakefield in April 2003. While at Wakefield, he established a
good rapport with several members of staff and developed friendships
with a small circle of other prisoners who provided him with valuable
assistance.
4. In October 2008, the man developed respiratory symptoms which did
not respond to two courses of antibiotics. He was consequently
referred for a chest X-Ray. In January 2009, he was admitted to
Pinderfields General Hospital after suffering from breathlessness and
low levels of oxygen in his blood. It was noted that the injuries he had
sustained in the road traffic accident in 1971 had permanently affected
his lung function, and made him much more susceptible to respiratory
problems.
5. The man’s respiratory condition remained stable until June 2010 when
he was diagnosed with heart failure and a leg oedema, a build up of
fluid in the skin tissues causing swelling. He was transferred to
Pinderfields Hospital on 6 July, after his condition deteriorated again
and he complained of chest pains. The following day, he was
diagnosed with right sided pneumonia, a lung infection and
septicaemia, an infection in the whole of the body. Medical staff
discussed treatment options with his and with his consent a do not
resuscitate form was completed. He died in July.
6. A post mortem found that the man died as a result of chronic
obstructive pulmonary disease, a lung disease which includes chronic
bronchitis (inflammation of the main air passages to the lungs) and
emphysema (where the air sacs of the lungs are damaged). He also
had ischemic heart disease meaning (a reduced blood supply to the
heart muscle).
7. This report makes two recommendations relating to the use of escort
chains and how their use is recorded in bedwatch logs.
THE INVESTIGATION PROCESS
8. After receiving notification from the Prison Service on the day that the
man had died, the Ombudsman appointed a senior investigator to carry
out the investigation. The senior investigator contacted the prison and
arranged to travel there for the purpose of opening the investigation.
9. The senior investigator formally opened the investigation on 20 July
2010 by meeting with members of staff and obtaining copies of the
man’s full prison records including medical records, wing history
sheets, security information, hospital bed watch logs and the family
liaison log. A bed watch log is a history recorded by escort officers of
events whilst a prisoner is an in patient at hospital outside the prison.
Governor A was appointed as the senior investigator’s liaison officer.
The senior investigator also visited Wakefield on 3 September and 3
November 2010 to conduct further interviews.
10. A clinical review into the care the man received while he was in
Wakefield was commissioned. A clinical reviewer was appointed to
conduct the review, which was received in October 2010.
11. In conducting his investigation the senior investigator carried out six
interviews with prison staff, all of which were recorded. The transcripts
of these interviews are attached to this report as annexes. He has also
met a senior prison manager to feedback what had been identified. He
followed up the feedback by writing to the Governor. The issue of this
report has been delayed after the report was given to another
investigator to complete. We apologise for the unacceptable delays
that have been the result.
12. One of my senior family liaison officers wrote to the man’s family to
inform them of the investigation and provide them with an opportunity
to ask any questions or raise any concerns about the care the man
received. At the time of issuing this report, the man’s family have not
raised any specific issues. The draft report has been shared with those
members of his family who wished to receive it.
HMP WAKEFIELD
13. The prison is located in Wakefield very close to the city centre. There
has been a prison on the site since 1594. It is a high security prison
and most of the prisoners are serving life sentences or have been
convicted of serious offences.
14. Since taking over responsibility in April 2004 for the investigation of all
deaths in custody, there have been 37 deaths at Wakefield (prior to the
issue of this report), including that of the man. Although the number
appears high, it should be recognised that Wakefield prison holds a
number of elderly prisoners, which inevitably brings about a higher
incidence of deaths. There are no similarities between those cases
and the circumstances of the man’s death.
Her Majesty’s Chief Inspector of Prisons
15. Her Majesty’s Chief Inspector of Prisons, reports on all Prison Service
establishments. The majority of inspections are pre-announced and
allow the prison being reported on to prepare for inspection. The most
recent inspection was carried out in December 2008 by the former
Chief Inspector of Prisons.
16. In the introduction to the report of the inspection, published in February
2009, the former Chief Inspector of Prisons said the prison had
improved considerably over the previous five years and that she was
pleased the improvement had been sustained. She said there was still
work to do in aspects of safety and staff prisoner relationships and
activities, including engaging offenders in treatment programmes.
17. In the main body of the inspection report, it was noted that, despite
provision for five hospital visits per day, “too many” outside hospital
appointments were cancelled with no record kept of the reasons why.
The inspection team also noted that many “older prisoners and those
with disabilities were dissatisfied with the support they received”. The
inspectorate report also noted that some disabled prisoners
complained of excessive noise and some bullying and intimidation
although they could find few comments in wing files to evidence such
occurrences.
Independent Monitoring Board (IMB)
18. Each prison has an Independent Monitoring Board (IMB) which is
made up of members from the local community. Their role is to
monitor the prison and report any concerns that they have regarding
the prison or how prisoners are treated. In the first instance, the Board
report to the Governor, or, if necessary, can report directly to
Parliament. Board members are able to visit any area of the prison at
any time and have direct access to any prisoner who they wish to see,
or who requests to see them. The Board holds regular meetings in the
prison, with the Governor attending for part of the meeting. The
Chairperson of the Board produces an annual report to the Secretary of
State for Justice.
19. In its most recent report, covering the period 1 May 2009 to 30 April
2010, the Board said that overall the Health Care Unit provides a
comprehensive service that meets the needs of the prison population.
The care of disabled offenders continued to be a challenge that was
being met by dedicated staff. The IMB noted that staff tried to
encourage disabled prisoners to participate in available activities.
ACCT and F2052SH
20. ACCT, the Prison Service process for supporting and monitoring those
prisoners thought to be at risk of harming themselves, was introduced
in 2007. (Before this, the equivalent system was called F2052SH). An
ACCT plan can be opened by anyone working in the prison if they have
any concerns that a prisoner might have tried, or, in the future, might
try to harm himself. The purpose of ACCT is to try to determine the
level of risk posed, the steps that might be taken to reduce this and the
extent to which staff need to monitor and supervise the prisoner.
Levels of observations (where staff must check the prisoner) and
interactions (where staff must have a conversation with the prisoner)
are flexible and can be set according to the perceived risk of harm. If
staff perceive the risk of harm to be very high, the prisoner may be
constantly observed, with a member of staff positioned outside their
cell at all times. Where the perceived risk is lower, the level of
observations may be several times an hour or day. Observations also
take place during the night.
KEY EVENTS
21. The man was born in 1940. After leaving school with no qualifications,
he found employment on a local farm.
22. In 1971, the man was involved in a road traffic accident. As a result,
his right leg (above the knee) and his right arm were amputated and he
also suffered significant chest injuries. The man was reliant on an
electric wheelchair to help him move around.
23. The man had several convictions for various offences in the years
following the accident. It is not clear from records whether any of these
convictions attracted a prison sentence. In 2000, he was arrested and
charged with various offences. He was remanded into custody to await
trial.
24. Whilst on remand, the man commented to staff on five occasions that
his situation was causing him such distress that he could not see any
positive outcomes. In August 2000, staff opened a Self Harm at Risk
Form (F2052SH) document after the man said that he struggled to see
how he would cope in the future. He was described as being
“extremely tearful” and was offered support through the Listener
scheme (Listeners are prisoners trained by the Samaritans to offer
support to their peers).
25. In early 2001, the man became frustrated by the legal delays resulting
in his case being put back by some months. In March 2001 staff found
that he had been hoarding medication in his cell and opened an
F2052SH. He was referred to the Health Care Centre. After his mood
started to improve, it was decided that he should remain in healthcare.
26. When the man attended Bristol Magistrates’ Court in June 2001,
custody staff at the court were concerned that he was depressed and
believed that he might harm himself if he was again remanded.
Another F2052SH was opened and it was recorded that the man was
quiet and withdrawn. However the F2052SH was closed a week later.
27. In September 2001, the man became particularly anxious about the
sentence he might receive. He also raised a concern with staff that he
might be moved from the Health Care Department to the main prison.
Again, he remained on an F2052SH for a week. Staff closed it after
this time as they were satisfied that he would not harm himself
28. In October 2001, the man was given an IPP (indeterminate sentence
for public protection) sentence with a recommendation that he serve a
minimum of five years in prison. After he was sentenced, an F2052SH
was opened by staff as they were concerned with how he would cope
with receiving an IPP sentence. Although he was distressed, staff
were satisfied that he was planning for his future and looking positively
to what he could achieve in custody. The F2052SH was closed within
forty-eight hours.
29. The man served the early part of his sentence at HMP Winchester
before being transferred to HMP Bristol in February 2002. He was then
transferred to HMP Wakefield in April 2003, returning to HMP Bristol for
a brief period in 2005 to allow accumulated visits to take place
(accumulated visits allow a prisoner to be moved to a prison nearer
home for a short period to make it easier for family and friends to
visit).
30. Following sentencing, however, it is clear from his prison records that
during 2002 and 2003 the man remained unhappy. In October 2002,
staff became concerned that he might be hoarding medication and
noted that he was threatening to kill himself. Staff searched his cell
and, although no drugs were found, he was placed on supervision for a
brief period and received support from the chaplaincy and the
Samaritans.
31. In May 2003, the man told staff he was distressed because of bad
news that he had received during a visit. He also told staff that he felt
he was only “existing” at Wakefield and had started to think about
hanging himself. An F2052SH was opened but was closed shortly
afterwards. The man assured staff that he was feeling much better and
regular assessments were established with the Health Care
Department.
32. Later that year, in November 2003, staff opened another F2052SH
after the man told staff he was very stressed by legal action that his
solicitor was taking on his behalf against the Prison Service. Additional
support was arranged by the Health Care Department and this
F2052SH was closed by staff after forty-eight hours.
33. The man also became concerned in that he may be transferred from
Wakefield. To reduce the likelihood of such a move, in November he
threatened to drive his electric wheelchair over the stairs and pour
boiling water over himself. He was assessed by a consultant
psychiatrist who acknowledged that the man was unhappy but did not
consider that he was suffering from a depressive illness.
34. In December 2003, the man told staff he was being bullied by other
prisoners on the wing. A security report was raised by staff and
following its review anti-bullying measures were put in place by wing
staff. Part of these anti bullying measures included a review of a
further accusation of bullying made by the man in January 2004. After
careful scrutiny security staff considered the allegation to be without
foundation.
35. On 31 December, the man told staff that he could see no point in
carrying on. Another F2052SH was opened and a multi disciplinary
team was established to provide him with support. Staff also reviewed
which programmes the man could be offered to help him cope with
prison. The F2052SH was closed on 2 January 2004
36. The man’s mood continued to cause concern in 2004. Between April
and June, and again in August, staff, were concerned as he attempted
to both hang and harm himself. On both occasions, staff opened
F2052SH documents which were closed once his outlook became
positive and he had convinced staff that he would not endanger his life
again
37. In June 2005, while at Bristol on accumulated visits, the man again
attempted to hang himself. An F2052SH was opened by staff and he
was closely monitored by staff. Staff made particular efforts to ensure
the man made use of association times and that he received support
from the chaplaincy and the Samaritans. This F2052SH was not
closed until July as staff at Wakefield wanted to ensure that he was
properly supported as he settled into the new regime. This was the last
occasion that the man attempted to hang himself.
38. On his return to Wakefield, the man was assigned a cell that had been
adapted for prisoners with physical disabilities. This, along with his
electric wheelchair, allowed him to maintain a significant degree of
independence. The disability co-ordinator at Wakefield was there for
much of the time that the man was there. When she was interviewed
by the senior investigator, she explained that the man was the only
prisoner with an electric wheelchair and that without it he was
effectively immobile. She explained that while the maintenance
programme for the man’s wheelchair was good, there were occasional
problems.
39. The man also had an electric bed in his cell that he could adjust for his
comfort and health needs. The man often needed medication to
reduce oedema, an excessive accumulation of watery fluid, to his left
foot. This is a normal occurrence for some-one suffering from reduced
mobility.
40. In April 2006, the man raised a landing alarm after he had boiling water
thrown over him. He told security staff that the water had been thrown
from the Remand Centre. Staff investigated the incident but they were
unable to identify who had assaulted the man.
41. In September 2006, the disability co-ordinator wrote a memo about the
man. She recommended that he be given a period of respite in
healthcare, as the man had increasingly behaved inappropriately
towards other prisoners, usually by using inappropriate language.
Some prisoners had retaliated by throwing food over him. She said the
man’s outbursts were inevitably followed by him being very emotional
and crying when prisoners responded in a manner which caused him
distress. He had also stopped shaving and sometimes slept in his
clothing, meaning that he sometimes appeared dirty and unkempt.
She said she had gone into the man’s cell on several occasions to find
him sitting in semi-darkness and staring into space. She was
particularly concerned that as a result of his behaviour the man was
starting to become isolated.
42. As a result of the disability co-ordinator’s concerns, staff opened both
an Assessment of Care and Custody Teamwork (ACCT) and a care
plan. This was closed on 18 October after a review conducted by staff.
The man was also involved in this review.
43. The next month, on 17 November, the disability co-ordinator spoke to
the man in his cell. He told her that staff and prisoners had both
abused him, referring to his disabilities. She asked him several times
to identify the individuals concerned but, again, he refused to do so.
44. During February 2007, the disability co-ordinator bought her concerns
directly to the attention of the deputy governor. She said that the man
now appeared dishevelled as he wore grubby clothes and had not had
his hair cut for some time. She said had spoken to the man about her
concerns and he had told her that he felt he was “going to seed”. The
man acknowledged to her that he would vent his frustration by finding
fault with anyone he came into contact with and told her that he felt he
was not making any progress.
45. The man developed respiratory problems in October 2008. As the
problems did not respond to antibiotics, the man was referred for a
chest X-ray. In January 2009, he was admitted to Pinderfields General
Hospital as he was suffering from breathlessness and low levels of
oxygen in the blood (low oxygen levels in the blood can cause
shortness of breath, headaches, fluid retention and insomnia). A
consultant physician in general and respiratory medicine obtained the
man’s X-rays from 1971 and compared them with the X-rays taken at
Pinderfields. As a result, the man was diagnosed with compensated
type 2 respiratory failure, meaning that the man’s breathing was so
poor that carbon dioxide accumulated in his body. He had also
developed right sided acquired pneumonia.
46. The man was then prescribed furosemide (a diuretic used in the
treatment of heart failure), and sabutamol and seretide inhalers (to help
his airways to remain open). His condition was monitored as a matter
of routine by the medical staff at Wakefield and Pinderfields and
subsequently remained stable.
47. In April 2010, the consultant physician undertook an assessment to
consider the man’s future long term use of oxygen. In order to conduct
this assessment, he needed arterial blood samples which in the normal
course of events would be taken from a patient’s arm. As the man had
only one arm, the risks of the procedure were increased and the
decision was taken that the samples should be taken by a doctor. The
Governor gave the consultant physician permission to bring
appropriate equipment into the prison to undertake the procedure and
ensured that blood samples could be taken immediately back to the
hospital for laboratory testing.
48. Two months later, the man developed an increased leg oedema and
was diagnosed with heart failure as his heart was having trouble
pumping enough blood around his body. Hospital staff requested an
additional electric socket to be installed in the man’s cell so that his bed
and wheelchair could be plugged in at the same time. This meant that
the man could always then elevate his foot.
49. The man’s personal officer at the time submitted a maintenance
request for the installation, marking it urgent. As it was taking some
time to action, staff asked the man if he would move across the landing
to another cell which contained more electric sockets to ensure prompt
remedial action. The disability co-ordinator recalled at interview that
the man refused to move cell. Although his condition improved, his leg
remained swollen.
50. In July 2010, the man’s condition deteriorated again and he asked to
be transferred to the health care centre as he was having difficulty
dressing and going to bed. He also said he was not eating properly.
On 2 July, staff decided he should be moved to the health care centre.
On 4 July, staff started to treat the man with oxygen but he continued
to be reasonably independent. On 6 July, the man reported that he
was experiencing chest pain and that it felt like the room was spinning.
Nursing staff discussed their concerns with the doctor who made the
decision that an ambulance should be called and he was taken to the
Accident and Emergency Department at Pinderfields.
51. The man was transferred without his electric wheelchair, effectively
rendering him immobile. The duty governor, consulted security staff
(the signature is illegible) and decided that an escort chain should be
used. The senior officer in the Health Care Department explained to
the senior investigator that he had advised that there were no medical
objections to the use of restraints and that the decision to use restraints
had been made by staff in the main prison. This decision was made
after a review was conducted to the requirements of the National
Security Framework which makes it clear that it is important to maintain
decency.
52. On 7 July, the man was diagnosed by the consultant physician with
right sided pneumonia and septicaemia (blood poisioning) and was
given antibiotics and fluids through a drip. This meant they entered the
blood stream much more quickly and were able to take effect promptly.
The consultant physician discussed treatment options with the man
and explained to him that because of his medical history he was not a
candidate for resuscitation or for admission to critical care facilities
where he might receive ventilation. The man told the consultant
physician that he wanted his two sons to be told about his medical
condition and then signed his consent to a completed “a do not
resuscitate” form. Duty governor B at Wakefield, contacted members
of the man’s family to inform them that he was in hospital, that his
diagnosis was extremely poor and that he had asked for his family to
be told what was happening.
53. It was noted in the bedwatch log that, at 3.30 pm on 7 July, Governor A
and Governor B authorised Officer A to remove the restraints.
However, it is not clear whether the escort chain was removed at that
time. A note on the bedwatch log at 10.10am on 8 July, made by
Officer B, states that “Duty Gov C gave permission for removal of
restraints”. Officer A also confirmed at interview that restraints were
still in place on 8 July.
54. The senior investigator interviewed Officer B, one of the escorting
officers. He explained that 10.10am on 8 July he had asked Governor
C, the duty governor that day, for permission to remove the escort
chain. After a prompt review of security requirements, the escort chain
was removed shortly afterwards.
55. At 11:30 am on 8 July, one of the man’s sons contacted the prison staff
at the hospital to ask after the man’s health. Prison staff arranged for a
member of medical staff to return the call. The man’s other son spoke
to prison staff that afternoon.
56. After receiving a chest scan, the man received the last rites at 3.30 pm
from the Father. Officer B told the Senior Investigator that the man’s
breathing was so laboured that it affected his ability to speak
coherently. Shortly after this, bedwatch staff noted that although the
man was still speaking, his health had markedly deteriorated.
57. The family liaison officer at HMP Wakefield spoke to members of the
man’s family on several occasions on 8 July and explained that the
man was extremely ill.
58. The man was seen by a doctor at 9.00am on the day the man died.
The doctor told staff that the man had a few hours to live. After a scan,
the man was moved to ward one. Staff informed a priest of the
situation. As the man’s condition deteriorated further, he was given
morphine as pain relief at 12.00 pm. The man declined lunch and as
his health deteriorated again medical staff made the decision at 1:40
pm that he should be moved to Ward 3, Bay 5.
59. A nurse became very concerned about the man’s condition at 4.30pm
and asked a doctor to attend. The doctor declared that the man had
died at 4.42pm.
60. Following the man’s death, Duty Governor A attempted to contact the
prison’s family liaison officer so that she could arrange to contact his
family. However, after the Duty Governor A could not get hold of her,
he asked both HMPs Bristol and Eastwood Park if they could help.
They could not provide any assistance. Duty Governor A then
contacted Avon and Somerset Police, who agreed to visit one of the
man’s sons, but who then found that the address had been
demolished. Eventually they obtained a telephone number and
informed the man’s family on 10 July. The Roman Catholic priest
visited them later that afternoon.
61. A post mortem identified that the man had died from chronic
obstructive pulmonary disease (non reversible lung disease) and
ischemic heart disease (reduced blood supply to the heart). The man’s
son discussed the information he had received from the coroner with
the prison’s family liaison officer on 12 July.
62. Governor C at Wakefield authorised the payment of funeral costs. The
man’s family also attended a memorial service held for him at
Wakefield. Staff and prisoners were informed by a Governor, and
several of the man’s friends were visited by prison staff. All staff were
made aware of the services of the care team.
ISSUES
Clinical Care
63. A clinical review into the care the man received while he was at
Wakefield was commissioned and a clinical reviewer appointed to
complete the review, which is attached to this report. The clinical
reviewer has concluded that the man received an acceptable level of
general healthcare whilst in Wakefield. However, she described the
care he received following the diagnosis of compensated type 2
respiratory failure in January 2009 as being of a “high standard”.
64. The clinical reviewer made four recommendations in her clinical review.
Three of these related to clinical record keeping, and the audit of these
records, and the fourth to the compiling of a checklist to ensure that the
disability suite meets the needs of individual prisoners. Because of the
delay in issuing this report, we have already received Wakefield’s
response to these recommendations. They have accepted the
recommendations and have developed an action plan as a result. As a
result we have not repeated the recommendations in this report.
Equipment provided to the man to help manage his disability
65. While he was at Wakefield, the man had access to various pieces of
equipment to help his mobility. These included an electric bed and an
electric wheelchair.
66. The electric bed was provided to enable him to raise his leg and
therefore alleviate the symptoms of oedema (swelling). However, in
June 2010, it became clear that the man could not use the bed properly
as he did not have enough electric sockets.
67. Although he was offered a move to another cell, the disability co-
ordinator recalled that he had refused. A request was made for
another socket to be installed, although it is not clear whether this was
done before the man went to Pinderfields on 6 July 2010.
68. The man also had access to an electric wheelchair, which he charged
using a socket in his cell. Although the man made a series of
complaints about his wheelchair in 2008 (as the chair had flat tyres)
this issue seems to have been resolved to his satisfaction. Officer C
noted at interview that the man had not reported any problems to her.
He explained that, when he did have problems, these were fixed but
that it sometimes took longer than for manual wheelchairs, which could
more easily be replaced.
69. It is clear that the man did occasionally have difficulty because of
problems with the equipment provided for him. It also seems that
these issues were resolved in a reasonable timescale.
Use of restraints
70. When the man was taken to Pinderfields on 6 July 2010, an escort
chain was used as a restraint, following a risk assessment. Authority to
remove the chain was given by Governors A and B on 7 July when his
condition deteriorated. However, it seems that the chain was not
removed until 8 July when Officer B spoke to Governor C.
71. There are two issues here. One is that the chain was seemingly not
removed on 7 July despite authorisation being given (Officer B has
confirmed that the chain was still being used on 8 July, and there is
nothing in the logs to dispute this). There was clearly some confusion,
and it would have helped had officers noted explicitly in the bedwatch
log that they had removed the chain, and not only that they had sought
authority to remove it.
72. More importantly, however, is that an escort chain was used in the first
place. While a risk assessment was carried out, and the decision to
use an escort chain was based on “the most recent and up to date
intelligence available”, the assessment did not seem to explore the
man’s individual circumstances in any great detail, other than noting
that he was in a wheelchair. However, this was not an electric
wheelchair, which meant he was effectively immobile.
73. Risk assessments will, by their nature, always contain an element of
personal opinion. However, on this occasion, it seems strange that an
escort chain was used when the man was effectively rendered
immobile without his electric wheelchair. Although the full extent of his
illness was not apparent when he was admitted to hospital, he was
clearly ill. Further, although it appears that authorisation to remove the
escort chain was given on 7 July, it seems that the chain was only
removed the next day. As a result, we make the following
recommendations:
The Governor should ensure that risk assessments take full
account of individual’s circumstances when deciding the level of
restraint
The Governor should ensure that, when restraints are removed,
staff explicitly record this in bedwatch logs
Reports of bullying
74. In December 2003, the man told staff that he was being bullied by
other prisoners. In 2006, there were two events which suggested that
the man might have been subject to bullying by other prisoners. In
April, he reported that a prisoner had thrown boiling water over him.
Staff were unable to identify the perpetrator. In September, the
disability co-ordinator noted that, after the man had used some
inappropriate language, prisoners had thrown some food over him.
The man also told her in November that he had been abused by both
members of staff and prisoners, with the abuse relating to his
disabilities. On the last two occasions, the man refused to name the
people who were abusing him.
75. It is impossible to investigate these allegations many years after it is
claimed that they happened. However, we have examined the
responses to the allegations, and believe that that they were dealt with
appropriately. In particular, the disability co-ordinator encouraged the
man on several occasions to give her more details in order that the
allegations could be further pursued.
CONCLUSION
76. The man had clear physical problems when he first came into prison.
Generally, his needs were well met, although at times there were
issues about the equipment provided for him.
77. In 2010, his health deteriorated extremely quickly. Medical staff acted
appropriately. However, during his transfer to Pinderfields Hospital, an
escort chain was used. Given how ill the man was and that he was
effectively immobile without an electronic wheelchair, this does not
seem to have been an appropriate risk assessment.
RECOMMENDATIONS
1. The Governor should ensure that risk assessments take full account of
individual’s circumstances when deciding the level of restraint
Not Accepted
All prisoners are individually risk assessed with due regard to all
available information.
It is clear that the man’s medical condition as an individual, coupled
with his current intelligence and record of offending was taken into
consideration when the use of just an escorting chain was authorised.
In line with the report, it would have been unclear to duty Governor A at
that time exactly what the man’s medical condition or capabilities would
have been. As an emergency blue light escort, the governor would not
only have to consider escape potential and Risk of Serious Harm to the
Public should he escape, but also the risk presented to the public by
the man on attendance at Hospital.
At the time of his death the man had failed to engage in any work to
address his offending behaviour and failed to evidence any risk in his
very substantial Risk to the Public.
All of the above factors would be taken into account in the
determination of the appropriate restraint arrangements, in addition to
the fact that the man would most likely be located in a ward within
hospital, with the associated risk of coming into contact with an
unsupervised child whose carer’s attentions may well be otherwise
focused.
2. The Governor should ensure that, when restraints are removed, staff
explicitly record this in bedwatch logs
Accepted
Once the man’s condition had been further assessed and
permission for the removal of restraints authorised this should have
been annotated in the log and actioned.
This is standard operating procedure for staff on Bedwatch duties and
a notice to staff will be circulated reminding staff of their
responsibilities.