Individual at Dovegate

A Report by the
Prisons and
Probation
Ombudsman
Nigel Newcomen CBE
Investigation into the death of a man at HMP
Dovegate in September 2009
Our Vision
‘To be a leading, independent investigatory body,
a model to others, that makes a significant contribution to
safer, fairer custody and offender supervision’
2
This is the report of an investigation into the death of a man, who was found dead in
his cell at HMP Dovegate in September 2009. A post-mortem showed that he died
from the effects of a combination of drugs. He was 38 years old. I offer my
condolences to his family and friends.
The investigation was carried out by an investigator. The local Primary Care Trust
(PCT) undertook a review of the man’s clinical care. Our investigation was
suspended until the police completed their own investigation; this lasted three years.
I am sorry for the consequent delay in the issue of this report.
The man had had problems with drugs for some time and had spent previous
periods in prison. He was on remand at Dovegate and was undergoing a drug
treatment programme. He acquired some illicit drugs and appears to have taken
these some time during a night in late September 2009. When prisoners’ cells were
unlocked the next morning, his cellmate found him unresponsive and summoned
staff. Attempts were made to resuscitate him but were unsuccessful. The clinical
review concluded that he received appropriate healthcare during his time in prison,
although it does note that he was not referred to the primary mental health team,
despite a history of depression.
While we cannot be certain, it is possible that the man obtained illicit drugs from a
newly arrived prisoner, which he then took in addition to his prescribed medication.
Prison staff received some intelligence to this effect but no immediate action was
taken. I recognise the pressures in a busy operational context, but consider that
some discussion should have taken place that night about whether to conduct a
search. However, I also recognise that this would have been unlikely to have been
in time to prevent him taking the illicit drugs. I am pleased to note that both
recommendations in the report have been accepted.
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
Prisons and Probation Ombudsman April 2013
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CONTENTS
Summary
The investigation process
HMP Dovegate
Key events
Issues
Recommendations
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SUMMARY
1. The man was remanded to custody in June 2009 and transferred to Dovegate
in September. He had a history of problems with drugs and alcohol, and had
previously spent time in prison. He agreed to accept treatment to try and
overcome his drug problems, and began a treatment programme. At Dovegate
he was located on a drug treatment wing.
2. In September 2009, a friend of the man’s arrived on his wing and he went to
see him in his cell. Another prisoner reported suspicions to staff that the new
prisoner had brought drugs onto the wing.
3. The wing manager asked officers to watch the new arrival and his cell, but did
not feel that the information he had received warranted a search at that stage.
Shortly afterwards, prisoners were locked into their cells for the night.
4. Some time between 10.00pm and 11.00pm a nurse went to the man’s cell to
give him his night medication, when he said he was feeling fine. His cellmate
said he heard him mumble in his sleep at about 1.00am.
5. When prisoners were unlocked later that morning, the man’s cellmate was
concerned that he was unresponsive. He called officers, who attempted to
revive him. They were joined by prison nurses and subsequently by
paramedics, but attempts to resuscitate him were unsuccessful. He was later
found to have died of the effects of a mixture of prescribed and illicit drugs.
6. Staffordshire police conducted an extensive investigation into the
circumstances around the man’s death. Ultimately, the Crown Prosecution
Service decided not to bring charges.
7. A clinical review of the man’s care in prison concluded that he had received
good care. He was helped to address his drug misuse problems, and when
other health issues arose they were dealt with appropriately. The emergency
response that morning was prompt.
8. Our investigation found that it is not possible to be certain how the man came
by the illicit drugs that contributed to his death, and therefore whether his death
could have reasonably been prevented. We make two recommendations,
about mental health referrals for prisoners with a history of depression, and
assessment of security information.
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THE INVESTIGATION PROCESS
9. This office was informed of the man’s death on 24 September 2009. The
investigator issued notices to staff and prisoners at Dovegate informing them of
the investigation and inviting anyone with relevant information to contact him.
No one came forward.
10. Staffordshire Police conducted an investigation into the circumstances
surrounding the man’s death. In line with our agreement with the police, this
office’s investigation was suspended until October 2012, when the police
completed their enquiries after the CPS decided that no charges would be
brought. The investigator kept in close contact with the police throughout their
investigation. For this investigation he had access to police materials, which
included witness statements and summary documents.
11. Serco, the company that runs Dovegate, carried out their own investigation
following the death of the man. Their report was not provided to our
investigator, although we were given the statements made by staff and
prisoners in the course of that investigation.
12. The investigator obtained the man’s prison record, including his medical
records. The local PCT carried out a clinical review of his medical care and
treatment at Dovegate.
13. HM Coroner for South Staffordshire was informed of the investigation. The
Coroner provided a copy of the post-mortem report. Throughout the course of
the investigation, the investigator remained in contact with the Coroner’s office.
This report has been sent to the Coroner.
14. One of our family liaison officers contacted the man’s mother to explain our
investigation and offer her the opportunity to raise any matters for the
investigation to consider. His family acknowledged that the police had
conducted a very thorough investigation, but were concerned that the prison did
not react more quickly to the intelligence about drugs. The family asked some
questions in response to the draft report. We have replied to these in a
separate letter.
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HMP DOVEGATE
15. HMP Dovegate is a category B prison for up to 1060 adult male prisoners
sentenced to over four years imprisonment and local remand prisoners. The
prison is managed by Serco. Healthcare services are provided by Serco
Health. M wing was opened in September 2009 and is an Integrated Drug
Treatment System (IDTS)1 wing, specifically for remand prisoners who have a
drug dependency. Prisoners are supported by the Counselling, Assessment,
Referral, Advice and Throughcare (CARAT) team, and many are on medication
to stabilise or assist their withdrawal from illegal drugs. Prisoners usually stay
on the wing for a maximum of 28 days.
Her Majesty’s Inspectorate of Prisons (HMIP)
16. The most recent published report on Dovegate by HMIP followed an inspection
in October 2011, two years after the man’s death. The previous inspection, in
2008, had found drugs to be a problem in the prison, relatively easy for
prisoners to acquire and a major security concern. The follow up report found
that, since the previous inspection, the integrated drug treatment system (IDTS)
had been fully introduced and there was an appropriate range of clinical
interventions for prisoners with drug problems. Inspectors found that the supply
reduction strategy was well integrated with the drug and alcohol strategy.
Independent Monitoring Board (IMB)
17. Each prison in England and Wales has an Independent Monitoring Board, of
unpaid volunteers from the local community who monitor all aspects of prison
life to help ensure that proper standards of care and decency are maintained.
The last report published by the IMB for Dovegate was for the year 2010-2011.
In relation to drugs, the report noted that the monthly harm reduction meetings
seemed to be effective, but that the monthly supply reduction meetings were
rarely held. In their report for 2009- 2010, the IMB noted that the quantity of
drugs being brought in by remand prisoners was a challenge with which the
prison was coping.
Previous deaths at Dovegate
18. The man was the tenth prisoner to die in HMP Dovegate since this office took
over responsibility for investigating deaths in prison custody in 2004. There
have since been a further seven deaths. In a previous report, this office made
recommendations about managing prisoners who suffer or have suffered from
depression and this report contains one further such recommendation.
1 The Integrated Drug Treatment system aims to increase the volume and quality of substance
misuse treatment available to prisoners, with particular emphasis on early custody; improved
integration between clinical and CARAT services; and reinforcing continuity of care between prison
and the community.
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KEY EVENTS
19. The man was born in 1971 and was brought up in the Stoke-on-Trent area. He
had a history of drug and alcohol problems and had used heroin for 10 years.
He had a number of previous convictions and had spent time in prison before.
He suffered from back pain since being involved in a road accident when he
was 26 years old and had also been treated for depression.
20. Very shortly after his release from a previous sentence in June 2009, the man
was arrested on suspicion of burglary. When taken into police custody, he had
with him a prescription for methadone (a heroin substitute). He told the police
doctor that he was also prescribed diazepam (an anxiety relieving medication)
and medication for depression. On 10 June 2009, he was charged with
burglary and remanded into custody at HMP Shrewsbury.
21. At a routine reception health screen it was noted that the man was receiving
treatment for depression. He was referred for counselling. He began an
alcohol detoxification programme. He also agreed to undergo treatment for
withdrawal from drugs and signed a consent form to begin a course of Subutex
(used to treat opioid addiction). He saw a psychotherapist at Shrewsbury. He
was noted to be very positive and motivated to make changes for the future.
22. The man transferred to HMP Dovegate on 8 September 2009. He was located
on M wing, which is an Integrated Drug Treatment System (IDTS) wing for
remand prisoners. He was allocated a double cell that he shared with a
cellmate. He had the lower bunk.
23. A Prison Custody Officer (PCO) was the man’s assigned drug worker on the
Counselling, Assessment, Referral, Advice and Throughcare (CARAT) team.
This included being responsible for drawing up a care plan in relation to his
drug treatment. She saw him on 9 September, when he admitted that he had
illicitly been taking Subutex in prison.
24. The man had been prescribed Subutex as part of his drug treatment but, at a
case conference on 14 September, at his request this was changed to
methadone. He was also prescribed anti-inflammatory medication for back
pain.
25. The man told his drug worker that he had no intention of using heroin again and
therefore did not intend to complete the heroin module of his drug programme.
They discussed the risks involved in heroin and how these could be reduced.
On 18 September, he told her that he felt more stable taking methadone.
26. On 21 September, the man had a review meeting with a member of the CARAT
team. She noted that he looked unwell, and was sweating, but as this was
consistent with withdrawal symptoms, she had no concerns about him. Later
that day, he attended a clinical review, at which his drug worker, and a doctor
and prison nurse, were present. He was sweating and looked pale. He said
that he felt unwell, and the doctor agreed that his methadone prescription would
be gradually increased from 20mgs to 50mgs.
27. At 2.00pm on 22 September the man again said that he felt unwell. A nurse
went to M wing and assessed him. His blood pressure, pulse and temperature
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were all within normal limits, and the nurse gave him some paracetamol. At
10.00pm a nurse woke he to give him his prescribed medication and asked him
how he felt. He said that he felt better and declined further paracetamol.
28. On 23 September, the man told a member of the CARAT team that he was
concerned about a cancelled Drug Intervention Programme meeting with his
community drug worker. She spoke to his drug worker, who said that she was
aware of the cancellation and had made arrangements to rearrange it. He was
pleased it was being sorted out.
29. During the evening of 23 September, four new prisoners arrived on M wing.
One of whom, Prisoner A, already knew a number of prisoners on the wing,
including the man. Several prisoners went to this prisoner’s cell to greet him
and officers noted that there was a good deal of activity around him.
30. Some time between 6.00pm and 6.30pm, Prisoner B went to take menu cards
to the cells on M wing. As he approached Prisoner A’s cell he said he heard
him say “Give us a chance, I’ve only just got it out of my arse”. When he went
into the cell, Prisoner A, the man and another prisoner were there and he saw a
package of brown powder on the desk, when Prisoner A stepped in front of it,
blocking his view. He said Prisoner A then handed the man a small wrap of
paper, which he took to be drugs. The man put it into his pocket, and Prisoner
B left the cell. When police questioned Prisoner A, he denied that any drugs
were involved, and suggested that what he passed to the man was a roll-up
cigarette.
31. Between five and ten minutes later Prisoner B told the Unit Manager that he
had seen something that suggested that Prisoner A had some drugs. He also
said that there was a lot of activity around his cell. It does not appear that
Prisoner B mentioned that he had seen the man in the cell. Prisoner B later told
police that he told the Unit Manager that he thought drugs were involved. The
Unit Manager said Prisoner B did not specifically mention drugs, but it was
implicit that they both assumed that to be the case.
32. The Unit Manager told Prisoner B that he would report what he had told him.
He told police that he had been unable to deal with the information straight
away as he was dealing with another incident. He filled out a Security
Information Report (SIR), which he submitted the next morning and asked two
PCOs to monitor Prisoner A and maintain a visible presence around him and
his cell. He did not mention to either of the officers that this prisoner might have
passed something to the man. When interviewed, neither PCOs could recall
whether the Unit Manager specifically mentioned drugs but, as M wing was a
drug treatment wing, they both assumed that any illegal activity would have
been likely to involve drugs. Both said they made a point of watching Prisoner
A and his cell. One PCO noted various prisoners, including the man, around
Prisoner A’s cell on at least two occasions. Staff dispersed the groups.
33. Later that evening, approximately an hour after he had gone into Prisoner A’s
cell, Prisoner B saw Prisoner A on the wing, apparently under the influence of
drugs. He also saw the man on the wing that evening but said he appeared to
be acting normally.
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34. At approximately 7.45pm, a PCO gave the man his IDTS drugs pack2 for the
night. Prisoners were then locked into their cells until the morning.
35. Between 10.00pm and 11.00pm PCO A escorted a nurse dispensing night
medication to prisoners on the wing, including the man. When they reached his
cell, he came to the door and took his medication. The nurse stated he said he
was fine when she asked.
36. The man’s cellmate later told Serco’s investigation team that the man took
“something” that night. He told the police that he heard him mumbling in his
sleep at about 1.00am.
37. Between 5.15am and 5.30am, PCO A conducted a roll count of the wing to
check all prisoners were present. When interviewed by the police, she said that
she did not notice anything untoward about the man’s cell. When the shifts
changed and day staff came on duty, a further check was made at around
6.55am. She and another PCO said that he was lying on his bed, slightly
propped up and noted nothing unusual about his appearance.
38. PCO B was working at the medication dispensing hatch on M wing when,
between 7.30am and 7.50am, he heard shouting and saw a number of
prisoners around the man’s cell. He ran to the cell to see what the problem
was, thinking some prisoners might be fighting. As he got near, the man’s
cellmate came out and said that the man was not breathing. When he went into
the cell, he saw him lying on his bed. He was on his back and his left arm was
hanging over the edge of the bed. He could see that his lips were blue and
there were traces of vomit around his mouth. He could see no movement. He
pressed the emergency alarm to get help then moved his head and cleared his
airway.
39. The Unit Manager was working on the lower landing of the wing when he
became aware that something was wrong and went to the cell. When he
arrived, he saw PCO B clearing the man’s airway and he radioed to request an
emergency ambulance. Between them they moved him onto the floor and the
PCO began to try to revive him by giving him rescue breaths (often referred to
as mouth-to-mouth resuscitation).
40. Two nurses arrived just as the officers moved the man onto the cell floor. The
nurses applied an oxygen mask to him and performed cardiopulmonary
resuscitation (CPR – which is a mixture of rescue breaths and chest
compressions to keep blood and oxygen circulating around the body).
41. Another PCO heard the alarm and went to M wing. As he arrived, there was a
group of prisoners around the cell. The Unit Manager and PCO B were inside.
The Unit Manager asked for the prisoners to be locked back in their cells and
the PCO assisted other staff in doing this. He then returned to the cell and
assisted with the resuscitation attempts. At 8.24am, the ambulance crew
arrived at the cell and the paramedics, with the nurses, continued to try to
revive the man. By 9.10am, he still had no heartbeat, was not breathing, and
was not responding to treatment. Paramedics advised that no more treatment
2 Many drug users have had a poor diet, and these packs contain energy-giving foods such as chocolate and energy
bars to help prisoners who might be suffering withdrawal symptoms.
10
should be given, and attempts to resuscitate him stopped. At 10.00am a locum
doctor working in the prison, officially certified his death.
Informing the man’s family
42. The prison appointed a family liaison officer. The family liaison officer, the
prison chaplain and one of the prison’s senior managers visited the man’s
mother, who was his nominated next of kin, at 10.40am that morning and
informed her of her son’s death.
Debrief
43. A debrief for staff who had been involved in the emergency response was held
on the morning of 25 September, to ensure they had the opportunity to discuss
any issues arising and to remind them of the support available. Notices were
posted to inform other staff of the man’s death.
Informing prisoners
44. Prisoners were formally informed of the man’s death by notices from the
Director. His cellmate was offered individual counselling and support.
Post-mortem report
45. The post-mortem report indicated that the man’s death was due to:
1(a) pulmonary congestion and oedema
1(b) recent intake of heroin together with methadone, diazepoxide
and chlordiazepoxide.
46. This means that the man died from a build-up of fluid in his lungs when his
system became depressed because of a combination of drugs. This included
therapeutic doses of those prescribed to him as part of the detoxification
programme plus an additional recent intake of heroin.
Funeral
47. The funeral was held on 7 October 2009. The prison was represented by the
family liaison officer and the chaplain. In line with national guidance, the prison
contributed to the costs.
Police investigation
48. Staffordshire police conducted an investigation into the circumstances in which
the man died. Prisoner A denied supplying any drugs to him, who he described
as a friend. He said that he knew many prisoners on the wing, a number of
whom came to see him when he arrived, which was why staff might have
noticed that his cell was busy. No charges were brought in relation to the
death.
11
ISSUES
Healthcare
49. On reception at Shrewsbury, the man received a routine health screen. This
appropriately identified his drug and alcohol problems, the medication he was
taking, his history of depression, and his ongoing back pain. He was given
treatment for withdrawal from alcohol and drugs and referred for counselling.
Staff contacted his doctor to confirm his prescriptions. When he transferred to
Dovegate he was located on the drug treatment wing and referred to the
CARATs team. His prescription was changed from Subutex to methadone
when he said that Subutex was not working well for him. The dosage was
increased when he was observed to be suffering from symptoms of drug
withdrawal. He was given medication for depression and received pain relief for
his back problems.
50. The clinical review concluded that the care given to the man during his time in
prison was appropriate and responsive to his needs. His death was not related
to any failure in the care that he received. However, the clinical review notes
that although he had a history of depression his records do not indicate that he
was referred to the primary mental health team at Dovegate.
The Healthcare Manager should ensure that prisoners with a history of
depression are referred to the primary mental health team for assessment.
Assessment of intelligence
51. The National Offender Management Service (NOMS) has a National Security
Framework (NSF) which includes guidance on the management of intelligence
and completing security information reports (SIR) whenever information is
received about a prisoner. The intelligence is evaluated by the prison’s security
department for reliability and the potential impact on the prison’s security. The
author should indicate whether in their view the information needs to be
assessed immediately, within 24 hours, or within 72 hours. Both the NSF and
Dovegate’s local security strategy say that, on receiving intelligence, staff
should submit an SIR. There is no guidance on any action beyond this.
52. Prisons evaluate a high level of intelligence information. Between 2009 and
2010, there were over 8000 SIRs submitted in Dovegate. Almost a quarter of
these involved information about drugs.
53. Prison staff often need to make quick decisions in response to situations.
There is no central guidance for prison officers on how to classify information as
requiring immediate action; this is a matter for individual judgement. The Unit
Manager told the police that on average he received reports like the one from
Prisoner B between three and six times a day. In this instance, it was a single
piece of intelligence and he said that he did not know how reliable a source the
prisoner was. He was therefore unable to assess the likely accuracy of the
information. However, even if the information was true, the immediate threat to
the security of the wing or the prison was low.
54. The Unit Manager received the information from Prisoner B at approximately
6.30pm. He filled out an SIR, but did not submit it at that time. In his statement
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to the police, he said that there is no obligation on staff to submit SIRs
immediately and he was aware that the prison’s intelligence unit is only staffed
between 8.00am and 5.00pm. Had he submitted the report when he received
the information, the SIR would not have been acted upon by the intelligence
unit until the following morning. We are therefore satisfied that he acted
appropriately in submitting the SIR report at 7.00am the next morning.
55. The Unit Manager also mentioned the risk involved if staff had made a direct
intervention at that time. Prisoner B passed the information to him while
prisoners on the wing were unlocked for association3. The number of officers
on the wing in relation to the number of prisoners was low. Many of the
prisoners on the wing were withdrawing from drugs, which sometimes made
them volatile. He said that if staff tried to search a prisoner and met resistance,
they risked a dangerous confrontation.
56. Once prisoners had been locked in their cells, the situation was different. Staff
would have been able to conduct a cell search. The Unit Manager had received
information that suggested a new prisoner had brought drugs on the wing that
evening. At Dovegate, if a member of staff judges that some intelligence needs
to be acted on urgently while the intelligence unit is staffed (during office hours),
they can contact them directly. Outside those hours they can contact the duty
manager, but this was not done. It is important to note that while Prisoner B’s
and his respective accounts of the conversation between them differ a little, it
does not appear that the prisoner told him that he saw the man take anything
from Prisoner B, so it is unlikely that his cell would have been identified for a
search. However, a newly arrived prisoner who attracted the attention Prisoner
A appeared to have done that evening ought to have raised suspicion.
Combined with the intelligence received, we consider that the Unit Manager
should have at least discussed with the duty manager that evening whether to
take any further action.
The Director should ensure that when intelligence is received that a newly
arrived prisoner is in possession of drugs, managers consider and
document whether to take immediate action.
57. Although there is some circumstantial evidence that the man might have
obtained drugs from Prisoner A on that particular evening, it is not possible to
know for certain how or when he obtained the drugs that contributed to his
death. He had admitted to his drug worker on 9 September to taking illicitly
obtained Subutex. As well as his prescribed methadone, the post-mortem
report showed the presence of diazepam and chlorodiazepoxide (neither of
which had been prescribed) and heroin. During his time at Dovegate he was
not subject to any cell searches and he did not take any drug tests. It is
therefore possible that he might have taken illicit drugs on more than one
occasion.
Observation through the night
58. When prisoners begin drug treatment programmes that involve medication
prescribed as a substitute for illicit drug use, they are subject to observations
once an hour, usually for the first day, to ensure their wellbeing and then
3 When prisoners are out of their cells and can socialise together.
13
frequent monitoring for the first 72 hours. The man had been on a drug
treatment programme since before he arrived in Dovegate and would no longer
have been subject to frequent checks.
59. Prisoners are not routinely observed during the night unless there are specific
security concerns, or if they are on special monitoring arrangements such as if
they have just begun drug treatment or are thought to be at risk of harming
themselves. This did not apply to the man. The last time he had any
interaction with staff was when the nurse gave him his medication between
10.00 and 11.00pm. His cellmate said he heard him mumbling in his sleep at
approximately 1.00am. During the roll check shortly before 5.30am there was
apparently nothing untoward about him, and staff did not notice anything when
they made a visual check shortly before 7.00am. These checks are principally
for security reasons to ensure that prisoners are present and not to check on
their wellbeing and it is possible that he was not alive at those times.
Emergency response
60. When the man was found by his cellmate to be unresponsive, staff reacted
swiftly. An emergency call was put out, an ambulance was requested without
waiting for healthcare staff to arrive, and uniformed staff moved him from his
bed and started attempts to resuscitate him. Resuscitation attempts were
carried out by nurses, prison officers, and paramedics.
61. The clinical review considered the emergency response. It notes that the
ambulance was called and arrived in a timely fashion. The review goes on to
say that there were no difficulties in the ambulance crew accessing the prison.
We are satisfied that the response was appropriate.
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RECOMMENDATIONS
1. The Healthcare Manager should ensure that prisoners with a history of depression
are referred to the primary mental health team.
This recommendation was accepted. NOMS commented:
“HMP Dovegate follow evidence based guidelines by National Institute of Clinical
Excellence (NICE) Depression in Adults (2009). Guidelines state that patients with
depression are reviewed every 6 months. The man was at H.M.P Dovegate for
approx. 2.5 weeks. The care of patients with depression can be managed by a
professional which may be an R.M.N from Primary Mental Health Team or a G.P.
I can confirm that patients at HMP Dovegate are managed by either the G.P or
Primary Mental Health Team which consists of 3 R.M.Ns and a Lead Nurse.”
2. The Director should ensure that when intelligence is received that a newly arrived
prisoner is in possession of drugs, managers consider and document whether to
take immediate action.
This recommendation was also accepted. NOMS commented:
“The Security Management within the prison will send a briefing note with what to
do if Intelligence is received in this action point circumstance. This briefing note
will go to Dovegate All Managers, Dovegate Duty Directors, and Dovegate SMT.”
15