Individual at Acklington

Investigation into the circumstances surrounding the
death of a man, a prisoner at HMP Acklington,
in December 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2010
This report considers the circumstances of the death of a man at HMP
Acklington in December 2009. He was 65 years old when he died from
natural causes. A post mortem showed that he died from bronchial
pneumonia.
I offer my sincere condolences to the man’s family and friends for their loss.
One the Family Liaison team contacted his family at the start of the
investigation.
The investigation was carried out by my colleague. Both he and I would like
to thank the Governor and all of his staff for their full and ready co-operation
during the course of our enquiries. I also thank the local Care Trust for the
appointment of a clinical reviewer.
As the man died from natural causes, the findings of the clinical review play
an essential part in my report. The review shows that he received good care
whilst in custody that was equitable to that he could have expected in the
community. I am grateful to the clinical reviewer for his timely review which
enabled this report to be produced so quickly.
The man’s family told the investigator that they did not believe that he
received good care whilst he was in prison. I have considered their concerns
carefully and reached the conclusion that his care was equivalent to what he
would have received in the community. Neither the clinical reviewer nor I
make any recommendations.
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.
Jane Webb
Deputy Prisons and Probation Ombudsman April
2010
CONTENTS
Summary
The Investigation Process
HMP Acklington
Key Findings
Issues
Conclusion
SUMMARY
The man was born in June 1944, and lived in the Darlington area prior to his
conviction. He had been married for 42 years and had two daughters.
On 4 June 2008, the man appeared at Crown Court and was sentenced to
five years in prison for sex offences. He was sent to HMP Holme House and
on 18 June transferred to HMP Acklington as that establishment has a
vulnerable prisoners unit which runs the sex offender treatment programme.
An Initial Reception Healthcare assessment was undertaken by a nurse who
confirmed his medical history and medication.
The man was examined by the prison doctor on 10 October, who found a
swelling in his abdomen and requested an ultrasound scan. On 31 October,
he had an ultrasound scan on his abdomen. The scan showed no
abnormalities.
On 3 March 2009, a prison doctor assessed the man and recorded that he
had a cough with green sputum. The doctor prescribed a course of
antibiotics. He next saw a prison doctor on 8 December, as he complained of
being breathless and was bringing up yellow phlem. The doctor prescribed a
weeks course of antibiotics.
On the morning of 17 December, the man again saw a prison doctor as he
was experiencing shortness of breath. The doctor tested his breathing, which
improved with the use of an oxygen mask, and decided to admit him to the
hospital as an emergency for further investigation. He was taken by
ambulance to General Hospital.
A hospital doctor saw the man and diagnosed a chest infection and a lung
problem. He was to be moved to a ward for further examination and tests.
Later that evening a hospital doctor told him that he could expect to remain in
hospital for at least three to four days.
The following morning the man gave his permission for prison staff to contact
his wife to inform her that he was in hospital. By the next day his condition
had deteriorated significantly and he was transferred to the High Dependancy
Unit at the hospital. He was visited by members of his family, who travelled
from the Darlington area.
By 20 December, the man’s condition had become critical. A hospital doctor
certified that he died at 1.54pm. The cause of death was bronchial
pneumonia. Acklington staff maintained contact with the family and liaised
with the funeral directors regarding financial assistance towards the funeral
expenses.
This investigation highlights that the care the man received was equitable with
that he could have expected in the community. I make no recommendations.
THE INVESTIGATION PROCESS
1. The investigation was opened on 21 December 2009 when the
investigator issued notices announcing the investigation to staff and
prisoners. The notices included an invitation to those who wished to
submit information relating to the man’s death to make themselves known
to the investigator. No prisoners came forward as a result.
2. The investigator contacted HMP Acklington on 21 December to obtain
copies of all relevant documentation relating to the man. Further contact
with the prison was made by telephone.
3. The local Care Trust arranged for a clinical reviewer to carry out a review
of the man’s clinical care. The Ombudsman’s investigator had excellent
liaison with the appointed clinical reviewer.
4. The investigator contacted Her Majesty’s Coroner for North
Northumberland to inform him of the nature and scope of my investigation
and request a copy of the post mortem report. Upon completion, my
report will be sent to the Coroner to assist his enquiries into the man’s
death.
5. One of the Family Liaison team contacted the man’s family at the
beginning of the investigation and offered the opportunity to raise
questions and concerns for consideration. His family raised the following
concerns:
• They believe he did not received good care whilst he was at HMP
Acklington.
• They cannot understand why they were not informed immediately
when he was admitted to hospital.
• They had received his property but not the money from his prison
account, or two cheques that had been sent.
6. I have attempted to address the issues raised within the report. I hope
that it provides a better understanding of the treatment he was given and
the events following the man’s death.
HMP ACKLINGTON
7. HMP Acklington opened in 1972 as a category C prison. It is situated on a
former RAF station near Amble in Northumberland and has the capacity to
accommodate 946 prisoners.
8. Healthcare is provided by the Care Trust Adult Directorate. Nurses and a
prison doctor (provided through a local practice) deliver primary healthcare
during the daytime, seven days a week. There is no out of hours medical
cover, although a doctor can be contacted by prison staff by telephone
after 6.00pm. Prisoners who require inpatient nursing care are transferred
to an outside hospital or another prison.
9. Her Majesty’s Chief Inspector of Prisons last reported on Acklington
following an unannounced inspection in June 2009. The Chief Inspector
found, since the last inspection in 2006, “a greatly energised and much
better managed prison”.
10. Specifically regarding healthcare services the Chief Inspector made the
following comments:
“The department was open from 7.30am until 7.45pm Monday to
Thursday, 7.30am until 5pm on Friday and 8.30am until 5pm at
weekends and on public holidays. All the registered nurses were
general trained and all staff were employed by the local Primary Care
Trust.
Medical cover was provided by a local GP practice, which ran five
weekly surgeries and two sessions specifically for the integrated drug
treatment system (IDTS). At other times, GPs were available by
telephone.
There was a lead nurse for older prisoners and one for prisoners with
disabilities. Both roles were relatively new appointments and staff were
only just beginning to set up systems and processes to ensure that
they saw all their caseload of patients.
Prisoners with life-long conditions were seen by the practice nurse,
who used templates devised by the lead GP to monitor patients and
referred them to the lead GP if required.”
11. The Independent Monitoring Board (IMB) Annual Report for 2007-2008
strongly criticised the standard of accommodation on several wings at
Acklington. However the report did state:
“There have been quite a few changes within the accommodation at
Acklington over the past few years. There has been a number of new
builds, the latest L wing coming on stream in May 2008”
12. L wing, which is where the man lived, holds 64 prisoners and is designated
as the Vulnerable Prisoner (VP) unit. These prisoners, because of the
nature of their offences, are kept apart from the rest of the prisoners.
13. Since April 2004, when the Ombudsman began investigating all deaths in
prison custody in England and Wales, 18 prisoners have died in Acklington
including the man. The last death occurred in January 2009. Of the 17
previous cases, 11 were due to natural causes, but there are no similarities
with the man’s death.
KEY FINDINGS
14. The man was born in June 1944, and lived in the Darlington area prior to
his conviction. He had been married 42 years and had three daughters
and one son. His wife also wished the report to include the following “that
he was a loving father to his four children and a loving grandfather to his 20
grandchildren. He was also an accomplished musician and taught his
grandchildren to play the guitar.”
15. On 4 June 2008, the man appeared at Crown Court and was sentenced to
five years in prison for sex offences. He was sent to HMP Holme House
where an Initial Reception Healthcare assessment was undertaken by a
nurse. The man said that he had no thoughts of self harm but had
suffered from depression in the past and had been prescribed Mirtazapine
(anti-depressant) for the past three months. He told the nurse that he had
been treated for tuberculosis (TB) (infection of the lungs) in 1989 and a
further lung infection in 2008. He said that he had been a smoker but
stopped after he had contracted TB. He had also been prescribed
medication of Tamulosin (for treatment of protrate gland) and Zopiclone
(for treatment of insomnia) and was concerned about contracting another
chest infection.
16. The nurse recorded that the man wore hearing aids in both ears, his
weight was 63kg, and his blood pressure was 138/93. (The normal range
for blood pressure is 100/70 to 140/90, although the pressure does vary
throughout the day depending on the individual’s activities. A blood
pressure reading of greater than 140/90 is classed as high and a reading
of 90/60 or below is classed as low.) Later the same day a prison doctor
saw him and confirmed his prescription for Mirtazapine and Tamulosin
only.
17. The man was next assessed by a second nurse five days later who
recorded that he had settled into the prison routine well and had no
concerns or thoughts of self harm. The nurse recorded that his weight
was 63.6kg, and his blood pressure was 166/91.
18. On 18 June, the man was transferred to HMP Acklington to participate in
the sex offender treatment programme. An Initial Reception Healthcare
assessment was undertaken by a third nurse which confirmed his medical
history and medication. He told the nurse details of his own doctor. The
nurse referred him to the prison doctor for an assessment of his suitability
for exercise in the gym.
19. A second prison doctor saw the man on 26 June. The man told the doctor
that one of his lungs was damaged as a result of contracting TB 20 years
previously. He also told the doctor that he used to get recurrent chest
infections but was able to manage gentle exercise. The doctor assessed
him as unsuitable to exercise in the gym.
20. A fourth nurse saw the man on 16 July to conduct a mental health review.
The nurse recorded that he had settled at Acklington and was in contact
with his wife and older granddaughter. He said he had no thoughts of self
harm, had no problems sleeping and his appetite was good. The nurse
gave advice on the mental health services and support that was available
to him if he felt that he needed any help.
21. Two days later a third prison doctor saw the man who said that he no
longer felt depressed. The doctor advised him to reduce the dose of
Mirtazapine to one tablet on alternate nights for the next week and then
stop taking it completely.
22. On 10 September, the man saw a fifth nurse as he complained of a head
cold and was concerned about contracting a chest infection. The nurse
recorded that an appointment was needed with the doctor and that his
blood pressure was 159/76 with a pulse of 110. Due to his raised blood
pressure the nurse referred him for a further check with a nurse the
following day. The next day a sixth nurse saw him and recorded that his
pulse was 100; his blood pressure was 164/84 in his right arm and 160/86
in his left arm.
23. The man saw the third prison doctor five days later. The doctor recorded
that he had a cold with nasal congestion, but that his chest was clear. The
doctor recorded his blood pressure as 178/80, and requested it should be
taken at regular intervals over the following four weeks, together with
blood tests for glucose and cholesterol.
24. Nursing staff conducted blood pressure checks in accordance with the
third prison doctor’s instructions as detailed in the table below:
Date BP reading
16/09/08 126/71
22/09/08 151/87
24/09/08 168/88
25/09/08 137/97
29/09/08 160/79
06/10/08 150/80
25. The third prison doctor saw the man again on 10 October, who recorded
that his blood pressure was 165/70. The doctor made a diagnosis of
hyperdynamic circulation (increase in pulse and blood pressure caused by
certain physiological and psychiatric illnesses). On examining him, the
doctor also found a swelling in his abdomen and requested an ultrasound
scan along with further cardiovascular related blood tests.
26. Three days later a seventh nurse recorded the man’s blood pressure as
168/88 and the following day the third prison doctor reviewed the blood
test results which were within normal range.
27. At the end of the month, on 31 October, the man had an ultrasound scan
on his abdomen. The scan showed that there were no abnormalities in the
liver, pancreas, gallbladder, spleen or kidneys.
28. The man had a pneumococcal vaccination (to reduce the risk of
contracting pneumonia) on 10 November. He next saw a member of
healthcare staff on Friday 9 January 2009, when he was seen by an eighth
nurse as he complained of a chesty cough. The nurse referred him to be
seen by the doctor.
29. Five days later the second prison doctor assessed the man who told the
doctor that he had a chesty cough and had been short of breath for the
past few days. The doctor prescribed a course of Amoxicillin (an antibiotic
for the treatment of bacterial infections).
30. The visiting optician was in Acklington on 3 February and saw the man.
As a result of his examination new distance vision spectacles were
required. These were ordered for him and arrived on 16 February.
31. On 3 March, a ninth nurse conducted an elderly health and welfare
assessment with the man. The nurse recorded that he had no mobility
problems though he could at times struggle with stairs due to shortness of
breath. The nurse was aware that he had a recent eye test and had
received new glasses. He told the nurse that he had no problems with
eating or drinking. He also said that he associated with others on the wing
and played the guitar. He confirmed that his current medication was
Tamsulosin. The nurse recorded his blood pressure as 192/96 and
referred him straight away to see the doctor.
32. Later that same day a fourth prison doctor saw the man and recorded that
he had a cough with green sputum. He told the doctor that he had no
chest pain. The doctor prescribed another course of Amoxicillin.
33. Ten days later the man saw the eighth nurse as he had wax in both ear
canals. The nurse issued olive oil drops and advised him how frequently
to use them. He was told not to wear his hearing aids until he had seen a
nurse in a week’s time. The nurse saw him a week later and removed wax
from both ears. He was allowed to use his hearing aids and he said that
he could hear much more clearly.
34. The man was next seen on 6 May when he complained of feeling unwell.
The tenth nurse examined him and recorded that he had the symptoms of
a common cold and prescribed paracetamol.
35. On 27 August, the man had a general check up with the dentist. It was
recorded that his oral hygiene was quite good but he was encouraged to
start cleaning interdentally using either floss or interdental brushes.
36. The man’s next contact with healthcare was on 8 December, when the
third prison doctor saw him as he complained of being breathless and
bringing up yellow phlem. The doctor recorded his blood pressure as
178/91 and prescribed a weeks course of Amoxicillin.
37. Six days later, on 14 December, an eleveth nurse responded to a call from
the man’s wing in the early evening as he complained of stomach pain.
The nurse saw him who said that he had not vomitted or felt sick. The
nurse encouraged him to eat but to make sure he drank plenty of fluids.
The nurse said that he would be seen the following morning. The next
morning, a twelth nurse saw him who said that the pains had subsided and
he felt much better.
38. On the morning of 17 December, a fifth prison doctor saw the man as he
was expereincing shortness of breath. The doctor tested his breathing
which improved with the use of an oxygen mask, but deteriorated when it
was taken away. As he had only just completed a course of antibiotics,
and as there was no obvious reason for his shortness of breath, the doctor
decided to admit him to the hospital as an emergency for further
investigation.
39. The man was taken by ambulance to the General Hospital emergency
department. A risk assessment had been completed that authorised an
escort of two officers and the use of a single cuffs, which was only
required for transfer to the hospital and movement around the hospital. An
escort restraint chain (a two metre chain with a cuff at either end) was
applied when he was on the ward and removed when requested by
hospital staff for treatment purposes.
40. The man arrived at hospital at 11.55am and blood tests and x-rays were
taken. By 3.35pm a hospital doctor saw him and told him that he had a
chest infection and a lung problem. He was to be moved to a ward for
further tests and asessment. It was only later that evening that a hospital
doctor told him that he could expect to remain in hospital for at least three
to four days.
41. The following morning he gave his permission for prison staff to contact his
wife to inform her that he was in hospital. A Senior Officer (SO) contacted
the man’s wife and explained he had been admitted to hospital, and gave
details of the hospital doctor’s assessment. The SO gave her the
telephone number for the ward at the hospital.
42. By the next day the man’s condition had deteriorated significantly and the
Governor gave the order to remove all restraints. He was transferred to the
High Dependancy Unit at the hospital.and was visited by members of his
family, who travelled from the Darlington area.
43. On 20 December, the man’s condition had become critical. A hospital
doctor certified that he had died at 1.54pm. The hospital staff contacted
the family directly to inform them of his death. The Governor contacted
the man’s wife to offer condolences, but she said that the hospital had
already informed her that her husband had died. The governor explained
that the prison family liaison officer would contact her the following day.
44. The next day the prison family liaison officer contacted the man’s wife.
She said that the funeral was arranged for 4 January 2010, and that she
did not want the prison to be represented at the service. He arranged to
take the man’s possesions to her on 29 December.
45. On 22 December, Acklington received a fax from the funeral directors in
Darlington to confirm that the man’s wife had approached them to conduct
the funeral. The Governor rang the funeral directors to ask for the full
invoice to be sent to the prison, and the deposit to be refunded to the
man’s wife.
46. The next day the prison family liaison officer confirmed by email to the
Governor that two cheques received for the man’s personal account had
not been cashed and had been returned to the senders. He had £130 in
his personal account but, due to the bank holiday period, it was not
possible to close the account in time for the visit arranged for 29
December. The amount was to have been given to his wife in person at
the funeral. However as no staff were to attend the service, the money
was posted with a letter asking for acknowledgement of receipt.
47. After the funeral on 4 January 2010, the Governor again contacted the
funeral directors to have the full invoice sent to Acklington. He also
contacted the man’s wife to assure her that the prison was meeting the full
cost of the funeral and that the funeral directors would reimburse her
deposit.
ISSUES
Clinical care
48. As I have said, the man’s family has expressed concerns about the quality
of care he received at the prison. The investigator and clinical reviewer
have carefully considered their views. They have examined the relevant
records and also spoken to staff. The clinical review makes the following
comments concerning the clinical care that the man received whilst in
prison:
“The standard of clinical care afforded to him at the relevant time would
seem to equate with that afforded to a man of similar age and
circumstance in the community setting.
“His death was not suspicious with no indication on the evidence as
presented to me that his death was preventable.”
49. At Acklington routine doctor appointments are only available Monday to
Friday, with an on call out of hours service available for evenings and
weekends. There were two instances detailed in this report where the
man had to wait five days after being referred by a nurse for a routine
appointment with a doctor. On each occasion the five day period spanned
a weekend and therefore his wait to see the doctor was not uncommon
with what could be expected out in the community.
50. The clinical reviewer further said that the man’s death from bronchial
pneumonia ”…was not as a result of a lack of medical intervention”. I echo
the reviewer’s findings and am satisfied that he received appropriate
attention.
Use of restraints
51. Unfortunately there have been too many reports in which the Ombudsman
has criticised the use of restraints when prisoners are under escort in
outside hospital. I am satisfied that the prison properly assessed the risks
presented by the man. It is pleasing to recognise the good practice at
Acklington which ensured that he was treated with dignity and respect
during the final days of his life.
Family liaison
52. When the man was admitted to hospital on 17 December prison staff were
not informed by the hospital staff until later that evening that he would
remain as an in patient for three or four days. Prisons do not routinely
inform the next of kin that their relative has been admitted to hospital. The
decision is made after considering the prisoner’s health and any security
issues. On this occasion the prison had no reason to anticipate that he
would deteriorate so quickly. I believe that it was reasonable to ask for his
consent and notify his next of kin the following day. He might have been
returned to the prison that same day.
53. Following the man’s death I am satisfied that the prison followed the
guidance given in PSO 2710, “Follow up to death in custody”. In addition
to the hospital staff informing the man’s family of his death, the prison also
offered their condolences and a family liaison officer was appointed.
Acklington honoured the family’s request that staff and prisoners should
not attend the funeral service.
54. The Governor liaised with the funeral directors to ensure that Acklington
met its financial obligations under PSO2710. The governor continued to
maintain contact with the family by letter and telephone to update them on
the actions taken by the prison.
CONCLUSION
55. During his time at Acklington, the man had regular contact with healthcare
staff and doctors which were well documented. Like the clinical reviewer, I
believe that the care he received was equitable to that expected in the
community. There were two occasions when there was a delay between
the nurse referring him and a doctor’s appointment taking place. However
the clinical review confirms that his medical treatment was appropriate and
that his death could not have been prevented. I hope that my report
addresses the concerns raised by the man’s family.