Individual at Highpoint

Investigation into the circumstances surrounding the
death of a man in hospital, in May 2008, whilst in the
custody of HMP Highpoint
Report by the Prisons and Probation Ombudsman for
England and Wales
April 2009
This is a report into the death of a man. He was a prisoner at HMP Highpoint, and
died of natural causes in hospital. He had only spent one day in Highpoint after
transferring from HMP Wormwood Scrubs.
The investigation was led by my one of my investigators. I must thank both Suffolk
and Hammersmith & Fulham Primary Care Trusts (PCTs) for the appointment of two
reviewers to conduct independent clinical reviews. I am also grateful to the
Governor and staff of HMP Highpoint for their assistance.
I offer my sincere condolences to the man’s family for their loss. One of my family
liaison officers made contact with the man’s family to offer them the opportunity to be
involved in the investigation process. Unfortunately, a delay in receiving the clinical
reviews has held up the issuing of this report, and I apologise for any distress this
has caused.
The clinical reviews note that the man had some significant health problems, and
show that he received broadly appropriate care whilst in prison. Indeed, one of the
reviewers commends the care he received in his short time at Highpoint. There are
some issues over the management of information in healthcare at Wormwood
Scrubs. The clinical reviewer’s report makes a number of recommendations that
would improve the way records are maintained and the consequent provision of
service. Wormwood Scrubs have already carried out an internal review of the care
the man received and are aware of some of the failings identified in the clinical
review. I hope that the Governor has implemented plans to address these
shortcomings, but I nevertheless draw the clinical reviewer’s recommendations to his
attention.
I make three further recommendations to the head of healthcare at Wormwood
Scrubs. I am pleased to note that the Prison Service have accepted these
recommendations. I also draw attention to the long period during which the man was
subject to physical restraints in hospital, despite the very poor state of his health. I
note the Prison Service’s comments in relation to this.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2009
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CONTENTS
Summary
The investigation process
HMP Highpoint
Key findings
Issues
Recommendations
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SUMMARY
The man was serving a sentence of two and a half years imprisonment. He had a
number of health problems, including a long history of ulcers (and associated
stomach issues such as constipation) and diabetes. He had previously undergone a
partial amputation of his left foot. At the time of his imprisonment he had been under
the care of an outside hospital.
When first taken into custody, the man was held at HMP Brixton. His health
problems were noted in reception and he remained in contact with the healthcare
centre there until he transferred to HMP Wormwood Scrubs in November 2007. He
complained on reception of chest pains and was taken straight to healthcare, where
he was assessed and kept under observation. He remained in Wormwood Scrubs’
healthcare centre for a week.
The man’s time at Wormwood Scrubs lasted until 1 April 2008, and he was in
continuous contact with healthcare. His treatment was kept under review, although
at one point he was found not to be receiving his second daily dose of medication for
diabetes. He was given responsibility for his own drugs as a result, despite some
concern at his previous compliance with his medication. On more than one occasion
he complained of stomach pains, and on 6 March 2008 he was taken to hospital for
tests.
On 1 April, the man was transferred to HMP Highpoint. He was sick during the
journey, and unwell at reception, and so was taken straight to healthcare. The
prison doctor carried out an examination, and referred him to the local hospital. He
was taken there in an emergency ambulance. He was diagnosed with a peptic ulcer,
given medication, and returned to prison.
The man’s condition had not improved by the following morning. He was assessed
throughout the day, and in the afternoon the decision was taken to refer him back to
hospital. A taxi was ordered, but before it arrived he was found lying on the floor of
his cell. Once again, an emergency ambulance was summoned and he was taken to
hospital.
The man thereafter remained in hospital. Healthcare staff at Highpoint maintained
daily contact with hospital staff, but his condition did not improve sufficiently for him
to return to prison. By early May, he was on a life support machine. The prison had
begun the process to apply for compassionate release to allow the man to go to a
hospice. However, on 6 May before this process was complete, doctors decided that
there was no further treatment they could provide. The man’s family gathered at his
bedside and his life support machine was switched off. He died that evening.
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THE INVESTIGATION PROCESS
1. My investigator visited Highpoint and spoke to the staff who had cared for the
man. He interviewed three members of staff. The interviews were recorded and
the transcripts are attached to this report. Notices were posted to staff and
prisoners about the investigation inviting their contributions, but none was
received.
2. In addition, my investigator studied all relevant prison records relating to the man.
They included his main prison record, medical records and statements made by
staff. He visited the healthcare centre, including the areas where he spent his
brief time in Highpoint.
3. Suffolk Primary Care Trust (PCT) identified an independent healthcare consultant
to carry out a review of the man’s clinical care. I am grateful to her for
undertaking this review. In addition, Hammersmith and Fulham PCT
commissioned a review of the man’s medical care in Wormwood Scrubs. This
review was conducted by another clinical reviewer, to whom I am equally grateful.
My investigator discussed aspects of the man’s care with healthcare staff at
Highpoint and with both clinical reviewers.
4. I wrote to HM Coroner for Suffolk to inform him of the nature and scope of my
investigation. A copy of the post mortem report was made available to me. Upon
completion, my report will be sent to the Coroner to assist in his enquiries into the
man’s death.
5. One of my family liaison officers contacted the man’s daughter at the beginning of
the investigation and offered the opportunity to raise questions and concerns for
us to consider. His wife had asked whether he received medical attention in
good time. When his family had visited him in Wormwood Scrubs, he had
complained of being in pain but said that no action was taken despite his
reporting it to staff. I hope that the quality and level of his contact with healthcare
staff is reflected in my report, and help address the family’s concerns. A copy of
my report will be made available to the man’s family on completion, and it will be
translated into his wife’s first language.
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HMP HIGHPOINT
6. HMP Highpoint is located at Stradishall, about 13 miles from Bury St Edmunds in
Suffolk. Originally split into north and south sites, the north site is now a separate
prison called HMP Edmunds Hill. Highpoint holds sentenced adult male
prisoners with a security category of C or below.
7. The healthcare centre is staffed between 7.30am and 8.00pm Monday to Friday
and 8.00am and 5.00pm at weekends. There are between three and five
members of staff on duty. A doctor covers both Highpoint and Edmunds Hill and
attends each prison on a surgery basis between the hours of 9.00am and
5.00pm. If a doctor is required outside those hours, the local on-call service is
used.
Previous deaths at Highpoint
8. This is the fourth death at Highpoint I have investigated since I took over
responsibility for all such investigations. None of the circumstances of the
previous three deaths is relevant to the death of the man who is the subject of
this report.
HM Chief Inspector of Prisons’ reports
9. The most recent report published by HM Chief Inspector of Prisons on Highpoint
is that on an announced inspection in May 2007. None of the issues raised in the
report touches upon this investigation.
10. The most recent inspection report on Wormwood Scrubs followed an
unannounced inspection in June 2008. It does not contain any issues which are
of relevance here.
Independent Monitoring Board (IMB) reports
11. Each prison in England and Wales has an Independent Monitoring Board
responsible for monitoring day-to-day life in the prison and to ensure that proper
standards of care and decency are maintained. The most recent annual reports
published by the IMBs for Highpoint and Wormwood Scrubs do not raise any
issues relevant to this investigation.
Prisoner transfers
12. Regulations for prisoner transfers are contained in Prison Service Order (PSO)
1025. This PSO introduces the Prisoner Escort Record (PER) and is designed to
ensure that, when a prisoner is moved between prisons (or other external
destinations), those responsible for him/her are made aware of any risks or
vulnerabilities. A PER form must be completed for every external movement,
highlighting the known risks: medical, security and other. PSO 1025 says that
healthcare staff at the dispatching prison must sign the PER form to show that
they have considered medical risks. The form contains a “First Aid Given” box
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which must be ticked to indicate if the prisoner has been given first aid for any
reason before leaving the prison.
13. Once the prisoner is being moved, escorting staff must maintain a record of
events on the PER form. If incidents occur, they must be highlighted so prison
staff at the receiving jail are aware of any risks and vulnerabilities.
14. Regulations for continuity of healthcare for prisoners are contained in PSO 3050.
This PSO notes that, when prisoners are being transferred, current healthcare
needs should be assessed to ensure continuity of care. Written guidelines
should include the identification of physical problems. The PSO goes on to say
that “local policies should ensure that there are systems in place to ensure
appropriate and continuing clinical care in any transfer or release”.
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KEY FINDINGS
15. The man was remanded into custody at HMP Brixton on 31 August 2007,
following an appearance first at the Magistrates Court and then at the Crown
Court. The notes of his reception health screening at Brixton refer to his
diabetes, an allergy to penicillin, and that he had previously had a partial
amputation of his left foot. On 7 September, to assist with any application for
bail, his doctor wrote a letter indicating that he was not a well man and detailing
his ailments.
16. A charge of robbery was laid against the man on 6 November. On 12 November,
following an appearance at the Crown Court, he was transferred to HMP
Wormwood Scrubs.
17. On reception, the man was given a medical screening. He complained of chest
pain, and pain in his foot. The chest pain was not radiating (had it been so this
might have indicated problems with his heart), and he was not thought to be at
imminent risk of becoming seriously ill. He was nevertheless taken from
reception directly to the healthcare centre for observation. The following day, the
prison doctor wrote to an outside hospital urgently referring him for tests. There
is no indication in the records as to whether this referral was followed up.
18. Having complained of light-headedness, the man was assessed by healthcare
staff on 14 November. He was discharged from healthcare onto normal location
five days later but was to attend the healthcare centre each morning, at mid-day
and again in the afternoon, to get his medication.
19. The man continued to have contact with the healthcare department for his health
issues, including podiatry and diabetes. On 23 November, he told staff that he
had not been receiving his second daily dose of medication. At this point he was
given the medication to hold in his own possession. He also told staff that he had
had four endoscopies (internal examinations using a thin, flexible telescope to
view the inside of the stomach) at an outside hospital, and was awaiting a further
appointment in connection with his foot. He was asked to obtain a letter from the
hospital about this. He saw the diabetes nurse consultant on 6 December. His
diabetes had been poorly controlled and the nurse found that, despite having had
diabetes for some time, he had no understanding of the condition. (He had, for
example, declined medication on 17 November, claiming to be “fed up”.) A
further review was planned for the following month. However, the records do not
show any note of this review. The clinical reviewer contacted the diabetes nurse
consultant who confirmed that the man refused to attend the further review.
20. Solicitors representing the man wrote to the prison doctor on 6 December 2007
expressing concern that their client was not receiving full medication. The
healthcare department responded on 18 December to say that they only provided
medical reports requested by the courts. They pointed out that the solicitors
could arrange for an independent examination of the man if they so wished. The
records do not show if the solicitors followed this up.
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21. On 13 February 2008, the man appeared at the Crown Court. He was sentenced
to two years and six months imprisonment.
22. The prison doctor was called to see the man at 8.30am on 6 March. He had
suffered abdominal pain since the previous day, and vomited twice. The doctor
referred him to hospital to be assessed for pancreatitis and a gastric ulcer, and
he was taken to hospital at 4.00pm. He returned to Wormwood Scrubs later that
day. His prisoner medical record does not contain a discharge summary from the
hospital.
23. After the man experienced further abdominal pain, healthcare staff were called to
see him again on 8 March. The prison doctor examined him and prescribed
medication to treat constipation. The medical record asks for blood tests to be
carried out the following Monday to exclude pancreatitis. The records do not
show whether these tests were carried out.
24. As part of his sentence progression, the man was transferred from Wormwood
Scrubs to Highpoint, a category C (lower security) prison, on 1 April 2008. His
personal medical record contained an entry declaring him “fit for transfer”. The
medical section on the Prisoner Record Escort (PER) form completed before he
left Wormwood Scrubs was ticked to show “no known risk”. The box to indicate
whether the prisoner has been given any first aid before leaving the prison was
left empty.
25. The transfer vehicle left Wormwood Scrubs at mid-day. The PER form shows
that at 1.10pm the man complained of feeling sick. Staff gave him some water,
and provided sick bags. He was checked at 1.25pm and had been sick. He told
escort staff he now felt better. The PER form shows that he was checked again
at 1.55pm and at 2.15pm. On both occasions he was noted as being “ok”.
26. The transfer vehicle arrived at Highpoint at 2.25pm. All prisoners are given an
initial health screening on arrival, and the man was seen by a nurse. The initial
health screening nurse was sufficiently concerned at the man’s appearance to
contact the healthcare centre. He spoke to his nurse colleague and arranged for
him to be taken to healthcare for assessment. He made a note that the man
claimed he had not been taking his medication prior to transfer, although he did
not give a reason why. His reception papers also noted his diabetes and that he
had had a stomach ulcer five years previously.
27. Having spoken to the initial health screening nurse, the nurse colleague was
working in one of the offices in the healthcare centre whilst the man was brought
across. This was at approximately 4.00pm. When he arrived in the healthcare
centre, the nurse colleague could see him along the length of the corridor. She
was so concerned at his apparent frailty that she went straight to help him in to
see the doctor. She did not think he looked well enough to wait in the waiting
room.
28. Once the nurse colleague had helped him onto the examination couch, the man
told her that he had been unwell before leaving Wormwood Scrubs. He said that
he had told staff he felt sick and that he did not want to get on the vehicle. He
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said that they gave him some liquid, told him it would stop him from being sick,
and that he should get on the vehicle. He said that the liquid had not worked. He
told the nurse colleague this while she was carrying out nursing observations
(such as checking his blood pressure and temperature). She had not received
any documentation to support his version of events and so had to rely on his
word. She told my investigator in interview that, bearing in mind his condition
when she saw him, she thought it likely that he would have been unwell before
travelling.
29. The doctor on duty that day examined the man. He told her that he had run out
of Lansoprazole (a medicine used to treat problems with stomach acids or peptic
ulcers), and had not taken any since 48 hours before his transfer. He said that
he had told staff that he had run out.
30. The nurse colleague, the doctor on duty and the healthcare manager discussed
the man’s care. As Highpoint does not have night-time nursing cover, they
concluded that he should be in hospital. Although he was stable, the doctor on
duty was concerned at the waiting time for a standard transfer to hospital and so
called an ambulance. The nurse colleague remained with him until the
paramedics arrived, and he was taken to the outside hospital in an emergency
ambulance at 5.05pm. In hospital he underwent x-rays and blood tests. He was
diagnosed as having a peptic ulcer and was discharged. He returned to
Highpoint at 11.15pm. On his return to Highpoint, the man was located in the
segregation unit where he could be observed through the night. Although clearly
not desirable, I judge this was the best that could be done in the circumstances.
31. The following morning (2 April), the man was still presenting as unwell. He was
taken to the healthcare centre for monitoring, and the initial health screening
nurse referred him once again to the doctor. He was still vomiting, so the doctor
on duty prescribed medication and asked for him to be kept under observation.
He remained in the healthcare centre until shortly before mid-day. He was
judged to be clinically stable, so was moved to a cell on the induction wing unit
with instructions for him to continue to be monitored there by nursing staff. On
the way from the healthcare centre to the wing, he collapsed and continued to
vomit. He had to finish the journey in a wheelchair.
32. At 2.30pm, the man was seen by a Sister, the Acting Health Services Manager.
At 3.00pm, he was reviewed by the Sister and his condition was seen to be
worsening. The Sister discussed this with the doctor on duty and they agreed
that the man needed to be returned to hospital. The doctor on duty telephoned
the outside hospital to re-refer the man and express dissatisfaction that he had
been discharged the previous day. A taxi was ordered at 3.50pm, but at 5.20pm
it had still not arrived. The records do not show whether he was monitored
between these times, but at this point the staff nurse went to the man’s cell and
found him lying on the floor. An emergency ambulance was summoned and he
was taken to hospital. He was admitted to the Intensive Care Unit and underwent
emergency surgery for a perforated ulcer.
33. When a prisoner from Highpoint is in hospital, there is daily contact between the
hospital and the healthcare centre. The man’s family were informed that he was
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in hospital on 3 April. They were told where he was and given contact details.
They were given authorisation to visit (required as part of the security risk
assessment for prisoners in hospital) and arrived at the hospital later that day.
34. Prison security measures also meant that two prison officers were always with
the man in hospital. This is known as bedwatch. My investigator spoke to two of
the officers who spent time on bedwatch with him while he was in hospital. They
both said that, while he was in hospital, staff had little interaction with him owing
to his condition and to the breathing and other medical equipment around him.
He was not able to move other than occasionally getting from his bed to a chair
next to it. On 20 April, after he had been in hospital for over two weeks, it was
agreed that physical security restraints (handcuffs or other chains) should not be
routinely applied whilst he was in the Intensive Care Unit.
35. Records indicate that the man’s condition initially seemed to slowly improve
whilst in hospital. From 15 April he was to be weaned off the ventilator, but
problems with his blood pressure meant that he had to continue to use it. By 25
April, his condition was noted to be deteriorating. His wound had re-opened and
at one stage he had had to be taken back to the operating theatre.
36. As the man was seriously ill, prison staff at Highpoint began the process to apply
for him to be released on compassionate grounds. They thought that it might be
possible for him to be transferred to a hospice, and began to compile the
necessary documentation.
37. The bedwatch officers with the man on 6 May 2008 arrived at the hospital at
approximately 7.45am. The officers who had been on duty overnight gave them
a handover briefing. It was in this briefing that they learned that medical staff had
agreed to turn off the life support machine that day. One of the bedwatch officers
informed the duty governor at Highpoint.
38. The man’s wife was at the hospital, and asked the doctor if they would leave the
machines on until the rest of his family could make their way to the hospital. The
doctor agreed and the rest of the family arrived in the early afternoon. I am
pleased to note that, during this difficult time for the family, the prison officers
stood to one side and made themselves as unobtrusive as possible. This
displayed a degree of sensitivity that reflects well on the Prison Service and
which I hope the family found appropriate.
39. The life support machines were switched off at 4.21pm. At this point the officers
withdrew from the room and waited nearby. At 7.05pm, the man was pronounced
dead. At approximately 7.30pm, a nurse came and told the bedwatch officers
that he had died.
40. One of the bedwatch officers telephoned the duty governor and informed him of
the man’s death. The duty governor asked the bedwatch officer if any support
was needed, then said that the officers could leave the hospital. The second
bedwatch officer went straight home, and the bedwatch officer who made the call,
went back to Highpoint to return the prison equipment before she too went home.
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41. After a death in custody, a debrief is usually held on the same day to ensure that
staff involved have an opportunity to discuss any issues arising. In addition, a
critical incident debrief may be carried out within five to ten days in order to give
staff an opportunity to understand the circumstances in greater detail, review their
thoughts and feelings, and to help with the reactions some people may
experience after being involved in a traumatic incident. No debriefs were held
following the man’s death. However, both bedwatch officers were offered support
at the time and subsequently.
42. The prison appointed a family liaison officer, who remained in contact with the
family to offer ongoing support. The prison assisted the family with the funeral
costs.
Post mortem report
43. The post mortem examination was carried out on 6 May 2008. The conclusion
was that the man had died from natural causes. The cause of death was given
as:
1 (a) multi-organ failure
(b) intra-abdominal sepsis
(c) perforated gastric ulcer
2. type II diabetes mellitus
peripheral vascular disease.
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ISSUES
Clinical care
44. The man undoubtedly suffered from serious health problems. He had previously
had a partial amputation of his left foot. He had a history of duodenal and gastric
ulcers going back several years, and had suffered badly from constipation. He
was in constant contact with the healthcare departments of the three prisons
where he was held.
Wormwood Scrubs’ report into the man’s care while in custody there
45. An undated care plan in the man’s record shows that, following his admittance to
hospital, Wormwood Scrubs were notified “re treatment at discharge”. The head
of safer prisons at Wormwood Scrubs, instigated a review of the man’s care until
he transferred to Highpoint. Between 23 and 28 April, the head of safer prisons
was in correspondence with staff at Highpoint to obtain the necessary
documentation to carry out the review (which was conducted by one of the
healthcare managers).
46. The review notes that although the man told staff at Highpoint that he had
complained of abdominal pain on a number of occasions, his medical records do
not include any complaints after 8 March. There is no indication from the file that
he complained of pain on the day of his transfer to Highpoint. He had been seen
by a doctor in healthcare for abdominal pain on two occasions.
47. The review says that it is uncertain whether the referral to hospital was followed
up. There is no clear policy for following up referrals. The review also points out
that the records do not make apparent what issues were considered when the
man was certified as fit to transfer to another prison. Because there is no clear
policy on what should be considered in these circumstances, it is not certain what
checks were made on him. In relation to his having told staff at Highpoint that he
had not received his medication for 48 hours prior to his transfer, the review
notes that he was issued with a 28 day supply to hold in his own possession on
19 March.
Clinical review into the man’s care in Wormwood Scrubs
48. The clinical review addresses the man’s time in Wormwood Scrubs. The man
had complained of chest pain on reception, and was housed in the healthcare
centre for observation. He further complained of chest and epigastric (stomach)
pain on 6 March and on 8 March. This pain was found to be caused by
constipation. He had been taken to hospital on one of these occasions.
49. The review notes that the man’s blood sugar control had been problematic for
some time. Medications were adjusted on several occasions to improve the
levels. At one point he had not been receiving the correct dosage, and he was
subsequently given control of his own medication (known as in-possession
medication). However, the review also notes some evidence that he did not
always comply with his medication, having refused medication in November 2007
13
and refused to attend a review with the diabetic nurse consultant in January
2008.
50. When the man was taken to hospital on 6 March, no discharge information was
obtained by the prison. Discharge summaries contain valuable information, and
should be obtained from external healthcare providers.
51. The clinical reviewer makes a number of recommendations which would improve
the management of healthcare in Wormwood Scrubs. The recommendations
cover assessment screening, management of medications, assessments prior to
transfer, medical information from external agencies, and record-keeping. The
review does conclude, though, that none of the deficiencies identified directly
related to the man’s death.
52. Having told healthcare staff in Wormwood Scrubs that he had been attending an
outside hospital in relation to his stomach problems, the man was asked to obtain
a letter from the hospital. This was in relation to his foot, and did not play a part
in his death. Nevertheless, whilst prisoners are in custody they have far less
autonomy to do such things than ordinary patients. Their health is in the hands of
the prison’s medical system, and in this case staff in the healthcare centre should
have made efforts to obtain the necessary information from the hospital
themselves.
53. Staff in Wormwood Scrubs did have concerns about the man’s compliance with
his medication. Despite this, he was at one point given responsibility for
maintaining his own medication. He received a good level of observation from
healthcare staff, but the papers do not make it clear whether a risk assessment
was carried out as to whether it was safe to let him hold his own medication.
54. The man’s solicitors raised concerns with the prison doctor that he was not
receiving his full medication. This may have referred to the period in November
when he had not been receiving his second daily dose of medication for his
diabetes. The prison’s response simply stated that the prison was only obliged to
provide medical reports requested by the courts. His records do not show
whether there was a good reason to respond in such stark terms, but this reply
seems inadequate and unnecessary in view of the fairly simple point made. The
records do not show if the solicitors followed it up. I understand that there are
sensitivities about the release of medical information, but in my view it would
have been reasonable for the prison to have supplied some information relating
to the man’s care. I do not make a formal recommendation, but healthcare at
Wormwood Scrubs may wish to consider whether such a response was
appropriate and to learn the lessons therefrom.
55. The day after the man arrived at Wormwood Scrubs, the prison doctor wrote to
another outside hospital urgently referring him for tests. This referral does not
seem to have been followed up. In this case it does not seem likely that this had
an effect on the man’s prognosis. However, in other cases it might make a
considerable difference to the treatment and ongoing care of a prisoner.
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Recommendation: The head of healthcare at Wormwood Scrubs should
consider putting in place a system of monitoring referrals to outside health
agencies to ensure that all referrals are acted upon.
56. When the man was taken to hospital on 6 March, no discharge information was
obtained by the prison. Once again, this does not seem likely to have made a
great difference in this case but could do so in others.
Recommendation: The head of healthcare at Wormwood Scrubs should
consider putting in place a system to ensure that discharge information is
obtained whenever prisoners are referred to outside health agencies.
57. The clinical reviewer makes several recommendations to improve the
management of healthcare in Wormwood Scrubs. Her review concludes that
none of the deficiencies directly related to the man’s death. As a consequence, I
do not repeat all of the recommendations here but bring them to the attention of
healthcare manager of Wormwood Scrubs. However, I would fully concur with
the recommendation that the decision-making process leading to prisoners being
assessed as fit for transfer must be documented in the prisoner’s medical record.
Recommendation: The head of healthcare at Wormwood Scrubs should
ensure that the decision-making process in assessing prisoners as fit for
transfer is documented in the medical records.
Clinical review into the man’s care in Highpoint
58. The review addresses the man’s care from his arrival at Highpoint until his death.
The reviewer has found that prison and healthcare staff showed concern and
care of the highest order for the brief period that the man was in Highpoint. He
was assessed on reception and taken directly to hospital. When returned from
hospital he was kept under observation. The following day, when he was found
to be seriously ill, he was immediately referred once again to hospital. When
there were delays with the taxi due to take him there, and his condition worsened,
an ambulance was summoned urgently.
Other matters
59. I note that the bedwatch officers said that staff had little interaction with the man
because of his condition, and that he was not able to move other than
occasionally getting from his bed to a chair next to it. So far as I can see, it was
over a fortnight before it was agreed that physical security restraints should not
be routinely applied. I understand the culture of risk aversion that surrounds
decisions about the use of restraints, but question whether he could not safely
have been released from restraints earlier. I have chosen not to make a formal
recommendation, but invite the Governor to consider this matter with his senior
management team in light of this report. (The Prison Service have responded to
this and the response is on page 18.)
60. No hot debrief was held for staff in the light of the man’s death. The death of a
prisoner can be a traumatic experience for staff as well as for fellow prisoners. I
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note that both officers who were on bedwatch with him on the day he died were
offered support, both at the time and subsequently. As he had spent such a short
period of time in Highpoint, and as his death occurred after a significant stay in
hospital, I do not feel that the lack of a debrief in this instance was unreasonable.
Conclusion
61. The man came into prison with a number of health problems. Throughout his
time in custody he was in contact with prison healthcare, and his medication was
kept under regular review. The clinical reviews of his time in Wormwood Scrubs
and Highpoint respectively both find that he received the care he required.
However, there are some issues around the management of information in the
healthcare department in Wormwood Scrubs which were identified in the prison’s
own review, and in the clinical review. I make three recommendations based on
the information contained in the reviews, but I would also draw the attention of
the Governor of Wormwood Scrubs to the full list of recommendations in the
clinical reviewers report. I also invite the Governor of Highpoint to consider
whether restraints were applied for too long to the man given the state of his
health.
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RECOMMENDATIONS
The head of healthcare at Wormwood Scrubs should consider putting in place a
system of monitoring referrals to outside health agencies to ensure that all referrals
are acted upon.
The Prison Service have accepted this recommendation. They comment that
Healthcare are awaiting the implementation of the clinical information system which
will assist with identifying and tracking referrals.
The head of healthcare at Wormwood Scrubs should consider putting in place a
system to ensure that discharge information is obtained whenever prisoners are
referred to outside health agencies.
The Prison Service have accepted this recommendation. They say that Healthcare
are working on a template for the discharge information from hospitals, and have met
with at least one of the hospitals where they regularly send patients.
The head of healthcare at Wormwood Scrubs should ensure that the decision-
making process in assessing prisoners as fit for transfer is documented in the
medical records.
The Prison Service have accepted this recommendation. They say that the “fit for
transfer” documentation is currently being reviewed.
The Prison Service have also responded to my comments in paragraph 61. I invited
the Governor to consider whether the man was kept in restraints whilst in hospital for
longer than he might have been. The Prison Service say that the prison received
daily updates saying that his condition was improving. Therefore, on a daily basis a
discussion amongst senior managers took place regarding the level of restraint
required. Every prisoner is individually risk assessed for the appropriate levels of
restraints when they have an external appointment or stay. The man was unknown
to the prison, which made undertaking a full risk assessment difficult. Once his
condition deteriorated arrangements were made for the removal of restraints.
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