Individual at Maidstone

Investigation into the circumstances surrounding the
death of a man in January 2010 at hospital,
whilst in the custody of HMP Maidstone
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2011
This is the report of an investigation into the death of a man who died at
hospital in January 2010. He was serving a life sentence and had been in
prison since April 2006. I extend my condolences to his family and friends
and hope that this report explains the circumstances that led to his death. His
daughter has recently contacted this office and asked to be included in the
investigation process. I am sorry that my report has been delayed and
apologise for any additional distress this may have caused.
The investigation was lead by one of my investigators. He visited HMP
Maidstone and interviewed a number of staff there. He also interviewed a
nurse at HMP Elmley who had met the man. One of my family liaison officers
contacted the man’s next of kin to discuss the investigation.
I would like to thank the Governor and his staff for their assistance during this
investigation. In particular, I thank the liaison for my investigator and the
family liaison officer who provided further useful information. A clinical review
was commissioned from the local Primary Care Trust. They appointed a
clinical reviewer to conduct the review, and I am grateful for her report.
The man took an overdose of prescription medication in December 2009.
Initially it was thought that he had suffered a stroke, but he told both hospital
and prison staff that he had taken an overdose of medication prescribed to
another prisoner. He was stabilised at hospital and returned to HMP
Maidstone on 8 January 2010. However, on his return, he was assessed as
being too poorly to be managed there and was immediately transferred to the
healthcare centre at HMP Elmley. The next day, the hospital contacted the
prison to ask for him to be brought back to hospital, where he was diagnosed
with an MRSA infection. His condition deteriorated and he died several days
later.
He had previously taken an overdose of prescription medication at HMP
Albany, which he said was in part because of his frustration at not being able
to access an offender behaviour programme. He was moved to Maidstone,
but was also not able to access the course there, and missed an opportunity
to enrol on a course at HMP Usk. While I cannot be sure that his final
overdose was due to the same frustrations, I am concerned that prisoners are
not receiving proper and adequate information to help them either access the
programmes or fully understand the reasons for delays.
I make six recommendations as a result of this investigation which concern
medical practice at Maidstone and, in particular, about in possession
medication.
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.
Thea Walton
Acting Deputy Prisons and Probation Ombudsman July 2011
CONTENTS
Summary
The investigation process
HMP Maidstone
Key events
Issues
Conclusion
Recommendations
SUMMARY
1. The man was remanded into custody at HMP Peterborough in April 2006,
having been charged with serious offences. Whilst on remand, he made
the first of three suicide attempts. He was treated at hospital and returned
to the prison to await sentence.
2. On 24 November, he was sentenced to life imprisonment under the terms
of imprisonment for public protection (IPP, a sentence which sets a
minimum term of custody, after which release can only be authorised by
the parole board). He was transferred to HMP Albany in March 2007
having started his sentence at HMP Winchester. Staff there noticed that
he seemed to be low in mood and at times tearful. He was treated by
medical staff and appeared to settle down.
3. In July 2008, other prisoners alerted staff that the man was giving his
possessions and money away. They were also told that he was writing a
Will. Prison staff responded by opening an Assessment, Care in Custody
and Teamwork document (ACCT is a flexible, prisoner centred
assessment and care planning system which aims to identify individual
needs and offer personalised care and support during and after crisis in a
supportive and caring environment) to ensure that he was given
appropriate support.
4. The man told prison staff he was becoming frustrated with his sentence
and wanted to move to HMP Maidstone where he believed that he could
complete the extended sex offender treatment plan (SOTP) course. His
mood improved and the ACCT was closed in August.
5. On 6 September, he did not collect his breakfast. Staff checked his cell
and he was found to be drowsy. He told staff that he had taken an
overdose of prescribed medication. He was transferred to hospital and
told a consultant psychiatrist that a prison move had been blocked and he
had hoarded tablets over a period of weeks. Following treatment, he was
discharged back to prison with a recommendation that he should be
assessed by mental health workers in the prison. The consultant also
suggested that he should not be prescribed codeine or opiate based
medication if possible.
6. The man was transferred to HMP Maidstone on 9 October and quickly
settled into the prison regime, although he was unhappy to discover that
Maidstone did not run the SOTP course. He applied to transfer to another
prison.
7. An application for parole was refused in June 2009, and a
recommendation made that he attend the extended SOTP course. He
decided to appeal this decision but continued to engage with the regime at
Maidstone. Staff at the prison made regular entries in his personal record
that his behaviour in the prison was very positive and he was well liked by
both prison staff and prisoners. Staff at Maidstone made enquires about a
possible transfer to enable him to undertake the SOTP Course.
8. On 28 December, prisoners were seen gathered outside the man’s cell.
When staff went to the cell they found him to be unresponsive.
Healthcare staff on the wing at that time examined him and they believed
that he had had a stroke. He was transferred to hospital by emergency
ambulance. He was assessed at the hospital and thought to have taken
an overdose of opiates. Once stabilised, he was transferred to Maidstone
Hospital. He told prison officers that he had taken an overdose of other
prisoner’s medication.
9. Eleven days later, on 8 January, hospital staff contacted Maidstone to
discuss discharging the man. Prison staff raised concerns about the
limited medical facilities which were available. Nevertheless, he was
discharged back to the prison the following day. Prison healthcare staff
assessed him as being too ill to be managed at Maidstone, which does
not have in patient facilities. Arrangements were made to transfer him to
HMP Elmley, where there is an inpatient’s unit, and he was taken there by
taxi.
10. The next day, the hospital contacted the prison and asked for him to be
returned as soon as possible. Test results had shown that he had
contracted MRSA (metillin resistant staphylococcus aureus, a type of
bacteria that is resistant to some antibiotics). He returned to hospital, but
his condition deteriorated and he died.
11. I make six recommendations as a result of this investigation. They refer to
the medication in possession policy for prisoners, the administration of
medication, communication between HMP Maidstone and the hospital,
record keeping, sentence planning and the allocation of SOTP courses.
THE INVESTIGATION PROCESS
12. Following notification of the man’s death, the investigation was allocated
to one of my investigators. He visited Maidstone and spoke with staff who
had come into contact with the man. Notices were posted to staff and
prisoners about the investigation, inviting them to contribute if they
wished. No prisoners came forward to take part in the investigation.
13. The investigator was provided with all the relevant prison records for the
man. They included his main prison record, medical records and
statements made by staff after he died. He also visited the cell where the
man was taken ill.
14. The local Primary Care Trust identified a clinical reviewer to carry out a
review of the man’s clinical care whilst he was at Maidstone. I am grateful
to her for producing a timely and useful review.
15. The investigator also contacted HM Coroner to inform him of the scope
and nature of my investigation and to request a copy of the post mortem
report. The Coroner will receive a copy of my report to assist him in his
enquiries into the man’s death.
16. The investigator interviewed nine prison officers and five healthcare staff,
four from HMP Maidstone and one from HMP Elmley. The clinical
reviewer also interviewed two doctors involved in the delivery of primary
healthcare services at HMP Maidstone.
17. One of my family liaison officers contacted the man’s sister, his nominated
next of kin. This was to explain the purpose of my investigation and to
provide an opportunity to raise any issues his family had about the care he
received. She said that she had no concerns at that stage about the care
her brother received in prison. She said that he had always been very
complimentary about the care he received and told her that both staff and
prisoners were always very good to him. She mentioned that other
prisoners would help him by collecting his meals when his legs were
particularly bad. She spoke very positively about the care and support
she had received from Maidstone following her brother’s death,
particularly from the family liaison officer.
18. The man’s sister said her brother had tried three times to take his own life.
She felt that his feelings of despair may have been compounded by
problems regarding a transfer to complete a sex offender treatment
programme. She said her brother was often terribly depressed,
particularly regarding the length of his sentence, but on other occasions
would seem positive about the future. She mentioned that he had written
in a diary (which had been returned to her with his belongings) that “by
March I will be with my Dad”, who had died some years previously.
19. She said they came from a large family of nine boys and three girls. One
of the man’s daughters contacted my office in November 2010 and spoke
with both the investigator and family liaison officer. She daughter said she
knew very little about the circumstances of her father’s death and asked to
receive a copy of my report when it was available. The man’s sister and
daughter will have the opportunity to see and comment on the draft report.
I hope the findings of my investigation help to answer any questions they
may have about the circumstances of his death.
Response to the draft report
20. The report was issued in draft to the man’s sister and daughter. Having
considered the findings of the investigation the man’s daughter raised
concerns about the treatment of her father’s MRSA and the decision to
discharge him from hospital given the extent of his health needs at this
time. She asked why Maidstone prison did not consider sending her
father back to hospital rather than transferring him to Elmley.
21. It is not within my remit to comment on the treatment the man received in
outside hospital, nor is the decision by hospital staff to discharge him. In
her assessment of the man’s clinical care, the clinical reviewer concluded
that in her opinion he should not have been discharged from Maidstone
hospital at this time. I would like to draw attention to her comments
regarding my third recommendation in which she says the issue of
inappropriate discharge has been taken forward by her manager via the
Clinical Quality Review Meetings held with the Acute Primary Care Trust. I
hope this provides some reassurance to the family and demonstrates the
seriousness with which this matter is regarded.
22. It is within my gift to consider the actions of prison healthcare staff on
receiving the man back to Maidstone. Given the options available at this
time, I consider staff carried out a prompt and thorough assessment of
him and that their decision to transfer him to a nearby prison with more
adequate healthcare facilities was appropriate and reasonable. His
daughter also requested clarity about her father’s escort from the hospital.
I have added information to the report which I hope provides further clarity
about this.
23. The man’s sister commented that she would have expected prison staff to
have noticed there was a problem with him after he took an overdose on
28 December, given an officer entered his cell twice that morning without
eliciting a response. She said she was however appreciative of the care
her brother received in prison and did not wish to raise anything further.
24. The draft report was also issued to the National Offender Management
Service (NOMS). Their response to my recommendations is included in
the report.
HMP MAIDSTONE
25. HMP Maidstone was built in 1819 and is a category C prison,
accommodating adult male prisoners. (Prisons are categorised A, B, C
and D according to the seriousness of the prisoners offence and the risk
posed to the public should they escape. Category A prisons house the
most dangerous prisoners with category D being the least secure and are
generally known as open prisons.)
26. The prison does not have a 24 hour in patient healthcare unit, but there is
a healthcare team which serves the prison between 8.00am and 5.00pm.
There is also a locum doctor on call service.
HM Chief Inspector of Prisons
27. The former Chief Inspector of Prisons completed an inspection of
Maidstone in 2007. In her report, she said:
“Staff–prisoner relationships were mixed but aspects of diversity
were managed well, with particular attention paid to the of the large
number of older and disabled prisoners …Maidstone suffered from a
lack of investment in its regime. Prisoners received timed
appointments to see the GP. Access to the primary care mental
health service was straightforward. Several visiting health
professionals held regular clinics in the prison.”
28. There was also a follow up inspection in September 2009 and in her
report she commented that whilst work on offender management was
progressing well, work with IPP prisoners was limited. However, she also
commented that the prison had made considerable progress in addressing
issues identified in the 2007 inspection.
Ministry of Justice performance ratings
29. The Ministry of Justice publishes quarterly ratings which scores each
prison’s performance. In the latest ratings in 2010, Maidstone was
assessed as a good performing prison.
Independent Monitoring Board (IMB) report.
30. Every prison is monitored by an Independent Monitoring Board, members
of which are drawn from the local community, whose role is to ensure
standards of decency and care are maintained. They have full access to
prisoners and every part of the establishment, and produce an annual
report for the Secretary of State for Justice.
31. In their annual report published in 2010, the IMB commented on the
provision of healthcare services. They said:
“The staffing level is still below full complement and bank staff are
often called upon to cover shifts. The new prisoner electronic records
‘System 1’ has been introduced but regrettably it is not interactive
with the new P-Nomis system which is also in use. Clinical
Governance meetings were better supported for a while by the PCT
but this has since tailed off again. The Board has been advised that
HMPs East Sutton Park, Blantyre House and Maidstone, which are
clustered for healthcare provision by the PCT, is to be put out to
tender during 2010. The Board receives few legitimate complaints
from prisoners about health care provision.”
32. The man’s death is the seventh death at HMP Maidstone, since 2004
when this office took responsibility for investigating deaths in prison
custody. There are no direct similarities between this and the other
investigations.
Suicide and self harm monitoring
33. The Assessment, Care in Custody and Teamwork (ACCT) procedures aim
to help and monitor prisoners at risk of harming themselves. The key
aims of ACCT are to create a safe and caring environment, identify
prisoners’ individual needs, and provide individualised care and support
before, during and after a period of crisis. Once an ACCT is closed a post
closure review should take place within seven days.
KEY EVENTS
34. The man was remanded into custody in April 2006 at HMP Peterborough
having been charged with serious sexual offences. He was 76 years old
when he entered prison.
35. The clinical reviewer has confirmed from the prison medical file that the
man was registered as disabled. However, it has not been possible to
determine when his registration took place. He reported that he had a
history of asthma, arthritis and prostate surgery prior to coming into
custody.
36. On 25 June 2006, whilst still on remand, the man made the first of three
suicide attempts. He took an overdose of promethazine, which had been
prescribed for the treatment of nausea. He was admitted to the Intensive
Care Unit at hospital for treatment. Four days later, he was assessed by a
registered mental health nurse (RMN) and found to have no long term
mental health issues. At the assessment, he said that he had taken the
overdose to help him sleep, rather than commit suicide, and that he did
not intend taking an overdose again. A recommendation was made that
he be reviewed by a community psychiatric nurse specialising in the care
of the elderly. The clinical reviewer found no reference in the medical
record that this recommendation was carried out.
37. On his return to Peterborough the next day, the man was given support
and monitored under the ACCT process as a result of the overdose. He
told staff on13 July that he deeply regretted trying to take own life and
explained that “things got on top of him and he had had enough“. The
ACCT procedures were closed on 20 July.
38. He was sentenced to life imprisonment by a Crown Court on 24 November
2006. He was sentenced under the terms of indeterminate period of
imprisonment for public protection (IPP, a sentence which sets a minimum
term of custody, after which release can only be authorised by the Parole
Board). He had to serve a minimum of three years and six months before
he could apply for release on parole.
39. After initially serving his sentence at HMP Winchester, the man was
transferred to HMP Albany on 26 March 2007. He was noted to be
suffering from mood swings and was also seen to be tearful. He was
initially prescribed mirtazapine, an anti depressant, and he was
supervised taking this prescription for one month. He was allowed to have
other medication, including pain killers, in his possession, at that time.
(This means that he was given a supply of the drug to administer himself,
rather than receiving each dose individually from healthcare staff.)
40. In January and February 2008, the man underwent orthopaedic surgery
for carpel tunnel syndrome (carpal tunnel syndrome is thought to be
caused by compression of the median nerve in the wrist, which causes
numbness) in both of his hands. He was diagnosed as glucose intolerant
in January 2008 and his weight, diet and exercise regime were discussed
at that time.
41. In May, his prescription for mirtazapine was discontinued because he was
responding well to an increasing dose of amitriptyline (an anti-depressant
which can also be used as a pain killer) prescribed to address hip and
knee pain. The clinical reviewer comments that mirtazapine was
recommenced in July 2008, although the medical record does not make it
clear why or if he continued to receive amitriptyline.
42. On 24 July, a second ACCT was opened by staff at Albany as they were
concerned that the man might harm himself. Information had been
passed to prison staff that he had been giving possessions and cash away
and that he was writing a Will. He told staff that he did not think his
sentence and offender behaviour courses were progressing. When he
moved to Albany, he had realised that it was to a prison which was too far
away from his elderly friends who would be unable to visit him.
43. He continued to be supported using the ACCT process. During a review
meeting with staff, he said that he had reached a standstill in his sentence
and so he wanted a move to Maidstone. He was reviewed regularly and
on 18 August the ACCT was closed. The closing comments were that he
was “feeling a whole lot more positive than previously and has changed
his stance regarding programmes here”.
44. A few weeks later, on 6 September, the man was found to be drowsy in
his cell having not collected his breakfast. He told staff that he had taken
an overdose of paracetamol, mirtazapine and amitriptyline. He had also
written a will and a letter which were placed on the table in his cell. He
was transferred to hospital and admitted to the Intensive Therapy Unit
(ITU).
45. He was stabilised and, following further tests, hospital staff decided that
he had not taken paracetamol. Before he returned to prison, he was
reviewed by the consultant psychiatrist for older people’s mental health.
He told the psychiatrist that he felt that a move to HMP Maidstone had
been thwarted. He said that he had been hoarding tablets over a period
of weeks prior to his suicide attempt but had no depressive symptoms.
The consultant suggested that his level of suicide risk should be taken
seriously as there was evidence of planning and forethought. His
medication should be reviewed and more closely monitored. The
consultant also suggested that it was vitally important that codeine or
opiate based medications were avoided in his case, as they are highly
dangerous in an overdose. He should have another assessment from the
prison mental health in reach team to assess whether he required
antidepressant treatment or ongoing psychological support.
46. As a result of the overdose, the ACCT procedures were opened again on
12 September, when the man returned to the prison. He returned to C
wing where he had lived before the overdose. Prison staff interviewed
him during the ACCT process. He told the interviewing officer that he had
become frustrated with his offender supervisor, who he thought was not
doing enough to help him to progress to a Category C prison. He told the
officer that he wanted to progress with his offending behaviour work. He
also said he had received no visits for two and a half years and wanted to
be nearer his family.
47. On 15 September, he was seen by a community psychiatric nurse (CPN),
who followed up on the issues identified by the psychiatrist. No evidence
of ongoing mental illness was identified during this interview. It is not
clear from the medical record whether his in possession medication was
reviewed in line with the consultant’s suggestions.
48. Prison staff supported the man’s application to transfer to a Category C
prison and undertake the extended sex offender treatment programme
(SOTP). On 3 October, his ACCT was closed. During the closing review,
he said that he felt better, and that his offender supervisor would now
personally update him on the progress of his application to transfer and
undertake SOTP. He said that he was fully aware of the support that was
being offered and how to access such support.
49. The man was transferred from HMP Albany on 8 October. He stayed at
HMP Lewes overnight whilst en route to HMP Maidstone. As a part of the
reception into Lewes, he was interviewed by reception staff and a cell
sharing risk assessment (CSRA, an assessment to see if a prisoner
should share a cell) form was completed by Officer Roscoe. An officer
noted that “LIDS [an information database] shows as an open ACCT No
Document Received. He states it has been closed and has no issues”.
50. When the man arrived at HMP Maidstone the next day, reception staff
noted in the CSRA that he should have a cell on the ground floor as he
had a recent history of suicide attempts and of being supported through
the ACCT process. He was also assessed on reception to the prison by
healthcare staff and his history of depression, previous overdoses and
ACCT support was noted.
51. On 10 October, he was interviewed by the prison the Disability Liaison
Officer. She noted in her assessment that he should be located on the
ground floor of his wing, with a “buddy” to collect his meals and be allowed
to keep his walking stick. She also noted that he did not describe himself
as disabled. He was located on Thanet wing in a ground floor cell. He
underwent a second health care screening on 14 October, and was
referred to the optician to follow up previous treatment for glaucoma. His
medication was also noted.
52. The same day, an officer interviewed him and wrote in his personal record
that he was happy to be at Maidstone, had no thoughts of suicide or self
harm and was relaxed and happy. He was looking forward to receiving
visits from his family.
53. On 16 October, the man again talked with the officer, who was now his
personal officer (personal officers are officers who should be a prisoner’s
first port of call if they have any issues or concerns). He told the officer
that he was unhappy to find out that Maidstone did not run the extended
SOTP course and wished to transfer again so that he could undertake the
course. He also told him that staff at Albany had told him that he could do
the course at Maidstone and he believed that they wanted get rid of him.
On 21 October, he made an application to move to another prison where
he could undertake the extended SOTP course.
54. A probation officer at HMP Maidstone met the man on 4 November. She
discussed his family and personal circumstances and wrote in the record
of the interview that he “feels he has little to live for and had twice
attempted to take his own life”. She also wrote that “there is clearly some
urgency necessary in facilitating progress in his SP [Sentence Plan]
targets as he is 79 and not seemingly in the best of health”.
55. On 14 November, the man was reviewed by the prison doctor as he had
become concerned that he was losing his memory. The doctor arranged
for him to be reviewed in one month.
56. The man also asked to see the Independent Monitoring Board about
moving to another prison. On 25 November, the probation officer wrote in
his sentence planning file, “Over recent weeks I have contacted all EX
[Extended] SOTP sites- a small no [number] have replied but no good
news”.
57. The next day, 26 November, the probation officer recorded that HMP Usk
had indicated that they would consider offering a place but needed to see
the man’s Structured Assessment of Risk and Need (SARN is an
assessment used in prison and probation to assess future needs of sexual
offenders). This document had not been received from Albany.
58. In the meantime, the man settled into Maidstone and was regularly
described in his personal history as polite to staff and displaying good
wing behaviour. On 29 January, the probation officer made further entries
in his sentence planning documents. She also sent an email asking for
further information on his SARN document which suggest that he had
formalised his complaints though the Prison Reform Trust and Prisons
and Probation Ombudsman. (There is no record of a complaint having
been made to my office.) She wrote that she thought the offer of a place
at Usk might have expired. She also wrote that he had previously
attempted suicide.
59. Having been seen by the older prisoners’ coordinator for a physical check
up, the man was referred for further tests and, on 3 April, was diagnosed
with non insulin dependant diabetes. He was given advice about how to
care for his diabetes, including measuring his blood glucose level and
managing his diet. He was also given medication, and referred to other
healthcare professionals (including a podiatrist) to help manage his
symptoms.
60. Probation staff at Maidstone liaised with staff at Albany in order to prepare
papers to enable the man to be transferred to Usk, which was running two
extended SOTP courses in July. He told an officer that, as he had
completed the SOTP course, he now wished to progress to the extended
SOTP. He applied for consideration for early release on parole licence in
June.
61. The possibility of a transfer to Usk appears to have been interrupted by an
instruction from the lifer manager’s office at Maidstone. It stated that the
policy that IPP prisoners staying at a prison until the outcome of their
parole applications, applied to him. (This policy is covered in Prison
Service Order (PSO) 6010, which is entitled “Generic Parole Process”.)
As such, he stayed at Maidstone and was not transferred to undertake the
extended SOTP at Usk.
62. The man had applied for consideration for release on parole licence in
June and he received the Parole Board’s decision on 7 July. His
application was rejected with the recommendation that he should
complete the extended SOTP programme.
63. On 20 July, he was reviewed by the prison doctor after complaining of
neck pain. His medication was continued and he was referred for
physiotherapy.
64. A week later, he discussed his situation with an officer. He told the officer
that he was waiting to see a legal representative as he was considering
appealing against his parole decision. The officer wrote in his record that
there seemed to be confusion over which course he needed to complete,
whether this had to be done before release and which prison could
provide the course.
65. In an interview with an officer on 27 August, the man said that he was
determined to stay positive about the courses which he needed to do. At
that time, he did not have a job in the prison but was socialising with new
prisoners of a similar age and had started to use the exercise yard again.
66. On 17 September, he was seen by a consultant opthalmologist, following
a screening undertaken because of his diabetes. He was referred for
bilateral cataract surgery, which is an operation to address cloudiness
affecting his eyesight.
67. Later the same month, he complained of pains in his knees. He was seen
by a doctor, who prescribed codeine, an opiate based pain relief drug, to
be taken twice a day. He was reviewed in October and advised to use his
pain relief only if he needed it. He continued to maintain good
relationships with wing staff and the comments recorded on his personal
record show him to be keen to progress his sentence plan.
68. He was drug tested on 20 October, and tested positive for opiates. This
was thought to be because he was taking prescribed codeine and so no
disciplinary action was taken. On 26 October, his medication was
reviewed and he was advised to continue to take one codeine tablet a
day.
69. On 17 November, he discussed his situation with an officer. The officer
wrote that he was working in a prison workshop which he was enjoying.
He also said that he had no news about a prison move but was patient
and willing to wait as he understood that moves take time to organise.
70. The man was reviewed by the physiotherapist on 2 December. The
physiotherapist decided that he could manage his own exercise regime
and he was discharged. Some time later in December, he attended a
review for his asthma. There were no concerns and he was advised to
carry on taking his medication.
71. The investigator has seen a copy of an email trail which ends on 21
December. This shows that the man had been selected to be transferred
to HMP Bure on 30 December to undertake the Extended SOTP. I can
find no evidence of this being discussed directly with him.
72. On 28 December, an officer commenced his duties on the man’s wing at
8.30am. The officer unlocked the cell and said good morning to him. He
did not reply, so the officer looked into the cell and saw him on his bed.
He could see that he was breathing. (28 December was a Bank Holiday
when prisoners are allowed to stay in their cell in the mornings.)
73. The officer continued with his duties and went back to the man’s cell at
approximately 10.15am to undertake routine checks of the fixtures and
fittings on the cell. This is known as the cell fabric check. The officer
thought that he remained asleep during the check. Once he had
completed his checks, he moved on to the next cell.
74. At approximately 11.45am, the officer was going about his duties when he
noticed a group of prisoners standing at the entrance to the man’s cell.
Another prisoner, who was friends with the man, had gone into his cell
and found him to be unresponsive.
75. Wing staff immediately called healthcare staff to ask them to attend.
However, at the time the call was made, the nurse from the healthcare
team came on to the wing having planned to see another prisoner. This
meant that the man was assessed more quickly. The nurse found him
lying face down and breathing in a very laboured way and showing
weakness on his left side. The nurse thought that he had probably had a
stroke.
76. An ambulance was called and the man was transferred to hospital. He
was assessed and found not to have had a stroke. The team at the
hospital believed that he might have taken an overdose of opiates. He
suffered a fit and was transferred to the intensive therapy unit (ITU). On
the assumption that he had taken an overdose, prison staff opened the
ACCT support procedures for him whilst he was in hospital on 29
December. Staff were to make hourly observations and engage in
conversation with him to ensure that he was supported. Staff at the
hospital were unable to contact the man’s sister, and the Methodist
chaplain at the prison agreed to do so.
77. The man responded to treatment and was transferred to ITU at another
hospital. On 31 December, he told an officer that he had taken an
overdose of 40 sleeping tablets, a mixture of his own and other prisoner’s
medication. The officer wrote in the bed watch log that he said he tried to
take his own life “over moving prison” but it was not worth it and he would
not try again. The officer also wrote that his statement “must be taken in
context with medication that he is on and coming off”.
78. On 2 January, the man was screened for MRSA which is a routine
procedure at hospital. He was found to have traces of the bacteria on his
body and he was treated with anti bacterial body wash. Doctors also
ordered blood tests on 7 January.
79. Four days later, an officer wrote in the man’s bed watch log that “it
remains obvious that he is unhappy at how he has been treated
previously”. At 9.00pm on the same day, an officer wrote on the bed
watch log that the man
“… spoke about how he’s going to go to the new prison now, it seems
that this situation was over a simple misunderstanding which could
have been resolved through simple communication with staff.”
80. On 7 January, the hospital contacted Maidstone to discuss discharging
the man. A nurse told the hospital that there were limited medical facilities
at Maidstone. He was made aware that the man used a catheter and
crutches, and asked the hospital to confirm that he was able to manage
independently himself before he was discharged. He was discharged and
escorted back to prison by prison officers in a taxi the next day. The
Person Escort Record (PER) for that journey noted that whilst he was very
frail he was able to move about independently with the assistance of
crutches. The PER is a document which accompanies prisoners between
prisons and other locations such as hospital and courts. It serves a
communication tool about risks that a prisoner poses on escort and
provides a chronological record of the journey. The urinary catheter
remained in place and the hospital had instructed him how to clean it.
81. The man returned to his cell before being assessed by healthcare staff.
They concluded that there were not sufficient medical facilities to look
after him properly at Maidstone and arrangements were made to transfer
him to HMP Elmley, which has a dedicated hospital wing. He was
transferred again by taxi with officers to Elmley and admitted into the
prison’s hospital wing at about 7.20pm. He was interviewed on reception
by a nurse, who completed the required documentation for admission.
82. On 9 January, the man told staff at Elmley that he regretted taking the
tablets and was looking forward to returning to Maidstone to continue his
courses. Later that day, Elmley received a telephone call from Maidstone
Hospital requesting him be returned to hospital. The results from his
blood tests had shown that his MRSA infection was more serious than
originally thought. He left Elmley at 4.00pm, arriving at the hospital at
5.00pm.
83. On arrival at hospital, he was admitted to the medical assessment unit.
He was diagnosed with MRSA bacteraemia (meaning that bacteria were
present in his blood). His condition began to deteriorate and he
developed bilateral pleural effusions (excess fluid that envelopes the
lungs), pneumonia, an abscess on his spleen and a deep vein thrombosis
(a blood clot).
84. On 13 January, a governor conducted a prison management visit.
Following a risk assessment he decided that because the man was so ill
restraints need no longer be used and he authorised their removal. One
of Maidstone’s family liaison officers spoke to the man’s sister to update
her, and agreed to contact her again should her brother’s condition
change.
85. The man’s condition continued to deteriorate and, on 18 January and after
discussions with medical staff, he requested that he should not be
resuscitated if he were to stop breathing. Medical staff agreed to keep
him comfortable.
86. On 20 January, the man was given the last rites and was placed on the
Liverpool Care Pathway (a care approach which is used to improve the
quality of care to the dying in their last hours). The family liaison officer
spoke to his sister to inform her of his condition. He passed away a few
days later.
87. The man’s sister, who he had named as his next of kin, was informed of
his death by medical staff at the hospital. This was followed up by a
telephone call from Maidstone prison. She was very appreciative of the
care and support offered to her brother. She told my family liaison officer
that although she was offered assistance by the prison with funeral costs,
it was her brother’s wish to pay for his own funeral, which he organised
and paid for in advance. She was also highly appreciative that the prison
helped arrange and pay for transport so that his daughters could attend
the funeral.
88. Staff were informed of the man’s death by way of briefings and notices put
around the prison.
89. On 5 July, the Coroner for Mid Kent and Medway sent my investigator a
copy of the man’s post mortem report, which gives the cause of death as
multi organ failure and sepsis (infection of the blood). No toxicology tests
were undertaken, and it is therefore not possible to comment on the
specific drugs which he took as an overdose.
ISSUES
Clinical care
90. A clinical reviewer was appointed to conduct a clinical review of the man’s
care by the local PCT. She has identified that, while some aspects of his
care were equitable with what would be expected in the community, there
were other contributory factors in his death that were not managed as
well. In conclusion, however, she considers that, given his age and range
of illnesses, his death was unlikely to have been avoided.
Medication in possession
91. Following an attempted overdose in September 2008, when the man said
he had taken a combination of prescription drugs, a consultant psychiatrist
at hospital advised that he should not be prescribed opiate based
medications. However, a year later, he was prescribed codeine to
address pains in his knees, and this medication was given “in
possession”.
92. When interviewed, a prison doctor said that he was not aware of the
advice from the consultant. (His colleague also confirmed that he had not
seen the advice and that he issued a repeat prescription, although for a
reduced dosage.) The doctors thought that the move from a paper-based
to electronic record system might have been the cause of this oversight.
93. The clinical reviewer has found that, following the man’s arrival at
Maidstone, no assessment was made of his suitability to hold medication
“in possession”. Although Maidstone has a policy covering in possession
medication, which says that a risk assessment should be carried out on
any patient being considered for in possession medication, it would seem
that the policy was not followed.
94. Another reason why in possession medication should only be issued after
a full risk assessment is that medication is often used as currency in
prisons, and prisoners sometimes sell, or are bullied because of, the
prescription medication they have in their possession. The man told staff,
after his overdose at Maidstone, that he taken a supply of another
prisoner’s medication. It is impossible to prove whether this was indeed
the case, but I would urge both the Governor and Head of Healthcare to
ensure that all staff are aware of the issues surrounding the misuse of
medication and the dangers this can pose.
The Head of Healthcare should ensure that the policy for in
possession drugs is reviewed and updated where necessary in
accordance with current practice. In addition, the Head of
Healthcare should ensure that risk assessments are conducted
before medication is issued in possession, and that the outcomes of
these assessments are noted on the relevant medical records.
95. During an interview with a nurse, the clinical reviewer asked whether he
was aware that the consultant psychiatrist had advised that the man
should not be prescribed opiate-based drugs. He replied that it was for
doctors to prescribe drugs and that, even though he was aware of the
consultant’s advice, he did not think that any of the nursing staff had
challenged the prescription. The clinical reviewer believes that nursing
staff should not administer a medication if they believe it is not in the best
interests of the patient (this is known as contra-indication). I agree, and
make the following recommendation.
The Head of Healthcare should ensure that registered general
nurses do not administer a medication which they believe is contra-
indicated for a patient’s needs, without clarifying with the
prescribing medical practitioner and obtaining an explanation as to
why the prescription has been issued.
Communication between HMP Maidstone and the hospital
96. The clinical reviewer considers that the man should not have been
transferred from hospital back to HMP Maidstone on 8 January 2010.
This was a clinical decision which is outside my Terms of Reference,
although I would recommend that both the Governor and Head of
Healthcare read the relevant section of the clinical review.
97. However, the clinical reviewer also mentions that communication between
the hospital and the prison could have been improved. In particular, she
notes that the prison did not receive a transfer letter from the hospital
when the man was discharged, and also that conversations between staff
and the hospital should have been recorded better.
The Head of Healthcare should ensure that protocols are in place
with local hospitals so that transfer letters are sent with any prisoner
being discharged from hospital to prison.
The Head of Healthcare should ensure that all conversations
regarding discharge are accurately recorded in the appropriate
medical records.
Management of long term health issues
98. As noted above, the clinical reviewer has found that the man was able to
access appropriate healthcare services to help him with his diabetes. She
also notes that there is an older prisoners’ coordinator at Maidstone,
which she views as good practice. She also makes some
recommendations on this issue, which I do not repeat here but again
suggest that both the Governor and Head of Healthcare fully appraise
themselves with her suggestions.
Clinical record keeping
99. The clinical reviewer also comments in her clinical review about the
standard of record keeping in the man’s medical records. While I again
refer the reader to the clinical review on this issue, I make a
recommendation of my own.
The Head of Healthcare should ensure that all staff accurately and
fully record all relevant information on the appropriate medical
records, in accordance with professional record keeping guidelines.
Access to the Sex Offender Treatment Programme (SOTP)
100. It is clear that the man was highly frustrated at not being able to
progress through his sentence planning programme. This was almost
certainly a factor in the overdose he took while at Albany, although it is not
clear whether it was a factor in the overdose he took shortly before he
died.
101. This is not the first investigation I have undertaken where difficulties in
sentence planning progression are likely to have been a factor in a suicide
attempt. I appreciate that courses are often oversubscribed, and that
population pressures can mean that transfers are often difficult to achieve.
However, I do not think that it is acceptable for a man of his age to be
moved around the prison estate with no real plan as to how he might
complete the correct offending behaviour courses. In particular, his move
from Albany to Maidstone appears to have been misguided, as Maidstone
does not provide the course that he required.
102. It is also unfortunate that the man then remained at Maidstone while his
Parole Board hearing took place, which meant he missed the opportunity
to attend a course at HMP Usk. (The Parole Board rejected the
application, saying that he needed to attend an extended SOTP course,
the very course he had been trying to attend for some months.) A place
was arranged for him at Bure to attend the course, but it seems likely that
he had not been told this when he took his overdose.
103. In considering this matter, I believe there are two aspects that need to be
addressed. The first is a local matter for Maidstone. Staff told my
investigator that the man could not be moved to Usk to attend the course
because it was “policy” that those with outstanding Parole Board hearings
should not be moved. I have consulted PSO 6010 which, at section 2.5.1,
deals explicitly with this issue. I quote the paragraph in full [where an
action in a PSO is mandatory, it is highlighted in italics]:
“The parole process is considerably disrupted if a prisoner is
transferred during the course of a review. While it is accepted that
there are exceptional compassionate, security or discipline reasons
for such a move, prisoners whose applications for parole are
underway should not normally be transferred before their parole
dossier has been completed. Only in exceptional circumstances may
prisoners be transferred. This may be appropriate, for example,
where it is necessary to transfer the prisoner to complete offending
behaviour work as identified through the sentence planning process.
In cases where this has been necessary Governors must inform the
Parole Board and PPCS of the reasons for the move.”
104. It is clear from the PSO that it covers the exact circumstances in which the
man found himself. He was at Maidstone and had applied for parole, but
during this process could have gone to Usk to “complete some offender
behaving work as identified in the sentence planning process.” I believe
that staff at Maidstone have not fully understood this provision of the PSO.
It is clear to me that the provisions of the PSO allow for prisoners to be
transferred in order to address offending behaviour issues, without which
it is much less likely that a parole application would be successful.
The Governor should ensure that staff are aware of the provisions of
PSO 6010, and specifically section 2.5.1, which deals with the transfer
of prisoners with outstanding Parole Board hearings.
105. There is also a wider issue, however. The man was frustrated in his
attempts to address his offending behaviour, which was likely to be a
condition of any attempt to obtain parole. (This was borne out by the
failure of his parole application.) While it is unrealistic to expect the
National Offender Management Service (NOMS, who are responsible for
prisons in England and Wales) to be able to significantly increase the
number of SOTP places which it can offer, especially given the current
financial restrictions, I would urge them to review how prisoners are
informed of the best way to access courses, and the likely length of time
before they are able to go on a course.
Risk of self harm
106. In the course of his sentence, the man harmed himself three times and, on
the first two occasions, the Assessment, Care in Custody and Teamwork
support procedures were used effectively. Each time it seems that he
wanted to progress in his sentence by undertaking a specific offending
behaviour course. He took an overdose whilst he was at Peterborough.
Then, at Albany, staff recognised the significance of him giving away his
possessions and put the ACCT procedures in place again. He took
another overdose whilst he was still at Albany and again the ACCT
support mechanism kept him safe. Mental health assessments were
made as were requests for further transfers.
107. Regrettably these efforts did lead to the offer of a place on a course but
the man was not given the information before, on 28 December, he took a
third overdose which ultimately led to his death. It is very sad that he did
not share the level of his frustration with staff or prisoners and neither did
they notice that he was at risk.
Use of restraints
108. I am pleased to note that the man was visited by a Governor while he was
in hospital and that, as a result of this visit, a risk assessment was carried
out on the level of restraint used. This led to all restraints being removed
as the risk of re-offending or escape was deemed to be low.
CONCLUSION
109. The man took three overdoses of prescribed medication, one whilst on
remand and two more as a sentenced prisoner. On the last occasion, he
probably used other prisoner’s medication although, in the absence of
toxicology reports, it has not been possible to verify exactly what he may
have taken.
110. This investigation highlights the fact that he was becoming increasingly
frustrated with the delays in addressing his offending behaviour and in
particular accessing the extended sex offender treatment programme.
Although it is not clear whether he took the overdose because he was
frustrated at remaining at Maidstone or because did not want to move to
Bure, evidence of his frustration at Albany strongly suggests it was the
former. As was noted on his bedwatch log, simple communication might
have prevented his overdose and subsequent death.
111. As a result of the final overdose, he was taken to hospital. While there, he
was identified as having contracted MRSA. He was discharged back to
prison, despite Maidstone not having the facilities to cater for his illness,
and he was quickly moved again to HMP Elmley. The same day that he
arrived at Elmley, the hospital asked for him to return because his
infection was more serious than first thought. He died there a few days
later.
112. This is a sorry story of an elderly man who wanted to progress through his
sentence by completing a specific offending behaviour course. He was
sent to a prison where the course was not available and there took a third
overdose. Although his death was ultimately due to an infection from the
subsequent hospital treatment, I believe that his distress deserves
attention by the prison and NOMS. I do not think that it is seemly for a
prisoner to overdose in an attempt to reduce his risk of re-offending.
RECOMMENDATIONS
1. The Head of Healthcare should ensure that the policy for in possession
drugs is reviewed and updated where necessary in accordance with
current practice. In addition, the Head of Healthcare should ensure that
risk assessments are conducted before medication is issued in
possession, and that the outcomes of these assessments are noted on
the relevant medical records.
Accepted
A risk assessment for having medication in possession is undertaken on
all offenders. A copy is scanned onto their electronic file and a hard copy
is kept in the pharmacy at the point of issue. For those who are not
considered suitable to have their medication in possession their risk
assessment is reviewed at least every 6 months or following any
significant occurrence.
For those who are considered suitable to have their medication in
possession their risk assessment is reviewed following any change in
circumstances or significant occurrence e.g. opening an ACCT document.
2. The Head of Healthcare should ensure that all registered general nurses
do not administer a medication which they believe is contra-indicated for a
patient’s needs, without clarifying with the prescribing medical practitioner
and obtaining an explanation as to why the prescription has been issued.
Accepted
All registered nurses have been reminded of their responsibility regarding
administration of medication and now follow the NMC Guidelines on
administration of drugs as detailed in NMC document Standards for
Medicines Management 2010
3. The Head of Healthcare should ensure that protocols are in place with
local hospitals so that transfer letters are sent with any prisoner being
discharged from hospital to prison.
Not Accepted
There are protocols and agreements in place with the local hospitals that
they will send a discharge letter out with the patient. However the
hospitals frequently send the letters out by post and it can take 6 – 8
weeks for these letters to arrive.
However my investigator received the following response from the clinical
reviewer regarding this recommendation.
As you are aware, my Line Manager has raised the issue of inappropriate
discharge via the Clinical Quality Review Meetings held with the Acute
Trust.
In addition to this, documentation and communication within the discharge
process will be the focus of a piece of work within the Safer, Smarter Care
Programme undertaken by the PCT and some of our Provider Services.
I propose that we invite the Head of Healthcare and the Clinical Nurse
Manager to be part of the sub-group for this piece of work, as the issues
identified at the Clinical Review are similar to issues experienced by other
Provider Services.
I hope this provides you with the required assurance that the
recommendation made for the PCT/Acute Trust is being taken forward.
4. The Head of Healthcare should ensure that all conversations regarding
discharge are accurately recorded in the appropriate medical records.
Accepted
All conversations with local hospitals regarding discharge or potential
discharge is documented on SystmOne
5. The Head of Healthcare should ensure that all staff accurately and fully
record all relevant information on the appropriate medical records, in
accordance with professional record keeping guidelines.
Accepted
All staff have been reminded of their responsibility regarding maintaining
records. They now follow the NMC Guidelines Record Keeping published
July 2009
6. The Governor should ensure that staff are aware of the provisions of PSO
6010, and specifically section 2.5.1, which deals with the transfer of
prisoners with outstanding Parole Board hearings.
Accepted
All Staff have been made aware of the provisions of PSO6010 section
2.5.1 and will liaise with sending establishments to ensure that if offender
request to transfer in exceptional circumstances the disruption to the
Parole process is kept to a minimum.