Individual at Preston

Investigation into the death of a man
at HMP Preston in January 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2011
This report considers the circumstances surrounding the death of the man at HMP
Preston on 1 January 2010. The man was found collapsed in his cell at 9.40am. He
was 48 years old. A post-mortem examination found that he died from
bronchopneumonia (inflammation of the walls of the airways) caused by chronic
obstruction pulmonary disease (COPD). This is a chronic respiratory condition that
results in the narrowing of the airways.
I offer my sincere condolences to all those who knew the man.
The investigation was conducted by one of my investigators on my behalf. I would
like to thank the governing Governor for his co-operation. I also extend thanks to
the liaison for the Ombudsman’s office. In addition, I thank the clinical reviewer who
conducted a review of the man’s clinical care. I apologise for the delay in issuing my
report.
The man was remanded into custody in 1995, and sentenced to life imprisonment in
1997. He spent time at HMP Holme House, HMP Durham and HMP Wormwood
Scrubs, before transferring to HMP Garth in April 2003. He remained at Garth until
24 December 2009, eight days before his death, when he moved to Preston.
This is the fourth death from natural causes at Preston since 2004, when the
Ombudsman’s office began investigating all deaths in custody. I have looked into
various aspects of the man’s clinical care, and I endorse four recommendations
made by the clinical reviewer.
The version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation
Jane Webb
Acting Prisons and Probation Ombudsman March 2011
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CONTENTS
Summary
The investigation process
HMP Preston
Key findings
Issues
Recommendations
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SUMMARY
The man was remanded to HMP Holme House in July 1995. He transferred to HMP
Durham, and then to St Nicholas Hospital in Newcastle for psychiatric assessment,
in 1996. After being sentenced to life imprisonment for murder, he returned to
Holme House, and in January 1997 he transferred to HMP Wormwood Scrubs. In
May 1999, the mental health team at Wormwood Scrubs noted that he displayed
odd, psychotic behaviour. One year later, in May 2000, he transferred to the prison’s
mental health observation unit. He moved to St Nicholas Hospital under the Mental
Health Act in January 2001, but returned to Wormwood Scrubs in April 2002.
The man suffered an asthma attack in September 2002. This was his first recorded
asthma attack in a prison setting. In April 2003, he transferred to HMP Garth. Two
years later, he suffered his first serious episode of breathing difficulties. Over the
next six months, he became short of breath on numerous occasions. He spent time
in the prison’s healthcare unit as well as in outside hospital, and was treated for
asthma.
During 2006, he continued to experience shortness of breath, and was eventually
diagnosed with chronic obstructive pulmonary disease (COPD), a chronic respiratory
condition that results in narrowing of the airways. It is not easily reversible, often
becomes progressively worse over time, and most commonly results from smoking.
He was advised to stop smoking but refused to do so.
Episodes of shortness of breath continued in 2007. In June and July he spent time
in hospital, and was prescribed antibiotics for an infection which was exacerbating
his asthma and COPD. There was little of note in his clinical record between July
2007 and January 2009. It is possible that during this period his health was more
stable and he was less prone to attacks. In April 2009, he was found to be very
breathless in his cell. The nurse who attended noticed that the cell was very smoky.
He was advised about smoking and the effects that it was having on his health, but
when the nurse returned a few minutes later, he was found to be smoking again.
The man also saw a respiratory consultant in April.
In August, the man again saw a respiratory consultant. He told the consultant that
he had stopped smoking three months earlier and that his breathing was well
controlled. A doctor from the prison raised concerns that the consultant had not fully
understood the true clinical picture. The man saw the consultant again in October;
he was advised to stop smoking and referred to a smoking cessation service. He
also had a chest X-ray and was referred to a chest physiotherapist.
The man was seen by a doctor at Garth on 3 November, when he presented with
shortness of breath. On 18 November, he was admitted to hospital and stayed there
for five days before being discharged. He spent six nights in hospital after being
admitted on 5 December. After his return to Garth on 12 December, the man was
reviewed and assessed as stable. Ten days later, he was seen by a physiotherapist.
On 24 December, he transferred to HMP Preston under a regional protocol for
prisoners requiring more comprehensive medical care. He was accommodated in
the healthcare unit and appeared to settle well. Medical staff noted no concerns
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between 24 and 30 December. He was reviewed by the first prison doctor on 31
December, when he reported no concerns and said he was feeling well.
In January 2010, he was found collapsed in his cell. Members of healthcare staff
checked for signs of life and began cardio-pulmonary resuscitation (CPR). This
continued when paramedics arrived, but the efforts were unsuccessful, and he was
pronounced dead at 10.28am.
A post-mortem examination found that the man died from bronchopneumonia
(inflammation of the walls of the airways) caused by COPD.
In conjunction with the clinical reviewer, I have investigated various aspects of his
medical care, including chronic disease management, smoking cessation, care
planning, clinical records, the transfer to Preston and the use of a defibrillator (a
piece of medical equipment that monitors a patient’s heart rhythm and administers a
shock if necessary). I endorse four recommendations made by the clinical reviewer.
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THE INVESTIGATION PROCESS
1. One of my senior investigators opened the investigation on 4 January 2010.
Upon visiting HMP Preston, he met the liaison officer for the Ombudsman,
who facilitated access to all of the records regarding the man’s period in
custody, including his clinical record. My investigator also met the deputy
governor, the acting head of healthcare, Chair of the Independent Monitoring
Board (IMB) and a member of the Prison Officers’ Association (POA).
2. One of my family liaison officers (FLOs) wrote to the man’s mother to explain
the purpose of the investigation and offer the family the opportunity to raise
any questions or concerns. The man’s family raised no issues of concern at
the outset of my investigation. They were also offered the opportunity to
receive and comment on the draft version of this report. However, to date
they have chosen not to do so. I hope that the findings of my investigation
answer any questions they may have had, should they review the report in the
future.
3. Central Lancashire Primary Care Trust (PCT) appointed a clinical reviewer to
conduct a review of the man’s clinical care whilst in custody. (The purpose of
a clinical review is to examine the medical care that a prisoner received whilst
in custody, which should be of an equivalent standard to what might have
been expected in the community.) His findings are summarised in this report
and the full clinical review is included as an annex.
4. During the course of the investigation, my investigator conducted recorded
interviews with six members of Preston’s staff. Transcripts of these interviews
were produced.
5. My office disclosed the clinical reviewer’s clinical review to the healthcare
manager at HMP Garth. The head of Prison Health for NHS Central
Lancashire, wished to make representations about the content of the clinical
review. The clinical reviewer was unavailable to liaise with her and so she
provided her comments directly to my investigator. These have been
incorporated into this report. She also supplied her own root cause analysis
into the man’s death, which is included as an annex.
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HMP PRESTON
6. HMP Preston has a maximum operational capacity of 800. It serves courts
from north-west England and holds remanded, unsentenced and convicted
adult male prisoners. In addition to standard residential location, the prison
has units for induction, drug dependency, vulnerable prisoners, segregation
and reintegration.
7. Healthcare at Preston is provided by Central Lancashire Primary Care Trust
(PCT). The healthcare unit has inpatient facilities for prisoners with mental
health needs and those with physical health problems. The inpatient beds are
a regional facility that can be used by prisoners from other north-west prisons,
should they require comprehensive healthcare support. The other prisons
involved in the regional programme are Garth, Wymott, Haverigg, Lancaster,
Kirkham, Buckley Hall and Risley. Referrals are made by clinical staff from
these prisons, after which staff from Preston visit prisoners and decide
whether to accept them. Decisions are reached based on clinical need.
Performance
8. The Ministry of Justice produces quarterly performance figures for all prisons
in England and Wales. Every establishment is given a rating between 1 and 4
based on 34 agreed performance indicators (a rating of 1 indicates serious
concerns about performance, whereas a rating of 4 means exceptional
performance). For quarter 3 of 2009-2010 (October, November and
December 2009) Preston received a rating of 3, indicating good performance.
The most recent figures available at the time of writing are for quarter 4 of
2009-2010 (January, February and March 2010), at which time Preston
maintained its rating of 3.
9. HM Chief Inspector of Prisons inspected Preston in August 2009. Her report
found that the prison was performing reasonably well despite managing “a
wide range of transient, needy and sometimes difficult prisoners in conditions
largely designed and built in the 19th century”.
Previous deaths at Preston
10. The Ombudsman’s office has been responsible for investigating deaths in
custody since April 2004. Prior to the man’s death, three prisoners have died
from natural causes whilst in the care of Preston. Two of these deaths were
from peritonitis and one was from pneumonia. There are no similarities
between the previous deaths and that of the man.
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KEY FINDINGS
July 1995 – April 2002
11. The man was remanded to HMP Holme House on 1 July 1995. In early 1996,
he was transferred to HMP Durham and then to St Nicholas Hospital in
Newcastle for psychiatric assessment. He was assessed as suffering from a
paranoid psychotic illness, but denied that he was mentally ill. Having been
sentenced to life imprisonment for murder, he man returned to Holme House.
On 15 January 1997, he was transferred to HMP Wormwood Scrubs.
12. In May 1999, the mental health team at Wormwood Scrubs noted that the
man displayed odd, psychotic behaviour, and by April 2000 mental health
professionals thought there was evidence that he was suffering from an
untreated mental illness. On 20 May 2000, he was transferred to the mental
health observation unit in Wormwood Scrubs.
13. On 31 January 2001, the man was transferred to the St Nicholas Hospital in
Newcastle under Section 47 of the Mental Health Act. Section 47 provides for
sentenced prisoners to be transferred to a hospital for treatment. He was
thought to be suffering from schizophrenia and psychosis. In addition to the
mental health concerns, he was also diagnosed with asthma during his time at
the hospital. In April 2002, he returned to Wormwood Scrubs after being
deemed well enough to return to a prison setting.
September 2002 – January 2009
14. On 23 September 2002, a note was made in the man’s clinical record that he
had suffered an asthma attack. Although he had been diagnosed with asthma
whilst in the St Nicholas Hospital, this was his first recorded asthma attack
whilst in a prison setting.
15. In April 2003, the man was transferred to HMP Garth. Two years later, on 3
May 2005, he suffered his first serious episode of breathing difficulties. An
entry in his clinical record notes that he was short of breath, cold and clammy,
and had low blood pressure. He was admitted to Chorley District Hospital
where he remained for two days, before returning to Garth on 5 May.
16. The man suffered shortness of breath on 24 October. A note in his clinical
record stated that although he had been prescribed an inhaler by this point,
he had not used it for several days prior to him feeling unwell. In December,
The man again felt unwell and struggled to breathe. He was transferred to the
healthcare unit within the prison for overnight observation, and treated with a
nebuliser (a piece of medical equipment used to administer medication in the
form of a mist inhaled into the lungs). He was prescribed a five-day course of
Prednisolone, a corticosteroid medication often used in the treatment of
asthma.
17. On 10 January 2006, the man again suffered shortness of breath. On 24
January, he commenced nicotine replacement therapy using patches.
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18. Between February and August, the man suffered from six separate episodes
involving the familiar symptoms of him struggling to breathe. In July, the first
prison doctor noted in the clinical record that the man’s “asthma [is]
uncontrolled, patient refuses to stop smoking”. On 17 August, Prednisolone
was prescribed on a long-term maintenance basis rather than as a short
course, and a referral was made to a respiratory physician.
19. Following the referral, the man suffered three further incidents involving
shortness of breath. He saw a respiratory physician at Chorley District
Hospital on 21 September, but suffered three more episodes by November.
20. On 10 December, following tests at the hospital, he was diagnosed with
chronic obstructive pulmonary disease (COPD). This is a chronic respiratory
condition which results in narrowing of the airways, limiting the flow of air to
and from the lungs. It is not easily reversible, often becomes progressively
worse over time, and most commonly results from smoking. Despite being
advised to stop smoking, he refused to do so.
21. The man was again admitted to Chorley District Hospital on 5 January 2007,
and was discharged two days later after a diagnosis of and treatment for
acute exacerbation of asthma with COPD. He suffered four further episodes
between February and June, though none of these resulted in hospitalisation.
22. On 16 June, the man experienced severe shortness of breath and was taken
to hospital by emergency ambulance. He was initially admitted to the medical
assessment unit and then transferred to the intensive care unit (ICU), where
he spent the next 24 hours. He was then moved to a general ward and, five
days later, on 22 June, discharged from hospital to the healthcare unit at
Garth. The man was admitted to hospital again on 10 July, and returned to
the prison on 13 July. During his time in hospital he was prescribed
antibiotics as a result of an infection exacerbating his asthma and COPD.
23. Little of note was recorded in the man’s clinical record between July 2007 and
August 2008. Between August 2008 and January 2009, there is no
information at all about his physical health. It is possible that he was more
stable and less prone to attacks during this time.
April 2009 – January 2010
24. On 7 April 2009, the man was found to be very breathless in his cell. The
nurse who attended noticed that the cell was very smoky. The man was
advised about smoking and the effects it was having on his health. However,
when the nurse returned to his cell with a nebuliser, he was found to be
smoking again.
25. A note was made in the man’s clinical record on 22 June that he had seen a
respiratory consultant in April, but a follow-up letter had not been received.
There was also concern about the man’s prescription medication, in particular
the high dose of Prednisolone that he had been using for a prolonged period.
9
26. The man was seen at Chorley District Hospital on 13 August by a respiratory
consultant. The man told the respiratory consultant that he had stopped
smoking three months previously and that his breathing was well controlled
under his medication. On 9 September, a second prison doctor from Garth
raised concerns about the man’s medication and whether the respiratory
consultant had fully understood the true clinical picture. Five days later, the
doctor referred the man back to the respiratory consultant with particular
concerns about his medication.
27. The man attended the respiratory consultant’s chest clinic on 12 October. He
was advised to stop smoking and referred to a smoking cessation service.
His Prednisolone medication was also changed to a reducing course. The
dosage was halved for three days, halved again for another three days, and
then would cease completely. A chest X-ray was undertaken, and the man
was referred to a chest physiotherapist.
28. The man was again seen by the second prison doctor on 5 November due to
shortness of breath. He was prescribed a 30mg daily dose of Prednisolone
for five days. This was a higher dosage than he had been prescribed before
the reducing course 18 days earlier, though it was for a short period rather
than on a long-term basis.
29. On 18 November, the man was referred to Chorley District Hospital and
transferred by emergency ambulance after being very short of breath. A note
was made in his clinical record that he continued to smoke despite claiming
otherwise. He was admitted to the ICU, and moved to a general ward two
days later. The man returned to the healthcare unit at Garth on 23 November.
30. The man was again admitted to hospital on 5 December, and stayed on a
general ward for six nights. He was given antibiotics and diagnosed with
acute infective exacerbation of COPD. On 12 December, he was reviewed at
Garth by a third prison doctor and found to be in a stable condition.
31. A respiratory physiotherapist saw the man on 22 December at the request of
his consultant. Two days later, the man was transferred to HMP Preston’s
healthcare unit under a regional bed protocol. This is an arrangement
whereby prisons in the Central Lancashire area are able to transfer prisoners
with chronic and/or difficult to manage conditions to Preston, which has more
comprehensive healthcare facilities. When the man arrived, he seemed to
settle well. He was located on H2 unit, which is the part of the healthcare unit
used for people with physical health problems. A nursing care plan was
opened.
32. Members of staff noted no medical concerns in the man’s clinical record
between 24 and 30 December. On 31 December, he saw the second prison
doctor (who covers both Garth and Preston) who completed a routine review,
stating that the man had no concerns and felt well.
10
33. On the morning of the man’s death, a healthcare support worker began her
shift on H2 unit at 7.30am. During interview with my investigator, she said
that upon starting work, she checked all of the prisoners on the unit by looking
through the observation panels in the cell doors. She saw that the man was
asleep in his bed and did not have any cause for concern.
34. In her original statement to the police following the man’s death, the
healthcare support worker said she had last seen him alive just before
9.30am, when she had taken his breakfast to his cell. However, she later
changed her statement to say that she did not see the man at this time.
During interview, she clarified that a prisoner with responsibility for serving
breakfast to the other prisoners had arrived on the unit, and that he had been
the one to offer the man his breakfast. This was between 9.00am and
9.25am. She recalled that the man had declined his breakfast but was
observed to be alive and responsive by the prisoner who had offered it to him.
35. The deputy healthcare manager was also working on the morning. She said
during interview with my investigator that she left the healthcare unit at around
8.20am to undertake duties dispensing medication to prisoners in other areas
of the prison. She returned to H2 at 9.40am and agreed with the healthcare
support worker that they would immediately undertake routine observations of
the prisoners on the unit. The deputy healthcare manager explained that
checks such as temperature, blood pressure and respiratory function were
done at least once per day and recorded in the prisoners’ clinical records.
She asked the healthcare support worker to start opening the cells and said
she would follow with the necessary medical equipment.
36. The man was located in the cell at the end of H2 landing. The healthcare
support worker went to this cell before any others. She recalled during
interview looking through the observation panel and seeing the man on the
floor of the cell. She said that his back was against the wall and his legs were
straight out on the floor. His head was to one side and his eyes appeared to
be rolled back. She said she immediately thought this was a serious situation,
and shouted to the deputy healthcare manager for help whilst opening the cell
door.
37. The deputy healthcare manager said she heard the healthcare support worker
shout for help only seconds after she had left to begin unlocking cells. She
immediately went to the man’s cell, which took only a few seconds. Upon
arrival, the deputy healthcare manager said she saw that the man was lying in
the cell, and was partially propped up against either a chair or the wall. He
appeared to have been incontinent of urine, and had some saliva and food on
his face. His eyes were wide open. The deputy healthcare manager said the
man did not respond to a slight shake, and that she was not able to find a
pulse in his wrist or neck.
38. The healthcare support worker was, at this point, carrying the radio for H2
unit. The deputy healthcare manager explained that this unit’s radio had the
unique call sign Hotel 4. She further explained that nurses based in the main
areas of the prison, with call signs of Hotel 2 and Hotel 3, would be
11
responsible for responding to medical emergencies. After checking the man
for signs of life, the deputy healthcare manager took the radio from the
healthcare support worker and gave a message to the prison’s
communications room, making them aware that she required urgent medical
assistance. She then asked the healthcare support worker to retrieve an
oxygen cylinder and a bag containing emergency medical equipment from a
treatment room located close by on the same landing.
39. At around 9.30am, the first nurse on the scene had made her way from H1,
where she was based, to H2 to complete some work. She was therefore in an
office on H2 landing when she heard the healthcare support worker shout for
assistance, and then, a few seconds later, heard the deputy healthcare
manager ask for the oxygen and emergency equipment. At this time, she left
the office where she was working and went to the man’s cell, where she and
the deputy healthcare manager commenced cardio-pulmonary resuscitation
(CPR). The deputy healthcare manager administered artificial breaths using
an ambu-bag. This is a piece of medical equipment which resembles a large
face mask and is attached to an oxygen cylinder. The first nurse on the scene
commenced chest compressions.
40. The second nurse on the scene and third nurse on the scene, the nurses
assigned to radio call signs Hotel 2 and Hotel 3 respectively, were in a
medical treatment room in the main prison when they received instructions
from the communications room to attend H2 immediately. Both explained
during interview that H2 was only a short distance from where they were, and
they arrived within one to two minutes. The third nurse on the scene then
attached an automated external defibrillator (AED) to the man’s chest. This is
a piece of medical equipment that monitors heart rhythms and administers a
shock if required. In this case, the AED did not detect a viable heart rhythm.
41. After attaching the AED, the third nurse on the scene relieved the first nurse
on the scene and began performing chest compressions. A short time later, a
fourth nurse also arrived at the cell. He and the third nurse on the scene
continued cycles of chest compressions whilst the deputy healthcare manager
administered breaths using the ambu-bag. The CPR continued until
paramedics arrived at around 10.10am. The paramedics attached their own
equipment to the man and continued to attempt CPR for almost a further 20
minutes. However, the attempts were not successful, and the man was
pronounced dead at 10.28am.
42. A subsequent post-mortem examination found that the man died from
bronchopneumonia (inflammation of the walls of the airways) caused by
COPD.
12
ISSUES
Clinical care
Chronic disease management
43. It was noted in the man’s clinical record that he had six nurse-led asthma
reviews between July 2005 and December 2006. However, there is no written
evidence in his clinical record that he received an asthma review after this
time. The clinical reviewer noted that regular and ongoing monitoring of the
man’s asthma would be expected, and should have been recorded.
44. The National Institute of Clinical Excellence (NICE) states that mild to
moderate asthma sufferers must be clinically assessed and monitored at least
annually. Severe sufferers should have such assessments twice a year.
45. Whilst the clinical record indicates that healthcare staff at Garth taught the
man about inhaler and peak flow techniques, there is evidence to suggest that
he had poor skills in these areas. This was noted in a letter from the man’s
respiratory consultant, to a doctor at Garth, on 16 April 2007. The clinical
reviewer felt that this could have been addressed by healthcare staff on an
ongoing basis.
46. The clinical reviewer advised the healthcare manager to ensure that systems
existed to identify and review prisoners with chronic disease. In response, the
head of prison health said that such systems did exist and had done so for a
number of years. She went on to say that prisoners are screened upon
arrival, and at any time afterwards as a result of self-request or referral. She
pointed out that the man had gone through this process for COPD, and had
been referred and seen for Nicotine Replacement Therapy (NRT).
47. Although it was encouraging to learn that systems existed for the referral and
treatment of patients with chronic disease, there was nevertheless no
evidence that the man had regular asthma reviews in line with NICE
guidelines. I therefore endorse the following recommendation made by the
clinical reviewer.
The healthcare manager at Garth should ensure systems exist to make
certain that prisoners with clearly identified chronic disease are
managed through review and education in accordance with the PCT’s
chosen national or local guidance.
48. Incomplete prescription charts were appended to the man’s clinical record.
However, he was seemingly compliant with his medication and recording of
his prescriptions is legible.
49. The clinical record makes it clear that the man was short of breath on many
occasions. The available prescription charts, however, indicate that only two
nebulisers were prescribed for use as required. It is unclear if the man had a
nebuliser in his possession. In the respiratory consultant’s letter to Garth on
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24 April 2009, it is suggested that this was the case, and that the man was
using a nebuliser once or twice per day. His prescription charts, though, are
not clear about whether this medication was for use in possession, or was
simply prescribed in the healthcare unit after episodes of shortness of breath.
The clinical reviewer wrote:
“If nebulisers were used as [when required] medication there should have
been a clear prescription of this in the in-possession prescription section
on the back sheet. If the man had at any time a nebuliser machine in his
possession, one would expect to see clinical reasoning/rationale for this in
his notes and, in terms of safe practice, evidence that the patient had been
given training in the use of a named medical device, together with a
shared risk assessment in terms of security.”
50. With reference to the clinical reviewer’s comment, I ask the head of
healthcare at Garth to ensure that all prescription charts are clearly completed
for in-possession medication.
Smoking cessation
51. It was well documented that the man was a smoker and continued to smoke
throughout his sentence, despite advice from healthcare professionals. There
is no evidence of a strategy to support him stopping smoking prior to 2006.
52. There is evidence in the man’s clinical record of a stop smoking management
plan in January 2006. This involved him being given nicotine replacement
therapy. However, this attempt at smoking cessation had failed by the end of
February.
53. The clinical reviewer wrote:
“There is inconsistent evidence regarding the approach to helping The
man to stop smoking. It is known that smoking is a major issue with
regard to exacerbating asthma/COPD.”
54. The man’s respiratory consultant, wrote to the doctor at Garth on 1 May 2008,
stating:
“Clearly the key to his future management of his asthma and COPD
primarily relates to his smoking cessation and I shall leave this in your
hands.”
55. Several comments made in the man’s clinical record refer to his refusal to
stop smoking. Whilst individual choice is a factor, it should be taken into
account that his illness was aggravated by smoking. The clinical reviewer
could not find any clear plan or strategy by healthcare staff to work proactively
with the man to reduce his level of smoking. However, he also noted that this
might not have happened due to a lack of understanding of, or training about,
stop smoking interventions.
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56. The clinical reviewer wrote:
“The available nursing documentation contains only one formal nursing
care plan and this dates from August 2006, wherein a nursing action
states ‘for staff to discourage [The man] from smoking’. There are no
review dates on this piece of documentation.”
57. Following an inpatient stay in hospital in November 2009, the man’s clinical
record indicates that members of staff were supervising and reducing his
tobacco consumption. However, in December, it was noted that he had no
cigarettes and was looking in bins and asking other prisoners for tobacco.
The clinical reviewer commented that “this does not evidence that the man
was participating in a controlled programme of smoking management”.
58. The clinical reviewer concluded that the head of healthcare at Garth should
conduct a training needs analysis with regard to knowledge and skills around
smoking cessation. The head of prison health responded by saying that such
analyses had been completed on at least two occasions in the five years prior
to the man’s death. Staff members had undertaken NRT training to facilitate
the smoking cessation service, and a local protocol based on the PCT’s policy
was in place.
59. The clinical reviewer also commented on record keeping with regard to
prisoners’ smoking status. The head of prison health said that this already
occurred and had done for a number of years. However, as the man’s
smoking status did not seem to be consistently recorded, I endorse the
following recommendation made by the clinical reviewer.
Prisoners’ smoking status should be recorded on all medical records
and stop smoking advice offered routinely and opportunistically at any
healthcare intervention.
Care planning and nursing care
60. The clinical reviewer found one pertinent care plan in the man’s clinical
record, relating to his asthma and COPD. There was no regular referral in the
clinical record to this care plan, which did not appear to have been updated
regularly. The clinical reviewer wrote:
“Given the increasing complexity of his healthcare problems, particularly in
the latter half of 2009, the care plan does not demonstrate sound
application of the nursing process in managing the man’s needs.”
61. In particular, the clinical reviewer noted that the care plan should have
specifically referred to the man’s frequent episodes of shortness of breath,
management plans, his smoking status and actions to reduce this, the use of
his inhaler and his mental health issues. The clinical reviewer also thought
the plan should have referred to members of healthcare staff accompanying
the man to outpatients appointments due to his limited social skills.
15
62. The clinical reviewer found the daily record of the man’s clinical care to be
legible and compliant with record keeping guidelines. However, healthcare
staff did not always note the time of appointments/entries, or their own role in
the healthcare unit. The entries under the heading of ‘care plan review’ were
detailed but did not seem to be influenced by the care plan. The head of
prison health said care plans were routinely checked by healthcare managers
at both Garth and Preston.
63. Given that healthcare staff did not consistently record their dealings with the
man in his care plan, I endorse the following recommendation made by the
clinical reviewer.
The head of healthcare is advised to ensure a regular care plan audit is
undertaken for patients and that plans are used to lead and influence the
individual care of each patient.
Clinical records
64. The role of the clinical record is to provide a list of occurrences. The man’s
record was detailed and informative about his interventions with healthcare
staff and frequent hospital admissions. However, the clinical reviewer noted
that this record did not demonstrate a plan of care in the absence of a
comprehensive care plan in the nursing record. He wrote:
“The man suffered from chronic respiratory illness with frequent
exacerbations. Management of his condition may have benefited from a
definitive ‘pathways’ approach to assessment, planned care delivery and
case review.”
65. There were no medical notes relating to the man’s respiratory problems
between August 2008 and January 2009. Whilst he may not have
experienced any physical health problems during this period, this seems
unlikely considering the frequency of issues over the remainder of the clinical
record, as well as his asthma and COPD.
66. I endorse the following recommendation made by the clinical reviewer.
The head of healthcare should consider adopting a ‘pathways’ approach
to the management of chronic disease.
Transfer to Preston
67. The man was transferred to Preston on 24 December 2009 due to
deterioration in his health. Preston has a regional inpatients unit for chronic
medical conditions, and covers all prisons within Central Lancashire PCT.
This means that prisoners from a number of establishments, including Garth,
can transfer to Preston if they require regular nursing care in a healthcare
setting. Decisions are made based on clinical need, outside the normal
arrangements covering the transfer of prisoners.
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68. The clinical reviewer noted that the man should have been consulted over his
move to Preston and, if any consultation had taken place, it should have been
noted in his clinical record. He also notes that, whilst there are written
guidelines about the transfer of prisoners within the Central Lancashire PCT
to Preston, the reasons for the man’s move were not recorded in his clinical
record. The clinical reviewer said there was “no evidence of discussion or
assessment either between the two establishments or with the patient”.
69. A specific form exists for prisoners transferred to Preston under the regional
protocol. However, it seems that this was not completed in the man’s case. I
note the recommendation by the clinical reviewer in this area, and ask that the
heads of healthcare at Garth and Preston ensure that all transfers between
healthcare facilities under the regional protocol are fully documented in
prisoners’ medical records.
Use of the defibrillator
70. During the immediate response to the man’s collapse a defibrillator was
brought to the cell and attached to his chest. This piece of equipment
monitors the patient and advises whether or not to administer an electric
shock based on the heart rhythm. On this occasion, no shock was advised,
but this was not noted in the man’s clinical record.
71. The clinical reviewer wrote:
“The patient was attached to a defibrillator and, although not specifically
recorded in the notes, defibrillation does not appear to have been required.
The man was attended by paramedics who confirmed death at 10.28am.”
72. The use of the defibrillator was noted in the clinical record. However, the
advice given by the defibrillator was not recorded. In this case, it appears that
there was no shockable heart rhythm and so an electrical shock was not
advised. The clinical reviewer felt that for reasons of clarity and
thoroughness, this should be fully documented in the clinical record. The
head of prison health pointed out that the defibrillators used at Preston
electronically recorded the incident in the device’s memory, and that this
information could be downloaded from the machine to evidence the steps
taken during the resuscitation attempt, and the corresponding heart rhythm of
the patient.
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RECOMMENDATIONS
1. The healthcare manager at Garth should ensure systems exist to make
certain that prisoners with clearly identified chronic disease are managed
through review and education in accordance with the PCT’s chosen national
or local guidance.
The recommendation was accepted. Garth reported that chronic disease
clinics were in place and that patients were routinely monitored.
2. Prisoners’ smoking status should be recorded on all medical records and stop
smoking advice offered routinely and opportunistically at any healthcare
intervention.
The recommendation was accepted. Smoking status was routinely recorded
as part of the reception screening process, and smoking cessation advice was
offered by GP and nurse-led services. A lead nurse was appointed for
smoking cessation services.
3. The head of healthcare is advised to ensure a regular care plan audit is
undertaken for patients and that plans are used to lead and influence the
individual care of each patient.
The recommendation was accepted. Care plans were recorded on the
electronic patient record and were accessible for audit purposes.
4. The head of healthcare should consider adopting a ‘pathways’ approach to
the management of chronic disease.
The recommendation was accepted. Chronic disease pathways and registers
were being established on the electronic patient record and will be available
for audit purposes.
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