Individual at Acklington

Investigation into the circumstances surrounding the
death of a man
at HMP Acklington in March 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2011
This report considers the circumstances surrounding the death of a man at HMP
Acklington in March 2010. The man was found collapsed in his cell at around
7.25am. He was 64 years old. A subsequent post-mortem examination found that
the man died from ischaemic heart disease (reduced blood supply to the heart)
caused by coronary artery atheroma (swelling in the artery walls which reduces
blood flow).
I offer my sincere condolences to the man’s family and all those who knew him.
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.
The man was remanded to HMP Durham after appearing in court in February 2009.
He reported experiencing frequent fits and, despite various tests being conducted,
no diagnosis was reached as to their cause. He also received ongoing support from
the mental health team. In late August, he transferred to HMP Acklington and
remained there until his death.
This is the 14th death from natural causes at Acklington since 2004, when the
Ombudsman’s office began investigating all deaths in custody. Before this man’s
death, the last such death occurred in 2009. Four weeks after this man’s death,
another prisoner died from natural causes at Acklington.
I have looked into the man’s clinical care, including the lack of information which
accompanied him to Acklington and the processes relating to keeping him safe. I
make four recommendations and endorse a further three recommendations made by
the clinical reviewer. As some of the recommendations relate to the man’s care at
Durham, I will also send my report to the Governor for his consideration.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman January 2011
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CONTENTS
Summary
The investigation process
HMP Acklington
Key events
Issues:
Clinical care
Assessment, Care in Custody and Teamwork (ACCT)
Emergency response
Issues raised by the man’s family
Conclusion
Recommendations
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SUMMARY
The man appeared in court on 16 February 2009 and was remanded to HMP
Durham. He attended a medical appointment, a substance misuse assessment, and
a mental health assessment. He told staff that he had fits once per week. The man
undertook a week long alcohol detoxification programme in the healthcare unit.
Although he appeared to settle well, there were some concerns about the man’s
memory. In early March, he suffered what was described as a “funny turn” and he
was discharged to a residential wing on 8 March.
The man saw a consultant psychiatrist on 23 March, who confirmed that he had very
poor memory. The psychiatrist believed that this was due to alcohol consumption.
He saw the doctor in April who thought that his fits, which were now four or five times
per day, were panic attacks. She prescribed diazepam and referred the man to the
community psychiatric nurse (CPN).
In May, the man said he was still having fits two or three times daily. The
psychiatrist noted that he was depressed and suggested anti-depressants and an
electroencephalogram (EEG).
On 20 May, the man was convicted at a crown court. He returned to Durham to
await sentencing. He was taken to hospital on 14 June after falling from his bed and
suffering a head injury. When he returned to prison the next day, he was admitted to
the healthcare unit but discharged on 16 June. An EEG showed that his brain
activity was within normal limits.
The man was sentenced to a nine-year extended sentence. He saw the
psychiatrist, who thought he was chronically depressed and changed his medication.
The Assessment, Care in Custody and Teamwork (ACCT) process was put in place
as the man was judged to be at risk of harming himself. He transferred to HMP
Acklington on 28 August and the ACCT remained open until 8 September.
The man continued to have regular fits which remained undiagnosed despite hospital
tests. He refused any more treatment from 27 January 2010 onwards.
The man was found collapsed in his cell at 7.25am on a day in March and officers
started cardio-pulmonary resuscitation (CPR). Paramedics arrived within 15
minutes, but there were no signs of life. The paramedics declared that life was
extinct at 7.57am, and a prison doctor pronounced the man’s death at 8.40am. A
post-mortem found that he died from ischaemic heart disease (reduced blood supply
to the heart) caused by coronary artery atheroma (swelling in the artery walls which
reduces blood flow).
I have investigated issues around clinical care, including handing over information
between prisons and the ACCT process. I make four recommendations and endorse
a further three recommendations made by the clinical reviewer.
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THE INVESTIGATION PROCESS
1. One of my senior investigators opened the investigation on 16 March 2010.
He visited HMP Acklington on 25 March and met the following people:
• The PPO’s liaison officer
• A Governor
• Two family liaison officers
• The Chair of Acklington’s Independent Monitoring Board (IMB)
• The representative for the Prison Officers’ Association
2. The various people present at the meeting explained the background to the
man’s imprisonment, his time at Acklington and the circumstances of his
death. The two family liaison officers discussed family liaison issues, and the
Governor explained that she had attended the man’s funeral.
3. The liaison for the Ombudsman’s office provided my investigator with all of the
records relating to the man’s time in custody.
4. One of my family liaison officers (FLOs) spoke to the man’s daughter by
telephone on 31 March. She asked whether her father had tried to summon
help in the hours before he was discovered by members of staff on the
morning of his death. I have tried to answer this question as part of the
report, which I hope will help the man’s family to better understand the events
leading to his death.
5. My investigator returned to Acklington in May 2010 and conducted recorded
interviews with five members of staff. My investigator also spoke informally to
three prisoners who were living in cells near to the man at the time of his
death. The content of those conversations is summarised in this report.
6. Northumberland Primary Care Trust (PCT) appointed Custodial Care
Innovative Solutions (CCIS) 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.)
The clinical reviewer from CCIS consulted the man’s medical records from
HMP Durham and Acklington, as well as receiving information from his
community general practitioner (GP). Her findings are summarised in this
report.
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HMP ACKLINGTON
7. Acklington is a category C prison for convicted adult male prisoners. On
arrival into prison, prisoners are risk assessed and given a category based on
their offence and the risk that they pose to the public should they escape.
Category C prisoners are defined as those who cannot be trusted in open
prison conditions but who would not have the ability or resources to make a
determined escape.
8. Located near the town of Amble in Northumberland, and built on a former
Royal Air Force base, it is the northernmost prison in England. Acklington has
an operational capacity of 946 and has 11 residential units.
9. Healthcare at Acklington is provided by Northumberland Primary Care Trust
(PCT) and offers general health provision, mental health support and
dentistry. Primary healthcare is provided by a doctor and nurses during the
daytime, seven days a week. There is no out of hours medical cover,
although a doctor can be contacted by telephone after 6.00pm. All healthcare
is provided on an outpatient basis as there are no inpatient facilities at
Acklington. Prisoners requiring inpatient care are transferred to an outside
hospital or to another prison.
Performance
10. 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. The most recent figures
available at the time of writing are for quarter 4 of 2009-2010 (January,
February and March 2010). For this period, Acklington received a rating of 3,
indicating good performance.
11. HM Chief Inspector of Prisons inspected Acklington in June 2009. Although
the prison had previously received a critical report in 2006, inspectors found
“a greatly energised and much better managed prison” during their visit in
2009. Although progress had been made in all areas, HM Chief Inspector of
Prisons’ report noted that some of the older buildings remained unfit for
purpose, many prisoners spent too much time in their cells, work with older
prisoners was underdeveloped, and mental health provision was insufficient.
12. An Independent Monitoring Board (IMB) is made up of volunteers from the
community in which a prison is located. IMBs must satisfy themselves as to
the humane and just treatment of people held in custody, and they report to
the Justice Secretary annually. At the time of writing, the most recently
available IMB report for Acklington covered the period July 2008 to June
2009.
13. Regarding healthcare, the IMB noted that there was an increasing need to
manage prisoners with illnesses associated with aging, whilst acknowledging
that Acklington had no inpatient facilities. The Board also reported that “the
actual ability of staff to deliver healthcare interventions is currently hampered
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by lack of space”. They went on to report that staff struggled to find
appropriate consultation space within healthcare, and that access to
consultation rooms on the residential units was very poor with little opportunity
for confidential consultation. However, the IMB also reported that the
healthcare team “work in difficult and challenging conditions [and] always offer
their best efforts to those seeking their support”.
Previous deaths at Acklington
14. The Ombudsman’s office has been responsible for investigating all deaths in
custody since April 2004. Prior to this man’s death, 13 prisoners have died
from natural causes whilst at Acklington. One of these deaths occurred in
2004, four in 2005, two in 2006, one in 2007, four in 2008, and one in 2009.
Four weeks after this man’s death, another prisoner died from natural causes
at Acklington.
HMP DURHAM
15. HMP Durham holds a maximum of 981 prisoners and serves courts from its
local area. It accommodates remand, unsentenced and convicted prisoners
over 21 years of age. There are seven residential units that include medical
treatment rooms for outpatients. A separate inpatient unit accommodates
prisoners with more complex medical requirements.
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KEY EVENTS
HMP Durham
16. The man was born in 1945 in Bradford, West Yorkshire. He was 64 years old
at the time of his death, and was serving a nine-year extended sentence for
arson. He had previously been sentenced to two years in custody, also for an
offence of arson, in 2005.
17. The man was remanded to HMP Durham on 16 February 2009 whilst awaiting
trial for arson. A first reception health screening was completed upon his
arrival. (This is a short medical assessment completed for all prisoners.) In
this man’s case, alcohol consumption was identified as a problem and he was
referred for a substance misuse assessment. He was also referred for a
mental health assessment and a review of his medication. Additionally, the
man completed a consent form so that the prison could access his previous
medical records.
18. On the same day, the man had a substance misuse assessment. He
disclosed that he drank half a litre of gin daily and had done so for several
years. A week-long detoxification programme was recommended, and the
man was prescribed Haloperidol (a medication used for the treatment of
alcohol withdrawal). He also saw a general practitioner (GP) and was
prescribed paracetamol to relieve back pain.
19. Also on the day of the man’s arrival, a Community Psychiatric Nurse (CPN)
made an entry in his clinical record, noting a telephone call from the
community mental health team in Newcastle-upon-Tyne. The CPN was told
that the man had alcohol-related mental health problems, and was possibly in
the early stages of dementia. He was due to be assessed by a CPN but had
been remanded into custody. The man was admitted to the prison’s
healthcare unit (cell M2-09) for further assessment of his cognitive
functioning.
20. The next day, 17 February, the man spoke with a nurse about his alcohol
consumption, again saying he drank half a litre of gin daily. The nurse noted
in the clinical record that a seven-day detoxification regime was in place and
he would be monitored on the unit. The man also saw a medical student
working at Durham, after suffering a fit. The man reported that the fits had
started around four months earlier and that he experienced them
approximately once per week. The medical student wrote in the clinical
record that the man was vague in his description of the fits, and attributed
them to a reduction in alcohol consumption.
21. The man seemed to find the healthcare unit agreeable for the next few days.
An entry in his clinical record on 19 February reported that he had a “settled
day … and joined in all activities”. The next day, an administrator in Durham’s
healthcare unit noted that, as a result of his referral to the mental health team,
an appointment had been made with the man for 26 February.
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22. Over the next few days there were no recorded healthcare concerns about the
man. Entries in his clinical record consistently described him as “settled” and
participating in activities such as education, exercise and association (the time
prisoners spend out of their cell with others from the same unit).
23. On 25 February, a doctor wrote in the clinical record that he had seen the
man and whilst he appeared “cognitively intact” on a superficial level (that is,
he was able to think, respond and behave appropriately in everyday
situations), he also gave an inconsistent account of owning a house and
swimming pool in Australia. The next day, a nurse wrote in the clinical record
that the man was due for an assessment by a registered mental health nurse
(RMN). The original referral had been completed on the day of his arrival (16
February) but the nurse noted that as he was now in the healthcare unit, she
would refer him to the inpatient manager in view of his possible cognitive
impairment. There is no indication that a mental health assessment took
place on 26 February as originally planned.
24. No health concerns were recorded over the next few days. The man left the
prison for a court appearance on 3 March, and the next day a note was made
in his clinical record that an appointment had been made for 23 March with a
consultant psychiatrist. (This appointment was a result of the original referral
rather than anything arising from the court appearance.) On 6 March, a nurse
noted that the man’s cell mate had witnessed him having what was described
as a “funny turn”, although he could not recall feeling unwell. There was no
further explanation given about what characterised this incident.
25. On 8 March, the man was discharged from the healthcare unit. A note in the
clinical record explained that this was a temporary measure due to the urgent
needs of other prisoners, and the possibility remained to re-admit him when a
bed became available again. He moved to B wing, in cell B2-15.
26. There are no entries in the man’s wing history record between 18 March and
17 June, and little is known about his experiences on B wing. However, he
did attend a number of medical appointments during this time. On 23 March,
he saw a consultant psychiatrist for a mental health assessment. The doctor
described him as “self-assured, friendly and sophisticated”. He referred to
assessments in 2004 and 2005, noting that whilst the man had “a substantial
cognitive deficit especially in terms of poor memory”, there had been little
change and “certainly no ongoing deterioration in the interim”.
27. The consultant psychiatrist thought it likely that the man’s alcohol
consumption had led to Wernicke’s encephalopathy. (This is a syndrome
characterised by, amongst other things, confusion and impairment of short-
term memory and commonly associated with prolonged alcohol consumption.)
The consultant psychiatrist asked the court to consider hospitalisation under
Section 37 of the Mental Health Act. (This is a treatment order that can be
used as an alternative to imprisonment for people with a mental illness.) At
this point, the man was maintaining his innocence and had not yet been
convicted.
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28. On 9 April, a nurse wrote in the clinical record that the man’s cell mate had
approached her at the teatime clinic to say he was worried about him. He
said the man had looked unwell at lunchtime, though he had not reported it at
the time. When the nurse spoke to the man, she did not think that he looked
unwell but suffered chronic pain and “absent episodes”. A GP appointment
was made for 20 April when he saw a doctor. He had felt unwell whilst
waiting for his appointment. The episodes that he complained of were
described by the doctor as panic attacks, occurring four or five times per day
since his admission to prison. She prescribed diazepam, a medication
commonly used for treating anxiety, and also referred the man to the CPN. In
addition, the doctor asked for an electrocardiogram (ECG) to be performed.
This involves connecting electrodes to the skin to obtain a reading of the
electrical activity of the heart.
29. On the referral form to the mental health team, the doctor indicated that the
man’s referral was ‘urgent’, meaning that he should have been seen within 48
hours. One week later, however, on 27 April, an entry was made in the man’s
clinical record to say that, due to the number of referrals received by the
mental health team, his referral had been re-graded to ‘routine’. This meant
he should have been seen within seven working days.
30. On 29 April, a number of tests (blood count, thyroid function, plasma glucose
level, liver function, urea and electrolytes, lipoprotein electrophoresis) were
conducted from a single blood sample, and all the results were found to be
normal. An ECG was also performed. The following day, an administrator in
Durham’s healthcare unit noted in the clinical record that an appointment had
been made for the man with a nurse (the CPN) for 18 May.
31. The man submitted a formal complaint about healthcare on 1 May. (The
formal complaints procedure involves prisoners completing a form and leaving
it in a box on the unit. Complaints are responded to by an appropriate
member of staff.) He wrote on the form that, although he had been prescribed
paracetamol and diazepam, he was unable to obtain more of this medication
from the nurses on the unit.
32. A nurse saw the man on 5 May when she attended B wing to see his cell
mate. He told her that he was still having what were described as panic or
anxiety attacks two or three times daily. This was confirmed by his cell mate.
He asked for more paracetamol, but a nurse on B wing advised the nurse that
this was being addressed. The next day, the primary care co-ordinator at
Durham wrote to the man about his complaint. She explained that, whilst his
paracetamol was on repeat prescription and could be obtained from nurses on
the unit, his diazepam was not. She advised the man to make an
appointment with a doctor so that this could be reviewed.
33. On 7 May, the man had an appointment with a nurse. This was listed as a
physical care pathway appointment, which is used for prisoners taking anti-
psychotic medication (which the man was not prescribed). The nurse wrote in
the clinical record:
10
“Confused as to why he had been called up. Explained the purpose of the
appointment which confused him further, as he is not taking anti-psychotic
medication at the present time. It appears he was prescribed a course of
haloperidol in February for his alcoholism, which has now expired.”
34. The man told the nurse that, other than an episode of depression due to
family problems in the past, he did not suffer from any mental illness and did
not require or want anti-psychotic medication. He was, however, keen to
have a new prescription for diazepam, and the nurse advised him to arrange a
review appointment with a doctor.
35. Four days later, the man had an appointment with a GP at Durham who noted
that he had seen the result of the ECG and it suggested the absence of P-
waves. (P-waves are formed on the ECG as part of the heart’s normal
beating process. Their absence can indicate atrial fibrillation, a type of
abnormal heart rhythm.) The GP was not convinced that the P-waves were
genuinely absent and, believing that this may have been an error, suggested
that the ECG was repeated. He also speculated that the episodes described
as panic attacks could be due to tachycardia (an accelerated heartbeat).
36. On the same day, the man attended a second appointment with the
consultant psychiatrist. He spoke more about the episodes that had
previously been described as panic attacks, and told the consultant
psychiatrist that he seemed to go into a different world five or six times per
day, for two or three minutes each time. The consultant psychiatrist wrote:
“He claimed to have some warning that these episodes were about to
occur because he notices that he starts sweating. He then enters into this
disassociated state when he is not really aware of what is going on around
him.”
37. Regarding depression, the consultant psychiatrist wrote:
“He agreed that he is quite depressed. He agreed that his alcohol abuse,
for which he offers no apology and about which he expresses no regret, is
motivated by a desire to blot everything out. I recalled with him that he
had used the word ‘depressed’ to me the last time and that he had used it
again today. I advised him that, in view of his depressed state, he should
be taking anti-depressants and certainly in preference to medicating
himself with alcohol. He agreed that he would take a medication if it were
prescribed.”
38. In conclusion, the consultant psychiatrist’s recommendation about the man
was “essentially unchanged”. He suggested 20mg of fluoxetine (an anti-
depressant) daily, and also recommended an electroencephalogram (EEG).
This monitors electrical activity in the brain (sometimes called brainwaves)
using electrodes placed on the scalp. There had been a suggestion in 2005
that the man’s fits might be caused by temporal lobe epilepsy (a type of
epilepsy characterised by seizures).
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39. On 14 May, a prison GP prescribed fluoxetine for the man as recommended
by the consultant psychiatrist. He also referred the man to the EEG
department at outside hospital and described his symptoms. On the same
day, the man saw another GP at Durham and told her that he had suffered a
head injury around one year earlier but could not recall the details.
40. The man saw the CPN on 18 May, 19 working days after the referral form was
received by Durham’s mental health team. The CPN wrote in the clinical
record that he presented as a “generally pleasant and co-operative man”. He
described his ‘panic attacks’ and said they happened at any time, rather than
in particular situations. The man said his mood was low but this was due to
being in prison. There were no problems with appetite, sleep, concentration
or communication skills. The CPN planned to see him again in five or six
weeks, but would offer some support if necessary following his court
appearance on 20 May.
41. Two days after this meeting, the man was convicted at a crown court. He
returned to Durham to await sentencing. On 5 June, he again saw the CPN,
who described him as pleasant and amiable with no thoughts of self-harm or
suicide. She wrote in the clinical record that he would be reviewed again in
five or six weeks.
42. At 11.55pm on 14 June, a nurse was called to B wing. The man’s cell mate
had alerted wing staff that the man had fallen from the top bunk and was
having a fit. The nurse wrote in the clinical record that when she arrived, the
man was lying on the floor of the cell with “copious amounts of blood coming
from an injury he had sustained to his head”.
43. As the nurse was unable to get a response from the man, who appeared to be
unconscious and was breathing heavily, she asked for an ambulance to be
called. The man remained in a semi-conscious state for around 15 minutes,
becoming quite agitated at times. The nurse reported that he would not
tolerate an oxygen mask on his face. By the time the ambulance arrived, the
man was more alert and able to respond to verbal commands, but had lost
blood from two cuts to his head. He was taken by ambulance to outside
hospital.
44. The man arrived at the hospital at 12.41am on 15 June, less than an hour
after the nurse examined him. He had a tender bruise to the right side of his
head, redness over his right shoulder, a bruise and abrasion to his right
elbow, and tenderness in his right ankle. X-rays were performed on his skull
and right ankle, and no injuries to the bone were found. The cuts to his head
were surgically glued.
45. Returning to the prison at 3.15am, the man was admitted to the healthcare
unit for observation. The nurse who was called to B wing to see the man a
few hours’ earlier wrote in the clinical record that regular monitoring of brain
functioning would take place and he would see a doctor in the morning
regarding the episode that had led to his fall. The subsequent observations
did not indicate any immediate cause for alarm.
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46. The man saw a GP at Durham, that morning. He felt better although he was
sore in various places due to the fall. The bleeding from his head had
stopped. The GP recommended that the man was observed in the healthcare
unit, with a follow-up appointment one week later. He slept for much of the
day and told a nurse that he wanted to be discharged from the healthcare unit
due to the noise. The nurse said she would discuss his request with the
doctor the next day.
47. Also on 15 June, an appointment was received from outside hospital for the
man to attend for an EEG on 2 July.
48. The next day, the man saw a prison doctor. He said he felt well and wanted
to return to B wing. He was unable to remember anything about falling from
his bed until he awoke on the floor. The man also said that he was not keen
to go to hospital whilst a prisoner. The doctor agreed to discharge the man
from the healthcare unit and suggested that he should have a lower bunk, but
he wanted to return to the same cell because he was friendly with his cell
mate. Given that there was no clear indication what caused the fits or how
often they might occur, the doctor allowed this.
49. On 17 June, a senior officer wrote an entry in the man’s wing history record.
This was the first such entry for three months. The senior officer wrote that
there were no concerns, other than the man injuring himself as a result of the
fall. One week later, the man discussed the EEG with a doctor and said he
did not want to attend and so the appointment was cancelled. However, after
a further conversation with a GP at Durham, the man agreed to go to hospital
and a new appointment was made for 21 July.
50. No medical issues were recorded during the latter half of June, and no entries
were made in the man’s wing history record either. On 4 July, a nurse was
asked to attend B wing because the man was having difficulties with balance
when walking out of his cell. He told the nurse that he had experienced such
episodes before but could not explain them. He said he had eaten breakfast
but the officers on the unit did not think this was the case. A prison GP saw
the man and, although there was nothing new to report, decided to admit him
to the healthcare unit for observation.
51. The next day, 5 July, the same prison GP saw the man and wrote in the
clinical record that he seemed better, although he reported having two fits
since being admitted to healthcare. Two days later, his cell mate alerted staff
as the man was having a fit in his cell. On 8 July, the prison GP noted that
the cause of the episodes remained unclear, but there was no reason not to
allow him to return to B wing.
52. The CPN saw the man on 10 July and reported that he presented quite well.
He was preoccupied by the episodes and believed there was an organic
cause. He said he spent most of his time in his cell and had a good
relationship with his cell mate. The man did not see the purpose of trying to
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associate with prisoners who were mostly much younger than him. The CPN
planned to see him again in five to six weeks.
53. On 17 July, an entry was made in the man’s wing history record saying that
there were no concerns to report, other than him being somewhat quiet at
times. Four days later, the man attended outside hospital for his EEG. The
graph produced was within normal limits, with no focal or epilepiform
abnormalities (which, if present, can indicate epilepsy). He did not experience
any fits or seizures during the process. On 23 July, the man saw a prison
doctor and said he was still experiencing up to four fits per day.
54. The man attended a crown court on 24 July and received a nine-year
extended sentence. (This meant that he would spend four years in prison and
a further five years in the community on licence.) Three days later, a note in
the clinical record explained that the man’s pre-sentence report (written by a
probation officer to aid the sentencing decision) warned of deteriorating
mental health and a risk of suicide. A prison doctor wrote in the clinical record
that, as the man had an appointment arranged with the consultant psychiatrist
for 10 August, he would await the outcome before taking any further action.
55. On 2 August, the man was described in his wing history record as “a model
prisoner” who had good relations with staff and other prisoners and who was
always polite.
56. Sentenced prisoners are categorised from A to D (A being the highest) based
on their offence and the risk they would pose if they were to escape. The
man was categorised as C on 5 August. Category C prisoners are defined as
those who cannot be trusted in open prison conditions but who would not
have the ability or resources to make a determined escape.
57. The man did not attend his scheduled appointment with the consultant
psychiatrist on 10 August. He saw the CPN three days later and they
discussed the missed appointment. The man said he did not know about it
but could not see the purpose of the appointment either. The CPN suggested
that it would be a good opportunity to discuss the results of his recent tests,
as he was still complaining of fits. She noted that he was unwilling to look at
ways of coping with them, instead spending “virtually all of his time in his cell”.
58. On 17 August, the man saw the consultant psychiatrist (the appointment
having been rearranged from 10 August). They discussed the man’s fits, and
the consultant psychiatrist wrote in a follow-up letter that he had little doubt
they were not caused by epilepsy, but by “a phenomenon of his custody and
his rather chronically depressed state”. The man also told the consultant
psychiatrist that he would not survive until his release date of February 2011.
When asked, he confirmed that he was referring to the prospect of taking his
own life. The consultant psychiatrist recommended a prescription for an anti-
depressant and suggested mirtazapine. (At this point, the man was already
prescribed fluoxetine, though the consultant psychiatrist did not mention this
in his follow-up letter to the prison GP.)
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59. The next day, an administrator in Durham’s healthcare unit wrote that she had
received the consultant psychiatrist’s letter to the prison GP, and was
concerned that the man might pose a risk of suicide. As the information had
not been passed to anyone the previous day, the administrator spoke to two
nurses who suggested that she contact a senior officer on B wing. She asked
a senior officer (SO) to speak to the man, who would also be reviewed by the
CPN the following day. There is nothing in the man’s wing history sheet to
indicate whether or not the staff spoke to him.
60. The CPN saw the man on the morning of 19 August. She wrote in his clinical
record that “he was reluctant to discuss with me his thoughts around suicide,
but eventually admitted he had made plans, but would not say how or when”.
The man felt that he had no future and could not imagine spending years in
prison. The CPN discussed the possibility of starting the Assessment, Care in
Custody and Teamwork (ACCT) process. (The ACCT process is used by all
prisons to provide additional support and monitoring to people considered to
be at increased risk of self-harm or suicide.)
61. At 11.40am the same day, the CPN completed a Concern and Keep Safe
form, which is the first part of the ACCT process. She was concerned
because the man had expressed thoughts about killing himself, felt that he
had no future and would struggle to cope with a long sentence.
62. An Immediate Action Plan was formed at midday. (Immediate actions are
those which are necessary to keep the prisoner safe over the next 24 hours.)
A senior officer completed the form, saying that the man should be located in
a double cell for support, and have access to the telephone and to a Listener
(a prisoner trained by the Samaritans) as required. Unit staff were required to
have at least one conversation per day with the man, and also observe him
(and record their observations) twice during the day. Staff would also talk with
the man at the start of night duty, and observe him at least twice during the
night.
63. At 3.00pm, the man attended an assessment interview with a psychologist
who was also an ACCT assessor. (Prisoners subject to the ACCT process
must be interviewed by a trained ACCT assessor within 24 hours of the initial
concern being raised.) He described his main problem as being in prison, and
said that nothing would help apart from being released as he did not think he
could cope with the length of his sentence.
64. Although he had not harmed himself, the man said he thought about killing
himself every day and talked about the idea of cutting his wrists. He said he
did not want to die but wanted to be out of prison and saw killing himself as a
way out. He also talked about his fits and feeling depressed. The man said
he did not have any contact with his family. He enjoyed making things with
his hands but did not want to go to work or education classes in prison. It was
agreed that he would continue to see the CPN and apply for an art and design
course. He would also find something that he enjoyed doing that could
occupy his time, whilst remaining subject to ACCT.
15
65. After the assessment interview, the first ACCT review took place. The man, a
senior officer and an officer discussed his situation. The senior officer noted
on the review form that the man appeared distraught and, due to his “strange
behaviour” would remain subject to the ACCT process. A further review
meeting was arranged for 26 August, and a note made to invite the CPN.
66. A Caremap was produced the same day. This document lists the issues
experienced by the prisoner, as well as the goals and actions required to
overcome the issues. The senior officer wrote that the man was having
trouble accepting his sentence. He would receive support from the unit staff
and the CPN in order to try and come to terms with his situation. His fits were
mentioned, though the cause had not yet been ascertained. It was noted that
the man was thinking about harming himself, and was awaiting a further
appointment with the consultant psychiatrist.
67. Conversations with and observations of the man were recorded in the ongoing
record section of his ACCT document over the next two days, although there
was nothing of particular note. On 21 August, a prison GP noted in the
clinical record that he had read the letter from the consultant psychiatrist
(arising from the man’s appointment on 17 August) in which he had
recommended an anti-depressant. The prison GP noted that, whilst the man
was already prescribed fluoxetine, it might be reasonable to withdraw this and
prescribe mirtazapine instead. Four days later, a prison doctor did this.
68. On 26 August, a second ACCT review took place. The man, a senior officer
and an officer discussed his circumstances. The senior officer wrote on the
review form that the man continued to protest his innocence and did not
accept his situation. He was not planning for the future, other than saying he
might have to hurt himself to get out of prison. The senior officer noted that
he was “incoherent and rambling at times”. The ACCT remained in place and
a further review was arranged for 1 September. Again, a note was made to
invite the CPN.
69. No mention was made in the man’s wing history record or clinical record
about a discussion regarding transfer to HMP Acklington. However, at
5.40pm on 27 August, an entry was made in the ongoing ACCT record of a
conversation with an officer. The man had mentioned that he was being
transferred to Acklington the following day. It is unclear how this issue was
first raised and whether there was any discussion about how such a move
might affect him.
70. On 28 August, a ‘prisoner fit for transfer’ form was completed by a member of
staff in Durham’s healthcare unit. (It is unclear who filled in this form because
it required only a signature from the member of staff, which is illegible.) The
person noted that the man was subject to the ACCT process, but was not
suffering from any physical or mental illness that would prevent him from
being transferred and cared for safely in the receiving prison. The person
completing the form also wrote that there was no need to communicate
healthcare information to the receiving prison. The man was assessed as fit
for transfer and he left Durham at 7.30am the same day.
16
71. On the same morning, an officer spoke to the Safer Custody office (the
department responsible for suicide prevention and the management of the
ACCT process) at Acklington to explain that the man was subject to the ACCT
process. He was advised that an ACCT review would be conducted upon the
man’s arrival at Acklington.
HMP Acklington
72. When the man arrived at Acklington, an initial reception healthcare
assessment was completed by a nurse. His current medication was listed, as
well as the fact that he was subject to the ACCT process. However, there
was no mention of his fits or his involvement with the mental health team at
Durham. The man was not referred to a doctor or nurse for further
assessment.
73. An ACCT review was conducted at 3.30pm on D wing, where the man had
been accommodated. He was present at the review, with a senior officer, an
officer, a nurse and a Salvation Army chaplain. The senior officer noted that
the man was happy to be at Acklington and in a single cell. He maintained
good eye contact throughout the review and understood what was said, his
main concern being his insistence that he was innocent and should not be in
prison. He was not permitted to have medication or razors in his cell,
although he claimed that his thoughts of self-harm had reduced. He remained
subject to the ACCT process, with a further review arranged for 1 September.
A note was made to invite a representative from the mental health in-reach
team, as well as the man’s offender supervisor.
74. The next day, 29 August, an officer wrote in the man’s wing history record that
he was very depressed about the length of his sentence, had no family
support, suffered from fits and memory loss, used a walking stick, and was to
remain on the ground floor as it was more accessible. He described the man
as “extremely vulnerable”.
75. The fourth ACCT review took place on 1 September. The man was present,
as were a senior officer, an officer and the chaplain. The senior officer
reported that the man remained in a very low mood and could not accept his
situation. He claimed to have no thoughts about harming himself, but might
do so if he had the means and his mood was low. He remained subject to the
ACCT process and a review was arranged for 8 September, with the CPN and
chaplain invited.
76. The next day, the man’s offender supervisor wrote a long entry in the man’s
offender management unit (OMU) record. (The OMU risk assesses prisoners,
helps them to use their sentence constructively and liaises with community
offender managers, previously known as probation officers.) The man’s
offender supervisor’s entry was an overview of their induction meeting. He
noted that the man was very bitter about the length of his sentence and
continued to maintain his innocence. He had applied to start working in the
engineering workshop, which he thought was a positive move.
17
77. On 2 September, a senior officer wrote in the ongoing record section of the
ACCT document that he had seen the man standing in the association area of
D wing, appearing disorientated. He escorted the man to his cell but was
unsure if he had genuinely been taken ill or simply wanted attention. The
senior officer wrote that he got the feeling the man was laughing at being
asked questions and that he was “not quite sure what to make” of him.
78. An ACCT review (the fifth) took place on 8 September. In addition to the man,
a senior officer, an officer and the chaplain attended. The senior officer wrote
that the man was feeling much better and had no thoughts of self-harm.
Everyone present agreed that it was appropriate to close the ACCT
document. The senior officer explained that support was still available if he
required it. A post-closure ACCT review meeting was arranged for 16
September.
79. An officer wrote in the wing history record on the morning of 12 September
that the man had told him about a bad fit he had experienced the previous
night. He said he saw flashing lights for around five minutes and was
unsteady on his feet. As a result, the man saw a nurse and described the
periodic episodes that he had experienced for the past seven months. He
said he often saw flashing white lights for around five minutes but had
experienced these symptoms for a number of hours during the previous night.
The nurse noted that it was difficult to assess the man because of the
possibility that he had dementia. On the same day, a further nurse wrote that
the man had told her that investigations had been carried out into the cause of
his episodes whilst he was in Durham. She noted that he had an appointment
with a GP.
80. On 14 September, a nurse wrote in the clinical record that another nurse had
completed an elderly assessment for the man. He was not forthcoming during
the interview and seemed low in mood. She was unsure if he was being
obstructive or suffering from memory loss. The nurse wrote that the man had
a GP appointment and asked the doctor to assess any memory loss.
However, there is nothing in the clinical record to suggest that this
appointment took place.
81. The man’s offender manager from the community visited Acklington on 16
September and met him and his current offender supervisor. He agreed to
attend an alcohol awareness course and be assessed for a thinking skills
programme (a group programme focusing on offending behaviour and
avoiding it in the future). He also expressed an interest in going to education
classes to spend more time out of his cell. Regarding his offence, the man
continued to maintain his innocence.
82. On the same day, a senior officer, an officer and the man attended the ACCT
post-closure review. The purpose of such a review is to examine what has
happened since the closure of the ACCT, and to decide whether it should
remain closed or be re-opened. The senior officer wrote that, although the
18
man was in a generally low mood, he had no thoughts of self-harm. The
ACCT remained closed.
83. On 25 September, a nurse wrote in the clinical record that the man had
refused to swallow his paracetamol tablets when the nurse gave them to him.
Instead he had walked away from the treatment area with the tablets in his
mouth. Unit officers searched his mouth and pockets but found nothing.
84. Three days later, 28 September, a nurse wrote in the clinical record that she
was called to see the man after unit officers witnessed him having a fit.
During interview with my investigator, the nurse explained that she had not
witnessed the episode herself, and she conducted some simple tests (blood
pressure, blood sugar level etc.) when she arrived. She thought that the
man’s blood pressure was slightly high, and that one of his pupils was slow to
respond to light. She therefore asked for an ambulance to be called, and the
man was admitted to outside hospital.
85. The next day, the nurse spoke to one of the officers who had accompanied
the man to hospital. She was told that he was awaiting tests and would be
discharged depending on the results. The man returned to Acklington that
evening. A consultant physician at outside hospital wrote to the prison and
explained that the results of the tests had been normal. They included a
computerised tomography (CT) scan, which involves scanning a patient’s
head or body and producing an image that can be used to help diagnosis
illnesses and conditions. The consultant physician suggested that there could
be a cardiovascular cause to the man’s symptoms and arranged an
appointment for a 24-hour ECG.
86. The man attended an appointment with a doctor at Acklington on 30
September, who noted that he had not experienced any previous fits. (This
was, of course, not the case.) She also noted that the man would soon have
a CT head scan and tilt table testing. (Tilt table testing involves the patient
lying on a special table whilst connected to an ECG. The table is then tilted
so that the patient is in an upright position, and changes in blood pressure
and heart rhythms are monitored.)
87. Two days later, a nurse saw the man at the request of unit officers. He
reported having a couple of fits and an officer had seen him clutching his
stomach as if in pain. The nurse noted that, whilst she was talking with the
man, he seemed to have vacant episodes and admitted having memory
problems. She wrote that he would need his elderly assessment reviewed
and she would see him again the next week. The following day, 3 October, a
nurse saw the man at the request of unit staff after he had what was
described in the clinical record as a “funny turn”. He was sitting on the floor of
his cell, but declined healthcare input.
88. An entry was made in the man’s clinical record about him failing to attend an
appointment on 6 October, though there were no details about the nature of
the appointment. The same day, the outside hospital the man was attending
19
sent a letter to Acklington asking the man to attend the cardiology department
for 24-hour ECG monitoring on 15 October.
89. On 8 October, a nurse wrote that the man had been seen at the medication
dispensing hatch, where he asked for paracetamol. He was told that it had
been stopped and an appointment was made for him to see the doctor. One
week later, a prison doctor noted in the clinical record that paracetamol had
been restarted for general aches and pains, though did not specify why it had
previously been stopped.
90. Although the man’s hospital appointment on 15 October was registered on his
clinical record, there is no indication whether or not he attended. However, on
21 October, the consultant physician at outside hospital wrote to the prison,
saying he understood that the man had declined to attend. (The only mention
of this in the clinical record was an entry almost a month later, which simply
noted that the letter from the consultant physician had arrived.)
91. A nurse wrote in the man’s clinical record on 21 October that she went to see
him the previous night as unit officers reported that he had collapsed when
sitting on his bed watching television. He told her that these episodes were
happening four or five times per day. At the time of the assessment he looked
well, although his blood pressure was slightly high. The nurse told the
investigator that she made an appointment for the man to see a doctor the
next day, although there is no evidence of this in the clinical record.
92. The next recorded appointment was on 26 October, when the man saw a
prison doctor. He wrote about the man’s “bizarre history” of brief but frequent
episodes of going into what he described as “another world”. He told the
prison doctor that the episodes had only started since his arrival at Acklington
and had not happened at Durham (though again, this was not the case, as he
had complained of similar episodes throughout his time at Durham).
93. The next entry of any significance in the man’s clinical record was some 19
days later, on 14 November. A nurse wrote that there was some question as
to whether the man was being bullied for his medication. The man said this
was not the case and would tell officers if it happened. No further context was
given in the clinical record about how these concerns had come to light, and
there is no corresponding entry in the wing history record.
94. On 19 December, an officer wrote in the wing history record that the man had
settled well, spent most of his association time on the landing playing pool,
and was treated with respect by other prisoners due to his age. On 2 January
2010, he wrote that the man “still plods on to every challenge daily life sets”
and was always polite.
95. A nurse noted in the clinical record on 13 January that the man was given
paracetamol for “general aches and pains”. (This was the first entry in his
clinical record for almost two months, the previous entry having been written
on 14 November.) Four days later, an officer noted in the wing history record
that the man looked “a bit down” but did not have any particular problems.
20
96. The man reported more fits on 27 January. He was seen by a nurse who
wrote in the clinical record, in reference to the recent fits, that “nobody has
seen him have one”. (Previous fits had been witnessed; the nurse herself had
reported on 28 September 2009 that unit officers had witnessed him
experiencing a fit.) The nurse checked the man’s blood pressure and pupil
response. He asked for sleeping tablets and the nurse arranged a review with
the GP. However, there is no evidence in the clinical record of such a review
taking place.
97. The next day, the man moved to E wing as he had gained enhanced prisoner
status and had additional privileges. On 31 January, an officer wrote in the
wing history record:
“Having been approached by one or two prisoners on the landing, who
have said that [the man] had taken a funny turn and also they thought he
might be depressed, I have spoken at length to him. He said (and this has
been confirmed by healthcare) that he has been taking turns for a number
of years now and despite a lot of medical tests they can find nothing wrong
with him. Healthcare have also confirmed that he has a history of
depression, but not of self-harm. [The man] has stated he has no thoughts
of self-harm and does not want to talk to prison Listeners but I have asked
landing staff to keep an eye on him. Unit manager informed.”
98. A corresponding entry in the man’s clinical record was made by a nurse. As
he did not want any healthcare intervention, none was given, though unit staff
were advised to contact the healthcare unit if they were concerned about him.
This was the last entry in the man’s clinical record until the day of his death,
six weeks later.
99. During interview with my investigator, an officer spoke about his general
impressions of the man. He said the man was significantly older than most of
the other prisoners and, because of his age, the younger prisoners tended to
treat him well and look after him. The officer said the man was generally quiet
and kept himself to himself.
100. A senior officer described the man in similar terms. He said:
“He was no problem on the unit. Everybody tended to treat him like a
father figure, all the prisoners tended to just leave him alone and he just
got on with his own thing. He sat a lot … in his cell, watching TV.”
101. On 7 February, an officer wrote in the man’s wing history record that he had
settled well and was “keeping himself very much to himself up to now and
rarely coming to the attention of staff”. This was the last entry in his wing
history record.
21
The eve of the man’s death and the day of the man’s death
102. After the man’s death, an officer support grade (OSG) wrote a statement
about his overnight shift on E wing on the eve/the day of the man’s death.
The OSG explained that he had carried out roll checks (counting all prisoners
on the unit to check that they are present) at 9.00pm and 10.30pm on the eve
of the man’s death and at 5.30am on the day of his death. The OSG wrote:
“This would mean that the last time I saw [the man] would have been
around 5.30am and although regretfully I cannot recall exactly what [he]
was doing at this time, I can assure you that if I had seen him in any form
of pain, distress or anything else out of the ordinary, I would have taken
appropriate action.”
103. My investigator spoke to the three prisoners who were in the two cells
adjacent to the man and the cell opposite, and asked if they had seen or
heard anything untoward on the morning of the man’s death. An inmate from
the cell opposite the man did not see or hear anything, but had noticed that
the man was often short of breath. Similarly a further inmate, from one of the
adjacent cells, said the man frequently made noises, almost as if he were
shouting, during the day and night. However, he did not hear anything that
gave him cause for concern on the morning of the man’s death. A further
inmate, who was in the other adjacent cell, said the man suffered from
frequent fits and made lots of noise. He went on to explain that at around
7.00am on the day of the man’s death, he heard the man making a different
noise which he described as “yelping”. The inmate said that, although he had
not heard the man make such a noise before, he often made other noises and
so he did not alert members of staff to the situation.
104. During his interview with my investigator, an officer said he arrived at
Acklington shortly after 7.00am on the day of the man’s death and made his
way to E wing to take over from the night staff. Having arrived on the unit at
around 7.10am, he received a handover report from an OSG and then began
to conduct a roll check of his own, to confirm that the number of prisoners was
consistent with the earlier count. The officer explained that he started with
one of the two ground floor landings, went upstairs to one of the first floor
landings, across to the other first floor landing, and then downstairs to the
second ground floor landing. The man was in cell E1-11, on the last landing
to be checked.
105. When he reached the man’s cell, the officer opened the observation flap and
saw him “lying face down, fully clothed, over his bed … his legs were trailing
the floor and his arms were straight down by his side, his hands were in a
fist”. This immediately struck the officer as something out of the ordinary, and
he did not think it was a natural sleeping position. He tried to get the man’s
attention by calling out to him and kicking the cell door, but there was no
response. He then shouted to a senior officer who was in the unit office
approximately 30 feet away.
22
106. In his written statement and during his interview with my investigator, the
senior officer explained that he arrived on E wing around 7.20am. As the
senior officer, he was in charge of the wing for the duration of his shift. He
was in the office whilst the officer was completing the roll check, and said that
after a few minutes, he heard the officer shouting his name. The senior officer
said he immediately thought something was wrong because it was unusual to
be shouted in such a way during the roll count. He left the office immediately
and arrived outside the man’s cell around ten seconds later.
107. The senior officer looked through the observation panel and saw the man in
the cell. He said it was not a comfortable or usual position for sleep, but he
thought the man might have fainted or fallen asleep on the floor. He tried to
raise a response but was unable to do so, and so opened the cell door and
went into the cell. The senior officer felt the man’s neck but did not detect a
pulse. Due to restricted space in the cell, he and the officer moved the man
into the corridor of E wing. (All other prisoners remained locked in their cells
at this time.)
108. The senior officer and officer continued to check for signs of life. They could
not find a pulse and the man did not appear to be breathing. The senior
officer asked an officer who had just arrived on the unit to begin his shift, to
call a ‘code blue’ using his radio. (This is the radio call sign that alerts the
communications room to a serious, life-threatening situation, and usually
indicates that someone has stopped breathing. When receiving a ‘code blue’
message, the communications room will ordinarily contact healthcare staff via
the radio system to inform them of the need for medical assistance. In
addition, a specific alert noise is sent to every radio in the prison to alert the
staff to the situation.)
109. When they could not get a response from the man, the senior officer and
officer began cardio-pulmonary resuscitation (CPR). The senior officer
performed chest compressions whilst the officer administered mouth-to-mouth
breathing. Both officers had received relevant training and felt confident in
their ability to perform CPR effectively.
110. The officer said that, as he was performing CPR, he noticed that the man was
still warm. Other members of staff began to arrive, and the senior officer
asked them to stay back so that CPR could be carried out effectively and
without distraction. The officer recalled that a defibrillator (a piece of medical
equipment which is attached to a patient’s chest and administers an electric
shock if necessary) arrived but as nobody present was trained to use it,
manual CPR continued.
111. Three nurses were all in the healthcare unit, discussing their work for the day
ahead, when they received a message over their radios at approximately
7.30am, alerting them to the situation on E wing. The nurses immediately left
the healthcare unit to attend, taking with them an oxygen cylinder and a bag
containing emergency equipment. On their way to E wing, a further message
was received over the radio, advising that a defibrillator was required.
Although the nurses did not have this equipment with them at the time, all
23
three spoke during interviews with my investigator about the defibrillators in
the treatment rooms of each residential unit, and so they would have access
to one when they arrived at E wing. The radio message about the defibrillator
made it clear to the nurses that they were responding to a very serious
situation.
112. According to all three nurses, it took around four or five minutes for them to
get from the healthcare unit to E wing. Upon arrival, they found the senior
officer and officer performing CPR. One of the nurses attached the
defibrillator to the man’s chest and inserted a tube into his mouth to open his
airway. The oxygen cylinder was attached to a squeezable bag which the
nurse then used to artificially ‘breathe’ oxygen into the man’s lungs using the
tube that had been inserted.
113. The other two nurses performed chest compressions. The defibrillator
attempted to find a heart rhythm (an electric shock can only work if there is
electrical activity in the heart in a particular rhythm) but advised that this was
not present and that manual chest compressions should continue. The
nurses continued their efforts with CPR until paramedics arrived.
114. A report completed by the paramedics from the North East Ambulance
Service Trust recorded the time of the 999 call as 7.35am. They arrived at the
prison at 7.43am and were with the man two minutes later. He showed no
signs of life, his pupils were fixed and dilated and he was not breathing. An
ECG was attached to the man which showed that there was no heartbeat.
CPR was discontinued at 7.57am when the paramedics declared that his “life
was extinct”. The man was moved back into his cell and the door was locked.
A prison doctor pronounced his death at 8.40am.
115. The prison Governor ensured that representatives from the staff care and
welfare team were in the prison. She spoke to and debriefed the members of
staff who had been involved. This was done on an individual rather than
group basis as the nurses had returned to the healthcare department and the
officer who had carried out CPR went home.
116. At 8.40am, the prison Governor spoke to two prison family liaison officers
about the man’s death. There was no readily available information about his
next of kin, although they were able to use the prison’s old computer system
to retrieve a name and address for his daughter. This had been supplied at
the time of the man’s previous term of imprisonment (he had been sentenced
to two years for arson in 2005). One of the family liaison officers spent the
next two hours contacting various people, such as police officers, healthcare,
and the offender manager, in an attempt to verify the address for the man’s
daughter.
117. At 10.30am, the family liaison officers left the prison, arriving at the address at
1.00pm to find the property empty. After some investigation in the local area,
they were able to find the new address for the man’s daughter, and delivered
the news of his death at 2.00pm. The family liaison officers remained in
24
contact with the man’s family for some time after his death, and the prison
contributed to the funeral expenses.
118. A post-mortem examination found that the man died from ischaemic heart
disease (reduced blood supply to the heart) caused by coronary artery
atheroma (swelling in the artery walls which reduces blood flow).
119. The man’s funeral took place on 24 March and was attended by the prison
Governor, a prison family liaison officer and the prison chaplain.
25
ISSUES
Clinical care
120. A review of the man’s clinical care was carried out by a clinical reviewer from
CCIS. She assessed the care he was given whilst he was at HMP Durham as
well as at Acklington, where he died. The clinical reviewer concluded that the
man’s physical and mental health needs were met by the healthcare staff at
Durham and Acklington and, when necessary, by referral to outside hospital.
Healthcare support at Durham
121. From the time of his reception into Durham, the man attended numerous
appointments regarding his physical and mental health needs. Many related
to his frequent collapses (see below for further information) and the various
but unsuccessful attempts made to diagnose them. The clinical record was
comprehensive and it was easy to see when the man had attended
appointments, who he had seen, and the reasons for them.
122. The man was first referred to the mental health team in February 2009, shortly
after he was remanded to Durham. However, due to various delays, he was
not seen by a CPN until 18 May. After the original referral, an appointment
was made for 26 February, though this only resulted in a further referral. The
second referral was initially marked ‘urgent’, indicating that the appointment
should take place within 48 hours, but was downgraded to ‘routine’, allowing
seven working days for an appointment. This timescale was not met, and the
man was actually seen 19 working days after the referral. However, the man
did have two appointments with a consultant psychiatrist in the interim.
Although the man himself received appropriate mental health support by way
of his appointments with the consultant psychiatrist, Durham should ensure
that referrals for CPN support are followed up promptly and within the
published timescales. Although I do not make a recommendation in this
regard, the healthcare manager will wish to assess the referral processes to
ensure that delays like this do not occur.
123. Despite the man’s ongoing medical treatment and uncertainty about the cause
of his fits, it appears that healthcare staff at Durham did not provide a
handover to their colleagues at Acklington. The man had been assessed by
hospital specialists as well as prison healthcare staff. He may well have been
‘fit for transfer’ and his clinical record contained copious information, but the
attempts to diagnose his fits should have been communicated directly to
Acklington. Noting that there was no need to communicate any healthcare
information to the receiving prison was, in my view, inaccurate and
insufficient.
The head of healthcare at Durham should ensure that up to date
healthcare information is sent to each receiving prison, particularly
regarding prisoners who are having continuing treatment or have
undiagnosed symptoms.
26
Continuity of care at Acklington
124. Not surprisingly given the absence of handover information, the man’s
involvement with the healthcare team at Acklington was not nearly as
extensive as had been the case at Durham. In particular, there was no
evidence of ongoing mental health support following his transfer. He saw a
psychiatrist at Durham twice, and had regular support from a CPN. This did
not continue after his transfer, nor was there any assessment of what ongoing
support, if any, might be required. This is particularly significant given that the
man transferred to Acklington whilst subject to the ACCT process (the issue is
covered in more detail below).
125. Although there was no handover, the man’s extensive clinical record was
available to staff at Acklington. There is little evidence, however, that it was
read. With regard to the man’s fits in particular, it sometimes seemed that
Acklington staff were re-treading ground already covered at Durham. It also
meant that information from the man, such as his statement that the fits
started since he came to Acklington, were taken at face value even though
they were well documented in the clinical record.
126. The clinical record at Acklington was not always particularly clear. After the
man was taken to hospital on 28 September, he returned to the prison and
attended an appointment with a doctor on 30 September. It was noted that
the man would undergo a CT scan and tilt table testing, but there was nothing
in the clinical record stating whether or not these tests took place.
Additionally, a hospital appointment was made for 15 October for a 24-hour
ECG, which the man apparently declined. The appointment itself was
recorded, and more than a month later, when a letter from the hospital was
scanned into the clinical record, a note was made that he had not attended.
However, no mention was made at the time of the man’s failure to attend the
appointment and the reasons behind this, and neither was an alternative
arranged.
Undiagnosed symptoms
127. It is clear that the man’s reported fits were both puzzling and troubling to
healthcare staff at Durham and Acklington, as well as to hospital specialists.
The fits remained undiagnosed at the time of his death, and there was no real
consensus about whether the cause was physiological or psychological.
128. The man complained of fits from the time he arrived at Durham. They were
initially thought to be alcohol-related, and were later described as panic
attacks. In searching for a physiological cause, both an ECG and EEG were
carried out, but neither test provided any illumination.
129. Although no diagnosis was made, the fits certainly had the potential to cause
injury. In June 2009, the man was taken to hospital after he fell from the top
bunk whilst suffering from a fit. He was not seriously injured, and although it
was recommended that he should be moved to a lower bunk, he eventually
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returned to the same cell and bed. The clinical reviewer made the following
recommendation, which I endorse.
The healthcare manager at Durham should ensure that risk assessments
are undertaken and documented in a timelier manner for individuals with
a history of seizures, to ensure that they are not placed at additional risk
of injury.
130. After he transferred to Acklington, the man continued to suffer from fits, and
efforts were again made to diagnose them. After an ECG in September 2009,
an appointment was made for 24-hour ECG monitoring, though the man did
not attend to have the device fitted. It is unclear whether or not a CT scan
and tilt table tests were undertaken.
131. Members of healthcare staff treated the man as and when required. This was
usually in response to concerns raised by other prisoners or members of staff.
Their interventions, however, were limited because of the lack of a medical
diagnosis.
132. In relation to this undiagnosed condition, the clinical reviewer made the
following recommendation, which I endorse.
The healthcare managers at Durham and Acklington should ensure that
staff undertake more robust care planning and adopt an assessment
tool for individuals who have a history of seizures (including frequency,
type, duration and warning signs).
133. The appointment for a 24-hour ECG was part of the attempt to diagnose the
man’s condition. However, this was impeded because he did not attend the
appointment, having previously expressed concerns about attending hospital
as a prisoner. I endorse the clinical reviewer’s recommendation in this area.
The healthcare manager at Acklington should consider training
members of staff to complete ECG recordings within the prison rather
than using an outside hospital.
Assessment, Care in Custody and Teamwork (ACCT)
134. The ACCT process is intended to provide additional support and monitoring
for prisoners who are considered to be at risk from self-harm or suicide. The
process was started for this man at Durham on 19 August 2009 after an
appointment with a CPN.
135. An assessment interview was conducted, and a plan was made to keep the
man safe. His first ACCT review took place on the afternoon of 19 August.
Although the officer who had completed his detailed assessment interview
was present, the CPN was not. A note was made on the review form to invite
her to the next review. This took place on 26 August, but again nobody was
present from the mental health team. Again, a note was made to invite the
CPN to the next review.
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136. The man was transferred to Acklington on 28 August. There was no evidence
in the ACCT document of the move being discussed with him beforehand. He
was certainly aware of the impending transfer on 27 August, because he
mentioned it to a member of staff, but the way in which he was initially told
was not recorded.
137. Prison Service Orders (PSOs) provide instructions to prisons about
procedures that must be followed. PSO 2700 relates to suicide prevention
and self-harm management. In terms of transferring prisoners who are
subject to the ACCT process, paragraph 15.7.3 states that “the proposed
transfer, and issues arising from it, must be discussed at a case review with
the prisoner”. Paragraph 15.7.4 goes on to say that “the prisoner should be
given information about the regime and facilities of the new environment”.
The man had an ACCT review on 26 August, two days before his transfer, but
there was no mention of the transfer on the review form and therefore no
indication that it was discussed. Although he was told about the transfer in
advance of it happening, there was nothing in the ACCT document to indicate
when he was told and whether he was made aware of Acklington’s regime
and facilities.
The Safer Custody manager at Durham should ensure that, in
accordance with PSO 2700, transfers are discussed with prisoners
during ACCT reviews.
138. Paragraph 15.7.2 of the same PSO covers the actions that prisons should
take in advance of prisoners being transferred. It states:
“The intention to transfer a prisoner on an open ACCT Plan … must be
discussed with the receiving establishment, a record must be retained in
the sending establishment to show this has been done (as well a record
[sic] made in the ACCT Plan), and relevant information must be conveyed
either with or ahead of the prisoner.”
139. On 27 August, an email was sent from a member of staff at Durham to a
member of staff at Acklington. The member of staff at Durham explained that
the man would be transferring to Acklington the next day, and that he was
subject to ACCT. On 28 August, an officer (at Durham) wrote in the ongoing
record of the man’s ACCT document that he had spoken to the Safer Custody
office at Acklington and confirmed that an ACCT review would be carried out
upon the man’s arrival. However, at this point the man had already left
Durham and was on his way to Acklington. There was no evidence of any
other discussion between staff at Durham and Acklington about the man’s
transfer.
The Safer Custody manager at Durham should ensure that, in
accordance with PSO 2700, discussions about transferring prisoners
subject to the ACCT process take place with the receiving establishment
in advance of the transfer.
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140. An ACCT review took place at Acklington on the day of the man’s arrival. In
addition to unit staff, it was attended by a member of the healthcare team and
one of the prison chaplains. Further reviews took place on 1 and 8
September. Both reviews noted that a CPN should be invited to the next
review, although this did not seem to happen.
141. On 8 September, the man’s ACCT document was closed. A post-closure
review took place eight days later. Based on the reviews that had taken
place, and the post-closure review form, there is no reason to conclude that
this decision was anything other than reasonable.
142. The ACCT review forms at both Durham and Acklington included notes about
inviting mental health staff, although this did not happen. I therefore make the
following recommendation to both establishments:
The Safer Custody managers at Durham and Acklington should ensure
that ACCT reviews are multi-disciplinary wherever possible, and that
mental health professionals attend particularly when the prisoner is
being treated by their team.
Emergency response
143. When an officer saw the man on the morning of his death, he immediately
alerted the senior officer. The response was swift; the officer and senior
officer started CPR, and three nurses from the healthcare unit reached the
man within a few minutes. Attempts at CPR continued uninterrupted until the
paramedics arrived.
144. A defibrillator arrived before the nurses, but was not used initially because
nobody present was trained in its use. When the nurses arrived, they
attached the defibrillator to the man. It did not find a suitable heart rhythm
and so did not administer a shock. During interview with my investigator, one
of the nurses who performed chest compressions on the man emphasised the
importance of using a defibrillator as early as possible to maximise the chance
of resuscitation.
145. It is good practice for Acklington to have defibrillators on the residential units
where they can be accessed by prison officers as well as medical staff.
However, if the equipment is to be useful, members of staff need to be trained
in how to use them. I am pleased that, on 17 May 2010, the liaison for the
Ombudsman’s office told my investigator that 35 members of staff of various
grades were trained to use defibrillators. A further 37 had also expressed
interest in undertaking such training. The liaison for the Ombudsman’s office
intends to arrange further training, to be delivered by the North East
Ambulance Service, and so I do not make a recommendation on the matter.
146. Overall, the emergency response on the day of the man’s death was quick
and professional. Despite sustained and valiant efforts by the members of
staff involved, resuscitation was not successful.
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Issues raised by the man’s family
147. At 7.25am on the morning of his death, the man was found fully dressed and
lying in an unusual position in his cell. His daughter asked if he had tried to
summon help earlier in the morning.
148. All cells have an alarm bell which prisoners can use to alert members of staff
that they require attention. The alarm bells are linked to a computer system
which automatically records the date and time at which they are activated. My
investigator obtained the records for the man’s cell, which showed that he did
not activate his cell alarm bell on the morning of his death. My investigator
also looked at the records for the cells adjacent to the man’s cell, and found
that none of these alarm bells were activated either
149. An inmate who was in one of the adjacent cells said he heard the man making
noises around 7.00am on the morning of his death. He said that although he
had not heard these particular noises before, it was not unusual for the man to
make noises during the day and night. He did not attempt to contact anyone
at the time of hearing the noises, but told members of staff what he had heard
after he learned of the man’s death.
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CONCLUSION
150. The man appeared in court in February 2009 and was remanded to HMP
Durham. He attended numerous healthcare appointments for both physical
and mental health issues, and had ongoing support from a CPN and a
consultant psychiatrist. The clinical reviewer concluded that the man’s
physical and mental health needs were met by the healthcare staff at Durham
and Acklington and, when necessary, by referral to outside hospital.
151. In terms of his physical health issues, the man regularly told staff that he
experienced fits several times a day. Despite numerous tests being carried
out, the cause of the fits remained undiagnosed. Whilst both prisons took his
complaints seriously, Acklington staff would have benefited from a handover
from Durham and from paying closer attention to the healthcare records which
accompanied him.
152. In August 2009, the ACCT process was started after the man said he felt like
harming or killing himself. On 28 August, he was transferred to HMP
Acklington whilst remaining subject to the ACCT process. This was
discontinued on 8 September after a review meeting. Although I am pleased
that the man remained safe throughout, I am concerned that the transfer
between prisons seems to have happened without sufficient joint planning
beforehand.
153. The man was found collapsed in his cell on the morning of his death. Despite
sustained attempts at resuscitation, he could not be revived. A post-mortem
examination found that he died from ischaemic heart disease (reduced blood
supply to the heart) caused by coronary artery atheroma (swelling in the
artery walls which reduces blood flow). The man was 64 years old at the time
of his death.
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RECOMMENDATIONS
Healthcare:
1. The head of healthcare at Durham should ensure that up to date healthcare
information is sent to each receiving prison, particularly regarding prisoners
who are having continuing treatment or have undiagnosed symptoms.
The recommendation was accepted. Durham stated that current practice was
to provide medical records for each transferring prisoner.
2. The healthcare manager at Durham should ensure that risk assessments are
undertaken and documented in a timelier manner for individuals with a history
of seizures, to ensure that they are not placed at additional risk of injury.
The recommendation was accepted. Healthcare staff will be reminded of the
potential injury risks associated with seizures. Such medical information will
be gathered at initial health screenings, and members of staff will clearly
identify prisoners who should be located on the ground floor and/or in a lower
bunk.
3. The healthcare managers at Durham and Acklington should ensure that staff
undertake more robust care planning and adopt an assessment tool for
individuals who have a history of seizures (including frequency, type, duration
and warning signs).
The recommendation was accepted by both Durham and Acklington. Durham
will liaise with specialist services regarding existing assessment tools for
prisoners who experience seizures. Acklington has developed an
assessment tool for prisoners presenting with clinical symptoms that require
further assessment and monitoring. Care plans will be introduced where
warranted by a prisoner’s condition.
4. The healthcare manager at Acklington should consider training members of
staff to complete ECG recordings within the prison rather than using an
outside hospital.
The recommendation was accepted. Acklington’s medical staff are trained in
performing ECGs, although this will be updated through training.
Assessment, Care in Custody and Teamwork (ACCT):
5. The Safer Custody manager at Durham should ensure that, in accordance
with PSO 2700, transfers are discussed with prisoners during ACCT reviews.
The recommendation was accepted. Prisoners subject to ACCT who are
pending transfer to another establishment will have a review in the 24 hours
before the transfer. During this review, the prisoner will be provided with all
relevant information about the transfer.
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6. The Safer Custody manager at Durham should ensure that, in accordance
with PSO 2700, discussions about transferring prisoners subject to the ACCT
process take place with the receiving establishment in advance of the
transfer.
The recommendation was accepted. All Safer Custody staff are aware of the
issue and will ensure that receiving establishments have, in advance of
transfers, relevant information about prisoners subject to ACCT.
7. The Safer Custody managers at Durham and Acklington should ensure that
ACCT reviews are multi-disciplinary wherever possible, and that mental health
professionals attend particularly when the prisoner is being treated by their
team.
The recommendation was accepted by Durham. All members of staff there
were informed of the correct procedures of management and support for
prisoners subject to ACCT. It will also be reiterated at all ACCT foundation
and case manager training events.
At the time of issuing this final report, a response from Acklington regarding
this recommendation had not been received.
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