Individual at Brixton

Investigation into the circumstances surrounding the
death of a man at HMP Brixton on 15 May 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2009
This is the report of an investigation into the death of a man who was found dead in
his cell at HMP Brixton on 15 May 2007. The man was 24 years old.
I wish to offer my sincere sympathy and condolences to the man’s family and friends
for their loss. I must also apologise for the delay in issuing this report. This was in
part due to the time taken to establish the cause of the man’s death, and to obtain
the subsequent clinical review conducted by a firm on behalf of Lambeth PCT.
The investigation was conducted by one of my Senior Investigators. I am grateful to
the Governor of HMP Brixton and his staff for their help and co-operation during my
inquiries. I also thank those prisoners who agreed to take part in the investigation
process. Finally, I must thank the clinical reviewer for his report concerning the
man’s care during his detoxification from alcohol.
This report highlights the dangers associated with withdrawal from alcohol after
heavy consumption over a prolonged period. The clinical review team have made a
large number of generic recommendations in relation to a series of deaths at Brixton,
but none is directly relevant to the circumstances described in this report. I have
made two recommendations of my own which have been accepted and implemented
by the Governor.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2009
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CONTENTS
Summary 4
The Investigation Process 5
HMP Brixton 6
Key Findings 8
Issues 13
Recommendations 16
Annexes
1. Clinical Review and report
2. Interview Transcripts
3. Supporting Documents
3
SUMMARY
The man was arrested for assault and a public order offence on 8 May 2007. After
pleading guilty to the charges at a Magistrates Court on 10 May, and spending that
night at Hornchurch Police Station due to lack of cell space, he arrived at HMP
Brixton on Friday 11 May.
During the reception process, the man told the healthcare nurse that he drank a
large amount of alcohol and took a number of controlled drugs each day. The nurse
referred him to see the doctor who started the man on a chlordiazepoxide alcohol
detoxification regime.
The following day, the man saw the substance misuse nurse and another doctor who
prescribed a methadone programme and a benzodiazepine detoxification regime.
The man received his prescribed medication over the weekend, but on Monday 14
May a decision was made by the first nurse and the prison pharmacist to stop the
chlordiazepoxide.
The man was transferred to A wing during the afternoon of 14 May. During the
following night the man was shivering and his cell mate became concerned. He rang
the cell bell to summon the night officer. When the officer arrived at the cell the man
told him that he did not want a nurse. The officer returned on other occasions and
saw that the man was apparently asleep in his bed.
Just before 8.20am on 15 May, the man’s cell was opened along with others on the
wing. It was believed that he was still sleeping when he did not answer the officer’s
call. His cell mate was asked to wake him after a few more minutes so that the man
could collect his medication. A short while later, the man’s friend came to the cell
and discovered that he appeared to be dead.
The alarm was raised and staff responded but found that there was nothing to be
done. The man was pronounced dead at 8.40am by a prison doctor.
In December 2007, the post mortem examination report determined that the man
died of fatal cardiac arrhythmia due to alcohol withdrawal syndrome. (An arrhythmia
is an abnormality of the heart's rhythm that disturbs the electrical impulses which
regulate the heart.) Amongst other things, my report recommends that the Governor
and Healthcare Manager ensure that regular recording of blood pressure and pulse
rates are a standard element of alcohol detoxification regimes.
4
THE INVESTIGATION PROCESS
1. The investigation was opened at HMP Brixton on 23 May 2007. The Governor
and his staff produced the man’s core record and a large number of other
documents for examination. Notices were displayed around the prison to
inform both staff and prisoners of the investigation.
2. My investigator formally interviewed a number of members of staff and
prisoners regarding the man’s death. The transcripts of those interviews are
attached to this report.
3. One of my Family Liaison Officers contacted the man’s sister who had been
listed as his next of kin. This gave her the opportunity to discuss the purpose of
the investigation and to raise any questions she wanted explored and
addressed. The man’s sister raised several issues about the circumstances of
her brother’s death. She was concerned about the apparent lack of medical
intervention after the man pressed his cell bell during the night of 14/15 May,
whether the injuries the man received during his arrest played any part in his
death, and the way that she was told about her brother’s death and the lack of
ongoing contact from the prison subsequently. The man’s father instructed a
solicitor to act on his behalf in connection with the investigations into his son’s
death. I hope this report helps the man’s family better understand the events
leading to his discovery on the morning of 15 May 2007.
4. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation and to request a copy of the post mortem report.
The cause of the man’s death was not known until the Home Office Pathologist
(who carried out the post mortem) published his report in December 2007.
5. Upon completion, this investigation report will be sent to the Coroner to assist
with the inquest into the man’s death.
6. Lambeth Primary Care Trust was asked to prepare a clinical review of the care
that the man received whilst at Brixton. A private company, commissioned by
the PCT, prepared the report. My office received a copy in March 2008, but we
felt that a further report was needed to clarify the detoxification treatment that
the man received. That report was received in June 2008. It was prepared by
the section head for offender health (substance misuse) at the Department of
Health.
7. As a result of questions raised in the clinical reports, some further investigation
and interviewing was required regarding the dispensing of the chlordiazepoxide
prescribed for the man.
5
HMP BRIXTON
8. Brixton first opened in 1819 and in its time has been both a prison for
women and a military prison. Brixton’s primary role now is as a local prison
holding remand and trial prisoners committed from the local magistrates
courts, as well as the Inner London and Southwark Crown Courts.
9. Ms Anne Owers, Her Majesty’s Chief Inspector of Prisons, writes in the
introduction to her May 2008 inspection report on Brixton:
“This will be a disappointing report for the committed management team
and the many hardworking staff at Brixton. There are things that can and
must be managed better – in particular, the supply of drugs, which
requires effective internal management and support from both police and
prison security services. However, it is hard to see how Brixton, given its
physical limitations, can be transformed into an effective local prison,
offering both decency and rehabilitation to its 800 prisoners. Those
responsible for offender management in the London area need to decide
what role Brixton can and should play in their strategy – perhaps as a
resettlement prison for south London – and then ensure that it is
resourced for that role. Without that, Brixton will simply continue to recycle
its prisoners and risk demoralising its managers and staff.”
10. At the time of the man’s death, HMP Brixton was in the process of introducing
the Integrated Drug Treatment System (IDTS). IDTS is a new approach to drug
treatment that involves drug workers, prison healthcare, and uniformed prison
staff working together more closely. IDTS represents the first step in a user's
journey towards giving up drugs. This may involve them being prescribed
medication such as methadone or subutex (buprenorphine).
11. In the section of her 2008 report relating to substance use, the Chief Inspector,
Ms Owers, writes:
“The integrated drug treatment system (IDTS) had started, but full
implementation had been hampered by delays in adaptations to the
dedicated drug treatment wing. There was good psychosocial support for
drug users, but there was little for prisoners with alcohol problems and no
separate alcohol strategy. Drug testing was inadequate, and the
availability of illicit drugs potentially undermined the good therapeutic
work.”
“Basic alcohol awareness was provided by CARAT workers, but there was
no alcohol-specific strategy. There had been no alcohol needs analysis,
and it was not possible to ascertain the demand for such work. At the time
of the inspection, 30 of the CARAT team’s cases (about 10%) indicated
alcohol as their primary or secondary substance of choice.”
12. In May 2007, healthcare services were commissioned directly by the prison.
The visiting doctors came from a local GP practice and mental health services
were provided by the Oxleys NHS Trust. HMP Brixton also directly employed
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the healthcare staff. Heathcare services at Brixton are now commissioned by
Lambeth PCT and are provided by Care UK Ltd and other providers under
contract to the company.
13. Each prison has an Independent Monitoring Board (IMB). IMB members are
independent and unpaid. They monitor day-to-day life in the prison to ensure
that proper standards of care and decency are maintained. In the executive
summary of the latest IMB report for Brixton (2006-2007), the chairperson
writes:
“The Independent Monitoring Board (‘the Board’) of HMP Brixton accepts
that the past year has been a challenging one for all involved within the
prison largely because of the very high turnover of prisoners and the
pressures on places. The Board recognised the need for change in order
to achieve high standards and it is to the prison’s credit that there have
been many new initiatives during the reporting year. The Board looks
forward to seeing the full impact of these and proposed changes in the
coming year.”
14. Later in the IMB report, comment is made on the prison’s response to a series
of six deaths occurring during the reporting year (I have excluded the reference
to my own office as this has been the subject of separate correspondence):
“… the Deputy Governor held a meeting on 29 May 2007 to discuss the
recent deaths and to try to identify any common themes or actions that
need to be taken. The meeting commissioned the following pieces of
work: a review of reception processes; exit survey of prisoners; survey of
mid-term prisoners for their views on Reception and how their concerns
had been addressed; an assessment of healthcare staff and discipline
grades; and a re-launch of the Insiders scheme. This is all highly
commendable and should contribute positively to the Safer Custody
agenda at HMP Brixton.”
15. Since I was given responsibility for investigating all deaths in prison custody in
April 2004, there have been nine deaths at Brixton prior to that of the man. In a
report issued a year before the man’s death, I made a recommendation
reminding staff of the correct procedure for the administration of methadone as
set out in the relevant guidance. This should include regular monitoring of
blood pressure and pulse.
7
KEY FINDINGS
16. On Tuesday 8 May 2007, police were called to a disturbance in a town in
Essex. After a violent struggle, they arrested the man. The man was taken to
the local police station and charged with a public order offence and assaulting
a police officer. He appeared at a Magistrates Court on 10 May, and was
sentenced to four months imprisonment after pleading guilty to the charges.
17. The man was held overnight at Hornchurch Police Station due to a lack of
prison cell spaces. The following day (Friday 11 May), he was taken to HMP
Brixton and went through the usual reception process. He was seen by the
second nurse who completed the First Reception Health Screen form. The
man told the nurse that he had last been in prison earlier in the year at
Leicester. The man had bruises on his face and arms which he said he had
sustained at the police station. He said that he was allergic to penicillin and
had been diagnosed with epilepsy but was not taking any treatment for the
condition. When asked about substance abuse, the man told the nurse that he
drank two to two and a half bottles of vodka. Although the frequency is not
clear from the form, he answered “none” when asked how much he had drunk
in the week before coming into custody.
18. When asked about any drug use, the man said that he used heroin,
benzodiazepines, amphetamine and crack cocaine daily, and had last used
methadone over the previous weekend. The man denied any mental health
problems then or in the past. The second nurse referred the man to see a
doctor in relation to his substance misuse. Whilst still in reception, the man
saw the prison doctor who started him on an alcohol detoxification regime
consisting of daily vitamin B and thiamine and a reducing dose of
chlordiazepoxide (librium). He received his first 25mg dose before moving onto
a wing.
19. As part of the reception process, the man saw the first officer who carried out a
Cell Sharing Risk Assessment (CSRA). During the course of the interview for
that process, the man told the officer that he had previously been convicted of
racially abusing a police officer. For that reason the officer assessed the risk
that the man might assault a cell mate as being high. Later, a governor agreed
with the assessment. He decided that the man could share a cell, but only with
another white prisoner. The man was put into a cell on G wing sharing with a
man he knew, first cell mate.
20. The man telephoned his sister that evening. The conversation consisted
mainly of the man asking to be sent some money and talking to his sister about
his arrest and his injuries. The man did not mention drugs or any withdrawal
symptoms he was having.
21. The next day the man was seen by the third nurse, a substance misuse nurse.
He told the nurse that he used £50 of heroin, £100 of crack cocaine, and eight
to ten ‘blues’ (valium), and drank one and a half bottles of vodka and ten cans
of Stella lager daily. When interviewed by my investigator, the third nurse said
that the man’s daily list of drugs and alcohol was believable but she always
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checks by taking a urine sample for testing. In the man’s case he tested
positive only for opiates and benzodiazepines, although he had been in custody
since the evening of 8 May. The nurse noted that the man also complained of
withdrawal symptoms, hot and cold flushes, aching bones, gastro-intestinal
symptoms and insomnia.
22. The third nurse put the man onto a benzodiazepine detoxification regime
starting at 15mg twice a day and a methadone maintenance regime starting at
20mls. The man was to be reviewed by the substance misuse doctor the
following Monday (14 May).
23. The man received two out of the three 25mg of chlordiazepoxide on 12 May,
missing the noon dose. On 13 May, he received the morning and midday
doses but did not get the evening dose. He did receive two doses of diazepam
and 30mls of methadone. In order to be given his medication, the man was
required to attend the medication hatch on the wing at set times during the day.
24. The second officer wrote the following entry in the wing history sheet about the
man and his cell mate on the night of 13 May:
“Prisoners (the man) and (his first cell mate) have been demanding to see
a doctor and to have medication – This is the third night in a row that they
have done this – I have checked with H6 (on call nurse) on all occasions
and they have had all they are entitled to. Remind them both in the
morning to put apps in to see doctor as now the man is claiming to be
allergic to his meds and his first cell mate is throwing up all the time.”
25. In her interview with my investigator, the second officer was asked if she was
concerned about either man’s health. She replied:
“Obviously I am not medically trained but that was on the third night and
they didn’t appear any different on that day than they had done the two
previous days so from my point of view they weren’t any worse health-
wise. They were the same and I didn’t have keys to open the door so I
couldn’t see any evidence of there being any vomit in the cell or anyone
looking like they were so ill that they couldn’t do anything else. They were
both sort of standing up wandering around the cell and because we were
watching the man’s first cell mate … you would go up there when they
weren’t looking at you looking and they would just be sitting there smoking
or watching the tv or chatting or doing what they do.”
26. The fourth officer who was on the day shift on G wing on 14 May wrote the
following entry in the man’s history sheet:
“The man has been a complete drain on staff over the weekend. He has
many issues he expects staff to resolve rather than help himself. Also the
man has been warned about his use of cell bell.”
27. During an interview with my investigator the officer explained what was meant
by the above entry:
9
“The man, over the course of the weekend had many queries, he wanted
and requested items over and over again, for example I had given him a
tube of toothpaste on the Saturday but on Sunday he wants another one,
he also had issues around his clothing where I had given him a complete
kit change top to bottom socks etc, and yet on Sunday he required another
pair. Because of the busyness of the wing that sort of behaviour from
prisoners is a drain on staff if you are dealing with the same prisoner for
the same things over and over again … there were just constant enquiries,
well not enquiries so much, constant needs, constant requests for
information. I can give an example … if he asked me about a visit on
Saturday morning he would ask me again the same question Saturday
afternoon and then Sunday morning and again. Just because the wing is
so busy and so many prisoners need your one to one attention, answering
the same question five times is a drain on staff.”
28. The fifth officer also said that the man appeared to be coping with his
detoxification regime. She was unaware if he was collecting his medication, but
presumed that he was. The man and his first cell mate had been told that they
would be moving to A wing on 14 May, although it was unlikely that they would
remain together, at least initially.
29. Later that morning the man saw the substance misuse doctor. The doctor
noted, “still feels rough, keep on 40mls for seven days and review. The man
was also given first dose of hep b vaccination.” The man did not complain to
the doctor about any of the issues he had raised with night staff over the
weekend.
30. The man saw the fourth nurse on the wing and approached her. She later
entered on the computerised medical record that he complained of enuresis
(bedwetting). The fourth nurse said that the man was active and appeared to
be in a good frame of mind when she spoke to him. He did not say anything
about the drugs he was on or any other problems. The nurse asked a
colleague, the first nurse, to collect a urine sample from the man. The first
nurse later noted that the man had been given a specimen bottle but was
unable to provide a sample at that time.
31. The first nurse gave the man his two doses of diazepam that day and recorded
that “nil” symptoms were assessed. The man also received his 40mls of
methadone in the afternoon of 14 May, but he did not get any chlordiazepoxide
at all that day.
32. The alcohol detoxification regime sheet has a line through the chlordiazepoxide
and “stopped ref. to” the first nurse written above it. My investigator interviewed
the first nurse and spoke with the pharmacist. The first nurse said that he saw
the prescriptions for chlordiazepoxide and diazepam and realised that the man
had been prescribed two doses of benzodiazepine medication when only one
was needed. He also pointed out that both drugs and the prescribed
methadone have a side effect of depressing the respiratory system. The
10
pharmacist had agreed with the decision and praised the nurse for noticing the
duplication.
33. In the afternoon the man was moved to A wing and into cell 20 on the two’s
landing. There is no evidence that another Cell Sharing Risk Assessment was
completed. The man’s new cell mate was a black man born in Ghana. The
man was directed to his cell by the sixth officer. He described the man as
glassy eyed, coherent, but not quite ‘with it’. The officer also remembered that
the man kept calling ‘sarge’. The man’s second cell mate said that the man told
him he had been given his medication just before he came to the cell.
34. The man and his second cell mate went to collect their tea meal and returned to
their cell to eat it. The man did not eat all of his food and offered some to his
cell mate. The man’s second cell mate was then taken out of the cell for a legal
visit.
35. At some time during the evening association period, the man spoke to the
seventh officer who was in the wing office on the three’s landing. He asked him
if it was possible to be put into a cell with his first cell mate again. The officer
told him that it was not possible at that time but that that he would see what
could be done the following day.
36. When the man’s second cell mate returned to the cell, he saw that the man was
lying on the top bunk, fully clothed and shivering. The man asked him how long
he had been asleep and his cell mate told him that he had been away for about
two hours.
37. The man went back to sleep for a while but when he awoke the man’s second
cell mate saw that he was still shivering. He pressed the cell bell at 10.15pm to
call for an officer and the eighth officer responded. The officer was told by the
man’s second cell mate that the man was not well and the eighth officer saw for
himself that the man was shivering. He told the man that he would get a nurse
but the man told him that he did not want one. The eighth officer said that he
would return later to check on him. He returned to the cell about an hour later.
When he opened the door observation flap, the man’s second cell mate came
to the door and told him that the man was asleep. The eighth officer checked
the cell about two hours later and saw that both occupants were apparently
asleep in their beds.
38. At approximately 8.20am on 15 May, the sixth officer began to unlock the cells
on A2 landing for ‘free flow’, a system whereby certain gates around the prison
are opened and staff stand by those gates and other areas. Prisoners are then
allowed to walk to wherever they need to be, such as healthcare, gym or the
medication hatch. The officer opened the man’s cell, saw both men were in
their beds and called out to the man that he had a doctor’s appointment. The
sixth officer shook the bottom of the man’s mattress. The man’s second cell
mate woke at that point and explained that the man had had a bad night. The
officer told the man’s second cell mate to let the man sleep for another 15
minutes.
11
39. The seventh officer went to the man’s cell to tell him that he needed to collect
his medication from the hatch on the landing below. He found the man still
apparently asleep and his cell mate in the process of getting dressed. The
man’s second cell mate laughed and said that the man was still asleep. The
officer told the cell mate to inform the man that he needed to get down to
medication, and that he would return shortly to check.
40. A short while later the man’s first cell mate went to the man’s cell to see him.
The man’s second cell mate was in the cell talking to another prisoner. The
man’s first cell mate clapped his hands and told the man to get up. He pulled
back the bedclothes and saw that the man was blue in colour. The man’s first
cell mate left the cell and called out to the seventh officer who immediately
returned. The officer later told my investigator that his initial impression was
that the man was dead. The sixth officer arrived at the cell and the seventh
officer told him to remain at the door while he went to alert healthcare staff. He
ran to the medication hatch, but saw that the man’s first cell mate was already
there telling the nurse that the man was dead in his cell. The seventh officer
informed the first Senior Officer (SO) of the situation and the SO then put out a
‘code one’ message over the radio timed at 8.22am. (Brixton, like many other
prisons, uses a number code system for alerting staff to medical emergencies,
with ‘code one’ indicating the most serious and urgent.)
41. The sixth officer waited by the cell door to keep away the prisoners who had
begun to gather around. After looking at the man, the sixth officer also believed
that the man had been dead for some time.
42. The first Principal Officer (PO) was on A1 landing when he was approached by
a prisoner who told him that there was a dead body on the two’s. The first PO
followed the prisoner to the man’s cell. The prisoner told him that he was First
Aid trained and they both entered the cell. The prisoner checked the man for a
pulse but could not detect one. Again the PO’s first thought was that the man
was dead. The two men left the cell and the first PO went in search of the
man’s cell mate.
43. Healthcare staff responded to the ‘code one’ call. A nurse entered the cell and
checked the man for a pulse, any response to stimuli or signs of breathing.
She could not find any. A Senior Healthcare Nurse also attended the cell and
confirmed the lack of vital signs. In her interview with my investigator, she said
that in her opinion the man had been dead for some time as his skin was blue
and he was quite stiff.
44. One of the doctors at the prison, attended the man’s cell and pronounced him
dead at 8.40am.
45. Two white and two pink tablets, which were later determined to be indigestion
remedy and ibuprofen respectively, were found in the man’s cell.
46. The first Principal Officer found the man’s second cell mate being comforted by
other prisoners in a cell opposite. The first Principal Officer took him and three
other prisoners to another cell where the man’s second cell mate was spoken
12
to by healthcare staff. Later, they were taken to a holding room on A one
landing where they were given tea.
47. A second Principal Officer, a family liaison officer for the prison and the Deputy
Governor set out to break the news to the man’s family. They arrived at his
sister’s address but no one was at home. The second Principal Officer then
telephoned the man’s sister and explained that he needed to speak with her.
The man’s sister was unwilling to return home without being told why it was so
important but the Principal Officer was not happy to pass on such news on the
telephone. Eventually, a compromise was reached with the Principal Officer
agreeing to meet the man’s sister and her father in a local supermarket car
park.
48. Later that day the staff involved in the discovery of the man were brought
together for a ‘hot de-brief’. (The purposes of a hot debrief are to acknowledge
what happened and the role of the staff involved, to normalise the situation and
to ensure that the immediate staff needs have been met.)
49. A post mortem examination was conducted by a Home Office Pathologist. His
report was not completed until December 2007. The pathologist concluded that
the man died of a fatal cardiac arrhythmia due to alcohol withdrawal syndrome.
(An arrhythmia is an abnormality of the heart's rhythm that disturbs the
electrical impulses which regulate the heart. The heart may beat too slowly, too
quickly or in an irregular way. The symptoms a person may experience include
palpitations, loss of consciousness, dizziness and breathlessness. In extreme
cases, certain types of arrhythmia can cause sudden cardiac death.)
50. Alcohol withdrawal syndrome is a cluster of symptoms observed in persons
who stop drinking alcohol following continuous and heavy consumption. Milder
forms of the syndrome include tremulousness, seizures, and hallucinations,
typically occurring between six and 48 hours after the last drink. A more
serious syndrome, delirium tremens (DTs), involves profound confusion,
hallucinations, and severe autonomic nervous system overactivity, typically
beginning between 48 and 96 hours after the last drink
51. In a report in June 2007, a forensic scientist stated that the man had a level of
chlordiazepoxide in his system below that to be expected from his prescribed
dose, which would accord with his not taking the drug on 14 May and only
having taken it for two days. The forensic scientist wrote that he could not rule
out some post mortem breakdown of the drug. His conclusion was, “It is
possible that the man’s alcohol withdrawal symptoms were not adequately
controlled when he died, however, I cannot say whether this was a causal
factor in his death.”
13
ISSUES
Family concerns
52. The man’s sister was concerned about the apparent lack of medical
intervention during the night of 14/15 May. As detailed earlier, the night duty
officer (the eighth officer) responded to the cell bell and offered to fetch the
nurse to see the man. The man told the officer that he was alright and did not
want the nurse. The officer returned later, as he said he would, and the man’s
second cell mate told him that the man was asleep. On a later check the officer
saw that both men were apparently asleep. I believe the officer’s actions to be
reasonable under the circumstances.
53. Various injuries were noted on the man when he arrived at the local police
station and his family have asked whether those injuries played any part in his
death. A thorough post mortem examination was carried out by a Home Office
pathologist on 16 May 2007. In his report the pathologist writes, “Multiple
injuries were found at post mortem examination, although these were of minor
severity, and most were non-recent. Some of the injuries could have been
sustained during the man’s arrest, although these did not, in my opinion,
contribute to his death.”
54. The final matter raised by the family was how the news of the man’s death was
passed to them. They feel that more could have been done to ensure the news
was broken in more appropriate surroundings. I obviously have great sympathy
for the bereaved family. It is deeply upsetting to lose someone so young, so
unexpectedly, when they are in prison. However, my judgement is that, while
the eventual location was manifestly not ideal, the prison staff did their best to
accommodate the family’s wishes and needs at that time.
Clinical Review
55. Lambeth Primary Care Trust agreed to carry out a review of the man’s clinical
care and treatment while at Brixton. After a considerable delay, Lambeth PCT
commissioned a private company (that conducts work for the Department of
Health as well as other organisations.) to carry out the review on its behalf.
The review following the man’s death was one of five reviews into deaths at
Brixton commissioned in the same way, and at the same time, from the
company. No specific recommendations were made in the man’s review, but a
number of generic recommendations were made based on the findings from all
five reviews. I have judged it sufficient simply to append the clinical review to
this report.
56. After receipt of the clinical review, Lambeth PCT asked the section head for
offender health (substance misuse) at the Department of Health, to comment
specifically on the detoxification arrangements relating to the man. His report is
also appended to this report but I reproduce part of his conclusion here:
“The first night clinical management of the man’s substance withdrawal
was consistent with Dept Health (2006) guidance with regard to alcohol.
14
It is unclear whether an opioid prescription would have been indicated at
that time, as no withdrawal scale was used. His management on the first
night had, in my view, no bearing on the man’s death.
“The clinical substance misuse assessment carried out with the man on
12th May was satisfactory in every regard excepting the absence of
baseline blood pressure and pulse readings.
“The prescribed management of the man’s poly-substance dependence
from 12th to 14th May 2007 was broadly consistent with Dept Health prison
clinical guidance. The guidance recommends that methadone is
prescribed and given in sub-divided doses during the first five days of
treatment, but the fact that the methadone was prescribed in full single-
day doses appears to have no relevance to the man’s death. The
benzodiazepine reduction regimen was considerably more brisk than
Dept Health guidance, but as reduction had not begun at the time the
man died, this too was not a factor.
“There appears to have been a significant break-down in communication
that resulted in the man not receiving five of his prescribed doses of
chlordiazepoxide (two at 25 milligrams and three at 20 milligrams).
“The very heavy dependent pattern of drinking, the possibility of sedative
(valium) dependence, and a history of epilepsy mean that in my opinion
regular recording of blood pressure and pulse rates would have been
indicated in this case; increases in either blood pressure or pulse are often
signs of unmanaged withdrawal.”
Chlordiazepoxide
57. The man was prescribed chlordiazepoxide (librium) by the doctor when he first
arrived at Brixton to help relieve the symptoms of his detoxification from
alcohol. The following day another doctor prescribed methadone and a
benzodiazepine detoxification regime using diazepam (valium). On Monday 14
May, the first nurse looked at the three charts and was concerned that two
different benzodiazepines had been prescribed. An additional concern was the
possible effect of all three drugs on the man’s respiratory system. The first
nurse brought the matter to the attention of the prison pharmacist who agreed
and stopped the chlordiazepoxide.
58. Both the pharmacist and the nurse realised that the decision had to be
confirmed by a doctor. Unfortunately, the first nurse believed that the
pharmacist would inform the doctor and the pharmacist believed that the nurse
would do it. Both members of staff think it likely that a doctor was spoken to
about the decision but there is no record thereof, and no specific recollection of
such a conversation.
59. My investigator asked the clinical reviewer to comment on the decision of the
nurse and the pharmacist to stop the chlordiazepoxide:
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“From the documents we reviewed at our meeting it is clear that there had
been a clinical decision to discontinue the man's chlordiazepoxide
prescription, to avoid a risk of over-sedation. This is understandable, as
the therapeutic 'window' between effective pharmacological management
of coexisting opiate, alcohol and tranquilliser withdrawal, and poisoning (ie
overdose) is relatively narrow.
“My recommendation made in my report dated 23rd June 2008 remains
unchanged: that the regular recording of blood pressure and pulse rates
should be a standard element of alcohol detoxification, as these are
reliable indicators of severity of alcohol withdrawal. Unfortunately, without
these data I am unable to be certain that the man had experienced very
marked alcohol withdrawal and had died as a consequence of this.”
60. Once the chlordiazepoxide was stopped, the man should have been
reassessed to confirm whether the decision was correct or not.
The Governor and the Healthcare Manager should ensure that the
regular recording of blood pressure and pulse rates is a standard
element of alcohol detoxification regimes.
Staff response
61. Staff responded swiftly once concern about the man was raised. One issue I
must address, however, is the absence of any resuscitation attempt. Brixton’s
death in custody contingency plan makes it clear that the task of the first staff
on the scene is to attempt to maintain life and to raise the alarm. After raising
the alarm with a ‘code 1’ message, the next listed action is to “ensure that you
render first aid as appropriate”. In most circumstances I would expect the staff
to carry out Cardio Pulmonary Resuscitation (CPR) until relieved or advised to
stop by medical staff. However, in this case each person who saw the man
lying on his bunk was of the opinion that he had died some time previously.
This was based on his colour, temperature and lack of breathing or pulse.
Under the circumstances, I do not believe it would have been respectful either
to the staff concerned or to the man’s memory had CPR been attempted.
Cell Sharing Risk Assessment
62. When the man arrived at Brixton on 11 May, a CSRA was properly completed.
As a result a decision was made that he should only share a cell with another
white prisoner. On 14 May, the man was put into a cell on A wing with a black
Ghanaian man. Luckily, that oversight did not cause any problems on this
occasion. Nevertheless, the fact remains that no re-assessment was
undertaken before the man was allocated a cell.
The Governor should remind staff of the importance of the Cell
Sharing Risk Assessment procedure and instigate any training
required.
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RECOMMENDATIONS
1. The Governor and the Healthcare Manager should ensure that that the regular
recording of blood pressure and pulse rates is a standard element of alcohol
detoxification regimes.
This recommendation has been accepted and completed. The Governor
responded,
“1. All patients identified at reception as having a drug and/or alcohol
problem should have baseline observations completed.
2. There are clear reception protocols in place and staff are inducted and
sign to confirm they have read and understood the SOP
3. Patients undergoing alcohol detoxification should have daily monitoring
of BP and pulse
4. Clear protocols are in place for all nursing staff and assisted alcohol
withdrawal
5. All staff receive training in alcohol awareness
6. There is a lead nurse for alcohol
7. Monitoring of alcohol treatment is ongoing via the IDTS Implementation
Meeting and Clinical Governance Meeting”.
2. The Governor should remind staff of the importance of the Cell Sharing Risk
Assessment procedure and instigate any training required.
This recommendation has been accepted and completed. The Governor
responded,
“Staff Information Notice issued reminding staff of Cell Sharing Risk Assessment
procedures”.
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