Individual at Doncaster

Investigation into the circumstances surrounding the
death of a man
at HMP Doncaster on 6 July 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2010
Final Report: January 2010
This is the report of an investigation into the circumstances of the death of the man
on 6 July 2008, a day after he arrived at HMP Doncaster on remand. He was 32
years old at the time of his death from a drug overdose. His death was sudden and
it must be very difficult for his family and those who knew and loved him to bear such
a loss. I would like to offer my sincere condolences to his family, friends and to all
those who knew him.
My colleague conducted the investigation on behalf of the Prisons and Probation
Ombudsman. An independent review into the man’s care was undertaken by the
Quality Commissioning Governance Manager, on behalf of NHS Doncaster. I am
grateful for his valuable contribution. I would also like to thank the Director of
Doncaster, and the Head of Internal Affairs, for their cooperation and assistance with
the investigation. I am particularly grateful to the member of the prison staff who
provided a very high standard of liaison.
I apologise for the delay in producing this report. The investigation was suspended
for a considerable time while the police conducted their own enquiries. Misusing
controlled medication is a serious matter, particularly when it occurs in prison. I am
satisfied that the Director and the local police are taking appropriate action.
Recommendations aside, the report concludes that for the short time the man was at
Doncaster, the medical care he received was appropriate and in accordance with
local policies at the time. However, it is acknowledged that illegal drugs and drug
abuse in prison are a national problem for both state and privately run prisons such
as Doncaster. The man’s death could not have been foreseen by the prison. He
took Subutex illegally in prison and this, combined with his poor health and
prescribed methadone, proved to be a fatal combination.
I make four recommendations, three relating to recordkeeping and one regarding
family liaison. The first recommends that escort staff record any symptoms
indicating ill health or injury on the Prisoner Escort Form. The clinical reviewer has
commented on the poor quality of healthcare records and the second
recommendation asks staff to remember the requirement to keep accurate and
legible records. In common with a past investigation at Doncaster, the investigation
has found that a culture of falsifying records continues. Once again, I recommend
that the Director make sure attention is given to ensuring compliance with the
requirement for accurate recording of observations and effective management
checks.
Sadly, the prison’s handling of conveying the news of the man’s death to his family
fell short of what is expected and was not compliant with Prison Service instructions.
The consequences were avoidable and caused distress to his mother. It is
recommended that in the future, all circumstances are taken into account in deciding
whether to notify all named next of kin.
Doncaster prison’s detailed response to my recommendations is on the final page of
this report.
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The man’s mother raised a number of questions following the publication of my draft
report. These related to clinical issues and the Primary Care Trust have responded
to these in an additional annex to this report.
Jane Webb
Deputy Prisons and Probation Ombudsman January 2010
3
CONTENTS
Summary 5
The investigation process 7
HMP Doncaster 9
Key findings 10
Issues 17
Recommendations 20
4
SUMMARY
The man died on 6 July 2008 from a drug overdose. He was 32 years old and had a
longstanding history of alcohol and drug misuse. He had been remanded to HMP
Doncaster the previous day.
The man arrived at Doncaster from court at around 11.00am on Saturday 5 July. He
was known to staff from previous periods of custody at Doncaster. On this occasion,
reception staff saw he was vomiting but it was not noted on the prisoner escort
paperwork. During the reception process, he made several trips to the toilet to be
sick. The reception nurse who assessed him identified that he was withdrawing from
substance misuse and therefore suitable for Houseblock 3, detoxification wing. He
was not placed on the wing immediately as there were no spaces at the time. He
went to B wing cell 2-24 later in the day.
His cellmate, said that the man was clearly suffering withdrawal symptoms. He
recalled the man obtaining Subutex from another prisoner and being sick every five
or ten minutes thereafter. During the early evening, the man’s cellmate remembered
ringing the cell bell for help on the man’s behalf because he was too ill to do it
himself. Staff attended and the cellmate recalls that the man said staff had given
him something to stop him being sick.
At around 8.00pm, the man was taken to see the prison doctor, for a routine first
night appointment. The man told the doctor that he suffered from deep vein
thrombosis and had suffered a recent heart attack. He said he took a spray to
relieve angina symptoms. The doctor prescribed Clexane and warfarin for the deep
vein thrombosis, 15 mgs of diazepam for withdrawal and 30 mgs of methadone.
This prescription was based on nominal levels until the man’s usual prescription
could be confirmed on the following Monday.
The cell mate, who was awake during the night, confirmed that around 3.30am he
saw the man sitting up in bed. The Prison Custody Officer (PCO) completed the
Night Patrol Log but it does not record whether he received the required responses.
An internal investigation following the man’s death showed that another PCO,
marked that he had completed the early morning checks on his cell when he had not.
I make a recommendation regarding this and it is disappointing that it is not the first
time that this has appeared in one of the Ombudsman’s reports.
At 7.14am, a PCO accompanied the prison nurse as she dispensed medication to
prisoners in their cells. As the PCO could not rouse the man, he called the nurse
and, on her instruction, asked another officer to make a code red emergency call
over the radio net. Nursing staff responded swiftly and began cardio pulmonary
resuscitation. At 7.35am, ambulance paramedics arrived and following an
examination, the man was pronounced dead. During this time, the man’s cellmate
was removed from the cell and cared for appropriately.
The prison discovered that during the reception and first healthscreen procedures,
the man had named his partner and his mother, respectively, as his next of kin. The
police broke the news to the man’s partner on behalf of the prison. Prison Service
guidance provides for more than one next of kin to be told of a prisoner’s death. It
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would have been sensitive and appropriate for the prison to have reflected upon the
circumstances and visited the man’s mother to tell her at the same time as the police
spoke with his partner. This led to a wholly avoidable and regrettable sequence of
events and I make another recommendation in respect of this.
I consider that the medical care he received at Doncaster was appropriate and in
accordance with local policies at the time. Recordkeeping and the culture of
falsifying records, as identified in a previous investigation, remains a concern.
Nevertheless, I judge that the man’s death could not have been predicted by the
prison. Evidence was given by his cellmate that he illegally obtained and used
Subutex. The toxicology report provided to the coroner suggests that methadone
and Subutex were present in his body. These substances, combined with the effects
of alcohol withdrawal and his poor health, proved to be a fatal combination.
I make a further three recommendations for the Director of HMP Doncaster relating
to recordkeeping and family liaison and one for GSL regarding recordkeeping while
escorting prisoners.
6
THE INVESTIGATION PROCESS
1. I was notified of the man’s death on 6 July 2008. Terms of Reference and
notices were issued to staff and prisoners at Doncaster telling them that an
investigation would be taking place, and inviting those who wished to see
the investigator to make themselves known. The investigator, asked for
copies of the man’s prison records and clinical record relevant both to this
period on remand and to a previous sentence served at Doncaster in
January 2008.
2. The Investigator also contacted HM Coroner to inform him of the nature and
scope of the investigation and to request a copy of the post mortem report.
The report concludes that the man died of:
1a. Alcoholic ketoacidosis in association with use of methadone and
buprenorphine
3. The Coroner has requested a copy of this report upon completion and I am
happy to comply.
4. The Investigator visited Doncaster in August 2008 and January and March
2009. She met the deputy director, head of internal affairs and members of
healthcare staff. She visited B wing where the man had been located and
talked informally with staff. She also went to HMP Leeds to talk to the man’s
cell mate.
5. A clinical review of the man’s medical care at Doncaster was commissioned
from NHS Doncaster and undertaken by the Quality Commissioning
Governance Manager. His review appears as an annex to this report.
6. One of the Ombudsman’s Family Liaison Officers, spoke with the man’s
mother and his partner and then with professionals involved with his partner.
His mother raised a concern that she was told of her son’s death by his
partner and not the prison. She was also critical of the difficulty she had
contacting anyone at the prison once she had been told the news. I hope
her concerns have been addressed during the investigation.
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HMP DONCASTER
7. HMP Doncaster is a local, privately run, category B prison. The
accommodation is arranged in three identical triangular shaped
Houseblocks, each with four wings. There are 95 prisoners per wing with
cells arranged on two levels. Doncaster has an operating capacity of 1145
prisoners. It holds remand and sentenced young offenders and adult males.
In her report of an unannounced inspection between 11 and 15 February
2008, HM Chief Inspector of Prisons described some aspects of the
accommodation as squalid and poorly equipped. However, she
commended the amount of time prisoners spent out of their cells and the
prison’s resettlement work.
8. The First Night Centre is located on Houseblock 3. The IMB described it as
a busy and demanding unit with around 1170 prisoners per month moving
on and off the unit. Dame Anne found the First Night Centre was better
managed than in previous inspections, but there was a need for further
improvements in detoxification arrangements.
9. Healthcare is provided by Serco Health and is based on two floors. A 29
bed in-patient unit is located on the upper floor with primary healthcare
services on the lower floor. In her inspection, Dame Anne commented on a
worrying deterioration in healthcare:
“There was no needs analysis, governance was weak, access to a GP
and dentist poor, and medicines management and in patient services
were inadequate.”
10. The integrated drug treatment system (IDTS) was only partially in place at
the time the man died. Dame Anne noted that the clinical lead was also the
drug strategy co-ordinator and had little time for the role.
11. Dame Anne’s report also drew attention to the availability of drugs on the
wings. This issue is very pertinent to the circumstances surrounding the
death of the man and is supported by evidence within the toxicology report
provided to the Coroner. The report found that:
“Statistics showed drug use was most prevalent on Houseblocks 2 and
3 and least on Houseblock 1 (which included the voluntary testing unit
and vulnerable prisoners unit). In our survey, 34% of adult prisoners
thought it was easy to get drugs in the prison compared to 19% in
2005.”
12. Although the inspection highlighted a “worrying deterioration” in healthcare,
this was balanced against much that is positive in the prison.
13. The Independent Monitoring Board (IMB) report for 2007/2008 says that
understaffing and overcrowding have affected the prison’s ability to address
serious problems such as drug addiction and offending behaviour. The IMB
also highlighted that, following a criticism by Dame Anne, the practice of
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nursing staff dispensing medication on the wings with discipline staff in
attendance has ceased.
14. The purpose of IDTS is to address substance misuse problems in remand
and sentenced prisoners. It enhances systems already in place such as first
night prescribing of medication and opiate replacement therapy. There are
specialist nursing staff who support and treat those with substance misuse
problems. On the detoxification wing where the man was located, wing
staff carried out checks every 30 minutes and recorded the outcome on a 5
Day Detoxification Record throughout the day and night.
15. Since 2004, the Prison and Probation Ombudsman’s office has investigated
a number of substance related deaths in prisons and approved premises.
However, they continue to remain comparatively rare in prisons.
9
KEY FINDINGS
16. The man appeared at a local Magistrates Court in July 2008, where he was
remanded into custody to await sentence. He arrived at the prison at
around 11.00am. Prison staff saw that he was unwell as he stepped off the
prison van. Prison Custody Officers were on reception duty. One of them
said he knew the man from his past sentences and did not recall him being
ill when he arrived on previous occasions. He said that the man “got off the
bus carrying a plastic bag into which he had been vomiting”. He said he
was told by the escort van staff (GSL) that the man had been ill on the
journey. The investigator, noted that the Prisoner Escort Record (PER) did
not refer to him being unwell when he transferred from the escort company
to the prison. However, one of the PCO officers completed an Officer’s
Report indicating that the man was suffering from “illness” while in the
reception area. Staff recalled that he was the only prisoner to arrive that day
on that particular prison van and therefore the reception process was fairly
swift.
17. The officers carried out of a full search of the man. They then asked him to
sit outside the nurses’ office to await a first reception health check. Both
officers commented to the investigator that he was able to carry out every
task asked of him. The man told the officers he was very thirsty and asked
for water on a number of occasions which they provided. One of the officers
recalls that he also went to the toilet frequently to be sick. The other officer
asked him if he was “alright and he kept saying he was ok, but he was very
thirsty”. The officer estimated that it took around half an hour for a prisoner
to go through the reception process. He told the investigator that, other than
being sick, he could not recall any other indications that the man was unwell.
The investigator gained the impression that as staff knew the man misused
drugs, they assumed he was suffering from drug withdrawal symptoms.
18. As he was clearly unwell, he was given priority to see the nurse. He
underwent a preliminary health screen and was assessed as needing to be
located on the Integrated Drug Treatment Strategy (IDTS) wing.
19. In the IDTS/Substance Misuse Services document completed by nursing
staff, it was recorded that the man had said that he had a heart attack three
weeks earlier. However, the post mortem found no evidence that he had
suffered a heart attack either recently or in the past. He said that he was
“fine now” and was not on medication. The nurse recorded that he was to
be monitored for signs of heart pain and start alcohol detoxification.
However, he later told the prison doctor that he used a spray for angina. His
methadone dosage was to be confirmed two days later on Monday and the
“statutory dose of diazepam to be given after GP seen prisoner”. The sheet
on which this information is recorded is clearly written, but the time is
illegible.
20. At the time of the man’s imprisonment, Doncaster was in the early stages of
implementing IDTS. However, prisoners identified through the reception
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health screen as having substance abuse problems were “fast tracked” to
the IDTS detoxification wing and he benefited from this.
21. Prisoners are permitted a telephone call shortly after they are received into
prison so that they can tell a family member or friend where they are. One
of the Prison Custody Officers recalls the man using the telephone but was
unable to say to whom he made the call. (Prisoner telephone calls are
recorded in the main prison but not at reception.) Reception staff said that
he gave his partner as his next of kin, although the chaplain, acting as family
liaison officer, found no next of kin details on the prison computer system.
22. At around 12.15pm, he was escorted to Houseblock 3. He could not go to
the IDTS wing immediately as there were no spaces. In interview, one of
the Prisons’ Custody Officers recalled that he might have taken the man up
to the wing. He said “I’m sure it was me that day that took him up and [upon
handing the man over to staff] we just said he’s not been very well, he had
been sick in reception”. The other Prison Custody Officer was unable to say
whether wing staff indicated that they would take any action.
23. When a space on the IDTS wing became available, the man moved to cell
2-24, B wing, a double cell which he shared with another prisoner – his
cellmate. The investigator visited HMP Leeds and spoke with the man’s
cellmate who was most helpful to the investigator, however he
acknowledged that he too was suffering from substance withdrawal and had
taken valium to ease his symptoms. Therefore, while there is little dispute
over the sequence of events he related to her, she noted that his
recollection of timings differed significantly in some respects to that of staff.
He recalled that he had been taken to the cell five or six minutes before the
man who had arrived at 5.05pm. The man’s cellmate said that he could tell
which drugs the man had been misusing in the community from his
symptoms as he too was detoxing from alcohol and drugs. He said the man
asked if he could have the bottom bunk and he agreed.
24. Tea was served to prisoners at around 5.30pm. The cellmate said that the
man did not eat his tea because he “couldn’t stomach it” due to sickness.
He recalled that the man appeared to go over to where food was being
served, but changed his mind. He watched as the man then went to another
prisoner’s cell door located by the telephones. The cell door was already
unlocked and the man went inside. He later emerged with a carton of milk
and, according to the cellmate, some Subutex. (Subutex is a brand of
buprenorphine, a drug which is used to replace heroin and reduce
withdrawal symptoms.) The cellmate said in his statement to the Deputy
Director that he was escorted by a prison custody officer to get his
methadone at around 7.00pm. When he returned, the man admitted to him
that he had snorted Subutex.
25. It was obvious to the man’s cellmate, that the man continued to suffer the
effects of substance withdrawal. The cellmate tried to reassure the man that
staff “had to give him something within 24 hours”. The cellmate said that the
man revealed that he had used drugs the day before he came into prison,
11
but did not say what he had taken. The cellmate recalled that having
snorted the Subutex, the man was sick every five or ten minutes.
26. The cellmate remembered that, during the early evening, possibly around
8.00pm, he rang the cell bell because the man was vomiting badly and could
not reach the bell himself. Cell bell records are not kept by the prison and
therefore it is not possible to say when the cellmate rang the bell. He said
that the man told the officer “you haven’t given me any meds” (meaning
medication). The cellmate explained that the officer escorted the man from
the cell and he then set about cleaning it. He said the officer took the man
to the office on the wing. When the man returned, he told his cellmate that
staff had given him something to drink to stop him being sick.
27. He said that at around 9.00pm, an officer took the man outside the cell
again, shut the door and spoke with him outside. He returned around five
minutes later, sat down and had a cigarette. The cellmate said that he went
back to his own bed and lay down. The cellmate told the investigator that
the man was removed from the cell twice that night.
28. A third Prison Custody Officer was on duty on the IDTS wing. He escorted
the man to see, the prison doctor at around 8.00pm. In his statement, the
third PCO said that on the way, the man confided to him about the amount
of weight he had put on since his release from his last prison sentence at
Doncaster in February. He said this was due to his excessive drinking and
drug misuse. He also spoke about his immediate concern about getting his
methadone. The 3rd PCO said he told the man that these matters were best
raised with the medical staff. During their conversation, The A third Prison
Custody Officer said the man spoke very fondly of his partner, PCO White
noted that the man’s eye contact was poor and his “mood seemed low as if
he had things on his mind”.
29. The prison doctor, a general surgeon and part-time prison doctor assessed
the man in the presence of the healthcare nurse. He explained that he saw
the man as a matter of course as a new reception prisoner and not
specifically because of his substance misuse. The prison doctor noticed
that the man had evidence of deep vein thrombosis on his leg. He said that
the man told him that he had suffered a heart attack and took a GTN spray
to relieve symptoms of angina. This was the first time that he had
mentioned he was taking this medication. As he seemed familiar with heart
medication, the prison doctor thought there must be some truth in what he
said but this would need to be confirmed with the man’s doctor. In the
meantime, he prescribed the GTN spray for the man to use in case he had
an angina attack.
30. The prison doctor prescribed Clexane and warfarin for the DVT, along with
15 mgs of diazepam (to assist with alcohol withdrawal symptoms) and 30
mgs of methadone. Healthcare Nurse noted in her statement that she was
unhappy that Clexane had been prescribed with the other medication. The
prison doctor explained to the investigator that some nursing staff held this
view because the effect of Clexane is immediate. (If all is normal, then
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warfarin, which takes longer to act, can be given at the same time so that it
remains active when the shorter acting Clexane has worn off. This gives
both an immediate and a longer lasting effect.) The prison doctor explained
that although one worked differently to the other, the result was the same.
The man told the doctor that he had not had Clexane for the past four days
which was why Mr Kharmis considered it safe to prescribe both Clexane and
warfarin. The clinical reviewer noted that nursing staff made a decision not
to give some of this medication because of their uncertainty about the
prescription. The clinical reviewer said this decision was not a contributing
factor to the man’s death and staff were right to question a prescription for a
treatment that they thought needed clarification.
31. The prison doctor and the nursing staff were clear about the prison
prescribing policy. Staff explained to the investigator and to the clinical
reviewer that methadone is prescribed at the nominal level of 30 mgs until
the amount that the prisoner had been prescribed in the community is
confirmed by the relevant prescribing service. This is because prisoners’
accounts of their level of medication in the community are not always
accurate, and it is verified before a further prescription is given. As the man
was received into the prison on a Saturday, confirmation would not have
been possible until the following Monday. Therefore he was prescribed the
nominal level until his dosage could be confirmed. He would receive the first
dose the following morning.
32. The cellmate told the investigator that he heard the man being sick at
around 12.30am. When he got up at around 2.00am to 2.30am to make a
cup of tea and use the bathroom, he heard him snoring loudly in a rhythmic
and slow manner. The cellmate said that he stayed awake for around an
hour and during that time, while he was sitting in the chair, he saw the man
sitting up in the bottom bunk. He said the observation flap on the cell was
closed and no-one else could see in.
33. The cellmate could not remember whether officers checked their cell during
the night. He said he thought that at about 5.00am the cell light went on, the
flap was opened and went down again at around 5.30am. He thought that
the officer had a clipboard and “checked people off” and that they did not
carry keys at night to open the cells.
34. The Night Patrol log gives a clear instruction to staff before starting duty that
when checking a prisoner, staff must be able to see part of his body clearly
and obtain a physical and/or verbal response. It asks staff to confirm they
have patrolled the prisoner living area twice hourly varying the route on each
occasion. If there is any doubt, then the Night Orderly Officer is to be
contacted. The night patrol log was completed by the night Prison Custody
Officer who wrote that night checks had been carried out at 11.00pm,
1.30am and 4.30am. Routine visits by the duty director were noted at
11.12pm and 3.23am. There is no record as to whether the man gave a
verbal or physical response to the night checks. It is possible that he did
because the cellmate could say with some certainty that the man was alive
at around 5.30am and he could feel him moving on the bottom bunk. He
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said an officer opened the door at 7.15am. The man was lying on the
bottom bunk with his arm outstretched and looked white. He said he
checked the man’s pulse but found him cold to touch.
35. The log entitled “5 Day Detox Watch For Prisoner” was completed by five
staff over a seven hour 30 minute period. The cell number 2.24 is
handwritten at the top of the page and suggests that the man was in cell
2.24 from 11.30am when the log started. It is unlikely that this is correct as,
according to one of the Prison Custody Officers, he escorted the man to the
Houseblock at 12.15pm and the other PCO supports this timing in his
statement. The log gives a pre printed column for time in half observation
spaces. The next column gives an initial and the final column a pre printed
“NAD” and space for a comment next to it. [NAD stands for Nothing
Abnormal Detected.] The log continues until 7.00am and each column is
ticked next to the NAD space.
36. At 6.00am, 6.30am and 7.00am on 6 July, the day-shift PCO ticked against
“NAD” in each timed column indicating that he checked cell 2-24 at these
times and nothing abnormal was detected. After the man died, an internal
investigation by the prison found that the day-shift PCO had not made the
checks at these times. The prison dealt with the matter through their
disciplinary procedures.
37. That morning, all the PCOs escorted the Healthcare & IDTS nurse, as she
dispensed the morning medication on B wing. The PCO present task was to
open the celI doors. He said that at 7.14am, while the other PCOs were
with Nurse Smith at cell 2.23, he unlocked cell 2.24 to wake the man in
readiness for his medication. He said that he called the man’s name but did
not get a response. He then shook the man and felt that he was cold, his
fingers were blue and his chest was not moving. He called the Healthcare
nurse and, upon her instruction, asked the day-shift PCO to make a code
red emergency call over the radio net. (The code indicates the nature of the
emergency.)
38. The Healthcare nurse told the investigator that she was issuing the morning
medication to cell 2-23 during her round at around 7.13am when she was
called to cell 2.24. She said that the man was not breathing and there was
no pulse when she examined him. She told my investigator that she started
cardio pulmonary resuscitation (CPR) even though she assessed that he
had died some time earlier. My investigator asked her why she started CPR
when she thought that he had died and she said that she did so because it
was her duty and she was not qualified to pronounce death in an individual.
She said that she had asked the other PCO to call a code red emergency
medical response. The day-shift PCO confirmed that he did so and said that
he then went to open the gates to allow the medical staff to come through.
The Radio Operators Monitoring Log confirms that at 7.14am a code red
medical response was called over the net by the day-shift PCO .
39. The Healthcare nurse said that all the nurses who formed the medical team,
responded to the emergency call. She said they arrived with an emergency
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response bag and a defibrillator machine. (A defibrillator is a machine that
delivers a controlled electric shock to restore normal heart rhythm after a
heart attack.) The defibrillator machine was immediately attached to the
man. The defibrillator indicated that cardio pulmonary resuscitation (CPR)
should be carried out. This was started by two of the nurses of the medical
team.
40. In her statement, one of the nurses of the medical team confirmed that the
Healthcare Nurse gave the man 30 chest compressions and she gave two
rescue breaths. She said they continued with CPR until the ambulance
arrived at around 7.35am and paramedics took over his care.
41. One of the PCO’s said that while efforts were made to resuscitate the man,
he and the day-shift PCO took the man’s cellmate out of the cell to the upper
showers and he remained with him. They asked the mental health nurse, to
speak to him. The cellmate was re-located to cell 3-40 on D wing.
42. One of the nurses from the medical team was one of the nurses who
responded to the code red emergency call. She said that one of the other
nurses carried the response bag. She confirmed that healthcare staff
started CPR prompted by the spoken instructions from the defibrillator
machine and that they carried on until the paramedics arrived. She said that
the de-fibrillator pads were removed from the man at 7.40am and the
ambulance paramedics put their own attachments on the man. She added
that CPR was stopped on the paramedics’ instruction. An Incident Report
completed by the deputy director, records that, following examination by the
paramedics, the man was pronounced dead.
43. Another nurse also responded to the emergency code red call. She had
heard the call over someone else’s radio as she arrived at the gate of the
prison. When she entered the cell, she found one of her colleague nurses
giving the man chest compressions, while another nurse was giving breaths.
She assisted with CPR and noted that the man’s body was too stiff to move
or to insert an airway. In these circumstances, healthcare staff made a
judgement as to whether or not to commence CPR.
44. The mental health nurse said she fetched the oxygen tank from healthcare.
When she returned with it, she was asked if she would speak to the cellmate
who had shared a cell with the man. In her statement, she said that the
man’s cellmate was moved to D wing because he had disclosed to an officer
that the man had obtained Subutex from another prisoner and snorted it.
45. In the Incident Report prepared by the Deputy Director, he said that the
man’s cellmate had been relocated to the First Night Centre with Buddy
Support. An Assessment, Care in Custody and Teamwork (ACCT)
document was re-opened by the unit manager on Houseblock 3 in order to
support the cellmate during this difficult time. (ACCT is a process to monitor
and support prisoners at risk of self-harm and suicide.)
15
46. In accordance with Prison Service policy, the police were notified. A
statement completed by the Gatehouse Supervisor confirmed that an
Inspector and a Detective Sergeant, went to the prison to start their
investigation into the man’s death.
47. The chaplain, who also acted as family liaison officer, attended the man’s
cell at 7.45am and spoke with staff to offer support. He then went to
Houseblock 3D and spoke with the man’s cellmate.
48. An entry at 8.35am in his family liaison log records that the man did not have
any next of kin recorded on the prison computer information management
system. He spoke with the duty director and with Head of Internal Affairs.,
who told the investigator that a search of the prison records revealed two
next of kin. The man’s partner was recorded as his next of kin on his core
record and he had given his mother as his next of kin to nursing staff as
noted on his clinical record. Head of Internal Affairs said that only one
named next of kin can be notified and, in these circumstances, the prison
would look at who was visiting or, as in the man’s case, with whom he was
living at the time of his death. At the time of his death, he had been living
with his partner. The police and the prison were aware that his partner was
vulnerable. Therefore the police offered to assume this responsibility and
visit her at home to give her the very sad news. The prison accepted this
offer. Understandably, and as expected, the man’s partner was most upset.
Around six hours later when she was in a position to do so, she telephoned
the man’s mother and gave her the tragic news. This was said to have been
delivered in an unfortunate and forthright way and must have been a very
distressing experience for his mother.
49. A hot debrief was held on 6 July. Staff were given the opportunity to raise
immediate issues and to seek support through their managers or the staff
care team.
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ISSUES
Clinical care
50. The clinical review was undertaken by the Quality Commisioning
Governance Manager, on behalf of NHS Doncaster. He reviewed all
necessary records and conducted joint interviews with the investigator. He
noted that the man had entered Doncaster in July 2008, at a time when the
service provided to people with substance misuse problems was evolving.
The clinical review acknowledges that the way “care is arranged and
provided is now, very different to that which was in place at the time”. He
further judges that “It would appear from the evidence that the death of the
man could not have been foreseen or prevented by the healthcare that he
received”.
Record keeping
51. The man vomited a number of times on the vehicle escort from the
Magistrates court to the prison and in reception. Escort staff did not record
this on the Prisoner Escort Form.
The Director of GSL should ensure that staff responsible for escorting
prisoners records any noticeable symptoms of ill health or injury on
the Prisoner Escort Form.
52. The log entitled “5 Day Detox Watch For Prisoner” was inaccurately
completed and is misleading. It said that staff checked on the man at half
hourly intervals and that all was well. He was clearly very unwell and his cell
mate had called staff. The investigator noticed that the log columns do not
have sufficient space for staff to write informative entries. One of the PCO’s
said he escorted the man up to Houseblock 3 from reception at 12.15pm.
He did not immediately go to B wing where cell 2.24 is located but to D wing
to await a space on B wing. However, the log starts at 11.30am and cell
2.24 is marked at the top of the page suggesting that he was located in cell
2.24 when he was probably still in reception. While these early entries do
not have a direct bearing on his death, it casts doubt upon the
professionalism of the staff completing them and renders the documents
worthless. This is particularly pertinent in the light of the final entries made
by the day-shift PCO that are relevant to the investigation and are
misleading.
53. At 6.00am, 6.30am and 7.00am, the day-shift PCO ticked the section of the
form to indicate nothing abnormal. As part of the prison’s procedures when
a death in custody occurs, the Head of Internal Affairs conducted an internal
investigation into the man’s death on behalf of the prison. During his
investigation, he viewed the closed circuit television tapes showing the
man’s cell. He noted that although the day-shift PCO ticked the column to
say that he had checked cell 2.24 from 6.00am onwards, the tape showed
that he had not done so. It is possible that the record was completed at the
beginning of his shift without him actually making the checks. The
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investigator was informed that disciplinary action has been taken against the
day-shift PCO..
54. The falsification of documents is a very serious matter. It gives misleading
information and falls well beneath the professional standards required of
prison staff. I am concerned that the falsification of documents is not
confined to one area of the prison but appears to form part of a wider culture
as similar practices were found by the Ombudsman following an
investigation into a self-inflicted death at Doncaster in 2006. I therefore
repeat the recommendation.
The Director should develop a strategy to reduce the incidence of
falsifying documents, which is a grave breach of trust. This should
include ensuring that all staff are fully aware of the necessity of
accurately recording observations at the time they take place and that
management checks ensure compliance.
55. The clinical review acknowledges that there is little healthcare
documentation because of the short period of time the man was in custody.
However, the clinical reviewer found that the man had two prescription
charts. He also noted that some entries within the prison healthcare were
difficult to read, were not timed and incomprehensible abbreviations were
used. I often make recommendations regarding the importance of making
proper and legible entries in the clinical record. It is a key component of
delivering effective medical care.
The Head of Healthcare should ensure that staff are reminded of the
requirements to keep accurate and legible records
Breaking the news of the man’s death to family
56. Prison Service Order (PSO) 2710 “Follow up to deaths in custody” gives
instructions to prisons on actions to be taken after a death in custody. The
only mandatory requirement in this PSO is “Arrange notification to the next
of kin and any other person reasonably nominated by the prisoner as soon
as possible in a suitable manner”. Further instructions in “Guidance
supplementary to chapter 4 of the PSO – Liaison with bereaved families
following a death in custody” set out who should be regarded as the family.
It says “every family is different and has its own dynamics. A Family Liaison
Officer needs to be flexible and open-minded and should approach the
family in accordance with its individual needs” and “the family may… at odds
amongst themselves… and there may be several branches all with equal
rights to information…the Family Liaison Officer should be prepared to deal
with different sections of one family if necessary”. The instructions also list
good practice in delivering the news and cites face to face notification by the
prison as best practice.
57. The police broke the news of the man’s death to his partner and, as
expected, she found it extremely difficult. Prison staff had been aware of his
partner’s vulnerability and the possible response. In these circumstances,
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the prison agreed that the police should visit her. However, given their
knowledge of his partner’s fragility and that he had also cited his mother as
next of kin, it would have been more sensitive and appropriate for the duty
director and the chaplain to visit the man’s mother at the same time to
personally give her the tragic news of her son’s death, rather than leave this
task to his partner. Head of Internal Affairs was under the mistaken
impression that only one next of kin could be notified. The result is that the
man’s mother learned of her son’s death in a most unfortunate way. I am
pleased, however, that his mother said that when the chaplain visited her
home with her son’s property he had been very supportive.
The Director should ensure that prison managers and staff, particularly
those acting as Family Liaison Officers, comply with the requirements
of PSO 2710 and the supplementary guidance. They should consider
all the circumstances when breaking bad news to the prisoner’s family.
In the event of more than one next of kin or a divided family, they
should consider the right of equal access to information and make a
judgement as to whether it would be more appropriate for all members
to be told at the same time.
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CONCLUSION
58. The man was clearly suffering badly from drug and alcohol withdrawal
symptoms when he arrived at Doncaster. It is possible that he had learned
from his previous custodial experiences at Doncaster that it was unlikely that
he would receive any medication until the day after his arrival because of the
policies and procedures in place at the time. In these circumstances, it is
likely that he chose to self-medicate with Subutex, illegally obtained from
another prisoner, in order to ease his symptoms rather than wait until the
following morning for medical relief. He was discovered by staff and
healthcare attended his cell and acted very quickly, but sadly he was
pronounced dead shortly afterwards. The post mortem report concludes
that he died from alcoholic ketoacidosis caused by a combination of
methadone and Subutex use.
59. The ease with which he was able to obtain drugs in the prison is a concern I
share with Dame Anne Owers. It is difficult to say whether if staff had
properly carried out the necessary night checks and obtained the
appropriate responses, that the outcome would have been different. It may
not have made a difference to him, but could be crucial in the future. The
culture and practice of falsification of documents must cease.
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RECOMMENDATIONS
1. The Director of GSL should ensure that staff responsible for escorting prisoners
record any noticeable symptoms of ill health or injury on the Prisoner Escort
Form.
Prison response: None
2. The Director should develop a strategy to reduce the incidence of falsifying
documents, which is a grave breach of trust. This should include ensuring that all
staff are fully aware of the necessity of accurately recording observations at the
time they take place and that management checks ensure compliance.
Prison response: The issue of falsifying documents is being addressed.
Management checks are regularly carried out by the Head of Internal
Services. This involves routinely checking CCTV evidence against records
of procedures carried out by staff i.e cell searches, night patrols, roll
checks etc. Where it is found that recorded checks have not been carried
out those staff involved face disciplinary procedures. It is considered a
matter of gross misconduct and in the absence of exceptional
circumstances the most likely outcome is a dismissal.
3. The Head of Healthcare should ensure that staff are reminded of the
requirements to keep accurate and legible records.
Prison response: Healthcare staff are reminded of their obligation to keep
accurate and legible records keeping on an ongoing basis.
4. The Director should ensure that prison managers and staff, particularly those
acting as Family Liaison Officers, comply with the requirements of PSO 2710 and
the supplementary guidance. They should consider all the circumstances when
breaking bad news to the prisoner’s family. In the event of more than one next of
kin or a divided family, they should consider the right of equal access to
information and make a judgement as to whether it would be more appropriate for
all members to be told at the same time.
Prison response: Staff acting as Family Liaison Officers will continue to
comply with the requirements of PSO 2710. However, on occasion it will be
necessary to make a judgment on the best information available to them at
the time. The decision they make will always be in the best interest of the
next of kin of the deceased but will nevertheless be an 'judgment call’.
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