Individual at Garth

Investigation into the circumstances surrounding the
death of a man
in March 2010, in hospital,
whilst in the custody of HMP Garth
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2011
This is the report of an investigation into the circumstances of the death of a
man.
He died in hospital in March 2010 whilst in the custody of HMP Garth. My
Senior Family Liaison Officer spoke to his niece to explain the purpose of my
investigation. I offer my condolences to his family, and I apologise for any
added distress caused by the delay issuing my report.
The investigation was undertaken by one of my senior investigators. Both he
and I would like to thank the Governor of Garth and his staff for their
participation in this investigation.
He was transferred to Garth in January 2010. He was an elderly man, who
had been in prison for a number of years. Although he had no major health
issues, he had problems with his back and had suffered from high blood
pressure for some time. After his arrival at Garth, he complained on several
occasions of pain and occasional loss of vision in his left eye, and was taken
to hospital a number of times. In the early hours of 5 March, his health
deteriorated, and later that morning he was taken to hospital. Doctors said
that he appeared to have suffered a stroke. Hospital staff did what they could
to make him comfortable, and he died early in the morning the next day.
The local Primary Care Trust (PCT) commissioned a clinical reviewer to
review the man’s clinical care, and I greatly appreciate his assistance. The
clinical reviewer finds that he received good medical care at Garth. He makes
three recommendations to the Head of Healthcare at HMP Kingston about his
care during his time there, and I draw her attention to the clinical review. My
investigator has discussed the recommendations with her, and I have
included her responses in this report.
I do not think that it was dignified that the escort chain was only removed ten
minutes before he died and so I make one recommendation relating to
security assessments on prisoners who are in outside hospital. I am pleased
to see that the National Offender Management Service has accepted this
recommendation.
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 June 2011
2
CONTENTS
Summary
The investigation process
HMP Garth
Key Events
Issues
Conclusion
Recommendation
3
SUMMARY
1. The man was sentenced to life imprisonment in 1983. He had therefore
spent a number of years in the prison system, and was 65 years old
when he died.
2. He did not have any major health problems in the course of his sentence,
apart from an occasion where his hepatitis made him unwell in early
2000. He complained of chest pain later that year, and was prescribed
medication to treat high blood pressure. He also suffered some pain in
his back, which was found to be caused by sciatica.
3. In July 2009, whilst in HMP Kingston, he complained of headaches and
was prescribed medication for high blood pressure. In September he
hurt his head whilst rearranging the furniture in his cell, and sustained a
cut which needed stitching. Over the next few months he continued to
be monitored by healthcare staff, but was described as a difficult patient
to deal with. He was argumentative and occasionally aggressive
towards staff, and would not always comply with his medication or
treatment.
4. In January 2010, he was transferred to HMP Garth. The day after he
arrived, he was given an initial health screening where staff assessed
that his blood pressure was very high and referred him directly to
hospital. Although he was not admitted on that occasion, he continued
to be monitored by healthcare staff on the days after his return to prison.
He remained a difficult patient to deal with, refusing to engage fully with
staff and not complying with the suggested dosage for his medication.
5. He continued to suffer from high blood pressure, and on 22 January
complained of loss of vision in his left eye. He was taken to hospital for
tests, and found to have a blocked vein in his eye (a retinal occlusion).
He was prescribed aspirin, but continued to complain of headaches.
Following further loss of vision and other problems, he moved several
times between hospital, the prison’s healthcare centre, and an ordinary
prison wing through mid to late February.
6. On 1 March, he refused to take his blood pressure medication, saying
that it made his pain worse. He took his medication the following
morning, but later that day refused all medication before asking for some
painkillers. He refused his blood pressure medication in the afternoon of
3 March but took his medication at night.
7. The following day he refused to have his eye drops. He took his
medication that night, but was later sick. During the early hours of 5
March he became unwell and later that morning the doctor came to see
him. He arranged for him to be taken to hospital.
8. A security assessment was carried out, and in view of his previous
behaviour it was agreed that he should be restrained with an escort
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chain whilst he was in hospital. The chain was removed whilst he was
undergoing medical assessment, but replaced when the assessment
was complete.
9. Later that afternoon healthcare staff were told that he may have had a
stroke. By this stage he was extremely unwell. His blood pressure was
very high, and he had had a massive bleed to his brain. Nursing staff
provided an oxygen mask to assist his breathing, but he was not
expected to live much longer. In the early hours he was given some
medication to ease his pain, but nursing staff said that he would not
recover from the bleed on his brain. At approximately 2.18am escorting
staff removed the handcuffs and his death was confirmed ten minutes
later at 2.28am.
10. Through his years in custody, he had lost contact with any friends or
family outside prison. Although prison staff had considered contacting
his family when it was suspected that he had had a stroke, they had not
managed to trace anyone before he died. Having asked for assistance
from the police, his family were eventually traced and notified.
11. I do not think that it was dignified for a man at the end of his life to be
restrained by an escort chain and so I make one recommendation
relating to security assessments on prisoners in outside hospital. In
addition the clinical reviewer makes three recommendations to the Head
of Healthcare at HMP Kingston, which have been drawn to her attention
and the responses to which are included in this report.
5
THE INVESTIGATION PROCESS
12. HMP Garth provided the Ombudsman’s investigator with the man’s
prison record. He also obtained his medical records. He spoke to staff
who knew him at Garth, as well as to the Head of Healthcare at HMP
Kingston.
13. Notices were issued to staff and prisoners informing them of the
investigation and inviting anyone with relevant information to contact my
investigator. No further information was received.
14. The local Primary Care Trust (PCT) conducted a clinical review of the
man’s care and treatment. This was undertaken by the clinical reviewer.
My investigator discussed the report with him, and they worked together
through the investigation. Unfortunately, a delay receiving the review
contributed to the overall delay in publishing this report.
15. My investigator maintained ongoing contact with his liaison officer in
Garth throughout the investigation. He also wrote to the Head of
Healthcare at HMP Kingston and spoke with her on the telephone. He
provided ongoing feedback to his liaison officer at Garth during the
investigation.
16. My Senior Family Liaison Officer contacted the man’s niece to explain
our investigation and offer the opportunity to contribute. The family
asked if the report could indicate his offence and sentence, and give
details of how and where he died. I hope that my report addresses the
family’s questions.
17. My investigator wrote to HM Coroner to inform him of the nature and
scope of my investigation and to request a copy of the post mortem
report. Throughout the course of the investigation, my investigator
remained in contact with the Coroner’s office. Upon completion, this
report will be sent to the Coroner to assist his enquiries into the man’s
death.
6
HMP GARTH
18. HMP Garth is a category B training prison, which opened in 1988. It
holds category B prisoners (not the highest security, but for whom
escape must be made very difficult) who are serving sentences of four
years or more, including life sentence prisoners.
19. Healthcare is provided by the local Primary Care Trust (PCT). The team
includes general and mental health nurses, and the prison has 24-hour
care. Although it has since closed, at the time of the man’s death there
was an eight bed in-patient unit.
Previous deaths at Garth
20. Since my office took over responsibility for investigating deaths in prison
custody in 2004, the man is the eighth prisoner to have died whilst in the
custody of Garth. In 2007 I made a recommendation relating to the
importance of updating next of kin records, which I draw to the
Governor’s attention in this report. I do not repeat my recommendation
here as I think it unlikely that he would have been able to provide contact
information.
Her Majesty’s Inspectorate of Prisons
21. The last report published on Garth by HM Chief Inspector of Prisons
followed an unannounced inspection from 30 March – 3 April 2009. The
report does not raise any issues which are relevant to this investigation.
Independent Monitoring Board (IMB)
22. Each prison in England and Wales has an Independent Monitoring
Board, made up of members of the community, responsible for
monitoring day-to-day life in the prison and to ensure that proper
standards of care and decency are maintained. The last report
published by the IMB for Garth does not contain any issues that are
relevant to this investigation.
Security arrangements when under escort
23. On each occasion when a prisoner is escorted outside of the prison to
hospital a risk assessment is completed which considers the risk to the
public, potential for escape and likelihood of outside assistance. The
assessment informs the decision about the number of escorting officers
and the type of restraint to be used. The alternatives are single security
handcuffs, which were used for the man, or a two metre long escort
chain with cuff at either end to attach the prisoner to one of the escort
officers. The assessment also determines the circumstances and the
authority required for the restraints to be removed. The risk assessment
should be reviewed by prison managers each day that a prisoner is in
hospital and amended where necessary.
7
KEY EVENTS
24. The man was born in South Wales in October 1944. He was 65 years
old when he died.
25. He said that he had had difficulties from a young age, being taken into
care at the age of eight. After leaving school, he had lived a rather
nomadic lifestyle, living for some time in the Midlands. He sometimes
worked as a labourer on building sites.
26. In December 1983, he was convicted at Crown Court of having
committed murder in July of that year. He was sentenced to life
imprisonment.
27. He spent many years in the prison system in a number of prisons. He
was often described as a difficult prisoner, not engaging with staff, going
on hunger strike and/or threatening to cause damage to property if he did
not get what he wanted. Records show that on occasions he also
refused to take the medication he had been prescribed as a form of
protest. He was initially in contact with his family, but through the years
contact faded.
28. His medical notes show few major problems throughout his sentence.
After becoming ill he was diagnosed with hepatitis B in early 2000. On
15 December 2000, he complained of chest pain, and he was prescribed
drugs to treat hypertension (high blood pressure) and cardiovascular
(heart) disease. Records show that he continued to be prescribed this
medication until 2003, but do not show why it was stopped. There are no
notes of any further incidents of chest pain, or any further medical
investigation. There are also references on the medical files to him
having had laser surgery on his eye to correct cataracts, but again there
is no clear indication as to when this was.
29. In 2008, he complained of pain in his back, saying that he had suffered
from this for some years. This was found to be due to sciatica (pain in
the back or, more commonly, leg, caused by compression on the sciatic
nerve in the lower back) and was treated, using medication, by prison
medical staff.
30. On 6 November 2008, he was transferred to HMP Kingston. In July
2009, he was again prescribed medication for high blood pressure after
complaining of headaches. There are concerns noted in the medical
records over whether he took his medication as directed. He was
prescribed further medication for his blood pressure on 18 September.
31. A note on his medical file shows that on 20 September he suffered an
injury to his head. This was caused by a stereo speaker falling from a
shelf while he was rearranging his cell. The injury required five sutures
(which are similar to stitches and used to close a wound), but appeared
to be only superficial.
8
32. On 12 October, he became angry with healthcare staff who were treating
him. He made threats against them and refused to take his medication.
He was referred to the prison doctor, and attended his appointment on
21 October. Once there, however, he refused to take his medication or
have his blood pressure monitored.
33. He saw the locum prison doctor on 21 October. He again refused to
comply with his medication or to have his blood pressure monitored.
34. The next time he was seen by healthcare staff was on 11 November. He
approached the staff and said that he had been suffering with flu-type
symptoms for three weeks. However, he was again confrontational and
argued over the treatment offered, although he did accept paracetamol.
35. Complaining of headaches, he saw healthcare staff three days later on
14 November, and was given more paracetamol. On 18 November, he
again told staff that he was suffering constant headaches. He asked for
paracetamol and ibuprofen, but said that he did not want to deal further
with healthcare staff.
36. He had a review of his medication with a prison doctor on 16 December.
The doctor noted that he had refused to take his blood pressure
medication, and told him that this might be a cause of his persistent
headaches. He allowed the doctor to take his blood pressure, which was
noted to be high. He was, though, still argumentative. The doctor
advised him to consider his situation, and to make a further appointment
if he wanted. It does not appear that he did so.
37. He transferred out of HMP Kingston in January 2010. After a stopover at
HMP Woodhill, he arrived at Garth on 6 January.
38. During his induction assessment at Garth, he said that he had no family
or friends, and was not in contact with anybody outside the prison. He
was given a reception health screening on 7 January, and was referred
for a mental health assessment. As part of his initial health screening,
he was noted to have high blood pressure. Staff were sufficiently
concerned to refer him to hospital, and he was taken there that
afternoon. He was assessed but was not admitted, and he returned to
prison that day for ongoing observation by healthcare staff.
39. He saw Nurse A in healthcare on 10 January. He was unhappy with the
medication which had been prescribed, and said that he had previously
been taking double the dosage. The nurse explained that it was
important that he followed the doctor’s advice, but he said that he was
prepared to be taken to the segregation unit if his demands were not
met. His demands included a soft bed, draught-free windows, better
heating and better painkilling medicine. The nurse said that he would
raise the issue of medication with the prison doctor. (The segregation
unit is an area of the prison where prisoners are separated from the
9
general prison population. This can be for their own protection, or to
maintain the good order of the prison.)
40. Having been referred for a mental health assessment at his reception
screening, he was assessed by Nurse B, a mental health nurse, on 19
January. He told her that he was still in prison after such a long time
because he refused to engage with offending behaviour work. He said
that he had not considered progressing, and was quite happy to remain
in prison. She found no evidence of mental illness, low mood, or any
other cause for concern. No follow-up from the mental health team was
considered necessary.
41. On 22 January, he complained of a sudden loss of vision in his left eye.
He was seen in the healthcare centre, and his blood pressure was noted
to be high. He was taken to the ophthalmology department at hospital
for treatment, returning the same day. He was referred for further eye
tests, and on 23 January it was noted that one of the veins in his eye
was blocked (known as a retinal occlusion). He was prescribed aspirin
(which can be used to thin the blood).
42. When attending the healthcare centre for treatments on 16 February, he
complained of severe headaches. His blood pressure was still high. At
11.01pm Nurse C was called to see him, as he was still suffering
headaches. He seemed anxious and asked for co-codamol (for the
treatment of pain). She advised him to rest in the dark and contact
healthcare again if the pain worsened.
43. The following morning he complained of pain and loss of vision in his left
eye, and had been sick. He was again referred to hospital and, following
assessment in the ophthalmology department he was admitted
overnight. He returned to prison the following day, 18 February, with a
follow up outpatient appointment planned. However, after suffering a
bleed behind his eye, he had to return to hospital, before coming back to
prison and staying in the healthcare centre for observation.
44. Although discharged from healthcare on 19 February, he had problems
administering his eye drop medicine, and had to return. Following
discussion with healthcare staff, he returned to an ordinary prison wing,
C wing, on 20 February. However, on 24 February, he reported severe
pain in his left eye. He said that he still had no vision in that eye. He
was taken back to hospital as an emergency. After treatment he
returned to prison later that day, with a prescription for dihydrocodeine (a
strong painkiller). He was once again taken to the healthcare centre for
observation. He did not sleep well due to the pain, and in addition to
dihydrocodeine, he was given paracetamol and ibuprofen (both
prescribed to relieve pain).
45. Over the following days, he continued to complain of pain and loss of
vision. On 1 March, he refused to take the medication prescribed for
high blood pressure. He said that taking it made his pain worse. He
10
took his medication the following morning, but later that day refused all of
his medication. He said that he wanted to go back to the prison wing.
That afternoon he requested, and was given, some painkillers. The
following day, 3 March, he refused his blood pressure medication in the
afternoon, saying that it made his pain worse, but took his medication at
night.
46. On 4 March, he refused to have his eye drops, but accepted an
increased dosage of dihydrocodeine. He took his medication that night,
but was later sick. During the early hours of 5 March he asked the night
staff for some hot water, and he appeared to be confused and unsteady
on his feet. He fell, and two members of staff went into his cell and
helped him into his bed. He was again sick, and staff provided clean
bedding and clothing.
47. When his cell was unlocked at 8.00am, he tried to get out of bed but was
unable to do so. He did not respond to attempts by staff to engage with
him, and appeared to be disorientated and unable to speak. He had also
suffered some incontinence. The staff washed him and provided more
clean clothing. After helping him into a chair, they called the doctor. He
was not well enough to have breakfast or to take his medication. The
doctor came to see him, and after assessing him telephoned the Medical
Assessment Unit (MAU) at the hospital for advice. In the light of this
advice, he was taken to the hospital at 11.00am.
48. A security assessment was carried out, and in view of his previous
aggressive behaviour it was agreed that he should be subject to a
security escort chain (medical advice was that he could not wear
handcuffs). It was removed whilst he was undergoing medical
assessment, but replaced when the assessment was complete.
49. Later that afternoon healthcare staff contacted the MAU and were told
that he might have had a stroke. In the light of this, at approximately
4.00pm, prison staff began to consider how to contact his next of kin.
The records showed this to be his brother, but he was listed as being of
no fixed abode. He was believed to live in the Brighton area, so the local
probation service was contacted for any assistance they might be able to
provide.
50. When a prisoner is in hospital outside of the prison, they are generally
accompanied by one or more prison officers who are known as the
bedwatch staff. The bedwatch log shows that a consultant assessed him
at 6.05pm, who said that there was not much that could be done for him
at this time. He was referred for a chest x-ray. Once this was completed
he was given a change of clothing. Prison healthcare staff again
contacted the MAU at 7.21pm and were told that he was extremely
unwell. His blood pressure was very high, and he had a massive bleed
to his brain. At 7.40pm nursing staff provided an oxygen mask to assist
his breathing. At 8.00pm his bedding was changed while his clinical
observations were taken.
11
51. The bedwatch staff changed shifts at 9.00pm. The officers coming on
duty found that he was in a very poor state of health, and although
relatively comfortable, was not expected to live much longer. By
11.00pm he was having trouble breathing, and was under close
observation from nursing staff. At 12.25am on 6 March the ward doctor
visited and asked the bedwatch staff about his family.
52. At 1.30am he was given some medication to ease his pain, but nursing
staff said that at this point they knew that he would not recover from the
bleed on his brain. At approximately 2.18am, the bedwatch staff took the
decision to remove the security restraints from him. At 2.28am it was
confirmed that he had died.
53. He had not been in contact with his family for some years, and the
details held for his next of kin were out of date. The prison staff were
unable to trace any of his family, and so they contacted the local police
to ask for assistance. Eventually, the police found contact details for his
nephew, and news of his death, as well as the prison’s contact details,
were passed to the family by the police a few days later.
54. The prison arranged and paid for his funeral and his family were invited
to attend.
Debrief
55. It is usual following the death of a prisoner for the prison to hold a
debriefing session with staff involved in his or her care. These ensure
that staff have an opportunity to discuss any issues arising, and for
support to be made available. A debrief was held with the prison officers
who had been on bedwatch duty with him when he died. No issues were
raised.
Support for staff and prisoners
56. Notices were posted in the prison informing both staff and prisoners of
his death. They were advised where to seek help if they felt they needed
to.
Post Mortem
57. A post mortem was carried out by a consultant pathologist on 6 July
2010. He concluded that the man’s death was due to:
1a Spontaneous acute intracerebral haemorrhage
1b Bilateral idiopathic adrenal cortical hyperplasia and
hypertension
58. In layman’s terms, he died of internal bleeding in his brain having
suffered a stroke.
12
ISSUES
Clinical care
59. The clinical reviewer notes that the man’s medical history through most
of his sentence was unremarkable. He became unwell through his
hepatitis in 2000, but this seems to have been the only occasion. He
had ongoing issues with sciatica and with high blood pressure, but no
significant health issues.
60. The clinical reviewer addresses the man’s care whilst in Kingston, prior
to his transfer to Garth. Although his comments do not appear to be
relevant to the circumstances of his death, he moved to Garth less than
three months before he died, and so I refer to them in my report. He
notes that there appeared to be some changes in his character after he
sustained a head injury in September 2009. He notes that he
complained to healthcare staff at Kingston of headaches, after having
received a recent head injury. Although he had a known history of high
blood pressure, and occasionally refused his medication, further
investigations were not undertaken at this stage. He recommends that
the Head of Healthcare at Kingston reviews the staff training needs in
relation to Clinical Decision Making and Assessment skills.
61. He also notes that when the man saw the locum prison doctor on 16
December, his blood pressure was very close to the level that the
National Institute for Health and Clinical Excellence (NICE) cites as
potentially dangerous, but again there does not seem to have been any
follow-up. He recommends that the Head of Healthcare at Kingston
ensures staff are aware of the NICE guidance, both generally, and
specifically relating to hypertension.
62. The investigator discussed the clinical reviewer’s recommendations with
the Head of Healthcare at Kingston. She notes that he had complained
of headaches prior to the incident when he hurt his head. She also
pointed out that he saw a doctor on a number of occasions about his
blood pressure and his medication. He refused to comply with his
medication on more than one occasion, and also refused to attend
healthcare for assessments. She said that healthcare staff are aware of
the NICE guidelines, but cannot treat patients against their will. Having
raised these issues with her, I do not make any recommendations but I
draw the clinical reviewer’s report in its entirety to her attention.
63. The man’s clinical records do not indicate whether, before he was
transferred to Garth, he was medically assessed as fit for transfer. This
should be a routine practice for every prisoner transferring to another
prison. The clinical reviewer recommends that the Head of Healthcare at
Kingston reviews protocols for ensuring that prisoners are medically
reviewed prior to transfer. Again, the investigator raised this question
with the Head of Healthcare. She explained that all prisoners transferred
out of Kingston are assessed to establish that they are fit for transfer,
13
and gave examples of instances where transfers have been blocked by
healthcare because someone was considered not fit. Fitness for transfer
is documented on a form which is attached to the front of the sealed
pack containing the medical record, which travels with the prisoner. As
the form is on the outside of the sealed medical record, once the
receiving prison has opened the pack the form may well be discarded
with the packaging. I accept this possibility, and she was adamant that
he would have been assessed before transfer. I once again draw her
attention to the clinical reviewer’s comments, and invite her to consider
whether Kingston should have some way of recording prisoners being
marked fit for transfer. Kingston now has electronic medical records, so
this is something that should be fairly easily achieved.
64. The clinical reviewer notes that, once he arrived at Garth, the care the
man received was at least as good as he could have expected in the
community. On arrival, his condition was noted and acted upon. He was
monitored regularly, and was engaged with and consulted with regards
to his care. Records were well maintained, and care and interventions
were timely and responsive.
65. I have considered whether, bearing in mind how he presented when his
cell was unlocked on 5 March, an ambulance should have been
summoned earlier. He had been unwell for a while, and his symptoms
had not appeared suddenly. He had suffered some incontinence, and
staff showed care for his dignity by cleaning and dressing him while the
doctor was on his way to see him. As soon as the doctor saw him, an
ambulance was called. In the circumstances I think that the actions by
staff were reasonable and that the ambulance was called at the
appropriate time.
66. I have been told that he was a difficult patient for healthcare staff to treat.
He complained of health problems, yet was argumentative and often
would not comply with medication. Notwithstanding the clinical
reviewer’s comments and the Head of Healthcare’s replies, I do not think
that there was more that could have been done for him whilst he was at
Kingston. Once he had arrived at Garth, I agree with the clinical
reviewer that his care was timely and responsive. He was taken to
hospital whenever it was judged necessary, and was monitored whilst in
prison. Refusal to comply with treatment can raise the question of
whether the person was competent to make that decision. He was given
a mental health assessment on 19 January, and no evidence of mental
illness was found. Although it does not seem that his mental capacity
was specifically assessed, I have seen no evidence that he was
incapable of deciding whether or not to accept medical treatment.
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Use of restraints
67. The man was moved to hospital in the late morning of 5 March. He was
security assessed before leaving the prison, and in view of his previous
difficult behaviour it was agreed that he should be subject to physical
restraints by way of an escort chain (a pair of handcuffs with a long chain
attaching the prisoner to a prison officer) and two escorts. Once he
arrived in hospital, his health deteriorated rapidly. Staff from the prison
healthcare remained in contact with the hospital and were kept updated
on his condition.
68. By 9.00pm on 5 March, he was not expected to live much longer. He
was not, however, reassessed as to whether his security should be
changed. In the event, his security restraints were removed just ten
minutes before he died.
69. The investigator has discussed this with the governor who was duty
governor on 5 March. The Governor said that, whilst he was made
aware that he was becoming increasingly ill, he was not made aware of
the seriousness of his condition. At the point when the prison began to
try to contact the family, the duty governor also discussed the security
arrangements with the deputy governor. At this stage, they judged that
the security escort chain was still necessary. Although I am pleased to
see that this was considered, I believe that further security assessments
should have taken place in the hours that followed.
70. It was helpful that prison healthcare staff continued to seek regular
updates on his condition. However he deteriorated rapidly and it
appears that the duty governor was not made aware of how quickly this
was happening, either by the healthcare or the bedwatch staff.
Therefore the security arrangements were not reassessed. When the
officers on bedwatch realised that he was close to the end of his life, they
took the decision to remove his security restraints. Prisons have a
responsibility to protect the public by preventing prisoners from escaping.
By this stage it was clear that he was very poorly and did not present a
risk to the public. The bedwatch staff acted promptly and made their
decision without waiting for management approval. I think that it was a
reasonable and humane decision, and I am pleased that it was
supported by the duty governor when discussed at the debrief.
71. Garth is aware that there was a breakdown in communication through
the night about security assessments. It is most regrettable that he was
not reassessed and allowed more dignified time in his final hours. The
investigator was told that, from now on the duty governor will reassess
security whenever it is requested, or when the prisoner’s circumstances
change. Although it will be of little comfort to his family, I am pleased to
see that this is being acted upon and I recommend that the effectiveness
of this system is kept under review.
15
The Governor should ensure that effective systems are in place to
facilitate regular communication between bedwatch staff and the
prison and that security is regularly reassessed when a patient is in
outside hospital.
Informing the family
72. Over his years in prison, the man had gradually lost contact with his
family. When he went into hospital for the last time, staff began to make
efforts to establish who to contact. Sadly, he died before they were able
to do so. The prison was unable to locate any family, and had to seek
assistance from the police. The family were not therefore informed of his
death until some days after he had died.
73. The situation concerning his next of kin is obviously not ideal, and it
would have been better if the prison had been able to make earlier
contact with his family. However he had been out of touch with his family
for a number of years, the last visit from his family being in 1993.
Although his brother was listed as his next of kin, he was recorded as of
no fixed abode.
74. In a previous report of a death at HMP Garth in 2007, I made a
recommendation about maintaining data for prisoners’ next of kin. It is
not clear whether the prison had made any attempt to update the next of
kin record for him. However I think it likely that, even had the prison
sought to update their records, he would have been unable to provide
details of any next of kin. I do not think it unreasonable, therefore, that
the prison was unable to contact anyone at the time when he died.
Consequently, I do not make a recommendation, but remind the
Governor of my previous recommendation and ask her to consider
whether there are reasonable systems in place to ensure that prisoners’
family details are updated periodically.
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CONCLUSION
75. He was an elderly man who had spent a number of years in the prison
system. He had had some problems with high blood pressure, and had
complained of headaches. Towards the end of 2009, whilst in Kingston,
he injured his head and, in the subsequent months, complained to staff
about headaches. He was, however, a difficult patient for healthcare
staff to engage with, and would sometimes not comply with medicine
prescribed to him.
76. At the beginning of 2010, he was transferred to Garth. At his reception
health screening the day afterwards, his health problems were identified
to the extent that he was taken straightaway to hospital over concerns
about his blood pressure.
77. Over the next few weeks, he continued to complain of headaches and
loss of vision. Like the clinical reviewer, I believe that he was treated
appropriately and referred to hospital on several occasions. He was
largely located in the healthcare centre when back in prison.
78. In early March, his health took a turn for the worse. He was still not
complying with his medication and treatment, but I judge that staff did
their best to look after him. During the night of 5 and 6 March, he
became quite unwell, and was confused and disorientated. In the
morning the prison doctor sent him to hospital.
79. His security was assessed. An escort chain was put in place and he was
accompanied by two prison officers. The restraints were removed while
he received medical treatment, and replaced afterwards.
80. That afternoon it was became known that he might have suffered a
stroke. Prison staff began to try to contact his family, but because of the
number of years that he had been out of contact, found this a difficult
task.
81. His condition continued to deteriorate. He had suffered a large bleed to
the brain, and was not expected to live much longer. He began to have
trouble breathing, and an oxygen mask was provided. Painkillers were
administered at 1.30am and at 2.18am the bedwatch officers decided to
remove the escort chain. His death was confirmed ten minutes later.
82. It appears that he received good medical care whilst in Garth. Any
problems were identified and addressed, even though he was not always
the easiest patient to deal with. The only issue identified relates to
security assessments when prisoners are in hospital. The prison has
already identified this, and my single recommendation seeks to ensure
that the changes put in place prove to be effective.
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RECOMMENDATION
The Governor should ensure that effective systems are in place to facilitate
regular communication between bedwatch staff and the prison and that
security is regularly reassessed when a patient is in outside hospital
The National Offender Management Service has accepted this
recommendation. The Head of Security will revise current systems to ensure
that once bedwatch staff have been advised that a patient is in the last stages
of his life the cuffing arrangements are reviewed. It is intended that this
should be in place by 31 May 2011.
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