Individual at Bristol

Investigation into the circumstances surrounding the
death of a male prisoner
at HMP Bristol in January 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2010
This is the report of an investigation into the death from natural causes of a male
prisoner at HMP Bristol on 7 January 2010.
I extend my sincere condolences to the man’s family and friends and all those
affected by his loss.
This investigation was undertaken by an investigator from my office. I should like to
thank the Governor of Bristol, and his staff for their co-operation. A clinical review of
the man’s care and treatment has been carried out by a doctor from Bristol Primary
Care Trust.
The man died suddenly and unexpectedly. He died from a subarachnoid
haemorrhage following the rupture of a cerebral aneurysm (this condition is
explained later on in my report). The clinical reviewer found that it would not have
been possible to anticipate the haemorrhage that caused the man’s death.
I make three recommendations. Two concern the likely needs of the cell-mate
following a death in custody.
Jane Webb
Acting Prisons and Probation Ombudsman October 2010
2
CONTENTS
Summary 4
The investigation process 5
HMP Bristol 6
Key findings 7
Issues 11
Conclusion 14
Recommendations 15
Meeting with the man’s family after issue of the draft report 16
3
SUMMARY
The man arrived in HMP Bristol on 9 December 2009. He had been sentenced to
just over four months imprisonment for driving offences.
During healthcare reception screening at Bristol, the man denied having any health
problems and also said that he was not registered with a general practitioner. The
nurse’s own assessment of the man was that he appeared fit and healthy.
The man had several contacts with healthcare in early January 2010. He reported to
a nurse that he was feeling discomfort from an old leg injury and an appointment was
made for him to see a doctor. On a separate occasion he reported pain from a
dental abscess and difficulty sleeping. He was prescribed antibiotics, paracetamol
and sleeping tablets.
The man’s cell-mate said that the man would often ask night staff to leave on the in-
cell night light. He would ring the cell bell later on in the night for the light to be
switched off. This is what he did on the night of 6 January.
At about 5.45am on 7 January, the night staff, who were carrying out a routine roll
check, looked into the man’s cell. The man was lying on the floor and his cell-mate
was in bed. The staff tried to rouse the prisoners but neither responded. (The man’s
cell-mate has hearing difficulties and had removed his hearing aid upon going to
bed.) It was not entirely clear to staff whether it was an emergency situation so they
called a senior member of staff. He arrived a few minutes later and also tried,
without success, to obtain a response from the prisoners. Staff then went into the
cell and found that the man’s breathing was laboured. An emergency call was
issued and a healthcare nurse responded.
An emergency ambulance had also been called and the paramedics arrived at just
after 6.10am. The man was then taken to hospital where he was placed on a life-
support machine. Following examinations, it became apparent that the man would
not survive. Life-support was maintained pending the arrival of his family. At post
mortem, the man’s cause of death was found to be subarachnoid haemorrhage
following the rupture of a cerebral artery aneurysm.
4
THE INVESTIGATION PROCESS
1. The Ombudsman’s appointed investigator first visited HMP Bristol on 5
February 2010 when he met the prison’s Deputy Governor and the Head of
Operations. The investigator did not carry out any formal interviews with staff
but he did speak with several people during his visit, including the head of
healthcare. He also spoke by telephone with the man’s former cell-mate.
2. Bristol Primary Care Trust agreed to carry out a review of the man’s clinical
care and treatment at Bristol and I am grateful to the clinical reviewer for his
report.
3. Upon his initial arrival in Bristol, the man named his ex-wife as his principal
family contact. One of the Ombudsman’s Family Liaison Officers telephoned
both the man’s ex-wife and his father to explain the investigation process and to
give them the opportunity to raise any issues or concerns they wished to be
considered. The man’s ex-wife and father both wanted to know why the man
rang his cell bell at just after midnight on the night before his death. Both also
wanted an explanation of the sequence of events when the man was observed
to be lying on the floor of his cell. I hope my report answers the family’s
questions.
5
HMP BRISTOL
4. HMP Bristol is a 19th century local prison holding just over 600 prisoners. It
receives adult male prisoners and a limited number of young offenders, both
convicted and remand, from all local courts. It also serves as a category B
facility for the West of England. (A category B prison holds prisoners for whom
the very highest conditions of security are not necessary, but for whom escape
must be made very difficult.)
5. The most recent inspection of Bristol by Her Majesty’s Chief Inspector of
Prisons, was an unannounced short follow-up inspection in March 2008. She
found that Bristol had improved since the time of the previous inspection,
although she also found that there remained a need for further improvement in
a number of areas such as opportunities for purposeful activity.
6. All prisons in England and Wales have an Independent Monitoring Board (IMB).
IMB members are volunteers who monitor day-to-day life in the prison to help
ensure proper standards of care and decency are maintained. In its report for
the year from 1 August 2008 to 31 July 2009, the Independent Monitoring
Board (IMB) at Bristol wrote in a chapter about its overall assessment of the
prison that:
“… HMP Bristol has generally improved over the reporting period. The
prison has Level 3 status (one below the highest level) and is striving to
move to the next stage. The Board is confident that, in a spirit of challenge
and partnership, when the concerns in this report are addressed fully the
prison should improve further.”
7. Since my office took over responsibility for investigating all deaths in prison
custody in 2004, there have been 20 deaths attributed to natural causes at
Bristol up to and including the man’s death.
6
KEY FINDINGS
8. The man arrived in Bristol on 9 December 2009 having been sentenced at court
to four months and four days imprisonment. As part of the standard prison
reception process the man was seen by a nurse for a health screening
assessment. The man reported being a heavy drinker, although he declined an
offer of assistance with this. He said he was not registered with a general
practitioner and denied having any health problems. He also denied having
ever misused drugs. Nothing was recorded about the man declaring any drug
allergies. The nurse’s own assessment of the man was that he appeared “fit
and healthy”.
9. Another aspect of prison health provision is a follow-up secondary health
assessment within one week of the initial assessment. The man declined to
have a secondary assessment. He was advised to contact a nurse if he had
any health problems.
10. The man did not have a prison job and nor did he go to education. However,
the man’s cell-mate, told my investigator that he would come out of his cell at
association times and was on friendly terms with other prisoners.
11. On 2 January 2010, the man saw a nurse to report discomfort in his leg. He
told the nurse that he had had a skin graft about two years previously following
an injury to his shin. The nurse examined the man’s leg and noted that the
area was “inflamed and hot to touch”. The nurse made an appointment for the
man to see a doctor.
12. Two days later, the man had a consultation with one of the prison doctors about
a separate matter. The man reported having a dental abscess, although he
said he had pierced the abscess himself the previous night. The man was “not
keen” to see a dentist, but would like antibiotics. He also reported trouble
sleeping since coming into prison. The doctor prescribed sleeping tablets
(zopiclone) and a course of antibiotics (metronidazole) for the dental abscess.
The doctor also noted the man telling him that he was getting into trouble for
ringing his cell bell at night. The report of the consultation makes no mention of
the man’s symptoms from two days previously when he was experiencing
discomfort in his leg.
13. On the following day, the man had a consultation with another of the prison
doctors. The doctor prescribed 32 paracetamol tablets, although she made no
note about the man’s medical complaint that day, nor about her reason for
prescribing medication. She did note that the man should take one or two
paracetamol tablets, four times per day when required. The doctor
subsequently told the independent clinical reviewer, that she had written the
prescription for dental pain.
14. The man’s cell-mate, has hearing difficulties and wears a hearing aid. The cell-
mate told the investigator that he and the man got on well together. He said
that for about the last ten days before his death the man had complained of
headaches but nurses “fobbed him off with aspirin”.
7
15. My investigator spoke with Bristol’s healthcare manager about procedures
allowing nurses to dispense un-prescribed medication (known in the prison as
‘special sick’). The healthcare manager said that nurses can prescribe up to
three days worth of ‘special sick’ medication for conditions such as headache or
toothache. After that, the prisoner must be seen by a doctor. Prisoners can
report ‘special sick’ either during drug dispensing rounds or can inform an
officer who will ask a nurse to call into the wing. All medication dispensed
through the ‘special sick’ process should be recorded in the prisoner’s clinical
records. The man’s records contain no reference to him being issued with any
‘special sick’ medication.
16. The man’s cell-mate also told my investigator that the man had been getting
into trouble for ringing his cell bell at night. He explained that staff usually
switched off the in-cell night light at around 11.30pm each night. The man
would often ask for the light to be left on at that stage and would ring the cell
bell an hour or two later to ask for the light to be switched off. The cellmate
said that it was at about 1.15am on 7 January, that the man rang the cell bell for
the night light to be switched off. The cellmate fell asleep shortly after that.
(The records show that the cell bell was in fact activated at 0.53am – not
1.15am as the cellmate thought – and was answered one minute later.) The
cell-mate said that later in the night he heard the man making “weird breathing
noises”. This was at about 3.00am. Although the cell-mate said that he now
felt guilty for not doing anything, he had not realised at the time that there was
anything to worry about.
17. From around 5.30am, an officer and an officer support grade began to carry out
the final roll check of the night shift before arrival of the day staff. The officer
reached the man’s cell at around 5.45am and on looking into the cell saw him
lying face down on the floor. The officer knocked on the door and shouted out,
but got no response from either prisoner (the man’s cell-mate, who was in the
top bunk, was sleeping and was not wearing his hearing aid). The officer called
to his colleague and he came across from the other side of the landing. They
tried once more to get a response from the two prisoners, but again without
success. In their statements, both members of staff mention that the man was
making “strange noises”.
18. The staff called for the attendance of the night orderly officer. They were not
certain that it was necessarily a medical emergency at that stage. When the
night orderly officer arrived he went into the cell and tried to get a response
from the man by shouting and shaking him. The night orderly officer then
noticed some blood on the floor and issued a ‘Code Red’ emergency alarm.
This was issued at 5.50am. (A ‘Code Red’ alarm indicates that a prisoner is
bleeding and that healthcare attendance is needed.) Although the man did not
respond to the night orderly officer’s efforts, he was breathing unaided.
19. At night time in Bristol, nurses do not carry keys so if they are required to attend
to a prisoner they must be escorted to the wing. When the nurse on duty heard
the Code Red call she collected the emergency equipment pending arrival of
the assistant night orderly officer. When the nurse arrived at the cell she
8
examined the man and found that his breathing was laboured and he had a
rapid pulse. The man’s blood oxygen saturation1 was low so the nurse gave
him oxygen. She also asked the night orderly officer to call an ambulance. The
nurse used a torch to check the man’s pupils and from their appearance
thought it likely that there was bleeding in his brain.
20. The call to the ambulance service was made at 6.00am and the ambulance
arrived 12 minutes later. After they had examined the man, the paramedics
decided that he needed to be taken to hospital.
21. The man was of a large build. He was about six feet tall and weighted around
19 stones. As he needed to be taken down four flights of stairs the only safe
option was thought to be to use a ‘motorised evacuation chair’. (This is an
electrically powered chair with wheels that can negotiate stair ways.) The
assistant night orderly officer told my investigator that he collected the chair and
the man was strapped in. Unfortunately, when staff attempted to use the chair
it could not be used properly due to the steepness of the stairs and the
cramped layout. Staff decided, instead, to physically carry the man with him
remaining in the chair. He was carried by three officers and one paramedic.
22. The ambulance was timed as leaving the prison at 7.05am. The man was
accompanied by two prison officers but no cuffs or other restraints were
deemed necessary.
23. Staff at the prison checked the man’s records for details of his next-of-kin and a
possible name and address were identified. This turned out to be the man’s ex-
wife and the mother of his children. Due to the urgency of the situation, prison
staff telephoned the number listed, but without success. Travel conditions were
poor that day following heavy snow fall, so the prison asked the local police to
help. Police officers visited the man’s ex-wife at her home to inform her of the
news. By this time hospital staff had already explained to the prison that the
man’s death was inevitable but he was being kept alive artificially pending the
arrival of his family.
24. The man’s ex-wife went to the hospital with other family members and they
were met there by a trained family liaison officer, and one of Bristol’s chaplains.
Bristol then withdrew all its staff from the hospital to allow the man’s family to be
alone with him in his final few hours. The man died in hospital at 4.30pm.
25. The prison held a hot debrief the following morning to consider the events of the
previous day. A member of the prison care team attended the meeting and
staff were informed of the support available from that team.
26. At post mortem, the man’s death was found to have been caused through a
subarachnoid haemorrhage which was secondary to a cerebral artery
aneurysm (bleeding into the brain following the rupture of a blood vessel).
1 Oxygen saturation is the amount of oxygen circulating in the bloodstream. Normal saturation levels
are between 95 to 100 percent. the man’s saturation was 55 percent when first checked and
fluctuated between 89 and 93 percent with oxygen.
9
27. Bristol’s Head of Operations, made further contact with the man’s family to offer
support with funeral arrangements and expenses. The family came into the
prison and visited the man’s cell. The same chaplain said a prayer at the cell.
The family met the man’s cell-mate, and he gave them a condolences card that
had been signed by a number of the prisoners. The man’s property was also
handed to the family. There was further contact between the prison and the
family during the course of the following weeks and the chaplain conducted the
man’s funeral.
28. The investigator asked the head of operations about the actions of the officer
and the officer support grade when they first discovered the man. In particular,
whether they should have gone into the cell straight away without waiting for
the night orderly officer to attend. The head of operations said that the staff
acted correctly in first calling for senior support. This was because there were
two prisoners in the cell and the situation with the man was initially unclear.
This was especially so because some prisoners choose to sleep on the floor
rather than on their beds. (All prisons have contingency plans dealing with
entry of cells at night time. Ordinarily, staff should only enter a cell in the case
of an emergency and before entering must consider the potential risks and
dangers of doing so.) The investigator also asked the head of operations
whether the night staff could recall why the man pressed his cell bell earlier in
the night. The head of operations said that the night staff could not recall the
reason.
29. When the investigator spoke with the man’s cell-mate, he said that he was
dissatisfied with his treatment following the man’s death. He said he was not
offered counselling, all that he received was some sleeping tablets, and not
even a sufficient number of those. In addition, when after five days he was
eventually allowed back in the cell, it had not been cleaned.
30. The investigator asked the healthcare manager about support offered to cell-
mates following a death in custody. The healthcare manager said cell-mates
are offered mental health support and that might include a transfer to
healthcare. After that, ongoing support is provided according to their needs.
10
ISSUES
Clinical care
31. The man died from a subarachnoid haemorrhage which was secondary to a
ruptured cerebral artery aneurysm. A cerebral aneurysm is the bulging out of a
weak or thin point of a blood vessel in the brain. The aneurysm will not
necessarily rupture and an un-ruptured aneurysm may go unnoticed throughout
a person’s lifetime. Similarly, most cerebral aneurysms remain unnoticed until
or unless they rupture. Where the aneurysm does burst it will cause bleeding
into the surrounding tissue. This bleeding is called a haemorrhage. A
subarachnoid haemorrhage is where the bleeding is into the space between the
skull and the brain. The prognosis for people whose aneurysm has ruptured
largely depends on factors such as the age and general health of the individual,
the location of the aneurysm, the extent of bleeding and the time between the
rupture and medical attention. It is thought that around 40 per cent of patients
whose aneurysm has ruptured do not survive the first 24 hours.
32. The clinical reviewer considered whether the man’s collapse could have been
predicted. He explained that the early symptoms of a subarachnoid
haemorrhage may include an extremely severe headache, vomiting, neck
stiffness and weakness. The clinical reviewer points out that there is no
evidence of the man having these early symptoms. Instead, the post mortem
findings indicate a sudden, devastating and un-survivable haemorrhage leading
to a rapid collapse and death.
33. The man’s cell-mate, said that the man had been suffering with headaches for
around ten days before his death. The man’s cell-mate said that the man
complained to nurses and they responded by giving him aspirin. The
healthcare manager told my investigator that nurses are able to dispense
medication without prescription for complaints such as headaches. However,
this can only be done for up to three days and any such medication should be
noted in the prisoner’s records. The man’s records contain no such entries.
34. The man did have contact with clinicians in the days leading up to his death.
On 2 January (five days before his death), he saw a nurse to report discomfort
from an old leg injury. There is no record that he also reported a headache.
On 4 January (three days before his death), the man saw a doctor to report a
dental abscess and he asked for antibiotics. He also reported trouble sleeping
since arriving in custody. The doctor wrote prescriptions for antibiotics and
sleeping tablets. Again, there is no record that the man reported a headache.
On the following afternoon (less than two days before his death), the man was
prescribed paracetamol. But this, it seems, was for toothache. There is no
obvious explanation why the man’s cell-mate would falsely report that the man
had suffered with headaches in his final ten days, but the documented evidence
is clearly at variance with what the man’s cell-mate has said.
11
35. The clinical reviewer’s overall conclusion was that the man’s death could not
have been predicted. He made one recommendation which I have adopted and
adapted into a recommendation of my own:
The healthcare manager should remind staff of their responsibility to
document all contacts, particularly where prescribing occurs, in
accordance with the standards of the General Medical Council and the
Nursing and Midwifery Council.
The man’s use of the cell bell
36. The man’s ex-wife, as well as his father, both asked for clarification about the
man’s reasons for pressing his cell bell on the night of his death and whether
staff responded appropriately. The records show that it was at 0.53am that he
rang the cell bell and the bell was answered one minute later. The staff on duty
that night could not recall why the man had pressed his cell bell. The man’s
cell-mate told my investigator that it had been the man’s practice to ask staff to
leave the night light on and to ring the cell bell later when he wanted the light
switched off. He said that this is what happened on that particular night.
37. The man himself mentioned to one of Bristol’s doctors that he was getting into
trouble with staff for ringing his cell bell at night. Cell bells should only be used
in the case of an emergency so I would expect a prison to take action if a
prisoner was misusing his cell bell. If a prison fails to take appropriate action,
abuse of the system will lead to confusion among prisoners about when they
should or should not use the bell. This might also lead to mixed messages from
staff with some officers attempting to control the abuse and others condoning or
at least allowing it to continue. Much more importantly, staff may cease to
respond promptly to bells if they believe that it is likely to have been used for a
trivial reason. The Governor might wish to consider usage of the cell bell
system by prisoners and how abuse of the system is dealt with by staff.
The response when the man was found
38. The officer and the officer support grade were conducting the early morning roll
check on A wing when they saw the man lying on the floor in his cell. The time
was 5.45am. The staff tried to obtain a response from the man or his cell-mate,
but neither responded (the man’s cell-mate has hearing difficulties and had
removed his hearing aid to sleep). The staff called for the attendance of the
night orderly officer, who arrived a few minutes later. When he attended he
unlocked the cell and it was only then that staff realised that it was a potential
emergency and that support from healthcare was needed.
39. Only one of the two members of staff who first attended the man’s cell was a
fully trained officer. There were two prisoners in the cell and the situation with
the man was unclear. It was entirely appropriate therefore for the staff to call
for senior assistance rather than to go into the cell at that stage.
12
Asking the police to contact the man’s family
40. When it became clear that the man was unlikely to survive, the prison realised
that his family needed to be contacted swiftly. The man had not identified any
next-of-kin when he came into the prison, but a likely person was identified from
checking his letters and telephone records (this person turned out to be his ex-
wife). Due to the urgency of the situation, combined with poor travelling
conditions caused by heavy snow falls, Bristol first tried to make contact by
telephone. When this proved unsuccessful, the local police were asked to help.
Police officers visited the man’s ex-wife’s home to inform her about what had
happened. This allowed her to attend the hospital with other family members
and to be with the man for the final few hours of his life. I consider that Bristol
deserves to be commended for its swift, thoughtful, pragmatic and
compassionate approach.
Support for the man’s cell-mate
41. The man’s cell-mate complained to my investigator about the lack of support
following the man’s death. He said that he was issued a small supply of
sleeping tablets, but no counselling. I understand from the evidence of the
healthcare manager that mental health support is offered to cell-mates following
a death in prison. The man’s cell-mate also complained that when he was
moved back to the cell, which was some days after the man’s death, the cell
had not been cleaned. There was still blood on the cell floor and the toilet had
not been cleaned. I am certain that the failure to clean the cell was an
inadvertent oversight, but that will be of no consolation to the man’s cell-mate.
I recommend that the Governor assure himself that arrangements are in place
to ensure appropriate support is offered to cell-mates following a death in
custody.
I recommend that the Governor assure himself that appropriate arrangements
are in place to ensure that cells are cleaned adequately following a death in
custody.
13
CONCLUSION
42. The man appeared fit and well apart from minor ailments. Unfortunately, he had
an undiagnosed cerebral artery aneurysm that ruptured at some time in the
early hours of 7 January 2010. The rupture resulted in an extensive
subarachnoid haemorrhage which the clinical reviewer has said was un-
survivable.
14
RECOMMENDATIONS
The following recommendations were made in the draft version of this report. The
service’s response is included in italics following each recommendation.
1. I recommend that the Governor assure himself that arrangements are in place
to ensure appropriate support is offered to cell-mates following a death in
custody.
Service response: Recommendation accepted and action completed. This now forms
part of the Death on Custody contingency plans.
2. I recommend that the Governor assure himself that appropriate arrangements
are in place to ensure that cells are cleaned adequately following a death in
custody.
Service response: Recommendation accepted and action completed. This now forms
part of the Death on Custody contingency plans.
3. The healthcare manager should remind staff of their responsibility to document
all contacts, particularly where prescribing occurs, in accordance with the
standards of the General Medical Council and the Nursing and Midwifery
Council.
Service response: Recommendation accepted and action completed. A reminder has
been issued to all staff.
15
MEETING WITH THE MAN’S FAMILY AFTER ISSUE OF THE DRAFT REPORT
In accordance with set procedures, copies of the report were sent in draft form to the
man’s family as well as to the Prison Service and HM Coroner.
The man’s father requested a meeting to discuss the draft report and he was visited
by the investigator and another of my family liaison officers. The man’s brother was
also at the meeting. The man’s father said that as a child, his son had been allergic
to aspirin. It concerned him therefore that his son might have been given aspirin by
the nurses; as was suggested by his son’s cell-mate. He wondered whether aspirin
could cause an aneurysm to rupture.
Following the meeting, the investigator asked the clinical reviewer for his comments.
The clinical reviewer said that aspirin will lead to a slowing in the clotting process so
wounds or injuries tend to "ooze" for longer. Aspirin can therefore lead to a more
prolonged bleed. However, aspirin would not precipitate (or cause) a bleed the
clinical reviewer also pointed out that there was nothing in the man’s clinical records
about him having an allergy or intolerance to aspirin. Nor is there any evidence that
the man was ever given aspirin. The man was prescribed paracetamol, but the
clinical reviewer advised that this drug has no effect on the clotting or bleeding
process.
16