Individual at Isle of Wight

Investigation into the death of a man
at HMP Isle of Wight in January 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2011
This is the report of an investigation into the death of the man. The man died in his
cell at Parkhurst, HMP Isle of Wight in January 2010, following a serious of seizures.
He was 24 years old.
I extend my condolences and those of my colleagues to his family. I hope that my
report goes some way to answering some of the questions I know they have raised.
I must also apologise for the delay in completing my report.
The man’s death was investigated by one of my senior investigators and one of my
family liaison officers. The clinical reviewer on behalf of Isle of Wight Primary Care
Trust, provided a clinical review of the man’s healthcare treatment during his time in
Parkhurst. I am grateful for his report which is annexed to this report.
My investigation raises a number of issues with regard to the healthcare provided to
the man on the night he died and I make a number of recommendations in respect of
this. However, I appreciate that many of the decisions taken by staff were made with
extreme weather conditions in mind.
The first post mortem into the man’s death was inconclusive. His seizures were
possibly caused by a pre-existing brain injury. It is thought these were caused by a
previous head injury which may have been sustained from one of two incidents that
occurred whilst the man was at HMP Brixton, some months before he transferred to
the Isle of Wight. Subsequent neurological examinations confirm that his head was
injured in the months and years before he died and that the injuries were a factor in
his death. However, due to the lack of documentation my report raises further
questions about what happened at Brixton and which, regrettably, I am unable to
answer.
I will send a copy of this report to the Governor of Brixton as well as to the Governor
at the Isle of Wight.
The 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
Deputy Ombudsman May 2011
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CONTENTS
Summary
The Investigation Process
HMP Isle of Wight - Parkhurst
Key Events
Issues
Conclusion
Recommendations
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SUMMARY
Convicted on 25 January 2007 for a number of serious offences, the man was
returned to the custody at HMP Brixton where he had spent the majority of his time
on remand.
On 1 May 2008, the man told staff that he had been assaulted by two prisoners who
came into his cell and slapped him across the face. He was seen by a nurse who
recorded that there were no signs of injury and no further treatment was required.
The man did not tell staff the names of those involved. He was moved to another
wing for his own safety.
Approximately two months later, the man was found unconscious in his prison cell.
The prison doctor recorded that he had bruising around both eyes and had suffered
bleeding to his nose. The man was semi-drowsy and uncooperative, and was
immediately taken to Kings College Hospital. He was deemed fit for discharge from
the hospital later that day. Although he had been admitted due to a suspected drugs
overdose, the discharge letter recorded that there was no indication that this was the
case. Over the following days, he man was observed by healthcare staff as
confused, withdrawn and disorientated.
No further significant entries were made in the man’s prison record and he remained
at Brixton for another year until he transferred to HMP Isle of Wight, Albany, on 8
July 2009. (In 2009, HMP Albany, HMP Parkhurst and HMP Camp Hill were joined
operationally as a cluster of prisons known as HMP Isle of Wight.) On his arrival at
Albany, no specific medical issues were highlighted.
On 24 September, the man had a seizure and was taken to St Mary’s Hospital on the
Isle of Wight which is next door to the prison. No cause for the seizure was identified
and he returned to the prison later that day. One of the conditions which was
considered as a possible diagnosis was sickle cell anaemia, which is more prevalent
in people like the man who are of African or Caribbean descent. A few days later the
man was seen by the prison doctor who referred him to a consultant neurologist at St
Mary’s. Although there is evidence that the referral letter was received, no
appointment was subsequently made. My investigator was told that this was due to
a long waiting list at the hospital and limited resources to escort prisoners to
appointments.
The man was reported to have suffered another seizure on 4 November. One of the
prison doctors made arrangements for an urgent brain scan. This took place on 10
November at St Mary’s, but the results were inconclusive.
On 21 December, the man was transferred from the Isle of Wight Albany site, to the
Parkhurst site for reasons of safety. On his arrival at Parkhurst he was assessed by
a member of the healthcare team. It was reported that he was fit and well but
wanted to see a doctor as he was experiencing some pain in his right arm.
During the evening of 5 January 2010, the Isle of Wight experienced, what was
described as, the worst snow fall for 30 years. This caused extreme difficulty for
travel on the island, with many roads closed.
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In the early hours of the following day the man suffered what was to be the first of a
series of seizures which eventually led to his death. An Operational Support Grade
officer went to his cell. He contacted and received guidance from a nurse based in
the healthcare unit of the Albany site. When the man’s condition deteriorated over
the following hours, he was attended by one of the prison doctors, who due to the
adverse weather conditions had been trapped at St Mary’s Hospital, a short distance
from the prison. Despite attempts by the doctor, staff, and paramedics to treat the
man, he died before his transfer to the accident and emergency department at St
Mary’s could be facilitated.
My investigation identifies concerns about transferring records when prisoners move
from one prison to another. I also comment on the health care provided for prisoner
with seizures and abnormal test results. I am concerned about the arrangements in
place for booking outpatient appointments and the availability of escort staff to
facilitate these appointments. Consideration should also be given to the location of
emergency equipment and also to the health care arrangements during the night.
Finally I comment on the policy for staff to go into a cell at night and the
arrangements for telling the family that their relative has died.
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THE INVESTIGATION PROCESS
1. One of my investigators from my office, carried out the investigation into the
man’s death. Notices announcing the investigation and its terms of reference
were issued to both staff and prisoners at HMP Isle of Wight, Parkhurst site.
The notices were displayed around the prison and invited staff and prisoners to
contact the investigator with any information relevant to my investigation.
2. The man obtained documentation relating to the time that the man spent at
Parkhurst and visited the prison to interview staff. He also spoke with the man’s
cellmate. During the course of the investigation, my investigator provided
feedback to the controller of Parkhurst.
3. My investigator also liaised with Parkhurst’s Independent Monitoring Board
(IMB). (IMB members are independent and unpaid. They monitor day-to-day
life in the prison to ensure that proper standards of care and decency are
maintained.) The Prison Officers Association was made aware that an
investigation into the man’s death was being completed. My investigator also
liaised with a Detective Sergeant (DS) from Hampshire Constabulary, acting on
behalf of the coroner. My investigator was in contact with the Coroner’s office
and a copy of this report will be sent to Her Majesty’s Coroner for the Isle of
Wight, to assist him with his enquiries. A copy of this report will also be sent to
the National Offender Management Service.
4. My investigator also asked for information relating to the man from HMP Brixton.
Despite my investigator contacting Brixton prison on several occasions, the
prison was not able to produce all of the information requested. Therefore my
investigator drew from limited medical records, incident reports and observation
logs to describe what happened to the man during his time at Brixton. A copy of
this report has also been sent to the Governor of Brixton. In response to the
draft report Brixton produced a number of additional documents relating to the
man’s time at the prison. Following receipt of this information and feedback from
the National Offender Management Service several amendments have been
made to the draft report.
5. A clinical review was undertaken on behalf of the Isle of Wight Primary Care
Trust (PCT) by the clinical reviewer, consultant in public health. He was assisted
in undertaking his review by a panel appointed by the PCT. Together with my
investigator, the clinical reviewer conducted interviews with some of the staff
who provided care to the man during his time on the Isle of Wight.
6. As part of the investigation, confirmation was sought from the man’s general
practitioner (GP) in the community as to whether there was history of the man
suffering from seizures or epilepsy. The man’s GP confirmed that there was no
previous history and that the man only went to his practice once, complaining of
abdominal pain.
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7. One of my family liaison officers contacted the man’s mother, as his next of kin,
to discuss the purpose and scope of the investigation and give her the
opportunity to raise any questions or issues she had about his death. My
investigator and my family liaison officer met the man’s mother and other
relatives who raised the following concerns:
• Whilst in Brixton, the man was physically attacked by another
prisoner. His family told my family liaison officer that, although the
man reported this to the prison authorities, no action was taken.
The man’s mother was concerned that the man may have been
subject to bullying at both Brixton and Albany prisons.
• The man’s mother said that, whilst in Brixton, the man was admitted
to hospital for a week. She expressed her concern about not being
informed of this by the prison.
• Despite his epilepsy diagnosis in November 2009, the man did not
attend a scheduled hospital appointment on 21 December.
• The man’s family also raised a number of additional concerns about
the sequence of events in the early hours of 6 January 2010,
specifically the lack of urgency in responding to the man and the
delay in requesting an emergency ambulance. They feel strongly
that the man could have survived had he received more immediate
medical attention.
8. I hope that this report helps clarify the family’s concerns and any other issues
that remain unclear, helping them to better understand what happened to their
son and the healthcare he received in custody.
The man’s mother and her legal representative received a copy of my draft
report. No further representations were made in response to the findings,
their preference being to raise matters directly with the Coroner at the inquest.
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HMP ISLE OF WIGHT - PARKHURST
9. HMP Isle of Wight was inaugurated on 1st April 2009. It is the organisational
amalgamation of the former Albany, Camp Hill and Parkhurst prisons. The three
sites are roughly equal in size, with a total operational capacity of just under
1,700 places. The prison governor took up post following the amalgamation.
Each site has its own director, who reports to the governor. Before his death the
man lived on both the Albany and latterly Parkhurst sites.
10. Parkhurst was a high security prison until the mid 1990s, when it was converted
to its current role. It now caters for long-term and life sentence category B
prisoners and remand prisoners from the Isle of Wight courts. Parkhurst has five
wings.
11. Health services at HMP Isle of Wight are commissioned by the Isle of Wight
Primary Care Trust (PCT) and healthcare at Parkhurst is clustered with both
Albany and Camp Hill. There are three nurses on duty at Parkhurst from 7.30am
to 6.00pm from Monday to Friday. General Practitioners (GPs) from a local
community practice attend Parkhurst for four three-hour sessions each week.
Evenings and weekends are covered by on call GPs from the same community
practice. Prisoners with more serious conditions or clinical needs are referred to
the local hospital. (Beacon Healthcare provides the current general practice
contract for the Isle of Wight prison healthcare.)
12. A new inpatient healthcare centre was completed and opened in October 2009
and is situated on the Albany site. Previously the healthcare centre for the three
prisons was situated on the Parkhurst site. During the night, a nurse is based in
the healthcare centre on the Albany site. Although unable to leave the
healthcare centre to attend to the needs of prisoners in Albany or either of the
other sites, the nurse can give medical advice over the telephone to staff on any
of the three Isle of Wight sites.
13. The last full inspection of Parkhurst by Her Majesty’s Chief Inspector of Prisons,
was in December 2008, which is before the prisons were clustered and whilst
Parkhurst had its own inpatient unit. In her report Her Majesty’s Chief Inspector
of Prisons commented that “Health services were unacceptably weak” at
Parkhurst. On the provision of healthcare at the prison. She wrote:
“Staffing levels in primary [health] care and inpatients were minimal, and there
were vacancies across the cluster. This resulted in a limited health service for
prisoners. There was only one member of the health services team on duty at
night, based on the inpatient unit [a new inpatient unit has now opened at
Albany], who was expected to attend to incidents at Parkhurst and provide
telephone advice to staff at Albany and Camp Hill.”
14. The Chief Inspector’s team were also shown evidence of several breaches of the
NHS standard of a maximum 18-week wait from first referral to consultation with
a secondary care provider. Appointments were cancelled by the prison due to
lack of staff and by the hospital for a variety of reasons.
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15. The Inspectorate returned to the Isle of Wight in October 2010 and their most
recent report is awaited. I understand that the Inspectorate remains concerned
about healthcare at the prison and have some concerns about the level of
healthcare cover outside of the core day.
16. The man’s death is the eighth natural cause death to have occurred at the
Parkhurst site since the Ombudsman took on the responsibility for the
investigation of deaths in custody in April 2004. However, there appears to be
no similarities with regard to these deaths and that of the man.
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KEY EVENTS
17. On 25 January 2007, the man was convicted of multiple serious offences. He
was sentenced to 14 years imprisonment, which was later reduced to 12 years.
After conviction, he was held at HMP Brixton, where he had spent the majority of
his time on remand.
18. On 1 May 2008, the man approached a senior officer to say he was being bullied
because two mobile phones had been found in his cell the previous day. He told
staff that two prisoners had entered his cell and slapped him several times
across his face. The man was seen by a nurse who recorded that there were no
signs of any injury or that he was suffering from any discomfort. The nurse
noted that no further treatment was required. Officers placed the man on victim
support and Rule 45 (at his own request), and he was also moved to a different
wing. (Rule 45 is when a prisoner is segregated from other prisoners, either for
disciplinary reasons or for their own protection. Victim support is used to support
those who experience bullying.) However, the man would not name the
prisoners involved in the incident and as the perpetrators could not be identified
no further action was taken.
19. One of the prison doctors wrote in the man’s medical record that the man had
been found unconscious and in a drowsy state in his cell. However, the wing
observation book contradicts the doctor’s record of events. It records that staff
responded to the man after he had been heard shouting for assistance. In the
medical notes the doctor records that the man had suffered bruising around both
eyes and was bleeding from his nose. The doctor noted that staff had observed
the man as having what he described as three, “vacant attacks” and that he was
semi drowsy and uncooperative. It was also noted that the man had a
superficial laceration below his left ear. At 12.40pm, as a consequence of his
presentation, the man was admitted to the accident and emergency department
of King’s College Hospital. It was recorded in the orderly officer’s observation
log that the man had been admitted to hospital due to a head injury and a
suspected overdose. The man returned to the prison at 6.00pm, returning to his
cell on C wing.
20. A discharge letter from King’s College Hospital, written the same day, reported
that the man had allegedly taken an overdose. However, it reported that his
paracetamol and salicylate levels (a measurement of aspirin in the body) were
normal. He was deemed fit for discharge from hospital, but the hospital doctor
advised that he would require a psychological assessment. No other significant
information was recorded on the discharge letter.
21. Two days later, on 26 July, the man was further assessed by the doctor. He
noted that the man appeared confused and withdrawn. He reported that the
man had urine soaked clothes, stared into space, and ignored all speech
directed toward him. The doctor encouraged him to attend to his personal
hygiene. The man was asked if he was okay and he replied that it was a
“personal matter”. There is nothing recorded to suggest that further enquiries
were made as to the cause of this behaviour. The doctor made a
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recommendation that the man be admitted to the healthcare centre. At around
4.00pm the man was transferred to D wing.
22. Whilst in healthcare the man remained under regular observation by healthcare
staff, his confused and disorientated state was again recorded on several
occasions. On 28 July, the man was assessed by the prison’s psychiatrist. The
prison’s psychiatrist recorded that the man denied any thoughts of suicide or
harming himself. The man’s confused and disorientated state continued until 31
July. However, on 1 August, staff recorded in his medical records that he was
no longer confused, was well orientated, and that he had no physical or mental
symptoms of illness. The man transferred back to C wing.
23. For the following year nothing of any significance was recorded in the limited
prison records. On 8 July 2009, the man transferred to HMP Isle of Wight,
Albany. My investigator has been unable to establish the reason for his transfer.
(Although prisoners from London courts often go to the Isle of Wight.) On his
arrival at Albany, the man was medically assessed, but no specific medical
issues were highlighted.
24. The man was moved to the prison’s segregation unit on 3 August, for disobeying
an order from an officer. This was one of a number of adjudications whilst the
man was in custody. (‘Adjudication’ is the term used to describe a prison
hearing after a prisoner has allegedly broken a prison rule.) While the man was
in prison, he was placed on report four times for fighting, twice for disobeying a
lawful order, and for possession of an unauthorised article (a mobile telephone).
There was also security information that indicated the man had links to drugs.
25. On 24 September, the man had a seizure on the wing. A nurse recorded in the
man’s medical record that he appeared to have had a fit, and presented as
agitated. An ambulance was called and the man was taken to the Accident and
Emergency Department at St Mary’s Hospital, Newport. No cause was identified
for the seizure and the man was discharged and returned to the prison.
26. Five days later, on 29 September, the man was seen by one of the prison’s
general practitioners (GPs). He wrote in the man’s medical record that the man
presented with symptoms of dizziness and appeared anaemic. As a
consequence of his assessment, the doctor wrote to the neurology department
at St Mary’s Hospital, seeking an appointment for further investigations to be
completed. The doctor reported that the man had recently had a tonic clonic
seizure recently. (A tonic clonic is a seizure that happens in two stages. The
first, tonic, stage, is when the body’s muscles contract and a person becomes
stiff. They might cry out, and breathing can become irregular. The second,
clonic, stage happens when the limbs jerk. This is caused by the muscles
contracting and relaxing in quick succession.)
27. In his letter to the neurology department the doctor reported that, although the
man had been admitted to St Mary’s Hospital previously, his condition had not
been fully investigated due to a shortage of doctors. He said the man had been
discharged and had been well, except for experiencing some dizziness. The
doctor said that no signs of neurological disease had been found, but the man
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did have a sickle cell trait and he appeared pale. Some blood investigations
were started. The doctor asked that the man be referred to a consultant
neurologist with a view to further investigations. (Sickle cell trait is an inherited
condition in which a person has abnormal haemoglobin in the red blood cells.
Haemoglobin is the main substance of the red blood cell. It helps red blood cells
carry oxygen from the air in the lungs to all parts of the body. The condition is
more common in people of African and Caribbean descent.)
28. A letter dated 15 October was sent from Southampton University Hospital Trust
addressed to Albany healthcare. The letter invited staff to contact them to
arrange an appointment for the man with their consultant neurologist. The
prison had to respond within two weeks or the referral would be cancelled.
(However, the letter was not received by the prison healthcare unit until 12
November.)
29. On 3 November, the man was said to have been seen by staff to have
apparently taken a handful of unknown pills. The man assured staff that he had
not taken any. He was assessed by healthcare staff and discharged without any
further treatment.
30. The following day, 4 November, healthcare staff were told that the man
appeared to have had another fit, although this was not witnessed by staff. The
man was reviewed by a second prison doctor, on 6 November. The doctor did
not identify anything unusual and noted that the man was still awaiting a
neurology appointment. He recorded in the man’s medical record, “CT brain
requested as appointment with neurologist might take very long time to
materialise”. (Computerised tomography (CT) is a test that uses X-ray
equipment and computer software to create pictures of the inside of the body,
including the brain.)
31. The man had a CT scan of his brain on 10 November, at St Mary’s Hospital. In
the clinical report of the scan, it was noted that the man had previously had two
episodes of suspected convulsions, but had no history of epilepsy or head injury
and “there is marked symmetrical atrophy of the frontal lobes. The remainder of
the cerebral hemispheres look normal”. (Symmetrical atrophy of the frontal
lobes is where there is a marked decrease in the size of the front part of the
brain. This can cause dementia like symptoms, particularly in respect of speech,
for example repeating words over and over, not remembering words or phrases
and can also affect a person’s behaviour and personality.)
32. The CT scan results were not, as should have been, forwarded to the consultant
neurologist at St Mary’s Hospital. In a letter to the clinical reviewer, the
consultant neurologist said that he was not aware that the man had had a
second convulsion or of the results from the CT scan.
33. On 11 November, a third prison doctor, reviewed the CT scan report. The doctor
noted in the medical record that the man should be recalled for a further
assessment on 2 December, to ensure that the situation was under control and
that everything was in place with regard to his general health needs. The
appointment on 2 December did not take place. In interview the doctor accepted
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that the appointment did not appear to have taken place and offered no
explanation. In response to questions raised by the clinical reviewer, as to why
the man was not seen on 2 December, the healthcare centre at Albany said,
“He [The man] was definitely on the waiting list for Albany, however at
around the time the recall would of happened the man was located in the
segregation unit and was then subsequently transferred to Parkhurst.”
(My investigator has not found any evidence that the man was in the segregation
unit at this time.)
34. The letter from Southampton University Hospital Trust about the man’s referral
to a consultant neurologist was received at the prison on 12 November. The
same day Albany’s healthcare department tried to arrange an appointment for
the man at the neurology department at St Mary’s Hospital. The prison was
informed that St Mary’s breach date, the target date for which the neurology
department was to have offered an appointment by, was 12 January. The first
member from the prison’s healthcare centre explained that escorts to healthcare
appointment have to be booked in advance. At that time, it was not possible to
facilitate an appointment before March. The hospital was not able to book an
appointment that far ahead and agreed to get back in touch with the prison with
a revised appointment.
35. In interview the prison doctor explained that healthcare staff rely on prison staff
to provide escorts for pre arranged hospital appointments. Therefore, only four
prisoners a day are able to attend outpatient appointments at the hospital. The
doctor explained that the member of the prison’s healthcare centre was probably
attempting to book a March appointment for the man when escort staff would be
available.
36. A further attempt was made to book a neurology appointment on 18 November,
by a second member of the healthcare staff. The second member of the
healthcare staff noted her contact with St Mary’s Hospital. She said that she
was informed that the hospital were only taking patients names and numbers
and that they would be in contact when clinic dates became available. The first
member of the prison healthcare staff attempted to book a further appointment
on 1 December. However, she was informed that the neurology department was
still unable to offer an appointment date for the man.
37. In a statement by the neurology department at St Mary’s Hospital, annexed in
the clinical reviewer’s clinical review, the department says that the prison
contacted them on only two occasions, 12 November and 1 December, to book
an appointment. According to the statement, on both occasions the prison was
informed that they “…did not have sufficient clinic capacity available to
appointment the patient.”
38. The man was again moved to the segregation unit, having become aggressive
with other prisoners on 12 December. The following day, during routine medical
rounds on the unit, the man told the nurse that he would have another fit if he
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remained on the unit. However, during his time in the segregation unit, no
further fits were recorded. The man was returned to the wing two days later.
39. On 18 December, The man was moved back to the segregation unit, for his own
protection. It was alleged by other prisoners that the man had made
inappropriate racist comments to them. Staff therefore decided that it was
unsafe for him to remain on normal location at Albany. As threats had been
made against him by other prisoners and his cell had been vandalised. On 21
December 2009, the man was transferred to the Parkhurst site of the Isle of
Wight prison.
40. Although Parkhurst and Albany are part of the same prison, the man was
assessed by a member of the healthcare team on his transfer. He told the nurse
that he was fit and well but would like to see a doctor as he was experiencing
some pain in his right arm.
41. On 5 January 2010, the Isle of Wight Council released a severe weather
warning. They reported that the Meteorological Office was predicting a high risk
of showers, turning to heavy sleet or snow during the evening and that priority
would be given to keeping the islands’ primary roads safe. That evening, the
council reported that heavy snowfall had caused major traffic delays across the
island. It was reported that continuing snow showers were making it extremely
difficult to completely clear the primary road network. People were advised not
to travel unless absolutely necessary. The snow fall was reported as the worst
on the island for 30 years.
42. After the day and evening regime is completed, a prison enters night state.
Night state is when the prison is fully locked up for the night and staffing levels
are reduced to a minimum. The role of the staff on duty is to monitor the security
of the wing and the prisoners held there. During the night, as well as officers
and operational support grades (OSGs), there is a senior officer (SO) on duty,
referred to as the night orderly officer. The night orderly officer is responsible for
the prison and in the event of an incident staff will refer to them for advice and
instructions. If necessary, the night orderly officer in turn will contact the on call
duty governor for advice.
43. At Isle of Wight prison, there is only one nurse at the Albany site overnight for all
three prison sites. The nurse is not allowed to leave the healthcare centre to
attend either the main Albany site or the Parkhurst and Camphill sites, but can
provide advice to officers on the telephone. There is no healthcare professional
on site at night at Parkhurst.
January 2010
44. At about 1.00am on the day the man died, the man and his cellmate were
watching television. The cellmate explained to my investigator that he was in
bed and the man was sitting in a chair with a magazine talking to him. He said
that the man started to chew on his thumb and then stopped talking. The
cellmate said that he asked the man a question but did not receive a reply. He
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saw that the man’s fists were tightly clenched, his eyes were rolling, his lip went
down on one side and he was dribbling from the corner of his mouth. The
cellmate asked the man if he was ok, but did not get a response.
45. Ten minutes later at approximately 1.10am, the cellmate pressed the cell alarm
bell and an OSG responded. When the OSG looked into the cell he saw that the
man was on the floor and appeared to be having a fit. The OSG told my
investigator that he did not go in to the cell because it was a double cell and he
was on his own. The OSG explained to my investigator that officers are not
permitted to enter a double cell on their own. They either had to wait for other
staff to arrive or get permission from the night orderly officer. This was for
security reasons, to prevent prisoners feigning an emergency and overpowering
staff.
46. During his interview with my investigator, the OSG said he had received first aid
training when he was a life saving instructor, and had also been on a first aid
course when he first joined the Prison Service. However, he said he had not
received any recent training. Whilst standing outside the cell, he asked the
man’s cellmate to hold the man’s head to prevent it from hitting the floor, and he
took out his radio to contact the control room. The radio battery was faulty and
so he walked to the office, a short distance away, to report the incident.
47. At 1.11am, the OSG contacted the officer in the prison’s control room to report
that the man was having a fit. The officer contacted the SO, who was the night
orderly officer and told him what was happening. The SO said that he would go
to the wing. The officer in the prison’s control room contacted the OSG to
inform him that the SO would be there shortly. At this point, the OSG returned to
the cell and asked the cellmate to look after the man as best he could.
48. At 1.13am the OSG contacted the control room again to report that the man had
stopped fitting. A few minutes later the SO and the night orderly officer’s
assistant, arrived on the wing. During this time, the OSG asked the cellmate to
put the man into the recovery position. When the OSG saw the SO and the
night orderly officer’s assist arrive on the wing he called them to the cell. The
SO and the night orderly officer’s assist then entered the cell and attended to the
man, who was still lying on the floor. They spent some time trying to get a
response from him and at that point there was some movement, but he was
unable to speak very much. As time went on, the man became more lucid and
he started to respond to the officers. The officers asked him if he had taken any
medication, whether legal or illegal, or had had any alcohol. They also asked
the man whether he had any pain or if he had banged his head. During their
assessment of the man, the night orderly officer’s assist asked for some
protective gloves and OSG left the wing to obtain them, returning a few minutes
later. The officers then lifted the man on to the bottom bunk of the bed and
advised him to try and rest. All of the officers then left the vicinity of the cell and
the SO contacted Albany healthcare to tell them of what had happened and seek
advice.
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49. The SO spoke to the nurse in the Albany healthcare unit. The nurse told my
investigator that one of his duties during the night was to offer medical advice
over the telephone to officers from any one of the three Isle of Wight prison sites.
The nurse said that he would do this by accessing the electronic computer
records of prisoners in order to assist him provide advice about a prisoner.
50. The nurse told my investigator that the SO explained that the man had had a fit
and asked if he was a known epileptic. The nurse said he checked the
electronic medical records and found that the man had a history of seizures
which he confirmed to the SO. The nurse said he asked how long the fit had
lasted and was told by the SO that the seizure had lasted for about five minutes.
During interview with my investigator the SO said that the nurse had told him
that,
“… as long as the fits aren’t lasting more than ten minutes it shouldn’t be a
problem because of starving the brain of oxygen and things like that, so he
was happy with that and that would have been it at that point … He advised
us to make sure he [the man] saw healthcare in the morning.”
51. As a consequence of his contact with the SO, the nurse made the following entry
in the man’s electronic medical record.
“At 1.45 spoke with [night orderly officer] Oscar 1 – The man located in D
wing experienced seizure, found on floor, cellmate states lost consciousness,
generalised chaotic movements of all four limbs, lasting for approximately five
minutes, sitting up and becoming more lucid at time of phone call. Vision
entries suggest that this is not a new problem – awaiting St Mary’s specialist
neurology follow up will advise D wing’s clinic manager.”
52. The man’s cellmate told my investigator that, after staff had left the cell, the man
became more active. He said the man got out of bed and put some magazines
away in a locker before returning to bed.
53. At 2.13am, the man’s cellmate used the cell bell again. The OSG went to the
cell and found that the man was on the floor. The cellmate explained to him that
the man had been getting out of bed, fell forwards and appeared to have another
fit. The man’s cellmate told my investigator that he asked for an ambulance to
be called as he did not feel that it was appropriate for the man to remain in the
cell. During his interview with my investigator, the OSG said that it was not his
decision as to whether an ambulance should be called to an incident. In the
event no ambulance was called.
54. The man’s cellmate said that during the fit the man continued to kick out, so he
tried to help by holding his head to prevent him causing further injury to himself.
The fit was much shorter than the previous one, lasting about a minute, and
when it stopped, the OSG asked the cellmate to put the man in the recovery
position. Again the OSG remained outside the cell. The OSG then contacted
the control room to report the incident. The control room contacted the orderly
officer. During his interview with my investigator, the SO said:
16
“When control contacted me I said to control can you ask the OSG to time
how long this fit lasts, because of the information I’d had before, as it didn’t
last more than 10 minutes. Then again when we got there, and it was similar
in a sense really, because the fit had finished. My understanding was, from
what I was told, that it lasted about a minute on that occasion.”
55. The SO went to the wing and was accompanied by two officers. Whilst the OSG
remained at the door, the other officers went into the cell to provide assistance.
The cellmate told my investigator that he again asked staff to call an ambulance.
Although the man was in a very confused state, he was able to sit up. With
some assistance from the officers, the man got back into bed. The officers
tucked him in more tightly and asked the cellmate to monitor him.
56. During his interview with my investigator, the SO explained that he made contact
with the nurse in the Albany healthcare unit for a second time. He said that he
told the nurse:
“… [I] explained to him that [the man] had had another fit, explained to him
that this one had only lasted a minute. He said again, as long as they’re not
lasting more than 10 minutes it’s not really a major problem, and I said to him
is it a problem that he’s now had multiple fits and again he stressed that it’s
not a problem as long as they’re not lasting more than 10 minutes. So on that
advice I’ve again told the OSG to keep a check on the cell and again you
know let us know.”
The attending officers left the OSG alone on the wing at about 2.40am and he
was told to monitor and time the fits should they happen again.
57. During interview my investigator asked the nurse in Albany healthcare unit
whether he thought an ambulance would need to be called if someone had two
fits within an hour. The nurse said that, in his opinion, he would not call one at
that stage. The nurse also confirmed that he did not consider calling the out of
hours doctors’ service at that stage.
58. At 2.30pm, the nurse made a note in the man’s medical records that the night
orderly officer had advised that the second seizure had lasted for approximately
one minute. (I note that this entry was not made until after a later entry made at
3.00am. The nurse said that this was because of a computer error.)
59. My investigator asked the SO if he had considered calling an ambulance at this
point. The SO said he did not. He understood that he should first seek advice
from the nurse based in the Albany site’s healthcare centre. He went on to
explain that, until October 2009, when the Isle of Wight prison’s healthcare
centre was based on the Parkhurst site, he would have met the on duty nurse
and have escorted them to the prisoner for assessment. The SO said the nurse
would then have seen the prisoner, taken his basic clinical observations
including his pulse and blood pressure. The nurse would have then made a
decision about whether the prisoner should remain at the prison or be moved
elsewhere. The SO said that he was not medically trained and, as there were
now no nurses based at Parkhurst, this meant that he sometimes had to seek
17
medical advice about a prisoner who he may have not seen, seeking advice
from a nurse who was in a similar position. The SO said that it concerned him
that something might be missed when explaining a prisoner’s condition. The SO
confirmed that he was able to dial 999 if he believed the situation was urgent
enough. However, he spoke to the nurse and was told that the man would be
fine to be left to see a member of healthcare staff in the morning.
60. At about 2.30am, whilst the OSG was patrolling the wing, he checked on the
man again. He told my investigator: “The man was standing up by the bed and it
looked like he was talking to the cellmate so I thought well good he’s recovered.”
The OSG said he was therefore surprised when the cell bell was activated again
20 minutes later, at around 2.50am.
61. The OSG responded to the cell bell. On his arrival at the cell, he saw that the
man was lying at the far end of the cell, almost against the wall. The cellmate
explained to the OSG that the man had fallen over and cut his head. Again the
OSG remained outside the cell. The OSG put out another call on the radio for
assistance. He went downstairs to get two pairs of gloves, two dressings and
two swabs in order to clean the man’s wound before taking the equipment back
up to the cell. He laid the items out so that they were ready for those who
attended.
62. While they waited for assistance, the OSG told my investigator, “… it was just
me outside talking to the cellmate because he was in a panic”. The OSG
advised the man’s cellmate (through the cell door) to make sure that the man
was breathing and was in the recovery position. It is unclear whether the man
was conscious during this time. While he was waiting, the OSG said he
telephoned the communications department twice to find out what was
happening. He was told that the night orderly officer and his assistant were
waiting for a doctor to arrive.
63. When the SO was informed of the third fit, he did not go straight the man’s wing.
When my investigator asked him about this, the SO explained:
“… [I did not go to the wing] at that point, not straightaway. Again, because
my information is it’s not a problem, it’s fits and things like that, what I did on
this occasion was I spoke to, I radioed back to control room. I got to the point
when I thought if I ring Albany again are they just going to tell me the same
thing again really, it’s still multiple fits, they’re still not lasting more than 10
minutes. I at that point just felt I wasn’t happy with that, that to me wasn’t
enough, so I decided to contact control and got control to get me … IDOC
[IDOC, now known as Island Health Line, is the Isle of Wight’s out of hours
GP Service].”
64. The SO telephoned IDOC and spoke to a nurse. He provided her with the man’s
details including his symptoms, age and ethnicity. He was told that a doctor
would telephone him back. In a report of the services provided by Beacon,
Island Health Line, it is noted that the SO made the call at 3.07am.
18
65. In the man’s electronic medical record the nurse in Albany healthcare unit noted
that at 3.00pm he had a, “further seizure – have contacted IDOC for advice on
management.”
66. A few minutes later the third prison doctor, who was coincidentally, one of the
prison doctors who had previously been involved in the man’s care, telephoned
the SO to discuss the situation. The doctor was stranded at St Mary’s Hospital
due to the extreme weather conditions and working as an out of hours’ GP. He
said that he would walk across the road from the hospital to the prison. The
doctor arrived at Parkhurst at about 3.25am. The SO, along with other staff,
accompanied the doctor to the wing.
67. At 3.30am, the man had a fourth fit. The fit lasted about one minute and stopped
just as the doctor, the SO and the two officers arrived on the wing. According to
the OSG they arrived at 3.31am.
68. The OSG updated the doctor and the officers on the latest situation, including
the fourth fit. The SO said they were told that the man appeared to have
stopped breathing during his last fit. They went straight to the cell and unlocked
the door. The doctor explained to the investigator that when he went into the
cell, the man was lying on the floor in the recovery position with his head away
from the door. The man’s muscles were tense but there were no active jerking
movements. The doctor checked his blood pressure and his pupils for their
response to light. The man did not respond to his name being called, although
the doctor explained to my investigator that it is not uncommon for someone not
to respond to their name immediately after a fit.
69. However, the doctor was more concerned that, even though the man’s pupils
reacted normally to light, he could not get a response to deep pain stimulus.
The doctor explained that if someone does not respond to their name, it is
possible to induce a pain response from someone who is conscious, for example
by pinching their Achilles tendons. The doctor said he was concerned that he
did not appear to be getting a response from the man. He said the man was
scoring low on the Glasgow Coma Scale, (an objective way for medical staff to
measure someone’s state of consciousness). The doctor decided it was
necessary to admit the man to hospital for further observation and treatment.
The man’s cellmate told my investigator that the man did not reply to any of the
questions he was asked and was obviously distressed. During the course of the
doctors’ medical examination, a chair was placed outside the cell for the man’s
to sit on.
70. At 3.46am, the doctor contacted ambulance control and requested an
ambulance. At that time, he requested an urgent but non-blue light response.
He told the investigator:
“My feeling was that he [the man] was stable in terms of his cardiovascular
and respiratory output, there were no signs of any obstruction, the fits could
be managed on an ad hoc basis and the other thing that one had to bear in
mind was the weather conditions, all the ambulance crews were scattered
19
across the island. My feeling was that we could maintain the situation over
the next hour and that was the discussion we had.”
71. At 3.53am, the SO contacted the officer in the control room, and advised that the
man would be going to hospital. Once this had been arranged, the SO decided,
given that the doctor, the OSG and the two officers were all in attendance, that
there were enough staff on the wing to deal with the situation. The senior officer
left the wing to arrange the paperwork necessary for the man to be escorted out
of the prison. The SO also arranged for two officers to be on standby, ready to
escort the man to hospital. As the ambulance was not due to arrive for about an
hour, the officers carried on with their normal duties. Then, at about 4.50am,
both officers went to D wing. On the way there, they collected the escort bag,
used to carry items such as handcuffs, and the escort record.
72. At the same time as the Ambulance Service received the request from the doctor
that their vehicle with stretcher capability was requested elsewhere on the Isle of
Wight to back up another paramedic crew. There were just four Ambulance
Service vehicles available that night for the whole of the Isle of Wight. Only one
had a stretcher, the other three vehicles were four by four vehicles which cannot
carry someone on a stretcher. This arrangement was in line with the normal
contractual arrangements that the Isle of Wight Ambulance Service has in place.
That night they also implemented a clinical triage support desk to assess 999
calls and send the most appropriate resource to the incident.
73. At 4.05am, the SO asked the control room to contact the duty governor to inform
him of the situation. As duty governor he had to be informed that a prisoner was
being taken out to St Mary’s Hospital.
74. While they were waiting for the ambulance, the man’s consciousness was
variable. The doctor told my investigator:
“… he never responded to [his] name but there was obviously purposeful
movements, he tried to rise up, he tried to move around the cell. And I
suggested to him that the best place for him was on the floor in the recovery
position and he was just to lie still whilst the ambulance crew came to collect
him. There was never any sign of respiratory obstruction or anything else like
that … up until that point and there was nothing coming out of his mouth that
caused me concern.”
75. At 4.43am, the man had a fifth fit. The doctor explained to my investigator that
this fit was different to the previous ones. The first four fits had all been tonic
clonic, meaning that the man’s movements were jerky and he moved forwards
and backwards. The doctor said:
“This fit was totally different to the ones that preceded it in that it was a full
body muscle spasm. Everything just went into complete, for want of a better
phrase, contraction. So much so he actually came up off the ground and went
back down and as he came down it was perfectly obvious that this was
significantly different. So that was the point at which I felt for his carotid pulse,
couldn’t feel it, realised that he wasn’t breathing and rolled him over onto his
20
back to commence cardio pulmonary resuscitation.” (A carotid pulse is taken
from the main artery in the neck.)
76. The doctor started cardio pulmonary resuscitation (CPR) and continued for two
to three minutes. (CPR is an emergency procedure which is attempted in an
effort to revive someone in cardiac arrest.) When the escort officer arrived on
the wing, ready to escort the man to hospital, he took over from the doctor and
continued CPR. During this time, the doctor asked whether an emergency
ambulance should be called and, at 4.47am, one of the officers radioed the
control room requesting an emergency ambulance. The officer in the control
room, requested the attendance of a blue light ambulance straight away. He
had to provide very little detail as the Ambulance Service was already aware of
most of the details of the incident due to the previous telephone call from the
doctor. The doctor continued to give mouth to mouth resuscitation whilst the
escort officer administered chest compression at approximately 15
compressions per two breaths, which is in line with national guidance.
77. Four minutes later, at 4.51am, the officer again radioed the control room and this
time asked for a defibrillator. (A defibrillator is a small portable machine that
searches for an irregular heart rhythm. If one is found, the defibrillator can
deliver an electric shock to reset the rhythm.) The officer in the control room
contacted the SO, asking him to collect the defibrillator. The only defibrillator in
the prison was in the treatments room, which is below D wing. The SO was
already on his way to the wing at this point and he therefore collected the
defibrillator, arriving on the wing about a minute later, at 4.52am.
78. The doctor and the escort officer attached the defibrillator to the man. The
defibrillator repeatedly advised “no shock”. Staff continued with CPR.
79. The doctor explained to my investigator that, during the resuscitation attempt,
the man produced quite a lot of liquid from his mouth. He said the man’s
abdominal muscles had contracted during the fit which caused him to aspirate,
meaning that he had forced the content of his stomach into the back of his
throat, which had then gone down into his lungs. The doctor tried to maintain an
airway. The doctor told the investigator that he considered clearing the man’s
airway, but was concerned that if his oxygen levels dropped, it would decrease
his chances of survival. The doctor therefore decided to continue with the CPR
rather than spend time clearing the back of the man’s throat.
80. At 4.52am, the ambulance crew arrived at the prison’s main gate in a four by
four vehicle. The snow at the prison was reported by the paramedics to be five
to six inches deep by this time. The paramedics were escorted to the wing by a
third officer and arrived at 5.01am. The paramedics then attempted to clear The
man’s airways and insert a short tube, via his mouth into his throat, to improve
his breathing. The paramedics reported that when they tried to ventilate the
man, he vomited. When a paramedic checked for sounds of breathing, he
believed he could hear fluid on the man’s lungs.
21
81. Resuscitation was attempted for 30 minutes by the paramedics and the doctor.
However, the man’s pupils did not respond to light and despite having applied
suction to clear his airways, his oxygen levels were poor. Eventually at 5.22am
the doctor pronounced that the man had died.
82. The SO contacted the control room so that the duty governor could be informed
of the man’s death. The SO was then instructed to start the contingency plans
for dealing with a death in custody.
83. Shortly before the man died, the cellmate was moved to another cell on D wing
where he spent the rest of the night. The SO arranged for the man’s cell to be
sealed to await the arrival of the coroner and the police. He also informed the
man’s cellmate that the man had died. The SO arranged for one of the prison’s
Imams to visit the man’s cellmate and he was later seen by the doctor in order to
talk the evening’s events through.
84. At 5.50am, the prison’s family liaison officer, was contacted at home to inform
her of the man’s death. Due to the poor weather conditions on the Isle of Wight
that evening, the decision was taken that it would not be possible to tell the
man’s family, in London, of his death in person. At 8.05am, the prison liaison
officer telephoned the Metropolitan Police to speak to staff at the police station
closest to the man’s mother’s home. However, she found that the local Police
Station did not open until 1.00pm. The prison liaison officer therefore spoke to
the Metropolitan Police control room, who agreed to send an officer to break the
news of the man’s death to his mother.
85. The prison family liaison officer then contacted the family liaison officer at HMP
Brixton, to ask him to assist the police. In addition, the chaplain at Brixton, said
he would pay a pastoral visit to the man’s mother the following day, as he knew
her son quite well when he was at Brixton prison.
86. When the family liaison officer enquired whether the police had spoken to the
man’s mother, she was informed that they would not break the news until
6.00pm that evening. The prison liaison officer therefore contacted the prison
liaison officer in Brixton to explain the latest situation. The officer said that he
would go to the man’s mother’s house himself and put a letter through the door
asking her to contact him. At 5.20pm, the man’s mother telephoned the prison
liaison officer at Brixton, who then broke the news to her of her son’s death. I
will consider the appropriateness of this decision later in the investigation report.
Post mortem
87. A post mortem examination of the man was conducted on 8 January by the
Home Office Pathologist. The pathologist suggested that the man’s death may
well have resulted form a neurological disorder capable of generating seizures.
He reported that initial appearances suggest that the man may have received
significant head injuries in the past, possibly by a fall on to the back of the head.
However, the autopsy was inconclusive and further tests were required on the
brain, and from toxicology.
22
88. A subsequent neuropathlogical examination of the man’s brain, performed by the
consultant neuropathologist at Frenchay Hospital reported that the man
“… had sustained cranial trauma months to years prior to his death. The
trauma had caused severe bruising of the brain (contusion); swelling of brain
tissue (infarction), bleeding into the layers of tissue that cover the front of the
brain (the arachnoid and dura) and into the spaces between them (the
subarachnoid and subdural spaces); and the formation of fibrous scar tissue
extending over and into the brain. The distribution of the injuries to the brain
suggests forceful impact of the front or back of the head against a hard
surface. Injuries of this type carry a high risk of subsequent epilepsy.”
89. The consultant neuropathologist also reported that during the hours prior to the
man’s death, the supply of blood to his brain fell below the level needed to
maintain the viability of nerve cells, causing irreversible damage.
90. In a supplementary report to his original report of 8 February, the Home Office
pathologist assessed that either of the incidents reported at Brixton could have
been the cause of the relevant head injury. He said,
“This pattern of injury could have been brought about by a very heavy blow or
blows, or by a fall on to the back or front of the head, although the latter site is
much more likely to have shown obvious evidence of impact at the time,
because of the comparative lack of hair there.”
91. The pathologist concluded that pre-existing brain injury was highly relevant to
the circumstances of the man’s death. The Home Office pathologist accordingly
recommended that the cause of death was modified to read:
a) Sudden death in epilepsy.
b) Old blunt force head injury.
23
ISSUES
Clinical Care
The man’s time at Brixton
92. The man’s family expressed their concern that he had been assaulted whilst at
Brixton. On 1 May 2008, the man alleged that he was slapped in the face by two
prisoners because of an issue over mobile telephones. He was seen by a nurse
at the time and no injuries were noted. Unfortunately, the man did not name the
alleged attackers and no further action was taken against the perpetrators. (It is
not unusual for prisoners to decline, for a variety of reasons, to provide further
details when they have made an allegation of this nature.)
93. On 24 July, the man was found, in what the first prison doctor reports as being
unconscious and in a drowsy state with bruising around both eyes and a
bleeding nose. The prison recorded that this was due to a head injury and a
suspected overdose. However, when he was assessed at hospital, no evidence
was found to support the view that he had overdosed. The man returned to
Brixton that evening and spent a few days in healthcare. He was confused and
withdrawn, although no cause for his mental state was identified.
94. Again, it is not possible to be sure about what happened to the man or to explain
how he came to be found in his cell. It is also not known what action, if any, was
taken by staff outside healthcare to follow up this incident. Despite my
investigator’s best efforts, not all of the man’s records from Brixton were
available for this investigation. In his clinical review the clinical reviewer
concluded that in his view,
“… the episode of illness that the man experienced between 24 July and 2
August 2008, is unlikely to have resulted from an overdose or from an
epileptic seizure, but is compatible with the man having sustained a head
injury as a result of an assault with the later complication / consequence of
post trauma seizures.”
95. My investigator has been unable to establish with any certainty what happened
to the man whilst he was a Brixton due to the lack of records relating to the time
that he spent there. Although some wing sheets were available, they did not
cover the period relating to the above incidents. In my reports I often comment
on record keeping within the Prison Service and the importance of keeping
records securely and transferring them with a prisoner whenever they move from
one prison to another. It is concerning that not all records relating to the above
incidents can be accounted for. As a consequence I make the following
recommendation to the Governor of Brixton.
The Governor of Brixton should remind all staff of the need to keep
records securely and to satisfy himself that when prisoners are transferred
to another establishment all of their prison records accompany them.
24
Care given to the man following his seizure on 24 September 2009
96. On 24 September 2009, the man was taken to the accident and emergency
department at St Mary’s Hospital, Isle of Wight, following an apparent seizure.
No cause could be found for the seizure and he returned to prison. On 29
September, he was seen by a prison doctor who referred him for a neurology
appointment at St Mary’s. No connection was made with the incident that had
occurred in Brixton in July 2008 at that time. The clinical review panel concluded
that this was likely to have been the man’s first seizure.
97. The panel reviewed the appropriateness of the care the man received on this
occasion and concluded that it was “normal” for a patient not to be prescribed
medication after one seizure. Given the information available to staff in
September 2009, the panel finds that the man’s care at this time was
appropriate.
Care given to The man following his seizure on 4 November 2009
98. The man’s next seizure occurred on 4 November. The clinical reviewer reports
that although this was not observed by staff it was accepted that a seizure had
taken place. The man was assessed by one of the prison doctors two days
later. The doctor noted no abnormal neurological findings and recorded that the
man was awaiting a neurological appointment. The doctor arranged for a CT
scan to be taken for fear that the neurological appointment “… might take very
long to materialise”.
99. The clinical reviewer and the clinical review panel identifies that the CT brain
scan taken on 10 November showed an abnormality. However, this information
was not passed on to the consultant neurologist at St Mary’s Hospital, who was
unaware of the apparent second seizure. The consultant neurologist advised
the clinical reviewer and the clinical review panel, in retrospect, that:
“If I had been told of a second convulsion I would have either asked for the
appointment to be brought forward or written with advice. However the
investigation ordered from primary care was similar to that which I would have
organised and the findings of atrophy would not have altered the management
advice I would have given”.
100. In conclusion, the clinical reviewer and the clinical review panel write that:
“In respect to prisoners who are not acutely withdrawing from alcohol/drugs,
are without an established diagnosis of epilepsy and have suffered more than
one seizure, they should be referred urgently for a neurology opinion and if
this is delayed, the neurologist should be contacted for advice on the
management of repeat seizures. If potentially relevant, significantly abnormal
laboratory/imaging result are received following an outpatient referral having
been made (regardless of the specialty), these findings should be passed by
the professional who ordered the test onto the consultant due to see the
case.”
25
I concur with the clinical reviewer’s findings and as such make the following
recommendation.
The Head of Healthcare should remind all clinicians that prisoners who
suffer from more than one seizure should be referred to a neurologist.
When there is a delay in getting an appointment, staff should contact the
neurologist for advice on the management of repeat seizures.
The Head of Healthcare should remind all clinicians that abnormal clinical
test results are effectively communicated to those involved in a prisoner’s
care.
Neurology appointment
101. The clinical reviewer and the clinical review panel conclude that:
“… had the man been in the community he is likely to have experienced a
similar wait for a neurology outpatient appointment, however he/ his relatives
might have pressed (as did prison healthcare) to be seen in neurology
outpatients before the end of 2009.”
102. My investigator established that despite the fact that the hospital
referral/appointments letter was sent on 15 October, it was not received by the
prison until 12 November, by which time the deadline for responding had
passed. That same day, the prison healthcare attempted to make an
appointment for the man. However, the next available escort for the man to be
taken to hospital was in March 2010. The neurology department advised
healthcare staff that they were unable to assist by making an appointment that
far in advance. The hospital’s own target required that the man was seen before
12 January. Despite two further attempts by the prison to make a neurology
appointment, none was made.
103. My investigator was unable to establish the exact reason for the delay in the
man’s appointment being made. Although, in response to enquiries from the
clinical reviewer St Mary’ Hospital told the clinical review panel that they did not
have sufficient clinic capacity to offer the man an earlier appointment. My
investigator also established problems booking outpatient’s appointments within
healthcare at the prison. During his interview with my investigator the third
prison doctor said:
“We have terrible issues getting any patient out of the prison to be seen in
hospital. We average 30% of expected hospital appointments. On a good
day when we get 100% we get four patients out, two in the morning, two in the
afternoon across the three [prison] sites. The endless negotiations that are
involved trying to find suitable dates, because we are working so much further
into the future [to arrange appointments] than the hospitals are, creates a
terribly complex situation and one that is very difficult, so as you can see form
the notes in this situation the sort of dates that we were trying to get the man
out for, the neurologist and neurology department weren’t able to offer us
because for reasons I’m unaware of to be honest with you but as I said just
26
the general principle of getting patients out for outpatients appointments is
very time consuming and very difficult.”
104. The ‘breach date’ (latest possible target date) for the man’s neurology
appointment at St Mary’s Hospital was 12 January. The doctor told my
investigator that, had the man been in the community, the hospital would have
been obliged to see him by that date. My investigator asked the doctor whether
he thought the man did not receive the same service as he would have in the
community. The doctor agreed that the man’s access to healthcare services had
been affected by being in custody because the prison had difficulty fitting in with
the hospital arrangements for booking outpatient appointments.
105. My investigator asked the doctor whether there would have been a different
outcome if the man had seen a neurologist. The doctor said:
“My feeling is that had he seen a neurologist a diagnosis would still not have
been clear in that he would have been referred for further investigations which
again would all take time to arrange so quite possibly we would have a
tentative diagnosis anyway, I don’t think if had only had one appointment with
a neurologist we would have moved that much further forward.”
106. An individual’s health is paramount, irrespective of whether or not they are in
prison custody and should be equitable with that of the wider community. It is
therefore essential that prisoners who are required to attend important outpatient
appointments at hospital do so promptly and that their attendance of such
appointments is not compromised by the availability of escort staff. I note that, in
her recent inspection, the Chief Inspector recommended that prisoners should
be able to attend appointments at outside hospitals without cancellations or
delays. I make a similar recommendation.
The Governor and Head of Healthcare should review the prison’s policies
and procedures to avoid delays and cancellations when booking
prisoners’ outpatient appointments and escort arrangements.
107. The man’s family wanted to know whether prison staff were briefed about the
man’s history of seizures whilst he was in custody. In the review, the clinical
reviewer clarified that officers are trained in first aid, including responding to
individuals having seizures. Although, the man had suffered a number of
seizures during his time in prison no formal diagnosis had yet been made.
However, confidential medical information is not passed on by healthcare staff to
officers unless there is a considered reason for doing so. The clinical reviewer
for example goes on to comment that prisoners will often tell staff about
themselves and any medical issues they may have, such as if they are diabetic.
in the man’s case, if he was to continue to be at risk of having seizures, I would
expect officers to be made aware of that risk and how to manage seizures while
waiting for a healthcare professional to attend.
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The man’s first and second seizures
108. The man had a seizure shortly after 1.00am. Officers contacted the healthcare
unit, located on the Albany site, for advice. The night time healthcare provision
at Parkhurst meant that the nurse was unable to leave the unit on a different site,
so the man would only have been seen by a doctor if he had been taken to
hospital or one had come to the prison. When the SO first contacted the nurse,
he advised that, as the man had stopped fitting, was conscious and comfortable,
a transfer to hospital was not required.
109. Both the clinical reviewer and the clinical review panel reviewed the way that the
man’s first seizure was dealt with by medical staff. They conclude that, in the
circumstances, it was not necessary after the first seizure for him to be
transferred to hospital.
110. The clinical review panel also considers the second seizure, which occurred
approximately an hour later and concludes that:
“… in hindsight and having been able to consider the case in detail, two fits
close together (approximately an hour apart) represented a significant
progression in the man’s undiagnosed and un-medicated condition in less
than ideal circumstances. The panel further understood the significant
disruption to the prison system of a transfer to hospital at night but considered
that a referral to the emergency department at that point was the most
appropriate course of action and is what is likely to have occurred had the
man been in the community.”
111. The clinical reviewer added that, “Had he been transferred at that stage further
seizures may have been controlled/ prevented.” The panel also comments on
the weather conditions that night:
“Due to the extreme weather conditions that night, transfer to the hospital
would have been difficult. The Isle of Wight Ambulance Service had only one
ambulance that could take a stretcher case in the snow. Sitting cases could
be transported more readily and at that stage a sitting transfer might have
been attempted, although there would have been a risk of a further seizure
occurring during the transfer.”
112. It is not sensible to speculate whether the man would have died had he been
transferred to hospital after his second seizure. The weather was a relevant
factor that night, as it might have impacted on the speed at which the man could
be transferred to hospital. However, the medical need was the most important
factor that should have informed the decision whether or not to send him to
hospital. Given the conclusions of the clinical review, I conclude that the man
should probably have gone to hospital after the second seizure. Therefore
again, I do not think that he received the same level of care as if he had been in
the community. I therefore recommend the following:
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The Governor, Head of Healthcare and the Primary Care Trust should
review the management of seizures and the appropriate thresholds for
transferring prisoners to hospital.
The man’s third and fourth seizures
113. There were no healthcare staff present during or after the man’s third fit and care
was provided by his cellmate, under the supervision of the OSG. I will comment
later in this report on the man’s cellmate being relied upon to look after the man.
114. As the man’s fourth fit started, when the doctor arrived on the wing. The fit
lasted about a minute and by the time the doctor reached the cell it had finished.
The clinical review noted that the doctor who attended was only on duty at St
Mary’s Hospital due to the weather conditions. It was a fortunate coincidence
and improved the treatment given to the man. However, it was not part of the
usual night time arrangements and cannot be relied upon should another
prisoner be in the same situation. The panel concluded that:
“The doctor did his best to help the man in very difficult circumstances,
however, had he not been available, the panel concluded that the man is
likely to have been transferred to St Mary’s potentially before he suffered his
fifth and fatal fit. In retrospect and even given the very difficult weather
conditions the panel is concerned that following his fourth fit, the man was
unconscious on a cell floor, although under constant medical attention.”
115. Shortly afterwards, the doctor spoke to ambulance control to request an
ambulance. It was agreed that this one would be sent in the next hour based on
the doctors’ assessment of the man’s medical condition at that time. The clinical
review did not make any specific comment on this. In light of the fact that I have
already commented that it would have been appropriate to transfer the man to
hospital after the second seizure, I make no further recommendation.
The man’s fifth fit
116. The man had a fifth fit at 4.43am. The clinical review panel concludes that,
“… the attending doctor did his best to help the man in very difficult
circumstances, however, had he not been available the man is likely to have
been transferred to St Mary’s, potentially before he suffered his fifth and fatal
fit.”
However, the panel concludes that, at that stage: “… everything possible was
done to save the man”.
117. While the doctor was attending to the man, he requested a defibrillator. The
machine was not on the wing and the SO received a radio call asking him to
collect it from the treatments room. Coincidentally, the SO was near the
treatment room when he received the request and therefore arrived with it
shortly afterwards. However, had the senior officer not already been on his way
over to the wing, it would have taken longer to arrive. The importance of a
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defibrillator being available quickly cannot be underestimated, and in many
cases a delay of only a few minutes can significantly affect the chances of
effective resuscitation.
118. During his interview with the investigator, the SO also explained that he was not
defibrillator-trained, although he thought that the escort officer was. He told my
investigator that defibrillator training had been asked for by staff for some time.
119. As part of the clinical review, the clinical reviewer says:
“The panel noted that the fifth fit was different in nature in that he vomited and
immediately aspirated stomach contents. The attending doctor commenced
cardio pulmonary resuscitation but the quantity of vomit meant that the
facemasks that were available were not adequate. There was some delay in
obtaining a defibrillator but when this was obtained it advised ‘no shock’ and
in my view this is what the machine is likely to have advised had the
defibrillator been obtained earlier.”
120. During his interview with the doctor, my investigator asked if there was anything
that could have helped him treat the man that night. The doctor suggested that
wings at the prison should have resuscitation masks in the “Laerdal model”. (A
self-powered emergency aspirator capable of clearing a patient’s airway.)
121. In light of the above issues, the clinical reviewer and the clinical review panel
make the following recommendations:
The Governor and Head of Healthcare should review access to
resuscitation equipment, including face masks, on the prison wings.
The Governor and Head of Healthcare should consider placing
defibrillators at strategic points throughout the establishment and ensure
that sufficient staff are trained in their use.
122. The clinical review concludes:
“In respect to the events of the morning of 6 January 2010, the panel noted
the very difficult circumstances and that staff tried to help the man, but
concluded that had he been in the community, in normal weather conditions,
he is likely to have been hospitalised before he suffered his third fit although
he may still have died”.
The review notes that the prison staff who assisted the doctor that night and who
were first aid trained, were of great assistance.
123. However, the clinical review panel goes on to conclude that,
“Finally, in my view the man did not receive care equivalent to that he would
have relieved in the community in that he is likely to have reached hospital
before his fifth fit although his prognosis might have been poor.”
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124. Although I agree with the clinical reviewer’s and the panel’s conclusions, I am
obliged to consider the appropriateness of staff’s response given the extreme
conditions. Unfortunately, on that night, weather conditions were far from
“normal” and I recognise their impact on the care that the man received.
Night time Healthcare provision at Parkhurst
125. Until October 2009, there was night time healthcare cover at the Parkhurst site.
However, since the building of a new healthcare centre on the Albany site,
healthcare cover for Parkhurst and Camphill is now based there. This means
that there is no member of healthcare staff on the Parkhurst site at night. Should
medical assistance be required at night, staff are able to contact the nurse in
Albany by telephone to seek advice. The nurse is unable to attend any
incidents.
126. The SO explained to my investigator:
“I have stressed my concerns since [the man’s death] at Parkhurst and I’ve
pointed out that at 1.15am when I got the first call I would have gone straight to
our old healthcare, picked up the nurse, go over with Oscar 2. the nurse would
see him then, the nurse would have taken his pulse, his blood pressure, his
blood saturation through a little machine they’ve got and at that point they will
have made the decision he needs to go out or doesn’t need to go out. I’m not
medically trained, I’m giving third party information over the phone without
witnessing it myself and I believe in the age old thing of, probably not right to
say it, Chinese whispers things get lost in conversation and do I explain it in the
same way that I’ve been explained it, do I stress that it’s urgent or not urgent,
without that person actually seeing it who assesses the urgency of it? I know I’m
allowed to ring 999 if I believe it’s that important, but if I’ve spoken to a nurse
who has told me it shouldn’t be a problem, make sure he sees healthcare in the
morning, and again after the second occasion it was written in the obs book [the
wing observation book is a record of any issues staff should be aware of] again
must see nurse or healthcare first thing in the morning.”
127. During his interview with the investigator, the nurse in the Albany healthcare unit
explained that, in his opinion, he did not consider that two fits in less than an
hour was a reason to call an ambulance, particularly as they were followed by
reported signs of recovery. However, had there been another seizure, he would
have said that the man should be taken to accident and emergency. In interview
the nurse told my investigator that it was difficult to interpret a prisoner’s
condition when given information by an officer over the telephone adding that it
would be easier if he was able to see the prisoner in person. (I have already
considered the appropriateness of this judgement above and do not comment on
it further.)
128. In the man’s case, the SO decided to contact the out of hours’ doctor service
after the third fit. This is predominantly a telephone service, but GPs provide
advice and can visit a patient if they believe the situation is serious enough
based on the information they are provided. In the man’s case, this also meant
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that he received direct care from a medical professional who came to the prison.
The doctor was only on duty at the hospital because of the weather conditions.
129. I fully understand that three independent sites making up the Isle of Wight prison
cause difficulty providing healthcare during the night. However, I am surprised
that a prison of this size, some 1,700 prisoners, does not require more than just
one nurse based on duty on the Albany site. The nurse who is based in the
healthcare centre at Albany, cannot attend incidents at any of the sites because
they cannot leave the inpatients’ unit.
130. In considering whether the arrangements are satisfactory, my investigator made
enquiries at HMP Sheppey which has a similar clustered arrangement with three
prisons holding a similar number of male prisoners. There each of the two
closed prisons has two nurses on duty each night who provide emergency
treatment to prisoners as required.
131. From the investigation of a recent death in Albany, which occurred after the man,
I understand that the Primary Care Trust are reviewing night time healthcare
arrangements. Nevertheless I make the following recommendation:
The Governor, Head of Healthcare and the Primary Care Trust should work
together to ensure that night healthcare provision sufficiently meets
prisoners’ needs across the Isle of Wight prison estate.
Going into cells at night
132. Having responded to the cell bell on the first occasion that night, the OSG said
he did not go into the cell because staff are not permitted to enter a double cell
at night on their own. They either wait for other staff to arrive or get permission
from the night orderly officer. During his interview with the investigator, the SO
explained that a member of staff should not enter a cell at night on their own
unless they felt it was a life threatening situation. The SO said,
“I think it depends on your own judgment of what’s going on, if something
looks absolutely life threatening with the duty of care and preservation of life
they would contact control”.
If a situation is not life threatening, the individual need of a prisoner must be
weighed against the security of the prison. During a night shift, there are fewer
staff in the prison and the risk is that prisoners can feign an illness and then
overpower an officer who goes into a cell alone. However, during this
investigation, no-one who was interviewed suggested that the man’s fits were
ever regarded as anything other than genuine.
133. It is understandable that the first time the OSG arrived at the cell he needed time
to assess the situation. At that time, the situation was not life-threatening.
However, it is harder to understand why he maintained that position over the
course of a number of hours when the situation became more serious.
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134. There is no record that the OSG asked if he could enter the cell that night. The
SO the night orderly officer, did not suggest that the OSG should go into the cell.
Consequently the responsibility fell to the man’s cellmate, to care for the man for
substantial amounts of time. Whilst the advice from healthcare initially
suggested that the situation was not “life threatening”, by the third fit staff were
sufficiently concerned to seek a medical opinion elsewhere.
135. The man’s cellmate looked after the man for 40 minutes, while the OSG stood
outside talking to them, awaiting the arrival of a doctor. Understandably, the
cellmate found this responsibility very distressing. The cellmate followed the
instructions he was given to put the man in the recovery position. However, this
arrangement was no substitute for someone trained in first aid (like the OSG) to
assist the man. Nevertheless, there is nothing to suggest that not entering the
cell directly contributed to the man’s death.
136. The then the National Offender Management Service Chief Operating Officer,
wrote to all Governors on 26 January 2010. This followed concerns raised by
my office in previous investigations regarding staff understanding of when they
can enter a cell at night. Although the letter was sent after the man died, it is
clearly relevant to this investigation. The letter outlined that all staff must be
aware of local procedures for what they should do if faced with a potentially life-
threatening situation when there are no other staff in the immediate vicinity.
137. I am concerned that the OSG believed he could not go into the cell in the
circumstances. There was no discussion about whether it would be appropriate
for him to do so. I recognise that the man’s condition worsened as the night
unfolded. However, I do not think it was reasonable for the man’s immediate
healthcare needs to be administered by a prisoner with a member of staff giving
instructions through the door. As soon as the OSG realised that the situation
was genuine, I believe that he should have gone into the cell. At least, he
should have sought permission from the night orderly officer. I therefore make
the following recommendation:
The Governor should ensure that all staff working at night, including
operational support grades, are aware of the prison’s policy regarding
entering cells in an emergency.
Radios
138. When the OSG took out his radio to contact the control room he found that the
battery was faulty and so instead he walked to the office to report the incident.
Whilst there is nothing to suggest that this contributed to the man’s death, it
could be crucial in other incidents. Although I make no formal recommendation,
I would ask the Governor to remind staff that radios should be checked before
they go on duty to ensure that they are in working order.
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Breaking the news of the man’s death to his family
139. Prison Service Order (PSO) 2710 on the Follow Up to Deaths in Custody
explains the role of the prison’s family liaison officer. Whilst there is no single
view on the most appropriate way to make first contact with a family, the
preferred approach is that it should be made directly by the prison. Ideally, the
family should be informed face to face by a prison family liaison officer, with a
chaplain or a Governor. Where face to face contact is not possible, it should be
followed swiftly by face to face contact.
140. When a face to face visit by the prison’s family liaison officer is not possible, an
officer from another prison, located closer to the family, should be asked to
break the news. The PSO accepts that at times it might be necessary for the
police to break the news but that this should not be seen as an “easy option” and
it is generally poor practice to do so.
141. Following the man’s death, the family liaison officer at Parkhurst initially
contacted the police to ask them to break the news to his mother. It was good
practice to follow up later in the day. The family liaison officer asked about
progress contacting the man’s mother, and was told that contact would not be
made until that evening. A family liaison officer from HMP Brixton therefore
agreed to deliver a letter to the man’s mother asking her to contact Parkhurst on
her return. The news of her son’s death was then given to her over the
telephone.
142. I would normally expect the prison’s family liaison officer to break the news of a
death in person. This includes when the death is at a prison on the Isle of Wight,
unless the distance is so considerable that it is impractical and would lead to a
significant delay. Whilst it is accepted that on this occasion snow on the Isle of
Wight might have prevented travel, it is questionable whether it was appropriate
to have approached the police to break the news of the man’s death to his
family. It is not normally the role of the police to do this and, as it turned out,
there was a delay of some hours in informing the man’s mother of her son’s
death because the police were not able to do so until the evening.
143. When this delay was identified, the family liaison officer at Brixton delivered a
letter to the man’s mother asking her to contact Parkhurst. There was no
certainty that his mother would receive the letter. It also meant that the man’s
mother was told of her son’s death by telephone. If the family liaison officer at
Parkhurst could not break the news in person, the family liaison officer at Brixton
could, and in my view should, have broken the news in person instead, in line
with the guidance. It was Parkhurst’s responsibility to make sure that the news
of the man’s death was broken to his family. I therefore make the following
recommendation:
The Governor of Parkhurst should ensure that the family is informed of a
prisoner’s death in person by a prison family liaison officer.
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CONCLUSION
144. The man’s first recorded seizure took place on 24 September, after his transfer
to the Isle of Wight. A further un-witnessed episode took place on 4 November,
before a serious of seizures led to his death in the early hours in January 2010.
Although the seriousness of his condition had been recognised by healthcare
staff at the prison and arrangements made for him to be seen by a consultant
neurologist, he was unable to do so before he died. Although a subsequent
emergency CT scan was taken, the results were not forwarded to the consultant
neurologist. However, the clinical review concludes that had the results been
forwarded the management of the man’s case would not have altered.
145. I make several recommendations with regard to the man’s treatment by
healthcare at HMP Isle of Wight under the guidance of the clinical review panel
and I concur with their final conclusion. I don’t think that the man received the
level of care that he would have had in the community, in particular he should
have been taken to hospital before his fifth seizure.
146. Perhaps more concerning is that the post mortem into the man’s death raises
the possibility that the serious of seizures that the man experienced in the
months leading to his death resulted from a pre-existing brain injury, which could
have been caused by the incidents that took place at Brixton. The post mortem
concludes that the man’s pre-existing brain injury was highly relevant to the
sequence of events that took place.
147. I regret that my own investigation has been unable to shed any further light on
the incidents that took place at Brixton prison. As a consequence, and given the
lack of evidence available to me, I believe it would not be appropriate for me to
comment further on these incidents but simply report my findings to the reader.
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RECOMMENDATIONS
1. The Governor of Brixton should remind all staff of the need to keep records
securely and to satisfy himself that when prisoners are transferred to another
establishment all of their prison records accompany them.
No response -
2. The Head of Healthcare should remind all clinicians that prisoners who suffer
from more than one seizure should be referred to a neurologist. When there is a
delay in getting an appointment, staff should contact the neurologist for advice on
the management of repeat seizures.
Accepted - Updated local guidance for Prison Healthcare staff and prison
colleagues have been developed and issued to clarify actions requried – based
on and to ensure compliance with national Institute for health and Clinical
Excellence (NICE) guidelines. N.B. New guidelines on epilepsy are expected to
be released by NICE in March 2011.
3. The Head of Healthcare should remind all clinicians that abnormal clinical test
results are effectively communicated to those involved in a prisoner’s care.
Accepted - All prison Healthcare staff have been reminded of the need for
abnormal clinical test results to be effectively communicated to those involved in
a prisoner’s care. Staff were reminded that in simple terms, this means that if an
individual staff member is the first to come into possession or knowledge of a
patient’s test results and he/she is either concerned or unsure of the implication
(or if the result has been clearly indicated as abnormal) he/she has a duty to
bring it to the attention of those involved in the patient’s care and particularly the
person responsible for leading that care.
4. The Governor and Head of Healthcare should review the prison’s policies and
procedures to avoid delays and cancellations when booking prisoners’ outpatient
appointments and escort arrangements.
Accepted - Work has and is ongoing in respect of this area of challenge. A
number of changes introduced recently are aimed at developing better
understanding and liaison between the Prison, Prison Healthcare and the local
hospital in order to improve the booking systems. A new software package has
recently been introduced to inform this process. A new contract for the provision
of neurology services to prisoners in HMP Isle of Wight is currently under
discussion between the commissioners and the provider of these services.
5. The Governor, Head of Healthcare and the Primary Care Trust should review the
management of seizures and the appropriate thresholds for transferring prisoners
to hospital.
Accepted - As for 2. above.
36
6. The Governor and Head of Healthcare should review access to resuscitation
equipment, including face masks, on the prison wings.
Accepted - The provision of resuscitation equipment was already the subject of
review and action at the time of the man’s death. Outcome was that in May 2010
– NHS Isle of Wight purchased and provided to HMP Isle of Wight six Automated
External Defibrillators (AEDs) and associated equipment (including masks).
Under a Memorandum of Understanding signed and dated 18th May 2010, these
were deployed to the Gyms and Night Orderly Offices of each of the three prison
sites making up HMP Isle of Wight.
7. The Governor and Head of Healthcare should consider placing defibrillators at
strategic points throughout the establishment and ensure that sufficient staff are
trained in their use.
Accepted - As for 6 above.
In addition, an AED is located in the Primary Healthcare Centre on each site and
the Inpatient Unit (IHU) at Albany. This makes a total of 10 AEDs.
A training session for Night Staff in the use of AEDs is planned to increase the
number of trained staff in post. This will increase the number of trained staff in
the vulnerable area of State ‘A’.
8. The Governor, Head of Healthcare and the Primary Care Trust should work
together to ensure that night healthcare provision sufficiently meets prisoners’
needs across the Isle of Wight prison estate.
Accepted – Work is ongoing in respect of ensuring clarity and equity of access to
healthcare across the 24 hour day. Simple written guidance and a clear flow
chart for prison staff on accessing healthcare services has recently been updated
and circulated
9. The Governor should ensure that all staff working at night, including operational
support grades, are aware of the prison’s policy regarding entering cells in an
emergency.
Accepted – Work on this action has commenced and all staff at HMP Isle of
Wight have been sent a personal copy of the Safer Custody produced video on
actions to take when entering a cell and use of anti-ligature knife. Currently 71%
of staff has confirmed they have viewed the video and this is recorded as training.
The Night Orders have been reviewed by Security and Operation Group and are
now in place. The review clearly sets out our policy on entering cells in an
emergency. Governor Grades conducting Night Visits have been clarifying any
training issues with regular night staff and providing information with respect to
entering a cell in state ‘A’.
10. The Governor of Parkhurst should ensure that the family is informed of a
prisoner’s death in person by a prison family liaison officer.
37
Accepted – Since the introduction of Death in Custody Lead this action is carried
out in all cases. The Contingency Plans have been amended as requested. HM
Prison Isle of Wight now has a lead governor grade on Death in Custody who
deploys the Family Liaison Officer to deliver the message to the family. The
system now employed ensures the deployment of trained Family Liaison Officers
and has, due to long distance visits, used the FLO of nearby establishment’s
where appropriate. When this occurs, our FLO is still deployed to help the family
and to five further information as near to time of death as practicable.
38