Individual at Holme House

Investigation into the circumstances surrounding the
death of a man, a prisoner at HMP Holme House,
in hospital in June 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2009
This is the report of an investigation into the death of a man who died in June 2008
in hospital whilst a prisoner at HMP Holme House. The man had transferred from
Holme House to the hospital two days earlier after being unwell for several days. He
was 54 years old.
A post mortem was held at the request of HM Coroner for Teesside. It found that the
man died from meningitis. I extend my sincere condolences to his family and
friends.
This investigation was undertaken by one of my investigators. In addition, a review
of his healthcare was commissioned from North Tees and Hartlepool Foundation
Trust. I am grateful to a doctor who carried out the review. I would also like to thank
the Governor of Holme House and his staff for their help and assistance. I am
particularly grateful to the prison’s liaison officer.
Prisoners and staff on B wing of houseblock six, where the man lived, were
concerned that he was becoming increasingly unwell before he was admitted to
hospital. It is clear from the investigation that wing staff made every effort to contact
staff in the healthcare centre, relaying their concerns for the man.
I am concerned about the timeliness and standard of care given to the man by the
healthcare centre. I make one recommendation to the Chief Executive of North Tees
Primary Care Trust: that his treatment by healthcare staff is subject to a root cause
analysis and that the performance of relevant staff is audited. I note three examples
of good practice for the attention of the Governor.
The draft report was circulated, with advance disclosure, to the Prison Service, North
Tees PCT and the Department of Health. A response was received to the
recommendation, which was included in that report.
In this final version of my report, the man’s family have commented on the pain their
brother suffered before he was admitted to hospital.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2009
2
CONTENTS
Summary
The Investigation Process
HMP Holme House
Key Findings
Issues
Recommendations
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SUMMARY
The man was received into HMP Holme House in December 2007. He had been
recalled to prison for failing to comply with licence conditions. A first reception health
screen conducted by a nurse raised no health issues other than he had a runny nose
and red hands. He was located on B wing and became the wing cleaner.
A few days later, the man saw a nurse for advice on stopping smoking, and asked
the doctor for a referral to the gym as he wanted to lose some weight. It is noted in
the man’s medical record that he received a regular prescription for Gaviscon (an
indigestion remedy) and some ointment for a fungal foot infection.
On 29 May 2008, the man was seen by a nurse in the healthcare centre. He was
flushed, with a cough and a temperature of 40 degrees (normal temperature is 37
degrees). A referral was made for the man to see the doctor the following day. He
was advised to take paracetamol and plenty of fluids.
The next day, a B wing officer requested that a wheelchair from healthcare be
provided for the man to get to the healthcare centre for his appointment with the
doctor. It was the officer’s opinion that the man was too unwell to walk to the
healthcare centre. Healthcare staff declined to fetch the man in a wheelchair. In the
afternoon, the officer went to the healthcare centre as the man was still too ill to go
and the doctor had not yet visited him in his cell. Later, he was examined in his cell
by the doctor and a nurse. The doctor prescribed pain relief.
On 1 June, the man made a great effort to go to the healthcare centre and was
examined by a nurse. He was feeling dizzy, had been vomiting and complained of
lower back pain. His hands were very red, although his temperature was now
normal. The nurse thought the man looked in pain and was hot and clammy to
touch. She spoke to the doctor who in turn prescribed an injection to help stop the
man’s sickness. He was told to contact healthcare if the problems persisted.
Around 6.00am on 2 June, the prisoner in the cell next door was woken by groaning
and moaning from the man’s cell. This was also heard by another prisoner. The
prisoners alerted night duty staff, and Operational Support Grade (OSG) opened the
hatch in the cell door. The man was seen pacing around his cell and did not respond
to the OSG’s questions. The OSG phoned healthcare, who advised that the man
should take paracetamol and they would come and visit him.
The man was becoming increasingly agitated and continued groaning. The OSG
spoke to the man again, but could not get him to respond. An officer then reported
for duty on the wing and went to the man’s cell. Following a conversation with two
prisoners, he called the Night Orderly Officer (NOO) to come to the cell for
immediate help. The NOO arrived with another officer and a nurse.
When the man’s cell was opened, it became very apparent that he was unwell. He
was pacing the room, agitated, disorientated and seemingly delirious. The nurse
was unable to take any clinical observations from the man, as they could not calm
him down. A nurse telephoned the on call doctor who advised that the man be taken
to hospital, and an ambulance was called. The paramedics found the man still
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disoriented, and taking his blood pressure, pulse and temperature proved to be
difficult. At 8.00am, he was transferred from Holme House to hospital. He was not
restrained but was accompanied by two officers.
On arrival at hospital, the man was admitted to the intensive care unit and placed on
a life support machine. His family was visited by the prison’s family liaison officer.
They were not at home so a letter was left for them to contact the hospital and the
prison.
The man’s sister arrived at the hospital later that evening. On 2 June 2008, the
man’s life support machine was turned off with the agreement of his family. The post
mortem report found that he had died of meningitis.
5
THE INVESTIGATION PROCESS
1. On 9 June 2008, a letter was sent to the Chief Executive of Stockton on Tees
Teaching Primary Care Trust (PCT), requesting a clinical review into the man’s
medical care whilst at Holme House.
2. My investigator visited Holme House and met with a Governor on 26 June 2008.
Notices of the Ombudsman’s Investigation and Terms of Reference were sent in
advance. Three prisoners responded to the notice of investigation and my
investigator visited two of those prisoners on B wing of houseblock six. The third
prisoner was not on the wing during the investigator’s visit. Whilst on the wing,
my investigator spoke to an officer and a Senior Officer (SO).
3. My investigator had received a letter from another prisoner’s solicitor indicating
that he wished to speak to her. The prisoner had been released from Holme
House before the investigator’s visit. She wrote to the prisoner at his home
address and confirmed this by telephone to the solicitor. At the time of the
circulation of this report the prisoner had not responded to my investigator.
4. No members of the Independent Monitoring Board (IMB) or the Prison Officers’
Association (POA) requested to see my investigator. The IMB and POA have
previous experience of the procedures for a death in custody investigation.
5. My investigator wrote to the Chief Executive of the PCT on 2 July. She asked for
a clinical reviewer to be appointed who would be independent of the PCT,
following concerns raised by prison staff about the man’s medical care. Despite
telephone calls and email messages throughout July and August, my investigator
was unable to make contact with the PCT to find out who would be conducting
the review.
6. On 14 July, my investigator visited HMP Kirklevington Grange to interview a
friend of the man’s from Holme House. Later that day, she went to Holme House
and interviewed three officers. The following day, my investigator interviewed
one officer and three friends of the man on houseblock six. On 8 and 9
September, my investigator and one of my assistant ombudsmen interviewed
healthcare staff and an operational support grade at Holme House.
7. My assistant ombudsman wrote to the Chief Executive of the PCT asking for
progress on the clinical review on 18 September. My investigator was contacted
on 23 September by the Assistant Director Integrated Governance. An
independent clinical reviewer had been identified and the man’s medical notes
were being forwarded him. The lateness of the clinical review caused a delay in
my completing this report, but I am very grateful to the clinical reviewer, a doctor,
for his review.
8. On 25 September, my investigator and one of my family liaison officers visited the
man’s sister at her home address. Other family members were present.
9. The man’s sister was concerned about rumours circulating within her hometown
that her brother had not received appropriate healthcare prior to being admitted to
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hospital. My colleagues told the man’s sister of the investigation process and
reassured her that the investigation would take into consideration the important
issue she had raised.
7
HMP HOLME HOUSE
10. Holme House is a category B prison for unconvicted, convicted and sentenced
male adults. It opened in May 1992. The prison primarily serves the
communities of the Tees Valley, South West Durham, East Durham and North
Yorkshire. It has a total of six residential units, known as houseblocks one to six.
It has an operational capacity (maximum crowded capacity) of 994.
11. Houseblock six is used for sentenced prisoners. In common with other
establishments, Holme House runs a personal officer scheme. Officers are
responsible for the prisoners in a specified number of cells and cover in each
other’s absence.
12. North Tees Primary Care Trust are the providers of healthcare services at Holme
House. There is an in patient unit with 28 beds and 24 hour nursing care. An out
of hours doctor’s service is covered by the prison doctor with help from an
emergency out of hours doctor service.
13. HM Chief Inspector of Prisons, Ms Anne Owers, conducted an announced
inspection of Holme House in April 2005. Following the inspection, Ms Owers
said of Holme House:
“Staff – prisoner relationships appeared to be good and were reported as such
in the survey. There was no evidence of disrespectful treatment of prisoners,
although there were some instances of staff dealing with prisoners in a
superficial manner or without regard to their individual needs. The healthcare
department provided a good range of clinical services, although in our survey
prisoner perceptions of the quality of healthcare were below the benchmark.
There had been problems in the recruitment of GPs but this was being
addressed. Inpatient care was provided in decent, clean surroundings but
there was limited opportunity for patients to associate. The mental health in-
reach service provided a good service to prisoners in the houseblocks.”
14. The most recent report by the prison’s Independent Monitoring Board (IMB) was
issued in 2005. The presented a generally favourable view of all areas of the
prison. The following comment was made of healthcare:
“There are concerns by nursing staff due to the rapid turnover of staff. The
perception is that qualified staff appointments within the prison are merely as a
stop-gap or stepping stone jobs. The unit has benefited from inclusion in the
roster of two officers easing safety and security issues.”
Most of the concerns raised by the IMB have since been addressed.
15. This is the sixth death from natural causes at Holme House that my office had
investigated since taking over responsibility for all death in custody investigations
in 2004. My previous investigations have not raised issues relevant to this one.
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KEY FINDINGS
16. On 26 December 2007, the man was received into Holme House. A first
reception health screen document was completed. The man did not report any
health issues to the nurse, other than a runny nose and red hands. The man’s
medical notes do not give the name of the nurse completing the screening
document. A secondary health assessment was completed and the man was
referred to the doctor about his red hands.
17. On the following two days, the man’s medical notes show a heading of ‘out
patients’ but no further information is recorded. On 2 January 2008, the medical
notes record that a doctor prescribed Fixodent (an oral adhesive for false teeth).
No other information was noted. The next day, the man saw a nurse for advice
and support to stop smoking. Later, he was examined by the doctor who noted
the man’s blood pressure reading of 125/77 (within the normal range of 130/80).
He was not short of breath and did not have any chest pain. The man’s weight
was noted as 81 kilograms and he asked the doctor to refer him to the gym to
help him lose weight.
18. On 12 January, the man was seen by a nurse. She recorded his smoking habits
and prescribed nicotine patches. On 15 February, it was noted that a doctor
prescribed Gaviscon (an indigestion remedy). There was no information
recorded as to why Gaviscon was prescribed. Four days later, the man saw a
nurse on houseblock six. The nurse noted that the man had blistering and itching
to his left foot and would discuss this with the doctor. Later that day, the doctor
prescribed Mycil (an anti-fungal ointment.)
19. The doctor prescribed Gaviscon and Mycil for the man again on 20 March. A
similar prescription was issued by the doctor on 17 April. On 8 May, it was
recorded that another prescription for Gaviscon was documented by the doctor.
These entries on his medical record were for repeat prescriptions and the man
did not see the doctor.
20. On 29 May, a nurse examined the man. He was breathless and coughing up
white and green phlegm. His temperature was 40 degrees and he was flushed
with a blood pressure reading of 158/85. The nurse said at interview that his
temperature was high and he had a fever. The nurse told my investigators:
” He did complain about a bit of lower back pain, which again I’ve not
recorded in the notes but I remember that. And we did sort of allude to, I did,
you know any rashes or sickness. There was no vomiting; it was a case of
somebody with a high temperature feeling unwell. The man was referred to
the doctor and advised to take plenty of fluid and paracetamol. I was
concerned but I felt quite comfortable him going back overnight, I was quite
comfortable with that decision.”
21. The nurse spoke to a senior colleague about the man’s symptoms, and made her
aware of his condition. She also recorded on the electronic recording system that
9
the man should see the doctor the following day. There is no indication from the
man’s medical notes that he was seen again that day.
22. On 30 May, an officer made an entry in the man’s personal file. The officer noted
that he had made contact with healthcare staff to remind them that the man had
an appointment with the doctor that morning. The officer told the healthcare staff
that the man would need a wheelchair and assistance to attend his appointment
as he was very unwell. The member of healthcare who spoke to the officer told
him that a wheelchair could not be provided and the man should attend the
healthcare centre. The officer continued the entry and noted that he had
contacted healthcare again in the afternoon to find out what was happening as
the man had not yet seen the doctor. He was told that, unless the man walked
down to healthcare for his appointment, he would not be seen by the doctor. The
officer was told that it was the doctor’s decision. The officer completed his entry
by adding that most of the day the man had been immobile in his cell.
23. A short while later, the officer went to the healthcare centre himself, as healthcare
staff had still not arrived to see the man. He insisted that a member of healthcare
staff should go to see the man in his cell.
24. At 3.10pm, the man was examined by the doctor in his cell. The doctor noted in
the man’s medical record, “says he is poorly and suffering from back pain, it is
not his chest. Non multum, could very well have come to OP [out patients].” At
interview, the doctor told my investigators:
“The man was lying on his bed. He was in pain; I wouldn’t say he was in
excessive pain because he was lying quite still and relaxed. I asked him
about his pain and I asked particularly about his chest because the day before
a nurse had noted that she thought he had a chest infection. She said that he
said that he felt ill, ‘poorly’ is the word that they use in this area [ the doctor’s
reference to ‘they’ is a term referring to prisoners], and he was suffering from
back pain but it was not his chest infection.”
25. The doctor prescribed Diclofenac (a non-steroidal anti-inflammatory drug) and
Baclofen (a muscle relaxant). There is no record of a blood pressure reading,
temperature, or pulse reading being taken during this examination.
26. The following day, the doctor again repeated a prescription for Gaviscon without
seeing the man. The following day a nurse saw the man in healthcare. The
nurse noted in the man’s medical record that he was complaining of lower back
pain, which had worsened overnight. He was unable to sleep and the pain was
the same whether he was lying or standing. The man felt dizzy when walking
and had vomited four times that morning.
27. The nurse examined him and noted he looked in pain, was hot and clammy to
touch. His temperature was 36.4 degrees and blood pressure 135/97 (higher
than the normal range). Both the man’s hands were red, and he told the nurse
he had had a similar problem about five years earlier when the symptoms had
subsided after about four weeks. The nurse discussed the man’s symptoms with
the doctor. The doctor prescribed a 10mg injection of Metoclopromide (a drug
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used for upset stomach and vomiting) which the nurse administered. The man
was advised to drink plenty of fluids, try to eat a light lunch and not take any
painkillers unless he had eaten something. The man was also told to contact
healthcare if the problems persisted.
28. A friend of the man’s assisted him with getting his meals from the servery, drinks
to keep his fluid intake up, and sat with him. On 1 June, another friend of the
man’s saw him on the landing. In interview, he described the man as being in
great pain and looking grey. The man was complaining of severe back pain and
could hardly stand up. The friend passed on some Deep Heat (a cream
medication to soothe back pain) to another prisoner to rub on the man’s back.
The man, who occupied a single cell, told his adjoining cell mate that if he was
unable to get out of bed that night he would bang the wall for him to ring his cell
bell. This friend’s cell was next to the man’s.
29. About 6.20am on 2 June, the man’s friend was woken by sounds coming from the
man’s cell. He could hear the man groaning and banging in his cell. Another
prisoner was also woken by the man’s shouting and banging from his cell. He
called out of his window to the prisoner next to the man’s cell, and told him to ring
his bell to alert staff. The prisoner rang his bell and night duty Operational
Support Grade (OSG) responded. The prisoner told the OSG that the man had
been very unwell and needed a nurse. The prisoner could still hear the man
moaning and groaning.
30. The OSG looked at the man through the hatch on his cell door, and saw that he
was lying face down on the bed. The OSG asked the man what was wrong but
he did not answer. In interview, the OSG said the man then got off the bed and
wandered around his cell, but did not respond to her questions and seemed
disoriented.
31. The OSG went to the wing office and telephoned the healthcare centre. She
explained what she had seen and that the man seemed to be disoriented. The
nurse advised the OSG to tell the man to take the paracetamol that he had been
prescribed. Whilst returning to the man’s cell she attended a cell bell in the cell
next to the man. The prisoner told the OSG that the man was smashing his cell.
The OSG then opened the hatch on the man’s cell door and he was standing by
the door. She told him to take the paracetamol.
32. An officer who had just reported for duty on the wing, came to the man’s cell and
asked the OSG what was the matter. The officer knew the man well and recalled
him from his previous custodial sentence. The OSG told the officer that the man
was not responding and seemed disoriented in his cell. The officer then spoke to
the prisoner in the cell next to the man. The prisoner told the officer that the man
had been unwell all weekend and had been moaning for some time. The officer
asked the prisoner if the man had taken anything (a reference to any illicit drugs).
The prisoner said that the man would never do anything like that in prison.
33. The officer then went to the man’s cell, but he too was unable to get the man to
respond to his voice. The OSG told the officer that she had spoken to the Night
Orderly Officer (NOO). The NOO had told the OSG that they were aware that the
11
man had a bad back and the nurse would come and see him at unlock time
(unlock is when prisoners are released from their cell to start their daily routine).
34. The officer went to see another prisoner and spoke to him through the hatch of
his cell door. This prisoner told the officer that the man needed help and he had
been sick all weekend. The officer went to the wing office, rang the NOO and
told him to come to the man’s cell and open the door, as he needed help
immediately.
35. At about 6.45am, the NOO, a night duty officer, the officer, and a nurse went to
the man’s cell. On opening the cell they found the man pacing, unable to
communicate and uncooperative. At interview, the officer told my investigator:
“When we first went into the cell the heat was unbelievable it was like the
tropics which was very unusual, his windows were shut and they were
steamed up and dripping with condensation, so I opened the windows and
tried to get some kind of reaction from the man, so I sat him down on the bed
and he wouldn’t settle he got back up pacing the cell.”
36. The officers were unable to make the man remain still and so could not measure
his pulse or blood pressure whilst he was so disoriented. The officer said that
they managed to get the blood pressure cuff onto the man’s arm but he ripped it
off, was still moaning and trying to move around the cell. He would not respond
to any questions or commands. At one stage, the man leant over the toilet in the
cell and tried to get water. The officer had to steer the man away from doing this.
37. The nurse noted that the man was hot and clammy. During interview, the nurse
told my investigators that the man was obviously distressed and agitated and she
was unable to examine him. The nurse said:
”He was really disorientated, he was stumbling around the cell, he had no
idea who we were. One of the day officers had come on, that apparently
knew him quite well because I understand the man had a little job on that
houseblock. So he was quite well known and he knew all the officers as well
and it was obvious that he didn’t recognise the officer that had come on that
morning. I just couldn’t pinpoint anything that, usually you can go in and you
think it could be this and I just looked at him and I thought I’ve got no idea
what this could be. So I’d taken the emergency bag with me so I thought well
I’ll do his blood pressure and his pulse and I’ll look in his eyes and go through
the usual scenario that we go through seeing a patient. But he was so
distressed and disorientated, I don’t know what the man thought we were
going to do to him, but he didn’t want us to touch him. He was pulling away
and he was getting really, really distressed and agitated. So we put a
mattress on the floor, I think I’d asked someone, I said can you get hold of a
nurse in the hospital [healthcare unit], ask her to ring the doctor, I need
somebody.”
38. The nurse in healthcare made telephone contact with the doctor. The doctor
advised that the man should go to outside hospital. The nurse contacted the
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hospital bed manager, and was advised that the man should be taken by
ambulance to the hospital’s Accident and Emergency Department.
39. After the mattress had been placed on the cell floor, the staff waited outside the
cell until the paramedics arrived, keeping a close watch on the man who was still
moving around the cell, incoherent and agitated. When the paramedics arrived
they too were unable to examine the man, despite many attempts to calm him.
The paramedics requested an evac chair (a chair with belts attached, which is
easy to lift and manoeuvre). They thought a stretcher was inappropriate given
the man’s distressed demeanour. A chair was brought from healthcare and the
man was taken to the ambulance.
40. A risk assessment was completed, and at 8.00am the man was escorted to
hospital by two officers. He was not restrained and was admitted to the hospital’s
intensive care unit. It was noted on the man’s bedwatch notes at 12.55pm that
his condition was deteriorating. The escort officers requested that the man’s
family be contacted to attend the hospital as he had been placed on a life support
machine.
41. Several attempts to contact the man’s sister were made by telephone by the duty
family liaison officer. At 3.15pm, the family liaison officer and a governor went to
her home. There was no one in so they left a letter asking the man’s sister to
contact the hospital as soon as possible, and left the family liaison officer’s
contact details. Later, the man’s sister returned home and went immediately to
the hospital where she stayed at his bedside.
42. At 2.00pm on 4 June, with the agreement of the man’s sister, his life support
system was switched off. He died at 2.05pm. His sister was at his bedside.
43. The following day, the family liaison officer visited the man’s sister with another
family liaison officer, who would take over the role of liaison officer. On 9 June,
this officer supported the man’s sister at the opening of his inquest.
44. On 12 June, the man’s sister, niece and a family friend visited their brother’s cell
on B wing and met some of his friends. A wing collection by his friends had been
organised for a floral tribute for the man’s funeral service. The man’s sister
thanked his friends for their kindness. They later visited the chapel, and met the
chaplain and lit a candle in memory of their brother.
45. The next day, the family liaison officer, a governor, and the chaplain attended
the man’s funeral. The prison offered financial support towards the funeral
expenses.
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ISSUES
Clinical Issues
46. A review of the man’s medical care was commissioned with Stockton on Tees
Teaching PCT. A doctor was asked to carry out this review. The doctor’s report
recorded the interventions by healthcare staff in response to the man’s symptoms
and the actions taken.
Healthcare provision prior to 29 May
47. The doctor has judged that the man received adequate attention for his minor
illnesses of indigestion and a fungal foot infection. He was also seen for health
promotion with smoking cessation advice and weight loss.
Response by healthcare to the man’s early signs of illness
48. On 29 May, the man was assessed by a nurse. Although he had a high
temperature of 40 degrees there were no other significant symptoms. A chest
infection was considered to be the cause of his illness and a follow up
appointment was made for the man to see the doctor the following day. The
doctor has noted that the man could have had his temperature re-taken a few
hours later, or healthcare staff could have asked wing discipline staff to report to
them on how the man was feeling.
49. In interview, the prison doctor said she examined the man in his cell on the
afternoon of 30 May. The man was lying on his bed, seemed unwell, and told her
he was poorly. He had some mobility in his legs and was able to talk to her about
his symptoms. The prison doctor prescribed a muscle relaxant medication to
help with his back pain, and painkillers. It was the prison doctor’s opinion that he
man could have walked to the healthcare centre for his appointment.
50. The doctor notes in his review that there were no detailed records made in the
medical record of the man’s physical state following the consultation. There was
no mention of any possible infection or any reference to the symptoms noted by
the nurse the day before.
51. The prison doctor’s examination of the man included his back, with a physical test
to eliminate sciatic nerve pain (of which there was none). The test is also used to
decide if back and neck pain is associated with meningitis. The man’s chest was
also examined and described as clear in his notes.
52. With regard to the man’s visit to the healthcare centre on 1 June, the doctor has
found that the healthcare team of the nurse and the prison doctor could have
could have formed the opinion that, as he was able to attend healthcare centre
that day, he was getting better. His temperature was recorded as normal,
although he was hot and clammy and both his hands were noted as red. The
doctor considers that the man’s temperature reading is likely to have been an
error. The vomiting was thought to have been caused by the medication
Diclofenac (prescribed the previous day). The doctor comments that this was not
14
an unreasonable view as the man had also been prescribed Gaviscon for his
stomach acid. However, the assumptions were incorrect and, furthermore, the
man was only seen in passing and was not formally assessed by the doctor.
The man’s admission to hospital
53. On the morning of 2 June, the man was so unwell that he was unaware of his
conduct. The man had previously asked his friend in the cell next door to ring his
cell bell if he banged on the wall to indicate he needed help during the night. It
would seem that the man was unable to do so due to his delirious state. The
prisoner was awoken by noises coming from the man’s cell and further calls from
another prisoner. The prisoner rang his cell bell and the OSG responded.
54. In interview, the OSG recalled that after answering the prisoner’s cell bell and
after observing the man she rang healthcare and spoke to a nurse. The OSG did
not mention ringing the NOO but did remember speaking to a nurse who told her
to tell the man to take the paracetamol prescribed the previous day.
55. The OSG was trying to convey this to the man through the hatch of his cell door
when an officer reported for early morning duty on B wing. The officer went to
the man’s cell and spoke to the OSG. The officer then spoke to the prisoner in
the cell next to the man, to ask if he knew if the man had taken any illicit
medication. The prisoner told the officer that the man had been unwell all
weekend and would never take any non-prescribed medication. The officer also
spoke to another prisoner who confirmed how ill the man had been. The officer
made contact with the NOO asking him to attend the man’s cell immediately with
a nurse.
56. When the officers entered the man’s cell it became apparent from the man’s
demeanour that he was very ill. Despite attempts to calm him the man was
disoriented and acting out of character.
57. Healthcare staff contacted the on call doctor who advised that the man be
admitted to hospital. An ambulance was called and the man was transferred to
hospital at 8.00am.
58. Self-evidently, there was a considerable gap between prison staff first being
alerted to the man’s condition at 6.20am to his transfer from Holme House by
ambulance at 8.00am. However, because of the man’s behaviour, which we now
know to have been caused by his medical condition, certain medical procedures
took longer than normal. The doctor judges that his admission to hospital was
dealt with as quickly as possible given his conduct that morning.
59. The doctor has also found that the man’s admission to hospital was dealt with as
an emergency and his clinical signs and symptoms were appropriate for an
emergency admission.
15
Overall judgment on the man’s clinical care
60. The doctor comes to the following conclusions about the man’s clinical care
between 29 May and 2 June 2008:
“In my opinion, there was a series of wrong assumptions made based on the
available clinical evidence. A greater index of suspicion may have led to a
more detailed examination and then the original diagnosis of simple back pain
challenged. Unfortunately, a more thorough follow up examination did not
happen.
“As regards the performance of individual healthcare professionals. In my
opinion, at best there were insufficient clinical details recorded and further
regular follow up appointments arranged. However, it may be the case that
this presentation of bacterial meningitis was unusual; and that is why it was not
suspected by anyone involved in the man’s care. At worst, the man was left
for the majority of the weekend without proper follow up and the clear
deterioration of his physical state went unnoticed. When he was seen in
healthcare on the 1 June, he was clinically worse and timely suspicion then of
something else going on was possible, with the available evidence.
Unfortunately, the opportunity was missed and only when the events of the 2
June unfolded with his delirium and further clinical deterioration, did the
healthcare department suspect more sinister pathology and arrange an
emergency admission.”
“This case should be a learning point for the healthcare department and in my
opinion must be included in the next significant event meeting at HMP Holme
House healthcare department. Once completed, and following further
discussions with the PCT, individuals will require further scrutiny of their
performance in order to learn from any shortcomings.”
The Chief Executive of North Tees and Hartlepool Foundation Trust, in
conjunction with the Governor, should conduct a root cause analysis
into the death of the man and include a performance standard of all
healthcare staff involved in his medical care.
Family concerns
61. Following the man’s death, his family felt well supported by the prison staff and
were offered help and assistance for which they were grateful. Several weeks
after their brother’s death, certain rumours circulated his home town that he had
not received appropriate healthcare and that he should have been sent into
hospital earlier.
62. Whilst the family were still appreciative of the support from Holme House, they
were concerned about the standard of healthcare their brother had received.
They had heard that he had been unwell for several weeks prior to his admission
to hospital with ‘flu type’ symptoms. The question that remained for his family is
whether he could have been diagnosed and treated earlier, and if he would have
survived.
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63. The man did not report any symptoms to healthcare staff until 29 May, four days
before he was admitted to hospital. I am unable to comment on any other
symptoms the man may have had before that time as there are no indications in
his medical notes or personal file.
64. In his clinical review, the doctor says a diagnosis of meningitis is often made in
community general practice after the patient has been admitted to hospital
following tests. The man’s case was no different and the presentation of his
bacterial meningitis was unusual. Nevertheless, an earlier diagnosis might have
helped the man.
65. The clinical review raises issues in relation to the actions of healthcare staff
which are endorsed in my recommendation.
Good practice on the part of the prison’s Family Liaison Officers
66. The family liaison officers offered sensitive assistance to the man’s family. They
visited them at the man’s sister’s home and accompanied her to the opening of
his inquest. The man’s family were very appreciative of their continued support
and in helping with arrangements following their brother’s death.
67. A written log of events was documented by the family liaison officers. It provided
a comprehensive and detailed account of all their interventions with the man’s
family. It was concise and clear, giving dates and times of when the officers saw
and spoke to the man’s family. My investigator noted that it was the most
informative family log she had seen during any such investigation.
I commend the good practice of the family liaison officers.
Support for the man from B Wing
68. Following the man’s death, a display of notices from my office initiated responses
from both officers and prisoners. At interview it became apparent that an officer
had raised his concerns over the man’s welfare with healthcare staff. Other B
wing staff also told my investigator of their worries concerning the man and the
assistance they gave to ensure he was as comfortable as possible. A friend of
the man’s, told my investigator that he thought the officers had been ‘spot on’ in
caring for the man.
69. The prisoner in the adjoining cell to the man looked after him for several days
before he was admitted to hospital. This prisoner helped the man with his
personal care, fetched his meals and made him drinks. He also sat with the man,
keeping him company whilst he was unwell in bed. Other friends on the wing
visited the man whilst he was unwell and offered their support.
70. The man was a trusted and reliable prisoner on B wing. He assisted wing staff as
a wing cleaner and was held in high esteem by staff. All three officers my
investigator spoke to on B wing praised the man for his behaviour and approach.
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I commend the staff and prisoners of B wing for their support of the man
during his illness.
I commend the prisoner in the next cell to the man for the assistance and
care shown to the man whilst he was unwell and ask that his personal file
be endorsed to that effect.
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RECOMMENDATIONS
The Chief Executive of North Tees Primary Care Trust
The Chief Executive of North Tees and Hartlepool Foundation Trust, in conjunction
with the Governor, should conduct a root cause analysis into the death of the man
and include a performance standard of all healthcare staff involved in his medical
care.
Accepted – “North Tees and Hartlepool Foundation Trust, in conjunction with the
Governor will carry out a root cause analysis into the death of the man. However,
not all the health concerns are purely the responsibility of North Tees and Hartlepool
Foundation Trust. (i.e. the doctors are employed by a separate organisation.”
GOOD PRACTICE
1. I commend the good practice of the family liaison officers.
2. I commend the staff and prisoners of B wing for their support of the man during
his illness.
3. I commend the prisoner in the next cell to the man for the assistance and care
shown to the man whilst he was unwell and ask that his personal file be
endorsed.
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