Individual at Leeds

Investigation into the death of a man
whilst in the custody of HMP Leeds
at Leeds General Infirmary
in July 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2011
This is a report into the death from natural causes of a man at Leeds General
Infirmary whilst a prisoner at HMP Leeds. He was 76 years old. I offer my sincere
condolences to his family for their loss. I apologise for the delay in issuing the report
and any additional distress this may have caused.
The investigation was led by my one of my investigators. I must thank Leeds
Community Primary Care Trust (PCT) for the appointment of the clinical reviewer. I
am also grateful to the Governor and staff of HMP Leeds.
The review of the man’s clinical care shows that he received good quality care whilst
in Leeds. He had serious health problems, with a history of chronic obstructive
pulmonary disease (COPD) and diabetes. Both these conditions were well managed
at Leeds, with appropriate investigations and treatment.
My report contains two recommendations. One relates to an occasion when there
was a delay in reviewing the results of a chest x-ray. Although this did not adversely
affect his health I agree with the clinical reviewer’s findings that systems are
improved to prevent any repetition. I also make a recommendation that Leeds
demonstrably promotes smoking cessation services to prisoners even when they
have previously declined this service.
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.
Thea Walton
Acting Deputy Ombudsman November 2011
2
CONTENTS
Summary
The Investigation Process
HMP Leeds
Key Events
Issues
Conclusion
Recommendations
3
SUMMARY
1. At the time of his death, the man was 76 years old and serving a twenty year
sentence at HMP Leeds.
2. The man first arrived at Leeds on 1 August 2008. He had two long standing
conditions affecting his lungs and general health, for which he took various
types of medication and an inhaler. Whilst at Leeds, he was admitted to
hospital on two occasions as an emergency patient. He was last admitted on
19 August 2009 when he was treated for a chest infection, increased
breathlessness and weight loss. Following each admission, he was
discharged from hospital and returned to prison.
3. He was given a follow up assessment by the community respiratory team in
early September 2009 and advice was given regarding his use of inhalers. In
September 2009, following treatment and due to his weakening condition and
inability to cope on the wing, it was decided that the man should be moved to
the healthcare inpatient unit. He remained in this unit until his death.
4. From October 2009 to May 2010, his lung condition deteriorated although he
remained reasonably stable for the latter part of this period. During this time
he underwent a series of further scans and tests at local hospital facilities
partly due to his difficulties in swallowing. The results of these tests did not
indicate any additional serious disease.
5. By late May 2010 he was observed to be struggling with his lung condition and
increased breathlessness. He had for some time been using nebulisers as
well as his inhaler, and required occasional additional oxygen.
6. In the early morning of 9 July 2010, a Healthcare Officer (HCO) was
undertaking routine observation checks of prisoners, when he found the man
collapsed in his cell. The HCO used his radio to issue an immediate call for
emergency medical assistance and then entered the cell. He found that the
man was not breathing. Uniformed and clinical staff responded quickly to the
HCO’s call for assistance. Using the defibrillator (a machine that applies
electrical impulses to the heart and advises whether there is any rhythm which
might be stimulated) the clinical staff found there was no shockable rhythm, so
continued with resuscitation and gave oxygen. Paramedics arrived swiftly
and, maintaining resuscitation, the man was transferred to Leeds General
Infirmary Accident and Emergency department. Resuscitation was continued
for a further ten minutes but, after finding no signs of life, the hospital doctor
pronounced the man dead at 6.44 am.
7. My investigation found the man to have received a high standard of care at
Leeds. However, I do make two recommendations for improvements that
should be made. These relate to following up on test results and promoting
smoking cessation.
4
THE INVESTIGATION PROCESS
8. The investigation was opened on 9 July 2010 by one of my investigators.
Notices were issued to staff and prisoners announcing the investigation. The
notices included an invitation to those who wished to submit information on
the man’s death to make themselves known to the investigator. No staff or
prisoners came forward as a result.
9. The investigator visited Leeds on 13 July. She was given access to all
relevant prison records relating to the man. They included his prison record,
medical records and statements made by staff.
10. Leeds Primary Care Trust appointed the clinical reviewer to carry out a review
of the man’s clinical care. My investigator discussed aspects of the man’s
treatment with healthcare staff at Leeds and with the clinical reviewer. The
clinical reviewer told the investigator that having reviewed the man’s medical
record he did not need to conduct formal interviews with staff.
11. My investigator contacted Leeds Coroner’s Office on 29 July and requested a
copy of the post mortem report. The report was sent to the Ombudsman’s
office on 23 November.
12. My senior family liaison officer wrote to the man’s wife on 2 August 2010. She
also wrote to his friend and executor of his estate on the same day. The
letters informed them of the opportunity to raise questions and concerns for
the investigator to consider. There has been no response from either the
man’s wife or executor. A copy of my report will be made available to the
family on completion should they wish to read it.
13. My report was issued in draft to the man’s family and to the National Offender
Management Service (NOMS). The man’s family did not make any comments
in response to the draft report. NOMS’ responses to my recommendations
are also included at the end of this report.
5
HMP LEEDS
14. HMP Leeds is a category B local prison. The prison serves Magistrates’ and
Crown Courts in the West Yorkshire area taking adult male prisoners on
remand until trial and for short periods after sentence. Up to 1154 prisoners
are held on six wings and the healthcare centre in accommodation certified
normally to hold 829 prisoners.
15. Healthcare staff are available in Leeds 24 hours a day. By day, there is a
doctor in the prison; at night, cover is provided by nursing staff. There is a
nineteen bed inpatient unit which is located directly above the main healthcare
department. The unit is staffed by prison and clinical healthcare staff. Primary
healthcare staff at Leeds prison are commissioned and provided by Leeds
Community Primary Care Trust.
16. The most recent inspection by Her Majesty’s Chief Inspector of Prisons was
undertaken in March 2010. This was an unannounced follow up to an earlier
inspection which took place in December 2007. None of the issues raised in
that report are relevant to the circumstances of the man’s death.
17. Each prison in England and Wales has an Independent Monitoring Board
responsible for monitoring day-to-day life in the prison and to ensure that
proper standards of care and decency are maintained. The most recent
annual report published by the IMB for Leeds does not contain any specific
issues which need to be reflected upon here.
18. The Ombudsman became responsible for investigating all deaths in prison
from 2004. Since that time there have been 18 deaths from natural causes at
Leeds, including that of the man. There are no apparent similarities between
either the circumstances of the deaths or the recommendations made.
6
KEY EVENTS
19. The man was born in Halifax on 6 January 1934. Prior to being sentenced he
lived in Halifax with one of his daughters. He had a history of chronic
obstructive pulmonary disease (COPD). This is a severe respiratory condition
mostly caused by long term smoking. He also suffered from type 2 diabetes.
Prior to being sentenced he was under the care of his doctor in the community
for his medical conditions.
20. On 14 May 2008, the man was convicted of a number of serious offences. He
was sentenced on 1 August 2008 to twenty years imprisonment. He had no
previous convictions and this sentence was his first experience of prison.
21. Before the man left Bradford Crown Court the dock officer completed a form
recording his sentence to accompany him to the prison. On this form the
Dock Officer also recorded “inhaler on person – very bad health – maybe not
long to live”.
22. On his arrival at Leeds, the man underwent a healthcare assessment during
the reception process. Nurse A recorded that he suffered from asthma and
diabetes, and the medication that he was currently taking. The screening
indicated that the man should be held on the vulnerable prisoner unit, and was
unfit for work. The man indicated he wished to see the doctor for a
prescription of his medication and said that he “felt chesty”. During the
healthcare assessment he was identified as a smoker and asked whether he
wished to quit. The man’s response was that he did not wish to do so. He
continued to smoke up until his death.
23. An appointment was made for the man to see a doctor the following morning.
In the meantime, he was prescribed his current medication. He was then
transferred to A wing, which is Leed’s vulnerable prisoners’ unit1.
24. Prison Doctor A saw the man on 2 August and diagnosed Chronic Obstructive
Pulmonary Disease (COPD) and type 2 diabetes. The doctor prescribed an
inhaler and some antibiotics. This was in addition to medication already
prescribed. Healthcare staff requested the man’s medical history from his GP
which was received by fax on 5 August. The following day the man was seen
by prison Doctor B for a review of his medication.
25. On 2 September 2009 the community respiratory team assessment suggested
that the man should be given smoking cessation advice. Subsequently, prison
Doctor B recorded that the man was a smoker and noted the health education
issue
26. The medical records show that over the next ten weeks healthcare staff
treated the man for two infections relating to his COPD. Due to increased
breathlessness he was seen by prison Doctor C on 2 September and advised
1 The vulnerable prisoner wing is a separate wing designed for prisoners who need to be separated
from the main prison population for their own safety. This is usually owing to the nature of their
offence.
7
about his use of the inhalers. He was prescribed a steroid and antibiotics.
Prison Doctor B examined the man again on 9 October, and requested a
chest x-ray. An appointment was arranged at the Leeds General Infirmary for
the x-ray for 27 October.
27. On 20 October the records show that the man underwent a further
examination by the prison Doctor B. As a result of this examination the man
was moved to a lower landing on A wing due to difficulties he was
experiencing in using the stairs.
28. The man was taken to Leeds General Infirmary on 27 October for his chest x-
ray appointment. He returned to the prison the same day.
29. On 30 October the man was examined again by prison Doctor B. At this time
the results of the man’s chest x-ray had not been received by the prison.
Prison Doctor B did not observe any increase in shortness of breath.
30. The man’s medical record shows that a letter regarding the chest x-ray was
received from the hospital on 15 November. The x-ray results found that the
man’s lungs showed symptoms consistent with someone who was suffering
from COPD. The results also showed some sign of infection and a follow-up
appointment was suggested for six weeks time. There is no record of these
results being reviewed by a member of healthcare staff. The man continued
to be issued with repeat prescriptions for the following two months.
31. On 21 January 2009 the man was seen by Nurse B because he was
experiencing muscular pain in his shoulders and arms. He was also having
trouble sleeping. An appointment was arranged for him to see the doctor on
2 February.
32. During his appointment with prison Doctor D found the man’s right wrist to be
swollen and that he was suffering from stiffness in his shoulders with limited
movements. The doctor also reviewed his chest x-ray report. This showed
that the man was suffering from COPD and had a probable infection. It
indicated a need for a repeat x-ray in six weeks time. The man’s blood was
also taken the results of which were considered normal. He was prescribed a
pain killer.
33. A CT scan of the man’s chest was requested on 6 February. A CT
(computerised tomography) scan is an enhanced form of x-ray used as a
supplement to normal x-rays as it yields more information.) This scan took
place at the Eccleshill Treatment Centre, Bradford on 16 February. On the
morning of his appointment, the man was seen by Nurse C because he was
complaining of headaches and general body pain. Nurse C gave the man
some paracetamol.
34. The prison Doctor B reviewed the results of the CT scan on 19 February. The
scan showed the presence of bronchiectasis, which is an abnormal widening
of a lung airway. This condition is associated with COPD and can make the
8
sufferer more susceptible to infections. During the remainder of February and
March the man’s current medication was maintained.
35. The man was examined again by prison Doctor D on 7 April. He said that he
was neither sleeping nor eating well. Prison Doctor D found that the man was
underweight, and prescribed him Ensure Plus liquid2. Further blood tests
were ordered, and he was reviewed again by prison Doctor D on 22 April.
The man complained of persistent aching in his arms and this, together with
the test results, resulted in the doctor prescribing him steroids for two weeks.
36. Prison Doctor D saw the man again on 11 May for a planned review. By this
time he had successfully gained weight, was reporting much less pain and
was feeling much better. The Ensure Plus liquid and the steroids were
gradually reduced over the next months.
37. On 4 July, the man attended the healthcare unit with increased
breathlessness and a possible chest infection. He was given a nebuliser (a
device similar to an inhaler used to treat more severe symptoms by which
medication is breathed in though a mouthpiece or mask) and antibiotic
treatment, and checked on A wing later in the day. The following day the man
was seen by Nurse D. He appeared brighter and did not complain about his
breathing. On 6 July the man was seen by the locum doctor who increased
his steroid dosage. Four days later, he presented himself again with breathing
difficulties and complained of not being able to sleep. He was examined by
prison Doctor B who prescribed different antibiotics.
38. On 13 July, Nurse E was called to the wing due to the man’s breathing
difficulties. He also complained of chest pain. The man was given nebuliser
treatment which eased his breathing. However, his chest pain persisted. An
emergency ambulance was called and the man was admitted to St James
University Hospital in Leeds. Nurse F contacted the hospital ward during this
admission, and was told the diagnosis was exacerbation of COPD. The man
was treated with oral antibiotics and given some new inhalers.
39. The man returned to Leeds on 17 July. Over the next month he was seen by
doctors and healthcare staff on nine occasions, both on the wing and in the
healthcare centre. The primary concerns were continued breathlessness,
chest infection, sleeplessness, and weight loss. On 19 August prison Doctor
E referred the man for an emergency admission to the Leeds General
Infirmary due to his chest condition and weight loss.
40. During his stay in hospital the man was treated for his chest infection and a
series of other tests and CT scans were undertaken. Other than the COPD
exacerbation no other problems were identified. The man returned to Leeds
on 25 August.
41. The Community Respiratory Team made a post-admission follow up visit to
the man on 2 September. A full respiratory assessment was undertaken, and
2 This is a food supplement designed to assist weight gain.
9
suggestions made regarding his inhalers. A recommendation to the doctor to
provide smoking cessation advice was recorded on the assessment form.
The man is recorded as “feeling back to his normal level”.
42. On 18 September prison staff asked a member of healthcare to see the man
in his cell on 18 September. The man was seen by healthcare officer. He
said had been awake all night with vomiting and diarrhoea. The man was
given some medication to ease his symptoms. Three days later he was seen
by Nurse G in surgery who found him walking poorly, breathless, in low mood,
and dehydrated. She considered the man was no longer fully able to cope
being on the wing. It was decided to admit him into the healthcare inpatient
unit on 23 September.
43. The man’s condition continued to deteriorate over the following weeks. Prison
Dr B examined him again on 16 October observing that he continued to lose
weight despite food supplements, he was suffering dysphagia (difficulty in
swallowing), and was experiencing abdominal pain. Prison Dr B referred the
man for a series of tests at the Leeds General Infirmary.
44. Between late October and December the man was taken to hospital for
various scans on six occasions. None of these scans indicated any serious
disease, although an inflammation of his stomach was identified for which he
was effectively treated.
45. By the middle of November it was noted the man was regaining weight,
though he remained frail. He was at this stage making use of both inhalers
and nebulisers to counter the symptoms of his COPD, and he was given
advice on how to use these most effectively. He continued to receive his
regular medications, and was regularly reviewed by healthcare staff. On 12
December prison Dr B recorded that he was a “smoker-rolls own cigarettes-
health education-smoking”, but it is not clear whether this means he was
actually given smoking cessation education.
46. The man’s condition had settled to the extent that by 4 January 2010
Healthcare Officer B recorded him to be “very independent in all aspects of his
daily living”. Over the next five months to May he was regularly described as
being mobile and taking exercise in his cell or around the healthcare unit. It
was also noted that he was “uncomplaining and self caring”. Despite these
positive notes, it was also clear that the man continued to suffer from
worsening breathlessness and received some occasional oxygen to assist
with this.
47. During this period he had two further escorted visits to the Leeds General
Infirmary, on 4 and 22 March. The first resulted in discharge from the care of
the gastroenterologist dealing with his stomach inflammation, and the second
was for the retinal scan required for patients suffering diabetes. This scan
indicated his retinas were normal and that the man’s diabetes remained well
managed.
10
48. On 7 March a formal five point care plan was written by the healthcare
manager to manage the man’s COPD and to promote his independence and
well being. His medical records show that this plan was adhered to through to
July.
49. Prison Doctor B saw the man on 27 May when he was observed to be
“struggling” with his COPD. He was prescribed steroids and antibiotics which
stabilised his symptoms within a few days.
50. In mid June the man was treated for a urinary tract infection. Regular nursing
reviews through the remainder of June indicated that he was settled, and able
to move around the unit. The last review on 27 June by Nurse H recorded the
same and that the man had no complaints at this time.
Events of 9 July 2010
51. At approximately 5.50 am on 9 July healthcare Officer (HCO) D was
undertaking a routine observation of prisoners in cells in the healthcare in-
patient unit. Healthcare Officer D looked into the man’s cell through the
observation panel and he saw him collapsed on the floor. He called out to the
man but did not receive any response. He used his radio to call for immediate
assistance from other staff. The officer also alerted the night orderly officer,
and the Senior Officer (SO), that he was breaking his sealed key pouch to
enter the man’s cell.3 The prison control room incident log records that this call
was made at 5.52 am.
52. Having entered the cell, Healthcare Officer D found the man had a slight
laceration to his head, was not breathing and had no pulse. He therefore
started cardiac pulmonary resuscitation (CPR) compressions, while waiting for
other staff to arrive and assist. A few minutes later the SO arrived, and a few
moments after him the first nurse on the scene arrived followed by the second
nurse on the scene carrying the medical emergency bag. The first nurse on
the scene gave the man breaths via a face mask, then applied the
defibrillator.4 The results of the defibrillator did not advise that an external
shock was appropriate so CPR was continued. The second nurse on the
scene gave the man oxygen while the first nurse on the scene and the SO
took over giving CPR compressions.
53. The SO called for an emergency ambulance. The prison control room incident
log records the SO’s request at 5.56 am. The ambulance arrived at the prison
at 6.04 am, and the paramedics entered the cell within a few minutes. The
nurses briefed the paramedics who took over the CPR. The man was quickly
transferred to the ambulance, with the nurses assisting to maintain the CPR.
The control room log shows that the man was in the ambulance at 6.20 am.
3 At night time officers carry keys in a sealed to pouch which only be opened in the case of an
emergency.
4 A defibrillator is a machine used to shock the patient’s heart and restore the heart's normal rhythmic
patterns. It cannot however, restart the heart if a detectable rhythm cannot be found.
11
54. The SO asked Officer A and Officer B to escort the man to hospital, with
appropriate instructions not to apply handcuffs. The control room incident log
records that the ambulance left the prison at 6.26am. The ambulance arrived
at Leeds General Infirmary at approximately 6.33am and clinical staff in the
Accident and Emergency department continued resuscitation attempts.
However, this was unsuccessful and the man was pronounced dead at
6.44am.
55. A post mortem was carried out at the Coroner’s request. The doctor who
carried out the post mortem found that the primary cause of the man’s death
was Ischaemic heart disease (an inadequate supply of blood to the heart
muscle) due to atherosclerotic coronary artery disease (narrowing of arteries
to the heart), with secondary causes as diabetes mellitus, hypertension and
chronic obstructive pulmonary disease (COPD). The immediate cause of his
death was a heart attack.
56. Healthcare Officer A was appointed as the prison’s family liaison officer. At
9.35am on 9 July he together with Governor A, visited the man’s wife at her
home. The man’s wife was given the news that the man had died. Later the
same day he gave the same news to his friend, by telephone.
57. Over the next eight weeks Healthcare Officer A liaised with, and offered
support, to the man’s family. He had telephone contact with the man, two of
her daughters, and two of her grandchildren. He also liaised with other
professionals involved with the family, and with the Coroner’s office and the
man’s solicitor.
58. Following the man’s death staff were offered access to the prison’s staff care
and welfare team. The man’s funeral took place on 6 August. The Prison
Chaplain conducted the funeral service and the prison paid the full cost of the
funeral in accordance with the guidance given in Prison Service Order 2510,
Follow up to Deaths in Custody.
12
ISSUES
Clinical Care
59. A clinical review was undertaken by the clinical reviewer on behalf of Leeds
Community PCT. The clinical reviewer concludes that it is likely the man had
a well established disease of his coronary arteries at the time he was taken
into custody and he was at risk of suffering a heart attack with its risk of
sudden death at any time. He considers it probable that even had the man
suffered his heart attack in the presence of healthcare staff or in a hospital the
man would not have survived.
60. The man was known to suffer from COPD and diabetes at the point of his
reception into Leeds. The clinical reviewer indicates that the treatments he
was given for his COPD were all of a good standard, and that the infections
that he suffered as a result of the disease were well managed. Similarly, he
found that the man’s diabetes was well controlled and monitored. In addition,
the clinical reviewer considers that the new presenting symptom of difficulty in
swallowing (dysphagia) was investigated in a timely and appropriate manner.
61. There is evidence that the results of the man’s first chest x-ray were
overlooked for a number of months until he presented with muscular pain
requiring a further scan. The clinical reviewer does not consider this oversight
was indicative of a frequent problem at Leeds and there was no negative
consequence to it on this occasion. However, it is important that robust
procedures are in place to follow up test results in a timely manner. I
therefore endorse the following recommendation made by the clinical
reviewer:
The Healthcare Manager at HMP Leeds should ensure that test and x-ray
results are reviewed promptly by the appropriate member of healthcare
staff.
62. The clinical review also highlights the importance of smoking cessation
advice. During his initial reception health screen the man was identified as a
smoker and asked whether he wished to quit. The man’s response was that
he did not wish to do so. On 2 September 2009 the community respiratory
team assessment suggested that the man should be given smoking cessation
advice. Subsequently, prison Dr B recorded that the man was a smoker and
noted the health education issue. It is not clear what action was taken. I agree
with the clinical reviewer’s recommendation and repeat it here:
The Healthcare Manager at HMP Leeds should ensure that smoking
cessation advice is given to all smokers on a regular basis and that the
outcome of this is clearly documented.
63. Despite the issues highlighted above, the overall standard of care given to the
man at Leeds was of a high quality.
13
Emergency Response
64. Following the discovery of the man in his cell both uniformed and clinical staff
responded swiftly and efficiently. Healthcare Officer D entered the man’s cell
and immediately summoned healthcare staff and an ambulance. He also
began resuscitation procedures. Healthcare staff arrived quickly with the
appropriate medical equipment. The emergency equipment was immediately
applied to the man. The control room log shows that the ambulance took six
minutes to reach the prison. On arrival the paramedics were quickly escorted
to the man’s cell where they started their own advanced life support
procedures. The man was taken to the ambulance where escort staff were
waiting. SO A gave the instruction that restraints should not be applied to the
man in case he required further emergency medical intervention. The
decision not to apply restraints was compassionate and appropriate in the
circumstances. It also offered the man some dignity when he died.
Conclusion
65. The man was a man in poor health whose medical needs were well served
while at Leeds. The staff responding to his collapse acted with
professionalism and consideration.
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RECOMMENDATIONS
1. The Head of Healthcare at HMP Leeds should ensure that test and x-ray
results are reviewed promptly by the appropriate member of healthcare staff.
Accepted- A new process now exists in healthcare whereby all diagnostic and
laboratory results received in to healthcare at HMP Leeds are forwarded
immediately to the GP are not scanned on to SystmOne electronic medical
records until they have been reviewed and commented upon.
2. The Healthcare Manager at HMP Leeds should ensure that smoking cessation
advice is given to all smokers on a regular basis and that the outcome of this
is clearly documented.
Not accepted- All prisoners are offered smoking cessation advice at screening
reception and can access health promotion advice at any point during their
stay. However, it is not possible within current resources for healthcare to
undertake to regularly revisit this for every prisoner who smokes. In addition,
evidence based practice in motivational interviewing for substance use would
suggest that repeated information giving is more likely to be counter-
productive rather than beneficial.
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