Individual at Whatton

Investigation into the circumstances surrounding the death
of a man in a local medical centre, while a prisoner
at HMP Whatton, in September 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2010
This is the report of an investigation into the circumstances of the death of
a life sentenced prisoner at HMP Whatton, on 14 September 2009. The man had a
longstanding heart condition and a heart replacement valve was fitted in 2001. A post
mortem found that the main cause of his death was acute heart failure.
The man’s parents had died some years ago while he was in prison. He was an only
child and no other next of kin or family members could be found. I would like to offer my
sincere condolences to all those who knew him and were affected by his death.
One of my investigators conducted the investigation. An independent review of the
man’s medical care was undertaken by a clinical reviewer, on behalf of Nottinghamshire
County Teaching Primary Care Trust (PCT). Not for the first time, I am grateful to this
clinical reviewer for his contribution.
I would also like to thank the Governor of Whatton and her staff for their cooperation. I
am grateful to the Head of the Secretariat and, particularly to the member of staff from
Safer Custody who provided a very high standard of prison liaison. I would like to
express my appreciation and thanks to the prisoners and staff on the man’s wing who
provided valuable information.
I make one recommendation about the monitoring of International Normalised Ratio
(INR) results as the investigation found that healthcare staff failed to act upon
information received from the hospital. On this occasion, it did not impact on the man’s
death, although it may prove critical in future. Aside from this, I judge that the care
given to him at Whatton was equal to that which he would have received in the
community.
The National Offender Management Service has accepted my recommendation and
their response is documented on page 20 of the report.
Jane Webb
Acting Prisons and Probation Ombudsman June 2010
2
CONTENTS
Summary 4
The investigation process 6
HMP Whatton 7
Key findings 8
Issues 16
Recommendation 19
3
SUMMARY
The man was a life sentenced prisoner, he had served nearly 21 years in prison when
he died. He served his sentence in a number of prisons, primarily in the north of
England, before going to Whatton in January 2008. The man’s behaviour in prison fell
short of what was expected on a number of occasions, however, he learned to read and
write and made progress.
From the outset, he had a number of medical conditions, including epilepsy (although
he did not have seizures in custody), stomach problems, high cholesterol and heart
disease. The most serious of these was heart failure, the condition from which he
subsequently died. The man collapsed a number of times and was sent to hospital in
the community.
In 1995, the man was diagnosed with mild aortic valve disease and an aortic valve
replacement was advised in 1996. However, this did not take place until his health
deteriorated at HMP Albany in January 2001. He underwent surgery for a mechanical
aortic valve replacement at a local hospital. (Hospital A) He was then prescribed
warfarin1, (an anti blood clotting drug requiring constant monitoring). He recovered and
was reviewed every year by a cardiologist.
The man’s clinical record is extensive because of his heart condition. He continued to
smoke against medical advice and did not eat very well. However, the clinical reviewer
noted that he complied with his medication.
A few days before the man’s death, prisoners on his wing noticed that he was violently
sick and sleeping most of the day. He refused to take advice from friends on the wing
to report this to healthcare.
On the day he died, the man was found collapsed in his cell at around lunchtime. A
wing officer went to healthcare and asked for a nurse, who put him on oxygen to help
his breathing, but noticed that he was coughing bright red blood. She asked for an
emergency ambulance to be called. A paramedic arrived within ten minutes and an
ambulance followed 50 minutes later.
The man was placed in restraints and, accompanied by two officers. He was taken by
ambulance to the local medical centre. Although urgent, his condition was not thought
to be life threatening. When he arrived at the hospital, medical staff carried out tests
and judged that he needed to stay in hospital overnight, although he appeared to be
recovering. At around 5.30pm, while in the cardiac unit, his condition suddenly
deteriorated and he had a heart attack.
The escort staff who accompanied him were caught by surprise at his rapid
deterioration and the restraints needed to be removed as a matter of urgency. The
restraint at one end was removed from the officer but the attachment at the other end
1 Warfarin is an anti coagulant drug used to thin the blood to stop clotting
4
could not be removed from the man as his body had rolled onto the chain. He could not
be moved because staff were carrying out cardio pulmonary resuscitation and using the
defibrillator. In these circumstances, not removing the restraint is regrettable, but
understandable. Hospital staff made every effort to save the man’s life, but sadly he
died at 7.10pm. No next of kin could be found.
The clinical reviewer commented that the man had severe cardiac disease and his life
expectancy was reduced. His death was understandable in the circumstances. He also
found no significant shortcomings in how the man’s medical care was managed at
Whatton. I have recommended that the head of healthcare should review the
healthcare department’s systems and protocols for management of hospital information
relating to these.
5
THE INVESTIGATION PROCESS
1. The man died on 14 September 2009. However, due to a misunderstanding
between the prison and the National Offender Management Service (NOMS)
regional office, this office was not notified of the man’s death until 30 September
2009. Terms of reference and notices were issued to staff and prisoners at Whatton
telling them that an investigation would be taking place, and inviting those who
wished to see the investigator to make themselves known. The investigator ,
requested copies of the man’s core record, clinical record, and other records
relevant to his time in custody and his death.
2. The investigator also contacted HM Coroner to inform him of the nature and scope
of my investigation and to request a copy of the post mortem report. A copy of the
report was received by the office. The post mortem found that he died of:
1a. Acute cardiac failure
b. Left ventricular hypertrophy
c. Aortic valve disease (prosthetic valve)
3. The Investigator and an Assistant Ombudsman visited Whatton on 2 December
2009. They met the prison’s Safer Custody Officer, and visited the wing where the
man lived before his death. The investigator spoke with prisoners and staff who
knew him. She then wrote to the Governor, on 22 December 2009, updating her on
the progress of the investigation.
4. A clinical review of the man’s medical care was commissioned from
Nottinghamshire County Teaching Primary Care Trust . The clinical reviewer
focussed on the clinical care the man received at Whatton.
5. The prison made every effort to locate and contact the man’s next of kin. His
parents died while he was in prison and he was an only child. Despite their efforts,
no next of kin were identified.
6
HMP WHATTON
10. HMP Whatton is a category C training prison for prisoners convicted of sexual
offences, or who have a sexual element in their offending history. It holds a higher
than average older population.
11. In response to overcrowding in prisons across England and Wales, Whatton
underwent rapid expansion in 2006, increasing the operational capacity from around
400 prisoners to 861 by 2008.
12. Healthcare at Whatton is provided by Nottinghamshire County Teaching Primary
Care Trust (PCT). The Independent Monitoring Board report for the period June
2008 to May 2009 said they were impressed by the “overall proactive management
of all aspects relating to healthcare”. The IMB judges that healthcare is responsive
to the frequently changing needs of the population. This is a challenge as 60 to 70
per cent of the prisoners at Whatton are aged 40 and over, compared with 20 per
cent of the adult population in the community. The IMB comments that it is therefore
inevitable that more prisoners will die of natural causes. The IMB concludes that
healthcare at Whatton continues to be excellent, with particular emphasis on
palliative care.
13. Despite a high ratio of older prisoners, Whatton does not have an inpatient
healthcare unit. The prison does not have 24 hour healthcare facilities and medical
staff are not on site during the night or at weekends. (I have commented on this in
previous death in custody reports). Out of hours medical care is provided by
Nottingham Emergency Medical Services (NEMS).
14. Healthcare professionals visit the prison on a regular basis and deliver care through
a series of clinics including a doctor, dentistry, chiropody, optician and psychiatry.
15. The IMB continues to voice concern about sex offenders sharing cells and the
vulnerability of some prisoners. The Board also noted that at the time of writing their
report, 11 percent of the prison population were life sentenced prisoners who were
over their tariff, such as this man. There was concern that the prison was not
adequately resourced to meet the needs of this population.
16. In her inspection report dated March 2007 the HM Chief Inspector of Prisons, said
that many aspects of the regime at Whatton that had been applauded in a previous
inspection were still in place. She acknowledged that the prison had to fully adapt to
the changes it had been asked to take on so rapidly.
16. There have been 20 deaths at Whatton since the Ombudsman’s office began
investigating all deaths in prison custody in 2004.
7
KEY FINDINGS
17. The man was remanded into custody at HMP Hull in September 1987, charged with
a murder. He was convicted and sentenced at a local Crown Court on 12 October
1988. A life sentence with a tariff 2 of 14 years imprisonment was imposed. His
tariff was later raised to 18 years following a review by the Home Secretary. The
man’s tariff expired on 25 September 2005, but he was not considered suitable for
immediate release into the community.
18. During his sentence, the man spent time in a number of prisons throughout England
before going to HMP Whatton in January 2008. Prison and clinical records kept
during the early years of the man’s sentence are extensive and in paper form.
Authors of the entries in those records did not always record their name, role or the
prison where the entries were made. As a consequence, it is sometimes difficult to
establish where the man was located in the earlier part of his sentence. The issue is
made more complex as he occasionally spent time at other prisons for a short period
in order to receive visits from family or friends.
19. The healthcare department at Hull wrote to the man’s community doctor on 22
September 1987. The doctor confirmed on 25 September 1987 that the man was
taking medication for epilepsy, did not abuse alcohol or drugs but was noted to be of
“below average intelligence”.
20. The man had a lengthy interview with healthcare staff at HMP Leeds on 9 March
1988. During that interview, he told the healthcare officer that he had suffered
epileptic fits since the age of two and had taken Epilem 3and Phenobarbitone 4
regularly until 1976. He said that his last epileptic fit was at the end of 1987.
While on remand at Leeds in March 1988, he complained of pain in the left side of
his chest which was treated with co-proxamol, a painkiller.
21. The man’s clinical record shows that on 19 February 1991, he was assessed as fit
for transfer to HMP Wakefield. Until July 1992, healthcare staff at Wakefield
reviewed him on a regular basis for various conditions including stomach pain, for
which he took Gaviscon5 to relieve the symptoms.
22. In mid-July 1992, he experienced shooting pains in his upper abdomen. The clinical
record shows that an electrocardiogram (ECG) was carried out. (An ECG is a
measurement of the electrical activity of the heart.) The record is difficult to read but
it is likely that the ECG was performed at a hospital as the word “discharged” is
written across the date of 10 July 1992. However, the clinical record makes it clear
2 A Tariff is the minimum time a prisoner has to spend in prison before the Parole Board for England and
Wales will consider release. At the time the man was imprisoned, the Home Secretary set the tariff. It is
now set by the Trial Judge.
3 Epilem (sodium valproate) is a medication to control epilepsy.
4 Phenobarbitone is one of the oldest drugs used for the treatment of epilepsy.
5 Gaviscon is medication for the relief of heartburn and indigestion.
8
that a referral was sent to a cardiologist. Again, it is not evident who made the
referral but the healthcare department were advised to check on the man in two
weeks.
23. In October 1992, the man was sent to hospital urgently after complaining of feeling
breathless. He was discharged 9 October without a discharge letter. Under those
circumstances, the prison spoke with hospital staff who thought that he had a viral
infection affecting the muscles around his heart area. No treatment was necessary
but a follow up appointment was made for 17 October. The man’s clinical record
says that he refused admission to the prison hospital for observation and signed a
refusal of treatment form.
24. The man was subsequently diagnosed with mild aortic valve disease with no specific
treatment advised. The hospital said they would see him every two years for review.
25. In May 1993, healthcare staff assessed him as fit to go to Hull to receive
accumulated visits from his family. (When prisoners live a long distance from their
home and are unable to receive visits, they can apply for a temporary move to a
prison nearer to their family.)
26. Throughout his time at Wakefield, the man visited healthcare regularly until his
transfer to HMP Frankland in December 1994. In February 1995, he complained of
chest pain again and healthcare staff noted that a hospital (Hospital B) had
diagnosed mild aortic valve disease. The man was working in the upholstery
workshop at Frankland at the time and he was worried that lifting heavy furniture
would worsen the condition. Healthcare staff advised that he should be excused
from work the following day; they prescribed painkillers and reassured him.
27. After an appointment at his follow-up clinic for aortic stenosis (a narrowing of the
aortic valve, which restricts the flow of blood), a Consultant Cardiologist, (Consultant
A) wrote to a medical officer, at Frankland on 31 July 1996. He said the man felt
breathless when climbing stairs and noted that his heart condition had deteriorated.
In the circumstances, he felt that the man would need an aortic valve replacement.
He agreed to see him in a year but wanted to be kept informed of developments in
the meantime.
28. The man was noted to have recently given up smoking, but described himself as
“feeling edgy”. A nurse said at interview that the man continued to smoke
throughout against medical advice and his clinical record shows that he regularly
complained of chest pain.
29. Consultant A reviewed him again on 30 July 1997. The doctor judged that it was
appropriate for the man to be referred to a Hospital (Hospital C) for aortic valve
replacement surgery as his condition had deteriorated. He had complained of dizzy
spells as well as feeling breathless when walking upstairs. The man was aware of
his impending appointment for a valve replacement in July 1997, as he told
9
healthcare staff of his concern that he had to keep cancelling his accumulated visits
while waiting for the operation.
30. On 14 May 1998, he transferred to HMP Albany on the Isle of Wight. His clinical
record shows that he collapsed while working in the prison gardens on 28 January
1999 and was sent to a hospital. (Hospital D) The diagnosis of aortic stenosis was
confirmed.
31. The man had chest pain again on 30 May 1999. In July, a locum medical officer,
referred him to the consultant cardiologist at Hospital D to ask for a prognosis as the
man had voiced concerns about his future prospects.
32. Throughout his sentence, the man’s behaviour on the wing sometimes fell below the
standard expected of an enhanced6 prisoner at times and he was downgraded to
standard privilege status. He was described as demanding of staff time and
patience, and the standard of hygiene in his cell was poor. This was interspersed
with other more positive entries made by wing staff which showed that there were
periods when he made an effort to conform to prison standards and rules. On 21
December 1999, he returned to Hull to go to his father’s funeral.
33. At Albany, an exercise stress test was cancelled twice due to a shortage of staff. On
8 December, an Honorary Consultant Cardiologist (Consultant B) at Hospital D
wrote to Healthcare to advise they would not send another appointment but would
wait for the prison to arrange for one. After he finally went for the test Consultant B
wrote to give the results in a letter dated 19 July 2000. He advised that the man
should be seen very soon at the cardiology clinic. The man attended the cardiac
clinics and cardiac catheterisation7 was advised.
34. Consultant B referred the man to a different Consultant Cardiologist (Consultant C)
at Hospital A, for cardiac catheterisation. In August 2000 Consultant B’s frustration
at the man missing important appointments is made clear in his letter to the
Governor of Albany. The Governor replied assuring Consultant B that every effort
would be made to ensure that the man attended the hospital for the procedure.
35. The man eventually underwent the cardiac catheterisation procedure successfully
on 21 November 2000. Consultant C advised that the man should be offered aortic
valve replacement. He said that the man was agreeable to this and he intended to
write to the appropriate cardiac surgeon to put his name on the waiting list.
36. The clinical record shows that on 16 January 2001, the man underwent surgery for a
mechanical aortic valve replacement at Hospital A. He was prescribed warfarin 8
6 Enhanced status is part of the Incentive and Earned Privileges Scheme to encourage positive behaviour
in prisons. There are three levels – basic, standard and enhanced, with the latter being the highest.
7 Cardiac catheterisation is the insertion of a thin plastic tube into a chamber or vessel of the heart to
measure information about the ability of the heart muscle, blood pressure and oxygen.
8 Warfarin is a drug used to thin the blood
10
(which the cardiac surgeon said he would have to take for the rest of his life because
of his mechanical heart valve) and pain relief. It was noted that he felt well after his
operation. He was reviewed by a new Consultant Cardiologist, (Consultant D) six
weeks later at the same hospital and was said to have made an excellent recovery.
The hospital suggested an annual review.
37. The man’s mother died in October 2001 and he went to the funeral in early
November. He was then sent to a number of prisons for a variety of reasons,
including accumulated visits with friends and family.
38. In December 2002, the Parole Board considered the man’s case and refused a
transfer to an open prison. The Board considered that, although he had made some
progress, there was still a great deal of work to complete before he could be
considered for a progressive move. In addition, the Board noted that he had been
subject to ten adjudications (disciplinary charges).
39. In May 2003, he transferred to HMP Littlehey. He went to the healthcare centre on 5
February 2004 complaining of “heaviness in his chest”. He was sent to hospital a
few days later following a collapse at work. The man was referred to a different
hospital (Hospital E) and the clinical record shows that the man refused to attend an
appointment at the hospital and signed a disclaimer on 28 February 2004. No
reason was given for his refusal on the disclaimer letter and the clinical record does
not mention the reasons.
40. The man was still under the care of Hospital E when he was transferred to HMP
Wymott in 2004 to undertake a specialist course designed to reduce his risk of re-
offending. A letter dated 5 May 2004, from Littlehey to Wymott, suggests that
Hospital E were unaware that he had transferred. The letter says that Hospital E
telephoned Littlehey asking why he did not attend for an appointment on 19 April
and did not realise that he had been transferred. In the circumstances, Hospital E
suggested the man be referred to the local cardiac outpatient department for
treatment and they would liaise with them regarding his care.
41. The man developed a complication following his aortic valve replacement surgery.
He was due to see to a Consultant Cardiologist (Consultant E) at a local Hospital
(Hospital F) on 30 September for a follow up appointment. The prison asked
Consultant E if he could see him earlier as he had developed a pyogenic
granuloma9 He considered the problem to be ongoing although the man denied it.
42. On 2 September 2004, the man missed a hospital cardiac appointment at a hospital
(Hospital G) due to a lack of escort staff. They arrived two hours after the
appointment and staff said they had called to say they would be late but the hospital
said the man would not be seen. The appointment was rearranged for 16
September.
9 A pyogenic granuloma is a harmless overgrowth of large numbers of tiny blood vessels.
11
43. Following the appointment on 16 September, the hospital told the prison that the
man had a sternal wire protruding through his skin and there was evidence of an
infection/abscess. On 8 November, the man was admitted to hospital and had an
operation to correct the problem.
44. The man regularly attended the International Normalised Ratio (INR) clinic to
monitor the clotting levels in his blood while on warfarin.
45. On 8 September 2006, he was found unconscious on his cell floor. An ambulance
was called and he regained consciousness on the way to the hospital. He
complained of chest and head pain. After investigation, he returned to the prison the
following day. A discharge letter said that no treatment or follow up appointment
was needed and advice was given about using a GTN10 spray.
46. In January 2008, the man transferred to Whatton. Healthcare staff continued to
monitor and adjust his medication as necessary. His behaviour on the wing was
variable and continued to give cause for concern at times. He received a number of
verbal warnings. Despite telling his personal officer that he wished to become an
enhanced status prisoner, he remained on standard as his behaviour did not
improve sufficiently for him to be upgraded.
47. A review of the man’s status under the Incentives and Earned Privileges scheme
was held on 2 July 2009. The review board concluded that the man’s behaviour had
improved sufficiently for him to be given enhanced status. He was working in the
prison workshop and his behaviour had improved over the previous few months.
The board felt that he had reflected upon his behaviour, was complying with his
sentence plan and he had become a mentor to other prisoners experiencing
difficulties.
48. A sentence planning and review report completed by the B wing residential manager
and countersigned by the Lifer Manager on 6 July confirms that he had made
progress in all areas. The recommendation was that he should be transferred to an
open prison where he would be able to build on the progress he had made and
continue to work towards his eventual release.
Events a few days before the man’s death
48. A fellow prisoner (prisoner A) spoke with the investigator. Prisoner A said that he
saw the man in the dining hall at lunchtime on Sunday 13 September and noticed
that he was breathless. Later that afternoon, the man “barged through” prisoner A’s
cell door unexpectedly as he needed to use the toilet urgently because he had
diarrhoea. He told prisoner A that he felt “collapsed and faint”. He spent around 15
minutes using the toilet in prisoner A’s cell. During this time he asked prisoner A to
switch on his fan as he could not breathe. The man returned to his own cell once he
had got his breath back. Prisoner A recalled that the man refused his offer of help.
10 A GTN spray is glyceryl trinitrate. It is used to ease angina pains.
12
He used the corridor wall to support himself as he returned to his own cell at the end
of the corridor. He said the man did the same thing the following day. The
investigator asked prisoner A why he did not tell wing officers that the man was
unwell. He explained that he did not tell an officer until the day after the man’s
collapse because prisoners are not meant to use a toilet in any cell other than their
own.
49. Another prisoner (prisoner B) said he knew the man well and was aware that hehad
been ill for around two weeks before his death. Prisoner B made a number of
observations about the man’s health and lifestyle. These included the man’s refusal
to go to the healthcare centre, despite urging him to do so, vomiting after every
meal, repeated visits to the toilet and developing a cough that prisoner B said he
had not heard before. He described the man’s diet as very poor. He said he
smoked, “ate rubbish and lived off pot noodles”.
50. Prisoner B was aware that the man had undergone a number of heart operations in
the past because he had shown him the scars. He recalled that about four days
before the man’s death, he noticed he was sleeping all day and was “really very ill”.
Prisoner B was able to confirm prisoner A’s version of events about the man using
his cell three days before his death, as he had witnessed it.
14 September 2009
53. The man’s wing record says that he was sick in his cell at lunchtime on the day he
died. The clinical record shows that at 12.10pm a wing officer went to the
healthcare centre to say that the man was vomiting and struggling to breathe. A
Senior Nurse went to his cell. When she arrived, the man told her that he had
coughed clots of blood the day before but did not tell healthcare staff. The Nurse
found that the man was pale and slightly grey, with an audible wheeze. He was
beginning to lose consciousness and she and the Officer lowered him to the floor
where he coughed bright red blood. The man was given oxygen and an emergency
ambulance was called. The paramedic arrived at 12.40pm.
54. The Radio Daily Transmission Log records that the ambulance was called at
12.30pm and arrived over an hour later at 13.28pm. Two escort officers11 went with
the man to the hospital in the ambulance, Officer A and Officer B. When Officer B
arrived at the prison to start his shift, he was told that he would have to leave the
prison immediately on an emergency escort. Officer B went to the cell. The
paramedics had put the man in a chair and wheeled him to the ambulance. He was
placed in restraints known as an escort chain. One end of the cuff was attached to
his wrist and the other to Officer B, linked with a long length of chain. The
Gatekeeper’s Daily Occurrence Book shows that the ambulance left the prison at
2.03pm. Officer A recalled that the ambulance did not travel under emergency “blue
11 An escort officer is a prison officer who accompanies a prisoner into the community for an appointment
or medical emergency.
13
light” conditions. The man was given oxygen and Officer B described him as quiet
and apparently exhausted throughout the journey.
55. Officer B said that the man was allocated a bay in the Accident and Emergency
Department at the local Medical Centre. Nursing staff carried out a number of tests
and the man was offered aspirin for his heart. He refused this on the basis that he
was not allowed to take it unless healthcare at Whatton agreed. Officer B gave the
direct telephone number of the healthcare department to hospital staff and, when
Whatton healthcare staff confirmed that the man should take aspirin, he did so.
56. Despite the man becoming more alert, doctors told the escort officers that he would
remain in hospital overnight. Officer B saw the man tell a doctor that he did not have
next of kin and that he was on his own.
57. At around 5.30pm, the man was moved to the cardiac care unit for observation. The
officers did not think that medical staff had any apparent concerns. Unexpectedly,
he suddenly struggled to breathe despite being given oxygen since he left the
prison. Officer A had left the area to make a telephone call to update the prison,
leaving Officer B on his own with him. Officer B alerted medical staff who came to
assist. The man’s condition deteriorated and medical staff judged that he was on
the verge of a heart attack. Senior Officer A arrived on the ward at this point
(6.40pm).
58. A few seconds before Senior Officer A arrived, Officer A had left the bay to
telephone the prison to ask permission for the restraints to be removed. Officer B
instantly assessed the situation and then told Senior Officer A that he wanted the
restraints removed immediately as a defibrillator12 was about to be used to shock
the man and he (the officer) did not want to receive an electric shock when this
happened.
59. A few seconds later, the man had a heart attack. Senior Officer A said he took the
restraint keys from Officer B’s pocket while he was using the telephone. He
immediately removed the cuff from Officer B as the medical staff needed to begin
chest compressions and apply the defibrillator. Senior Officer A said that he was
unable to remove the restraints from the man as he had rolled over and was lying on
top of the escort chain. Senior Officer A said that a few seconds later, Officer A
returned saying that Principal Officer A had given permission to remove the
restraints.
60. Officer A told the investigator that when it was clear that there was a medical
emergency, he had some discretion regarding removing restraints. He was waiting
for guidance from the medical staff because the man’s situation was not clear to him
and he was uncertain whether they were going to use a defibrillator or not. To pre-
empt matters in case removal of the restraints became essential, he sought
12 A defibrillator is a machine that delivers an electric shock to try and restart the heart in the event of
cardiac arrest.
14
permission from the prison. Sadly, despite the efforts of hospital staff, the man died
at 7.10pm.
61. At 8.10pm that evening, a hot debrief13 was held. According to the notes of the
meeting, Officers A and B attended along with other prison staff. The note records
that both Officer A and Officer B were offered support from staff care or employee
support services. They were also offered time off from work if they felt they needed
it.
62. The man had not listed any next of kin and the prison and the police were unable to
find or contact any family members. The investigator spoke with the Coroner’s
Officer. She confirmed that the man did not have any next of kin who had made
themselves known to the Coroner.
13 A hot debrief is a meeting held immediately after a death in prison custody. Staff are able to talk about
their experiences and learning points (if any) are identified. Members of the staff welfare team (care
team) are also usually present.
15
ISSUES
Clinical care
63. The clinical review was undertaken by the clinical reviewer for Nottinghamshire
Teaching Primary Care Trust (PCT). His review is based on prison medical
records and liaison with my investigator. He found that a comprehensive
reception screening took place at Whatton. It identified the major issues
concerning the man’s physical health and initial management plans were put in
place.
64. The clinical reviewer judged that overall, the medical care given to the man at
Whatton was satisfactory. He noted that the man frequently required warfarin dose
changes, which was consistent with his condition. In his opinion, the man’s warfarin
control was difficult to stabilize. He acknowledged that, while other medication and
lifestyle factors influenced warfarin control, healthcare staff were responsive and
they made clinical management changes and performed sufficient checks to try and
optimize control. The clinical reviewer noted that it was also difficult to take blood
from the man and the healthcare department did well to manage to get a sample.
65. The clinical reviewer concludes that the man had severe heart disease and his life
expectancy was therefore reduced. The doctor questions whether the stress of
diarrhoea in the few days immediately before the man’s death may have placed
undue stress on his heart which subsequently failed.
66. The clinical reviewer highlights one area of concern where healthcare did not act on
information received from the hospital:
“In my opinion, there were many occasions when the man’s INR was
not in the therapeutic window14 and this is completely understandable
considering the problems with medication interactions, and that his INR
varied even when no other medication changes were made and when
he otherwise appeared to be in stable health. On two occasions the
procedures in the Healthcare department did not flag up important
protocol changes; failing to act immediately from a fax from the hospital
of a low INR and failing to initiate enoxapirin treatment when INR
dropped below 1.8. These two episodes should be discussed at the
next clinical audit meeting in the healthcare department.”
67. The clinical reviewer recommends that healthcare staff failing to act immediately
on important information received from the hospital and not reacting appropriately
when the man’s INR fell below acceptable levels be discussed at the next clinical
audit meeting. I endorse his view that the matter needs to be reviewed and acted
upon by the healthcare department.
14 Therapeutic window (or pharmaceutical window) is an index for estimation of drug dosage which can
treat disease effectively while staying within the safety range.
16
The Head of Healthcare should review the systems and protocols regarding
receiving, analysing and acting upon information received from a hospital
relating to the monitoring of INR results. The Head of Healthcare should
ensure that all INR results are closely monitored and are acted upon in a
timely and appropriate manner.
Ambulance delay
68. I must comment on the fact that the ambulance took just over an hour to reach
the prison from the time it was called at 12.30pm to 13.28pm. A paramedic was
sent ahead and arrived within ten minutes but without the ability to take the man
to hospital immediately. The length of time the ambulance took to arrive at the
prison is a concern as the prison is in a rural location and does not have an
inpatient healthcare facility. It is around 16 miles to the local Medical Centre and
I am concerned about the distance from the prison to the hospital given there is
no internal out of hours medical support. Although there is little that can be done
about the location of the prison in relation to the nearest hospital, the Governor
might wish to keep under review the best way of minimising delays in accessing
medical attention for emergencies.
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CONCLUSION
31. The man was a life sentenced prisoner who spent many years in prison. Although
not in good health, his death was sudden and unexpected. He had long term heart
problems and had undergone an aortic valve replacement to help his condition.
Amongst other medication, he was required to take warfarin to help stop blood
clotting. Officers were unable to completely remove the restraints when the man
took a turn for the worse, but this was understandable as he had rolled onto the
chain while staff were attempting to resuscitate him.
32. The clinical reviewer is satisfied that, overall, the man received good care at
Whatton. He has suggested one recommendation regarding the raising of a protocol
for dealing with INR results and I endorse this recommendation. My
recommendation aside, I judge that the care the man received was comparable to
that which he would have received in the community.
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RECOMMENDATION
The Head of Healthcare should review the systems and protocols regarding
receiving, analysing and acting upon information received from a hospital
relating to the monitoring of INR results. The Head of Healthcare should
ensure that all INR results are closely monitored and are acted upon in a timely
and appropriate manner.
Accepted. Head of Healthcare has reviewed systems and protocols relating to receiving
and analysing and acting upon information received relating to INR results.
Lead INR nurse in place.
Standard Operating Procedure to be written reflecting the review.
Monitoring and audit processes relating to INR monitoring and action are in place.
Discussions regarding issues raised in the report to be discussed within nursing and
multi disciplinary team meetings.
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