Last week the PPO published reports relating to deaths in custody. The causes are categorised as follows:
- Natural Causes = 4
- Self-Inflicted = 1
- Other Non-Natural = 0
Below is a summary of the self-inlflicted death, with specific focus on those aspects of Healthcare services that are integral within prisons:
- Reception Screening
- The Management of Risk of Suicide and Self-Harm (Mental Health Teams),
- Psychoactive Substances/Illicit Drugs (Substance Misuse Services),
- Emergency Response (Primary Care Teams)
17 Oct 2018 – HMP High Down. Self-Inflicted Death.
On 20 August 2018, Mr Mark Kinman was remanded in prison custody, charged with firearms offences. He was moved to HMP High Down on 21 September. It is noted that although this was not his first time in prison, he had not been in prison for over 40 years.
On 13 October, Mr Kinman told a nurse that he felt depressed and asked for a GP appointment. The nurse made an appointment for 22 October.
On 15 October, Mr Kinman was moved to a different houseblock. He told a prisoner and an officer that he was worried he may not receive the goods he had ordered from the prison shop because he had been moved. The prisoner said Mr Kinman appeared very anxious but he tried to reassure him that the issue could be resolved easily.
Shortly after 8.00am on 17 October, an officer unlocked Mr Kinman’s cell. She did not look through the observation panel or enter the cell. At around 8.55am, Mr Kinman’s cellmate realised that Mr Kinman was unresponsive with a plastic bag over his head. Staff attended and radioed a medical emergency code at 8.57am. They did not attempt to resuscitate Mr Kinman as it was clear he was dead. At 8.59am, a paramedic confirmed Mr Kinman’s death.
Mr Kinman was moved to HMP High Down on 21 September. A nurse completed Mr Kinman’s healthscreen at 2.58pm. She recorded Mr Kinman used an inhaler for his asthma and had no thoughts of suicide or self-harm. The nurse referred Mr Kinman to the prison GP for an asthma check. The GP examined Mr Kinman at 3.32pm and prescribed his inhaler.
An officer completed Mr Kinman’s first night induction at 4.11pm. Mr Kinman told the officer that he had been transferred from Wandsworth because of fears for his safety, and said he was also under threat at High Down. The officer spoke with a prison manager, who said that Mr Kinman should be located on a standard residential wing, and that he had been advised what to do if he did feel under threat. There is no evidence that Mr Kinman raised any further concerns while at High Down.
Management of Risk of Suicide and Self Harm
Mr Kinman’s community medical record noted that he suffered from brief episodes of depression in 1997, 1999 and 2011, but did not require specialist services. When Mr Kinman approached a nurse on his houseblock and asked her to book him an appointment with the prison doctor she said he was very well presented and did not look like he was neglecting himself.
The nurse said she had been a general nurse for over 30 years and had completed suicide awareness training, although had not completed any formal training in identifying depression. She said she did not ask Mr Kinman any specific questions about why he felt depressed because they were not in a confidential area and he appeared in a rush.
Psychoactive Substances/Illicit Drugs
None. The post-mortem and toxicology reports were not available at the time of issuing this report. The coroner gave Mr Kinman’s provisional cause of death as plastic bag asphyxia (suffocation).
High Down’s local protocol, Governor Information Notice (GIN) 24/2017 reissued on 22 March 2017, is clear that an ambulance should be called immediately when a medical emergency code is radioed, in line with PSI 3/2013. In addition, GIN 118/2017 issued on 8 December 2017, advises staff that Surrey Ambulance Service introduced changes to ambulance response categories to ensure that their response to High Down is appropriate. In line with this information, High Down introduced Emergency Response Information Cards (E.R.I.C) to assist staff in calling an appropriate medical emergency code and providing the information requested by ambulance control centres.
The officer promptly and appropriately radioed a Code Blue medical emergency when he found Mr Kinman. An operational support grade (OSG) working in the control room, recorded on the communications log that a Code Blue medical emergency had been called at 8.57am. In his police statement he said he attempted to contact the officer over his radio to obtain more information about the situation, but got no response. The OSG said at around 9.00am, a prison manager, arrived at the communications room and he asked if he should request an ambulance, but she said, as Mr Kinman had been declared dead, an ambulance was not required.
An ambulance should have been requested immediately when the Code Blue was called. During the investigation it became apparent that it was not uncommon for the communications room to wait for the emergency response nurse to confirm if an ambulance was required before calling one. This is not in line with guidance. Although it did not affect the outcome in Mr Kinman’s case, there could be cases where any delay in requesting an ambulance could be crucial. In another recent investigation at High Down, investigators found that there was a delay before control room staff requested an ambulance following a medical emergency code.
The Clinical Reviewer concluded that overall Mr Kinman’s clinical care was good and equivalent to that which he could have expected to receive in the community. There were no issues or concerns relating to his physical healthcare and his pre- existing medical conditions were identified and managed appropriately and promptly. However, Mr Kinman should have had a secondary health screen within 7 days of transfer to High Down, but this did not happen. The oversight was identified by the healthcare team and they attempted to assess Mr Kinman on 16 October, but they were unable to locate him as he had moved to a different houseblock.
Mr Kinman’s community medical record was requested, received promptly and reviewed. However, there is no record of a summary being made about previous episodes of depression. The records rely on Mr Kinman self-reporting his previous history; he did not report a past history of depression at his reception interview.
The Clinical Reviewer concluded that, in the absence of any pressing concern, Mr Kinman would have received a similar response in a community setting but that the introduction of a simple depression questionnaire that all staff could complete would be beneficial.
Rec 1: The Head of Healthcare should review the training of clinical staff in depression identification and introduce a brief checklist of questions and observation to exclude suicide risk.
Rec 2: The Head of Healthcare should ensure:
- there is an audit of successful completion of secondary health assessments within 7 days of arrival; and
- nursing staff are reminded that all relevant history from community medical records is recorded accurately.
Rec 3: The Governor should ensure that control room staff call an ambulance immediately when a medical emergency code is called, in line with local and national guidance.
Full Report Here
Other Recommendations From Deaths Attributed To Natural Causes.
From the remaining reports published last week, these were the recommendations for those deaths in custody attributed to natural causes.
23 Nov 2017 – HMP High Down.
Rec 1: The Governor should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position and that risk assessments show clear justification for the use of restraints.
Rec 2: The Prison Group Director, Surrey and Sussex, should assure himself that the Governor takes effective action to address the inappropriate use of restraints at HMP High Down.
Rec 3: The Governor should ensure that when prisoners are considered as terminally ill, with a short time left to live, the option of compassionate release is fully considered with the patient and documented.
Full Report Here
25 Dec 2017 – HMP Styal.
Rec 1: The Governor should ensure that appropriate arrangements are in place to make sure that prisoners are able to attend hospital appointments.
Rec 2: The Governor and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints, and that assessments fully take into account the health of a prisoner and are based on the actual risk the prisoner presents at the time.
Full Report Here
03 Apr 2019 – HMP Wakefield.
Rec 1: The Head of Healthcare should ensure that an advance care plan is in place for terminally ill prisoners who are likely to die within twelve months.
Rec 2: The Governor and Head of Healthcare should ensure that
- all staff completing and authorising risk assessments for prisoners taken to hospital understand the legal position on the use of restraints;
- healthcare staff complete the healthcare section of the risk assessment form fully;
- risk assessments fully take into account the health of a prisoner;
- risk assessments are based on the actual risk the prisoner presents at the time; and
- restraints are not used during serious or invasive treatment, unless there are exceptional reasons for doing so.
Rec 3: The Governor should ensure that, in line with PSI 58/2010, the Prison and Probation Ombudsman is promptly provided with all requested documents following a death in custody.
Rec 4: The Governor should ensure that emergency contact details for prisoners’ next of kin are accurate and kept up to date and, in the event of a death, the prisoner’s family is informed as soon as possible, in line with national guidance.
Full Report Here
04 May 2019 – HMP North Sea Camp.
Full Report Here