Last week the PPO published 6 reports relating to deaths in custody. The causes are categorised as follows:
- Natural Causes = 5
- Self-Inflicted = 0
- Other Non-Natural = 1
Below is a summary of the other non-natural 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)
03 Aug 2018 – HMP Leeds. Other Non-Natural Death.
In January 2007, Mr Browning was charged with murder and remanded into custody. In September 2007, he was sentenced to life imprisonment with a minimum tariff of over 24 years. He received a further sentence of 40 months imprisonment in 2014 for assaulting another prisoner.
Mr Browning was a complex prisoner who was difficult to manage. He was diagnosed with personality disorder, depression and anxiety and was often assessed as a risk to himself, as well as to others. He frequently moved prisons and was segregated due to his disruptive behaviour. He also made several attempts to take his own life.
Records indicate that Mr Browning used illicit drugs regularly throughout his time in prison, most notably psychoactive substances (PS). He generally engaged with substance misuse services, although he refused to do so over the last 6 weeks of his life.
Mr Browning returned to HMP Leeds on 13 July, after a brief period at HMP Lincoln, where he had set fire to a cell and been found under the influence of PS. Staff said he seemed happy and more settled than previously. They did not suspect him of using PS. Staff made considerable efforts to engage with him and were in the process of making plans for the longer term, potentially involving a move to another prison nearer his mother.
On 2 August, staff and prisoners said that Mr Browning was his usual self. An officer checked him in his cell around 10.00pm and had a short conversation with him. The next morning, at 5.43am, the officer saw Mr Browning lying on the floor of his cell. The officer was initially unsure whether Mr Browning was asleep and asked another officer for her opinion.
When they could not get a response from Mr Browning, the officers went into the cell. They officers could not detect a pulse and noted that Mr Browning was cold and stiff. A nurse arrived a few seconds later and assessed Mr Browning. She did not start cardiopulmonary resuscitation since Mr Browning had clearly been dead for some time. Paramedics arrived and, at 6.03am, pronounced Mr Browning dead.
On 4 April, Mr Browning transferred to HMP Leeds so that his mother could visit him more easily. He remained subject to ACCT procedures and was referred to the mental health team. On 13 July, Mr Browning returned to Leeds, following a brief stay at HMP Lincoln from 29 June to 13 July.
Shortly after his return to Leeds, a nurse spoke to Mr Browning through the observation panel in his cell door. It was not possible to unlock him as he had arrived too late in the evening. The nurse was satisfied that there were no urgent issues that needed to be dealt with and he would be safe overnight. She said Mr Browning was calm and polite.
A nurse assessed Mr Browning the next morning. He refused to be referred to the substance misuse service. The nurse referred him to the mental health team, noting that he had a history of depression and self-harm and had attempted suicide in the past. The nurse noted that he could not get a urine sample from Mr Browning to test for drugs but that Mr Browning had a history of PS use. On 15 July, a nurse completed a secondary healthscreen.
Mr Browning had hypertension and cervical spondylosis but was not referred to the long-term conditions clinic when he returned to Leeds, as he should have been. This would have ensured that his quetiapine (antipsychotic medication) was monitored.
Management of Risk of Suicide and Self Harm
On 10 April, staff suspected Mr Browning was under the influence of PS. The next day staff closed Mr Browning’s ACCT.
On 12 May, Mr Browning told staff that he wanted to end his life and there was no longer any point in him being alive. He had also made a noose. Staff opened an ACCT and placed Mr Browning under constant observation. Mental health staff also assessed Mr Browning. On 18 May, Mr Browning said he felt much better and his ACCT observations were reduced. On 19 May, Mr Browning swallowed batteries and a razor.
On 24 May, Mr Browning began taking his prescribed medication again. This was quetiapine, gabapentin and ramipril. Mr Browning told healthcare staff he had started to feel better. On 29 May, staff closed Mr Browning’s ACCT. This was reopened on 2 June after Mr Browning cut his arm and took an overdose, stating that this was an attempt to take his life. He said he was sick of prison and his lack of progress. When checking that he had no more medication in his possession, staff found an improvised pipe for smoking PS in his cell.
On 9 June, Mr Browning set fire to his cell and was again segregated as a result. He said he thought it would help him get transferred to Manchester. He said he felt unsafe at Leeds due to having issues with other prisoners. Mr Browning told staff that he preferred being in the segregation unit rather than on a standard wing. He also told a substance misuse worker that he did not want to engage with them. On 14 June, staff closed Mr Browning’s ACCT.
Psychoactive Substances/Illicit Drugs
The post-mortem report said that there were no signs of self-harm and that the most likely cause of Mr Browning’s death was PS toxicity. There was evidence that Mr Browning had used PS in the hours before he died. Mr Browning’s body showed signs of pulmonary oedema (excess fluid in the lungs which makes it difficult to breathe). It was noted that this is commonly seen in deaths caused by drug toxicity. The pathologist said that the reddening of Mr Browning’s airways may have been due to the inhalation of PS.
Tramadol, ibuprofen, gabapentin, benzodiazepine, quetiapine and cannabis were also detected in Mr Browning’s system although the pathologist concluded that they were unlikely to have contributed to his death.
Over 4 minutes passed between an officer first looking into Mr Browning’s cell and his unlocking the cell door.
The officer left the cell for under a minute when another officer called him to the wing office. When he returned to the cell, the officer told the investigator that he was not sure whether his “eyes were tricking me” when he could see no signs that Mr Browning was breathing. He said that Mr Browning was lying on his side in what looked like a comfortable position, like the recovery position, and looked asleep. He wanted the opinion of another officer before opening the door, and for his own safety. The officer told the investigator that he would consider going into a cell on his own in a life-threatening situation if he had assessed it as safe to do so. He was uncertain, at the time, whether this was a life-threatening situation or that it was safe to do so.
The officer returned to the cell with another officer. They unlocked the door a minute later when they still got no response. On balance investigators considered that the delay in unlocking Mr Browning’s cell was understandable in the circumstances.
Even if they had gone into the cell earlier, it would not have affected the outcome for Mr Browning. When staff found Mr Browning, he had mottled skin, was cold to the touch and rigor mortis had begun to set in, indicating that he had been dead for some time. Staff decided not to attempt to resuscitate Mr Browning. The Clinical Reviewer commented that this was the correct, and most dignified, decision in accordance with NHSE protocol.
Paramedics arrived at 6.00am, assessed Mr Browning and pronounced him dead at 6.03am.
The Clinical Reviewer concluded that Mr Browning’s mental health care was of a good standard and equivalent to that which he could have expected to receive in the community.
Mr Browning had a long history of mental health issues including self-harm, attempted suicide, depression and personality disorder. He was a complex prisoner who received significant input from mental health services.
While the overall standard of Mr Browning’s mental health care was good, we are concerned that there were some omissions in record keeping.
Given the absence of referrals to the long-term conditions clinic when he returned to Leeds, the Clinical Reviewer concluded that Mr Browning’s physical healthcare was not equivalent to that which he could have expected to have received in the community, further noting that Mr Browning might not have been seen in the two weeks before he died even if he had been referred.
Rec 1: The Governor should ensure that when a prisoner is suspected to be under the influence of PS, all staff follow the instructions in Leeds’ PS policy.
Rec 2: The Governor should ensure that the key drug issues at Leeds are identified and that the prison’s local drugs strategy is revised to ensure that these key issues are being addressed, and published by September 2019, in accordance with HMPPS’s objective.
Rec 3: The Head of Healthcare must ensure that staff record significant decisions about prisoners’ care in accordance with the NMC code of conduct for record keeping.
Other Recommendations From Deaths Attributed To Natural Causes.
From the 5 remaining reports published last week, these were the recommendations for those deaths in custody attributed to natural causes.
12 Oct 2017 – HMP Stocken.
Rec 1: 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.
Rec 2: The Governor should ensure that full searches on prisoners going on hospital escorts are only undertaken following an appropriate risk assessment, and when there is sufficient intelligence to justify their use.
Rec 3: The Head of Healthcare and Head of OMU should ensure that all reports required for applications for early release on compassionate grounds for prisoners with terminal illnesses are prioritised and completed without delay.
Full Report 12 Oct 2017 – HMP Stocken.
10 Dec 2017 – HMP Littlehey.
Rec 1: The Head of Healthcare at Littlehey should review pharmacy services to ensure that labelling errors on medication do not occur.
Rec 2: The Head of Healthcare at Littlehey should ensure that there are effective processes to ensure that prisoners take their medication, and that staff monitor this.
Rec 3: The Governor and Head of Healthcare at Littlehey should ensure that staff respond with greater urgency and clarity to emergency situations.
Full Report 10 Dec 2017 – HMP Littlehey.
18 Aug 2018 – HMP Whatton.
Rec 1: The Governor should ensure that in line with PSI 64/2011:
- an appropriate contribution is made to Mr Ahmed’s family to cover the reasonable costs of his funeral; and
- staff are reminded to offer to contribute towards funeral costs promptly when there is a death in custody.
Full Report 18 Aug 2018 – HMP Whatton.
20 Dec 2018 – HMP Swaleside.
Rec 1: The Head of Healthcare should ensure that clinical staff review the healthcare needs of all new prisoners and ensure that those with pre-existing conditions are reviewed and managed in accordance with current NICE guidance.
Rec 2: The Head of Healthcare should ensure that when a specialist recommends a treatment, there is a process in place that allows for this to be given and identifies any prisoner who fails to comply with the recommendations.
Rec 3: The Governor should ensure that there are sufficient staff and transport available to escort prisoners to hospital appointments without delays.
Rec 4: The Governor of Swaleside should ensure that all documentation relating to a prisoner is stored securely and able to be retrieved as necessary.
Rec 5: The Governor should ensure that prison staff contact healthcare staff promptly, when prisoners report pain or other symptoms suggesting they are unwell.
Rec 6: The Head of Healthcare should ensure that all clinical staff have access to a watch or similar device to enable them to make a record of the time that an event took place, so that full and accurate records are maintained.
Rec 7: The Executive Director for Long-Term and High Security prisons should provide this office with an update on the progress of the Group Safety Team in addressing the prison’s continuing failure to comply with case law on the use of restraints.
Rec 8: The Governor should ensure that the cell bell logging system is in proper working order.
Full Report 20 Dec 2018 – HMP Swaleside.
27 Apr 2019 – HMP Littlehey.
Full Report 27 Apr 2019 – HMP Littlehey.