Last week the PPO published 4 reports relating to deaths in custody. The causes are categorised as follows:
- Natural Causes = 1
- Self-Inflicted = 1
- Other Non-Natural = 2
Below is a summary of those self-inlflicted and other non-natural deaths, 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)
29 Sep 2018 – HMP Dovegate. Self-Inflected Death.
Mr Marlon Watson had a significant history of illicit drug use. He also had a history of depression.
Mr Watson had a history of convictions for robbery, possession of a firearm, theft and other offences. He was released on licence in March 2016, having been in custody since November 2014.
On 17 April 2017, Mr Watson was recalled to custody, charged with robbery and possession of a firearm, and sent to HMP Leicester. On 27 June 2017, Mr Watson was convicted and sentenced to 9 years 4 months.
On 5 October 2017, Mr Watson transferred from Leicester to HMP Dovegate.
Mr Watson’s medical and security records show that while at Dovegate he used both illicit drugs and alcohol. He was offered support by substance misuse services, but chose not to engage.
On 28 September 2018, Mr Watson spoke to his partner on the phone. As a result, he apparently believed that their relationship was over and that she was in a new relationship.
On 29 September, at 9.16am, a member of staff found Mr Watson hanging in his cell. An ambulance was requested, staff began cardiopulmonary resuscitation and continued until paramedics arrived. Paramedics took over emergency treatment, but at 9.52am, pronounced Mr Watson dead.
The toxicology tests found that Mr Watson had used psychoactive substances (PS) immediately before his death.
A nurse saw Mr Watson in reception when he arrived at Dovegate. She recorded that Mr Watson had been prescribed sertraline (an antidepressant) while at Leicester, was not allowed to hold medication in his possession and had an outstanding hospital appointment for urinary problems. Mr Watson said he had no thoughts of self-harm or suicide. The nurse recorded that Mr Watson needed to occupy a single cell because of his bed-wetting.
Management of Risk of Suicide and Self Harm
Mr Watson had no recorded history of self-harm or attempted suicide. We do not consider that staff at Dovegate had any reason to consider that he presented a risk to himself or that they could have foreseen or prevented his death.
It appeared that the day before his death, following a phone call to his partner, Mr Watson believed that their relationship had ended. This was not known to prison staff.
Psychoactive Substances/Illicit Drugs
Mr Watson had a long history of abusing illicit drugs, including psychoactive substances (PS) commonly known as ‘spice’, and intelligence suggested that he was involved in smuggling drugs into the prison. He was repeatedly offered help and support by substance misuse staff but chose not to engage.
Toxicology results show that Mr Watson used PS immediately before his death. Reported side-effects of PS include mood swings, anxiety, paranoia and suicidal thoughts. It is therefore considered possible that Mr Watson’s actions were influenced directly by PS use.
From the time that a PCO found Mr Watson hanging and the other PCO called an emergency code at 9.16am, there was a delay of 5 minutes before the control room called an ambulance. Ambulance Service records show that the 999 call was received at 9.21am. Although this did not affect the outcome for Mr Watson it could be crucial in other emergencies.
The Clinical Reviewer was satisfied that the care that Mr Watson received from healthcare staff at Dovegate was equivalent to the care he would have received in the community.
The Clinical Reviewer determined that Mr Watson had access to the healthcare services he required, was referred to a specialist for his bed-wetting problems, and was repeatedly offered assistance and support from the substance misuse team, which he chose not to engage with. He also repeatedly failed to attend appointments with the GP.
Rec 1: The Director should ensure that control room staff call an ambulance as soon as a medical emergency code is broadcast.
Rec 2: The Chief Executive of HMPPS should provide the Ombudsman with a revised date for issuing detailed national guidance on measures to reduce the supply and demand of drugs in prisons, and an assurance that this new date will be met.
6 Jun 2018 – HMP Lincoln. Other Non-Natural Death.
On 3 May 2018, Mr Ashley Williams was convicted of grievous bodily harm. He was remanded in prison custody to await sentencing and sent to HMP Lincoln.
Mr Williams was assessed as posing too high a risk to share a cell and was allocated a single cell on arrival. His risk was reviewed two weeks later and his risk reduced. He was moved to a double cell on 5 June.
On 6 June, at around 8am, an officer unlocked Mr Williams’ cell. 20 minutes later, a prisoner went to Mr Williams’ cell and saw him lying face down on the top bunk. He noticed vomit on his mattress and when he looked closer, he saw that Mr Williams’ arms and face were discoloured. He pressed the general alarm to alert staff.
An officer responded and found that Mr Williams did not have a pulse and was cold to touch. Healthcare staff arrived and decided not to attempt resuscitation as Mr Williams had signs of rigor mortis. At 8.32am, a prison paramedic confirmed that Mr Williams had died.
The post-mortem examination found no injuries or natural disease that would have caused or contributed to Mr Williams’ death. Psychoactive substances (PS) were found in his blood and in the absence of an alternative, PS intoxication was given as the cause of death.
At reception, prison staff conducted a cell sharing risk assessment (CSRA) and noted that Mr Williams had assaulted a cellmate while serving a sentence in 2011. He was therefore assessed as high risk and allocated a single cell.
A nurse saw Mr Williams for an initial health screen. He recorded that Mr Williams said he had no health problems and no substance misuse issues, but was prescribed citalopram (an antidepressant). The nurse obtained Mr Williams’ consent to request his community medical record and tasked pharmacy staff to check his prescription with his GP. However, there is no record that this took place.
Management of Risk of Suicide and Self Harm
No concerns noted.
Psychoactive Substances/Illicit Drugs
The post-mortem report found no injuries or natural disease that would have caused or contributed to Mr Williams’ death. Toxicology analysis of Mr Williams’ blood found citalopram and pregabalin present at therapeutic levels, and 5f-ADB (a type of PS). The report noted that PS can cause chest pain and an irregular heartbeat as well as respiratory depression. It concluded that this was potentially lethal and in the absence of an alternative, PS intoxication was the cause of death.
There was no record of Mr Williams being seen under the influence of PS, or any other illicit substances, while he was at Lincoln. Records show one strand of intelligence indicating that Mr Williams was possibly involved in the distribution of PS.
Mr Williams was moved to a double cell the day before he was found dead. His cellmate had a history of illicit drug use. However, there is no expectation for officers to conduct a security review before moving a prisoner from a single to a double cell. The investigators were satisfied that staff acted appropriately and could not reasonably have foreseen Mr Williams’ death.
The drugs citalopram and pregabalin, both at therapeutic levels, were found in Mr Williams’ blood after his death, although neither was listed as a cause of death. Mr Williams was not prescribed pregabalin, so this must have obtained it illicitly. Pregabalin is a highly tradeable medication in prisons. Although it is used to treat epilepsy and nerve pain, it can also be taken to increase the euphoric effects of other drugs, such as opiates.
While the investigators recognised that the prison has a drug strategy, they were concerned that it does not cover diversion of prescribed medication. While the pregabalin in Mr William’s blood did not cause his death, they determined that work is required to reduce the availability of diverted medication.
Prison Service Instruction (PSI) 03/2013, Medical Response Codes, requires prisons to have a 2-code medical emergency response system. Lincoln’s local policy instructs staff to call the control room and to outline the medical issue if the incident is not life threatening. In more serious cases, a code blue should be used to indicate an emergency when a prisoner is unconscious, or having breathing difficulties, and code red when a prisoner is bleeding. The calling of a medical emergency code instructs the control room to call an ambulance immediately.
The officer who found Mr Williams told the investigator that he decided to request medical assistance instead of calling a medical emergency code blue, as it was clear that Mr Williams had died. He said he did not want to cause staff to panic and to call an ambulance, if there was nothing they could do. While there is no specific record showing that an officer asked healthcare staff to attend, the investigator was satisfied that staff requested medical assistance swiftly, and therefore considered that prison staff acted appropriately in the circumstances.
The Clinical Reviewer considered that most of the care Mr Williams received at Lincoln was equivalent to that which he could have expected to receive in the community. He continued to receive medication he said he was taking in the community and was appropriately seen by a mental health nurse.
There were however, aspects of Mr Williams’ care that fell short of expectations, namely that healthcare staff did not check his prescription with his community GP, request his previous mental health record or complete a secondary health screen.
Prison Service Order (PSO) 3050 – Continuity of Healthcare for Prisoners – requires that, when a new prisoner arrives in reception, prison staff try to obtain relevant information from the prisoner’s GP or other relevant health services the prisoner has recently been in contact with. Given that Mr Williams said he took antidepressants and had previous involvement with a mental health hospital, it was particularly important that healthcare staff should have obtained his community GP and mental health record. However, there is no record that staff obtained this information. The Clinical Reviewer considered that staff should have checked Mr Williams’ prescription and requested his mental health record.
PSO 3050 also requires that newly arrived prisoners should be offered a general health assessment in the week after first reception. This assessment is expected to be equivalent to a primary care assessment when registering with a new GP in the community. At interview, a nurse told the investigator that the prison healthcare team had decided to complete first and second health screens at the same time, as prisoners did not always turn up for a secondary screen. However, the concerns were that the nurse did not record that he had completed a secondary health screen.
Rec 1: The Chief Executive of HMPPS should provide the Ombudsman with a revised date for issuing detailed national guidance on measures to reduce the supply and demand of drugs in prisons, and an assurance that this new date will be met.
Rec 2: The Governor should ensure that the prison’s drug and alcohol strategy is amended to include measures to address the diversion of prescribed medication.
Rec 3: The Head of Healthcare should ensure that healthcare staff:
- routinely request community medical records for newly arrived prisoners;
- offer all prisoners a full general health assessment within a week of their arrival, in line with PSO 3050; and
- request previous mental health records when conducting a mental health triage assessment.
Rec 4: The Governor should ensure that, when a cell door is unlocked, officers satisfy themselves of the wellbeing of the prisoner and that there are no immediate issues that need attention.
21 Oct 2018 – HMP Eastwood Park. Other Non-Natural Death.
Ms Kelly Quilt had a long history of drug dependency and had spent much of her adult life in prison. On 19 October 2018, she was sentenced to 14 weeks imprisonment and sent to HMP Eastwood Park.
At Ms Quilt’s reception health screen, a nurse recorded her drug dependency history and that she was experiencing mild opiate withdrawal. She was located on the detoxification wing and kept under observation.
During the afternoon of 20 October, Ms Quilt reported having spasms in her hand. A nurse observed her and noted that she appeared to have normal movement, strength and circulation. She consulted a GP who advised that Ms Quilt be kept under observation.
During the night, Ms Quilt told another nurse about her hands and asked for pain relief. The nurse gave her mild pain relief. She noted that Ms Quilt appeared to use her hands perfectly well when she did not realise she was being observed, and thought she might be trying to obtain stronger medication.
During the early hours of 21 October, the nurse observed Ms Quilt three times and reported no concerns.
At approximately 7.30am, an officer performed a roll check and reported no concerns. At approximately 9.05am, another officer found Ms Quilt unresponsive when he unlocked her cell. He thought she was clearly dead, so did not call an emergency medical code but went in person to fetch nurses who were working nearby.
The nurses concluded that Ms Quilt had been dead for some time and did not attempt to resuscitate her. At 11.20am, a prison GP confirmed her death.
Ms Quilt was admitted to Eastwood Park shortly before 5.00pm. At 5.13pm, an officer recorded that Ms Quilt did not make a phone call on her arrival because she felt unwell from detoxing. She noted that Ms Quilt appeared tired during the induction interview due to withdrawing.
At 5.44pm, a nurse carried out Ms Quilt’s reception health screen. He noted her drug dependency issues and that she had used drugs within the last 3 months. He recorded that Ms Quilt’s urine tests were positive for heroin and cocaine, but negative for methadone. He recorded that she had a COWS score of 8 (indicating mild withdrawal). The nurse noted that Ms Quilt was not fit for a normal cell location.
At 6.18pm, a prison GP reviewed Ms Quilt. He noted her daily cocaine and heroin use, and that she said she had last used drugs 2 days previously. Ms Quilt told the GP that she also used diazepam (a tranquiliser), but he noted that she had tested negative for this in her drug tests and that she demonstrated no obvious withdrawal symptoms (cramps, shaking, seizures) at that time. In interview, the GP said that he could see no signs of diazepam withdrawal when he reviewed Ms Quilt and that there was nothing else that caused him undue concern. He renewed Ms Quilt’s prescription for methadone and metoclopramide (to prevent nausea and vomiting) and instructed that she should be monitored.
Ms Quilt was located on a wing which served as both the induction unit as well as the detoxification wing at Eastwood Park.
Management of Risk of Suicide and Self Harm
No concerns noted.
Psychoactive Substances/Illicit Drugs
The post-mortem report noted that the three blister packs found in Ms Quilt’s cell, contained what was thought to be mirtazapine (an antidepressant) and amitriptyline (which is used as a pain killer and as an antidepressant). Neither had been prescribed to Ms Quilt.
Post-mortem toxicology tests revealed no trace of opiates, cocaine or other illicit substances. There was also no trace of methadone (which could indicate Ms Quilt had been vomiting). Mirtazapine and amitriptyline were both detected, but at levels within a therapeutic range.
The post-mortem examination found no evidence of injury or of any significant injury or of any pre-existing natural disease that would have caused or contributed to Ms Quilt’s death. The pathologist concluded that the exact cause of death was unclear, but that overall appearances were suggestive of a death associated with withdrawal from regular heroin and cocaine use. She recorded the cause of death as ‘a sudden unexpected death following cessation of heroin and cocaine use’.
When the officer discovered Ms Quilt unresponsive in her cell, he did not immediately call a code blue emergency on the radio. The PPO would normally be critical if a member of staff fails to do this because it creates a delay before medical help arrives. However, it is clear from the nurses’ evidence that rigor mortis was present when Ms Quilt was found and that it would have been obvious, even to a lay person, that Ms Quilt was dead and past the point of resuscitation. Healthcare staff who saw Ms Quilt very shortly afterwards, confirmed that she had almost certainly been dead for some time and they did not attempt resuscitation.
In these exceptional circumstances it is accepted that it was not necessary for the officer to call a code blue, although the PPO make it clear, however, that these were exceptional circumstances and that it is expected that staff do err on the side of caution and call a code blue if they find a prisoner unresponsive. Investigators would never be critical of a member of staff for doing so.
The investigator was satisfied that healthcare staff took the appropriate decision not to attempt resuscitation when they attended to Ms Quilt.
The Clinical Reviewer is satisfied that the care Ms Quilt received at Eastwood Park was equivalent to that she could have expected in the community. Healthcare staff appropriately managed her drug withdrawal and regularly observed her on the induction unit, including throughout the night shift when prisoners were locked up.
It is likely that Ms Quilt had been dead for some time when she was discovered shortly after 9.00am on 21 October. However, the investigator had no reason to doubt that she was asleep and breathing normally as the nurse had recorded at 5.25am.
Rec 1: The Governor should ensure that a member of Prison Service staff informs a prisoner’s family or next of kin of their death promptly, in line with PSI 64/2011.
Other Recommendations From Deaths Attributed To Natural Causes.
From the one remaining report published last week, these were the recommendations for that death in custody attributed to natural causes.
** 13 Jun 2018 – HMP Littlehey. Natural Causes Death.**
Rec 1: The Governor and Head of Healthcare should ensure that prisoners who refuse medication and/or treatment and so increase their risk of serious health conditions, are discussed in the prison complex case meetings.
Rec 2: • The Governor should ensure that a member of Prison Service staff informs a prisoner’s family or next of kin of their death in person, in line with national guidance.