PPO Deaths In Custody Reports – Health Notes 3 Feb 2020

Last week the PPO published 4 reports relating to deaths in custody. The causes are categorised as follows:

  • Natural Causes = 3
  • Self-Inflicted = 0
  • Other Non-Natural = 1

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)

9 May 2018 – HMP Liverpool. Other Non-Natural Death.

Key Events

On 22 March 2018, Mr John Smith was sentenced to 13 years imprisonment for robbery and other offences. He was sent to HMP Liverpool.

On his arrival at Liverpool, it was noted at Mr Smith’s reception health screen that he had a history of opiate dependency and was on a daily dose of 50ml methadone for this. He also had chronic respiratory disease for which he received medication. Mr Smith had no recorded involvement with mental health services.

The drug dependency team monitored Mr Smith’s opiate withdrawal. Over the next few months, Mr Smith sought an increase in his methadone dose but staff noted that his withdrawal symptoms did not support this and declined.

Mr Smith was kept under review by the chronic health team. He had no significant concerns until April when a nurse noted that he was short of breath and showed signs of oxygen deficiency. A prison GP reviewed him and gave him a nebuliser to deliver his medication more efficiently. After a week’s course on the nebuliser, Mr Smith’s health returned to normal.

When a nurse was administering the nebuliser to Mr Smith, he noticed a strong smell of smoke in the cell. Over the course of a few hours, he noted this smell on a couple of occasions, and also that Mr Smith appeared to be under the influence of something. The nurse suspected illicit drug use, as did several officers and other healthcare staff, and he raised his concerns with officers on the wing. Two officers made entries in the wing log and in Mr Smith’s prison record but they did not open an intelligence report.

On 9 May, at approximately 12.20am, Mr Smith’s cell mate discovered him unresponsive in their cell. He alerted prison officers who called an emergency code. An ambulance was requested immediately and healthcare staff attended promptly. They performed cardiopulmonary resuscitation while awaiting the ambulance.

At 12.30am, the ambulance crew arrived and took over Mr Smith’s care. At 12.38am, paramedics pronounced Mr Smith dead.

Toxicology investigations found that Mr Smith had used psychoactive substances (PS) before he died.


Reception Screening

A nurse reviewed Mr Smith at a health screen on his reception at Liverpool. He performed Mr Smith’s observations and recorded that his NEWS score was 0. He recorded Mr Smith’s medication. He also referred him to the COPD community nursing team and was then located on the wing, specifically reserved for prisoners with drink or drug dependency concerns (DDU).

Management of Risk of Suicide and Self Harm

No concerns noted.

Psychoactive Substances/Illicit Drugs

Toxicological investigations found that Mr Smith had a number of drugs in his system when he died, including methadone at levels consistent with his methadone maintenance programme, and a synthetic cannabinoid (PS). The pathologist noted that there was evidence that Mr Smith had used PS before he died and that he may have been experiencing some of the effects associated with PS, such as increased heart rate, breathlessness, agitation, convulsions and hallucinations. The pathologist also noted that a number of cases of sudden cardiac death have been attributed to synthetic cannabinoid use.

The post-mortem found that Mr Smith died from cardiac failure caused by severe chronic COPD, which was in turn exacerbated by opioid and synthetic cannabinoid use. The post-mortem report also gave a secondary cause as advanced liver cirrhosis.

The pathologist commented that the use of opioid drugs can be lethal in someone with COPD. He added that the consumption of PS may have had a direct harmful cardiac effect on Mr Smith, due to his already weakened and overstressed heart.

Emergency Response

On the evening of 8 May, Mr Smith was locked in his cell with his cellmate. At about 12.20am on 9 May, his cellmate discovered Mr Smith unresponsive in their cell and raised the alarm by kicking on the cell door and shouting. An officer responded to this and saw Mr Smith lying on the floor of his cell, so made a Code Blue emergency call.

An officer and a Custodial Manager (CM) attended and unlocked Mr Smith’s cell. The officer recorded in Mr Smith’s prison notes that an ambulance was called at 12.32am, and that Hotel 1 attended. (Hotel 1 is the radio call sign given locally to the healthcare staff assigned to deal with emergency responses.)

Two nurses attended as Hotel 1. One of them recorded that they heard the Code Blue call at 12.20am. On arrival they saw Mr Smith on the floor unconscious and unresponsive. The nurse noted that an ambulance was called at 12.21am, and that at 12.23am, additional healthcare staff were asked to attend. The nurse recorded that Mr Smith was rolled onto his back, and that staff started cardiopulmonary resuscitation (CPR) and attached a defibrillator to him. She noted that they completed 4 cycles of CPR, but the defibrillator did not advise them to shock at any time.

Investigators were satisfied that this emergency response was conducted appropriately.

Clinical Care

The Clinical Reviewer concluded that the care Mr Smith received was not equivalent to that he could have expected in the community, in the sense that Mr Smith was not managed appropriately for his chronic health conditions, and not adequately monitored when his health deteriorated. Staff neglected to use the NEWS scoring tool consistently to assess his condition, and did not appropriately monitor him when his condition took a turn for the worse.

There were several occasions when the NEWS score was used to assess Mr Smith’s condition but staff failed to follow the guidelines from the National Institute for Clinical Excellence (NICE) on the frequency of observations. There were other occasions where the NEWS tool was not used at all, and when the Clinical Reviewer retrospectively applied the NEWS formula this indicated that Mr Smith should have received more clinical intervention or monitoring at the time.

The Clinical Reviewer also concluded that the care Mr Smith received at Liverpool for his substance withdrawal fell short of that which he could have expected in the community. Healthcare staff did not consistently use the COWS tool to monitor Mr Smith’s withdrawal symptoms, and did not increase his methadone dose when they should have done. She noted that the ‘Drug misuse and dependence: UK guidelines on clinical management’ recommends not under-dosing patients, and that greater benefits can be achieved with a daily methadone dose of between 60ml and 120ml. The Clinical Reviewer concluded that an increase in Mr Smith’s methadone dose from 50ml to 60ml would have been appropriate given his circumstances and presentation. Mr Smith felt that he was not given an adequate dose of methadone to keep him comfortable, and may have sought illicit substances to make up this shortfall.


Rec 1: The Head of Healthcare should ensure that staff appropriately manage prisoners with chronic health complaints and that staff use clinical tools to monitor prisoners experiencing a deterioration in their condition.

Rec 2: The Governor and Head of Healthcare should ensure that prisoners addicted to drugs are appropriately monitored and managed according to the relevant tools and guidelines.

Rec 3: The Governor should ensure that staff proactively manage incidents of suspected drug use and log intelligence reports for any suspicious incidents.

Rec 4: The Governor should ensure that a family liaison officer is appointed promptly when a prisoner dies so that he or she can inform the prisoner’s family or next of kin of his death in person as soon as possible, in line with national guidance.

Full PPO Report 9 May 2018 – HMP Liverpool. Other Non-Natural Death.

Other Recommendations From Deaths Attributed To Natural Causes.

From the 3 remaining reports published last week, these were the recommendations for those deaths in custody attributed to natural causes.

22 Sep 2016 – HMP Wymott. Natural Causes Death.


Rec 1: The Governor should ensure that the next of kin are informed as soon as possible when seriously ill prisoners are admitted to hospital, are provided with comprehensive and accurate information and are kept informed of progress.

Full PPO Report 22 Sep 2016 – HMP Wymott. Natural Causes Death.

28 Feb 2016 – HMP Wakefield. Natural Causes Death.


Rec 1: The Head of Healthcare should ensure that clinical staff assess and manage prisoners with deteriorating chronic condition effectively to enable good standards of care, including that:

  • All treatment and care us is fully documented in prisoners’ medical records to allow effective continuity of care.
  • Clinical staff use appropriate assessment and monitoring processes, in particular to monitor fluid balance and record vital signs.
  • Clinical staff have up to date training in using National Early Warning Scores and are aware of the triggers for escalation and when to refer to hospital promptly.

Rec 2: The Governor should discuss the Graham judgment and its implications with all managers taking decisions about the use of restraints for prisoners taken to hospital and ensure that they fully understand the legal position, that assessments take into account the health of a prisoner, and are based on the actual risk the prisoner presents at the time.

Full PPO Report 28 Feb 2016 – HMP Wakefield. Natural Causes Death.

28 Oct 2018 – HMP Chelmsford. Natural Causes Death.

No Recommendations

Full PPO Report 28 Oct 2018 – HMP Chelmsford. Natural Causes Death.

Thanks to Bill Oxford for making this photo available freely on Unsplash