Fatal Incident Investigations
Yesterday (23 February 2021) Sue McAllister, the Prisons and Probation Ombudsman (PPO), published the first Learning Lessons Bulletin analysing COVID-19 related deaths. The report explores the first wave of COVID-19 related deaths in prisons, looking at the 26 fatal incident investigations which the PPO started between the middle of March 2020 and the
end of May 2020.
The people who died of COVID
Between 18 March 2020 and 27 May 2020, the PPO began investigations into the deaths of 25 prisoners and one post-release death which were COVID-19 related.
Of the 26 deaths, the mean age was 67 years old, the youngest being 40 years old and the oldest being 90 years old.
All but two of the 26 prisoners who died were males, 22 were White British, three were Black, Asian or Minority Ethnic and one was White Irish.
The majority of the 26 deaths happened in hospital (22). Two prisoners died in their cells, one died in the prison healthcare centre and another died in a hospice.
Of the 26 deaths, 22 had COVID-19 as the main cause of death listed on the death certificate, and three noted COVID-19 as a contributory factor towards the death. In one case there was a dispute between the pathologist and the hospital doctor as to whether the main cause of death was COVID-19 induced organ failure or whether COVID-19 was just a contributory factor, which shows how complex categorising these deaths can be.
All 26 individuals had at least one underlying health condition or illness. In many cases these illnesses and health issues contributed towards their death along with COVID-19. In the 26 deaths, the most common underlying health condition listed in our reports was ischaemic heart disease (in 11 cases).
Where people caught COVID
It wasn’t always possible to establish where the people who died caught COVID. In eight out of the 26 cases it was likely they caught the virus in prison. In six cases it was likely they caught the virus either as an inpatient in hospital or attending hospital appointments.
In seven cases there was no reference in reports to which the PPO had access as to where the deceased caught the virus. In a further four cases the PPO was unable to say where they caught the virus.
In one case it is possible that a new cell mate who had been in the community and previously shared another cell with three other prisoners who had been in the community may have passed on the virus when moved into the deceased prisoner’s cell.
Lessons to be learnt
The Ombudsman makes it clear that there are limits to her knowledge about coronavirus in prisons. Because the PPO only investigates deaths within its remit, and does not investigate other cases where people in prison have contracted COVID-19, there is much that data and investigations cannot reveal. For instance, the PPO has no evidence on the care of those who have had COVID-19 and since recovered and no information about prisoners who are still suffering from the effects of long COVID-19 and have additional healthcare needs.
Nevertheless, the PPO makes a clear list of recommendations to HMPPS which it says should:
- ensure all staff adhere to infection control measures, including hand-washing and social distancing, unless there is a medical or security emergency
- give appropriate advice about shielding to all prisoners who are clinically vulnerable or clinically extremely vulnerable
- ensure prisoners have the mental capacity to understand the risks of choosing not to shield and, if they do not have the mental capacity taking appropriate steps to safeguard them
- protect prisoners who are shielding, so they do not have to leave the cell to collect medication or any other services which would put them at an unnecessary risk of contracting the virus
- ensure that prisoners who are shielding do not have to share cells with newly arrived prisoners who have not completed their self-isolation to ensure they are COVID-19 free
- ensure there is an effective communication system to notify staff of prisoners who are shielding and/or self-isolating due to COVID-19
- ensure that prisoners who are displaying possible COVID-19 symptoms are isolated to protect other prisoners and staff
- ensure that staff use the correct PPE, in line with HMPPS policies and PHE guidelines
- ensure risk assessments on the security arrangements (including restraints) required when prisoners are escorted to hospital take into account the effect of the prisoner’s current state of health and mobility on their risk of escape
- where prisoners are restrained when escorted to hospital, ensure that the risk to staff of exposure to COVID-19 is taken into account and that staff wear suitable PPE.