Preston prisoner put in handcuffs while in a coma - and died hours later
An investigation has finished into the death of a prisoner who was placed in handcuffs while in a coma.
Steven Lee, a prisoner at HMP Preston died on October 19, 2023 aged 60. This week a report has been released by the Prisons and Probation Ombudsman (PPO) looking into the circumstances, and whether lessons can be learned.
Ombudsman Adrian Usher slammed an “unacceptable delay in assessing the severity of the situation” when Mr Lee was found unresponsive in his cell, and said it was “completely unacceptable” that Mr Lee was restrained when he went to hospital.
What happened?
In December 2022, Mr Lee was remanded to custody and taken to HMP Forest Bank, charged with fraud. On September 1, 2023, he transferred to HMP Preston. At his initial health screen, he told a nurse that he had chest pains. The nurse sent him to hospital, and it was later confirmed that Mr Lee had had a heart attack. On September 15, Mr Lee returned to Preston and lived in the healthcare wing for a period of enhanced observations.
At 3.37pm on 19 October, a Healthcare Support Worker (HSW) went to Mr Lee’s cell to give him his medication. The HSW was unable to rouse him. A nearby nurse telephoned for an officer to open the cell door. The nurse and HSW thought that Mr Lee was in a deep sleep. Eleven minutes later, an officer opened the cell door. They tried to rouse Mr Lee but were unable to do so.
Seven minutes after that, the nurse asked a GP and another nurse to attend. At 3.57pm, a GP arrived, examined Mr Lee, and asked the nurse to call an ambulance. Another nurse arrived and recorded Mr Lee had a Glasgow Coma Scale score of 4, which indicated that he was in a coma, and she inserted an airway.
At 4.14pm ambulance paramedics arrived and took over Mr Lee’s treatment and at 4.59pm, they took him to hospital. Two officers escorted Mr Lee, who was restrained with an escort chain. At 5.55pm, hospital staff told the officers with Mr Lee that he would be placed on end-of-life care. At 6.05pm, the officers removed the restraint. Mr Lee died later that evening.
It was found that Mr Lee died of acute subdural haemorrhage - bleeding on the surface of the brain. He also had chronic kidney disease, ischemic heart disease, a stroke, and Type 2 diabetes which contributed to but did not cause his death.
Findings
It was found that there was a delay of 11 minutes opening Mr Lee’s cell door after staff found him unresponsive. There was a further nine-minute delay before staff requested an ambulance and a minute after that they radioed an emergency medical code. Mr Lee was also inappropriately restrained when he was taken to hospital in a coma.
The Ombudsman has made recommendations to the prison service.
He said: “The Head of Healthcare should ensure that where there are serious concerns about the health of a prisoner, staff use an emergency code to summon assistance and alert control room staff to call an ambulance immediately, in line with Prison Service Instruction (PSI) 03/2013.”
He added: “The Governor and Head of Healthcare should ensure that staff accurately reflect their professional opinion on restraint risk assessment forms, that there are clear and considered conversations between healthcare and prison staff about a prisoner’s risk where necessary and that these conversations are routinely documented.”
Action taken
An action plan shows that staff at HMP Preston have accepted the recommendations, and made changes. The Head of Safety and Head of Healthcare delivered a joint desk top exercise in July 2024 to explore the use of Code red/Code blue emergency codes at HMP Preston and the roles of individual functions. The Safety Team at HMP Preston has also delivered the national ‘responding to emergency situations’ video to operational staff at three training days.
The Head of Security has alsd sent guidance to all orderly officers and duty governors in relation to the policy requirements around cuffing arrangements on escort and to remind managers that decisions in relation to escort risk assessments.
The prison
The most recent inspection of HMP Preston was in June 2023. Inspectors reported that health care was very well led, and the Governor understood the importance of these services for such a complex and vulnerable population, appointing extra staff to support the work.
The Minstry of Justice
A Prison Service spokesperson said: “Our thoughts remain with the family and friends of Steven Lee. We have accepted all of the PPO’s recommendations in this report including improved staff training in medical emergencies and we are currently reviewing the arrangements around restraints during hospital visits."
They add that the use of handcuffs on a prisoner is decided on a case-by-case basis and must be justified by individual security considerations.