Lawrence Dugbazah

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Independent investigation into the
A report by the Prisons and Probation Ombudsman
death of Mr Lawrence Dugbazah,
a prisoner at HMP Littlehey,
on 6 January 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Lawrence Dugbazah died of heart disease on 6 January 2023, following seven weeks
of food refusal at HMP Littlehey. He had told staff that he saw no point in living and wanted
to die. He was the third man to take his life at Littlehey in three years. Mr Dugbazah was
38 years old. I offer my condolences to his family and friends.
Mr Dugbazah refused food from the moment he arrived at Littlehey on 18 November 2022.
He lost 30kg, a third of his body weight, over the next seven weeks. Staff managed him
using suicide and self-harm prevention procedures (known as ACCT) but he refused to
engage with the process.
Healthcare staff monitored Mr Dugbazah regularly and there was evidence that they
treated him with care and compassion in difficult circumstances. However, there was a
long delay in putting a food refusal care plan in place and then healthcare staff did not
always follow it which meant that important actions were missed.
Not enough was done to address whether Mr Dugbazah had underlying mental health
issues. A psychiatrist referral should have been done by day ten of food refusal but it was
not done until day 45. Mr Dugbazah died on the day the psychiatrist appointment was due
to take place and was never assessed. This was a missed opportunity.
Prolonged food refusal is fortunately rare. While many staff were trying their best to care
for Mr Dugbazah in very challenging circumstances, it was clear that they were unaware of
the policies and processes to manage food refusal in custody. Littlehey needs a much
more robust food and fluid refusal policy to ensure that staff are clear about how they
should care for prisoners in these circumstances, including assessing underlying mental
health needs and mental capacity.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman March 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 12
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Summary
Events
1. In June 2010, Mr Lawrence Dugbazah was given an Imprisonment for Public
Protection (IPP) sentence for sexual offences. He was released ten years later but
was recalled to prison on 31 March 2022, following allegations of further sexual
offences.
2. On 2 April, Mr Dugbazah was moved to HMP Thameside. Later that month, he
stopped eating. He said he was feeling low and did not understand why he was
back in prison.
3. On 23 May, staff started suicide and self-harm prevention procedures (known as
ACCT) for Mr Dugbazah as he was still not eating and said he did not care if he
died. A few days later, he told staff that he had a special diet outside prison (due to
his Irritable Bowel Syndrome) and that he was prepared to start eating again if he
was given an appropriate diet. Healthcare staff arranged this with the kitchen and
Mr Dugbazah resumed eating. Staff stopped ACCT monitoring on 6 June.
4. On 18 November, Mr Dugbazah was moved to HMP Littlehey. He told reception
staff that his mental health was poor anyway and it had got worse when he found
out he was being moved as it had unsettled him. He said he was facing a life
sentence, saw no point in living and would refuse all food and drink. Staff started
ACCT procedures and placed Mr Dugbazah under constant supervision
(subsequently reduced to one observation an hour).
5. When he arrived, Mr Dugbazah weighed just under 90kg (in the overweight range).
The reception nurse noted that he had high blood pressure.
6. On 21 November, the ACCT case coordinator invited the mental health team to
attend the second case review, but they had no record that Mr Dugbazah had been
referred to them. A mental health referral was made that day. However, Mr
Dugbazah refused to engage when a mental health nurse visited him on 23
November. He also refused to engage with the ACCT case reviews.
7. Mr Dugbazah was provided with foods in line with his requested diet, but he refused
to eat them.
8. Healthcare staff visited Mr Dugbazah regularly to carry out welfare checks.
However, he sometimes refused to have his clinical observations taken and to give
blood and urine samples.
9. On 15 December, healthcare staff put a food refusal care plan in place. It said that
daily GP visits should take place after day 3 of food refusal, that a psychiatrist
referral should be made by day 10 and that an urgent review should take place if
weight loss was greater than 10%. No psychiatrist referral was made, and no urgent
review took place (this was day 27 and Mr Dugbazah had lost almost 20% of his
body weight).
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10. Around a week later, Mr Dugbazah said he wanted some fizzy drinks to give him
some energy. Staff ordered several cans for him. However, he said he had vomited
when he had drunk one.
11. On 3 January 2023, a palliative care consultant and a palliative care nurse visited
Mr Dugbazah to discuss his end of life wishes. They put a Do Not Resuscitate order
in place for Mr Dugbazah in line with his wishes. The same day, healthcare staff
made a psychiatrist appointment for 6 January.
12. Shortly after lunchtime on 6 January, while staff were locking prisoners back in their
cells, staff noticed that Mr Dugbazah was on the toilet. An officer thought it seemed
strange and went back to check on him a few minutes later. When he asked Mr
Dugbazah if he was alright, he saw that he was slumped against the wall and
appeared vacant. He called a medical emergency code. Control room staff called
for an ambulance but were told there would be a long delay. Staff did not start CPR
in line with the DNR.
13. At around 1.35pm, a GP at Littlehey arrived at Mr Dugbazah’s cell and assessed
that he was showing no signs of life. Paramedics arrived around ten minutes later
and pronounced that Mr Dugbazah had died.
14. The post-mortem report concluded that Mr Dugbazah died from heart disease.
Weight loss was listed as a contributory factor.
Findings
15. Reception staff correctly started ACCT procedures when Mr Dugbazah arrived at
Littlehey, but they failed to refer him for a mental health assessment as they should
have done.
16. There was a long delay in healthcare staff starting a food refusal care plan and
important actions were not taken in line with the plan. There was a 35-day delay in
making a psychiatrist referral which meant Mr Dugbazah was not assessed before
he died.
17. There was limited input by the GP and no involvement by the safeguarding team.
Also, healthcare staff were unaware of the risks of refeeding syndrome (potentially
dangerous symptoms that can arise when a malnourished person starts eating
again).
18. Healthcare staff thought that Mr Dugbazah had the mental capacity to make
decisions about his food refusal, but no formal assessments were undertaken.
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Recommendations
• The Head of Healthcare should ensure that reception staff make an urgent mental
health referral when a prisoner presents as hopeless or expresses thoughts of
suicide or self-harm.
• The Head of Healthcare should develop a food and fluid refusal policy to ensure
that staff understand how they should manage prisoners who refuse food and fluids
and that:
• a food and fluid refusal care plan is initiated promptly and actions followed;
• the appropriate multidisciplinary team members are involved, including the
safeguarding team;
• the prisoner has at least daily contact that involves the offer of healthcare
provision including physical observations and meaningful conversation;
• a GP assesses the prisoner after three days of food refusal, specifies regular
review intervals and attends all multidisciplinary team reviews; and
• advice is sought from a specialist healthcare professional on the implications
of refeeding syndrome.
• The Head of Healthcare should ensure that all staff receive training in two stage
mental capacity assessments.
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The Investigation Process
19. HMPPS notified us of Mr Dugbazah’s death on 6 January 2023.
20. The investigator issued notices to staff and prisoners at HMP Littlehey informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
21. The investigator obtained copies of relevant extracts from Mr Dugbazah’s prison
and medical records.
22. NHS England commissioned two clinical reviewers to review Mr Dugbazah’s clinical
care at the prison. The investigator and one clinical reviewer jointly conducted 12
interviews between 21 February and 30 March. The other clinical reviewer and
another investigator conducted additional interviews on 6 July.
23. We informed HM Coroner for Cambridgeshire of the investigation. He gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
24. The Ombudsman’s family liaison officer contacted Mr Dugbazah’s brother to explain
the investigation and to ask if he had any matters he wanted us to consider. He did
not respond.
25. We shared our initial report with HMPPS and the healthcare provider at Littlehey.
They pointed out some factual inaccuracies, which have been amended in this
report. We also amended one of the recommendations following feedback. The
healthcare provider provided an action plan which is annexed to this report.
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Background Information
HMP Littlehey
26. HMP Littlehey is a category C training prison for men convicted of sexual offences.
It holds approximately 1,200 men.
27. Northamptonshire Healthcare NHS Foundation Trust provides healthcare services
at the prison. The prison healthcare centre is open on weekdays from 7.30am to
7.30pm, and at weekends from 8.00am to 5.30pm. A local practice provides GP
services, and there is a range of nurse-led clinics. There are no inpatient beds at
the prison.
HM Inspectorate of Prisons
28. The most recent inspection of HMP Littlehey was in 2019. Inspectors reported the
prison was overwhelmingly safe, and while the number of suicide and self-harm
procedures started had increased, the quality was good and improving. Inspectors
noted that there was positive input from healthcare staff where appropriate.
29. Inspectors reported that the number of deaths at Littlehey was likely a result of the
large population of older prisoners. They noted that palliative care at the prison was
highly developed, with a specialist nurse and end of life staff employed in dedicated
roles. HMIP identified this as an area of good practice, with well-integrated
strategies for the care of older prisoners and patients with terminal conditions.
Independent Monitoring Board
30. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 31 January 2022, the IMB
reported that the healthcare team worked well with prison staff to respond rapidly to
keep prisoners as safe as possible throughout the changing pandemic
requirements. They ensured prisoners continued to receive their medications and
access to medical consultations and treatments, which included the reintroduction
of on-wing deliveries and consultations when needed.
31. Between April 2021 and January 2022, healthcare staff saw 403 prisoners
transferred to Littlehey and attended 483 ACCT reviews, both an increase of almost
27% compared to the previous period.
Previous deaths at HMP Littlehey
32. Mr Dugbazah was the 44th prisoner to die at Littlehey since January 2020. Of the
previous deaths, 42 were from natural causes and two were self-inflicted. There
were no similarities between the findings from our investigation into Mr Dugbazah’s
death and the findings from our investigations into the previous deaths.
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Key Events
33. On 10 June 2010, Mr Lawrence Dugbazah was given an Imprisonment for Public
Protection (IPP) sentence for sexual offences. He was released in June 2020.
34. On 31 March 2022, Mr Dugbazah was recalled to prison following allegations of
further sexual offences.
35. Mr Dugbazah was prescribed medication for Irritable Bowel Syndrome (IBS),
asthma and eczema.
HMP Thameside
36. On 2 April, Mr Dugbazah was moved to HMP Thameside. Later that month, Mr
Dugbazah stopped eating. He said he was feeling low and did not understand why
he was back in prison. He told staff he wanted a single cell because he did not like
using the toilet in a shared cell due to his IBS. He said that one of the reasons he
had stopped eating was to reduce his need to use the toilet.
37. On 23 May, staff started suicide and self-harm prevention procedures (known as
ACCT) because he was still not eating and refused to engage with healthcare staff.
He said he would not eat until he was released from prison and did not care if he
died.
38. On 26 May, Mr Dugbazah was admitted to the prison’s inpatient unit (to a single
cell) as staff were concerned about his physical health as he was very weak.
Around a week later, he told staff that he ate a gluten-free, lactose-free and
caffeine-free diet outside prison and that he was ready to start eating again if he
was given the right diet. He started eating and drinking again once he was given
appropriate food and drinks.
39. At the case review on 6 June, staff noted that Mr Dugbazah had been eating two to
three meals a day after healthcare staff had arranged the appropriate diet. Mr
Dugbazah said he had been willing to engage more as he had felt listened to. He
asked for a single cell when he was moved back to a standard wing, but staff said
that he did not meet the criteria. (Mr Dugbazah was assessed as standard risk for
cell sharing so he was expected to share a cell and his health condition was not one
that required a single cell.) Staff stopped ACCT monitoring.
40. On 13 June, healthcare staff diagnosed Mr Dugbazah with mixed anxiety and
depressive disorder. A GP prescribed sertraline (an antidepressant).
41. Mr Dugbazah was moved back to a shared cell on a standard wing on 15 June. He
was initially unhappy but then appeared to settle. He got a job as a wing cleaner
and then in the kitchen. He continued to eat, though sometimes complained that he
was not getting the correct diet. He had regular meetings with his key worker and
his engagement was broadly positive. His main concerns were about getting his
special diet and delays with his court case.
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HMP Littlehey
42. On 18 November, Mr Dugbazah was moved to HMP Littlehey. He told reception
staff that his mental health was not good anyway and had got worse when he found
out he was being transferred as it had unsettled him. When asked if he felt suicidal,
he said he could not guarantee that he would not try to kill himself. He said he was
facing a life sentence, saw no point in living and would refuse all food and drink.
Prison staff started ACCT procedures and placed Mr Dugbazah under constant
supervision. They also started a prison food refusal log.
43. At his reception health screen, the nurse recorded Mr Dugbazah’s weight as 89.8kg
which gave a body mass index (BMI) of 29.73kg/m2 (in the overweight range). The
nurse took Mr Dugbazah’s clinical observations which were all normal apart from
his blood pressure which was high. There was no repeated blood pressure reading
recorded.
44. On 19 November, staff held the first ACCT case review. Mr Dugbazah refused to
engage and so staff held the review in his absence. The case review team noted
that Mr Dugbazah had appeared settled at Thameside and there was no evidence
he had ever self-harmed. They noted that his dietary requirements were being met
by the kitchen. They agreed to stop constant supervision and set observations at
three an hour. Mr Dugbazah was placed in a double cell on E Wing, but with no
cellmate.
45. Staff held the second case review on 21 November. The ACCT case coordinator
invited the mental health team to attend but they said that they had no record of Mr
Dugbazah as he had not been referred to them. Staff made a mental health referral
that day and the ACCT case coordinator noted that the mental health team would
attend the next review. The case review team reduced observations to two an hour.
46. On 23 November, a nurse from the mental health team visited Mr Dugbazah to
carry out a mental health assessment but he refused to engage and said he had
nothing to say.
47. The nurse attended the third case review later that morning, but Mr Dugbazah
refused to engage. The case review team reduced observations to one an hour.
48. That afternoon, a nurse visited Mr Dugbazah to carry out his secondary health
screen. He refused to engage and failed to attend the appointment rescheduled for
25 November. He had not collected his medications since he had arrived at
Littlehey (as he was on an ACCT, he was not allowed to keep his medication in his
possession and had to collect it from the medications hatch).
49. On 24 November, an officer recorded that he had put Mr Dugbazah’s gluten-free
box of food in his cell, but Mr Dugbazah had put it out on the landing and said he
did not want it. He continued to drink water. By this date, it was clear Mr Dugbazah
was not eating, but there is no evidence that anyone from healthcare considered
beginning a food refusal care plan.
50. Staff held the next case review on 28 November and then held weekly
multidisciplinary case reviews thereafter. Mr Dugbazah continued to refuse to
engage. Staff kept observations at one an hour.
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51. On 2 December, a nurse called the wing to ask if Mr Dugbazah would go to the
healthcare unit for a welfare check. The nurse then went over to the wing to see
him. He told her that he had not eaten anything since he had arrived. The nurse
noted that he had cups of water in his cell. He refused to let the nurse take clinical
observations. Wing staff recorded that they had tried to engage him in conversation,
but he was unwilling to engage, though remained polite.
52. On 7 December, Mr Dugbazah was due to attend court, but he refused to attend.
53. The same day, staff held a multidisciplinary team meeting (MDT) to discuss how to
care for Mr Dugbazah given his food refusal. Prison staff, safer custody staff, the
offender management unit and the mental health team attended. Staff agreed to
move Mr Dugbazah to a single cell on K Wing (this was actioned later that day).
54. On 8 December, healthcare staff called the wing to ask if Mr Dugbazah would go to
the healthcare unit for a welfare check but he refused. A healthcare assistant (HCA)
in the mental health team visited Mr Dugbazah in his cell. He refused to engage. He
told the HCA that he was not eating and would not eat ‘today, tomorrow or the day
after’ and he wanted to be taken out of prison in a body bag.
55. On 8, 9 and 10 December, healthcare staff contacted the wing to see if Mr
Dugbazah would attend the healthcare unit for a welfare check but he refused. On
11 December, a nurse visited Mr Dugbazah in his cell, but he refused to have his
clinical observations taken.
56. On 12 December, wing staff contacted healthcare staff to report that Mr Dugbazah
was feeling dizzy. He refused to attend the healthcare unit. He declined the next
day too.
57. On 14 December, the Deputy Head of Healthcare and a palliative care nurse visited
Mr Dugbazah in his cell. He was happy to engage with them. The Deputy Head of
Healthcare asked Mr Dugbazah if there was anything she could do to encourage
him to eat but he said there was not. He agreed to have his clinical observations
taken if nurses came to his cell. When they left the cell, a prisoner told them that Mr
Dugbazah was eating fruit, so the Deputy Head of Healthcare noted that she would
email the kitchen to ask for more fruit to be sent to Mr Dugbazah.
58. Nurses visited Mr Dugbazah later that day and took his observations. They
recorded that Mr Dugbazah had lost 17.6kg (almost 20% of his body weight) during
his four weeks at Littlehey. Nurses tried to take a blood sample but struggled as Mr
Dugbazah was dehydrated. He refused to let them have a second try as he said he
was scared of needles.
59. On 15 December, healthcare staff started a food refusal care plan, which said that
after day three of food refusal, the following should be carried out:
• Daily nursing interventions blood pressure and pulse check.
• Weekly (then daily) weight and urinalysis by nursing staff.
• After day three, daily visit/consultation by GP, apart from weekend until
point of deterioration.
• MHIRT referral day four and to be seen within the first week.
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• MHIRT to refer to Psychiatrist who needs to see prisoner before day ten of
food refusal.
• All clinical details to be recorded on SystmOne.
• Prison GP to consider prescribing supplements should BMI fall below 18.
• Bloods to be taken for U&E and renal function, repeated as needed.
• Ask patient to drink 1.5 litres of water daily with a teaspoon of salt added.
• If weight loss greater than 10%, urgent review required.
• Visit every day.
When the care plan was started, Mr Dugbazah had been refusing food for 27 days
and had lost almost 20% of his body weight. There is no record of a psychiatrist
referral (which should have been done by day ten of food refusal) or of an urgent
review (which should have been done when weight loss was greater than 10%).
60. On 16 December, healthcare staff took Mr Dugbazah’s clinical observations, but he
refused to have blood tests or provide a urine sample.
61. Later that day, a Custodial Manager (CM) held a key worker session with Mr
Dugbazah. Mr Dugbazah told him that he was in pain and wanted to die. The CM
had also been appointed as family liaison officer and asked Mr Dugbazah for
permission to contact his next of kin, but he refused. Mr Dugbazah received regular
key work sessions with the CM.
62. On 17 December, prison staff opened a self-isolator log for Mr Dugbazah, following
concerns about his refusal to engage with staff. Staff made regular entries.
(Opening a self-isolator log does not lead to any specific actions but encourages
staff to monitor the prisoner’s engagement with staff, other prisoners and the
regime.)
63. On 17 and 18 December, Mr Dugbazah refused to have his clinical observations
taken. He agreed on 19 December but refused to have blood glucose levels
measured or provide a urine sample.
64. On 20 December, Mr Dugbazah refused to attend court because he felt unwell. He
agreed to have a blood sample taken. Healthcare staff did not see him on 21
December. The reason is unclear.
65. On 22 December, Mr Dugbazah asked staff if they could get him some cans of fizzy
drink (Irn Bru) to give him some energy. Staff gave him several cans.
66. The same day, healthcare staff took Mr Dugbazah’s clinical observations and noted
he had high blood pressure and a high pulse rate. Mr Dugbazah said he felt unwell
and had vomited after drinking a fizzy drink. A GP at Littlehey reviewed the blood
test results, which were abnormal, so he made an appointment to see Mr
Dugbazah.
67. On 23 December, staff held a multidisciplinary team meeting to discuss Mr
Dugbazah. Staff attempted to engage him in the process and gain consent to
contact his next of kin, but he refused. Mr Dugbazah was not receiving visits from
family or friends and did not make phone calls while at Littlehey.
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68. Later that day, the palliative care nurse saw Mr Dugbazah and tried to discuss an
advanced care plan (for end of life planning) with him, but he refused. A prison GP
also visited Mr Dugbazah that day and prescribed an iron supplement for anaemia.
He recorded that Mr Dugbazah said he wanted to be left to die. He recorded that
there should continue to be welfare checks, weekly weight checks and a mental
health review. Mr Dugbazah agreed for the GP to visit again the following week.
69. On 29 December, a nurse saw Mr Dugbazah on the wing. She recorded that he
appeared to understand the consequences of his food refusal and gave coherent
answers about his decision.
70. On 30 December, the palliative care nurse completed an advanced care plan which
included a discussion about Mr Dugbazah’s preferred place of death. She noted
that Mr Dugbazah was happy to have this conversation, and she had no reason to
doubt his capacity. She noted that Mr Dugbazah had lost 26.9kg since arriving at
Littlehey, almost 30% of his body weight. Later that day, a prison GP saw Mr
Dugbazah and prescribed Fortisip, a nutritional supplement for malnutrition.
71. On 3 January 2023, a palliative care consultant and the palliative care nurse saw Mr
Dugbazah and discussed his food refusal with him. They recorded that he was clear
in his intention to die and did not want to be resuscitated. They completed a Do Not
Attempt Cardiopulmonary Resuscitation (DNACPR) form in line with Mr Dugbazah’s
wishes. Staff placed this on the noticeboard in Mr Dugbazah’s cell.
72. The same day, staff made a psychiatrist appointment for Mr Dugbazah, which was
scheduled for 6 January. (He died before this appointment took place.)
73. On 4 January, the CM held a key work session with Mr Dugbazah. He noted that he
was unwilling to engage until the CM wanted to discuss plans for what would
happen if Mr Dugbazah died in Littlehey. Mr Dugbazah told the CM that he wanted
to be cremated and his brother to inherit his possessions. The CM asked Mr
Dugbazah if he could contact his brother, but he did not answer.
74. A nurse recorded Mr Dugbazah’s weight on 4 January as 59kg. He had lost 30kg, a
third of his body weight, since he had arrived at Littlehey.
Events of 6 January 2023
75. On 6 January, staff held an ACCT case review, but Mr Dugbazah refused to
engage. Staff noted that he had an upcoming psychiatric appointment to assess his
mental capacity.
76. At 12.15pm, Officer A and Officer B were locking prisoners in their cells. When they
got to Mr Dugbazah’s cell, they saw he was sitting on the toilet. Officer A asked Mr
Dugbazah if he was alright, and he raised his hand to acknowledge them. Officer A
went back to the office and thought something was odd about Mr Dugbazah being
on the toilet so went back to check on him.
77. When Officer A checked on Mr Dugbazah again, he was still on the toilet, leaning
against the wall. He said he asked Mr Dugbazah if he was alright, and he seemed
vacant.
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78. At 12.31pm, Officer A called a code blue (a medical emergency code used when a
prisoner is unconscious or having breathing difficulties). Staff responded, including
Officer B. Control room staff called an ambulance at 12.34pm and updated the
ambulance five minutes later with Mr Dugbazah’s condition. The ambulance service
advised that it could be an hour wait.
79. Officer B said during interview that she tried to get a response from Mr Dugbazah
and his eyes were moving and he was struggling to breathe, but he was unable to
respond. Staff did not attempt resuscitation, in line with Mr Dugbazah’s wishes.
80. At around 1.35pm, a GP returned from a meeting and was told to attend Mr
Dugbazah’s cell. When he arrived, he checked for a heartbeat but could not find
one.
81. At 1.42pm, ambulance staff arrived at Mr Dugbazah’s cell. Paramedics initially
believed Mr Dugbazah to be showing signs of life, but he was pronounced dead at
1.52pm.
Contact with Mr Dugbazah’s family
82. On 6 January at 2.15pm, the family liaison officer (FLO) contacted HMP Lancaster
Farms to ask them to notify Mr Dugbazah’s listed next of kin, his brother, of his
death as the address was in Lancashire, over three hours travel from Littlehey.
Lancaster Farms sent two FLOs to the address, but Mr Dugbazah’s brother was not
there. The FLO at Littlehey contacted the police who were also unable to verify an
address.
83. The FLO tried contacting Mr Dugbazah’s other siblings, after finding some old
contact details in prison records. He spoke to one of Mr Dugbazah’s brothers and
broke the news of his death and offered his condolences. Mr Dugbazah’s listed next
of kin contacted the FLO shortly after. The FLO explained the circumstances,
offered condolences and said the prison would contribute toward the funeral costs.
Support for prisoners and staff
84. After Mr Dugbazah’s death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
85. The prison posted notices informing other prisoners of Mr Dugbazah’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Dugbazah’s death.
Post-mortem report
86. The post-mortem report found that Mr Dugbazah died from ischaemic heart
disease. The report found that on balance, Mr Dugbazah’s weight loss was likely to
have been a contributory factor.
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Findings
Reception
87. Staff correctly started ACCT procedures when Mr Dugbazah arrived at Littlehey. Mr
Dugbazah had been under the care of the mental health team at Thameside, his
previous prison, and he had expressed thoughts of suicide when he arrived at
Littlehey. According to National Institute for Health and Clinical Excellence (NICE)
guidelines, this should have triggered a mental health referral. The mental health
referral was not done until three days later, when the ACCT case review team
realised that one had not been done. We recommend:
The Head of Healthcare should ensure that reception staff make an urgent
mental health referral when a prisoner presents as hopeless or expresses
thoughts of suicide or self-harm.
ACCT management
88. It was good practice to open an ACCT for Mr Dugbazah as soon as he arrived at
Littlehey. Staff held regular, multidisciplinary ACCT reviews. The management of
the ACCT was complicated by the fact that Mr Dugbazah refused to engage
throughout. We consider that staff managed it appropriately in the circumstances.
Clinical care
Food refusal
89. The clinical reviewer found that there were many examples of caring,
compassionate nursing care with daily welfare checks undertaken to try to establish
rapport and engagement with Mr Dugbazah. However, she found that there were
many missed opportunities to start a healthcare directed food and fluid refusal care
plan and invite key multidisciplinary team members to assess Mr Dugbazah for an
underlying mental health disorder.
90. A food refusal care plan was not started until 15 December 2022 and by then, Mr
Dugbazah had been refusing food for 27 days and had already lost almost 20% of
his body weight. The care plan said that if Mr Dugbazah lost 10% of his body
weight, the primary care team should carry out an urgent review. This did not
happen. By 30 December, Mr Dugbazah had lost almost 30% of his body weight
and still there was no urgent review. The care plan also said that a psychiatric
assessment should be carried out by day ten of food refusal. Healthcare staff did
not make the psychiatrist appointment until 3 January (day 45), and the
appointment was for 6 January, the day Mr Dugbazah died, so he was never
assessed.
91. The care plan said that after day three of food refusal, there should be a daily visit
by a GP apart from at the weekend. There was very limited input from a GP at
Littlehey, who only worked two sessions a week on Thursdays and Fridays.
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92. Throughout Mr Dugbazah’s time at Littlehey, there was no involvement of the
safeguarding team or external support sought with regards to refeeding syndrome
(metabolic abnormalities that occur when a malnourished person starts feeding).
Guidelines say that extreme caution should be taken with recommencing food and
fluids as patients are at risk of refeeding syndrome. Specialist advice should have
been sought. It is possible that staff’s unfamiliarity with the process when a prisoner
refuses food was exacerbated by the lack of a food and fluid refusal policy at
Littlehey.
93. We recommend:
The Head of Healthcare should develop a food and fluid refusal policy to
ensure that staff understand how they should manage prisoners who refuse
food and fluids and that:
• a food and fluid refusal care plan is initiated promptly and actions
followed;
• the appropriate multidisciplinary team members are involved, including
the safeguarding team;
• the prisoner has at least daily contact that involves the offer of
healthcare provision including physical observations and meaningful
conversation;
• a GP assesses the prisoner after three days of food refusal, specifies
regular review intervals and attends all multidisciplinary team reviews;
and
• advice is sought from a specialist healthcare professional on the
implications of refeeding syndrome.
Mental capacity
94. Although it was accepted that Mr Dugbazah had the mental capacity to make
decisions about his food refusal, no formal two stage mental capacity assessments
were documented.
95. Mental capacity can fluctuate from day to day and as Mr Dugbazah became frailer
and more unwell from his food and fluid refusal there should have been
consideration of formal two stage mental capacity assessments.
96. We recommend:
The Head of Healthcare should ensure that all staff receive training in two
stage mental capacity assessments.
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Head of Healthcare to note
Blood pressure
97. When Mr Dugbazah arrived at Littlehey, the reception nurse noted that his blood
pressure reading was high but there was no record that she repeated the reading
as she should have done. The Head of Healthcare should remind staff of the correct
process for high blood pressure readings.
Areas of good practice
98. The clinical reviewer found evidence of sensitive and open communication with Mr
Dugbazah about his impending death and also in relation to Advance Care
Planning. Mr Dugbazah was reluctant to engage with staff and services in the
prison, but it is evident from the records that the Deputy Head of Healthcare and the
palliative care nurse made a concerted effort to communicate with him in order to
gain his trust.
Inquest
99. The inquest was held from 12 to 14 August 2024. The jury concluded that Mr
Dugbazah died from natural causes contributed to by self-neglect.
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