Individual at Isle of Wight

Investigation into the circumstances surrounding the
death of a man in outside hospital, whilst in the custody of
HMP Albany, in May 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2009
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
This is the report of an investigation into the death of a prisoner at HMP Albany who
died from natural causes in outside hospital, in May 2008.
In February 2008, the man had been sentenced to 12 years imprisonment. He
moved from HMP Bedford to HMP Albany at the end of that month. He was
admitted to hospital on 26 May and died three days later. He was 58 years old.
I would like to add my personal condolences to those already expressed to the
man’s family on behalf of this office by one of my Family Liaison Officers.
This investigation was undertaken by one of my colleagues. I am grateful for the
assistance he received at HMP Albany and would like to thank the Governor and his
staff for their cooperation. A doctor was identified by the local Primary Care Trust to
undertake a review of the man’s clinical care and I also greatly appreciate his
assistance.
The clinical review raises a number of learning points which the prison health
partnership will need to consider seriously. I note with concern the clinical reviewer’s
opinion that the man‘s care was not of an equivalent standard to that he would have
received in the wider community. I understand that the local Primary Care Trust, in
partnership with HMP Albany, is producing an action plan to address the learning
points. I have also made one recommendation that Albany should review its
bedwatch instructions.
I have been impressed by the support afforded by the prison to the man’s family. In
complete contrast, one of the entries in the bedwatch log was unprofessional,
disrespectful and wholly inappropriate.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2009
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CONTENTS
Summary
The investigation process
HMP Albany
Key events
Issues considered
Conclusion
Recommendations
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SUMMARY
The man was 58 years old when he died in hospital on 28 May 2008. He died from
natural causes as a consequence of carcinoma (cancer) of the lung.
He had been sentenced to 12 years imprisonment in February 2008. He was initially
received into custody at HMP Bedford and transferred to HMP Albany on 29
February.
During his first reception health screening interviews at Bedford and Albany, it was
recorded that the man had previously been diagnosed with emphysema and had
arthritis in his knee. It was also noted that he was a smoker.
On 9 May, the man told other prisoners that he had been coughing up blood. He
was seen by healthcare staff and an appointment was made with the prison doctor.
He was seen by a doctor on 13 May who requested that an x-ray be carried out. On
22 May, he attended the hospital for an x-ray.
During the morning of 26 May, the man was seen by healthcare staff as he was
experiencing shortness of breath and appeared to be confused. Around 1:05pm, he
collapsed onto the floor of his cell and cut his head. As healthcare staff could not
close the cut, he was taken to the Accident and Emergency (A&E) Department of the
local hospital. After receipt of the result of the earlier x-ray, which suggested that the
man had cancer in his lung, he was admitted to the Medical Assessment Unit (MAU).
On the following day, staff at the MAU contacted Albany and informed healthcare
staff that the man appeared to have widespread cancer and his prognosis was very
poor.
Whilst he was in hospital, a bedwatch was carried out by prison staff. The initial
security risk assessment was that handcuffs were to be used and two officers
needed to be at his bedside. This was later revised on 28 May and handcuffs were
no longer used. The man’s family were allowed to visit him whilst he was in hospital.
(A bedwatch log was maintained by the staff at the man’s bedside. The majority of
the entries made in the log were appropriate and respectful. However, my
investigator found one entry made during the evening of 27 May which was not
appropriate. This entry has been raised separately with the Governor.)
At approximately 9:35pm on 28 May, the officers on bedwatch duty saw that the man
was having breathing problems and they informed the nursing staff. At around
9:50pm, he was pronounced dead by a hospital doctor.
The clinical review carried out, the reviewer and a panel of his colleagues identified
issues relating to the provision of care for the man. The review panel makes two
recommendations for service improvement. In the clinical reviewer’s view, the
quality of care given to the man was not equivalent to that he would have received in
the community. I have made one recommendation of my own suggesting that the
Governor reviews his bedwatch instructions.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 29 May 2008 when my investigator issued
notices announcing the investigation to staff and to prisoners. The notices
included an invitation to those who wished to submit information relating to the
man’s death to make themselves known to my investigator. One prisoner
asked to see my investigator. My investigator also studied all relevant prison
records relating to the man, which included his main prison record and his
medical records.
2. My investigator visited Albany on 17 and 23 June and discussed aspects of the
man’s treatment with staff and prisoners. He interviewed a prisoner and two
officers.
3. The local Primary Care Trust commissioned a doctor from the PCT’s Public
Health Department to lead a panel review of the man’s clinical care. I am most
grateful to the doctor for undertaking such a thorough and timely review.
4. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation and to request a copy of the post mortem report.
Upon completion, this report will be sent to the Coroner to assist him in his
enquiries into the man’s death.
5. One of my Family Liaison Officers contacted the man’s family. This gave them
the opportunity to discuss the purpose of the investigation and to raise any
concerns or questions that they would like explored and addressed. His family
chose not to raise any concerns at that time. I understand that the family were
able to visit Albany after the man’s death to visit his cell and speak to other
prisoners who lived on his wing. His family spoke very positively about the help
and support they received from prison staff. I hope that this report provides the
family with a better understanding of the events leading up to his death.
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HMP ALBANY
6. Albany is a category B training prison situated near Newport on the Isle of
Wight. The prison occupies the site of a former military barracks, and was
opened in 1967. Albany has a varied regime with education and various
offending behaviour programmes. At the time of the man’s death the prison
could hold up to 566 adult male prisoners.
7. There are five wings (A – E) which are almost identical and hold between 94
and 96 prisoners in single cells with in cell power and access to electronic night
sanitation. There are three small ‘spurs' on each landing, with communal
recesses that house showers, toilets and wash basins. There are also two 40
bed units (F and G) which are comprised of single cells with en-suite facilities.
8. Health services at Albany and at the other two prisons on the Isle of Wight are
commissioned by the local Primary Care Trust (PCT). The prison’s healthcare
is clustered with HMP Camp Hill and is provided by HMP Parkhurst. Parkhurst
provides healthcare to the 1,500 or so prisoners on the island and has a 12 bed
in-patient facility (mainly for psychiatric patients). Prisoners’ medical needs are
catered for by way of out-patient clinics and core day primary nursing cover.
There are three nurses on duty from 7:30am to 5.30pm on Monday to Friday.
During weekends and evenings, one member of healthcare staff is on duty.
General Practitioners (GPs) from Medina Healthcare, a local community
practice, attend Albany for four sessions of three hours each week. Evenings
and weekends are covered by on call GPs from the local PCT. There is no
nursing or healthcare cover based at Albany during the night.
9. The most recent report of a full announced inspection by Her Majesty’s Chief
Inspector of Prisons was in November 2007. The inspection report noted that
public protection and the range of activities were good and that offending
programmes were of a very high standard. However, the Chief Inspector noted
that relationships between staff and prisoners were distant and mistrustful.
There were also insufficient work places, and systems to protect prisoners
against bullying and self-harm were not sufficiently robust.
10. The Independent Monitoring Board (IMB) in its most recent report for Albany
(2006-2007) drew attention to the difficulties faced by prisoners with mobility
problems. The IMB noted that the management team at Albany was aware of
this and every effort was being made to accommodate prisoners with mobility
difficulties in appropriate locations. The report also referred to the limited
availability of staff for escorts to accompany prisoners to the local hospital. The
report said, “we still feel that this problem will not go away due to the age of our
prisoners”.
11. During 2008, my office has investigated five deaths through natural causes at
Albany. There was no link between the circumstances surrounding this
investigation and the previous deaths.
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KEY EVENTS
12. On 7 February 2008, the man was sentenced to 12 years imprisonment. He
arrived at HMP Bedford the same day and transferred to HMP Albany on 29
February.
13. During his first reception health screen interviews at both prisons (on 7 and 29
February), it was recorded that the man had previously been diagnosed with
emphysema and arthritis. He was a smoker who continued to smoke and
refused assistance to help him stop. He was allowed to keep his medication in
possession. At Albany, he was located on A wing. Due to his breathing
problems, an officer arranged for him to move from a cell on the first landing
(the 2s) to a cell on the ground floor (the 1s).
14. During the morning of 31 March, the man was seen by a nurse in the
healthcare centre because he needed to complete a fitness form as he wanted
to play bowls.
15. On 9 May, the officer who arranged the cell move contacted healthcare after
the man told other prisoners that he was coughing up blood. A second nurse
saw the man on the wing and noted that his breathing and colour were good.
He said that he had a persistent cough which had blood stained sputum, and
that he was coughing so much that it was now a strain. An appointment was
made with the prison doctor to seek further advice.
16. A doctor saw the man four days later on 13 May. The doctor noted that the
man had lost three stone in the past few months. He decided to make an
urgent referral for him to have a chest x-ray at the local hospital. On 16 May, a
member of staff from the prison’s healthcare centre arranged an appointment
for him at the local hospital.
17. On 22 May, the man went to the hospital for an x-ray. (The result of the x-ray
was received by Albany on 28 May - two days after his admission to hospital).
The result of the x-ray was:
“There is a significant loss of volume of the right lung with a large mass
arising from the right hilum and measuring 10 X 8.3cm. There are also
infiltrative changes surrounding the mass. There is no evidence of any
pleural effusion. The right lung [(sic). I assume this is in error.] is
clear. The changes primarily are in keeping with a malignant tumour of
the right lung with ipsilateral metastatic disease. For further
investigation I would like to suggest bronchoscopy and CT of the
lungs.”
18. Around 9:00am on 26 May, a second officer noticed that the man’s speech was
slurred and he was acting differently. When interviewed as part of this
investigation, the officer said he became concerned about the man’s well being
and thought that he might have suffered a stroke. The second officer informed
Healthcare about his concerns and kept him under observation. A third nurse
attended his cell on two occasions during the morning at the second officer’s
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request. On his first visit just after 9:00am, the third nurse noted that the man
was able to answer simple questions. Because he was concerned about the
man’s condition, the second officer made regular checks throughout the
morning. At around 11:00am, the second officer made a further check on himn.
He observed that the man was incoherent and short of breath. The second
officer again requested medical assistance. When the third nurse saw him for
a second time he found him talking to other prisoners in his cell. He
complained of feeling short of breath when he lay down and the nurse
suggested that he sit propped up. The second officer asked the nurse whether
the man would be referred to hospital. The nurse replied that he would not
make a referral but had arranged an appointment for him to see the prison
doctor at 2:00pm. The nurse noted on the medical record that Albany was still
awaiting the result of the man’s earlier x-ray.
19. At approximately 1:05pm, the second officer checked the man and found him
sitting on his bed. The man spoke to him and appeared to be okay. As the
second officer walked away from the cell he heard a noise. The officer re-
checked the cell and discovered that the man had collapsed onto the floor in
front of his cell door. He immediately used his radio to summon medical
assistance. The officer told the man that he needed to move away from his cell
door so that it could be opened. With his colleague he then opened and
entered the cell. They discovered that the man had a deep cut to his left
eyebrow. The second officer asked his colleague to fetch the first aid kit.
When his colleague returned to the cell, they helped the man to sit on his bed.
The third nurse arrived at the cell shortly afterwards at approximately 1:11pm.
Whilst medical treatment was being carried out it was apparent that the man’s
head injury was serious and arrangements were made to take him to the local
hospital. At 1:56pm, the man arrived at the Accident and Emergency (A&E)
Department at the local hospital for treatment of his wound. He was later
admitted to the Medical Assessment Unit (MAU) at the hospital after the results
of his earlier x-ray (on 22 May) were received.
20. Whilst the man was an in-patient at the hospital, a bedwatch was carried out by
prison staff. The initial security risk assessment carried out on 26 May by the
Head of Security and Operations concluded that an escort chain should be
used and two officers needed to be in attendance at his bedside. During his
stay in hospital, the man was visited by his family.
21. On 27 May, the bedwatch logs show that the man was seriously ill. During the
day, he was noted to be confused following an episode of brachycardia (slow
heart rate). The doctors spoke with his family and explained that lung cancer
was suspected. The Duty Governor informed the Family Liaison Officer at
Albany that doctors at the hospital were talking about life expectancy of hours
rather than days. The third nurse contacted staff at the MAU and was told that
the man appeared to have widespread cancer in his lung, brain and abdomen.
The nurse was also informed that his prognosis was very poor. Later that
same day an officer, who was on bedwatch duty, made an inappropriate entry
in the bedwatch log to which I refer later in this report (paragraphs 35 - 37).
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22. On 28 May, two further officers were on bedwatch duty during the day. They
noted in the log that the man slept most of the morning and that, when he was
awake, he was not very coherent. The man had a CT (Computed
Tomography) scan around noon. He was found to have a lesion in the left
frontal lobe of his brain and a large tumour in his right lung. A hospital
consultant met the man’s family. He explained that he was very ill and that he
was being kept comfortable because a cure for his condition was not possible.
23. The Head of Security and Operations revised the security risk assessment at
3:20pm on 28 May. The man’s restraints were removed and were not re-
applied. At 6:45pm, another two officers reported for bedwatch duty. They
relieved the day bedwatch officers. At approximately 9:35pm, the relief
bedwatch officers saw that the man was having breathing problems. Nursing
staff were summoned and the officers left the room to allow the family some
privacy. The man’s family remained in the room with him. At around 9:50pm,
death was pronounced by a hospital doctor. One of the relief bedwatch officers
immediately informed the prison. The Head of Security and Operations met
with the man’s family and offered condolences on behalf of HMP Albany.
24. At 9:00am on 29 May, the Diversity Manager and an officer from Safer Custody
called all the prisoners on A wing together in the association area to inform
them of the man’s death. They also asked the prisoners whether they required
anything or wanted to speak to a Listener. (Listeners are trained by
Samaritans to provide confidential emotional support to fellow prisoners in
distress.) Three prisoners were upset and were spoken to individually following
the group meeting.
25. A principal officer was appointed as the prison’s Family Liaison Officer. He met
the family when they went to see the man in hospital during the morning of 28
May. The principal officer maintained contact with the family and assisted with
the funeral arrangements. The prison offered financial assistance with the
costs of the funeral.
26. The post mortem report records the man’s death as being due to natural
causes, as a consequence of a carcinoma (cancer) of the lung with cerebral
metastases (cancer in the brain).
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ISSUES CONSIDERED
Clinical care
27. A review of the man’s medical care was undertaken on behalf of the local
Primary Care Trust by a doctor who convened a review panel. The panel
comprised of a Chair, the clinical reviewer, a member of the Independent
Monitoring Board, a General Practitioner for the Isle of Wight prisons and a
Risk Incident and Claims Manager.
28. My investigator asked the panel whether the man’s condition could have been
diagnosed earlier. The clinical reviewer says that the man did not tell staff of
any health concerns at his first health screen interviews at either Albany or
Bedford. The clinical reviewer also says that a routine chest x-ray was not part
of the reception process but a tuberculosis (TB) risk form was used during the
health screening process. The man only reported that he suffered from
emphysema and arthritis.
29. The panel has expressed concerns about the delays arranging the man’s x-ray.
It was requested on 13 May and carried out on 22 May but it is unclear what
caused this delay. The result of the x-ray was not received by Albany until 28
May. However, the x-ray result was known to hospital staff soon after he was
admitted to hospital, on 26 May. During the panel’s discussion, the GP for Isle
of Wight prisons said that x-rays results in primary care are sent electronically
via a system called Pathlinks. The result is received the day after the x-ray has
been performed. The panel agreed that there should be a review of the
Pathlinks system and how it might be used by Healthcare at Albany. It also
agreed that the Chair and Risk Incident and Claims Manager should discuss
with the hospital the communication problems encountered in this case.
During the proposed new healthcare building programme at HMP Albany
there should be an assessment of the benefits of adopting the Pathlinks
system.
There should be a review to improve communication between Albany and
the hospital with regard to urgent x-ray and pathology reports.
30. The GP for Isle of Wight prisons advised that another referral route for the man
could have been the two week cancer referral under the cancer care
guidelines. The GP said that the man would have qualified, although this would
not have altered his prognosis.
31. The panel agreed that, had the man reported his symptoms earlier, tests could
have been performed more quickly. He and his family might then have known
about his prognosis earlier. However, it is very unlikely that an earlier
diagnosis would have altered the outcome. The GP said that a lesion on the
frontal lobe of the man’s brain might have affected his personality and he might
have acted out of character. This may explain why he did not bring his
symptoms to the attention of healthcare staff or his family.
9
32. Following tests on 28 May, the man was diagnosed with terminal cancer and
his family were informed that there was no active treatment for his condition.
He was kept comfortable and passed away later that day.
33. The clinical reviewer concludes that the man’s care was not equivalent to that
he would have received in the community. He says this was due to the delay in
obtaining a chest x-ray, and the result of that x-ray, although this did not alter
the eventual outcome.
Restraints
34. I am pleased to report that the man was properly assessed whilst he was in
hospital and, as a result, the level of restraints was reduced and the escort
chain removed. This was entirely appropriate and enabled the nursing staff to
have easy access when they carried out their duties. The bedwatch officers
remained on duty but withdrew whenhis condition deteriorated, allowing his
family to be alone with him when he died.
Bedwatch log
35. My investigator carefully studied the bedwatch logs completed by prison staff
during the time that the man spent in hospital. My investigator was shown a
copy of the guidance made available to staff undertaking escorts outside the
prison. The guidance gives no advice about what the log should or should not
contain or about the language and tone of the entries. The majority of the log
entries were appropriate and suitable, but my investigator found one that was
wholly lacking in respect and decency.
HMP Albany should conduct a review of bedwatch instructions. This
should include improved guidance and training for staff on what to write
on bedwatch logs and how to write it. The review should reflect whether
additions are required to the Visiting Manager’s Bedwatch Checklist.
36. During his bedwatch duty on 27 May, the officer on the initial bedwatch duty
wrote the following inappropriate entry in the bedwatch log:
“Prisoner was asleep on our arrival. Had to be told on numerous
occasions not to swear with the nurses present. Also warned about
trying to touch up the nurses. Noisy through the night P.I.T.A. Likes to
expose himself.”
37. When asked by his line manager, this officer said he was not sure exactly what
he meant by the “P.I.T.A.” abbreviation. I have to say that it is difficudelt to
accept the officer’s claim. If he was not sure, why did he take the trouble to
record the letters? In fact, it is manifest that P.I.T.A. is an abbreviation for pain
in the arse.
10
38. The officer on the initial bedwatch duty was in the hospital to monitor a
terminally ill man, although I accept he was not to know that the man would die
the following day. I am sorry to say that his entry is not consistent with the
Prison Service’s decency agenda, and was both unprofessional and wholly
inappropriate. I have chosen not to make a separate recommendation but
have written to the Governor of Albany personally. I am confident that this will
be sufficient to ensure that appropriate action will be taken.
39. The NOMS Safer Custody and Offender Policy Group confirmed that the officer
concerned accepts that the comment he made were not appropriate. He has
apologised and given assurances that it will not happen again.
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CONCLUSION
40. The man moved to Albany in February 2008 and died of natural causes in the
Medical Assessment Unit at the local hospital on 28 May 2008.
41. He entered custody with a very serious undiagnosed physical health problem.
It was only after his condition deteriorated and the prison referred him for
further investigation at the hospital that it was established that he had terminal
cancer. The disease was extensive and the prognosis poor. He died within
two days of the diagnosis.
42. I was pleased to note that the family were treated respectfully and
compassionately when they visited Albany after the man’s death. Albany’s
treatment of his family reflected well upon individuals, their place of work, and
the Service they represent.
43. In contrast, one of the entries in the bedwatch log was unprofessional,
disrespectful and wholly inappropriate. The Governor will wish to review and
strengthen existing procedures at Albany for management checks and the
monitoring and support of staff on bedwatch duty.
44. In light of the findings of my investigation and the clinical review, I conclude that
the care provided to the man was not equivalent to that he would have received
in the community. The review panel made two recommendations which I
endorse. They will need to be addressed by the local Primary Care Trust in
partnership with the Governor of Albany.
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RECOMMENDATIONS
HMP Albany
1. HMP Albany should conduct a review of bedwatch instructions. This should
include improved guidance and training for staff on what to write on bedwatch
logs and how to write it. The review should reflect whether additions are
required to the Visiting Manager’s Bedwatch Checklist.
Accepted - A full re-assessment of current bedwatch instructions will be
carried out and a training session for guidance to staff and managers will be
produced. The Visiting Manager Checklist will be included in this review.
Personal views and/or assessments are actively discouraged.
Clinical
2. During the proposed new healthcare building programme at HMP Albany
there should be an assessment of the benefits of adopting the Pathlinks
system.
Accepted - The new build steering group is considering the best options for all
electronic patient reports and records. It is not clear at this stage whether
Pathlinks will be part of that. This will be reviewed on an ongoing basis at
least until commissioning of the new build.
3. There should be a review to improve communication between Albany and the
local hospital with regard to urgent x-ray and pathology reports.
Accepted - This has been reviewed and a clear protocol is in place for urgent
reports. All prison healthcare staff, GPs and appropriate hospital staff have
been updated.
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