Individual at Holloway

Circumstances surrounding the death of
A woman on 22 June 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2006
This is the report of an investigation into the circumstances of the death of a
woman who was sent to Holloway on 21 May 2004. She was transferred to
outside hospital on 3 June 2004 where she was diagnosed with acute myeloid
leukaemia. She died in hospital on 22 June 2004. She was thirty four years
old and leaves a partner and four children.
I would like to extend my condolences to her family for their very sad loss. I
am sure it is little consolation that her illness was identified quickly by the
doctor at Holloway and appropriate treatment provided as soon as possible.
One of my investigators co-ordinated the investigation. The investigation
comprises two reports not published on my website. The first was a review of
the woman’s medical care during her short time in Holloway written by a
Specialist Nurse and Senior Lecturer in Clinical Practice. A further review
was commissioned from a Nurse Consultant who specialises in substance
misuse. My family liaison officer spoke to the woman’s family on several
occasions.
I note that both reports highlight issues with record keeping and aspects of the
woman’s prescribed detoxification regime. I am aware that the Healthcare
department in Holloway has made significant progress in the last year in
addressing these issues and the report includes a detailed response from the
prison highlighting these improvements. I am pleased and reassured by the
changes that have been made. The Governor of Holloway has already
accepted the single recommendation made in this report.
I also note that both reports praise the early identification at Holloway that the
woman was seriously ill and required treatment in outside hospital. The
second report also concludes that, had the changes to the woman’s
detoxification programme been made, they would not have increased her
chances of surviving leukaemia.
This version of my report, published on my website, has been amended to
remove the names of the woman who died and of those staff and prisoners
involved in my investigation.
Emma Bradley
Deputy Prisons and Probation Ombudsman
January 2006
Contents
Summary
Summary
The woman was received into custody at HMP Holloway on 21 May 2004. On
reception she was noted to be a polydrug abuser, who had been under the
care of her local drug support services. She was commenced on a ‘double
detox’ regime to manage her withdrawal from opiates and alcohol.
She continued on her prescribed detoxification regime over the next few days.
However, the documentation in the clinical records do not provide a clear
picture of her emotional, mental and physical state during the first few days of
the programme. Primarily, there is no mention of any observations being
taken, which would inform the planning of her treatment, care and
management.
On 29 May, she presented with physical symptoms that the attending medical
officer attributed to an upper respiratory tract infection, along with withdrawal
from the drugs and alcohol. She was prescribed antibiotics, tablets for the
sickness and painkillers.
During the evening of the 2 June, the woman complained of a high
temperature and pain on passing urine. Her urine was tested and the findings
were consistent with a urine infection. A decision was therefore taken to
change her antibiotic to one more appropriate for the treatment and
management of urine infections.
The following day she was seen again and examined by the duty medical
officer. She was noted to have a high temperature and on examination found
to have abdominal tenderness, including an enlarged spleen and liver. A
decision was taken to refer her to the local hospital for further assessment
and examination. By the evening of 3 June, she had been diagnosed with
Acute Myeloid Leukaemia. She remained in hospital and sadly died on 22
June 2004.
The clinical review concluded that the doctors involved in the woman’s care
acted appropriately. The signs and symptoms she was displaying could
easily have been mistaken for signs of withdrawal or a minor infection. The
doctor at Holloway recognised that she was clearly suffering from more than a
minor infection and referred her promptly to the local hospital for an expert
opinion and firm diagnosis. Sadly, this diagnosis was of a terminal illness
from which the woman would not recover.
Record keeping is an integral part of the care process and is a tool of
professional practice. It is not an optional extra to be fitted in if circumstances
allow. The clinical review and the review of the drug services afforded to the
woman both identified below acceptable standards of record keeping. The
records were confusing, illegible or unclear in places, unprofessional
language is used on occasions, abbreviations are frequently used and whilst a
standard care plan has been raised, it has not been made patient specific and
does not appear to have been actioned.
Healthcare professionals should be reminded of their professional
responsibility for records and record keeping, ensuring they:
• maintain factual, consistent and accurate records.
• provide current information on the care and condition of the patient
or client.
• provide evidence of the care planned, the decisions made, the care
delivered and the information shared.
• avoid abbreviations, jargon, meaningless phrases, irrelevant
speculation and offensive subject statements.
• are respectful to the patient or client.
The Governor of Holloway, has accepted this recommendation.
The critical incident review of the drug support services afforded to the
woman, whilst not directly related to her death, provide learning points for
improving practice and the development of the services for the clinical
management of substance misusers at HMP Holloway.
In response to my draft report the Governor provided me with the following
detailed account of actions already taken by the prison to improve substance
misuse services and record keeping:
“Substance Misuse Services
1. All appropriate clinical documentation from the point of reception to
the point of discharge has been reviewed and we have now
implemented a more comprehensive care package, earlier intervention
in risk management, an audit process for all paperwork, staff
accountability and the provision of a clear and robust response to gaps
identified in the recent Tavistock Report and Review of Detoxification
Services Report led by Islington PCT.
2. All existing detoxification-prescribing guidelines have been reviewed
and updated and we have implemented more up to date evidence
based practice, which focuses on a broader range of treatment options.
The evidence base has moved on significantly since the original
guidelines were written and it is our belief that women prisoners at
HMP Holloway are entitled to a service comparable to that found within
the NHS. These protocols are now in place.
3. Methadone has been replaced with Buprenorphine as the primary
agent of detoxification. However Methadone will continue to be offered
in cases where there is an absolute clinical need and certainly in the
cases of pregnancy there will be no interruption to prescribed treatment
providing women meet the eligibility criteria. We now insist that any
woman who presents in Reception claiming to be methadone
dependent will be more rigorously assessed before methadone may be
prescribed. This includes our staff contacting the outside prescribing
agency or General Practitioner as part of the information gathering
exercise in deciding on the eligibility for commencing methadone. We
insist on this information being faxed to us before a decision to
commence methadone can be taken. This information is assessed
alongside the presence of subjective and objective withdrawal features,
presenting symptoms, history documentation, urinalysis and detection
of current drug use detected in saliva.
We have also reviewed ‘the very generous’ prescribing of
Benzodiazepines with a view to developing a much more specific
clinical criteria as to the appropriateness of prescribing
Benzodiazepines. This is currently in operation.
4. There is now much greater emphasis on symptomatic prescribing in
those cases where Opiate-based substitution is not recommended.
5. We use more or less the same model of prescribing practice and
programmes as are currently in operation at HMP Wormwood Scrubs
(Conibeere Unit) during the detoxification process. This has proven to
be very effective in providing successful regime management and
keeping episodes of self harm at comparatively low levels. The
Conibeere Unit has been nominated by the Prison Service for the
prestigious Butler Trust Award for its safe and effective management of
those prisoners dependent on drugs and /or alcohol and for having
some of the lowest self harm figures per thousand of treatment
episodes per annum in the UK Prison Estate. We aspire towards
similar standards of excellence at HMP Holloway/YOI.
6. All maintenance prescribing at HMP Holloway is currently under
review with the emphasis being on safer practice, safer management
and much safer outcomes. All women on wing locations on
maintenance prescribing are being monitored and reviewed regularly
by the specialist Substance Misuse Doctor with a view to providing
quality care. This outpatient service is now being managed by a G
grade Clinical Nurse Leader.
7. We have introduced a weekly teaching and training programme
every Wednesday between 10.15 am and 11.45 am. This time is ring
fenced and so far this training has proven to be very successful in the
context of attendance and active participation. This training is open to
all staff, operational and clinical working within the detoxification areas.
8. We have commenced a monthly teaching and training session which
began on 29th June 2005 related to drugs, alcohol, Mental Health and
Dual Diagnosis which will be open to all prison service employees at
HMP Holloway.
9. We have introduced documented regular supervision for all clinical
staff with much more effective management of the SPDR (Appraisal)
process.
10. We are actively engaged with a number of services not least of all
Chaplaincy, Resettlement, Education and Gym so that these women
can take their rightful place in attending all of these activities post day
three of their detoxification. We are also in the process of enhancing
group work for all women through the introduction of Blood Borne
Virus, Drug Awareness, Relapse Prevention and Harm Minimisation
groups.
11. We intend to set up a representative/service user group to enable
the women to feedback to us any concerns they may have regarding
the quality of care they receive.
12. We have been involved in a recruitment drive in order to establish a
dedicated team to enhance the quality of the service we deliver. We
have successfully recruited five new staff nursing grades who will
commence employment shortly and we are determined to recruit a
further two over the coming months. We have appointed G-Grade
Nurse to oversee the safe management of women post detoxification.
We work closely with all of our colleagues at HMP Holloway including
Primary Care, Pharmacy, and CARAT Team, Mental Health In-reach
Team, Operational Staff and any partnership agencies.
Our primary focus is on comprehensive quality care, risk management,
reducing self-harm and improving the mental and physical health of the
women.
Records and Record Keeping
I can confirm that this now forms part of the job description for all
registered nursing staff in accordance with Nursing and Midwifery
Council Code of Professional Conduct, and clinical guidelines. “