Individual at Isle of Wight

Investigation into the circumstances surrounding the
death of a prisoner at HMP Albany,
in March 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2008
This is an investigation into the circumstances surrounding the death of a
prisoner at HMP Albany. The man died on 3 March 2008 at a hospital local to
the prison. The cause of death was recorded as disseminated clear-cell renal
adenocarcinoma (cancer of the kidney). Sadly, the man died just 20 days
before he was due to be released from prison.
The man was visited in hospital by his brother and sister on the night before
his death. I offer them my sincere sympathy and condolences for their loss,
as I do to all of those affected by the man’s death. I must also apologise for
the delay in issuing this report. This was due in part to the unexpected
sickness absence of the clinical review report writer.
The investigation was carried out on my behalf by one of my colleagues. An
independent review of the man’s medical care in prison was managed on
behalf of the Isle of Wight Primary Care Trust. As ever, I am most grateful to
the clinical reviewer for his assistance.
I would also like to thank the Governor and staff of Albany for their full and
ready co-operation during the course of the investigation. I am particularly
indebted to the head of the communications and standards department, and
his team, at Albany for the assistance that they provided my investigator.
My investigation found that the man received care equivalent to that which he
would have received in the community. I make four recommendations and
highlight one example of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2008
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CONTENTS
Summary 4
The investigation process 5
HMP Albany 7
Key findings 8
Issues 12
Recommendations and good practice 16
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SUMMARY
The man was sentenced to six years imprisonment on 26 March 2004. He
had a number of health problems at the time, including diabetes and asthma.
The man settled well into prison life and reported few additional health
problems during his first three years in custody.
After complaining of a chesty cough in March 2007, the man was referred for
a chest x-ray by a prison doctor. The results showed cancer, possibly
originating in the lung. A scan in May confirmed that the man had cancer of
the kidney that had spread to other parts of his body.
The man started a six week course of interferon (a drug that can help to
control or stabilise cancer) in July. He tolerated the interferon well, and a
further six week course was therefore prescribed in September. Throughout
the remainder of the year the man had very few symptoms, including little pain
or nausea.
A further scan on 11 February 2008 showed that the primary lesion, in the
man’s right kidney, had enlarged and extended compared to May 2007. The
lesions in his lung were also larger and more numerous. Despite this, at a
review with a prison doctor on 19 February, the man continued to say that he
was not experiencing pain or nausea.
As he was due for release on 23 March, prison staff began to make plans for
the man to take a place at a hostel near to where his brother lives. However,
following a sudden deterioration and increase in pain on the morning of 2
March, the man was admitted to a hospital local to the prison. His family were
informed, and he was visited by his brother and sister that evening. The
man’s condition did not improve. He died at 5.05am the following morning.
The clinical review panel found that the man received care equivalent to that
which he would have done in the community. I make four recommendations,
two of which relate to information sharing between the prison and the local
hospital. I also highlight one example of good practice.
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THE INVESTIGATION PROCESS
1. The investigation was opened 25 March 2008 when notices announcing
the investigation were issued 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. No
prisoners came forward as a result.
2. My investigator was given access to the man’s prison files, including his
medical record. He visited Albany on 26 June 2008 and interviewed one
member of staff. A clinical review panel was arranged on behalf of the
Isle of Wight Primary Care Trust. The panel, including the investigator,
clinical reviewer and several members of staff from Albany, met on 18 July
to discuss the medical care provided by the prison. Following the meeting
a clinical review report was written.
3. My senior family liaison officer wrote to the man’s brother, his nominated
next of kin, on 4 April 2008. No reply was received. A copy of this report
will be sent to him.
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HMP ALBANY
4. Albany is an establishment for category B and category C vulnerable
prisoners. The prison currently holds up to 566 adult male prisoners. The
average age of the population is significantly higher than in most prisons.
5. Health services at Albany are commissioned by the Isle of Wight Primary
Care Trust (PCT). The healthcare arrangements are managed in a cluster
which includes the two other prisons on the Isle of Wight, HMP Parkhurst
and HMP Camp Hill. Parkhurst is the only one of these establishments
with inpatient facilities.
6. At Albany, prisoners’ medical needs are catered for by way of outpatient
clinics and core day primary nursing cover, from 7.30am to 5.30pm
Monday to Friday. During weekends and evenings, one member of
healthcare staff is on duty. Doctors from a local practice attend Albany for
four sessions each week. Evenings and weekends are covered by on-call
doctors from the PCT. There is no nursing or healthcare cover based at
Albany overnight.
7. Her Majesty’s Chief Inspector of Prisons, Ms Anne Owers, last inspected
Albany in November 2007. Ms Owers found “a serious and chronic
shortage” of healthcare staff, which meant that only basic health
interventions could be delivered. There was usually only one trained
nurse and a support worker on duty at any one time. Ms Owers also found
that a high number of outside hospital appointments were cancelled due to
a shortage of escort staff.
8. The Independent Monitoring Board (IMB) annual report of 2006/07 also
noted problems with the availability of escorts to the local hospital. The
Board reported that only two escorts could be carried out per day, with
some appointments having to be cancelled.
9. This is the 12th death that I have investigated at Albany since April 2004,
when I began investigating all deaths in custody in England and Wales. It
is the 11th death to be due to natural causes. There have subsequently
been three further deaths at the establishment, all due to natural causes.
In previous reports I have made recommendations regarding the
development of a care pathway for prisoners diagnosed with cancer.
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KEY FINDINGS
10. The man was received at HMP Winchester on 26 March 2004, having
been sentenced to six years imprisonment on the same day. A reception
health screen (a routine health assessment for all new arrivals into prison)
was carried out following his arrival. At the health screen the man spoke
of his diabetes and asthma and also said that he had arthritis and suffered
recurrent headaches.
11. After three weeks at Winchester, the man transferred to HMP Albany on
16 April. He was seen by a nurse on the day of his arrival. The nurse
recorded that there were no immediate problems and that the man
seemed to be happy at Albany.
12. The man initially lived on A wing at Albany, and was noted to have settled
in well. On 6 May, his blood pressure was noted to be high at 169/117.
As a result, he was prescribed a course of lisinopril (medication to treat
high blood pressure) and was asked to come back for weekly checks.
13. On 27 October 2004, the man was reviewed by a prison doctor. His blood
pressure was now more stable at 136/90, and he was reported to have no
other problems. Through 2005, the man reported few health problems
other than some shoulder pain from an old injury and the occasional
nosebleed.
14. In early 2006, the man again reported few problems with his health. His
wife sadly died on 30 May, three days after he had been able to visit her in
hospital. The man attended her funeral on 7 June. As one would expect,
he was affected by his wife’s death over the following weeks but said that
talking to his friends on the wing helped.
15. The man complained of having a cough and cold and of feeling “a bit
wheezy” on 5 December. He was seen by a nurse who, given his history
of asthma, referred him to a prison doctor. The man was subsequently
seen by a doctor later on the same day and prescribed a course of
amoxicillin (an antibiotic).
16. In January 2007, the man reported experiencing a number of nosebleeds.
After complaining of a productive cough that had lasted for some time he
was seen by a second prison doctor, on 22 March. The doctor prescribed
a further course of amoxicillin and asked that the man be referred for a
chest x-ray. On 29 March, an appointment came through for 24 April.
17. The results of the chest x-ray showed pulmonary metastases, possibly
from a lung primary (cancer, possibly originating in the lung). The
consultant at the local hospital arranged for the man to undergo a
bronchoscopy (an examination of the airways of the lungs) on 8 May.
This showed nothing significant, and a CT scan (similar to an x-ray) was
arranged for 10 May.
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18. The results of the CT scan showed a large renal mass with multiple
bilateral pulmonary metastases (cancer of the kidney, which has spread to
other parts of the body). On 22 May, the urologist (specialist in the urinary
tract, including the kidneys) at the hospital wrote to the medical director at
a local hospice, to refer the man with a view to offering palliative care
(symptom control for the terminally ill). An appointment was later
arranged for 5 July.
19. The man was reviewed by a prison doctor, on 5 June, after complaining of
increased pain in his shoulder. The doctor prescribed co-codomol (pain
relief).
20. The medical director at the hospice wrote to Albany on 9 July, following
his appointment with the man four days earlier. He noted that the man
was displaying no symptoms of illness, but that any treatment would
essentially be palliative rather than curative.
21. Three days later, on 12 July, the man attended an appointment at the
hospital with a consultant oncologist (cancer specialist). The consultant
recommended that the man take a course of interferon (a drug that can
help to control or stabilise cancer that has spread). It was stressed to the
man that the response rate to interferon is only around 15 per cent and it
can have a number of side effects, including headaches, fatigue and flu-
like symptoms. The drug is injected three times a week, and the man
began his course on 19 July. He attended the healthcare centre for each
injection, which was carried out by a prison nurse.
22. A fortnight into his course, on 2 August, the man was reviewed by the
medical director at the hospice. The medical director noted that the man
was doing well at the time and determined that he did not need to see him
for another three months, unless he were to develop further symptoms.
23. The man attended a second appointment with the consultant oncologist
on 6 September. The consultant oncologist noted that the man was well
and had been tolerating his course of interferon reasonably well. He
therefore prescribed a further six week course.
24. Over the next six weeks, the man continued to tolerate the interferon well.
At his next appointment with the consultant oncologist, on 18 October, he
said that he had experienced a few side effects, but overall felt better
since he had been receiving the treatment. The consultant oncologist
requested that an appointment be made for the man to have another CT
scan to assess his response to the treatment.
25. Around three weeks later, on 8 November, the man attended an
appointment with the medical director at the hospice. The man told the
medical director that he was feeling very well at present. He also said that
he was due for release in early 2008 and was likely to be moving to a
town in southern England at that point.
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26. At a review with a prison doctor, on 30 November, the man said that he
was experiencing no pain or nausea at the time. Indeed, three days
previously he had returned 50 unused co-codamol tablets that had been
dispensed on 19 November. The doctor reported that the man was
upbeat, but noted that he might not be fully aware of his likely prognosis.
27. The man attended the hospital on 27 December for an appointment with
the consultant oncologist. The consultant oncologist noted that the man
was well and had no symptoms at the time. However, the consultant
oncologist observed that the man had yet to receive an appointment for
the CT scan that had been requested after his last review in October. He
had therefore put in an urgent request for a scan. On 3 January 2008, an
appointment was arranged for 24 January.
28. An entry in the man’s medical record indicates that the security
department at Albany mistakenly cancelled the taxi that was due to take
the man to hospital for his CT scan on 24 January. Once the mistake was
realised, a second taxi was booked. Unfortunately, it arrived too late for
the scan to go ahead. A new appointment was booked for 1 February.
29. On 1 February, the man duly attended the hospital in Newport for his
scan. On his arrival, however, the escorting staff were informed that there
was no appointment scheduled. The healthcare administrator at Albany
subsequently telephoned the member of hospital staff with whom she had
arranged the appointment the previous week. They were unable to offer
any explanation for the confusion. The administrator later arranged a new
appointment for 11 February.
30. The result of the man’s CT scan showed that the lesions in his lung were
larger and more numerous in comparison to his previous scan of May
2007. The primary lesion, in the man’s right kidney, had also enlarged
and extended further. The doctor discussed the results of the scan with
the man at a review on 19 February. The man said that he was not in
pain or experiencing nausea or shortness of breath, although the doctor
noted that he had a chronic cough. The man added that he was due for
release in March and would be staying in a town where his brother lived.
31. A week later, on 26 February, a nurse was called to see the man on the
wing as he was reportedly in a lot of pain. On her arrival, the man
complained of pain in his lower back and in his groin. He said that he was
taking co-codamol for pain relief, but this was not working. The nurse
spoke to a prison doctor who prescribed a course of dihydrocodeine
(DHC, a strong painkiller) which was to be reviewed on 28 February.
32. At his review, the man told the prison doctor that his back pain had
developed suddenly four days previously. The pain was worse when he
moved but had been eased by the DHC. The prison doctor considered
that, given the man’s diagnosis, this was likely to be more than simple
back pain. She noted that he had an appointment with the consultant
oncologist in the next week (on 6 March) and made a note for it to be
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followed up then. In the meantime, the prison doctor repeated the man’s
prescription of DHC.
33. On the following day, 29 February, an application for early release on
compassionate grounds was initiated. The form has sections to be
completed by a prison doctor, to detail the patient’s diagnosis and
prognosis, and the seconded offender manager, to detail the level of risk
posed. The final section is completed by the Governor with his summary
and recommendations.
34. A case conference was held to discuss the man on 1 March, attended by
another prison doctor. The panel noted that the man’s cancer was at the
same stage as it had been in January and that, other than recent back
pain, he was not feeling unwell.
35. On the following morning a prison nurse, was called to see the man in his
cell by wing staff. She found him very breathless and with acute pain in
his lower back. Due to the pain, the man was unable to walk. The prison
nurse asked for an ambulance to be called and, at around 10.45am, the
man was transferred to a local hospital. He was accompanied two officers
and handcuffs were not used.
36. At around 1.45pm a prison chaplain contacted the man’s brother, his
nominated next of kin, to inform him of his brother’s condition. Around an
hour later, given the man’s breathlessness and lack of mobility, the escort
was reduced to one officer. The officer was instructed to sit in the waiting
area and make frequent but irregular checks on the man. I consider this
to be an example of good practice.
The man was immobile following his admission to hospital. The
escorting officer was instructed to sit in the waiting area and to make
irregular checks on him, rather than sitting in the ward next to the
man.
37. In the evening, the man’s brother and sister arrived to visit him. They
were met by the chaplain and the principal officer (PO). During their visit,
it was agreed that the principal officer would be the family’s contact at the
prison and that he would contact the man’s brother by telephone if there
was any news.
38. Sadly, the man’s condition deteriorated. He died at 5.05am on 3 March.
The cause of death was recorded as disseminated clear-cell renal
adenocarcinoma (cancer of the kidney). The man had been due for
release from prison just 20 days later.
39. Just over an hour after the man’s death, the principal officer telephoned
his brother at around 6.25am to break the news to him. The man’s funeral
was held on 27 March and was conducted by the chaplain. At the request
of the family, all arrangements were made by the principal officer. The
prison acted in accordance with the instructions of Prison Service Order
10
(PSO) 2710.
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ISSUES
External hospital appointments
40. The man was due to attend an outpatient appointment at a hospital in
Newport, on 24 January 2008. However, he was apparently unable to
attend the appointment as the taxi due to take him to hospital was
mistakenly cancelled by the security department. There is no record of
the reason why the taxi might have been cancelled.
41. The clinical reviewer considers the effect that this cancellation would have
had on the man. He concludes that “at this stage of his condition the
cancellation would not have altered the outcome of his treatment or
prognosis”.
42. Nevertheless, there might be occasions in future in which a missed
hospital appointment could have more serious consequences for the
patient. It would be disappointing if such a situation were to arise.
The Governor should review procedures for arranging transport for
patients to outside hospital appointments, and the reasons for
cancelling booked escorts should be recorded.
43. The cancelled appointment was rearranged for 1 February. However, on
arrival at the rescheduled appointment the escorting staff were told that
the hospital had no record of it. The man therefore had to return to Albany
without having his scan. The scan eventually went ahead on 11 February
when the appointment was rearranged for a second time.
44. Albany has provision for staffing escorts for two hospital appointments per
day. This means that, if more than two outpatient appointments are
booked for the same day, they may need to cancel and rearrange those
that are deemed to be a lower priority. Due to the nature of his illness, the
man’s scan would have been a higher priority appointment. Having to re-
arrange his scan on two separate occasions might have resulted in other
patients’ appointments being cancelled.
45. The clinical review makes the following recommendation, to be taken
forward by the clinical risk and claims manager at Albany:
Prison healthcare should work to improve communication and
understanding with the hospital regarding the difficulties involved in
maintaining outpatient appointments.
Quality of care provided at Albany
46. The clinical review concludes that the care that the man received at
Albany was “comparative to that which he would have received in the
community”. The man was reviewed appropriately by the healthcare team
at Albany. Indeed, as he attended healthcare three times a week for his
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course of interferon he was able to benefit from more regular contact with
healthcare staff than those in the community who would normally self-
administer.
47. The review panel found that there were some areas of record-keeping that
could be improved. The following recommendation was made in the
clinical review, addressed to the primary healthcare manager:
The primary healthcare manager should review and seek to improve
the standard of record keeping and documentation.
Compassionate release
48. Chapter 12 of Prison Service Order (PSO) 6000 sets out the following
criteria for early release on compassionate grounds:
• the prisoner is suffering from a terminal illness and death is likely to
occur soon; or the prisoner is bedridden or similarly incapacitated; and
• the risk of re-offending is past; and
• there are adequate arrangements for the prisoner’s care and treatment
outside prison; and
• early release will bring some significant benefit to the prisoner or
his/her family.
49. The man was due to be released from prison on 23 March 2008. As he
was mobile and outwardly well for most of his illness, plans were being
made for him to take a place at a hostel in Havant, near to where his
brother lives. However, following the man’s sudden deterioration on 2
March, prison staff began to look for a hospice place instead.
50. It is standard practice at Albany to initiate an application form for early
release on compassionate grounds. Such action is commendable. In the
man’s case, an application was raised on 29 February 2008. At the time,
he was expected to live beyond his release date of 23 March and the form
was not therefore completed or sent to the Pre Release Section of the
Ministry of Justice. Sadly, the man deteriorated suddenly on 2 March and
died the following day.
51. It appears that the man’s family were given information regarding his
prognosis by staff at the hospital which was not provided to the prison.
Such information, in other circumstances, could be crucial in determining
the success of an application for compassionate release. The clinical
review notes that “it would be beneficial to aid documentation for the early
compassionate release if hospital records of a poor prognosis could be
shared with the prison”. The review panel makes the following
recommendation, addressed to the primary healthcare manager:
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The primary healthcare manager should ensure there is better
communication and information sharing by the specialist nursing
teams at the hospital and prison healthcare.
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RECOMMENDATIONS
1. The Governor should review procedures for arranging transport for
patients to outside hospital appointments, and the reasons for cancelling
booked escorts should be recorded.
Accepted – although the original taxi was cancelled by Security, another
taxi was provided for the escort. This was human error on the day and not
a breakdown of systems or procedures. This has been reviewed and we
are satisfied our escort transport systems operate well. This was the first
time such an occurrence had taken place and there has not been a repeat
since this event. The Security department will provide a log of cancelled
escorts including reason/accountable manager.
2. Prison healthcare should work to improve communication and
understanding with the hospital regarding the difficulties involved in
maintaining outpatient appointments.
Accepted – extensive work has been undertaken between prison
healthcare and the hospital’s clinical areas to improve understanding.
Updating of staff is recognised as being imperative in order to support this
process and is therefore ongoing. Work is ongoing in relation to bringing
specialists into the prison rather than the patient attending outpatients.
This closer working has enabled a single point of contact in relation to
appointments.
3. The primary healthcare manager should review and seek to improve the
standard of record keeping and documentation.
Accepted – staff awareness, training, and updates have been undertaken
and good practice in record keeping is now included in new staff induction
process.
4. The primary healthcare manager should ensure there is better
communication and information sharing by the specialist nursing teams at
the hospital and prison healthcare.
As point 2, and updating staff is recognised as being imperative in order to
support this process and is therefore ongoing. Initiatives such as
interdepartmental staff swaps, care pathways for prisoners and proactive
communication with departments are being explored.
GOOD PRACTICE
1. The man was immobile following his admission to hospital. The escorting
officer was instructed to sit in the waiting area and to make irregular
checks on him, rather than sitting in the ward next to the man.
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