Individual at Isle of Wight

Investigation into the circumstances surrounding the
death of a man who was
a prisoner at HMP Albany, in June 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2008
This is the report of an investigation into the death of a man who died in June
2007 at a hospital on the Isle of Wight. The man had been taken ill in his cell
at HMP Albany little more than an hour earlier. I offer my sincere sympathy
and condolences to all of those affected by his loss.
The man had been diagnosed with cancer of the colon around one month
previously. A post mortem examination confirmed the cause of death to be a
disseminated carcinoma of the sigmoid colon with a secondary condition of
chronic obstructive airways disease.
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 carried out by the
Isle of Wight Primary Care Trust. 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 especially
grateful to the Head of the Communication and Standards Department for the
liaison that he provided my investigator.
In general, I believe that the man was treated appropriately. However, I have
some concerns about the care he received on the day before he died. Given
the number of elderly prisoners at Albany, the Governor will wish to consider if
there are training and cultural issues amongst staff that need to be addressed.
I make six recommendations and highlight two examples of good practice.
This version of my report, published on my website, has been amended to
remove the name of the deceased and the names of staff and prisoners who
were involved in my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman
January 2008
CONTENTS
Summary 4
The Investigation Process 6
HMP Albany 7
Key Events 8
Issues 16
Recommendations and Good Practice 24
Annexes
SUMMARY
The man was remanded into custody at HMP Wormwood Scrubs on 24 July
2000. He did not settle well into prison life, and reported a number of panic
attacks and periods of depression in the run up to and during his trial. On one
occasion he apparently attempted suicide at court. He was convicted and
sentenced to 16 years imprisonment on 16 March 2001.
On 20 April 2001, the man transferred to HMP Rye Hill where he remained for
the following five years. His time at Rye Hill was not a happy one. He
continued to experience spells of depression, and would go through periods in
which he self-harmed and threatened suicide. There appear to have been
various motives for the man’s actions, including a lack of success with his
appeal, anger with his family for “deserting him”, his perceived treatment by
staff at Rye Hill, and as a protest at not being given a transfer to a different
prison. A total of 27 different F2052SH documents (the form used at the time
by the Prison Service to monitor and support prisoners deemed at risk of
suicide or self-harm) were opened by staff during the man’s time at Rye Hill.
On 5 July 2006, the man transferred to HMP Albany. He was assessed by a
nurse shortly after his arrival and reported a history of angina but no other
health problems. The man was much more settled at Albany. Other than one
occasion around two weeks after his arrival, he expressed no thoughts of
suicide or self-harm during the remainder of his time in custody.
The man was seen by a prison GP on 19 April 2007 after reporting
intermittent abdominal pain, constipation and weight loss. He attended an
outpatient appointment on 1 May at which the Consultant observed a mass on
his abdomen, and made a diagnosis of suspected cancer of the colon. A CT
scan on 8 May confirmed this.
The man began to deteriorate following his return from hospital. Notes made
by staff towards the end of the month indicate that they were concerned about
his health and how he was being managed on E wing. On 6 June, the man
moved to a cell on F&G wing, as this was a newly built wing with better
facilities such as in-cell showers. He was assigned a fellow prisoner to act as
his buddy (meaning that he would help the man with tasks such as collecting
meals and cell cleaning).
One morning in June 2007, the man’s buddy went to his cell and found that he
had defecated and passed blood. He reported this to staff who called
healthcare. The Healthcare Manager attended and noted that no member of
wing staff had been to see the man. He commented in the Medical Record
that, “I believe the officers are not taking any responsibility for this inmate.”
The Healthcare Manager’s assessment at the time was that the man was
coherent and as well as could be expected. However, in the evening the man
was seen by an officer who described him as being in “a bad state”. The man
deteriorated further and, at around 11.10pm, an officer was called to his cell.
The man told the officer that he was having difficulty breathing. The officer
and the night orderly officer telephoned the healthcare centre at neighbouring
HMP Parkhurst for guidance (there is no overnight healthcare facility at
Albany), and were advised to call for an ambulance.
The ambulance subsequently arrived around 11.25pm, and the man was
taken to a local hospital around 25 minutes later. While the ambulance crew
were in attendance, the man deteriorated further. By the time he arrived at
hospital he was unconscious. He did not regain consciousness, and was
pronounced dead at 12.28am.
My report concludes that, judged overall, the man received care equivalent to
that which he would have received in the community. However, I am
concerned about the level of personal and social care that he received in the
last couple of weeks of his life, most notably on the last day. The lines of
responsibility for such provision are unclear, and I make a recommendation
that guidelines are issued to clarify this.
I make six recommendations in total, and highlight two examples of good
practice.
THE INVESTIGATION PROCESS
The investigation was opened on 12 June 2007 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. Three prisoners
came forward as a result.
My investigator was given access to the man’s prison files, including the
medical record. He visited Albany on both 15 August 2007 and 24 September
2007, and interviewed six members of staff during the course of the
investigation. An independent clinical review of the man’s health needs whilst
he was in custody was carried out by the Isle of Wight Primary Care Trust.
My senior family liaison officer contacted the man’s brother on 26 June 2007.
He said that he had found it very difficult to arrange a visit to his brother in the
final days of his life, and that he could not speak to anyone about his brother’s
medical condition.
HMP ALBANY
HMP Albany was designed and built as a category C training prison on the
site of a former military barracks on the outskirts of Newport, Isle of Wight.
Shortly after opening in 1967, it was decided to upgrade the security. In 1970,
Albany subsequently became part of the dispersal (high security) system.
In 1992, Albany was re-designated as a category B closed training prison and,
from 1998, became an establishment for vulnerable prisoners only. In 2002, a
category C Unit was added and the certified normal accommodation is
currently 526. The average age of the population is significantly higher than
in most prisons.
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 establishment with in-patient facilities. Albany itself has
a healthcare unit designated for the delivery of primary care services.
HM Chief Inspector of Prisons, Ms Anne Owers, published a report on an
unannounced short follow-up inspection of Albany during October 2005. (The
last full inspection was in 2002.) In the short inspection report, Ms Owers
referred to healthcare, and said:
“Although progress had been made since the last inspection in some
healthcare areas, many had either stood still or regressed. The
perception of patients we spoke to was that healthcare generally had
deteriorated and was poor. This was in contrast to the last inspection
when 53% of prisoners in our survey thought that healthcare was good
or very good.”
This is the tenth death that I have investigated at Albany since April 2004,
and the ninth due to natural causes. The last Albany case that I
investigated (in December 2006) concluded that healthcare was lacking in
several areas. A recommendation made in that report with regard to the
care pathway for a prisoner who has been diagnosed with cancer is
repeated in this one.
KEY EVENTS
The man was received as an unconvicted prisoner at HMP Wormwood
Scrubs on 24 July 2000. He was admitted to the healthcare centre on arrival
because of recent dizzy spells and a history of angina and ischaemic heart
disease (the narrowing of the blood vessels supplying the heart, leading to a
reduced supply of blood). The man settled in well and made no complaints of
chest pain or of any discomfort overnight.
The man was assessed by a prison doctor the following day. The doctor
noted that he appeared well on examination and was not taking any
medication. The doctor also noted a family history of cancer. Two days later,
the man was passed fit by the doctor to live on a wing in the vulnerable
prisoners unit.
The man did not settle well into prison life. On 12 September, he reported
chest pain and, on the following day, was admitted to healthcare after he was
found to be hyperventilating. Entries over the following days indicate that the
man was suffering from depression, anxiety and panic attacks. He said that
this was because he felt that his family was “deserting him”. After five days in
healthcare, the man returned to the wing on 18 September.
Over the following months, the man experienced further depression and panic
attacks. An F2052SH (the form used at the time by the Prison Service to
monitor and support prisoners deemed at risk of suicide or self-harm) was
opened on 31 October for a few days. The man was subsequently referred to
a Specialist Registrar in Forensic Psychiatry. He was assessed on 20
November, and it was concluded that the man was suffering from an
“adjustment reaction” to imprisonment and the charges against him, rather
than a mental disorder.
The man continued to suffer anxiety and panic attacks in the lead up to and
during his trial. On 21 February 2001, an F2052SH was opened following an
incident at court in which the man was said to have “collapsed”. He later
claimed that he had attempted to kill himself. The F2052SH remained open
when the man was convicted and sentenced to 16 years imprisonment on 8
March. In the following days he said that he would kill himself if he was
unsuccessful with his appeal. The man was soon judged to be coping better,
however, and the F2052SH was closed on 21 March.
On 20 April, the man transferred to HMP Rye Hill. His history of angina and
panic attacks was noted on reception, and his general health was recorded to
be “satisfactory”. That evening, an F2052SH was opened on account of the
man’s “low mood”. It is not clear how long this form remained open. On 31
May, a further F2052SH was opened as the man’s appeal had been turned
down. Again, it is not clear how long this document remained open.
On 9 September, the man complained to wing staff that he was suffering
“heart pain”. A nurse was called out to see him, and noted that the man did
not look sweaty or clammy and was not short of breath. The nurse advised
him to rest and relax, and to contact healthcare if he had any further
problems.
Another F2052SH was opened on 14 November as the man had threatened
to self-harm when a further appeal was refused. An assessment noted that
he had “no suicidal ideation at present” but that the man said he would refuse
to eat and take medication. The man was noted to have refused breakfast on
15 November and 18 November. It is again unclear when the F2052SH was
closed.
The man attended an angina clinic on 16 February 2002, and again on 27
February. He was assessed by a psychiatrist on 25 February who noted that
he complained of feeling depressed and suffering panic attacks, but that he
was better when taking propranolol (a beta blocker, used to treat various
conditions including angina and anxiety).
On 11 July, the man was seen by a surgeon at a hospital local to Rye Hill. He
had been referred in April, having complained of pain and swelling in his right
testicle. The surgeon diagnosed a hydrocele (fluid on the testicle), and
requested an ultrasound to confirm this. An appointment was subsequently
booked for surgery to remove the hydrocele to take place on 29 October.
However, the surgery was cancelled as the man had not yet undergone the
requested ultrasound procedure by 29 October. It was noted in his medical
record that the man “will not let a female touch him”, and a male radiographer
only visited the hospital infrequently.
On 16 December, an F2052SH was opened as the man was noted to be very
low in mood. He said that he had deliberately banged his head on his cell
wall the previous night “to end it all”. The document was closed on the
following day when the man was noted to be calmer.
At around 10.30am on 23 January 2003, the man barricaded himself in his
cell and was observed to be carrying a bladed weapon. He had also been
seen to take all of his in-possession medication. The poisons unit at HMP
Birmingham was contacted for advice. At 12.20pm, Birmingham advised that
the man needed to be taken out of the cell within the hour. Around five
minutes later, the man began to complain of light-headedness. A Control and
Restraint team (C&R, the approved method to restrain violent prisoners by
use of force) therefore entered the cell at around 12.35pm and removed the
man. He was cuffed and taken to the local hospital by ambulance at around
12.45pm.
An F2052SH had been opened at 10.30am when the man first barricaded
himself into the cell. The document remained open during his time in hospital.
Whilst there, the man was seen by a psychiatrist who judged that he had no
mental health problems. The man returned to Rye Hill on 24 January, and
stayed in the healthcare centre overnight. The F2052SH was closed on 25
January.
The man attended the local hospital on 28 February for his ultrasound. The
results confirmed a right hydrocele. On 20 March, an F2052SH was opened
as the man said that he had broken a blade and swallowed it. He claimed to
have been assaulted during the C&R operation on 23 January, and was
aggrieved that he had not seen the police liaison officer. The man threatened
to overdose again, and said that he would cut himself if he was not given the
tablets. The psychiatrist deemed that the man was not depressed or
psychotic, and advised that he be given a chance to see the police liaison
officer. The F2052SH was closed on 4 April.
Another F2052SH was opened on 4 May when the man again claimed to
have swallowed a blade. He asked to see a nurse, and complained to her
about the structure of the prison, and discipline and healthcare staff. Two
days later, the man attempted to cut his left wrist. He said that the blade was
blunt and that otherwise, “I would have done it properly.” He alleged that he
was being bullied by both prisoners and staff. It is not clear whether these
allegations were investigated at the time.
The man made four lacerations to his left arm on 9 May, and on 11 May was
reported to have lacerated his arm again. He also claimed to have swallowed
two pieces of razor blade on this second occasion, and refused to be taken to
hospital. The F2052SH was closed on 14 May. By 11 July, the man said that
he was feeling better and had no thoughts of suicide or deliberate self-harm.
Surgery to remove the fluid on the man’s testicle was booked for 29
September. However, the operation had to be cancelled as there were not
enough staff available for the escort. The man was not happy about this and,
on 30 September, threatened to carry out the operation himself using blades
he had hidden on the wing. An F2052SH was therefore opened. At a
psychiatric review on 3 October, the man said that he no longer had any
thoughts of carrying out the operation himself. He also said that he did not
like being on an F2052SH, and that these events had taught him to be more
patient. The document was subsequently closed on 7 October. The man’s
operation was carried out on 18 November.
On 6 February 2004, the man reported he had heard voices in his head. He
saw a mental health nurse the same day, and told her that he was very upset
by this and did not want it to happen again. The nurse noted that the man’s
case had not been accepted by the Criminal Cases Review Commission. The
man was reviewed by a psychiatrist on 13 February who noted that he was
now doing well and feeling brighter in mood.
The remainder of 2004 was very difficult for the man. On 7 April, an F2052SH
was opened as he said that he had attempted to hang himself because he
had been turned down for a transfer. This was closed on 13 April, but another
document was opened on 21 April when the man made three incisions to his
arm. Two days later, the man said that he would hang himself if he was not
given a transfer. On 30 April, he said that he had swallowed a blade and
repeated his threat to kill himself if he was not given a transfer. On 6 May, the
man again cut his arm with a razor blade and claimed to be innocent.
The F2052SH was closed on 18 May. However, additional F2052SHs were
opened on ten further occasions through the remainder of 2004. The
documents were usually open for periods ranging from one to three weeks.
The man cut himself on at least two further occasions during the year, and
threatened suicide or self-harm on a number of other instances. He continued
to demand a transfer and to profess his innocence, and also claimed on one
occasion that his actions were due to bullying on the wing.
The man’s state of mind was better in early 2005, although a further F2052SH
was opened for a few days in the first week of January. Documents were also
opened on four more occasions through 2005 for periods ranging between
one and six days. The man was still prone to periods of depression, and said
on a couple of occasions that he found prison life stressful.
On 29 November, the man was due to undergo an x-ray at a local hospital,
but declined to attend. It is not clear from the records why he was due to
have this x-ray. On 28 January 2006, he complained of chest pain and was
assessed by a nurse. His blood pressure and pulse were taken and were
normal. The nurse noted that the man had recently received a letter from his
daughter, and thought that his pain may be anxiety related. She referred him
to a counsellor and advised on deep breathing exercises.
The man was noted to be suffering from ongoing depression over the first six
months of 2006, and F2052SHs were opened on three occasions during this
period. On 5 July, he transferred to HMP Albany. The man arrived on 6 July,
having stopped overnight at HMP Wandsworth.
The man was assessed by a nurse shortly after his arrival at Albany. He told
her that he had no medical problems other than angina which he said he had
around 30 years previously. The nurse noted that the man suffered from
depression and had been on a number of F2052SHs, but that he was not on
any medication at present.
The man was seen in a general medical clinic on 10 July as his blood
pressure had been raised over the weekend. It was noted to be fine. A
further check was taken on 15 July at which the man’s blood pressure was
again normal.
An F2052SH was opened on 17 July 2006 after the man apparently told a
Listener (a prisoner trained by the Samaritans to provide confidential
emotional support to fellow prisoners in distress) that he intended to kill
himself. The man had been upset by an earlier interview with Public
Protection Unit staff at which his offence was discussed. There were also
indications that he had failed to settle at Albany. The document was closed
on 22 July following an interview at which the man said that he no longer had
thoughts of killing himself. The man appeared to settle more readily into life at
Albany following this. He spoke of meeting up with people whom he had
known at other prisons, and expressed no further thoughts of suicide or self-
harm during the remainder of his time in custody.
On 24 July, the man reported a sudden pain and swelling in his right testicle.
He was seen by a prison GP, who prescribed doxycycline (an antibiotic).
However, the man’s condition did not improve and on 25 August he was
referred to a local hospital. He attended an outpatient appointment on 13
November at which a recurring hydrocele was diagnosed. The man was
subsequently placed on the waiting list for surgery.
The man had no further problems with his health until, on 19 April 2007, he
reported severe constipation during the previous three weeks. He also said
that he had been experiencing intermittent abdominal pain and had lost
weight. The man was seen by a prison GP, who referred him for a
colonoscopy (an examination of the colon).
On 30 April, the man said that he was experiencing dizzy spells at work. He
was allowed to rest in his cell rather than go to work for the remainder of the
week. He attended an outpatient appointment at the local hospital on 1 May
at which the consultant observed a palpable mass (a growth under the skin
that can be felt by the hands) on his abdomen. The consultant suspected
cancer of the colon and requested a CT scan and colonoscopy which was
booked for 22 May.
The man was admitted to hospital on 4 May for surgery on his hydrocele.
Given the suspicion of cancer, however, this procedure was cancelled and the
time was used instead to confirm the diagnosis. The man had a CT scan on 8
May, the results of which confirmed cancer of the colon with deposits in the
liver and lungs. A colonoscopy was attempted on 10 May, but was
unsuccessful and rebooked.
The man returned to Albany on 11 May, and was noted to be weak but
comfortable and not in undue pain. However, the following day he said that
he was experiencing acute abdominal pain when opening his bowels. As he
was taking Movicol (a laxative), this was happening frequently. The man had
also been observed by wing staff to be tearful. He was seen by a prison GP,
who prescribed co-codomol (a painkiller) and zopiclone (to aid sleeping). The
man was reviewed on 14 May and noted to be in good spirits and pain free.
The following day, the man requested diclofenac as he felt that this was a
better painkiller than co-codomol. He was seen by a prison GP who felt that
diclofenac was not appropriate and that the man would need a more effective
painkiller for his cancer. The man continued to request diclofenac over the
next two days. On 17 May, he was seen by a different prison GP, who ceded
to his wishes. The prison GP also prescribed omeprazole (a drug used to
reduce the production of gastric acid).
On 18 May, a prison officer made an entry in the wing observation book to say
that he had, “contacted HCC (Healthcare Centre) about the man and his
deteriorating state of health.” The officer went on to say that he had been told
by healthcare staff that the man had been seen the previous day and, “there
was not much more they could do for him.” The officer added that he asked if
anyone from healthcare was coming to see the man and had been told, “not
now but they may try again later.” A follow-up entry from a senior officer on
20 May said that healthcare had “belatedly arrived” and issued the man with
medication.
On 21 May, the man was admitted to the local hospital in preparation for his
rearranged colonoscopy. There had been some confusion at Albany as the
prison had not been informed of the date of the re-booked procedure. As a
consequence, a member of staff at the hospital had telephoned the prison to
enquire as to the man’s whereabouts. An escort was arranged at short notice
and the man was transferred to hospital the same day.
The colonoscopy went ahead on 22 May, and the man returned to Albany that
day. On 28 May, he was seen by a Healthcare Officer (HCO), who noted that
the man “continues to have problems on the wing … as management is
becoming a problem.”
The man was visited on the wing at lunchtime on 29 May by a nurse. She
noted that he was sitting up in bed and was alert and chatty, but that he
complained of diarrhoea around two hours after eating. The man was seen
later by a prison GP, who suggested he try immodium for the diarrhoea. The
prison GP also said that he would contact Occupational Therapy for an
assessment of the man’s daily care.
At 4.40pm on 29 May, a senior officer wrote in the wing observation book that
he was “very concerned” about the man’s health. He went on to say that he
had asked for a doctor to come and see the man but “healthcare seem
reluctant to do this, they say we should get him to them in a wheelchair.”
However, the senior officer added that staff were reluctant to do this “due to
stairs and lack of training”. He added that the man was “too weak to walk”. It
is not clear if this entry was made before or after the man saw the prison GP
that day.
On the following morning, the senior officer made a follow-up entry in which
he noted that he had been informed by another senior officer that the disability
liaison officer was dealing with the issue. The senior officer also wrote that,
“we are not equipped to cope with all the problems presented by the man’s
condition.”
On 31 May, the man was seen a prison GP. The man said that he still had
diarrhoea, and that his legs were weak meaning that he could not get out of
bed. The prison GP also noted that, on examination, the man’s liver was
grossly enlarged. He advised the man to eat what he could and, after
determining that there was no loss of muscle power in his legs, to try to start
moving around.
The same prison GP saw the man on 4 June. He noted that the man’s
condition was deteriorating and that he had still not got out of bed. The man
was also mildly dehydrated. The prison GP discussed with the man the
importance of taking fluids and trying to mobilise himself.
The man was seen by the disability liaison officer on the same day. She
spent around 30 minutes with him during which the man said that he was not
eating much. He said that he liked Cup-a-Soups but could not afford them, so
the disability liaison officer bought him two boxes. She told the man that she
would request a move to F&G wing for him, as this was a new wing with better
facilities such as in-cell sanitation and showers.
The man subsequently moved to F&G wing on 6 June, and was allocated a
cell on the ground floor. He was assigned a buddy on his new wing. (Albany
operates a ‘buddy’ system, whereby prisoners who are ill or have mobility
problems are assigned a fellow prisoner to help them with tasks such as
collecting meals and cell cleaning.)
One morning shortly after his move to F&G wing, the man experienced a
dizzy spell when going to the toilet. His buddy helped him back to his bed and
later recalled that the man was quite panicked, but that he calmed down after
a while. Later on the same morning, the man’s buddy returned to see him
and discovered that he had defecated and passed blood in his bed. The man
was embarrassed about this, and his buddy got him some clean underwear
and went to report what had happened to staff.
The man’s buddy went to the wing office and spoke to an officer. The officer
telephoned healthcare to request that someone come out and see the man.
He did not go and see the man himself and, at interview, said that he passed
on the same information that he had been given by the man’s buddy.
The Healthcare Manager came to see the man. He made the following entry
in the Medical Record:
“Had phone call from F&G re the man they stating he was covered in
shit and blood. On arriving on the wing officers were all sitting in the
office. The man was lying on his bed, no faeces or blood on his person
but two small areas of blood on his bottom sheet … talked to his
personal officer asking why we had a call regarding the man when he
was not covered in anything, he stated he had been told by an inmate
that he was in this state. I asked if he had checked and he said no as
this was not his job and he didn’t fancy looking at someone like that.”
At interview, the Healthcare Manager recalled that he spoke to the man and
that he was coherent. The man was able to stand and move between his bed
and his chair. However, the chair in his cell was too low, so the Healthcare
Manager asked wing staff to arrange for a high-backed chair to be brought in
instead. He also asked wing staff to arrange for a plastic cover for the man’s
mattress, and helped him to shave. The Healthcare Manager’s overall
impression was that the man presented quite well and was quite good at the
time.
The officer to whom the man’s buddy had earlier spoken went to the man’s
cell in the evening, to see how he was. He said that the man “was in a bad
state” and looked really ill. He described the man as lying on his back in bed
with his covers pulled up to his chin.
At around 11.10pm, an officer working the night shift went to the man’s
neighbour’s cell, having been alerted by the call bell. The man’s neighbour
told the officer that the man had been banging on the wall. The officer
therefore looked through the flap of the man’s cell. The man saw him and
said, “Help me, I can’t breathe properly.” The officer told the man to calm
down and not to panic, and said that he would go to get help.
The officer then returned to the wing office and telephoned the senior who
was Oscar 1 that night (Oscar 1 is the radio call sign of the Night Orderly
Officer, the person who is in charge of the prison overnight). He explained the
situation to the senior officer and asked for permission to unlock the man’s
cell, in line with local policy. The senior officer agreed, and the officer
therefore returned to the cell with an Operational Support Grade (OSG).
On entering the cell, the officer considered the man to be, “clearly having
difficulty breathing, but coherent and talking to me.” The man said that he
could not feel his legs and asked for oxygen. The officer told him that he did
not have oxygen and would have to contact healthcare. He helped the man to
sit up and rest on his pillow. This calmed the man down a little.
The officer then returned to the wing office so that he could telephone
healthcare. He met a senior officer and another officer, who was the
Assistant Night Orderly Officer, on arrival and updated them. As there is no
overnight healthcare provision at Albany, staff are required to telephone the
healthcare centre at HMP Parkhurst for advice. The senior officer duly spoke
to a nurse at Parkhurst. She said she would look up the man’s record and
phone back.
The nurse phoned back within a short while, and advised that they should call
an ambulance. At around 11.20pm, the senior officer contacted the control
room and passed this message on. The ambulance arrived at around
11.25pm, prior to which the senior officer and the F&G officer sat in the man’s
cell with him. The officer recalled that the man was coherent at this time and
able to hold a conversation. When the ambulance crew arrived, however, the
man’s condition deteriorated.
The ambulance left the prison at around 11.50pm. The man was
accompanied by the F&G officer and another officer, and cuffs were not used.
The man deteriorated further in the ambulance, and was unconscious when it
arrived at the local hospital. He did not recover consciousness, and was
pronounced dead at 12.28am. A post mortem report later gave the cause of
death as a disseminated carcinoma of the sigmoid colon with a secondary
condition of chronic obstructive airways disease.
The news of the man’s death was broken to his brother on 8 June. Due to the
distance that the man’s brother lived from Albany, a chaplain at a prison
closer to his house was asked to break the news. The chaplain agreed, and
visited the man’s brother and sister-in-law in their home. The man’s funeral
was held in early July, with the prison acting in accordance with Prison
Service Order (PSO) 2710.
ISSUES
The provision of personal and social care
The clinical review was conducted by the Isle of Wight Primary Care Trust.
The clinical reviewer notes that the healthcare that the man received was
“equivalent to care provided to patients in the community”. However, he goes
on to say that the personal care that the man received on the last day of his
life was a “possible exception” to this.
When he saw the man on that day, the Healthcare Manager commented in
the Medical Record, “I believe the officers are not taking any responsibility for
this inmate”. He also noted that he had asked the man’s personal officer why
he had not gone to see the man when told that he had defecated and passed
blood. The officer apparently replied that it was, “not his job and he didn’t
fancy looking at someone like that.”
At interview, the Healthcare Manager said that his opinion was that wing staff
“thought that they couldn’t cope” with the man, and that they “didn’t feel it was
a wing matter”. He went on to say that he thought that there was a lack of
clarity and misunderstanding with regard to whose responsibility it was for a
prisoner’s personal and social care. He said that he felt this was a shared
responsibility.
The officer said at interview that he did not go to the man’s cell because “the
buddies actually deal with that sort of thing,” and he had to trust them to deal
with it. He went on to say, “I am a prison officer not a hospital officer, and part
of our remit is not dealing with bodily fluids.” In terms of the responsibility of
wing staff for helping prisoners like the man with their personal care, the
officer said that they are a “go between, between the prisoner and
healthcare”. He added that there is the issue of “healthcare in confidence”,
meaning that wing staff cannot ask questions of healthcare staff about the
needs of prisoners.
The principal officer who is the manager of E wing and F&G wing, said at
interview that he would have expected a member of staff to go and see a
prisoner if they were told that the prisoner had defecated and passed blood.
He went on to say that the relationship between healthcare staff and wing
staff was good, and that there was a good rapport between staff.
The Director of Healthcare for the Isle of Wight prisons, said at interview that
there was increasing concern over the man’s personal and social care. She
explained that they were only commissioned to provide primary healthcare
(those health services that provide a central role in the local community, such
as GPs, pharmacists and dentists) at Albany, and that this does not include
personal and social care. The Director of Healthcare said that she would not
like to comment on the responsibilities of a wing officer in this area, but
thought that many staff go “above and beyond their duty”.
As the clinical reviewer notes, Albany is accommodating greater numbers of
older and frail prisoners. There appears to be some confusion as to where
the responsibility lies for providing personal and social care for those who
need it. The man’s buddies, on both F&G wing and on E wing, were a great
help to him in this area and should be commended for their efforts. However,
I am quite clear that it should not be the role of the buddy to help with the
personal care of another prisoner. However, from interviews and statements
of staff the lines of responsibility appear to be blurred. This has the potential
to create conflict between healthcare and wing staff that is detrimental to the
care of the prisoner.
The clinical reviewer makes the following recommendation, which I endorse:
The Governor and Director of Healthcare, together with the Primary Care
Trust, should jointly discuss and produce guidelines on the provision of
personal and social care for older or frail prisoners, including the roles
and responsibilities of healthcare and wing staff.
Terminal care plans
The man’s death, although expected, came about sooner than anticipated.
The Director of Healthcare said at interview that staff were caught unaware by
his death. She said that the expectation of how much longer the man might
live varied from three or four weeks to five or six months. She added that they
would expect the hospital consultant to lead on a terminal care pathway and
plans for future hospice care.
The Director of Healthcare also said that she thought that the man’s location
on F&G wing was suitable. HMP Parkhurst has inpatient facilities, but she
said that this would be very inappropriate for the man as it is used for
prisoners with mental health problems. The Healthcare Manager agreed that
the wing was a suitable location for the man. He said that, when he saw him
on the last day of his life, the man presented well and seemed quite good, and
he could not see any reason why he would need to be moved elsewhere. He
added that, had there been the time, they would have looked at hospice care
further down the line.
On the other hand, the man’s personal officer felt that he should not have
been on the wing and that hospital was “the only place for him”. He raised
this concern with the Duty Governor on the last day of the man’s life. The
wing manager agreed with the officer, and said that he felt that the best place
for the man was a loca hospital. The disability liaison officer also felt that the
man should have been in hospital rather than on the wing.
The clinical reviewer notes that, “no clear plan for advanced cancer/terminal
care was agreed either between the cancer team (at the local hospital) or
within the prison”. There also appear to have been widely differing views on
the most suitable accommodation where the man could be located. I do not
consider that the prison should wait for the hospital consultant to take the lead
in initiating this process. Rather, it should be a joint responsibility.
The clinical reviewer makes the following recommendation, which he repeats
from a previous report into a death in custody at Albany:
Prison healthcare should review with the PCT Clinical Governance Unit
the care pathway for a prisoner, where diagnosis of cancer is a
significant possibility.
This recommendation was accepted in my previous report, and the prison
provided the following response:
“A care pathway will be developed which will detail the prisoner’s
wishes, attitudes and behaviour which may inform the care provided.”
A target date of 1 December 2007 was given for completion of this action. I
hope that this can be achieved.
The clinical reviewer also makes the following recommendation:
Where a prisoner is diagnosed with advanced cancer a case conference
should be held, including clinicians from the local hospital, the
healthcare team and PCT Commissioners.
Arrangements for outpatient appointments
On 2 May 2007, an appointment for a colonoscopy was booked for the man
for 22 May. He subsequently spent time as an inpatient at the local hospital
from 4-11 May, during which time he had a colonoscopy. The Healthcare
Administrator at Albany spoke to the ward clerk at the hospital and confirmed
that the procedure booked for 22 May would therefore be cancelled.
However, the colonoscopy on 10 May was not a success and was rebooked
for the original slot on 22 May. Prison healthcare was not informed of this.
For this reason, a member of staff at the hospital had to telephone the prison
on 21 May to enquire why the man had not arrived in preparation for the
procedure the following day. Fortunately, an escort was arranged at short
notice and the man was transferred to hospital the same day.
I accept that healthcare staff at Albany were unaware of the man’s
appointment on 22 May, having been told that it would be cancelled.
Nevertheless, it is fortunate that hospital staff made enquiries as to his
whereabouts for otherwise he would have missed the procedure. It cannot be
guaranteed that such enquiries would be made in future. The clinical reviewer
therefore makes the following recommendation, which I endorse:
The Director of Healthcare should review arrangements for ensuring
prisoners attend urgent outpatient appointments.
Compassionate release
Chapter 12 of Prison Service Order 6000 sets out the following criteria for
compassionate release on medical 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.
As I have already commented, the man’s death came sooner than anticipated.
The Director of Healthcare at Albany spoke at interview of the uncertainty
over prognosis, with estimates ranging from three to four weeks to five or six
months. Her opinion was that the man was not at the stage where an
application for release on compassionate grounds would be successful.
Given the uncertainty over prognosis, I agree with the Director of Healthcare’s
view.
I am concerned, however, by her comment at interview that an application for
compassionate release would normally be generated by the patient, or their
solicitor on their behalf. Not all terminally ill patients will be well enough to
think about such issues, and some prisoners may not be aware of the
possibility of compassionate release. An application for compassionate
release on medical grounds is something that should be considered by the
Head of Healthcare and/or the Governor once it becomes clear that a
terminally ill prisoner is approaching the stage where such an application
might be successful.
Chapter 12 of PSO 6000 is implicit that Governors are expected to submit
applications in cases which merit them. Early release on compassionate
grounds is also featured in PSO 3050 (Continuity of Healthcare for Prisoners).
This too demonstrates that applications do not have to be submitted by
prisoners and that the onus is on the Governor to submit the application.
Issues raised by the man’s family
My senior family liaison officer contacted the man’s brother on 26 June 2007.
The man’s brother said that he had found it very difficult to arrange a visit in
the final days of his brother’s life, and that he could not speak to anyone about
his brother’s medical condition.
The man had a CT scan on 8 May 2007 that confirmed he had cancer of the
colon. On the following morning, he was allowed to telephone his brother
from hospital to tell him the news. Later that day, the man’s sister-in-law
telephoned the Healthcare Administrator to say that she and her husband
wished to visit the man in hospital. The Healthcare Administrator explained
the procedure for arranging a hospital visit, and gave them a contact number
in the security department. The man returned to Albany on 11 May before a
hospital visit could be arranged.
The process for booking a standard visit at Albany is that the prisoner
completes a visiting order with details including the visitor’s name, date of
birth and address. This is then passed to the correspondence office, who
post it out to the proposed visitor following approval from the security
department. On receipt of the visiting order, the proposed visitor must then
contact the prison to book the visit.
The man’s brother said that he received a visiting order two days after the
man had died, and that it was not filled in correctly. He felt that he should
have been allowed to see his brother given that he was seriously ill.
Prison Service Order (PSO) 4410 says:
“Governors may allow one or more special visits, subject to medical
advice, to a prisoner who is seriously ill. Restrictions on the number of
visitors or the time of the visits should, wherever practicable, be waived
in such cases.”
It is unfortunate that the man did not have the opportunity of receiving a visit
from his brother in the last days of his life. However, as I have previously
observed, his death occurred sooner than expected. It was thought that he
might live for another three weeks at least, and possibly for several months. I
do not therefore consider the timing of the visiting order to be inappropriate
(although it may be advisable in future to warn the next of kin in advance if
such an item has already been posted prior to a prisoner’s death).
However, the visiting order was not completed correctly when it was received
by the man’s brother. As a result, a new order would have had to have been
completed and posted in order to facilitate a visit and a delay of several days
would have occurred. Whilst it is a prisoner’s responsibility to ensure that the
details on a visiting order are correct, it would be extremely unfortunate if a
terminally ill prisoner were unable to receive a family visit on account of such
a mistake.
The Governor should ensure that visiting orders submitted by terminally
ill prisoners are checked by a member of staff.
The man’s brother also said that he could not speak to anyone at the prison
about his brother’s medical condition. I note that the man was permitted to
telephone his brother from hospital on 9 May 2007 after his condition was
diagnosed. His sister-in-law then spoke to the Healthcare Administrator over
the telephone on the same day.
The Healthcare Manager told my investigator that medical information must
not be passed over the phone to a relative or friend of a prisoner without first
obtaining the prisoner’s permission. He added that, if the prisoner was happy
for his condition to be discussed with a particular individual, then they would
do so and that this has happened many times in the past.
It is unfortunate that the man’s brother feels that he did not have the
opportunity to speak to a member of healthcare staff at Albany about his
brother’s condition. I am satisfied that healthcare staff would have been
happy to do so had the man given his permission. It is not clear, however, if
he was ever asked this.
The Governor should ensure that, when appropriate, the next of kin of a
terminal patient are given the opportunity to discuss the circumstances
of the illness in detail with a member of healthcare staff.
Family response to the draft report
On 10 December 2007, I received comments on my draft report from the
man’s brother, on behalf of the his family. He raised a number of issues,
which I will deal with in turn.
Emergency response on the night that the man died
The man’s brother commented that it was some time before his cell was
unlocked on the night of his death, as a result of which it was some time
before he was transferred to hospital. The man’s brother therefore felt that he
was denied medical care from hospital staff.
When he unlocked the man shortly after 11.10pm, the prison officer noted
that, whilst he was “clearly having difficulty breathing”, the man was coherent
and able to hold a conversation. The officer helped the man to sit up on his
pillow, and this calmed him down a little. At this point, the officer returned to
the wing office to seek the appropriate medical advice (by telephone to the
night nurse at HMP Parkhurst). Shortly afterwards the call was returned to
the night orderly officer and he was advised to request an ambulance, which
he did.
The telephone call to request an ambulance was made from the prison at
around 11.20pm, approximately ten minutes after the officer was first alerted
to the man’s cell. The ambulance arrived at around 11.25pm, and it was at
this point that the man began to deteriorate. The ambulance crew treated the
man in his cell for around 25 minutes before he was transferred to hospital,
where he later died.
Given these circumstances, I am satisfied that the officer and night orderly
officer acted appropriately on the night in question.
Was the wing a suitable environment for the man?
The man’s brother thought that he should have been in hospital several
months before his death, rather than being cared for on a prison wing.
There was a difference of opinion between those persons interviewed by my
investigator with regard to the most suitable environment in which to care for
the man. The healthcare professionals who were interviewed thought that the
wing was a suitable environment. However, the discipline staff who were
interviewed all thought that the man should have been in a hospital rather
than on the wing.
As I have noted previously in this report, the man’s death came about sooner
than expected. However, the clinical reviewer notes that there was “no clear
plan” agreed for the man’s advanced care either between the cancer team at
the local hospital or within the prison. The clinical reviewer subsequently
made two recommendations with regard to terminal care plans (see
recommendations 2 and 3), both of which were accepted.
The visiting system at Albany
The man’s brother was critical of the visiting system at Albany, in particular
that his brother had to complete the visiting order himself despite being very
ill. In my draft report, I recommended that “the Governor should ensure that
visiting orders submitted by terminally ill prisoners are checked by a member
of staff”. This recommendation was partially accepted by the Governor, and
he commented that “the FLO (Family Liaison Officer) team will monitor visit
applications and maintain personal family contact if the offender gives
agreement”.
The buddy system
The man’s brother was complimentary about the work done by the buddies,
and said that he would write to them to thank him for the care that they gave
his brother. The man’s brother went on to say that he thought that the
buddies should receive medical training.
The purpose of the buddy system is to help with social care for those
prisoners who need it. This encompasses tasks such as collecting meals for
a prisoner, or helping with cell cleaning. In the man’s case his buddies went a
step further and helped with his personal care, a task that is beyond their
remit but for which, as I have said earlier, they should be commended.
As I discussed earlier, it should not be the role of the buddy to help with the
personal care of another prisoner. I am also clear that it would not be
appropriate for buddies to provide medical care for another prisoner. I do not
therefore consider it necessary for buddies to undertake formal medical
training.
RECOMMENDATIONS AND GOOD PRACTICE
The Governor and Director of Healthcare, together with the Primary Care
Trust, should jointly discuss and produce guidelines on the provision of
personal and social care for older or frail prisoners, including the roles
and responsibilities of healthcare and wing staff.
Accepted – a joint proposal has been submitted to the PCT.
Prison healthcare should review with the PCT Clinical Governance Unit
the care pathway for a prisoner, where diagnosis of cancer is a
significant possibility.
Accepted – Prison Care Pathway now in place. This will be reviewed by the
Task Force and the PCT.
(This recommendation was made in a previous PPO report on a death at
Albany. The response was: “A care pathway will be developed which will
detail the prisoner’s wishes, attitudes and behaviour which may inform the
care provided”. This was completed on 1 December 2007.)
Where a prisoner is diagnosed with advanced cancer a case conference
should be held, including clinicians from the local hospital, the
healthcare team and PCT Commissioners.
Partially accepted – Involvement with PCT Commissioning occurs but clinical
involvement is subject to ongoing discussions. Talks are ongoing through the
Task Force and the PCT.
The Director of Healthcare should review arrangements for ensuring
prisoners attend urgent outpatient appointments.
Partially accepted – No urgent appointments have been missed. This was an
administrative error by the PCT. The establishment Health Care had not been
advised of the appointment. In the event, the appointment was still attended
on the day listed by the PCT.
The Governor should ensure that visiting orders submitted by terminally
ill prisoners are checked by a member of staff.
Partially accepted – When this information is known to staff, the FLO team will
monitor visit applications and maintain personal family contact if the offender
gives agreement.
The Governor should ensure that, when appropriate, the next of kin of a
terminal patient are given the opportunity to discuss the circumstances
of the illness in detail with a member of healthcare staff.
Partially accepted – Information must not be passed over the phone to a
relative or friend of an offender without first obtaining the offender’s
permission. If the offender is agreeable for his condition to be discussed with
a particular individual, then Health Care staff would do so. This is currently
the method in place and has happened numerous times in the past.
GOOD PRACTICE
The buddy system at Albany works well. The man’s buddies should be
commended for the help and support that they gave him.
A Family Liaison Officer at another prison was asked to break the news
of his death to the man’s next of kin, as they lived near to that prison.