Individual at Isle of Wight

Investigation into the circumstances surrounding the
death of a man, a prisoner at HMP Albany,
who died in hospital, Isle of Wight, 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
July 2007
This is the report of an investigation into the death of a man who died on 8
December 2006 in hospital, whilst a prisoner at HMP Albany.
The man was a life sentence prisoner. He had been admitted to hospital four weeks
before he died, suffering from a terminal illness. A post mortem was held at the
request of the Coroner and confirmed the cause of death as carcinoma of the kidney.
The man was 55 years old.
I extend my sincere condolences to the man’s family.
I would like to thank the Governor of Albany, and his staff for their help during this
investigation. I amparticularly gratefully to a governor for his assistance. I would
also like to thank the Isle of Wight Primary Care Trust (PCT) for the clinical review
into the man’s medical care.
Although he had been unwell and losing weight for several months, the diagnosis of
the man’s cancer was only made at the end of September 2006. By this time, the
tumour had progressed and surgery was unable to remove it. The clinical review
concludes that diagnosis of cancer of the kidney was delayed. This report makes
five recommendations for the attention of the Isle of Wight PCT in relation to
healthcare medication routines, the care of long term sick prisoners, and the
assessments of prisoners with physical illnesses.
I have also identified three points of good practice for the attention of the Governor.
The man was supported and assisted by dedicated prison staff. Regular risk
assessments ensured that during the last few weeks of the man’s life, whilst he was
an in­patient in hospital, restraints were only used when appropriate.
Albany has developed an excellent Family Liaison Officer Protocol. This document
was used from the man’s admittance into hospital until his funeral. The man’s family
were appreciative of the support they received from Albany and they are still in
contact with one of the governors. The family further commented on the caring
attitude of prison staff towards their brother. They particularly singled out a governor
and the chaplain who conducted their brother’s funeral.
In this final report all recommendations have been accepted by the Isle of Wight
PCT.
This version of my report, published on my website, has been amended to remove
the name of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2007
2
CONTENTS
Summary
The Investigation Process
HMP Albany
Key Findings
Issues
Recommendations
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SUMMARY
The man was a life sentence prisoner who had been convicted in 1978 for serious
sexual offences. He was released on life licence in 1995, but in 1999 he was
accused of another serious offence and his licence was revoked. In 2000, he was
convicted and sentenced for this further offence. The man served most of his
sentence at HMP Albany.
The man became unwell in late 2005 with symptoms of a severe skin rash,
excessive sweating, loss of appetite and weight. He was prescribed medication in
the form of lotions and creams. In September 2005, the man was referred to the
Consultant Haematologist at a hospital, but when the appointment became available
in January 2006 he declined to attend. During this period, the man was having
regular sessions with a psychotherapist, trying to address matters around his
depression and other personal problems. A psychiatrist assessed the man in 2006.
The assessment considered options for the man’s future mental health care.
In the spring of 2006, wing staff at Albany became very concerned over the man’s
physical health. He was losing weight, becoming lethargic and his skin rash was not
improving. On 24 April, a wing a senior officer submitted a report to a medical officer
raising concerns over the man’s health. The senior officer did not receive any
feedback from this report. However, the man was seen by a medical officer on 25
April. The medical officer noted that no abnormal physical signs were present but, in
view of the man’s weight loss and pallor, he arranged for a chest x­ray and further
blood tests.
A doctor saw the man on 26 April. He decided to give the man some high calorie
drinks to help try and build him up. The doctor noted that the man’s weight had been
69.8 kgs in 2004 but had fallen to only 53kgs. The doctor was to chase up the blood
test results and repeat them if necessary. The blood test results on 1 May revealed
a number of abnormalities including anaemia. The man was referred for gastric
endoscopy at hospital on 16 May. He did not receive an appointment date until 10
July.
During the summer, the man continued to lose weight and became increasingly frail.
He experienced great difficulty in collecting his medication from the healthcare unit.
The man was assisted by wing staff and fellow prisoners to help with his personal
care as it became harder for him to carry out these tasks. Prisoners and wing staff
brought the man’s food to his cell, although his appetite was very small by this time.
The man went on taking his prescribed nutritional supplement drinks to try to counter
his weight loss.
The endoscopy on 10 July showed some oesophageal thrush and mild gastritis. The
endoscopist said that the diagnosis could be carcinoma, lymphoma, hepatitis or HIV
and recommended further tests. An abdominal computerised tomography (CT) scan
was booked for 28 September 2006. On 1 September, the doctor saw the man
again because he felt unwell and an abdominal mass was felt. The doctor made a
further referral for suspected colorectal cancer, but the CT scan was not brought
forward and took place as originally booked on 28 September.
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A governor submitted a report to healthcare after speaking to the man on the wing.
The governor was extremely alarmed at the man’s physical condition. A few days
later, he underwent his CT scan where a tumour was observed near to his right
kidney. In mid October, the man attended hospital for blood transfusions in
preparation for surgery to remove the tumour.
On 31 October, the man was admitted to hospital for his surgery which he underwent
on 1 November. Sadly, the surgery was unsuccessful and the tumour was not
removed, having been deemed as inoperable due to its large size and attachment to
other tissue. The man remained at the hospital, and was given palliative care until
his death on 8 December.
My investigation found several areas of healthcare to be lacking. The time lapse
from the prescribing of medication to the wait for prisoners to be issued with their
medication fell below the expected standard. There was no in­cell issuing of
medication for frail, elderly or disabled prisoners. Moreover, in his review of the
man’s clinical care, the clinical review felt that the diagnosis of cancer was delayed.
On a much more positive note, the wing staff assisted and helped the man
exceptionally well. Senior management carried out risk assessments to ensure he
was only restrained in hospital when appropriate. An excellent Family Liaison Officer
Protocol ensured the man’s family were fully supported following his death.
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THE INVESTIGATION PRCESS
On 19 December 2006, my colleague, visited Albany to open the investigation into
the man’s death. She met with the Governor, and a governor, Delivery Strategy and
Programme Manager. This governor was also the prison’s Family Liaison Officer.
The Ombudsman’s Terms of References and Notices had been sent in advance of
my colleague’s visit. A Principal Officer (PO)representative of the local branch of the
Prison Officers’ Association, met with her and she explained the investigation
process. The Independent Monitoring Board (IMB) chose not to meet with my
colleague.
My colleague reviewed the man’s medical record and prison files, and requested
copies from those files to be forwarded to her. She visited B wing where the man
had been located before his admittance to hospital. She spoke to an officer and two
prisoners who had known the man.
A request was made to the Isle of Wight PCT for a clinical review of the man’s health
care. A doctor carried out this review on behalf of the PCT. I am most grateful to
him for his review.
One of my family liaison officers made contact with the man’s sister. No issues were
raised by her and she told my liaison officer that Albany had been very supportive
following her brother’s death.
On 23 and 24 January 2007, my colleague re­visited Albany to interview staff and
prisoners. She interviewed seven members of prison staff and four prisoners. My
colleague found wing staff and prisoners had showed great concern for the man
whilst he was resident on B wing. She also noted the positive attitude on the wing.
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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. Soon after it
opened in the 1967, it was decided to upgrade the security and in 1970 Albany
became part of the dispersal (high security) system.
In 1992, the prison was redesignated as a Category B closed training prison. In
1998, Albany changed from being half Vulnerable Prisoner Unit, half Normal
Location. It now only holds sex offenders and other vulnerable prisoners and
operates one regime. In 2002, a Category C Unit was added and the certified
normal accommodation is now 526. The average age of the population is
significantly higher than in most prisons.
The healthcare arrangements are managed in a cluster which includes HMP
Parkhurst and HMP Camp Hill. Parkhurst is the only establishment with in­patient
facilities. Albany itself has a healthcare unit designated for the delivery of primary
care services.
Her Majesty’s Chief Inspector of Prisons, published a report on an unannounced
short follow­up inspection of Albany during October 2005. The last full inspection
was in 2002. In the short inspection report, it 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.”
The report offered 13 recommendations in relation to healthcare services.
None of those recommendations relate to any issues that have been raised during
the present investigation.
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KEY FINDINGS
The man was received into Albany in 2004 from Frankland. He was located on B
wing and allocated work as a wing cleaner. Although he was receiving medication
for depression, the man was a fit and active man, exercising regularly and taking part
in long distance running within the confines of the prison grounds and gymnasium.
On 4 July 2005, his medical notes record that he attended the healthcare unit with a
rash, saying that he was feeling tired and not sleeping. The man was prescribed
some cream for the rash and medication to help restore his sleep pattern.
On 23 August, the man was seen again in healthcare. He complained that he was
feeling tired, had a loss of appetite, excessive sweating and a rash at night. He was
prescribed E45 cream. On 31 August, the man was seen in the healthcare unit
because of night sweats, weight loss and feeling tired. The medical officer made a
request for the man to have an x­ray. The appointment appears to have been
offered for 9 January 2006, but on this date the man declined to attend and signed a
‘prisoner hospital appointment cancellation form’.
Over the next few weeks, medical staff saw the man regularly in relation to his skin
rash. Several medications were prescribed, none of which seemed to offer him any
relief. Blood tests were also carried out during this time. The man was asked
whether he was under stress, which he denied, although it was noted that he had
been distressed following a psychological report. The notes record that the man
would be referred to a visiting psychiatrist for assessment. The psychiatrist referred
to the man’s present physical health symptoms and indicated that, until these issues
could be resolved, it would be difficult to address his psychological problems. The
psychiatrist noted that the man was receiving sessions with a psychotherapist, and
that this should continue.
An x­ray taken on 21 September did not reveal any abnormalities. On 23
September, a letter from the prison’s medical officer to a Consultant Haematologist
at a hospital was sent asking for a review of the man’s rash and skin condition. On
19 October, a nurse saw the man. She noted that he looked unwell, but that his skin
rash was being helped by the application of calamine lotion.
On 2 November, the man was seen by a Community Psychiatric Nurse (CPN). The
CPN noted that he was exhibiting symptoms of depression, was tearful and in a
negative thinking pattern. The note also records that the man was losing weight, had
sleep disturbance and lethargy. The CPN wrote that these symptoms would
probably be related to the man’s physical health problems.
On 25 November, the man was seen in healthcare by a nurse. He complained of
abdominal pain and of feeling nauseous. The man also told the nurse that he had
been in pain on and off for a week in his left kidney. The nurse tested a urine
sample which showed a trace of protein. The man was advised to drink plenty of
fluids and was given some paracetamol and Gaviscon liquid. On 26 November,he
had a medication review with the doctor.
8
Over the next few weeks, the man was seen regularly in the healthcare unit and his
medication was subject to review. As noted above, he declined to attend the
hospital appointment offered on 9 January 2006 concerning his rash.
On 24 April 2006, a senior officer (SO) submitted a report to the medical officer
which noted his concerns regarding the deterioration in the man’s physical health.
The SO had observed the man’s weight loss and lethargy. The SO had spoken to
the man who had admitted to feeling unwell and a loss of appetite.
On 25 April, the man attended healthcare. A nurse noted that he looked pale and
thin. He told the nurse that he could not stand prison food, only eating occasionally
although drinking fluids, tea and coffee. Later that day, the man was seen by the
medical officer, who ordered blood tests to be taken and sent as urgent to the
pathology laboratory.
On 5 May, the man was seen in the healthcare unit. He was advised about the
results of his recent blood tests which indicated that he was anaemic. Build Ups, a
high calorie nutritional drink, was prescribed to help the man with his lack of appetite
and to try to stabilise his weight.
On 16 May, the prison medical officer wrote a referral for the man to the
gastroenterology department at a hospital. The letter noted that the man was
anaemic, and had been suffering from dyspepsia and weight loss. An appointment
was made for the man to attend the hospital for an endoscopy on 10 July. He was
admitted to the local hospital for this investigation. No serious abnormalities were
found, but the endoscopist stated that the differential diagnosis included cancer,
lymphoma, hepatitis and HIV. It was suggested that an abdominal CT scan should
be considered.
On 7 August, a request was made for a CT scan. The scan appointment was
booked for late September. On 1 September, the prison’s medical officer examined
the man and felt an abdominal mass. The same day he made a referral for the man
to see the first available consultant in relation to suspected colorectal cancer.
In September, a governor submitted a report to the Head of Healthcare documenting
concerns of staff about the continued deterioration in the man’s health. The
governor had intervened on behalf of wing staff who had requested his involvement.
The report by the governor was filed in the man’s medical notes. A note on the
report by the Head of Healthcare indicated that the man had numerous appointments
at the hospital and with the prison’s medical officers. She further noted that it was,
‘already in hand’, but this was not communicated back to the governor. On 28
September, the man underwent his CT scan at hospital. The scan found a 9cm
lesion arising from the left adrenal gland in contact with the pancreas, left kidney and
spleen.
On 2 October, the man was again seen in healthcare. A treatment plan was being
developed and he was prescribed Ensure to help with his nutritional intake. On
Friday 6 October, the man was told the results from the scan by the medical officer
who discussed the illness and issues around anxiety. Later that day, the man was
taken by ambulance to a hospital, Accident and Emergency Department, as he was
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in severe pain. The man was given an x­ray which was noted to be abnormal.
However, no further information was disclosed on the patient discharge form. The
man went back to Albany after being prescribed painkillers.
The following day, the man was seen in healthcare. It was noted he was very weak
and sleeping most of the time. A prescription was written for continuous pain control.
On 9 October, the man attend hospital for a further out­patient appointment. He
returned to Albany but was then re­admitted to hospital as an in­patient the following
day. This was to conduct tests prior to surgery. The man was discharged from
hospital on 12 October.
On 15 October, the man was seen at a hospital’s out­patient department. He
returned to Albany later that day. On 25 October, the man attended hospital for a
blood transfusion. He was discharged the next day and again returned to Albany.
On 31 October, the man was again admitted to hospital in preparation for surgery. A
two­officer bed watch escorted him. On 1 November, he underwent surgery to
remove the tumour. The operation was unsuccessful and the tumour was not
removed due to its advanced state. Mechanical restraints were not used following
the surgery. The restraints were re­applied on 4 November, following a risk
assessment, as the man’s condition had slightly improved.
On 10 November, the restraints were again removed following a further risk
assessment. On 13 November, the man was seen by a palliative care doctor and
nurse from a local hospice. Hospice care was not available for himat that time, but it
was agreed that the situation would be reviewed in three weeks. The restraints were
later re­applied, as it was understood that the man could be discharged back to
Albany in the very near future. Over the following two days, discussion took place
between hospital staff and healthcare staff at Albany regarding a suitable location to
which the man could be discharged.
On 18 November, following a further risk assessment and the man’s continuing in­
patient care at the hospital, the restraints were once more removed. They were not
re­applied before his death.
On 22 November, a PCT funding panel met to discuss the man’s palliative care. It
was agreed that neither a discharge back to Albany nor his current palliative care on
the hospital ward were appropriate. Instead, it was agreed that the man would
transfer to a continuing care bed within the hospital. It was noted that the hospice
would be prepared to offer the man a bed when he reached the end stages of his
life.
On 25 November, the man was transferred to the continuing care ward in the
hospital. He received care from hospital staff and Macmillan nurses. On 27
November, the man consented for a governor to make contact with his sister when
he died. Over the next two weeks, the man was cared for in the hospital. He was
prescribed analgesia for pain control which included the use of a syringe pump.
On 8 December, the man died. In accordance with his wishes, the governor
contacted HMP Manchester to establish if a senior manager at the prison could visit
10
the man’s sister and give the news of her brother’s death. The Deputy Governor,
and Manchester’s Safer Custody Manager carried out this request.
A funeral service for the man was held at a local Crematorium. It was the wish of the
man’s sister that the funeral service take place locally. The man’s sister and
husband travelled to the Isle of Wight on 19 December for the service and to visit
Albany to speak to staff and her brother’s friends. All their expenses were met by
the prison.
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ISSUES
Clinical Review
A doctor from the Isle of Wight PCT carried out a review of the man’s medical care.
The review is based on clinical notes kept on the man and the transcripts of a
number of interviews undertaken by my investigator with officers and prisoners.
The doctor noted that the itchy rash that the man developed in July 2005 did not
resolve in spite of treatment with several medications. His referral to a hospital
specialist in September 2005 did not result in an appointment until January 2006
and, at this point, the man refused to attend.
The doctor concluded that the cause of his rash is unclear and that it may or may not
have been related to the renal cancer that was finally diagnosed in September 2006.
The doctor felt that it was unfortunate that the man declined the appointment in
January 2006. If he had attended, the outcome might have been different.
The man was seen promptly by prison healthcare in response to the representations
of the Senior Officer in April 2006, but the subsequent response to the confirmation
of abnormal blood tests was slow. The results of the blood test came back on 1
May, but they do not seem to have been discussed with the man until 11 May (the
date of the urgent referral for endoscopy of his oesophagus and stomach). The
possibility of cancer was raised in this referral letter but the man still had to wait eight
weeks for his endoscopy appointment. The endoscopy on 10 July showed some
mild thrush and mild gastritis. The endoscopist said that diagnosis could include
carcinoma, lymphoma, hepatitis and HIV. The endoscopist recommended an
abdominal CT scan, referral to haematology and further blood tests.
The prison’s medical officer did not make the referral for the CT scan until 7 August
and it was not marked urgent. The hospital received the form on 14 August and
booked the scan for 28 September.
When the prison’s medical officer palpated an abdominal mass during his
examination of the man on 1 September, he made an urgent referral to the Surgical
Department at the hospital. One of the surgeons there tried unsuccessfully to
expedite the CT scan. It was eventually undertaken as originally booked on 28
September.
The clinical reviewer felt that the abdominal CT scan request on 7 August should
have been marked as urgent, particularly as the possibility of malignancy had
already been endorsed by the endoscopist.
The clinical reviewer was unclear why healthcare staff did not respond to repeated
concerns expressed by prison officers about the man’s declining health.
The clinical reviewer made the following recommendation which I endorse:
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Prison healthcare should review with the PCT Clinical Governance Unit the
care pathway for a prisoner where the diagnosis of cancer is a significant
possibility.
The clinical reviewer was unable to conclude that the man’s care was equivalent to
that which he might have received in the community. Although the man declined to
see a consultant haematologist in January 2006, the clinical reviewer considered that
his diagnosis of cancer of the kidney was delayed.
The man’s location on the wing
The man first became unwell during the summer of 2005. He had a bad skin rash
and was losing weight. The man was working in the servery at this time and was
located on the fourth landing of B wing. As his condition started to deteriorate,
officers moved himonto the first landing. Subsequently, the man was moved to the
ground floor into a cell located nearest to the recess (toilet and showers). The cells
in B wing do not have in­cell sanitation, and the move to the ground floor enabled the
man to have ease of access to the toilet as his health further declined.
The man was allowed to go first to the servery to collect his meals. Staff offered him
first choice from the menu so he could choose food that appealed to his decreasing
appetite. Often the man would prefer to eat two puddings rather than a main meal
and a pudding. When it became difficult for him to collect his food from the servery,
which is located a short walk from the wing, either fellow prisoners, or prison staff
would collect his food for him.
In July 2006, a PO made an entry in the man’s wing history sheet relating his
concerns over the man’s physical condition and deteriorating health. This was
followed by a further entry in early October. In this entry, the PO said that the man’s
condition was so severe he could no longer be supported on the wing. This was
endorsed by a senior manager who noted that the prison’s medical officer was
seeing the man. Two weeks later, he was admitted to hospital. In interview, the PO
said he was conscious that two officers had supported Mr Monk’s needs, and he
described their assistance as exemplary.
A member of staff is an instructor and the disability liaison representative at Albany.
The instructor had known the man since his arrival at the prison. She had not seen
him for a long while until she observed him on the wing just before he was admitted
to hospital in October 2006. The instructor was shocked by the man's appearance.
In interview, she described him as shuffling along like a man of 90 and said he
looked very ill. An officer told the instructor he was worried about the man’s
deteriorating health. The instructor told my investigator that, if she had been made
aware of the man’s illness she would have assessed his situation, although she was
conscious of issues around patient confidentiality. She said that healthcare staff
normally made such a request.
It is clear from the accounts of staff and prisoners that the man was extremely ill and
finding it hard to cope on the wing. His suffering was distressing for all those
working and residing on B wing to witness.
13
Healthcare staff should involve the prison’s disability liaison representative in
completing assessments about prisoners where appropriate.
Collection of medication
The man spoke to an officer about the difficulty he had in collecting his medication.
The walk from B wing to healthcare took him approximately 20 minutes (the walk for
a fit and active person would take around one to two minutes). The man found it
painful and difficult to make this trip. Currently, all prisoners are required to collect
their medication from healthcare. There is no in cell medication routine at Albany.
The man had to make this trip two to three times a week. This was raised with
healthcare by wing staff but no action was taken to change the situation.
The man’s trips to collect medication and visits to healthcare caused him great
difficulty and distress. At no time did healthcare staff visit the man on the wing to
assess his mobility and care needs. Nor, as mentioned, did they ask the disability
liaison representative to carry out an assessment.
Albany does not operate a 24­hour healthcare facility. An assessment of the man’s
requirements might have led to a care package meeting some of his needs and
ensuring some retention of dignity and respect before his admittance to outside
hospital. For example, healthcare nurses could have brought his medication to his
cell and assisted him with his general personal care. An assessment might also
have identified the need for the man’s transfer to a prison with 24­hour healthcare
that could provide the health and social care appropriate to his needs.
During the course of my investigation, both prisoners and staff raised issues over the
medication routines at Albany. All prisoners have to collect their medication from
healthcare ­ even if they are disabled or unwell. They also described a delay
between the prescribing of medication by the medical officer to it becoming available
in the pharmacy. This was said to be up to four days.
My investigator wrote to the Deputy Director of Commissioning and Partnerships for
the Isle of Wight PCT raising concerns over these medication routines. The Deputy
Director replied that these concerns would be investigated further and the outcome
reported to the Prison Commissioning Group and the Prison Partnership Board.
Healthcare staff should consider dispensing medication to prisoners in their
cells when their mobility is impeded by their physical health.
The Prison Commissioning Group and Prison Partnership Board for the Isle of
Wight Prisons should respond to any outcomes or recommendations as a
result of the investigation into medication routines by the Isle of Wight PCT.
The man’s failing health
During interview, two officers both indicated their concerns over the man’s failing
health. The officers had observed the man’s deterioration and frailty. He had told
one of the officers in December 2005 that he would not see another Christmas. The
Officer continued to help the man on the wing, offering both practical and emotional
14
support. The officer remembered that in the summer of 2006 the man had removed
his top, and that he was shocked by his physical appearance. His body muscle
tissue had wasted away and skin was hanging from his body. The officer found it
distressing to see the man decline and the obvious pain he was suffering.
A second officer knew the man from his arrival on B wing. Together with the other
officer ensured the man was given the necessary and appropriate help as his
deterioration became obvious. The second officer said he too found it hard to watch
the man’s continued suffering. On 5 June, the second officer wrote in the man’s
personal file about his concerns over the man’s welfare and declining physical
condition. The second officer spoke to a member of healthcare staff about the man’s
condition but was told there was nothing to worry about.
In early 2006, a second PO took the man to healthcare after observing him working
in the servery. This PO Young noticed how unwell Mr Monks looked and that he was
finding his work difficult. (the man was serving the puddings on the servery. Prison
staff had allocated him this task as it involved little effort.) The PO was told by a
member of healthcare staff they were aware of the man’s ill health and were looking
into it. In April, the PO wrote a memo to healthcare raising his concerns about the
man’s deteriorating condition. The PO did not receive any feedback from healthcare.
In interview, the second PO praised two officers for their care and support for the
man whilst he was on B wing. Both officers had ensured that the man was given
practical help by other prisoners. The officers also spent time acting as emotional
support for the man.
A governor saw the man on B wing in September. This was at the request of wing
staff who were becoming increasingly alarmed about his wellbeing. The man
showed the governor sores and rashes on his legs. They were bleeding. The man
also removed his top and the governor saw how thin the man was and that the skin
was hanging from his bones. The governor described the man as looking ‘ghastly’
and wrote a report for healthcare outlining his worries. The governor did not receive
any feedback from this report. A few weeks later, the governor learnt that the man
was to have a CT scan.
Several prisoners located on B wing spoke to my investigator about their
observations of the man’s declining health, and the struggle he had to see
healthcare staff and collect his medication. They all described his weight loss, lack
of appetite and lethargy. There was a general feeling that the man’s health needs
were not being met by healthcare staff. The prisoners praised the wing staff for
supporting the man, in particular citing two officers.
My investigator also spoke with a psychotherapist who had worked with the man.
The psychotherapist had recorded in the man’s medical notes the decline in his
physical appearance, his weight loss, night sweats and rashes. During the summer
of 2006, the man would wear an excess of clothing and say he was cold even though
it was high summer. The psychotherapist understood from healthcare that the man
was undergoing tests and investigations. The psychotherapist said that the man was
frustrated by his illness and his sessions with her involved untangling the emotional
from the physical issues.
15
Healthcare staff should acknowledge the concerns of prison staff raised
verbally or in a letter or memo and, within the bounds of confidentiality,
demonstrate that they have noted their concerns and acted on them where
appropriate.
Use of Restraints
The man was escorted by two officers on admission to hospital. At one stage, the
escort was reduced to one officer. Restraints were removed for the operation and
only re­applied on two occasions, two days after his operation and for a very short
period when discussion was underway as to where the man would receive palliative
care. A full risk assessment was conducted when the restraints were removed.
An application for release on compassionate grounds was being prepared by
healthcare and hospital staff. However, given public protection concerns arising
from the seriousness of the man's offences, the application might well not have been
successful.
I commend the actions of senior management in carrying out regular risk
assessments for the removal of restraints and in acting with compassion
towards the man and his situation whilst in hospital.
The man’s support whilst on B wing
The man received exceptional help from two officers whilst he was on B wing. Both
officers went beyond the call of their normal duties in offering compassion,
assistance and emotional support to the man. I note their concerns for the man
over the 12 month period before he was admitted to hospital. I also happily record
the PO’s observation that both officers’ attitudes were exemplary.
The man’s friends on B wing were also supportive towards to him. The man was
described as a likeable man who was well thought of by his friends. They visited him
in his cell as he became weaker, talking to him and helping him with his daily routine.
My investigator was greatly impressed by the positive and caring attitude of both
staff and prisoners on B wing.
I commend the actions of two officers for the compassionate care they gave to
the man whilst he was located on B wing.
I note the good practice of the two Principal Officers for raising concerns
about the man’s health and actively responding to the views of wing staff.
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17
RECOMMENDATIONS
For the Isle of Wight PCT:
1. Prison healthcare should review with the PCT Clinical Governance Unit the
care pathway for a prisoner where the diagnosis of cancer is a significant
possibility.
Accepted – A care pathway will be developed which will detail the prisoner’s
wishes, attitudes and behaviour which may inform the care provide.
2. Healthcare staff should consider dispensing medication to prisoners in
their cells when their mobility is impeded by their physical health.
Accepted – If a prisoner is unable to attend healthcare due to mobility being
impeded by their physical health, medication will be provided by the
healthcare staff at the prisoner’s cell.
3. The Prison Commissioning Group and Prison Partnership Board for the Isle
of Wight Prisons should respond to any outcomes or recommendations as
a result of the investigation into medication routines by the Isle of Wight
PCT.
Accepted – A response will be generated following the publication of the
investigation commissioned by the Deputy Director.
4. Healthcare staff should involve the prison’s disability liaison representative
in completing assessments about prisoners where appropriate.
Accepted – When a request for assessment is submitted to the Occupational
Health Department at a hospital, Healthcare will add a note to the request
application and advise the prisoner inviting both to contact the
establishment’s Disability Liaison Officer to attend the assessment.
5. Healthcare staff should acknowledge the concerns of prison staff raised
verbally or in a letter or memo and, within the bounds of confidentiality,
demonstrate that they have noted their concerns and acted on them where
appropriate.
Accepted – All written correspondence will be replied to by Healthcare, within
the bounds of confidentiality.
Good Practice
1. I commend the actions of senior management in carrying out regular risk
assessments for the removal of restraints and in acting with compassion
towards the man and his situation whilst in hospital.
Accepted
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2. I commend the actions of two officers for the compassionate care they
gave to the man whilst he was located on B wing.
Accepted
3. I note the good practice of two Principal Officers for raising concerns about
the man’s health and actively responding to the views of wing staff.
Accepted
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ANNEXES
1. Documents considered during the investigation
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