Individual at Isle of Wight

Investigation into the death of a man, who was a
prisoner at HMP Albany, on 26 October 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
April 2006
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This is the report of an investigation into the death of a man who died from
apparently natural causes on 26 October 2005 at St Mary’s Hospital, Isle of
Wight. He was 73 years old.
The loss of a loved one is always distressing. I would like to add my personal
condolences to the man’s family to those already expressed by one of my
Family Liaison Officers on behalf of this office.
This investigation has been undertaken by one of my investigators. I would
like to thank the Governor of HMP Albany and his staff for their participation in
the investigation. A doctor was commissioned by Isle of Wight Primary Care
Trust to undertake a review of the man’s clinical care, and I appreciate his
assistance.
The roots of The man’s illness were not spotted by healthcare staff in prison
or in outside hospital, but the review finds that no grounds for criticism on that
score. In light of the findings of the clinical review, I have concluded that the
medical and other care the man received from Albany was entirely
appropriate. Indeed, my own investigation uncovered sensitive and
professional practice that reflects well upon the Prison Service.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2006
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CONTENTS
Summary 3
The investigation process 4
Background 5
HMP Albany 6
Key findings 7
ANNEXES
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Summary
1. The man was born in 1932. He was 73 years old when he died on 26
October 2005.
2. The man had been sentenced to life imprisonment in 1972. He was
released on life licence in 1994 but recalled into custody in 1996. He
arrived at HMP Albany on 24 September 1996.
3. On 18 October 2005, the man was taken to St Mary’s Hospital as he had
an infection behind his left knee. Whilst he was an in­patient at the
hospital, a bedwatch was carried out by prison officers. The security risk
assessment identified that a closeting (escort) chain was used. However,
this was removed when the man’s condition started to deteriorate on 21
October. The man died in hospital five days later.
4. The clinical review concludes that the man’s medical care whilst in prison
was appropriate.
5. On 18 November, one of my Family Liaison Officers contacted the man’s
family. Their concerns centred on the medical care that he had received
whilst in prison and the notification of his referral to hospital.
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The investigation process
6. My investigator studied all relevant prison records relating to the man.
These included his main prison record, his medical records and
statements from prison staff.
7. The Isle of Wight Primary Care Trust carried out a clinical review of the
medical care the man received while in prison. I am grateful to the
reviewer for undertaking this review in a most timely manner.
8. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of my investigation and to request a copy of the Post
Mortem report. Upon completion, this report will be sent to the Coroner to
assist him in his enquiries into the man’s death.
9. One of my Family Liaison Officers contacted the man’s family who told her
of their concerns. These centred on the medical care the man received
whilst he was in custody. The family also said that no­one was aware of
the man’s medical condition until very late on. The family wanted to know
why they were not informed immediately after the man was taken into
hospital. I hope the report provides the man’s relations with answers to
their concerns.
10.My investigator discussed aspects of the man’s treatment and the issues
raised by his family with both staff at Albany and the clinical reviewer.
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Background
11.The man was born in the north of England in 1932. He had been married
on two occasions and was the father to six children.
12.After finishing his education, the man joined the army. He was discharged
after 20 years service, having achieved the rank as a sergeant. His
conduct on discharge from the army was described as exemplary. After
leaving the army, he gained employment as an estate/housing agent until
his arrest.
13.Before being arrested, the man had been involved in a serious car
accident and had undergone surgery for internal injuries. The man was
sentenced to life imprisonment for murder in 1972 and was released on
licence in 1994.
14.The man was recalled into custody in August 1996 and arrived at Albany
in September 1996. Staff at Albany described the man as quite a solitary
individual who kept himself to himself and did not interact with staff or
other prisoners.
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HMP Albany
15.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 1960s, a decision was taken to upgrade the
security to make Albany part of the dispersal (now high security) system.
A later review concluded that Albany should no longer be a dispersal
prison and in 1992 it was re­designated as a category B closed training
prison.
16.Albany runs an integrated regime which means that it does not separate
vulnerable prisoners from the main prison population. Up to 530 prisoners
can be held at Albany. The accommodation consists of five four­storey
cell blocks (A to E wings). There is an 11 cell induction unit and a nine cell
segregation unit with two special cells. All wings are identical and hold a
maximum of 88 prisoners in single cells with in­cell power and electronic
access to night sanitation. In May 2003, a new ready to use unit opened
holding 80 category C prisoners.
17.Albany specialises in the management and treatment of sex offenders and
other vulnerable prisoners. The average age of the population is
significantly higher than in most prisons.
18.The prison’s healthcare is clustered with Camp Hill prison and is provided
by Parkhurst prison. Parkhurst provides healthcare to the 1,500 or so
prisoners on the island and has a 12 bed in patient facility (mainly
psychiatric). Prisoners’ medical needs are catered for by way of out
patient clinics and core day primary nursing cover. Neither Albany nor
Camp Hill has 24 hour nursing cover, but there is an on­call doctor who
covers all three prisons. Albany’s healthcare unit is designated for the
delivery of primary care services. When prisoners require urgent medical
nursing care, they are transferred to outside hospital.
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Key Findings
19.The man arrived at Albany on 24 September 1996, after being recalled
into custody. During his health screen interview it was noted that the man
had cardio vascular disease (poor blood circulation) in his legs.
20.On 20 August 2000, the man complained of abdominal discomfort and
constipation. He was admitted to St Mary’s Hospital, where he had a
laparotomy (abdominal surgery) and a small bowel resection.
21.On 23 August 2004, the man complained that he was experiencing pain in
his right calf after walking. This complaint had been an ongoing problem
for the man since 1997 when he had an operation to aid his circulation.
Consequently, a referral was made to the vascular surgeon at St Mary’s
Hospital where the man was seen on 20 January 2005.
22.On 7 September 2005, the man complained of swollen ankles. The man
had an electro cardio gram (ECG) and was referred for a chest x­ray.
23.On 14 September, the prison doctor saw the man. The doctor noted that
the man had fluid in his thighs and reviewed his medication to deal with
this condition. The result of the previous x­ray showed little of significance
apart from two old rib injuries.
24.On 19 September, an ultrasound scan was performed which showed no
deep vein thrombosis (DVT) in the man’s left leg. However, support
stockings were provided to aid the blood circulation in the man’s legs.
25.On 21 September, The man underwent another chest x­ray which again
showed little of significance.
26.On 12 October, The man saw the prison doctor who advised him to
continue to use the support stockings, despite the man being unhappy to
do so. It was noted that there was fluid accumulating around the man’s
knee region.
27.On 18 October, medical staff was called to the wing to see The man. The
swelling on his leg had got much worse, with fluid still accumulating, and
he also had a large inflamed area at the back of his calf. Due to his
condition, it was decided that The man needed to be transferred to
hospital for further assessment. He was later admitted to St Mary’s
Hospital. When The man left the prison a closeting (escort) chain was
used following a security risk assessment.
28.The restraints were removed on 21 October after a review of The man’s
situation, when it was deemed that there was no longer a risk of him trying
to escape from lawful custody.
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29.Around 1.30pm on 26 October, The man’s consultant informed the Head
of Operations and Security at Albany that the man’s death was imminent.
The Head of Operations and Security immediately asked the prison to
contact the man’s family and notify them of his circumstances. The Head
of Residence contacted the man’s family by phone and informed them
about his admission to hospital and his prognosis.
30.At 2:30pm on 26 October, the man’s room was cleared in case
resuscitation was required. It was noted on the bedwatch logs that he
continued to deteriorate rapidly.
31.At 2:55pm, one of the officers on bedwatch duties contacted the prison to
inform them that the man was going to be moved to the Intensive Care
Unit (ICU). The man was moved at 3:05pm to Colwell Ward as there was
no room on ICU.
32.At 4:25pm, a representative from the prison chaplaincy visited the man.
The man was unconscious by this time and died shortly after. Doctors
pronounced that the man was dead at 4:35pm.
33.The Duty Governor contacted the man’s family to offer his condolences
and support. He maintained contact with the family and offered to assist
with arranging the funeral and providing financial help. The man’s funeral
took place in November and the Head of Operations and Security attended
on behalf of the prison.
34.The post mortemidentifies that the cause of death was due to natural
causes as a consequence of multiple organ failure, sepsis (blood
poisoning) and disseminated gastric carcinoma (stomach cancer).
35.The man’s family asked whether he was displaying any symptoms that
should have been identified and whether the level of medical care was
appropriate. The Clinical Reviewer states that the man received
appropriate care following his presentation to healthcare staff. In
retrospect, the reviewer says that it would have been difficult for the
healthcare team at the prison and hospital to link the signs and symptoms
with which the man presented with what turned out to be the actual cause
of his death.
36.The man’s family also queried why they were not informed when the man
was referred to hospital. In an interview with my investigator, the Head of
Operations and Security said that the man had requested that no­one be
notified of his referral to hospital and this request had been respected.
When it became clear that the man was no longer able to make decisions
for himself, and due to his condition rapidly deteriorating, the Head of
Operations and Security decided that the family should be informed
immediately.
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37.In reviewing the bed watch log, it is clear that the staff involved with the
man’s care behaved with sensitivity. The decision to remove mechanical
restraints, following a risk assessment, was right and proper given the
circumstances. The security arrangements at the hospital seem to have
been suitable, and struck a good balance between public protection and
sensitivity to the situation.
38.In light of the findings of the Clinical Review, and my own investigation, I
conclude that the medical and other care of the man was entirely
appropriate. Indeed, I think that Albany treated the man with sensitivity
and professionalism. I make no recommendations.
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