Individual at Isle of Wight

The death of a man in October 2005 at St Mary’s Hospital,
Newport, Isle of Wight, whilst a prisoner at HMP Albany
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2006
This is the report of an investigation into the death on 22 October 2005 of a male
prisoner. The man, who was 48 years old, died at St Mary’s Hospital, Newport, whilst a
prisoner at HMP Albany.
The man’s death was caused by lung cancer. My colleagues and I would like to extend
our condolences to his family for their loss.
This office investigates all deaths of prisoners in custody, including those due to natural
causes. In this case, the investigation was carried out by one of my investigators on by
behalf. The clinical review was carried out by a representative from the Department of
Health, Isle of Wight, and I am grateful for his help. Both the clinical reviewer and I are
satisfied that the medical care provided for the man was detailed and comprehensive,
and equivalent to that he would have received in the community.
I commend Albany for the efforts they made in support of applications to have the man
released on compassionate licence and, when these were not successful, their referrals
to a local hospice. Unfortunately, at the time of the man’s death, a place had not yet
become available. The prison was also sensitive to the man’s changing health and
ensured that the use of escorts and handcuffs was continually reviewed, and reduced as
his condition deteriorated. In my view, the prison balanced well the needs of the man
and his family with their duty to protect the public. However, whilst I make no specific
recommendations in this report, I believe there are some learning points for Albany
concerning communication with families, and I have some concerns about a disciplinary
punishment imposed in August, two months after the man had suffered a serious heart
attack.
I would like especially to thank the prison appointed liaison Governor for his help in
ensuring all the relevant information was passed promptly to my investigator. The
liaison Governor was Albany’s Duty Governor on 22 October and was with the man
when he died.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2006
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Contents Page
Summary 4
Background 5
HMP Albany 6
The investigation process 7
Key Findings 8
Issues considered during the investigation 13
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3
Summary
· The man died, aged 48, on 22 October 2005 at St Mary’s Hospital, Newport, Isle
of Wight, whilst a serving prisoner at HMP Albany.
· Since June 2005, the man had suffered from several medical complaints and
spent considerable amounts of time at St Mary’s Hospital. He had had further
admissions to Southampton Hospital and to the Healthcentre at HMP Parkhurst.
· This was not the man’s first time in prison. Prison staff described him as
generally keeping himself to himself, polite and having trusted employment within
the prison. However, they said he had begun to experience what they perceived
as a relapse in his mental state and described some unpredictable behaviour.
Whilst serving an eight and a half year sentence during the 1990s, he had been
treated for paranoid schizophrenia.
· The man had asked for a transfer to Albany to enable him to undertake
programmes to address his offending behaviour. These were successfully
completed before his health deteriorated.
· He was diagnosed with lung cancer in August 2005. He was scheduled to attend
Southampton Hospital to have a procedure to remove fluid from his lungs and to
apply talc which would discourage further fluid from accumulating. Whilst he was
generally co­operative in hospital, on two occasions he refused to accept
treatment. From reports, it would appear that the main reason he refused was
because he was afraid of what would happen to him.
· Applications were made by Albany for him to be released on early
compassionate licence and to be referred to a hospice. Unfortunately, neither
was successful before his death.
· There was a delay and some confusion in informing his family of his passing.
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Background
1. The man was born in 1957 in Aldershot, and was 48 years old when he died
on 22 October 2005.
2. During the considerable time he spent in hospital, he had regular contact with
one sister in particular and she visited him with her own family a few days
before he passed away. He received a card from her and entries in
bedwatch logs show that he appreciated this greatly, showing it to staff and
keeping it by his side.
3. In reports, the man described himself as having had an isolated social life
and having sought company by visiting local pubs. There is some evidence
that he had been a heavy drinker. However, in recent reception health
screens, he stated that he did not drink excessively and did not therefore
engage in any treatment for this. He was a smoker and on occasion whilst in
prison told staff that he considered giving up.
4. The man had worked as a labourer in the building industry and felt that
finding employment would not be a problem on release. In the early 1990s,
he was exposed to asbestos which was initially considered to be the
explanation for his poor health. However, the post mortem showed that this
was not the case.
5. On 30 July 2001, he was remanded to HMP Bristol. He had been living in the
area although denied having a fixed address. Release plans show that, due
to unstable living conditions, the man would have initially been released to
live at an Approved Probation Premises in Bristol. He had decided that he
would then like to live near his family in Farnham, rather than Bristol, this
being somewhere he “just ended up for a while”.
6. The man had previously spent considerable amounts of time in prison, the
longest of these being an eight and a half year sentence received in 1992.
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HMP Albany
7. 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 1960s, it was decided to upgrade the security and
in 1970 Albany became part of the dispersal (high security) system.
8. 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 vulnerable prisoners
and operates one regime. In 2003, a Category C Unit was added and the
certified normal accommodation is now 530. The average age of the
population is significantly higher than in most prisons.
9. The healthcare arrangements are managed in a cluster, which includes HMP
Parkhurst and HMP Camp Hill, all within a short distance of one another on
the Isle of Wight. Parkhurst is the only one with in­patient facilities. Albany
itself has a healthcare unit designated for the delivery of Primary Care
services.
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The investigation process
10.My investigator requested all the relevant prison records relating to the man.
These included his medical records and core prison record. She also visited
the prison.
11.A representative from the Department of Health, Isle of Wight undertook the
clinical review on behalf of the Isle of Wight Primary Care Trust.
12.The Isle of Wight Coroner was informed of the Prisons and Probation
Ombudsman’s investigation. He kindly provided my office with the post
mortem report. The Coroner will receive a copy of this report when it is
completed.
13.The man’s sister was named by him as his next of kin. She was contacted by
one of my Family Liaison Officers and asked whether she or other members
of the family had any comments or concerns about her brother’s death. The
family raised the following matters:
· Whether the health care was appropriate and consistent with what it
would have been in the community?
· That the escorts at the hospital were excessive.
· A lack of communication from the prison and the hospital in the final
couple of weeks of the man’s life and at the time of his death.
14.Notices to staff and prisoners were supplied and displayed by the prison.
These invited anybody with information to talk to my investigator. In this
instance, only one other prisoner wished to be interviewed and he raised
general concerns about access to healthcare rather than information relating
to the man. His concerns have been passed to the clinical reviewer and have
not been included in this report.
15.A draft copy of this report was sent to the man’s family and Albany to enable
them to make any comments. All of their comments have been reflected in
the text of this final report.
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Key Findings
16.The man was remanded into custody at HMP Bristol on 31 July 2001. He
was convicted at Bristol Crown Court on 16 December 2002, and on 25 April
2003 he was sentenced to nine years imprisonment with a one year extended
licence. The man was transferred to HMP Parkhurst on the Isle of Wight on
23 May 2005. An application was made to the Court of Appeal and, on 3
December 2003, his sentence was reduced to seven years imprisonment with
three years extended licence.
17.The man’s sentence plan included attending Offending Behaviour
Programmes and he requested a transfer to Albany to enable him to attend
the identified courses. The transfer took place on 16 April 2004.
18.Wing records show many entries referring to the man’s polite, amiable
manner and how he seemed settled. A representative entry said he was
“progressing quietly through his sentence” and presented no real problems.
This continued until January 2005, when staff started to notice a difference in
his behaviour.
19.In that month, the man became aggressive with an officer during a cell
search, which his personal officer felt was out of character. The officers
reported that he “kept his head down” for a while, but then at the end of
March, he lost his job as a cleaner due to lack of interest and a poor attitude
toward the job. Staff recorded on 5 April that he seemed to have “a real split
personality at times”, and his personal officer told my investigator that she
had seen a different side to him.
20.On 10 June, the man suffered a heart attack. He was taken to St Mary’s
Hospital after he had started experiencing chest pains and remained there
until 16 June. The man’s personal officer said that he (the man) had initially
denied having a heart attack, stating that it was just a build up of anger and
then an “explosion”. There are several entries by various members of staff
who believed that the man had not entirely understood the severity of his
condition. The prison arranged for him to be moved to a ground floor cell so
that there was less need for him to use the stairs.
21.The man’s sisters have raised concerns that they were not informed that he
had had a heart attack. The relevant bedwatch log shows an entry by an
officer who had telephoned the prison control room to ascertain whether or
not the next of kin had been informed. The next of kin identified at that time
was the man’s brother. The officer does not remember the conversation or
what action was taken. The protocol at the moment is that it is the
responsibility of the hospital to inform next of kin in there is a life threatening
situation and/or for the prisoner to make the choice if he is able. I am
pleased to note that as a result of the concerns made by the family, the
Director of the Prison Healthcare Cluster will draw up a procedure with St
Mary’s Hospital to ensure that there is clarity about their respective roles and
that families are informed where appropriate.
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22.On 6 August, wing staff recorded that they noticed that the man did not seem
his usual self, “although he says he feels okay”.
23.The man disobeyed an order to return to his cell on 9 August. He was placed
on a disciplinary report and attended the adjudication on 10 August.
However, he again refused to move to his cell. He remained in the
segregation unit overnight to attend another adjudication the following
morning. During the night he complained of chest pains. The Orderly Officer
was called and the man was given medication to ease the pain. An
adjudication hearing took place on 11 August, where he pleaded guilty to
both offences. He received seven days stoppage of earnings and three days
cellular confinement respectively.
24.On 14 August, the man experienced more chest pain and was admitted to St
Mary’s Hospital where he had chest x­rays which showed one of his lungs to
be grossly abnormal. There was fluid on his lungs, a sample of which was
taken for tests, and he underwent a procedure to drain the fluid. On 17
August, he was informed that the tests showed that he had lung cancer. He
was understandably shocked, although the prison records show that he
remained “upbeat”. Referrals were made to four different specialists who
prepared a treatment plan. He was discharged from hospital on 18 August
with a palliative care plan.
25.The man was re­admitted to St Mary’s on 30 August with abdominal and back
pain, and the hospital contacted his sister to inform her of the situation.
26.A thoracoscopy (a procedure to view the chest wall) was scheduled for 12
September at Southampton Hospital. Another procedure to drain the fluid
from the chest and apply talc to discourage a re­accumulation was also due
to be carried out. The man was transferred to Southampton, but then refused
to have blood tests, blood pressure checks and either procedure. The next
day, prison staff recorded that he felt stressed about the way he was being
treated by medical staff and had no “faith in what may happen to him”. He
said that he wanted time to discuss matters with his family, and St Mary’s
informed his sister of the situation. The man returned to St Mary’s on 15
September, and steps were taken to try and rearrange the procedures.
27.A risk assessment is carried out whenever a prisoner is taken to hospital.
The man was assessed as high risk, having escaped from custody during a
previous sentence. He was escorted by two officers and also restrained by
handcuffs. These arrangements are common practice when prisoners are
admitted to hospital. The risk assessment is regularly reviewed and can be
amended according to the health and risk of the prisoner. On 16 September,
his health had deteriorated and a decision was taken to remove the handcuffs
although he remained subject to a two­person escort.
28.Bedwatch logs show that on 18 September he appeared to become paranoid
about his medication, claiming that hospital staff were “messing around” with
the dosage of painkillers and sleeping tablets. This was the first of many
entries recording his confused and somewhat incoherent state at times.
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29.The man had more treatment to remove fluid from his lungs. After a visit from
the Duty Governor on 19 September, the handcuffs were reapplied as there
had been an improvement in his mobility. This was to be reviewed daily.
30.On 20 September, the Governor signed an application for Early Release on
Compassionate Grounds due to the man’s ill health. It was not granted
because he was still considered to be at risk of committing further offences.
The man’s medical condition had deteriorated, but he was still mobile and
had been assessed as presenting medium/high psychopathic traits.
31.Two days later on 22 September, he discharged himself from hospital and
was returned to Albany. Staff at the prison were concerned about his health,
so he was taken to HMP Parkhurst which has inpatient facilities. Again he
presented as being confused, and started saying that everyone was trying to
stop him contacting his family. In fact the man had been in regular contact
with his sister throughout the time he was in hospital.
32.He experienced chest pains again on 25 September, and was readmitted to
St Mary’s by ambulance. He was escorted by two members of staff and
restrained with handcuffs. During the next few days, he found it difficult to
get comfortable and his medication was increased. From 29 September, the
records show that prison staff were increasingly concerned about his mental
state. Although, he was polite and co­operative when coherent, he
sometimes struggled to sleep and became increasingly confused.
33.Albany changed to a new format of bedwatch logs whilst the man was in
hospital. Those received by my investigator were of a good standard with
many detailed entries. From these and, discussions with staff, it seems clear
that the man was well cared for by the escort staff, who would open his
sweets for him, take him out onto the balcony for a change of scenery and
attend to his needs in conjunction with the medical staff. His sister is
concerned about occasions when she telephoned but did not get through to
him and feels that escort staff could have done more to help him answer the
telephone. My investigator could find no evidence that this was the case, and
it may be that during these occasions the man and the staff were not actually
at the bedside.
34.The thoracoscopy was rescheduled for 5 October, and the man was
transferred to Southampton a day earlier. During the evening he was booked
to go for an x­ray. He became confused and abusive, threatening to walk out
saying he was going to get the police as he believed that staff wanted to kill
him. Staff tried to reassure him and he telephoned his sister. He was also
given oxygen and calmed down. At 12:00am, he agreed to have the x­ray.
The operation was scheduled for 8:00am, but when he had a pre­operation
shower at 6:00am he told prison and hospital staff that he refused to go
ahead with the operation. His family have commented that as a result of a
bad experience during a separate sentence at another prison, he was
genuinely afraid of his medication being tampered with.
35.A report written about the bedwatch said that most of the time he was at his
bedside and settled. The report said that the man’s anxiety and paranoia
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were acerbated by fear of having an operation. Whilst prison staff were
sympathetic, they were also conscious of the risk of escape and danger to
the public. They recommended that the man be situated in a side room.
36.Medical staff offered to postpone the operation to the end of the day so that
the man could have time to think about it. He still declined and arrangements
were made for him to return to prison. Medical staff felt that he was in a
“comfortable state” and there was no need for him to return to St Mary’s
Hospital.
37.Unfortunately, he had to be re­admitted to St Mary’s the next day, when he
was placed on a drip and had more x­rays. On 7 October, he was seen by a
doctor who explained that he was unhappy that the man had refused to have
the operation. The man was reportedly very confused about it all and said
that he was frightened of the operation. The doctor said he would re­apply
for the operation, but if it could not proceed he would continue to drain the
fluid from his chest.
38.Over the next few days, staff reported that the man deteriorated quickly. On
11 October, the Director of the Prison Healthcare Cluster, telephoned the
man’s sister who was going to try to visit him in the following couple of days.
39.On 12 October, the man was visited by the Macmillan Nurses who visited
regularly until he passed away. On 15 October, he experienced a lot of chest
pain and more fluid was drained from his chest and painkillers were
administered. Prison staff asked for the risk assessment to be reviewed as
his health had deteriorated. Later that day, they were permitted to remove
the restraints on the condition they were re­applied if there was any
improvement in his health or if any problems arose. At no time was it
necessary for the handcuffs to be reapplied. Two officers remained with him
at all times until he died.
40.Over the next couple of days, the man slept much better and seemed a lot
brighter. His sister was due to visit on 17 October and he was said to be
looking forward to seeing her.
41.His sister and her family visited as arranged and he remained in good spirits
after the visit. His sister has raised some concerns over the escort
arrangements. This is discussed later in the report.
42.The Duty Governor visited on 21 October, and saw that the man was in very
poor health, and was not drinking or eating very much. He and the medical
staff discussed the issues and possibilities of moving him to a hospice. This
was the second time that a hospice place had been considered, the first
having been unsuccessful because no places were available. Later that
evening, the man was taken out to the balcony for a change of view, and
when he returned he had a new bottle attached to his chest drain. In the
early hours of the morning he became restless, moving from his bed to his
chair and back again. At 4:50am, he said he was “fed up” and wanted to go
outside, moved across his bed pulling his drain bottle and knocking over
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another bottle. He became very agitated and breathless and was given
medication to calm him down and ease the pain.
43.Next morning, the man was given more medication for his pain. He became
very confused about who was with him and talked loudly about some of his
offences. At 9:40am, he was given oxygen and managed to sleep for a
couple of hours. By lunchtime, he was awake and refused more oxygen. He
became abusive to prison and hospital staff who accepted that it was due to
his medication and poor health. He settled later that afternoon, although he
continued to take off the oxygen mask and was very breathless.
44.The Director of the Prison Healthcare Cluster contacted the man’s sister at
4:30pm to let her know that his condition was deteriorating. At 4:55pm, and
again an hour later, nurses were called because he was having problems
breathing. The oxygen level was increased, but again the man tried to
remove the mask. The prison officers and the nurse tried to hold his hand to
reassure him. He slipped into unconsciousness at 6:25pm and a few minutes
later the nurse listened to his heart and felt for a pulse. She notified staff that
he had passed away and at 6:50pm the man was pronounced dead.
45.The man’s family were not informed of his death until the following morning.
This caused some distress and the family are concerned that they were not
told sooner. My investigator could not find a clear explanation why this had
occurred. As the man’s family live on the mainland, Albany followed their
procedure and informed the police so that they could break the news face to
face. A telephone call had been made in the evening but the man’s sister
was at work. The caller was supposed to return the call at 11.00pm when
she would have returned. As far as I can determine, the initial call was made
by the police. The hospital did not contact the family because they believed
the prison had. It is clear that the Director of the Prison Healthcare Cluster
contacted the family the following day to extend the prison’s condolences. It
would appear that there was miscommunication which should have been
avoided.
Issues considered during the investigation
Communication
46.Throughout the man’s admissions to hospital he was subject to several
restrictions regarding visitors, including the visit by his sister and her family.
The restrictions were due to the nature of his offence. The prison recognised
that his health was deteriorating and carried out a further risk assessment,
which led to scheduled visitors being allowed to visit. Escort staff were
instructed to remain present during the visit and not to allow physical contact.
They were reminded to be compassionate and sensitive. The man was said
to be in good spirits after seeing his visitors.
47.The man’s sister expressed concern that she was not provided with
information about his condition in the last few weeks. It is known that he had
regular contact with his sister whilst he was in hospital. Furthermore, the
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Director of the Prison Healthcare Cluster contacted her on 11 October and
again on 22 October and she was able to visit her brother at St Mary’s
Hospital. She was also able to contact both the prison and the hospital for an
update on his condition at anytime. It is known too that the man telephoned
his sister on a number of occasions prior to her visit.
48.It is most regrettable that the way the news of the man’s death was passed to
his family was mishandled. I acknowledge the need to ask police to break
the news in this instance. However, it would have been best practice for the
prison to have asked the police to confirm when this had been done. I am
pleased to have been told that Albany are introducing the role of the Family
Liaison Officer into the contingency plans for informing next of kin. I hope this
will include clear arrangements for appropriate and timely communication to
avoid any such miscommunication in the future.
Escorts
49.The escort arrangements, which were a concern of his family, were
consistent with Prison Service procedures and the assessment of the man’s
risk. The prison reviewed the arrangements regularly and, when appropriate,
removed the handcuffs. I am satisfied that the escorting arrangements were
appropriate and sensitive to the man’s needs and presenting risk factors.
Healthcare and Discipline
50.The man had developed a terminal illness and palliative care was all the
treatment that could be given. It is clear from the records that he was given a
great deal of care by hospital staff and prison staff. The clinical review which
is annexed supports the view that the medical care the man received in
prison was equivalent to that which he would have received in the
community. He was looked after in hospital in the community for most of the
last two months of his life.
51.The man’s mental state also deteriorated, and I believe this accounted for
much of his confused and sometimes aggressive behaviour. My investigator
was advised that this would be consistent with his previous psychotic illness
coupled with the terminal illness. Both medical and prison staff were
sympathetic and tried to give reassurance as well as medical treatment.
However, the punishment of three days cellular confinement imposed in
August, just two months after the man had suffered a serious heart attack,
was a severe one and I doubt it was appropriate, especially as it followed a
plea of guilty. I make no recommendation, but the Governor will wish to
share my views with his fellow adjudicators.
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Identified areas of good practice
52.Staff at Albany applied for Early Release on Compassionate Grounds and
tried to find the man a place in a hospice. Unfortunately, at the time of his
death, neither application had been successful.
53.Albany provided funds so that the man had money to buy snacks, drinks and
phonecards whilst he was in hospital.
54.The bedwatch logs produced by prison staff are excellent, and contain a large
amount of information on which my own report is now based. The majority of
entries made by escort staff are informative. Importantly, they are respectful
and demonstrate compassion for the man.
55.The liaison Governor, as Duty Governor, was present when the man passed
away. He has commended the care and compassion shown by other staff in
the hours leading up to the man’s death. The Governing Governor has
written to the staff present to show his appreciation.
56.The prison met the costs of the funeral and the Governing Governor and
liaison Governor attended the funeral. They also took the man’s possessions
to his family.
57.A memorial service was held in the prison for those who wished to pay their
respects.
58.I am pleased to note that as a result of the family’s concerns about
notification of admissions to hospital, the Director of Prison Healthcare
Cluster is taking forward a protocol between Albany and St Mary’s Hospital.
Recommendations
59.I make no formal recommendations in this case, but believe there is some
learning for Albany in respect of communication with families which I hope
they will take on board as the new Family Liaison role develops.
60.I have also commented on the punishment imposed on the man in August
2005, just two months after he suffered a serious heart attack.
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