Individual at Isle of Wight

Investigation into the circumstances surrounding the death in
custody of a prisoner at HMP Albany, on 27 October 2004 at St
Mary’s Hospital, Newport, Isle of Wight
Report by the Prisons and Probation Ombudsman for
England and Wales
February 2006
This is the report of an investigation into the death of a man at St Mary’s
Hospital, Newport, Isle of Wight, on 27 October 2004, while in custody at HMP
Albany. The cause of death was adenocarcinoma (cancer) of the rectum
which had spread to his brain, lung, adrenal gland and lymphatic system.
One of my senior investigators conducted this investigation.
A clinical review into the care and treatment given to the man was undertaken
by an independent Clinical Investigator for my office.
I would like to extend my condolences to the man’s family for their loss. I
would also like to thank the Governor of HMP Albany, and his staff for their
help and co-operation during this investigation. I am especially grateful to the
Deputy Governor, who acted as the establishment’s liaison officer.
I make two recommendations in this report.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2006
CONTENTS Page
SUMMARY 4
CONDUCT OF THE INVESTIGATION 5
BACKGROUND INFORMATION 7
The man
HMP Albany
THE MAN’S TIME AT HMP ALBANY 9 - 11
EVENTS OF 24 OCTOBER 12
CLINICAL REVIEW 13
EVENTS AFTER THE MAN’S DEATH 14
CONSIDERATION AND CONCLUSIONS 15 - 16
RECOMMENDATIONS 17
ANNEXES 18
Summary
On 7 December 2001, the man who is the subject of this report was
sentenced to eight years imprisonment for various offences. On being
sentenced, the man was initially held in HMP Altcourse. On 23 January 2002,
he transferred to HMP Albany. He was a Category B prisoner until January
2005, when he achieved Category C status. He was due for release on 20
March 2007.
The man was an insulin dependent diabetic, whose health began to
deteriorate significantly during 2003. Around September 2003, he complained
of faecal incontinence. He was given support for pain and weight loss and
was referred to St Mary’s Hospital, Newport, Isle of Wight. He was then
referred to Southampton General Hospital, having been diagnosed by St
Mary’s with advanced cancer of the rectum. The cancer was downstaged
with chemotherapy and radiotherapy and a colostomy was undertaken in
December 2003. After chemotherapy and radiotherapy, further surgery took
place in June 2004.
On reviewing the man in August 2004, a consultant in radiotherapy and
oncology at Southampton General Hospital, raised the likelihood that the
cancer had spread to the man’s brain. This was confirmed by a CT scan at
the end of August. His health deteriorated significantly after this and the
cancer spread further to his lung, adrenal gland and lymphatic system.
On 24 October, the man was generally very weak and - after assessment by a
member of healthcare staff and with the agreement of the Medical Officer - he
was taken to St Mary’s Hospital where he sadly died on 27 October. He was
50 years old when he died.
Apart from periods of time spent as an inpatient in HMP Parkhurst, St. Mary’s
Hospital and Southampton General Hospital, the man was managed on
normal location during his time at Albany. It appears that he was no problem
for staff to manage. However, one officer voiced his concerns to the
Governor on 24 October when the man’s health had deteriorated to such an
extent that the officer considered that he could no longer function properly
within the prison.
The clinical review concluded that the man received basic care in that he
attended all his hospital appointments. However, the overall conclusion was
that the standard of care was inadequate in view of the terminal nature and
incapacitating symptoms of his illness.
Conduct of the investigation
During the course of initial inquiries, my investigator reviewed all the relevant
documentation and established a chronology of events. Notices were issued
to staff and prisoners telling them of the investigation and offering them the
opportunity of contributing. There were no responses to these notices.
One of my Family Liaison Officers contacted the man’s family and offered
them the opportunity to meet with her and my investigator to discuss the
purpose of the investigation and to raise any concerns or questions that they
would like explored and addressed. The man’s family did not want a meeting
but expressed some concerns which they wanted investigated. They
confirmed that they would like to see a copy of the draft report.
The family were concerned that the man’s medical problems (diabetes and
cancer) had not been diagnosed at the earliest opportunity and thought that
the man had missed some hospital appointments. The family were surprised
that, when the man’s possessions were returned to them, there were no
letters or cards as they were sure that he kept such items. He had also told
his mother that if anything happened to him he had left two letters, one for her
and one for his ex-partner. They have not received these letters. They said
that they had visited the prison, had seen the man’s cell and spoken to a
number of people who had known him, and had found this to have been a
positive experience.
The prison had paid £712 of the £940 cost of transferring the man’s body to
his home area to be buried. The remaining £228 was recouped from the
man’s prison account. The family wanted to know whether the prison were
prepared to pay anything towards the funeral expenses and said that the
prison had asked them to contribute towards the cost of transferring the man’s
body. They said that there was no prison representative at the funeral and no
flowers were sent by the prison. These issues are addressed in this report.
My investigator wrote to the Chair of the Albany branch of the Prison Officers’
Association (POA), and to the Chair of the Independent Monitoring Board
(IMB), to tell them about the investigation process and invite them to meet
with her. One member of staff was interviewed during the course of the
investigation. He was offered the opportunity of being accompanied by a
work colleague or Trade Union official.
My investigator contacted Her Majesty’s Coroner to tell him of the nature and
scope of the investigation. The Coroner provided a copy of the Post Mortem
report of 8 November 2004. This recorded the cause of death as natural
causes, namely disseminated adenocarcinoma of the rectum (cancer of the
rectum).
An independent Clinical Investigator for my office, undertook a clinical review
into the care and treatment given to the man while at Albany.
Background Information
The man
The man was born in September 1954. He was arrested by the North Wales
Police Family Protection Unit at Wrexham and, on 27 March 2001, was
charged with offences that occurred between 10 March 1994 and 28 February
1996. He was convicted and subsequently sentenced to eight years
imprisonment on 7 December 2001.
The man had a history of offending dating back to 1970. The offences were
varied and mainly consisted of motoring offences - taking a conveyance
without authority, driving without insurance, and driving while disqualified.
Sentences had included imprisonment, community service orders, probation
orders and financial penalties.
There was reference made during the man’s time at Albany that he would like
to be transferred to a prison closer to his family. It seems no actual
application was made by the man for a transfer, and there is no evidence to
suggest a transfer was formally considered by the prison despite a number of
entries in his medical record.
During 2003, the man’s health began to deteriorate dramatically. He was
diagnosed with insulin dependent diabetes in May 2003, and a biopsy in
October 2003 confirmed that he had advanced cancer of the rectum. His
health deteriorated further during 2004 and he was admitted to St Mary’s
Hospital on 24 October 2004. He passed away on 27 October, with some
members of his family at his bedside.
A prison officer told my investigator that the man was very brave throughout
his illness, particularly during the last few days of his life. The officer said that
the man laughed and joked throughout his treatment, and that he had a very
dry sense of humour. He said that the man tried to function normally right up
to the end.
HMP Albany
HMP Albany was designed and built as a category C training prison in the
early 1960s. Soon after it opened, 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 re-designated as a category B closed training prison.
Albany operates as an assessment centre for the core sex offender treatment
programme.
Up to 526 prisoners can be held at Albany. The accommodation consists of
five four-storey cell blocks designated 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 in-cell
power and access to electronic night sanitation. In May 2003, a new ready to
use unit (RTU) opened, housing 80 category C prisoners.
At the time the man was at Albany, the health services were directly managed
by the Prison Service in collaboration with the services for Parkhurst and
Camp Hill prisons. The healthcare service at Albany focuses on primary care
and operates from 8.00am to 9.00pm daily. There is a well established
working relationship with the Isle of Wight Primary Care Trust, which took over
funding and commissioning the health services for the three prisons in April
2005.
Records show three Albany prisoners died in custody in 2004, including this
man. In 2005, two Albany prisoners died in custody. The circumstances of all
these deaths were investigated by my office and all were from natural causes.
There are some common issues between the man’s case and one of these
other investigations that I shall refer to later.
The man’s time at Albany
On 23 January 2002, the man who died was transferred from HMP Altcourse
to Albany. He had been in Altcourse since being sentenced on 7 December
2001. In May 2003, he was diagnosed as an insulin dependent diabetic and
he received appropriate treatment and medication for this condition. On 5
September 2003, the man complained of bowel problems (severe
constipation) and he was seen by a medical officer in Healthcare. On 29
September 2003, he complained of a further change in bowel habit, this time
severe diarrhoea. He was again seen by a medical officer in Healthcare. On
1 October 2003, he was referred by a doctor at Albany, to the surgical team at
St. Mary’s Hospital. The referral letter said that the man had suffered a three
month change of bowel habit and malignancy needed to be excluded.
On 6 October 2003, the man’s mother, telephoned the prison. She was
concerned that her son had severe stomach pains when she visited him two
weeks previously. She was also concerned that he told her that a hospital
appointment had been cancelled due to a shortage of staff. The prison asked
her to write in with her concerns.
On 7 October 2003, the man was seen in Healthcare. There was concern
about his general health. He had not eaten properly for two months and was
reducing his insulin. He complained of having his bowels opened 25 times a
day. He said that he felt lethargic. A member of healthcare staff spoke to the
surgical team at St Mary’s Hospital, who confirmed that they would see him
within two weeks once a referral letter had been received. There was
agreement that the man needed to be referred to St Mary’s Hospital for
surgical assessment.
On 8 October 2003, the man was seen in Healthcare feeling very unwell. A
doctor requested an urgent appointment for him with the surgical team at St
Mary’s Hospital. He was admitted to St. Mary’s Hospital. The referral letter
explained that the doctor did not feel that the man could wait for an out patient
appointment and asked the hospital to investigate his change of bowel habit
over the past two months which was also disrupting his diabetic care. On the
same day, the prison phoned the man’s mother back to tell her that her son
was in hospital.
On 10 October 2003, biopsies were taken at St Mary’s Hospital and the man
was diagnosed with cancer of the rectum, which appeared to be fairly
advanced. The man was in hospital as an inpatient until 13 October. He had
a colostomy in December 2003 at Southampton General Hospital. Shortly
after, he started a course of chemotherapy and radiotherapy at Southampton
General to downstage the tumour prior to further surgery.
On 5 January 2004, it was noted in the medical record that a hospice was to
be contacted regarding the man’s management. There is only one hospice
located on the Isle of Wight (Mountbatten Hospice). Their policy is that
prisoners sent there are unescorted by prison staff and the man would
therefore need to be released under temporary licence (ROTL). Albany say
that in view of his offences, any risk assessment would need to have been
thorough and comprehensive and it is unlikely that they would have agreed to
such conditions.
In June 2004, the man underwent radical surgery. On 3 August 2004 a
consultant surgeon at St Mary’s Hospital, wrote a letter to the Governor
regarding the man’s recent operation. The letter said that the chances of the
man being totally cured were extremely remote, and asked if this could be
taken into account if there were any decisions to be made regarding his
future. The letter was copied to the doctor at Albany.
The Prison Service Order PSO 6000, ‘Early Release On Compassionate
Grounds’ (ERCG), sets out the procedures for the early release on licence for
all prisoners on compassionate grounds. It explains that early release on
compassionate grounds may be considered on the basis of a prisoner’s
medical condition or as a result of tragic family circumstances. It is granted
only in exceptional circumstances. Paragraph 12.4.1 states: ‘Early release
may be considered where a prisoner is suffering from a terminal illness and
death is likely to occur soon. There are no set time limits, but three months
may be considered to be an appropriate period. It is therefore essential to
obtain a clear medical opinion on the likely life expectancy. The Secretary of
State will also need to be satisfied that the risk of re-offending is past and that
there are adequate arrangements for the prisoner’s care and treatment
outside prison.’
Albany has no in-patient bed facility and HMP Parkhurst has only 12 beds
which are continually fully occupied, as they were at this time. The man
indicated that he did not want to be transferred to Parkhurst and wanted to
stay in Albany, on F and G Wing.
On 9 August, the man’s Medical Record noted that the consultant surgeon
was going to write to the Governor as the man was hoping to transfer nearer
to his family. There is no evidence that the consultant surgeon wrote the
letter or that this was followed up by the person who made the entry (the
signature is illegible).
On 18 August, the Stoma Nurse saw the man and documented how ill he
looked and his dramatic weight loss. This does not appear to have been
acted upon by the nurses.
On 20 August a consultant in radiotherapy and oncology, Southampton
General Hospital, wrote to the Governor. The letter stated that there was a
very high chance that the man’s cancer would recur. There was a request for
him to have a brain scan to investigate his complaint of severe headaches.
The letter also stated that the prognosis was poor for the man, and asked
whether it would be possible to transfer him to a prison closer to his family.
The man suggested a location. There is a handwritten note on that letter,
dated 27 August 2004, ‘please file.’ This letter was also sent to two doctors at
Albany. A senior officer working in Albany’s Observation Classification and
Allocation (OCA) Unit, dealt with the man’s transfer request in August.
Unfortunately, by the time this request was made, the man’s health was
significantly deteriorating and the possibility for a prison move was considered
impractical. To move the man to another prison would have needed
acceptance from them that they would take on the necessary care required to
look after him. There is an entry on the man’s history sheet on 5 August,
which states, ‘Wing aware, discussed prison move.’ At this time work began
on collating all relevant information to submit a case for compassionate
release. This included obtaining a detailed report from the Registered
Medical Practitioner, as well as Security Risk Assessments based on his
offences. On 15 October, the paperwork was sent for to the Prison Service
Parole Board for consideration of the man’s early release on compassionate
grounds. The Governor wrote to the consultant in radiotherapy and oncology
at Southampton General Hospital, on 20 October advising him that a request
had been submitted for the man’s early release.
On 26 August, there is a note in the man’s Medical Record (again with an
illegible signature): ‘Spoke to staff on E Wing regarding possible move of
prisons. Nothing has been decided or discussed with inmate, but wing staff
are aware he has a CT scan appointment.’ That same day, the CT scan
confirmed that the man had a brain tumour.
On 10 September, the dietician at Southampton Hospital wrote a letter to the
‘prison doctor’. There is no documented evidence in the Medical Record that
the recommendations in the letter were acted upon.
On 20 September, there is a note in the man’s Medical Record which states:
‘Weak, is trying to cope on codeine alone as pain management. To see
consultant oncologist 7 October. To see dietician here. Has parole coming
up in 12 months. Needs parole now to make most use of the time he has left-
4-6 months?.’ Again, there is no evidence that the man saw the dietician and
yet again the signature is illegible.
On 23 September, a handwritten letter was sent to a member of staff who
works in the kitchens at Parkhurst. The letter asked that person to see the
man as he was having difficulty maintaining his weight. There is no evidence
that this happened and in fact, despite several entries on the Medical Record,
there is no evidence that appropriate action was ever taken to help the man
gain weight.
On 24 September, the consultant in radiotherapy and oncology at
Southampton General hospital wrote to the Governor again. That letter
explained that the CT scan performed in August confirmed that the cancer
had spread to the man’s brain. The prognosis was stated to be as little as
one or two months, and was unlikely to be more than six to eight months.
That consultant asked whether consideration could be given to transferring
the man to a prison near his family or to release him on compassionate
grounds. That letter was also sent to a doctor at Albany.
On 15 October, the paperwork for consideration of early release for the man
on compassionate grounds, due to his medical condition, was sent by the
Discipline Clerk in Albany, to the Prison Service Area Manager’s Office. The
request was approved by a Governor at Albany.
On 20 October, the Governor wrote to the consultant in radiotherapy and
oncology in reply to his letter requesting consideration of compassionate
release or transfer of the man to a prison near his family. The letter from the
Governor said, ‘In summary we have submitted a request for the man’s early
release. We hope to have a decision soon. Under the circumstances I am
optimistic of the outcome.’
Events of 24 October
Wing staff, particularly one officer, became increasingly concerned about the
man’s wellbeing. He was not eating or moving from his cell on G2 landing.
On 24 October, that officer wrote a memo to the Governor, voicing his
concerns, and the officer moved the man to a ground floor cell, on G1 landing.
That officer said in his memo: ‘I am speaking on behalf of several staff who
are appalled, as I, at the condition and treatment of the man. In consultation
with other staff it was decided to move the man from his cell on G2 landing to
G1 landing as he could no longer negotiate the stairs. This man is barely
capable of functioning such is his physical deterioration.’ The officer also
advised healthcare about the man’s poor health that day and a member of
healthcare staff visited the man in his cell. The man was immediately
admitted to Parkhurst as an in-patient. There is an entry in the man’s Medical
Record: ‘Seen in Wing. Inmate has lost a considerable amount of weight in
the last few days and is not very coherent. Very sleepy and legs, feet and
ankles swollen. Not able to collect meals or make phone calls, not able to
leave cell at all. Has not eaten for a few days but still managing to drink.
Medical Officer contacted and agreed the man should be admitted to E3
(Parkhurst) until I can speak to the Healthcare Manager to try for a hospice’.
The man was transferred to St Mary’s Hospital on the same day. The officer
who had been concerned about the man told my investigator that the man had
not wanted to move from his cell on the second floor, and he felt that he
wanted to die in that cell. He thought that the man did not want his family to
see him when he was so ill. The officer said that the man was adamant that
he did not want to move from his cell on G2 landing, but the officer said that
he had no option but to move the man to a ground floor cell for his own
wellbeing as he was no longer able to negotiate the stairs to collect his meals.
The Governor replied to the officer’s memo and he said that he had not
realised the seriousness of the man’s condition until that day. He told the
officer that the man had been admitted to hospital.
The man’s health deteriorated further, the cancer had spread further to his
lung, adrenal gland and lymphatic system, and he died in St Mary’s Hospital
at around 12:15am on 27 October. The man was certified dead at 12:20am
by the doctor on duty. The man’s mother, two sisters and his partner were
with him when he died.
An officer who was on bedwatch duty and he informed the prison control room
immediately. The control room then informed the local police and duty
governor. The police arrived shortly after and they spoke to the man’s family,
who were still at the hospital.
Clinical review
The clinical review concludes that, despite a lack of documentary evidence in
the Medical Record, the man appears to have attended all his hospital
appointments for treatment and all follow-up appointments. The care given by
the hospital consultants appears to have been of a high standard and the
handover letters from the consultants to the prison doctors were thorough.
The consultants wrote on several occasions to the Governor and doctors at
Albany regarding their concerns. However, these concerns do not appear to
have been acted upon by the prison until 15 October, when they prepared the
paperwork for consideration of the man’s early release on compassionate
grounds. The Governor wrote to the consultant in radiotherapy and oncology,
on 20 October advising him that a request had been submitted for the man’s
early release.
The medication prescribed appears to have been well considered and
appropriate. However, there appears to have been some confusion on how to
best deal with the man’s constipation, which was probably caused by the
mixture of his condition and codeine based medicine.
The clinical review says that some of the entries in the man’s Medical Record
are confused and unclear. For example, the fronts of the prescription charts
are not completed adequately. The notes are generally unclear, with some
information on different sheets so the records do not always run
chronologically. There is very little mention in the Medical Record of the
man’s hospital appointments, diagnosis, treatment and care plan, which would
have made it difficult to provide a high standard of continuous care. Also, first
names are sometimes used in the Medical Record, which makes it difficult to
establish exactly who saw the man. In addition, there do not appear to be any
discharge/handover letters in the Medical Record. These are issues in
common with those that my office has addressed in the investigation of the
death of another prisoner at Albany, in September 2004.
The clinical review finds that an entry on 9 September appears to be the only
documentary evidence that healthcare staff contacted the hospital about the
man when he was an inpatient. All this meant that the man was not provided
with an appropriate level of continuous care.
Finally, there is no mention in the Medical Record of any counselling offered
to the man at what must have been a very traumatic time for him.
The review concludes that the man who died received ‘a basic level of care
which meant that he attended all his hospital appointments. However, in the
reviewer’s opinion, ‘the overall standard of care which the man received was
inadequate in view of the terminal nature and debilitating symptoms of his
illness.’
Events after the man’s death
A letter of condolence was sent by the Governor to the man’s mother on 27
October. A memorial service for the man was held shortly after his death and
was well attended.
The man’s funeral took place in the family’s locality. No representative from
Albany attended the funeral due to the distance involved. The prison did not
contribute any flowers as it is not their policy to do so. Prisoners may
organise a collection for flowers between themselves, but this did not happen
in this case.
PSO 2710 states that a prison should offer to pay reasonable funeral
expenses, but this is at the prison’s discretion. The prison contributed by
paying £712 for the man’s body to be transferred to his home area. The
remaining cost of £228 was recouped from the money in the man’s prison
account and the family say that the prison asked them to contribute towards
the cost of transferring the man’s body. No additional money was paid by the
prison towards the cost of the funeral. The man’s belongings were returned to
his family. The list of these belongings does not have any record of any
letters or cards.
Consideration and conclusions
The man’s health deteriorated during 2003, and in October 2003 he was
diagnosed with cancer of the rectum which appeared to be fairly advanced.
He was immediately scheduled for a course of radiotherapy and
chemotherapy to downstage the tumour before an operation in June 2004.
The man also had a colostomy in January 2004. In August 2004, a CT scan
revealed that the cancer had spread to his brain. The man’s health
deteriorated further until September 2004 when the hospital consultant
concluded that, sadly, his condition was terminal and he had only a matter of
months to live.
The man’s family have raised issues in respect of the care which he received
while in Albany. The clinical review concludes that, despite the lack of
documentation in the Medical Record, it seems that the man did attend all his
hospital appointments and all follow up appointments. However, the man’s
medical records were poorly completed and there was a clear lack of
communication between healthcare staff and the hospitals attended by him.
There was also a lack of communication between healthcare staff when
issues with the man’s care were identified and a lack of action in taking these
matters forward. In addition, no consideration was given to offering
counselling to him to help him come to terms with his terminal illness.
Overall this meant that the man received a poor standard of continuous care.
For example, there are notes in his medical record regarding management of
his healthcare which do not appear to have been followed up by healthcare
staff. The question of contacting a hospice was not followed up in January
2004, the matter of a transfer nearer the man’s home was not pursued in
August, recommendations from a dietician in September were not acted upon,
and there is no evidence that appropriate action was ever taken to help him
gain weight.
Members of healthcare staff should be reminded, in light of this report:
• that all entries in healthcare records should be dated accurately,
and they should state their position and sign and print their name
clearly after each entry;
• that Healthcare records should contain clear documentation in
chronological order to ensue that continuity of care is provided;
• that they should communicate appropriately with any hospital
involved in treating a prisoner to ensure an appropriate standard
of continuous care;
• that they should endeavour to provide a more holistic approach to
care to ensure that all the patient’s needs are met - clinical and
psychological - including counselling, if appropriate;
• that any action recommended regarding a patient’s care should
be taken forward appropriately and in a timely fashion;
• that one of their roles is as a patient’s advocate.
The prison was aware on 3 August 2004 that the prognosis for the man was
very poor. The hospital consultant wrote to the Governor and the prison
doctor on 3 August, 20 August and 24 September, detailing the prognosis and
asking that consideration be given to transferring the man to a prison closer to
his family. The letter of 24 September also asked whether compassionate
release could be considered for him as his life expectancy was thought to be
as little as one to two months, certainly no longer than six to eight months.
The options available to the prison were:
• Arrange for the man to be transferred to an appropriate hospice.
• Arrange for the man to be transferred to a prison closer to his family.
• Transfer the man to HMP Parkhurst which has an inpatient facility.
• Consider the man’s release, on licence, for compassionate reasons.
The prison considered the above options and on 15 October, the paperwork
was sent for to the Prison Service Parole Board for consideration of the man’s
early release on compassionate grounds. This was around seven weeks after
the prison had been made aware of the severity his condition. I feel that
perhaps this could have been done in a more speedy manner. The Governor
Jones wrote to the consultant, on 20 October advising him that a request had
been submitted for the man’s early release.
The prison paid £712 towards the cost of transferring the man’s body to his
home area. An additional £228 was recouped from his prison account. I have
found no evidence that the prison tried to recoup any further money from the
man’s family.
PSO 2710 indicates that the prison should give consideration to contributing
towards funeral costs, but no figure is mentioned. Ultimately this is the
prison’s decision. I take the view that Albany should have given further
consideration to their contribution, as the man’s family live a considerable
distance from the Isle of Wight.
I accept that it was difficult for the prison to be represented at the man’s
funeral due to the distance involved.
The prison maintains that all the man’s belongings have been returned and
they did not include any letters or cards. However, clearly this is an important
issue for the man’s family and, although I do not think a formal
recommendation is required, I suggest that the prison undertakes a thorough
check to ensure that there are no outstanding letters or cards.
Recommendations
1. Members of healthcare staff should be reminded, in light of this
report:
• that all entries in healthcare records should be dated accurately,
and they should state their position and sign and print their name
clearly after each entry;
• that Healthcare records should contain clear documentation in
chronological order to ensue that continuity of care is provided;
• that they should communicate appropriately with any hospital
involved in treating a prisoner to ensure an appropriate standard
of continuous care;
• that they should endeavour to provide a more holistic approach to
care to ensure that all the patient’s needs are met - clinical and
psychological - including counselling, if appropriate;
• that any action recommended regarding a patient’s care should
be taken forward appropriately and in a timely fashion;
• that one of their roles is as a patient’s advocate.
2. Using a risk assessed approach to the available options, the patient
should be involved in discussions about where they would prefer to be
cared for as the end of life approaches in accordance with the NHS
Cancer Plan, and the necessary arrangements made at an earliest
opportunity. The Governor and the PCT should arrange for this to be
done.
Prison service comment:
Albany has confirmed that a further search has been made to ensure
that all the man’s property has been located. No further items were
found.