Individual at Altcourse

Investigation into the death of a man following his release
on temporary licence from HMP Altcourse
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2009
This is the report of an investigation into the death of a man, a prisoner at HMP
Altcourse. The man died in August 2008 in outside hospital from natural causes. He
was only 26 years old.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
I would like to add my personal condolences to those already expressed to his family
on behalf of this office by one of my Family Liaison Officers.
The man had been diagnosed with Hodgkin’s disease in 2006. This was in
remission when he came into custody in October 2007. Unfortunately, the disease
returned and his prognosis was very poor. Little of his sentence was actually spent
in prison due to his health problems. The man died shortly after being released on
temporary licence.
A post mortem examination was not carried out as the Coroner was satisfied that
there were no suspicious circumstances surrounding the death. The verdict of the
inquest into the man was that he died from natural causes.
This investigation was undertaken by my colleague. I am grateful for the assistance
he received from staff at HMP Altcourse and would ask the Director to pass on these
sentiments. A doctor was asked by Liverpool Primary Care Trust to undertake a
review of the man’s clinical care and I also appreciate his assistance.
The clinical review raises a number of learning points that the prison health
partnership will need to consider seriously. The clinical reviewer has made three
recommendations that I have endorsed. I have made no separate recommendations
of my own.
Although the man’s family are concerned about the presence of bedwatch officers
even when their son was seriously ill, I am satisfied that the prison’s decisions were
appropriate. I have also been pleased to note the arrangements that were made for
his release on temporary licence so that he did not die as a prisoner.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2009
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CONTENTS
Summary
The investigation process
HMP Altcourse
Key events
Issues considered
Conclusion
Recommendations
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SUMMARY
The man was born in 1982. He was just 26 years old when he died in outside
hospital in August 2008. The man’s death was from natural causes as a
consequence of Hodgkin’s disease. (This is a malignant disorder of lymph tissue
that appears to originate in a particular lymph node and later spreads to the spleen,
liver and bone marrow. It occurs mostly in individuals between the ages of 15 and
35. It is characterised by progressive, painless enlargement of the lymph nodes,
spleen and general lymph tissue.)
The man had been remanded into custody at HMP Altcourse in October 2007. He
was sentenced in November to 15 months imprisonment and 18 months extended
licence after release. During his first prison reception health screen, it was noted
that the man had previously been diagnosed with Hodgkin’s disease which was in
remission.
During the following weeks the man complained of a rash and night sweats. He was
referred to a consultant at an outside hospital, and was seen in early December
2007. When the man was seen by the consultant he was told that the Hodgkin’s
disease had returned.
The man was admitted to hospital in December where he remained for over five
months until 3 June 2008. On his return to Altcourse, the man was initially located
on the Healthcare Centre before he moved back to Canal wing. Little more than
three weeks later in June, when the man’s condition deteriorated, he returned to
hospital and remained there until his death.
Whilst the man was in hospital, a bedwatch was carried out by prison staff. The
initial security risk assessment concluded that handcuffs were to be used and two
officers needed to be at his bedside. After another risk assessment it was decided
that handcuffs were no longer to be used. A further revision of the risk assessment
led to the man being allowed to stay in hospital with an escort of one officer. He was
also allowed a mobile telephone from his family so that he could contact them and
the prison. The man’s family were allowed to visit him whilst he was in hospital.
The man was released on temporary licence (ROTL) with no conditions on 12
August and the single officer on bedwatch duty was withdrawn. The man passed
away ten days later on 22 August.
The clinical review has identified a number of issues relating to the care provided for
the man. The review highlights areas of practice that could be improved, and makes
three recommendations for service improvement which I endorse. The prison health
partnership should consider the findings from the review and develop an action plan
to address the learning opportunities. I make no recommendations of my own.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 18 July 2008 when the investigator issued
notices announcing the investigation to both staff and prisoners. The notices
included an invitation to anyone who wished to contribute to the investigation to
make themself known to him. In the event no one came forward. The
investigator also studied all relevant prison records relating to the man. These
included his main prison record and his medical records.
2. The investigator visited Altcourse on 29 September and discussed aspects of
the man’s treatment with staff. He interviewed the Security Manager and a
Prison Custody Officer. The investigator also interviewed the Healthcare
Manager at Altcourse.
3. The Liverpool Primary Care Trust commissioned the doctor, a General
Practitioner/Reviewer, to carry out an independent review of the man’s clinical
care. I am grateful to him for undertaking the review most expeditiously.
4. The 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 in his
enquiries into the man’ death.
5. One of my Family Liaison Officers contacted the man’s family. This gave them
the opportunity to discuss the purpose of the investigation and to raise any
concerns or questions that they wanted explored and addressed. The man’s
family told my Family Liaison Officer about their frustration that he was required
to have a prison officer with him at all times, even when he was desperately ill
and unable to leave his bed. The family said that they were told in February
2008 that the man had just days to live. They questioned whether an officer
was necessary for someone as poorly as the man. My investigator has
explored these points. I hope that this report provides the family with a better
understanding of the events leading up to his death.
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HMP ALTCOURSE
6. HMP Altcourse is a privately run prison, located on the outskirts of Liverpool. It
opened in December 1997 and is managed by G4S. Altcourse receives both
sentenced and remand prisoners from the courts in Merseyside, Cheshire, and
North Wales. It also takes young offenders on remand, who live alongside
adults on all the units other than the Vulnerable Prisoners Unit. There are
seven house blocks which are named after the fences on the Grand National
steeplechase course.
7. A gymnasium, education block, chapel and the Healthcare Centre form the
central spine of the prison with accommodation blocks on either side. One side
of the prison houses mainly sentenced prisoners and vocational training units
including the enhanced unit. The other side holds the induction, detoxification,
and voluntary testing units and most remand prisoners
8. Health services at Altcourse are provided by Medacs, an international private
healthcare provider. The Healthcare Centre has two full time doctors, 38
nurses and its own pharmacist. It also has visiting specialists such as dentists,
opticians, chiropodists, psychiatrists and physiotherapists. As well as an out-
patients department, Altcourse has a 12 bed in-patient facility.
9. There have been four previous deaths from natural causes at Altcourse since
my office was given responsibility for investigating all deaths in prison custody
in 2004. None of my earlier reports raises concerns relevant to the
circumstances surrounding his death
Independent Monitoring Board
10. Each prison has an Independent Monitoring Board (IMB). IMB members are
independent and unpaid. They monitor day-to-day life in their prison and
ensure that proper standards of care and decency are maintained. Each IMB
produces an annual report. The report for Altcourse for the year 2007/08 has a
section on healthcare provision in the prison. It highlights the constraints under
which healthcare staff worked during this period:
“The Healthcare Department is desperately short of office, storage and
treatment space … Waiting times for all outpatient clinics (always a
source of pride to Healthcare at Altcourse) have inevitably been
extended by an increasing population and staff shortages.”
Her Majesty’s Chief Inspector of Prisons
11. The most recent inspection by Her Majesty’s Chief Inspector of Prisons was an
unannounced, short inspection carried out from 17 to 19 September 2007. In
her subsequent report, the Chief Inspector commended “the quantity and
quality of time out of cell for prisoners at Altcourse, which placed its regime
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among the best of any local prison in England and Wales.” She also noted,
“Altcourse remained an impressively respectful prison, with well maintained and
clean accommodation, and very good staff-prisoner relations.” Healthcare at
Altcourse was found to be “generally satisfactory”, with primary care services
providing “a good level of care”.
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KEY EVENTS
12. The man was diagnosed with Hodgkin’s disease in August 2006. He
underwent eight cycles of chemotherapy and went into complete remission. A
positron emission tomography (PET) scan at the end of his treatment was
negative. (This is a scanning device which uses a low dose radioactive tracer
to look at cell activity to show how the body is functioning.) The man was
remanded into custody on 19 October 2007 and arrived at HMP Altcourse later
that day. On 12 November, he was sentenced to 15 months imprisonment and
18 months extended licence (after his release from custody). This was not his
first time in prison.
13. During his first screen reception on 19 October, it was noted that there was no
evidence of mental illness and that he had previously been diagnosed with
Hodgkin’s disease which was in remission. He was located on Canal wing. On
the following day, the man was examined by a prison doctor, who recorded that
he was fit and well.
14. A week later on 24 October, the man was seen by a prison doctor for a review
of his Hodgkin’s disease. Blood tests were carried out and the doctor noted
that the man’s neck glands were not enlarged. The following day, the results of
the blood tests were received. It was noted that he had mild anaemia and his
Erythrocyte Sedimentation Rate (ESR) was in the high range. (ESR is a non-
specific inflammatory marker and it can be high as result of infection or
Hodgkin’s disease.) On examination there were no physical signs of
recurrence of the Hodgkin’s disease.
15. Three days later the man was given Cetirizine (an anti-allergy tablet) as he had
developed a rash. As this had little effect, an appointment was arranged for 30
October with the doctor. Unfortunately, he had not been told about the
appointment and did not attend. He was seen by another doctor on 3
November about the rash. The man was also complaining of night sweats.
When he was examined, it was noted that he had an eczema- like rash under
his arms and back. He was prescribed steroid cream and blood tests were
requested.
16. A third prison doctor wrote to a Consultant Haematologist on 5 November. In
his letter the doctor asked the consultant if he could continue with his care for
the man and arrange any necessary follow up appointments. On 19
November, healthcare staff rang the hospital to arrange an appointment for the
man to see a consultant.
17. Four days later, the man was seen again by a prison doctor because he felt
unwell. He still had night sweats and, when examined, had a lymph node
(small organs that can trap cancer cells travelling through the body) in his groin.
It was decided to make an urgent appointment with a consultant at the hospital,
as it was thought that this could be a recurrence of the Hodgkin’s disease.
Repeat blood tests were requested and he was admitted to the Healthcare
Centre for observation by a nurse. The man later decided, against the nurse’s
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advice that he did not want to stay in Healthcare. The prison doctor was told
about the man’s decision.
18. On 24 November, he still felt tired but again did not want to be admitted to the
Healthcare Centre. He said that he would contact staff if he felt worse during
the night. An appointment was arranged with the prison doctor for the next
day.
19. Two days later, the man was seen by a prison doctor and an appointment to
see a consultant at the hospital was arranged as a matter of urgency. Later
that day, the man felt drained and tired and was seen by locum prison doctor.
His blood pressure and pulse were both normal. His ESR was still high and he
was given iron tablets to help with his tiredness.
20. On 29 November, the man developed a dry cough and was seen by a prison
doctor. On examination, he was found to have a hard nodule on his right upper
thigh. He again did not want to be admitted to the Healthcare Centre.
21. Five days later, the man was seen in the Healthcare Centre as he was suffering
with abdominal pain and it was decided that he should be taken to hospital. He
was admitted to hospital later that day. The same doctor who saw the man on
(3 November) wrote on the same day to another Consultant Haematologist,
thanking him for admitting the man. He summarised the man’s recent medical
history and wrote that he had previously been diagnosed with Hodgkin’s
disease. The doctor from the 3 November added that he was disappointed that
the man had not kept his appointments with the first Consultant Haematologist
whilst he was not in custody.
22. On 7 December, whilst he was still in hospital, the man was told that he had
cancer throughout his body and also a chest infection. He returned to
Altcourse later that day, but still did not want to be admitted to the Healthcare
Centre. It was noted that he would return to hospital at a later date for further
treatment.
23. The man went back to hospital on 18 December as he had been experiencing
night sweats and shortness of breath. A computerised tomography (CT) scan
was performed and showed a large mass in his lung. A biopsy was undertaken
which confirmed that his Hodgkin’s disease had returned. He remained in
hospital for the next five months. Whilst he was in hospital, a bedwatch was
carried out by prison staff. The initial security risk assessment was that
handcuffs were to be used and two officers needed to be at his bedside. This
was revised on 21 December; only one officer was to be at the man’s bedside
and restraints were no longer to be used.
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24. A board considered release on temporary licence (ROTL) for the man on 21
December. The board comprised of the Director of Altcourse, Head of
Operations, and the Security Manager. They noted that the man had
committed offences whilst on bail and had also previously failed to surrender.
The board recommended that the man:
 Must remain in the company of an Altcourse officer at all times
 Must not consume alcohol
 Must not consume controlled drugs other than those prescribed by medical
professionals
 Must comply with all instructions given by an Altcourse PCO (Prison
Custody Officer).
25. In a letter dated 22 February 2008 a Specialist Registrar in Haematology wrote
that since his relapse the man had:
“… more or less been confined to hospital due to the intensive nature
of his chemotherapy … He was reviewed … by a professor ho was one
of the transplant consultants specialising in lymphoma. The plan for
the man was for a bone marrow harvest to be undertaken under
general anaesthetic on Monday the 3rd of March and the to proceed to
bone marrow transplant the following week.”
The operation took place and his bone marrow was successfully transplanted.
26. The man made an application for early release to the Parole Board on 3 March.
The Parole Board panel considered his application three days later and found
that he was not suitable for early release.
27. The man returned to Altcourse on 3 June. He was initially located on the
healthcare wing and then moved back to Canal wing on 5 June.
28. On Monday 23 June, the man asked to see a doctor. There is no further entry
until Wednesday 25 June when blood tests were carried out. (It is not clear
from the records when the appointment was made and no explanation for the
delay.) The man saw another prison doctor, on the following day. After his
consultation the doctor arranged for him to be immediately re-admitted to
hospital.
29. A security risk assessment signed by the Controller, on 26 June 2008 advised
that the man was to be escorted by two officers and that restraints were to be
used. The risk assessment was revised the next day by another Controller,
and restraints were removed with only one officer remaining at the man’s
bedside.
30. The man moved from Ward 22 to Ward 24 on 4 July. Four days later
permission was given by Altcourse for him to be allowed to use a mobile
telephone which was given to him by his family.
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31. When interviewed as part of this investigation, an officer who was on bedwatch
duty on a number of occasions, said:
“The man was different to a lot of the inmates. He was easy to get on
with, talk to and never gave me any problems. In saying that though,
the man, because of his illness, possibly, sometimes could be, a better
way to describe it would be ‘grumpy’. But for most of the time he was a
reasonable bloke … he had a very caring family, they were always
visiting and there were a lot of visitors from his sister … and her
husband and children; his mother and various friends. The man had a
very bad diet and one of my main roles, one of my interests as a PE
[Physical Education] Instructor is healthy nutrition and I was always
keen to point out how bad his diet was. And I think it used to be of
some cause for humour for his family and this sort of interaction
basically built up as I say this relationship that took place.”
32. On 9 August, he was moved from Ward 24 to the Critical Care Unit. According
to the bedwatch log the following day, doctors explained to him and his family
that they were going to give him 100 per cent oxygen. The doctor also said
that, although the man was coping, things would get a lot worse and he might
have to go onto a ventilator. The doctor informed the family of all the options
that were open to them. Later that same day, he was moved to a side room on
the Critical Care Ward.
33. Three days later on 12 August, the man was released on temporary licence
with no conditions and the officer on escort duty was withdrawn. The Security
Manager visited the man so that he could sign the ROTL paperwork. When
interviewed as part of this investigation, the Security Manager said:
“I went out to see the man; he was very, very poorly. I think he couldn’t
actually physically sign. But he was very poorly. He was talking but its
like, it’s hard to explain to see someone who you’ve been visiting if you
like for months and months and months to deteriorate that badly.
Although he’s not a relative of mine or anything it’s still upsetting to see
a young fellow who’s being, as an offender in custody, not a problem to
staff at all, always polite and pleasant, it has a bearing on things. If
he’d had been a nasty person who was always snarling and
argumentative with staff or causing problems then you don’t get that
sort of attachment as much. But because he was a nice guy ... when I
went out to bring the officer in, when he was going onto full licence, he
did look dreadful and tubes everywhere, a mask on his face for oxygen
and that. And he was still talking but it was laboured breathing,
laboured talking, and you just felt sorry for him really.”
34. The man passed away in hospital on 22 August 2008. The following day, the
hospital informed Altcourse of his death.
35. The Community Liaison and Diversity Manager, was appointed as Altcourse’s
Family Liaison Officer. He contacted the family via telephone on 23 August
and met with them two days later. He maintained contact with the family and
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assisted with the funeral arrangements. Altcourse also offered financial help
towards the costs of the funeral. The man’s funeral took place on 3 September
and one of the officers off the bedwatch attended at the express wish of the
family.
36. A post mortem did not take place as the man died of an existing condition and
there were no suspicious circumstances surrounding his death. The verdict of
the Coroner’s inquest into his death, which was held on 8 September 2008,
was that he died from natural causes.
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ISSUES CONSIDERED
Clinical care
37. A review of the man’s medical care was undertaken by a doctor on behalf of
Liverpool Primary Care Trust. The doctor reviewed the man’s medical notes
and the interventions of healthcare staff. The reviewer noted that his Hodgkin’s
disease was diagnosed prior to his arrival in custody. The reviewer noted that
the man had not attended his previous two follow up appointments at an
outside hospital with the first Consultant Haematologist.
38. From the medical records, it was clear that the man was seen regularly by
healthcare staff and referred to secondary care when appropriate. Staff at
Altcourse contacted the consultant’s secretary regarding his medication. The
clinical reviewer judges that the care provided to him by staff at Altcourse was
entirely appropriate. He had blood tests when necessary and action was taken
appropriately on the results. The clinical reviewer concludes that the man had
good nursing care and prison doctors were informed when necessary.
39. The man’s Erythrocyte Sedimentation Rate (ESR) was high on 24 October
2007. The clinical reviewer judges that, with hindsight, it would have been
better if this test had been repeated after one week. If still high without an
obvious cause, recurrence of the Hodgkin’s disease could have then been
suspected. The clinical reviewer concludes that, although it might have
resulted in earlier referral to hospital, this would not have altered the prognosis.
The Healthcare Manager at Altcourse should ensure that, where test
results are abnormal, follow-up tests are carried out within an appropriate
timescale.
40. On 23 November 2007, when it was suspected that there was recurrence of
Hodgkin’s disease, the consultant’s team was contacted to arrange an urgent
appointment. At the same time, the man was offered admission to Healthcare
for closer observation but he declined the offer. The prison doctor was
informed of his decision. The man was advised that if he felt unwell during the
night he could still contact a member of the healthcare team. He was again
offered admission to Healthcare on 29 November, but again refused. After he
was admitted to hospital in December, he was told he had widespread cancer
and remained in hospital for the next five months.
41. The clinical reviewer notes that, on his return to Altcourse, the man had basic
clinical observations carried out by nursing staff. Healthcare staff remained in
contact with hospital ward staff to clarify the care that he needed. The clinical
reviewer notes that the man was feeling unwell on 23 June but not seen by a
doctor until three days later. On 26 June, when his condition significantly
deteriorated he was again admitted to hospital as an emergency. I agree with
the reviewer that an earlier appointment should have been arranged.
42. When the man came back from hospital, no written communication was
provided other than a routine discharge summary which did not give any detail
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with regard to his prognosis. The clinical reviewer judges that it would have
assisted staff at Altcourse if more detailed information had been provided by
the hospital. Hospital letters were not in the file and the clinical reviewer
recommends that more information should recorded about hospital admissions.
The clinical reviewer also judges that it would also have been useful if the
cause of death had been communicated to Altcourse.
Information about hospital admissions should be recorded in a prisoner’s
medical record.
The healthcare provider at Altcourse should develop a protocol with
University Hospital Aintree to ensure that written care plans are provided
when prisoners are discharged.
43. The clinical reviewer has found no significant shortcomings regarding the
management of the man’s medical care whilst he was at Altcourse. He
concludes that the care provided to him was satisfactory and equivalent to that
he would have received in the community.
Concerns raised by the family
44. The man’s family raised a number of concerns that my investigator discussed
with HMP Altcourse. They told one of my Family Liaison Officers, about their
frustration that he was required to have a prison officer with him at all times,
even when he was desperately ill and unable to leave his bed. The family said
that they were told in February 2008 that the man had just days to live. They
questioned whether an officer escort was necessary for someone as poorly as
him. Head of Safer Custody at Altcourse, wrote in response to the concerns
raised by the family:
“The man’s health and his ability to become mobile changed on a daily
basis, due to this it was deemed appropriate to authorise an escorted
licence due to the potential risk presented, when it became apparent
the risk to the public was reduced he was re-categorised to Cat
[category] D and released on full unescorted licence.”
45. When interviewed as part of this investigation, the Security Manager said:
“From my conversations with the man he was happy with the way he
was being treated by the establishment. If anything I thought he was, I
thought, in my own head, that he was happy to have an officer there all
the time because it’s company. It wasn’t a case of ‘I want to be on my
own.’ Nine times out of ten he was in a solitary confinement room, a
solitary treatment room he’d got, you know where he would have been
on his own for 90 per cent of the time. And having that officer there, I
mean whenever I went out there were a couple of occasions where
there were officers that obviously I knew very well who were friends of
mine and we’d be laughing and joking and he would say ‘oh do you
want a sweet’ and he’d throw you the sweet. I think his quality of life
would have been hampered if he hadn’t have had somebody there just
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because he would have been bored stiff. And he knew most of the
officers so he got on well with them and rather than playing a
PlayStation game on your own you’ve got somebody to beat.”
46. A Pre-Sentence Report was completed by a Probation Officer on 8 November
2007. In her assessment of the risk of harm she wrote:
“The man is assessed of being at a high risk of causing serious harm to
the public and at medium risk to known adults, specifically to those
whom he continues to have ongoing disputes with … This assessment
is supported by the potential for serious harm caused by the behaviour
of him during the current offences and the level of physical harm and
emotional distress caused to the victims. For the risk of harm and
associated risk of reconviction to be managed and reduced, the man
would be required to undertake offending behaviour work as instructed
and address all areas identified which contribute to the current risk
assessment.”
47. The Probation Officer went to say that the specific offending courses that the
man should aim to complete during his sentence were:
 Enhanced Thinking Skills
 Victim Empathy
 Assessment for the CALM programme
 Access to the CARATs (counselling, assessment, referral and throughcare)
drugs service.
48. Unfortunately, because of his health problems, he was unable to complete the
above courses and therefore to reduce his perceived risk of re-offending.
49. In March 2008, a panel of the Parole Board considered and refused the man’s
application for early release. The Board wrote:
“The Panel considered all the information before it as well as the clear
benefits to the man’s of early release given the report on his state of
health in the representations, including recently submitted
representations. It is acknowledged that his progress in custody has
been hampered by his ill health through no fault of his own.
Nonetheless he has a serious offending history exemplified in the index
offences and he himself acknowledges the need to address his anger
management problems, thinking and behaviour in order to reduce the
risk of further offending. In addition neither of the addresses he has
supplied for release is, in the view of the Panel, suitable for parole for
the reasons stated in probation reports.”
50. In general, I am pleased to report that the man’s family spoke positively about
the family liaison officers at Altcourse and said that they had been very
supportive. From my own investigation, I have found that the action taken by
the prison was appropriate. The man had been convicted of a violent offence
but Altcourse continually reviewed his circumstances as his condition
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deteriorated. The final decision to release him on temporary licence meant that
he could stay in hospital without an escort being present. This meant that he
was able to spend the days before his death in the company of his friends and
family.
Use of restraints
51. The initial security risk assessment when the man was taken to hospital
identified that an escort chain should be used and that two officers needed to
be in attendance. This was entirely appropriate at that time and enabled the
nursing staff to have easy access when they carried out their duties. The use
of handcuffs for prisoners on escort to hospital has been the subject of recent
case law in relation to the issue of decent and humane treatment. (Judgement
by Mr Justice Mitting on 23 November 2007 in case of (1) Graham (2) Allen v
Secretary of State for Justice.) I know that the Prison Service is currently
drawing up new guidance in relation to this matter. Altcourse’s decision that he
should be handcuffed in the first instance was in line with the standard
procedures. At the time the handcuffs were applied, the man was conscious
and was judged to pose a security risk.
52. I am pleased to report that the risk assessment for the man was regularly
reviewed and revised during his time in hospital. As a result, the level of
restraints was reduced and the escort chain removed. The bedwatch was also
reduced to one officer. This continued until 12 August 2008 when the risk was
re-assessed and a full unescorted licence was authorised. In my judgement
this was all well managed. My investigator found that the bedwatch notes were
concise with legible and appropriate entries, and at interview bedwatch officers
spoke perceptively and compassionately about their relationship with the man.
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CONCLUSION
53. The man had Hodgkin’s disease which was in remission before he returned to
custody. Unfortunately, he had a recurrence and his Hodgkin’s disease spread
so that he needed further admission to hospital where he had stem cell
transplant and chemotherapy. It would appear the man was fit to be
discharged from hospital back to Altcourse on 3 June 2008. Initially he was
located in Healthcare, but then moved back to the wing in accordance with his
own wishes. Both the clinical reviewer and I believe this was completely
justifiable. Unfortunately, his condition deteriorated and he returned to hospital
on 26 June where he died in August after being released on temporary licence.
54. Although I judge that the man’s care was equivalent to what he would have
received in the wider community, the findings of the clinical review and my own
investigation highlight that some improvements to medical practices at
Altcourse could be made. I endorse the recommendations from the clinical
review. These will need to be addressed by the Director of Altcourse in
partnership with his healthcare provider.
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RECOMMENDATIONS
1. The Healthcare Manager at Altcourse should ensure that, where test results
are abnormal, follow-up tests are carried out within an appropriate timescale.
Accepted – All test results are now received electronically and are reviewed
by the doctor, who prescribes any required follow up immediately.
2. Information about hospital admissions should be recorded in a prisoner’s
medical record.
Accepted – This is current practice which is being reinforced with staff
3. The healthcare provider at Altcourse should develop a protocol with University
Hospital Aintree to ensure that written care plans are provided when prisoners
are discharged.
Accepted - A request has been forwarded to Liverpool Primary Care Trust to
request a meeting to address this issue.
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