Individual at Altcourse

Investigation into the circumstances surrounding the
death of a man in hospital whilst in the custody of HMP
Altcourse in June 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2009
This is the report of an investigation into the death of a man who died
in June 2008 in hospital whilst in the custody of HMP Altcourse. He had transferred
from Altcourse to the hospital earlier after being unwell for several weeks.
A post mortem was held at the request of HM Coroner for Liverpool. It found that the
man died from natural causes resulting from pancreatic cancer. I extend my sincere
condolences to the man’s family and friends.
This investigation was undertaken by two of my investigators. In addition, a review
of the man’s healthcare was commissioned from Liverpool Primary Care Trust. I am
grateful to a doctor who carried out the review. I would also like to thank the Director
of Altcourse and his staff for their help and assistance. I am particularly grateful to
the liaison officers.
The man arrived at Altcourse in March 2008, and spent a week in the healthcare unit
before transferring to the induction wing. Following a court appearance, he was
transferred to HMP Manchester. Two weeks later, he returned to Altcourse. On 6
June, he was admitted into the healthcare wing and later transferred to hospital. The
diagnosis of his terminal illness was not identified until he was admitted to hospital.
When the man arrived at Manchester, he tested positive for Subutex. There is no
evidence that he had been prescribed the drug at Altcourse, and I assume he had
come by it illicitly. Nevertheless, at Manchester he was then prescribed both
Subutex and Amitriptyline. In contrast, when he returned to Altcourse, there is no
reference to any detoxification medication. Although none of this is relevant to his
cause of death, I have been sufficiently concerned to make a number of
recommendations.
More positively, I have commended the bedwatch arrangements during the man’s
final stay in hospital.
In this final version of my report the healthcare manager of Altcourse has partially
accepted one of the recommendations. The Governor of Manchester, the Director of
Altcourse and the healthcare managers of both prisons have accepted the four other
recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2009
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CONTENTS
Summary
The Investigation Process
HMP Altcourse
Key Findings
Issues
Recommendations and Good Practice
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SUMMARY
The man arrived at HMP Altcourse in March 2008. On reception, it was noted that
he had insulin dependent diabetes and a leg ulcer. He spent his first week in the
healthcare unit being observed: his blood sugar levels were high and the leg ulcer
required attention. A week later he transferred to a normal wing.
Following a court appearance, the man transferred to HMP Manchester. On arrival
there, his urine sample tested positive for Subutex and he was given a prescription
for it. (Subutex is prescribed as a substitute for opiate drugs such as heroin, and is
used to help with drug withdrawal symptoms.) There is no evidence of the man
being treated for withdrawal symptoms in Altcourse; indeed, Subutex is not
prescribed at Altcourse. I assume he came by the drug illicitly.
A further two weeks later, the man returned from Manchester to Altcourse. His leg
ulcer still required daily dressing. No reference was made to any detoxification
medication. The man attended the healthcare unit on 12 April and was diagnosed
with a chest infection. Anti-biotic medication was prescribed.
The man had a painful back and was seen by a doctor on 16 April. He was
prescribed painkillers and a referral was made for him to see a physiotherapist.
During April and May, the man was seen regularly in healthcare for treatment to his
leg ulcer.
On 28 May, blood tests results indicated the man was unwell but no specific illness
was identified. He was seen by a nurse who recorded that the man looked dreadful
and pale. The following day he saw the doctor, and it was found following an
examination that his liver was enlarged. The doctor requested more blood tests, an
x-ray and ultrasound scan at an outside hospital and referred the man to a hospital
specialist.
Two days later, the man was escorted to hospital for his x-ray appointment. A scan
procedure was offered whilst he was at the hospital but the escorting officers
returned the man to Altcourse without the procedure taking place.
The man became increasingly unwell and was admitted to the healthcare unit for
observation. On 14 June, the man was transferred to hospital as he was breathless
and in some discomfort. He was handcuffed and escorted by two officers.
Five days later, the man was told he had terminal cancer. The next day, the
restraints were removed and the escort reduced to one officer. The man died with his
family at his bedside.
My report contains five recommendations and formally commends the bedwatch
arrangements as Good Practice.
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THE INVESTIGATION PROCESS
1. On 10 July 2008, the principal investigator visited Altcourse to open the
investigation into the man’s death. The Ombudsman’s terms of reference and
notices of investigation had been sent to the prison in advance of her visit.
2. My investigator met with a liaison officer and reviewed the man’s prison file
(copies of which were handed to her later). She visited the induction wing and
the healthcare unit. She also met the Chair of the Independent Monitoring
Board (IMB).
3. On 20 and 21 August, two of my investigators returned to Altcourse and
interviewed members of prison and healthcare staff. On 8 September, one of
the investigators interviewed another member of prison staff.
4. One of my family liaison officers spoke to the man’s next of kin, his former
wife. She did not wish to raise any issues in relation to this investigation and
told my officer she was grateful to prison staff for their help and support
following the man’s death. The man’s mother was also appreciative of the
assistance provided by the prison.
5. On 16 October, the principal investigator spoke to the healthcare manager at
Altcourse. The following day, the principal investigator spoke to the inpatient
manager at Manchester. My investigator told the manager that this report
would be sent to the Governor of Manchester.
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HMP ALTCOURSE
6. HMP Altcourse opened in December 1997. It is one of ten privately run
establishments within the contracted prisons estate. It is managed by GSL
UK Limited (which is itself owned by G4S).
7. Altcourse operates as a local category B male prison. It holds both convicted
and remand adults, and young offenders, sent from the courts in Merseyside,
Cheshire and North Wales. The prison has an operational capacity of 903
located in six main houseblocks. The site also contains a modern healthcare
centre, a rehabilitation unit, segregation unit, college and sports facilities.
Medical services are provided by Medacs.
8. The Independent Monitoring Board Annual Report 2007 says:
“The provider of healthcare at Altcourse changed again in December 2006
for the third time in as many years. The new provider is Medacs, a private
company with some experience of working in prisons. This was a time of
great concern for the loyal staff who were faced with another change of
employer and conditions of service. The fragility of the private companies
who are contracted to provide healthcare in this prison gives the Board
considerable concerns although it is to the credit of both healthcare staff
and GSL management that this had little effect on the service provided to
prisoners, apart from a temporary hiatus in the purchase of drugs for the
pharmacy which was resolved quickly by GSL intervention.”
9. The most recently published inspection report by Her Majesty’s Chief
Inspector of Prisons, dated April 2005, describes Altcourse as “a very good
local prison” which echoes the Prison Service’s own evaluation of the prison
as a high performing establishment. The Chief Inspector, Dame Anne Owers,
found that Altcourse was performing well against the Inspectorate’s ‘healthy
prison’ criteria of safety, respect, purposeful activity and resettlement. Dame
Owers wrote:
“The aim of the healthcare service at Altcourse is to treat the more minor
physical and mental health needs of prisoners on normal location where
possible. This means that only the most ill prisoners are generally
admitted and cared for in the 24 hour manned healthcare centre. The
inpatient facility has room for up to 12 patients in ten single cells and one
double cell.”
Dame Owers’ report concluded that prisoners have healthcare services equal
to those in the community.
10. There have been ten deaths previous at Altcourse since my office was given
responsibility for investigating all deaths in prison custody in 2004. Six of
those deaths have been apparently self inflicted, and four from natural
causes. None of my earlier reports raises concerns relevant to the
circumstances surrounding the man’s death.
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KEY FINDINGS
11. The man was born in Manchester in 1959 and died aged 49. He was
estranged from his wife and had been living with his mother. The man had a
history of substance misuse, and had previous experience in custody. Staff at
Altcourse told my investigators that the man had incurred no adjudications
(disciplinary hearings) and was a compliant and pleasant prisoner.
12. The man was received into Altcourse in March 2008. His medical notes
indicated that he was receiving insulin for type one diabetes and had a leg
wound. The man’s leg wound was cleaned and redressed by a nurse and he
was admitted to the healthcare unit for observation.
13. On 8 March, The man was examined by a doctor who noted that the leg
wound was actually a chronic skin ulcer. The doctor recorded that the man
should remain under review in the healthcare unit. The man was seen by
healthcare staff regularly and his blood sugar levels were checked daily.
14. The man asked to see the doctor on 11 March. On examination the doctor
noted his leg ulcer and his medication of an antibiotic, Flucloxacillin. It was
also recorded that the man’s blood sugar was too high and his insulin was
increased.
15. On 13 March, the man had an assessment to check the flow of blood to the
limbs (a Doppler Assessment). The leg wound appeared to be still infected
and a swab was taken to send for analysis.
16. The next day, the man was reviewed by a doctor. The ulcer was cleaner and
his blood sugar levels had improved. The doctor advised the man that he was
fit for normal location and work. The man was then transferred to the
induction unit. Arrangements were made for the man to attend the healthcare
unit on a daily basis to clean and redress his ulcer.
17. On 25 March 2008, the man was transferred to HMP Manchester following a
court appearance. Whilst at Manchester, he continued to receive treatment
for his leg ulcer. He was also prescribed medication for drug withdrawal
(Subutex) after being tested positive for the medication. A medication to help
him sleep and relax (Amitriptyline) was also prescribed. (There had been no
previous reference to the man suffering from drug withdrawal symptoms at
Altcourse.) My investigator spoke to the healthcare manager, and was told
the man was not receiving any detoxification medication whilst at Altcourse
and Subutex is not prescribed there. I conclude that he must have obtained it
illicitly. The man’s leg ulcer was treated and dressed in Manchester’s
healthcare unit. On 9 April, the man returned to Altcourse.
18. At Altcourse, the man was again examined by a nurse in reception. No
reference was made to drug withdrawal symptoms and no medication was
prescribed for any related symptoms. It was noted that he had a viral chest
infection with a slight wheeze, but was otherwise well. His leg ulcer was
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healing and a dry dressing was applied. Again, the man was advised to
attend the healthcare unit daily to treat his leg ulcer.
19. Two days later, the man was prescribed Ibuprofen for his leg pain. On 16
April, he saw a doctor with back pain. The doctor noted that the man had
strained his back whilst in Manchester and prescribed Tramadol for the pain
and advised physiotherapy. The regular appointments to examine the man’s
leg ulcer continued through April and May. On 30 April, the man was
sentenced to 21 months imprisonment for drug related offences.
20. A full set of blood tests were recorded on 28 May. They did not reveal
anything to indicate a specific illness but did show the man was unwell. Later
that day, a nurse noted in the clinical record that the man looked dreadful,
very pale, and was in abdominal pain. The man’s blood pressure was low
at100/60 (normal blood pressure would be in a range of around 130/80) and
his pulse rate was noted as 80 beats per minute (normal pulse rate is within
the range of 60-100 beats per minute).
21. On 29 May, the man was examined by a doctor. He noted that the man had
lost weight and felt unwell. The doctor ordered more blood tests and
contacted the hospital, requesting an urgent x-ray and ultrasound scan
appointment. Amitriptyline was prescribed to help the man sleep and relax
along with Nefopam, a medication to relieve pain.
22. During a medication round later that day, a nurse observed that the man
appeared to conceal the Amitriptyline. The nurse spoke to him and asked him
why he had not taken the medication. The man said he wanted to take it
later, nearer to bed time. The nurse insisted that the man take his medication
and noted this in his medical record.
23. The next day, the man was escorted by two prison custody officers (PCOs),
to hospital for his x-ray appointment. The x-ray was taken and a member of
the hospital staff noted that the man had also been referred for an ultrasound
scan. The member of staff suggested that the scan could be completed that
afternoon if the escort could wait about 20 minutes for a time slot. The escort
officers were not aware of the scan appointment being included as part of the
escort, so declined the offer and returned the man to Altcourse.
24. On 2 June, a doctor noted that the man appeared very pale. The doctor
offered the man a bed in the healthcare unit but he declined. No reason why
the man did not want to be admitted to the healthcare unit was noted in his
clinical record, but the doctor asked nursing staff to review him every day.
The man continued to go to healthcare daily to have the leg ulcer dressing
changed.
25. The doctor sent a letter to the head of operations on 5 June. The letter noted
that the doctor had seen the man in the healthcare unit that morning. The
man had told the doctor about the x-ray appointment, and that he had not had
his ultrasound scan procedure as the escorting officers did not wait. The
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doctor requested in his letter that, in future, all escorts to an outside hospital
for tests and procedures be carried out as directed by hospital staff.
26. The following day, the man agreed to be admitted to the healthcare unit. His
medical notes record that he settled well into the unit and spent most of his
time asleep or resting. His scan was re-booked on 8 June. Over the next four
days the man received nursing care by staff on the unit. It was noted that he
was poorly but comfortable.
27. On 12 June, a nurse from a hospital contacted healthcare staff to arrange an
urgent appointment for the man following the results of a blood test. The
appointment was made for 20 June. The doctor had asked for an earlier
appointment but the hospital was unable to provide one as the consultant had
no clinics until that date.
28. The following day, a doctor noted that the man was breathless although he
did not have any chest pain. On 14 June, the doctor made a note in the
man’s medical record that, should the man’s condition deteriorate further, he
should be contacted to refer him for an urgent admission to hospital.
29. Later that day, he was transferred to hospital as his condition was
deteriorating. A risk assessment was completed and the man was restrained
with a double cuff restraint (both the prisoner’s hands are cuffed together in
front of their body, then attached to an officer). He was escorted to hospital
by two officers. On arrival at hospital, the man was admitted for tests and
observation. The restraints were changed to an escort chain (an escort chain
is a 1.8 metre chain linked at one end to the prisoner and the other to an
officer).
30. On 19 June, the man was told by hospital medical staff that he had cancer.
The man received a visit from his family later that evening. The following day,
the restraints were removed on authorisation of the head of security and the
escort was reduced to one officer. The man was allowed family visits in line
with hospital practice. On 24 June, the prison’s family liaison officer visited
the man and then spoke to his family about the support and assistance the
prison could offer them.
31. The next day a senior house officer from the hospital, wrote to a prison doctor
informing him of the man terminal condition and poor prognosis. He had been
diagnosed with pancreatic cancer with liver metastases.
32. The man’s death was confirmed at 3.10am on 27 June 2008. His family was
at his bedside. The man’s former wife expressed her gratitude to the
bedwatch staff for their sensitive manner during the man’s inpatient stay at the
hospital. In particular, the family expressed their gratitude to a PCO the
bedwatch officer on duty when the man died, for his compassion and
understanding.
33. The duty director held a de-brief with members of the night staff on duty that
morning. The duty director noted that the PCO had liaised with the family,
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police and hospital staff following the man’s death. He was praised by the
duty director for his high standard of professionalism. All staff were made
aware of the welfare support services.
34. Later that day prayers were said for the man in the chapel at Altcourse. The
family was grateful for the support of the family liaison officer and the offer of
funeral expenses. They declined the offer of a prison representative at the
man’s funeral.
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ISSUES
Clinical Care
35. A review of the man’s medical care was commissioned through Liverpool
Primary Care Trust (PCT). A doctor reviewed the man’s medical notes and
the interventions of healthcare staff.
36. The clinical reviewer has found that the man’s treatment was appropriate. He
was assessed regularly and referred to the hospital under the ‘two week rule’
when his liver found to be enlarged on examination. (The two week rule is a
national guideline for referring patients from a GP to hospital when a cancer is
suspected. Two weeks is the maximum timeframe for the patient to be seen
at the hospital.) The man’s blood sugar levels were checked frequently when
he was first received into Altcourse. However, on his return to Altcourse on 9
April, the man’s blood sugar levels were not recorded which would have been
good practice. A blood test to monitor blood sugar levels over a previous
three month period would have been useful.
The healthcare manager should ensure that insulin dependent patients
with diabetes have their blood sugars monitored regularly. The test can
be done by the patient if appropriate, or by a member of the healthcare
staff.
Reception Health Screenings
37. After nearly two weeks at Altcourse, the man was transferred to Manchester
where he provided a urine sample that tested positive for Subutex. As a
result of this test the man was prescribed a gradual reducing dose of Subutex
and a relaxant of Amitriptyline. There is no reference in the man’s medical
notes from Manchester that healthcare staff had been in contact with their
colleagues at Altcourse to check his medication. The man had not received
any detoxification medication at Altcourse nor had he been on any regime for
drug withdrawal. Indeed, at this time Altcourse did not prescribe Subutex as a
medication. It is unclear how this medication managed to be found in the
man’s urine sample on reception into Manchester, although by far the most
likely is that he obtained the Subutex through illegal drug use whilst resident
at Altcourse.
38. On return to Altcourse from Manchester, there are no details in the reception
health screen document referring to any detoxification medication that the
man was receiving, or any contact with healthcare staff at Manchester.
39. It is of great concern that the man’s urine sample was positive for Subutex on
reception at Manchester, yet no contact was made with Altcourse to check
this. Likewise, on reception back into Altcourse, there was no contact with
Manchester to check the man’s medication.
40. My principal investigator spoke to the inpatient manager at Manchester. He
told her that, when prisoners return to court within the Manchester area, their
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medical notes do not go with them as they usually return to HMP Manchester.
In the man’s case, he was expected to return to Manchester after his court
appearance, but in fact was taken back to Altcourse.
41. Whilst these issues are not pertinent to the man’s death, there seems to have
been a lack of communication between the two prisons regarding medical
issues that could prove critical in another situation.
Where there is a chronic condition, prisoner’s medical records should
be obtained following transfer between prisons. Healthcare staff must
make contact with the transferring prison to gain information on any
prescribed medication.
In the light of this report, the Governor and Healthcare Manager at
Manchester should jointly review protocols governing the prescription
of Subutex.
In the light of this report, the Director of Altcourse should review his
drug strategy in respect of the illicit use of Subutex.
The outpatient appointment on 30 May
42. The man was referred to hospital for an x-ray and ultrasound scan
appointment. The x-ray appointment was arranged for 30 May in the
afternoon. The man was escorted to the hospital by two prison custody
officers. The x-ray procedure was completed and a member of the hospital
staff noted that the man had also been referred for an ultrasound scan. The
staff member told the officers that the scan could be arranged for the man
whilst he was at the hospital and a time slot would be offered. It was thought
the waiting time would be around 20 minutes. As the officers were unaware
that the man was also waiting for this procedure, it seems they declined the
offer of the scan appointment and returned to the prison. My investigators
interviewed the PCOs, but neither officer could recall escorting the man to
hospital on 30 May.
43. Several days later, the man told a doctor about what had happened when he
saw the doctor in healthcare. The doctor wrote a letter to the head of regimes
and services, to inform him of the lost opportunity for the man’s medical
procedure. The doctor further requested that, in future, escorting staff should
allow hospital staff to complete all medical procedures.
44. The head of regimes and services passed this information to the operations
manager. When my investigator enquired, she was told the operations
manager was unable to re-call the letter or the information. The head of
regimes and services said the escort paperwork indicated the x-ray
appointment but not an appointment for a scan. As a consequence, the
escorting officers did not have the information that a scan had been also been
requested by the doctor.
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45. Whilst I understand the reason why the escorting officers did not accept the
offer of a scan, it would have made sense for the man to have had the scan
when it was offered by hospital staff. A telephone call by the escorting
officers to the security department at Altcourse would presumably have been
all that was needed to gain permission to stay at the hospital and complete all
medical procedures.
46. At interview, the doctor said that in his opinion the missed opportunity for the
man to have a scan procedure that day would not have changed the outcome
as the man’s undiagnosed terminal illness was well advanced at that stage. I
note the good practice of the doctor in addressing operational issues in
relation to outside hospital appointments.
All outstanding outpatient appointments for a prisoner should be
confirmed by the security department with healthcare staff, immediately
prior to the prisoner attending the hospital under escort.
Bedwatch at hospital
47. Restraints were removed at an appropriate time during the man’s nursing care
and the head of security reduced the escort to one officer. I think this was
well managed. In addition, my investigator found that the bedwatch notes
were concise with legible and appropriate entries. The man’s family praised
the all the escorting staff for their sensitive and caring support offered to them
and the man. The PCO was noted as conducting himself to a high standard
of professionalism on the morning the man died. This was noted by the de-
brief manager. I am pleased to be able to reflect further upon that
professionalism in this report, and would be grateful if the comments in this
paragraph could be referred to the PCO personally.
48. I have formally acknowledged the bedwatch arrangements as an example of
good practice.
Family Liaison
49. The family liaison officer made contact with the family shortly before the man’s
death. The officer sensitively informed the family of the support that the
prison would be able to offer, including financial assistance with the funeral
arrangements. I am pleased to report the family’s gratitude for this
information and appreciation of the help they received following the man’s
death.
50. In the report of an investigation into a previous death in custody at Altcourse, I
had found that the family had not been offered this early support. I commend
the prison for ensuring that systems are now in place to support the families of
terminally ill prisoners.
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RECOMMENDATIONS AND GOOD PRACTICE
For the Healthcare Manager at HMP Altcourse
The healthcare manager should ensure that insulin dependent patients with
diabetes have their blood sugars monitored regularly. The test can be done
by the patient if appropriate, or by a member of the healthcare staff.
Partially Accepted – “Healthcare service is available to prisoners thirteen
hours per day and they are encouraged to attend should they want their
blood sugar monitored. A diabetic clinic is held within the healthcare. Blood
monitoring machines are made available to some prisoners for self-testing
purposes following thorough risk assessments.”
For the Healthcare Managers of HMP Altcourse and HMP Manchester
Where there is a chronic condition, prisoner’s medical records should be
obtained following transfer between prisons. Healthcare staff must make
contact with the transferring prison to gain information on any prescribed
medication.
Accepted – Altcourse, “Procedures already exist which state medical records
must accompany all transfers. In the event of failure, medical staff will
contact the dispatching prison for information. Such information is recorded
on System One.”
Manchester, “The Director of Healthcare will update the relevant protocols to
instruct and ensure that all information is sent or obtained by staff following
transfer between prisons. The protocol will include instructions to healthcare
staff that they must make and record direct contact with the transferring
prison to exchange information on prescribed medication.”
For the Governor and Healthcare Manager at HMP Manchester
In the light of this report, the Governor and Healthcare Manager at
Manchester should jointly review protocols governing the prescription of
Subutex.
Accepted – “In line with the implementation of the Integrated Drug Treatment
Services at Manchester, the Director of Healthcare will review with the
Governor the protocols governing the prescription of Subutex.”
For the Director of HMP Altcourse
In the light of this report, the Director of Altcourse should review his drug
strategy in respect of the illicit use of Subutex.
Accepted – “This strategy will be reviewed.”
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All outstanding outpatient appointments for a prisoner should be confirmed by
the security department with healthcare staff, immediately prior to the
prisoner attending the hospital under escort.
Accepted – “All appointments are confirmed in advance by the Security
Team. Depending on requirements of patients, risk assessments are drawn
up that ensure security is maintained and ensure that medical interventions
are permitted.”
Good Practice
The bedwatch arrangements at hospital were especially well managed, both
in respect of the use of restraints and level of escort, and in the
professionalism and sensitivity of the staff concerned.
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