Individual at Altcourse

Investigation into the death of a man at HMP Altcourse
on 17 August 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
August 2007
This is the report of an investigation into the circumstances surrounding the death of
a man on 17 August 2006. The man was diagnosed with terminal lung cancer whilst
a prisoner at HMP Altcourse. He spent his last days in the healthcare unit and died
as a result of his illness. He was 56 years old.
I extend my condolences to the man’s family and to all those touched by his death.
The investigation was undertaken by one of my colleagues. Both my colleague and I
would like to extend our thanks the Director of Altcourse, and his staff for their co-
operation during the investigation. Particular thanks go to the prison liaison officer
for gathering all relevant documentation and ensuring it was made available in a
timely way. I would also like to thank Liverpool Primary Care Trust for carrying out a
clinical review into the healthcare the man received at Altcourse.
The man had served 18 months of a long term sentence when he first began to
present symptoms. Whilst he struggled at times to come to terms with his illness,
and was resistant to a move from normal location to healthcare, it is clear that staff at
Altcourse continued to support him physically and mentally as best they could. I am
in no doubt as to the effectiveness of the palliative care he received, an observation I
have made in a previous report where the Liverpool Care Pathway took responsibility
for a prisoner’s terminal healthcare needs.
I make four recommendations. I also commend Altcourse for putting arrangements
in place to ensure the man’s last few months were as dignified as possible. I make
particular reference to a member of staff in healthcare and the action she took during
his final hours of life and have highlighted this and other staff support as two
examples of good practice. The clinical review found that the man received care of a
similar standard to that he would have received in a community setting. As well as
echoing a recommendation of my own on record keeping, the clinical review also
highlights two areas of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2007
2
CONTENTS
Summary 4
The Investigation Process 5
HMP Altcourse 6
Key Events 7
Issues 12
Clinical Review 15
Recommendations 16
3
SUMMARY
The man who died was arrested for a number of serious offences in December 2003.
He was convicted and on 16 August 2004, was sentenced to nine years
imprisonment. He had served two years of his sentence when he passed away
during the early hours of 17 August 2006.
The man settled into prison life well. He found employment quickly and maintained a
good work record. He also attended a number of courses and was showing
encouraging signs of development throughout the early part of his sentence.
He first complained of feeling unwell in May 2006. His symptoms worsened and,
following a number of visits to healthcare, he was sent to the local hospital for
exploratory procedures. In July 2006, the man was diagnosed with terminal lung
cancer. He spent two periods in hospital, but on 7 August he returned to the
healthcare unit at Altcourse for the last time, under the care of the Liverpool Care
Pathway and local district nurses.
The man spent a further 10 days in the healthcare unit and was cared for using the
Marie Curie Hospice model of nursing adapted for use in a custodial setting. During
the evening of 16 August, his condition deteriorated rapidly and he died peacefully at
2:50am the following morning. A member of the healthcare team was at his bedside.
4
THE INVESTIGATION PROCESS
1. The investigation was opened on 28 August 2006. My investigator obtained
all relevant prison records including the man’s medical and core records
covering the two years he spent in prison.
2. Notices to staff and prisoners were supplied and displayed around the prison.
These invited anybody with information to talk to my investigator. In this
instance, no staff or prisoners came forward. My investigator examined the
records and recorded significant events. From this evidence, she did not feel
it necessary to visit Altcourse and no interviews took place.
3. A representative from Liverpool Primary Care Trust was invited to undertake a
review of the clinical care the man received while in custody. The clinician’s
review is included as an annex to this report.
4. The Coroner was informed of the Ombudsman’s investigation. The post
mortem report recorded the cause of death as:
1a Metastatic Carcinoma of the lung
The Coroner will receive a copy of this report when it is completed to assist
him with his enquiries.
5. The man’s sister and daughter were contacted by one of my Family Liaison
Officers to ask whether they or other members of the family had any
comments or concerns about his death. The family raised no concerns and
will receive a copy of my report.
5
HMP ALTCOURSE
11. 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 (formerly Group 4).
12. 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 house blocks. The site also contains a modern healthcare
centre, a rehabilitation unit, segregation unit, college and sports facilities.
13. Reynoldstown unit, where the man was located, houses sentenced prisoners
wishing to undertake full time education courses, and vulnerable prisoners.
13. 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 HMCIP report found that Altcourse
was performing well against its own Healthy Prison criteria of safety, respect,
purposeful activity and resettlement.
14. HM Chief Inspector recorded that healthcare services at Altcourse, run by the
privately owned Veritas company, maintained good links with the Liverpool
Primary Care Trust (PCT). The Inspectorate’s survey of prisoners conducted
during the inspection scored healthcare well above the average for similar
prisons.
15. 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 10 single cells and one double cell.
6
KEY EVENTS
16. On the evening of 1 May 2006, the man was seen by the prison doctor on his
medical rounds. He complained that he had been experiencing abdominal
pain for a number of weeks and asked to be prescribed analgesia. The doctor
advised him to make a doctor’s appointment in the healthcare centre and
gave him two paracetamol for the pain. He was also advised that, if his
symptoms worsened, he was to return to healthcare in order for the doctor to
see him the following morning.
17. The man was seen by the doctor again on 5 May and requested analgesia for
a second time. A blood sample was taken and he was given paracetamol for
pain relief. The doctor explained that he would have to wait for the results of
the blood test. The man returned to his cell and spent an uncomfortable
weekend on the unit. His medical records did not record the outcome of his
blood tests.
18. He did not return to the healthcare centre until five weeks later. On 7 June,
he was seen on triage and asked for a doctor’s appointment. He also
requested a change in medication and complained that the current
prescription was having no effect. It is unclear from the records whether an
appointment was made.
19. On 12 June, staff working on the man’s unit informed healthcare that he was
still complaining of abdominal pain and wanted to see a member of the
healthcare team. When he arrived in healthcare he made the same complaint
and added that, although he did not feel sick, he had experienced problems
going to the toilet for approximately four weeks. The nurse made an entry in
his medical record which explained that the man was already under
investigation for gall stones and possible liver problems but that his abdomen
was quite tense. He was advised to drink more fluids and to let healthcare
know if the problem worsened overnight. No further action was taken as he
was due to see the doctor the following day.
20. Between 13 and 18 June, the man was seen by the doctor on two more
occasions. At his first appointment on 13 June, the doctor noted that he was
experiencing severe upper abdominal pain. He was prescribed analgesia and
more blood was taken for tests the following day. On 17 June during evening
medication, he complained of chest pain and told the nurse it had worsened
over the last couple of days. After he saw the doctor on 18 June, staff were
advised to continue the analgesia until the doctor reviewed his condition in 10
days time.
21. However, between 22 and 25 June, nurses were called to the unit three times
and noted that the man was still experiencing chest pains and muscular pains
when lying down.
22. A nurse attended to the man on 22 June and noted that, despite being in pain,
he was not unduly breathless or experiencing feelings of sickness. The
doctor saw him the following day, reviewed his condition, and noted no
7
change to his medication. Another member of nursing staff was called to the
unit on 24 June and found him breathless and in pain. The nurse
administered oxygen and gave him some aspirin. The entry in his medical
record stated that the pain seemed to be coming from between the man’s ribs
and eased when oxygen was given. He was seen by the doctor again the
next day and his breathlessness was recorded.
23. During that same week, one of the nurses attempted to chase up the man’s
referral for a hospital appointment made by the prison doctor some weeks
earlier. She was told a referral letter had been received on 14 May and there
was a 14 week waiting list for an appointment. The nurse left the direct
number for the hospital in his medical record and added that healthcare would
continue to wait for the appointment.
24. A Registered Mental Health Nurse was once again called to the unit on 27
June. The man was displaying signs of breathlessness and was pale. The
nurse established that he had been experiencing pain throughout the night
and had tried to use a ‘GT’ spray, given to him by nursing staff the previous
day, but to no effect. The nurse put out a ‘Code One’ emergency call and an
ambulance was called. Whilst waiting for the paramedics to arrive, the nurse
administered oxygen and the man’s breathing became more regulated. His
anxiety had decreased when paramedics arrived. He was taken to hospital
for a check up.
25. Later that same day, two escorts accompanying him to the hospital contacted
healthcare staff to update the centre on his progress. A nurse took the call
and noted in his medical record that he had a blood clot and was waiting in
the Accident and Emergency Department until a bed could be found to admit
him to hospital. The man was expected to remain there for at least three
days.
26. For the next three days, healthcare staff called the hospital for progress
reports and recorded all the information shared about his condition. On the
evening of 28 June, the man was moved to a ward following a CT scan. On
of the nurses on duty that day was told that the most likely diagnosis was
cancer of the lung but that, until the consultant saw him, nothing could be
confirmed. The following evening, the same nurse called again and spoke to
the staff nurse on the ward. The staff nurse confirmed that the man had now
been given the results of his scan, but she refused to discuss any more detail
over the phone and asked that healthcare staff speak to the consultant for
more information. He remained comfortable and pain free and the staff nurse
suggested a possible discharge in the next day or two.
27. The man was discharged on 30 June and returned to Altcourse. On arrival,
he was taken straight to the healthcare centre and was told to remain there
until the doctor could review his condition. At 3.30pm, the doctor visited him
and put a stop to his heart medication as it was no longer necessary. His new
medication was written up and administered. He was considered fit for
normal location and was discharged from healthcare back to his unit.
8
28. For the next week, the man remained mostly in his cell. He was seen by a
nurse on the morning of 5 July and complained that he been in pain all night.
The man preferred being on his unit and explained that he had not wanted to
call out night staff in case they admitted him to healthcare again. He was
given his medication and by lunchtime the pain had subsided. A memo was
sent to his unit manager to remind staff to transfer him to healthcare on 18
July in preparation for a hospital appointment the following day.
29. The man’s stay in normal location did not last long. The following afternoon
he was admitted to the healthcare centre and, on arrival, a nurse noticed he
had developed a small pressure area to his right side. He was placed in bed,
given oxygen and advised to sleep with the backrest on his bed in a fully
extended position for more comfort. At 7.30pm, a nurse made an entry in his
medical record which confirmed he had been given his medication and could
have further medication for the relief of breakthrough pain.
30. On 7 July, the man was seen by a doctor in healthcare. The doctor noted
that, although he seemed more comfortable than the day before, he was still
experiencing left sided chest pain and had difficulty swallowing food. The
man was given morphine for the pain and a soft diet was ordered from the
kitchen.
31. He remained in healthcare for the next three days and saw the doctor every
day as part of his routine morning rounds. Each time, the doctor monitored
his condition and noted any spells of dizziness and breakthrough pain. The
doctor changed his medication to help manage the man’s pain and address
the constipation he had begun to experience. He continued to ask if he could
be returned to his unit and was assessed as fit for normal location by the
doctor on 10 July. He returned to his cell later that day.
32. The two doctors who had continuously cared for the man, took the
opportunity to write a memo to the Director of Altcourse. The memo, dated 12
July, set out his condition and explained that his illness was probably terminal.
The memo further explained that, until a lung biopsy could be performed,
neither doctor could be sure what future treatment the man would need, how
frequently he would need it, or where the treatment was likely to take place.
33. He continued to experience pain over the next few days and nursing staff
were called to the unit to attend to him. On each occasion, his condition was
recorded in his medical record and medication for pain relief was
administered. The man said that he was finding it increasingly difficult to cope
with the pain and became distressed and anxious.
34. On 20 July, he was admitted to ward 15 at Fazakerly Hospital where he
remained in a comfortable condition. The following day, a nurse contacted
the ward for an update and was told his pain had yet to be fully controlled and,
unfortunately, the hospital could not carry out a lung biopsy. The procedure
was to be rescheduled.
9
35. The man remained in hospital for a further two weeks. During that time he
was x-rayed, scanned, and underwent other exploratory medical procedures
to determine the extent of his illness. Throughout his stay, healthcare staff
contacted the ward for regular progress reports and kept in touch with escort
staff on bedwatch duty. He remained in some pain and discomfort and
continued to receive pain relief via a syringe driver. The nurse made entries
in his medical record to confirm that both the healthcare manager and duty
manager were fully aware of the man’s situation, and were awaiting a
discharge date from the hospital consultant.
36. On 7 August, the man returned to Altcourse under a Palliative Care Plan
(PCP). He had been diagnosed with terminal cancer of the lung with
secondary spread. The plan was comprehensive and covered pain
management, appetite, mental health management, medication, district nurse
visits and symptom control care. The nursing care and discharge pack from
the hospital made clear to healthcare staff that he was to be placed on a
syringe driver to control the pain and was to be told why the driver would be
used.
37. Once settled back in healthcare, nursing staff began to follow the palliative
care plan. An anxiety care plan was opened to monitor his psychological
response to his diagnosis. Nurses were instructed to alleviate any feelings of
anxiety, allow him the time to express his feelings and to ask any questions
about his illness. Care plans were also opened for every symptom associated
with his illness, and nursing staff were made aware of the level of care and
support required to manage each area.
38. In the early hours of 8 August, the man became restless and experienced
feelings of sickness. At 6.30am, a nurse found him in pain and feeling
anxious. He was reassured but still appeared frightened and asked the nurse
to stay with him for a while. He was seen by a district nurse in the afternoon
and his syringe driver was replenished.
39. At 6.30pm, the doctor saw the man and had a long talk with him. The entry in
his medical record stated that he appeared frightened and tearful and wanted
a prisoner from his unit to visit him in healthcare. The doctor noted that the
man asked if he was dying and was told, “You know the answer to that
already”. The doctor then asked him if he had any other concerns and he
repeated his request to see another prisoner from his unit. The doctor
explained to him that his request would be passed on to security and
arranged for the chaplaincy to see him in the meantime.
40. By 8.00pm, the chaplain had arrived at his bedside and they said prayers
together. Once again, the man said that he wanted another prisoner to visit
“so he can hug him”. The entry in his PCP stated that the healthcare
manager would arrange the visit once his pain relief was under control.
41. His health continued to deteriorate and he was seen by the chaplain on a
daily basis. Healthcare staff followed the adapted care plan closely and
monitored his anxiety and pain relief levels. The man was also treated for
10
other symptoms attached to his illness and his diet and fluid intake was
recorded. Nurses constantly rotated him in bed to prevent further pressure
sores and noted that he did not like being moved, despite being told why it
was necessary to change his position.
42. On 15 August, his condition worsened. The chaplain visited him twice,
accompanied on the second occasion by the prisoner he wished to see. The
chaplain contacted the man’s next of kin and logged the event in a memo to
the Director of Altcourse.
43. At 2.00am on 17 August, the night duty nurse entered his room to attend to
his personal hygiene and change his bedding. At his request, the nurse
stayed behind and sat at his bedside. At approximately 2.51am, the man
passed away peacefully.
44. Immediately following his death, an incident log commenced and over the
course of the next few hours most of the relevant parties were informed. The
prison doctor on duty was informed at 3.00am and arrived at the prison at
4.33am. The doctor pronounced the man dead at 4.58am. The chaplain took
responsibility for informing his next of kin that he had died. The duty director,
started a debrief and the doctor, healthcare staff and prison staff who
attended were thanked for ensuring the man’s death was a dignified one.
Staff were also informed that care and support services were in place if
anyone felt they needed to access them.
45. The man’s funeral took place on 24 August and the funeral costs were met by
the prison.
11
ISSUES
46. The man participated well in the prison regime prior to his diagnosis and was
beginning to settle into his long term sentence when he became ill. It is clear
from his records that he preferred to remain on the unit to be treated, and this
was honoured by the prison until such time that he could only be cared for
properly in the healthcare centre.
47. I have no doubt that healthcare staff and unit staff did all they could, within
their means, to manage the man’s illness and make his life as comfortable
and dignified as possible. He was continuously reassured when struggling to
come to terms with his illness, received 24 hour inpatient care and, when
rapidly deteriorating, was compassionately managed by senior prison staff,
the chaplaincy and the healthcare team who followed his palliative care
package closely.
48. That said, although there would have been no effect on the ultimate outcome
for the man, the investigation highlighted a number of areas where practice
could be improved.
Record keeping
49. Prison Service Order 1025 provides guidance on when and how to complete a
Prisoner Escort Record (PER) form. Chapter 1 (1.8) states that ‘A PER form
is to be completed for every external movement of a prisoner, whether
responsibility transfers to another agency or not and to whatever destination’.
In this man’s case, not all transfers to the outside hospital were accompanied
by PER forms. Where a PER form was completed, it was not filled in
accurately and had been separated from its back page which details the
transfer, appropriate timings and whether restraints were used. Unfortunately,
I have not been able to establish why these inaccuracies occurred.
The Director should remind both dispatching and escort staff of the
purpose and importance of completing a PER form for every prisoner
transfer and refer staff to PSO 1025 for further guidance.
Healthcare Records
50. Healthcare staff at Altcourse showed great determination and commitment in
caring for the man during the last few weeks of his life. It is clear from his
medical record that nurses overcame difficulties quickly to ensure he was
made as comfortable as possible, and followed the palliative care plan
meticulously. What is not always clear from the record is who his primary
carers were for the duration of his stay in the healthcare unit and exactly when
he was transferred to the outside hospital and returned. The man’s medical
records were often difficult to read, incorrectly initialled and signed, and below
the expected standard.
The Healthcare Manager should remind staff that, in accordance with the
Nursing and Midwifery Council’s guidelines for records and record
12
keeping, all medical records should be legible, up to date and in
chronological order. In addition, audits of the quality and consistency
of records should be undertaken in partnership with the PCT on a
regular basis.
Release on Temporary Licence
51. The man had two stays in hospital, one of which resulted in him being away
from the prison for approximately two and a half weeks. This second stay in
hospital came at a time when he was undergoing exploratory procedures to
confirm his diagnosis and was in some considerable pain. Whilst it is not
clear whether release on temporary licence (ROTL) would have been
appropriate, there is no evidence that senior prison staff considered the option
as the best and most compassionate way to manage the man’s stay in
hospital.
The Director should remind senior staff to familiarise themselves with
PSO 2300 and to consider ROTL as a compassionate option where
prisoners experience lengthy stays in outside hospitals or other care
environments.
Following a Death in Custody
52. Immediately following the man’s death, both healthcare and prison staff began
to implement the local contingency plan for a death in custody. A number of
relevant individuals and agencies were contacted and made their way to the
prison to carry out their responsibilities. However, it is clear from the log of
events that, during the early hours of 17 August, the duty director, ran into
difficulties when attempting to contact the police and duty coroner. Paragraph
3.1 of Prison Service Order 2710 (PSO 2710) Follow up to Deaths in Custody
clearly lists all parties who require notification of a death in custody. The PSO
also states that:
“Governors/Directors are responsible for developing, implementing and
maintaining their local contingency plans and protocols for handling the
aftermath of a death in custody and for ensuring lessons are learnt and
shared”.
The man’s records show that it took the duty director approximately two and a
half hours to contact the local police to inform them of his death and longer to
contact the duty coroner. The log does not state when the duty coroner was
finally informed. During the hot debrief, the duty doctor raised the issue of
securing an improved emergency contingency plan in light of the difficulties. I
commend the doctor for bringing this to the attention of the Director.
The Director should review the local emergency contingency plan and
agree a joint protocol between the prison, the police and the coroner to
outline actions required when a death in custody occurs. The protocol
should focus particularly on ensuring that the contact details of all
authorities required to respond to a death are updated regularly.
13
Good Practice
53. The chaplaincy team gave ongoing support to the man. They helped him
when he experienced feelings of fear and frustration throughout his illness.
Both the chaplain and senior prison staff should be commended, particularly
for ensuring that his wish for a fellow prisoner to visit him in the healthcare
centre was met before he died.
54. During the early hours of the morning of 17 August, the night duty nurse who
attended to the man’s personal needs also took the decision to remain at his
bedside until he died. Her actions ensured that he died in the company of
someone who had cared for him. The level of compassion and
professionalism demonstrated deserves a particular mention.
14
CLINICAL REVIEW
55. The clinical review conducted by Liverpool Primary Care Trust commented
that the man’s illness, once formally diagnosed, was cared for holistically and
appropriately by adapting the Liverpool Care of the Dying Pathway to the
prison environment. The review also noted that this is recognised as a gold
standard for terminal care and concluded that all that could be done was done
for him.
56. The clinical reviewer also wrote favourably on the professional relationship
between Aintree Hospitals NHS Trust and the prison healthcare team,
particularly the communication between healthcare staff and outside
hospitals.
57. The clinical review did comment adversely on the presentation and content of
his medical records. A recommendation echoes my own finding in respect of
the legibility of some records.
Good Practice
58. Communication between Aintree Hospitals NHS Trust and the prison
healthcare staff was excellent and should be acknowledged.
59. The care given to the man was of a high standard and holistic, and the prison
healthcare staff need to be acknowledged for this.
15
RECOMMENDATIONS
1. The Director should remind both dispatching and escort staff of the
purpose and importance of completing a PER form for every prisoner
transfer and refer staff to PSO 1025 for further guidance.
The Office of Contracted Prisons accepted this recommendation and said the
following:
“A Director’s Notice to Staff has been circulated reminding staff of the purpose
and importance of completing a PER form.
2. The Healthcare Manager should remind staff that, in accordance with the
Nursing and Midwifery Council’s guidelines for records and record
keeping, all medical records should be legible, up to date and in
chronological order. In addition, audits of the quality and consistency
of records should be undertaken in partnership with the PCT on a
regular basis.
The Office of Contracted Prisons accepted this recommendation and said the
following:
“Since the death of this man, a clinical review IT system has been installed.
This should see the issue resolved. We believe that the clinical records were
in chronological order.
3. The Director should remind senior staff to familiarise themselves with
PSO 2300 and to consider ROTL as a compassionate option where
prisoners experience lengthy stays in outside hospitals or other care
environments.
The Office of Contracted Prisons accepted this recommendation and said the
following:
“Senior staff are familiar with PSO 2300 and in this case release on licence
was considered”.
4. The Director should review the local emergency contingency plan and
agree a joint protocol between the prison, the police and the coroner to
outline actions required when a death in custody occurs. The protocol
should focus particularly on ensuring that the contact details of all
authorities required to respond to a death are updated regularly.
The Office of Contracted Prisons accepted this recommendation and said the
following:
“Local contingency plans have been reviewed and amended. Regular
reviews are now diaried”.
16
GOOD PRACTICE
6. The chaplaincy team gave ongoing support to the man. They helped
when he experienced feelings of fear and frustration throughout his
illness. Both the chaplain and senior prison staff should be
commended, particularly for ensuring that his wish for a fellow prisoner
to visit him in the healthcare centre was met before he died.
7. During the early hours of the morning of 17 August, the night duty nurse
who attended to the man’s personal needs also took the decision to
remain at his bedside until he died. Her actions ensured that he died in
the company of someone who had cared for him. The level of
compassion and professionalism demonstrated deserves a particular
mention.
8. Communication between Aintree Hospitals NHS Trust and the prison
healthcare staff was excellent and should be acknowledged.
9. The care given to the man was of a high standard and holistic, and the
prison healthcare staff need to be acknowledged for this.
17
18