Individual at Birmingham

INVESTIGATION INTO THE DEATH OF A MAN
WHO DIED IN A HOSPICE WHILST A PRISONER AT HMP BIRMINGHAM
REPORT BY THE PRISONS AND PROBATION OMBUDSMAN FOR ENGLAND
AND WALES
July 2006
This is the report of an investigation into the circumstances of the death of a man
who died, according to his family, aged 45 years in a hospice in Birmingham. At the
time of his death the man was a sentenced prisoner in HMP Birmingham. The cause
of death given by the pathologist on 17 January 2006 at the post mortem was:
1a Bronchopneumonia
b Carcinoma of Bronchus
2 Metastasis of lung & lymph nodes
This investigation was carried out by two of my investigators. A doctor from the West
Midlands Postgraduate Medical and Dental Deanery carried out a clinical review of
the man’s medical care and treatment for which I am most grateful.
l extend my condolences to the man’s family on their loss.
I would like to thank the Governor of HMP Birmingham for making the necessary
facilities available to my investigators, and thanks also to the liaison officer for his
invaluable help and support
The Inquest into the man’s death was held on Wednesday 21 June. The verdict of
the jury was that the man died of natural causes.
Emma Bradley
Deputy Prisons & Probation Ombudsman July 2006
2
Contents
Summary 4
Investigative Process 5
HMP Birmingham 6
The man 7
Events leading to the man’s death 8
Issues 12
Consideration of Issues 13
Conclusions 17
Good Practice & Recommendations 18
Clinical Review Recommendations 19
3
Summary
The man was 45 years old when he died. He was received into HMP Birmingham in
January 2005 as a licence recall. At Birmingham, he completed a detoxification
programme for his substance misuse. The man was transferred to HMP
Featherstone on 20 May 2005.
On 30 October at Featherstone the man suffered a stroke and was admitted into the
New Cross Hospital (stroke unit). This stroke left him physically impaired and unable
to cope without 24 hour nursing care. On his discharge from the hospital on 30
November, the man was taken to HMP Birmingham.
Whilst in Birmingham the man stayed within the Healthcare Centre. During this
period of time he complained of pain, difficulties in breathing and generally feeling
unwell.
During December medical tests were arranged by two prison doctors. These
revealed that the man probably had cancer with bony metastasis. The man was
therefore placed on the pain relief medication Morphine. He was kept as comfortable
as possible. The man’s family were contacted by the prison doctor who informed
them of the sad news. The family visited the man on the ward in the Healthcare
Centre.
Staff were supportive of the man and his needs. A fellow prisoner befriended the
man and for a while they shared a cell together.
It became clear that the man was terminally ill and as his health continued to fail,
procedures were put in place to release him on temporary licence to a hospice.
On 12 January 2006, the man was transferred to a hospice in Birmingham where his
palliative care continued until his death on 15 January.
In this report a total of six recommendations are made regarding clinical care.
4
Investigation Process
My practice in apparent deaths from natural causes is to conduct an initial review to
determine the extent of the investigation required. My investigators visited
Birmingham on 19 January 2006, and spoke to the appointed liaison who outlined the
facts relating to the man’s stay in Birmingham and his transfer to the hospice. My
investigators were given access to the man’s records, including his medical record.
Notices to staff and prisoners were issued announcing the investigation and
providing them the opportunity to contribute to it.
A family liaison officer from my office contacted the family of the man. Both he and
my investigator met the family on 6 February and explained the purposes of the
investigation and its process. They also listened to the concerns of the family.
The clinical reviewer, an Associate Dean at West Midlands Postgraduate Medical
and Dental Deanery, carried out a clinical review of the management of the man’s
health needs whilst he was at Birmingham on behalf of Heart of Birmingham Primary
Care Trust.
My investigators interviewed several members of staff at Birmingham in relation to
the man’s health care.
The interviews took place over two days, and Birmingham kindly provided facilities to
enable my investigators to work uninterrupted.
Her Majesty’s Coroner for Birmingham was contacted to inform him of the nature and
scope of the investigation. A copy of the post mortem report was also requested. My
report was sent to the Coroner to assist with the Inquest which was held on 21 June.
5
HMP Birmingham
Birmingham is a local Victorian prison built in 1849. It is a category B prison serving
two Crown Courts and numerous Magistrates Courts in the West Midlands area. It is
a prison that holds adult males on remand and those sentenced.
Birmingham has recently undergone a multi million pound investment programme.
This includes a new Healthcare Centre.
The healthcare is provided by the Primary Care Trust (PCT) Heart of Birmingham,
although the PCT commissions Birmingham and Solihull Mental Health Trust to
provide the staff in the Healthcare Centre. The Healthcare Centre is able to hold 34
patients, 17 on each ward. Most cells are single occupancy although there are two
doubles on each ward.
6
The Man
The man was born and brought up in Birmingham. He had a happy childhood and
went to a mainstream school. The man left school at the age of 16 with a number of
formal qualifications. As a child and adult he had a good relationship with his family.
and had five children, four of whom are grown up and his youngest, a son, lives in
Ireland with relatives.
The man had a prolific offending history and had been in prison many times. It is
thought his addiction to heroin was the catalyst for these convictions.
The man was recalled to prison in January 2005 after breaching his early release
conditions from a previous period of imprisonment.
When my investigator visited the man’s sister, she expressed frustration at not
knowing why her brother’s licence was revoked.
The revocation of his licence was due to the fact he breached conditions 5(iii) and
5(vi):
“5(iii) Failed to live where reasonably approved by your supervising officer and notify
him or her in advance of any proposed change of address”.
“5(vi) Failed to be of good behaviour, not to commit any offence and not to take any
action which would jeopardise the objectives of your supervision namely to protect
the public, prevent you from re-offending and secure your successful re-integration
into the community”.
On 28 February the man appeared before Birmingham Crown Court and was
sentenced to 3 ½ years imprisonment for a further offence, committed whilst on
licence. For the breach of his licence he also had to serve the remaining time of 18
months.
7
Events leading up to the man’ death
The man began his recall period on 24 January 2005, at HMP Birmingham. He was
transferred to Featherstone on 20 May 2005 and returned to Birmingham on 30
November 2005.
During his stay at Birmingham the man commenced a 12 day detoxification
programme for his drug abuse. He completed this programme successfully.
There are a few other entries within the medical record. These relate to back pain,
which the man explained resulted from a fall five years previously. Other complaints
include cough, cold and toothache.
The most significant entry related to the man being admitted to hospital from
Featherstone on 30 October following a collapse and suspected overdose of five
Tramadol tablets. An ambulance was called and he was taken to New Cross
Hospital (stroke unit) before being transferred to West Park Rehabilitation Centre in
Wolverhampton. Whilst in New Cross Hospital it was confirmed that he had suffered
a stroke to the right side of his brain resulting in left sided weakness. This diagnosis
was confirmed by a CT scan. He was discharged from hospital to Birmingham
prison, as Featherstone prison did not provide the 24 hour nursing care that he
required.
He was discharged on the following medications; Aspirin, Simvastatin (lipid reducing
drug) Co-codamol, Folic Acid, Citalopram, Tramadol, Dihydrocodeine, Zopiclone and
Temazepam.
At Birmingham the man was located in the Healthcare Centre. He had poor mobility
of his left arm, left sided facial weakness and slurred speech.
On 1 December, the man was seen by a doctor who reviewed his medication. The
doctor changed the Co-codamol to Paracetamol and stopped the DF118 (pain killer)
and Temazepam. The consultation was recorded in the prisoner’s medical record.
On 2 December, the man saw the first doctor who was very involved in his care and
during this consultation he complained of pain. The man also told the doctor that he
was not eating. The possibility of the man receiving Fortisips (food supplement
drinks) was raised, although they were not thought to be appropriate at that stage.
The immediate plan was for nurses to commence a food and weight chart. This
would monitor the man’s food intake and also monitor his weight. The consultation
was concluded by the doctor writing “R/V (review) next week”
The following day, 3 December at 7am the man complained of feeling sick during the
nurses’ medication rounds. The man requested another painkiller from the nurse, as
he thought that there would be none in his system due to his vomiting. This nurse
did not give it to him, on the basis that there was no evidence of vomiting and she
would not want to risk an overdose of medication. She advised him not to eat or
drink until he felt better. The nurse’s entries are recorded in the Multi-disciplinary
Clinical Notes.
During the afternoon of 3 December, the man was seen by another registered
general nurse (RGN). She said that he appeared tired, and had not been eating due
8
to lack of appetite. She made an entry in the medical record for the doctor to see the
man on Monday (5 December).
The following day the man continued to complain of generalised pain and his appetite
remained poor. The man remained in his cell and declined the offer of association (a
period of time when prisoners mix with one another outside of their cells).
The man continued to suffer pain throughout December with only occasional days
where he was reportedly pain free. His general well-being was varied. On occasions
he enjoyed association and mixed well, but on others he remained in his cell.
On 10 December, the man was seen again by a nurse, she recorded in the clinical
notes that “The man has been feeling better today. No complaints of pain raised in
between medication. Utilised association time without any problems, spent time in
cells 1 and 4. Eating and drinking well”.
It should be noted that on 8/9/10 December entries do appear in the clinical notes
whereby the man requested more paracetamol but staff declined to give it, for fear of
exceeding maximum dosage.
However, on 12 December an entry recorded in the clinical notes by another nurse
said “The man complained that he continues to be in a great deal of pain. Also
informs me that he has vomited a small amount of blood, which has happened
before. He generally looks unwell, gaunt and pale in appearance, for doctor’s
attention today”.
The same day, after a consultation with the doctor it is recorded in the medical record
that “he is still in pain not eating well and coughed up blood. Suffering with SOB
(shortness of breath). On examination widespread crackles in lungs heard”. The
doctor prescribed the antibiotic Amoxicillin and a Salbutomol Inhaler to help with the
man’s breathing. She also requested a sputum culture from him and arranged for a
number of blood tests to be carried out.
On 20 December the same doctor telephoned for the blood test results. On receipt
of these she informed the man that they suggested a possible bone abnormality and
that a further test had been arranged for the next day. At this point his pain killer
Ibuprofen was changed to Diclofenac, a stronger painkiller.
At about 4.45pm the man was seen by a nurse. The man was worried about his
health, and wanted to know the results of his blood tests. During this one to one chat
the man asked to speak to the modern matron. A further entry at 6.55pm stated that
the modern matron was unable to visit the man that day, but would visit the following
day.
My investigators spoke to the modern matron to ask what it was the man wanted to
talk to her about. Unfortunately she was not able to recall this, although she
suspected it was about his pain control, which was addressed by the doctors.
On 21 December, the man went to New Cross Hospital in Wolverhampton for a bone
scan. He returned to the prison about 3pm. On his return he felt tired and in pain.
He remained in his cell over the association period and requested pain relief.
On 23 December, the probable diagnosis was made that the man had lung cancer
with bony secondaries and it was planned to start him on a sliding scale of Morphine.
9
This was explained to the man by the doctor who had arranged his tests. She faxed
an urgent request to the local oncology department. An appointment came through
on 5 January, but the man was too unwell to attend. The same day, the man was
due to have a chest x-ray, however he refused to go as he was struggling to breathe
and felt he would have found it too much of an ordeal. His first dose of Morphine was
administered at 4.25pm, when the man described his pain as slight. His next dose
was at 8pm. At 9.40pm the man requested additional Morphine. An extra 10mgs
was administered.
Over the next few days the man continued to be in pain, despite having received his
Morphine. His mood was variable, some days were better than others. He
interacted with other prisoners when he felt well enough to do so.
On 26 December, The man was reported to be “pain free at the present time”. His
spirits were recorded as good, and he was settled in mood. This note was written by
a RMN in the clinical notes.
On 27 December at 7.30pm a male nurse wrote “We have rang Badger Doctors to
recommend a safer dose 60mgs appears too much as the patient is frail and not
having the necessary observations for Morphine patients”. In the same entry he
continued with “I have declined to give him 10mgs more since he had 60mgs at
17:00hrs”.
The second doctor involved with the man’s medical care wrote in the medical record
the following day.
“If nursing staff feel unhappy about giving high doses of opiates at night when they
are unable to monitor his condition. Discussed nature of illness and the requirement
for effective pain relief.
Plan: nursing staff feel unable to give 60mgs at night they should give 40mgs but be
willing to give as many additional 10mg doses as he asks for.
Once requirements worked out slow release meds need to be prescribed.
Currently appears fairly stable. Cough white sputum looks better than last week.
Awaiting outcome of request for compassionate discharge”.
The first doctor repeated this instruction by making an entry on the prescription
charts so there was no doubt. She wrote “He can have top up doses of Oromorph as
frequently as required. He does not have to wait 4 hours. Please ensure it is given at
night when asked for. * DO NOT DENY HIM HIS PAIN RELIEF*”.
On 28 December an entry by a nurse expressed concern by the nursing staff
regarding the prison environment not being conducive for palliative care. These
concerns were raised with the clinical service manager and modern matron
The man’s health continued to deteriorate. Entries in the clinical record indicate that
staff appeared attentive to the man’s needs throughout a difficult time. On
consultation with the second doctor on 4 January a plan was put in place for a
member of staff from a hospice to visit. The man also requested at that point that his
family be informed of his ill health so a visit from them could be arranged. The same
day, the man’s father and sister were both contacted by the doctor.
10
On 5 January, a hospice worker visited the man. A note was made in the clinical
notes by another nurse “Worker from hospice visited today, will visit again on a
weekly basis but if need in between times can be contacted and will come in”.
On 6 January, this nurse discussed with the man the option of having a member of
the clergy visit. The man did not feel like a visit from a vicar at that time, but said he
would ask when he felt ready.
During 6 and 7 January, it would appear that the man had little sleep and complained
of a great deal of pain. He received a visit from his family which took place in the
group room in the healthcare centre.
It is also recorded that during that weekend the man asked to move cell, he
requested to share with a fellow prisoner he had befriended who offered him a great
deal of support. The sharing of the cell was arranged temporarily depending on what
the doctor thought. She had no objections. However, this cell sharing did not last
long due to the man’s failing health. My investigators spoke to the cell mate who
confirmed that he and the man were friends and shared a cell briefly He was unable
to add information that was relevant to this investigation.
On 12 January, an entry in the medical record made by the doctor states “Rapid
deterioration, unable to swallow seen by member of hospice, prognosis less than 48
hours, needs syringe driver. Urgent referral to hospice. Urgent ROTL (release on
temporary licence) meeting 4.45pm”.
A governor grade chaired the ROTL board, also in attendance were two other
governor grades, the doctor and a member of staff from the National Probation
Service. The board was in favour of the ROTL application and following the
authorisation of the governing governor, the man was discharged from Birmingham
prison to the hospice. He arrived at the hospice later that evening.
He was accompanied by a nurse in the ambulance for reassurance. It is the prison’s
policy to visit a prisoner after a ROTL, this is a visit that occurs after a prisoner has
been away from the establishment for 3 days. Sadly, due to the man’s rapid death,
no visit took place.
The hospice updated Birmingham prison’s healthcare staff for the few days that the
man was there and the clinical notes reflect this.
During 14 and 15 January the man was extremely poorly. He was unable to eat and
was placed on constant oxygen. His family attended his bedside and were present
when he passed away. The man died on 15 January at 2.30pm.
The family received a letter of condolence from the prison after the man’s death and
they were also offered assistance with the funeral expenses.
11
Issues
The man’s sister raised a number of issues with my liaison officer and investigator
during the visit they made to her.
Her issues were the following.
1 The exact date of the man’s diagnosis is not known to the family.
2 The family feel that, given the man’ difficulty in swallowing, he should have
been placed on a special diet.
3 The family experienced a long delay at the prison when visiting to collect the
man’s personal belongings.
4 The family feel that the man was not being assisted with personal hygiene, for
example, shaving and washing.
5 The family feel that the man should have been released to a hospice sooner.
I sympathise with the family over their loss and understand their concerns. I believe I
have attempted to address the concerns in a fair and independent manner.
Also during the course of the investigation other matters became of concern to my
investigators. These, too have been explored.
6 The issue of nurses questioning the doctors about the amount of Morphine
prescribed to the man, and indeed refusing to give extra to him on one
occasion.
7 There appears to be inadequate staffing levels in Healthcare.
8 I feel it is an issue that the Healthcare Centre is staffed by psychiatric nurses
rather than a multi-disciplinary team.
9 There appears to be confusion between ROTL and Release on
Compassionate Grounds. It appears that medical staff are unsure how to
initiate these processes and who to approach regarding them.
12
Consideration of Issues
1 Exact date of diagnosis being unknown. The investigation has concluded
that the man was informed of his cancer on 23 December. The medical
record shows that it was not until 4 January that he requested that his family
be notified. As the man was of sound mind it was appropriately left in his
hands as to when his family should be told of his diagnosis. This is entirely
consistent with medical confidentiality. The diagnosis was made on a highly
likely basis after a series of tests had been carried out. These were blood
tests, bone scans and x-rays. All of these results were indicative of cancer.
On receipt of this information on 23 December, the man was spoken to by a
doctor where he had the diagnosis of cancer explained to him and was then
prescribed Morphine to aid pain relief. For a confirmed diagnosis the man
would have required a tissue biopsy. It was felt that, given his condition and
the fact that this was an invasive procedure, the man would have been too
unwell to cope with it.
2 The man not having received a special diet. Whilst the possibility of
Fortisips (food supplement) drinks was discussed on his initial consultation on
2 December, the doctor did not feel it appropriate at that stage, as the man
was an adequate weight of 62Kg. A food and weight chart was commenced in
order for staff to monitor the man’s weight and food intake. However, as the
man’s health continued to deteriorate and he found it difficult to eat, the
decision was made to give him the Fortisips. These were dispensed from the
chemist on 5 January as instructed by the other doctor caring for the man.
The man was prescribed and received four of these drinks a day along with
other meals provided. The only entry that appears in the records relating to
the man being unable to swallow is made on 14 January. At that point he
was in the hospice.
The Clinical Reviewer confirms that the provision of a liquid food is normal
practice with cachetic patients.
3 Length of time the family were kept waiting at the prison when they
attended to collect the man’s personal belongings. The family say they
were kept waiting 55 minutes. On arrival the appointed governor did
apologise to the family and this seemed to be accepted at the time. When the
prison was asked about this delay, they confirmed that unfortunately the family
did experience a wait in reception. Whilst any delay is not ideal, it is the
circumstances in which the visit was taking place that made it particularly
distressing and unacceptable.
4 The man not receiving help with personal hygiene. My investigators did
ask the nursing staff, the clinical services manager and both doctors about
this. The nursing staff said that they offer patients a shower everyday, it is up
to the patient if he chooses to have one. A request for a bath can be made
and is usually accommodated. My investigators asked if they would
encourage a patient to have a shower/shave if he had not had one for a
couple of days. They were assured that encouragement would be given.
13
Both doctors involved in the man’s care said that up until the last week or so
the man would have been capable of washing and shaving himself. However,
the doctors felt that it should be appreciated that someone so ill and in so
much pain probably just did not want the aggravation of a shower and shave.
Both did feel that his cell was dirty, but this was probably due to the man
having regular visitors to his cell and the amount of cigarettes being smoked in
there.
The Clinical Reviewer addresses this issue in his key findings by saying “In
response to the specific query about the patient appearing ”unkempt” I am not
at all surprised that so ill a patient should have neglected his appearance and
bone pain could certainly have caused additional discomfort and failure to
perform the simplest acts in someone, especially with a recent stroke”.
The clinical services manager, said he would expect a note to be made within
the clinical notes if there was something significant to comment on like a
patient refusing a shower or being on a dirty protest. The fact that no entry
was made suggested to him that the man showered daily. However, my
investigators pointed out an entry on 8 January by a nurse “Given big bath,
shave, bed linen changed mattress turned and made to feel comfortable”. The
Clinical Services Manager was unable to comment on why that entry was
thought significant. The man’s sister feels that this entry occurred as a result
of her expressing concern about her brother to prison staff.
My investigators were sadly not entirely convinced that the man would have
received the encouragement and help he required with his personal hygiene.
Nurses did comment that there would only usually be two nurses working with
17 patients. It is for this reason it may not always, understandably, be
possible to take the time required with certain individuals from such a
demanding range of patients. However, I feel that this is no excuse and
address this in my recommendations.
5 Release on Temporary Licence (ROTL) not being considered sooner.
The man had the likely diagnosis of cancer with secondaries made on 23
December. The request for release on compassionate grounds was referred
to by a doctor on 28 December in the man’s medical record “Awaiting decision
of release on compassionate grounds”. On 4 January a worker from the
hospice visited the man after an urgent referral was made by the doctor. It
was hoped that a decision would be made within a week regarding the
hospice accepting the man into their care. The doctor and the hospice were
discussing the provision of an emergency bed if and when required as in fact
happened. The doctors were not planning to admit the man to the hospice at
that stage. The immediate plan was for the hospice worker to visit again the
following week. The doctors thought at that stage the man had three to six
months to live, although they accepted this was difficult to judge. However,
the man sadly deteriorated very quickly and this was not so. He was
transferred to the hospice on 12 January three weeks after his initial
diagnosis. It is extremely regrettable that perhaps he was not released
sooner, but it is of comfort to know that when he did pass away it was with
14
dignity and in the presence of his family in a hospice and not in a prison cell.
The sister reported to my family liaison officer that it was on her insistence
following a visit to her brother that he was transferred to the hospice.
.
6 Nurses questioning the Doctors about the amount of Morphine
prescribed and declining to give additional Morphine on one occasion.
Had specialist nurses been available, it is likely that the man would not have
been denied additional Morphine on the evening of 27 December 2005.
When my investigators spoke to nursing staff about caring for a dying man,
they felt that the nurses were uncomfortable with having to do that, given the
restrictions of the environment. Whilst it is disturbing to think the man was
denied his additional request, I accept that the nurse acted with the best of
intentions. I also note that the Nurses and Midwifery Code of Conduct says
“You must acknowledge the limits of your professional competence and only
undertake practice and accept responsibilities for those activities in which you
are competent”.
The Clinical Reviewer says “Only at home and in a hospice can an individual
patient have the ability to control personal pain relief. In palliative care patient
needs override dispensing protocols as clinical safety issues have become
irrelevant, although it is hard to see how a prison, given its rules, could
accommodate this.’’
7 Are staffing levels in healthcare adequate?
The nursing staff gave the impression that they were under resourced. The
healthcare centre has two wards, each holding 17 patients. Most of the
patients are mentally ill and there are few medical admissions. The nurses
have a huge demand put on them by these mentally ill patients. There are two
nurses on duty in the morning and three in the afternoon, plus the discipline
officers. These nurses specialise with psychiatric patients, not medically or
terminally ill patients. I feel it is for these reasons the man may not have
received at times the attention he required.
8 The healthcare centre is staffed by psychiatric nurses rather than a
multi-disciplinary team. Birmingham offers 24 hour nursing care. It has a
multi million pound healthcare centre, with beds for 34 patients. These
patients are primarily prisoners with psychiatric issues. The nurses specialise
in this field. The PCT commissions the MHT (Mental Health Trust) to provide
the staff for healthcare. Whilst I appreciate in the main these staff are able to
care for and manage the patients, there will be occasions when other
expertise is required. It is for this reason that I recommend a skill mix review.
9 Confusion between ROTL (Release on Temporary Licence) and Release
on Compassionate Grounds. I have concerns about the
way in which the man’s ROTL was handled initially. The first mention of
release appears in the medical notes on 28 December, “Awaiting decision of
release on compassionate grounds” (compassionate discharge is only granted
in the most exceptional cases. It is a permanent release on licence. Release
15
on Temporary Licence is “temporary release for a said period of time, this may
be attending hospital appointments, receiving inpatient treatment etc”).
When the doctor was interviewed by my investigators about who this issue
was raised with, she said “Everyone, healthcare staff, head of healthcare and
a governor grade”.
The governor grade, however, had no recollection of this. He became aware
of events on 6 January when he was spoken to about the man and his poor
health. A Form Comp 2 (Prisoner’s formal complaint under confidential
access) was completed by the other doctor on behalf of the man. On this form
a request was made for release on compassionate grounds. This form was
signed and dated 6 January.
On 9 January a letter was sent to the Early Release and Recall Department
within the Home Office from the doctor. The letter reflected on the poor
prognosis for the man and the devastating effect his diagnosis had on him and
his family.
“The man’s condition continues to deteriorate rapidly. I judge that his
prognosis is only a matter of months but could be as short as a few weeks. I
therefore urge you to look favourably on his request for release on
compassionate grounds as urgently as possible”
On 11 January, the governor grade was given the Form Comp 2 by the staff
officer. The governor grade was asked to look at this with some urgency.
It appears it was at this point it became clear that the man should be
considered for ROTL, instead of compassionate release. However, the doctor
states that at this stage it was still the plan to release on compassionate
grounds and the prognosis was still looking like weeks, possibly months. The
man only became considered for ROTL when he required an emergency
admission on the 12 January.
By 12 January, the man was so poorly that he had a life expectancy of just 48
hours. An emergency ROTL board was organised. The board concluded by
authorising the ROTL of the man and he was transferred to the hospice that
same day.
It is clear from the events mentioned that, despite their very good intentions,
the clinical team did not know the correct procedure or who to approach to
initiate the release of the man.
16
Conclusions
After extensive input from both doctors, the man was found to be terminally ill with
cancer. Throughout his stay at Birmingham he was located in the healthcare centre
before being transferred to a hospice for palliative care.
On the highly likely diagnosis of cancer, the doctors cared and did what was
practically possible in the given environment to keep the man as pain free as
possible. The general healthcare the man received was probably not as good as it
would have been in the community. This is obviously a concern for the prison which
needs to be addressed. The reason for this may be due to the fact that the PCT
commissions the Mental Health Trust to provide the staff for the Healthcare Centre.
This means that the staff are mainly registered mental nurses. These staff specialise
with psychiatric patients, not medically ill or terminally ill patients. Whilst I appreciate
that they did their best, it is sad that that the services of cancer specialists were not
sought sooner. Had specialist nurses been available or consulted, it is unlikely that
the man would have been denied his request for additional pain relief. Nevertheless,
I commend the nurses for their attempts at caring for a dying man in such a
restricting environment with the other demands put on them.
With regards to the ROTL Application I feel that, given the poor prognosis for the
man, it would have been emotionally beneficial to the family had he been released
sooner. This would have allowed the family more time with the man, especially those
family members who were unable to visit the prison. The possibility of release was
first mentioned within the medical notes (28 December) and at that time I accept that
the doctors genuinely thought the man had weeks, possibly months, to live. Sadly,
the man suffered a rapid deterioration that could not have been foreseen. On the
man hitting crisis point of a life expectancy of 48 hours I feel that the expediency of
his ROTL was handled very well. I feel on the whole the staff at Birmingham did a
reasonable job in caring for the man. However, there are lessons to be learned from
the man’s death and changes that should be implemented.
17
Good Practice
• I commend both doctors for the care and support they provided to the man.
• Sending a nurse to accompany the man in the ambulance to the hospice is
considered good practice.
I endorse the good practice identified by the Clinical Reviewer.
• The quality of the entries made within the clinical notes indicate that medical
staff acted diligently to keep the patient’s family informed of his clinical
problems.
Recommendations
• The PCT should undertake a skill mix review to ensure there are appropriately
trained staff on duty to manage and meet the clinical needs of both physically
and mentally ill patients located in healthcare at all times.
Prison Service Response Target Date for
Completion
Recommendation The PCT is responsible for the provision of primary care November 2006 –
partially accepted nursing support to the prison. In-patient services are subject to PCT
subject to a Commissioning agreement between the PCT approval to budget
and Birmingham and Solihull Mental Health Trust and staffing increase
(BSMHT). The PCT needs to review the Service Level and ability to recruit
Agreement and discuss with BSMHT the nature of the
service requirement for effective management of in-
patients.
The Project Director – Prison Healthcare has submitted a
report identifying key risks relating to nursing provision
and a proposal to increase nursing budgets and staffing
levels. If approved the Lead Nurse will be able to
implement wing based nursing services. The Healthcare
Unit, including in-patient areas, will be considered as an
individual wing for this review.
• Healthcare staff must provide terminally ill patients with appropriate levels of
health and social care to ensure their personal needs are met and maintained
at all times.
Prison Service Response Target Date for
Completion
Recommendation NHS services are not commissioned to provide ‘social January 2007
partially accepted care’. The PCT will work with HMP Birmingham,
Healthcare Commissioners and Strategic Health
Authority to identify how social care needs will be met in
the prison( The project director- prison healthcare has
already had initial discussions with the DOH Prison
Healthcare team)
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The newly appointed Lead Nurse has been asked to
undertake a training needs analysis for clinical staff- November 2006
palliative care will be an element of this work and,
subject to outcome, will be included in the clinical
education/development programme.
• In accordance with the NHS Cancer Plan steps should be taken to address
the training needs of staff to ensure they are able to deliver appropriate
palliative care pathways for patients and involve the patient in their care
planning and end of life wishes.
Prison Service Response Target Date for
Completion
Recommendation Lead nurse has now been appointed and is in post. Key October 2006
Accepted responsibility is to undertake training needs analysis for
members of the Healthcare Team and to organise
appropriate training for staff. All staff will have a
personal development plan.
• The PCT in partnership with the Governor of Birmingham should develop a
multi-professional pathway for the dying patient in line with the Liverpool Care
Pathway. It should include transfer to hospice, diet, pain relief and
communication. I would recommend that there needs to be further dialogue
between Prison Health and the Primary Care Trust, its cancer lead and the
Birmingham Cancer Network about the specific problems of palliative care in
prison.
Prison Service Response Target Date for
Completion
Recommendation The Healthcare manager will be asked to lead the January 2007
Accepted development of a multi-disciplinary pathway for
management of dying patient. The Liverpool Pathway
will be used as a basis for development of the local
pathway. Healthcare manager will seek advice, as
appropriate from PCT Cancer Lead and Birmingham
Cancer Network.
Draft pathway will be submitted to Prison Clinical
Governance Committee for ratification
• I recommend that the healthcare staff are refreshed in ROTL procedures and
are aware of how to initiate this process. It would also be beneficial to train
the staff on the differences between compassionate discharge and release on
temporary licence.
Prison Service Response Target Date for
Completion
Recommendation All GP’s to be given refresher training on ROTL and Sept 06
Accepted compassionate discharge by Governor
• Computerisation of medical records is now virtually universal in primary care in
the NHS and has been shown to be essential for the demonstration of good
quality care. This should be a major priority for the service here.
Prison Service Response Target Date for
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Completion
Recommendation PCT has approved funding proposal for the provision of December 2006
Accepted an EMIS clinical management system in HMP
Birmingham. BSMHT have ‘signed up’ to use of EMIS.
Project plan agreed.
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