Individual at Bristol

The Death in Custody of a prisoner
HMP Bristol – June 2004
Report by the Prisons and Probation Ombudsman for England
and Wales
March 2005
This is the report of an investigation into the circumstances surrounding the
death of a prisoner in HMP Bristol on 23 June 2004. The man had been
unwell for some time with lung cancer and his death was not unexpected. He
had chosen to remain in Bristol prison rather than go to the local hospice (St
Peter’s). He did, however, receive regular visits from a nurse at St Peter’s.
The nurse advised on appropriate respite care and pain relief medication for
him.
The investigation was led by one of my colleagues. An independent review of
the prisoner’s medical care in prison was commissioned from the Clinical
Governance Lead for Bristol North Primary Care Trust.
We would like to extend our condolences to the prisoner’s family and to those
touched by his death.
We would like to thank the management and staff at HMP Bristol for their
assistance and co­operation during the course of this investigation.
This report contains three general recommendations. However, I would like to
draw particular attention to the three other recommendations concerning good
practice revealed by the investigation. Given the very difficult challenge of
caring for a terminally ill man serving a discretionary life sentence, staff at
Bristol demonstrated high levels of professionalism and compassion.
Stephen Shaw CBE
Prisons and Probation Ombudsman
March 2005
2
Contents
Foreword ................................................................. 2
Summary ................................................................. 4
The investigation process ........................................... 5
Background ................................................................. 6
The events leading up to the prisoner’s death ........... 7 ­ 9
The prison response following the death.......... 10
Issues considered during the investigation
Compassionate release ............................... 11
Transfer to Kingston prison and a hospice in Southampton 12
Conclusions & Recommendations ..................... 13 ­14
Recommendations re: good practice ..................... 15
3
Summary
The prisoner was a 62 year old man who was serving a life sentence at HMP
Bristol. He died on 23 June 2004 from lung cancer. His death was not
connected to the fact that he had been in prison, nor to the level of care that
he received whilst in prison.
He was born in May 1942. Prior to his custodial sentence being imposed, he
lived in Portsmouth, Hampshire.
HMP Bristol is a local prison that generally holds people who are on remand.
Once people have been sentenced by a court, they are usually moved to
another prison. Bristol does accommodate some long term and life sentence
prisoners on one unit. This is the wing where the prisoner lived from
September 2003 to the time of his death.
The prisoner was first diagnosed with lung cancer in 1999. In June of that
year, an operation to remove the tumour was successful, but by September
2002, the cancer had recurred. At this time he was given chemotherapy and
the following September a course of radiotherapy. The prisoner was told in
September 2003 that his condition was terminal and that his prognosis was
three to six months.
Various options were looked at concerning the palliative care of the prisoner.
Staff at Bristol prison did much to explore the options that were available to
him. These included transferring himto Kingston prison in order that he could
be nearer his family, early release on compassionate grounds, respite care in
a hospice, and moving from his wing into the Healthcare Unit at the prison.
As it turned out, apart from a day visit to a hospice in Bristol, The prisoner
remained on B wing within Bristol until his death.
There were no major concerns raised by the clinical review about the medical
care that the inmate received. A couple of prisoners told my investigator that
he had complained of chest pains shortly before his death. They seemed to
be under the impression that he might have suffered a heart attack shortly
before he died. The post mortem report indicates that the prisoner died as a
result of a pulmonary thromboembolus (a rupturing of some arteries in his
lungs), which was due to his lung cancer. The chest pains were most likely
due to the size of the tumour in his lung. His heart was healthy.
This report makes three recommendations.
4
Investigation Process
My practice in investigations into a death from apparently natural causes is to
conduct an initial review to determine the extent of investigation required.
My colleague first visited HMP Bristol on 1 July 2004 and met with the Deputy
Governor. She was given a full briefing about the circumstances surrounding
his death and the current situation regarding family contacts and actions
instigated by the establishment to deal with the prisoner’s death. They met
with a representative of the Prison Officers Association. A notice to staff and
a notice to prisoners was issued by the prison, inviting anyone who might
have information relating to the prisoner’s death to make themselves known to
the inquiry team. No one came forward from these notices.
My colleague took away with her all of the files and records relating to the
deceased and then commissioned a clinical review from the Clinical
Governance Lead for Bristol North Primary Care Trust. My colleague then
returned to Bristol in November and spoke to four inmates who all knew the
prisoner, and to governors who had been involved in some of the decisions
relating to himand his care whilst in Bristol.
My family liaison officer contacted the prisoner’s brother. He had some
questions regarding his brother that he discussed with the family liaison
officer. He specifically asked the investigator to talk to prisoners who knew
his brother and to find out about any chest pains that he may have been
complaining about, the day before he died. The prisoner’s brother also
wanted to know why the prison would have handcuffed him, had he been
taken to a hospice. The third question that the prisoner’s brother had
concerned early release on compassionate grounds, and why consideration
could not have been given to releasing himinto the care of a hospice.
5
Background
The prisoner was brought up with three brothers and two sisters. He was
musically gifted, like his mother, and learnt to play the piano at an early age.
His father died when he was 9 years old, and his mother brought up the family
on her own.
The prisoner came to England in 1960 and qualified as a chef. He worked as
a chef and played music in his spare time. The prisoner’s lifestyle as a
musician meant that he spent a lot of time in pubs and clubs and he
developed a drink problem. He was married twice, but both marriages broke
down. He stopped drinking in 1984, after suffering a stroke.
The prisoner was convicted and given a life sentence in July 1998. The judge
passed a discretionary life sentence with a tariff of eight years saying that
both the pre­sentence report and psychiatric report indicated that it was not
known when he would no longer be a risk to the public.
The prisoner had his first Parole Board Review in April 2003. They did not
recommend himfor transfer to an open prison or release on life licence. His
next assessment would have been due in September 2004. The Parole
Board noted that he denied the offences for which he had been convicted and
hence he was unwilling to undertake some of the offending behaviour courses
that were considered appropriate for him. They also recognised that, due to
his medical conditions, he was unsuitable for some of the courses available to
help reduce the risk of re­offending.
The prisoner had been in Bristol prison since 17 July 2003 and had worked for
several months in the library. Staff at Bristol described him as polite and
respectful towards other prisoners and towards staff. The prisoner was a long
term smoker and suffered periodically from epilepsy and insomnia.
6
The Events Leading Up To The Prisoner’s Death
In March 1999, whilst in Winchester prison, the prisoner had a chest X­ray. A
nodule was found in his lung. He had this carcinoma of the lung excised in
June of that year in Southampton General Hospital.
In September 2002, the prisoner was in Full Sutton prison near York. He had
a CT scan which showed a probable recurrence of a tumour in his right chest
wall. He underwent six cycles of chemotherapy, which had the effect of
reducing the size of the tumours. After transferring to Bristol prison in July
2003, the prisoner was seen, in September by a Consultant Clinical
Oncologist. By this time the prisoner was experiencing some discomfort in his
chest. He was given radiotherapy for palliative care. The Oncologist felt that
the prisoner’s prognosis was three to six months at this stage.
The prison considered early release on compassionate grounds for the
prisoner. They completed the necessary paperwork in November 2003.
However, only the external consultant recommended release, due to the short
time that he felt the prisoner had left to live. Neither the Managing Medical
Officer, the Acting Senior Medical Officer, nor the in­charge Governor of HMP
Bristol recommended release. Because of these negative recommendations,
the application was not pursued further with the Parole Board.
A referral to a local hospice in December resulted in a member of the home
care teamvisiting the prisoner in Bristol on 16December. At this first
meeting, she explained her role and talked to the prisoner about his feelings
and how he was generally.
In January 2004, there is a note on the prisoner’s record that the Principal
Officer and B wing staff had raised concerns about himstaying on B wing and
about whether they could manage his care appropriately. Someone from
healthcare spoke to the prisoner following these concerns raised by staff.
She noted that he was ‘very content’ to stay on the wing and that he felt he
could cope satisfactorily. On 10 February, he indicated to medical staff that
he wanted to go to a hospice in Southampton to be near his family. Two days
later the homecare team member from the local hospice visited, and a multi­
disciplinary meeting was held. This involved prison medical staff and a
governor. The member of homecare team explained to the prisoner that
hospices could not normally admit a patient for more than two weeks at a
time. This meant that the prisoner would not have been able to go directly to
a hospice in Southampton, but he might have been able to go for short
periods of time from a prison in that area.
During February and March of 2004, the prisoner was becoming progressively
more unwell. He received visits from the homecare team member on 25
February, 10 March and 31 March. She noted that he was comfortable and
managing on the wing. On her latter visit she recommended that the prisoner
be given more pain relief medication. He was offered a bed within the
Healthcare Unit at Bristol at the end of March but declined this move.
In April he was reviewed by the doctor, who decided that further
chemotherapy treatment was not appropriate due to the fact that the prisoner
had a terminal condition. B wing staff raised concerns again about the
7
prisoner remaining on the wing, but a healthcare entry indicates that he was
continuing to refuse a bed within the Healthcare Unit.
A short term transfer to the local hospice for respite care was looked at. A
bed was offered by the hospice from 20 to 23 April. Arrangements were put in
place to escort the prisoner to the hospice and for prison staff to supervise his
stay there. However, there appears to have been some confusion over the
arrangements as regards handcuffing and the wearing of uniform by the
officers. This caused the visit to be cancelled at the last minute on 19 April.
The governor in the security department was under the impression that the
local hospice had said the stay could only go ahead if the prisoner was not
handcuffed and the staff wore civilian clothing. This was not in fact the case.
New arrangements were quickly made and he was offered a two night stay on
27 April. The prisoner refused to go to the hospice on the morning of 27
April. A nurse spent an hour talking to him about the situation. She noted
that he said he was ‘frightened’ and that he did not want to go to the hospice
because he said he ‘wouldn’t be coming out again’.
Another case conference was held on 5 May, attended by a mixture of
medical staff and prison discipline staff, as well as the prisoner. A note of this
case meeting shows that the prisoner raised concerns about being
handcuffed to the bed. It was explained to him that he would be handcuffed,
but not to the bed, when in the hospice and that he would not be ‘released’ to
go on his own. The group also discussed with himabout looking into a
transfer to Kingston prison, so that he might be able to go to a hospice near
Southampton for respite care. He agreed to let the staff know what he wanted
to do, once he had had time to decide. Two days later he told staff that he
would like a transfer to Kingston prison to be arranged. Several steps were
taken by staff at Bristol in order to try to arrange this move, but for various
reasons, which are detailed later in this report, Kingston prison declined the
transfer request.
On 2 June, he had a further oncology out patient appointment with the Doctor.
After this he went to look around the local hospice and spoke to the member
of the homecare team. Apparently the prisoner agreed, during this visit, to go
to the hospice for respite care / terminal care. A subsequent visit by the home
care team member on 17 June indicates the prisoner had changed his mind
about going to the hospice because he could not tolerate being handcuffed or
having people see him with prison staff around. A note of this meeting
indicates that he was noticeably weaker than on the homecare team
member’s previous visit. There is another note in the prisoner’s medical file
that the aim should be to get himto agree to go to the prison’s Healthcare
Centre when a bed became available. Four days later, on 21 June, there
were still no beds available in Healthcare.
At unlock on 23 June, a wing officer went around the wing and checked all
inmates. He said ‘Good Morning’ to the prisoner and reported that he got a
wave in reply. About ten minutes later, at 8:10am, the prisoner came out of
his cell (B1­28) and spoke to a friend of his. About five minutes later, the
prisoner asked the wing officer to get his medication for him as he did not feel
able to collect it himself. The wing officer said that this was not an unusual
request, and that the prisoner’s mobility meant that he would often ask for
8
medication to be brought up to him. The wing iofficer spoke to a Nurse about
this and she agreed to arrange for delivery of the prisoner’s medication.
Just before 08:40 he was found on his bed by another prisoner. He did not
seemto be breathing. The prisoner who found himtold another prisoner what
had happened. Another Wing Officer says that he shouted to her ‘Gov’. The
Officer rushed to the prisoner’s cell, thought he was not breathing, and so
immediately radioed a ‘code blue’ message to healthcare. On returning to the
cell another inmate said to the Wing Officer that he thought the prisoner was
breathing faintly. A PE Senior Officer and another Senior Officer arrived at
the prisoner’s cell a few seconds later. They had been downstairs in the wing
office and had run upstairs when a prisoner had told them of the situation.
The Wing Officer then ran off to get the resuscitation kit, as requested by the
Senior Officer. As she ran down the stairs, she passed the arriving healthcare
team, who were carrying with them the code blue response equipment.
The PESO said that the prisoner was lying on his bed and that within a few
seconds of her arrival he gasped twice, but then appeared to stop breathing.
The PESO immediately commenced mouth to mouth resuscitation and chest
compressions, aided by the SO. Healthcare staff arrived shortly after and
continued to try to resuscitate the prisoner. The doctor was notified by a
Healthcare Officer at 08:50 that morning. A Doctor attended the prisoner’s
cell on B wing at 08:53 and assessed the situation. Resuscitation had been
attempted for over 20 minutes. The Doctor found no pulse and on attaching
an ECG monitor found that the prisoner had no electrical activity and was not
shockable. He was pronounced dead at 09:05.
9
The Prison Response following the Death
Bristol prison has a comprehensive ‘Death in Custody’ booklet that is
completed by the orderly officer, investigating governor and the doctor in the
event of a prisoner’s death. It provides detailed information including prisoner
details, when and how the death occurred, Coroner information and post
mortem arrangements. My investigator found that most sections of this
booklet had been completed comprehensively and the document was very
useful.
The prison contingency plans for a death in custody were implemented. At
noon in the chapel, a hot debrief took place for all staff who had been
involved. Statements from all those staff who had been involved were taken
and these were found to carry an appropriate amount of detail.
A Doctor carried out the post mortem on 24 June and confirmed the cause of
death to be pulmonary thromboembolus, a consequence of deep vein
thrombosis, caused by lung cancer.
The prison held a memorial service for the deceased on 1 July in the chapel.
The governor issued a notice to prisoners informing them of the service and
invited B wing prisoners and others who knew himto attend and pay their
respects. The service was well attended by prisoners.
10
Issues considered during the investigation
Compassionate release
The prisoner was considered by the prison for early release on
compassionate grounds (under section 30 of the Crime (Sentences) Act
1997). The general principles governing early release on compassionate
grounds are:
· the release of the prisoner will not put the safety of the public at
risk;
· a decision to approve release would not normally be made on the
basis of facts of which the sentencing or appeal court was aware;
· there is some specific purpose to be served by early release.
The rules governing early release go on to say that where early release is to
be considered on medical grounds, the prisoner should be suffering from a
terminal illness and likely to die soon (guide is within the next three months).
The Secretary of State (via the Parole Board) must also be satisfied that the
risk of re­offending is past and that there are adequate arrangements for the
prisoner’s care and treatment outside prison.
The documentation was completed by staff at Bristol prison in November
2003. Neither the Managing Medical Officer, Acting Senior Medical Officer
nor the Governor of HMP Bristol felt able to recommend release at that time.
Their reasons were that the prisoner’s condition was not so severe as to make
him incapable of committing further criminal acts. The governor stated that
the prisoner had not completed any offending behaviour courses which might
have reduced his risk, and he was continuing to deny the offences of which he
had been convicted. The consultant in Clinical Oncology at Bristol
Haematology & Oncology Centre who looked after the prisoner, did support
the early release application due to the fact that he thought the prisoner had
only a few months left to live. He was, however, the only one who did, and
was not aware of the nature of the prisoner’s offence.
The probation team stated in their report that the prisoner’s sister had poor
health and would be unable to look after her brother directly. It was stated
that she would offer support to himif he was released near her home in
Southampton. The report did not go on to say where, if any, suitable
accommodation had been found. It would not have been possible for the
prisoner to have been admitted to a hospice on a long term basis at this point.
Hospices can normally only accommodate people for short periods ­ around
two weeks at a time for respite care.
Due to the fact that there was no real support for the compassionate release
application, the papers were not sent to the Parole Board for consideration.
This seems reasonable, given the fact that there was a negligible chance of
the application being successful at this time.
I am disappointed, though, that there does not appear to have been any
consideration given by the team at Bristol for early release on compassionate
11
grounds in the Spring of 2004 when the prisoner’s condition was clearly
deteriorating.
Transfer to Kingston Prison and a Hospice in
Southampton
On 7 May the prisoner decided to apply for transfer to Kingston prison. His
aim in doing so was to be able to go from Kingston, to a hospice near to his
relatives in Southampton.
Healthcare staff at Bristol responded very promptly to this request. On that
same day arrangements were started. The homecare team member at the
local hospice, was asked to recommend a hospice in the Southampton area
and the Bristol doctor wrote to the doctor at Kingston in order to inform him of
the prisoner’s situation.
On 24 May the lifer governor at Bristol wrote to the Healthcare Unit at Bristol
informing them that the lifer governor at Kingston had told her that they were
unable to take the prisoner on transfer. My investigator spoke to a Governor
and asked her the reasons why the transfer did not go ahead. She said that
whilst the member of homecare team was happy to contact a hospice in
Southampton, she could not actually liaise on their behalf with the prisoner,
and that a new relationship would have to be built up with staff at the
Southampton hospice. There seemed to be uncertainty over how long this
process would take, and whether the offer of a stay in the hospice would be
forthcoming in time for the prisoner to take advantage of it. Clearly, if the
chance of the prisoner getting into the hospice in Southampton was
diminished, there was no purpose in the transfer to Kingston going ahead.
The main concern expressed by Kingston prison was in relation to the fact
that all of his care, since July 2003, had been provided by the medical team at
Bristol prison and the surrounding hospitals. They felt that transferring all his
care at an advanced stage of his illness to a completely new area would not
be sensible or in the best interests of the patient. Kingston do not have an in­
patient facility nor 24 hour nursing cover. The Governor also said she
seemed to recall that the hospice that the prisoner wanted to go to, was not
actually the nearest hospice to Kingston anyway, and that there might have
been further complications in arranging a bed at an ‘out of area’ hospice.
The Governor told my investigator that the prisoner had ‘swung’ between
wanting to go to Kingston and being completely against it. This ties in with
what some of the prisoner’s friends told my investigator when she spoke with
them on B wing.
I can find no reason to criticise either Kingston or Bristol for their decision in
May, not to pursue a move for the prisoner any further.
12
Conclusions & Recommendations
Bristol prison cared for the prisoner to the best degree that is possible, within
a prison setting. The management and staff team were sensitive to his needs
and wishes and took all reasonable steps to accommodate them.
The regular visits and expert advice about medication from the homecare
team member, from the local hospice, is to be particularly commended.
These visits commenced in December 2003 and continued on a regular basis
until the prisoner’s death. The homecare team member also attended several
case reviews organised by the prison to discuss the management and care of
the prisoner and the options available to him.
The prisoner clearly had several changes of mind about whether he wanted to
stay in Bristol prison on B wing, move to the healthcare unit, attend the
hospice in Bristol for periods of respite care, or transfer to Kingston prison.
What is also apparent, however, is that he wished to be nearer to his family so
that they could visit him. Sadly, this was never arranged. Bristol staff did take
several steps to organise a transfer to Kingston prison but the reasons for not
going ahead with the transfer were reasonable in the circumstances.
The next best option, after a transfer nearer home, would have been for the
prisoner to be cared for in the local hospice for short periods when a place
was available. The first opportunity for the prisoner to stay in the hospice was
organised in April, but he declined due to the fact that he would have been
handcuffed to staff wearing uniform. I do not think that Bristol prison were
unreasonable in stipulating that a stay in hospice at this time would have
involved being handcuffed. The prisoner was still mobile in April and the
protection of others in the hospice and the public generally were considered to
be of paramount importance.
The prisoner agreed to go and visit the hospice, prior to deciding whether or
not he wanted to stay as a patient, in early June. On the member of
homecare’s next visit in mid­June, the prisoner had changed his mind again
about going to the hospice as he did not want to be handcuffed. The
governors at Bristol whom my investigator spoke to about the prisoner told her
that their decision was that he would have been handcuffed initially on arriving
at the hospice, but that a later risk assessment might well have indicated that
there was no continuing need for them. This decision was also reasonable
and the prisoner was made aware that the handcuffing issue would be
regularly reviewed. One of the governors seemed to think that it was not just
the handcuffing issue that made himdecline the hospice, but his fear about
dying when he went to one.
Concerns were expressed by the staff on B wing about the prisoner
continuing to live on the wing, as he grew progressively more unwell. The
prisoner was periodically offered the opportunity of moving to the Healthcare
Unit within Bristol, but decided each time he wanted to stay on the wing. The
prisoner’s friends were on B wing and he felt more comfortable with them and
13
staff he was familiar with. Bristol took an understanding approach to his
location in the prison and did not seek to enforce a move to a place where he
would not be happy. Several of the prisoners said that nursing staff visited
the prisoner on an almost daily basis and that arrangements for his meals and
medication were made as necessary. I do not think that the prisoner was
disadvantaged by remaining on B wing instead of going to the Healthcare
Unit.
The first two recommendations are from the clinical review carried out by a
Doctor.
National
Recommendation 1 ­ There was a short delay in the initial referral. Best
practice, in line with the cancer care pathway, would advise that any
haemoptysis in a patient over 50 who is a smoker, should have an
urgent referral for a chest X­ray.
The ultimate goal of the government is to offer patients a maximum of a one
month wait from a urgent referral for suspected cancer to the beginning of
treatment.
Recommendation 2 – Bristol prison medical team should give consideration
to ‘resuscitation policies’ being put into place for certain patients. It was not in
the prisoner’s best interests to have been resuscitated. Although this would
be easy to develop, it would be complex to implement due to the many
different staff and disciplines involved.
Prisons should develop clear policy statements about the resuscitation
of prisoners in accordance with national guidance on consent to
treatment.
Recommendation 3 – The Prison Service’s Safety Custody Group should
remind governors that Applications for Early Release on Compassionate
Grounds should be considered by prisons at regular intervals whilst
they are caring for someone who is terminally ill.
14
Recommendations re: Good Practice
The multi­disciplinary case conferences held to discuss all aspects of the
prisoner’s medical and general care with him were an example of good
practice.
The ‘Death in Custody Booklet’ produced by HMP Bristol provides a useful
summary of relevant information.
The early involvement of nursing staff from a local hospice for terminally ill
cancer patients is good practice. It ensures that patient support and
appropriate advice on palliative care medication is given.
15