Individual at Bullingdon

Investigation into the circumstances surrounding the
death of a man at hospital,
in August 2006 whilst a prisoner at
HMP Bullingdon
Report by the Prisons and Probation Ombudsman for
England and Wales
February 2007
This is the report into the death of a man who died in 4 August 2006 in hospital,
whilst a prisoner at HMP Bullingdon. He was 39 years old.
Although a prisoner at Bullingdon, first on remand in February 2005 and then
sentenced in June 2006, the man had been an in-patient in hospital since January
2006, being treated for a stomach disorder. He was diagnosed on 28 June as
having metastatic gastric cancer. A post mortem confirmed the diagnosis.
I would like to offer my sincere condolences to the man’s family and friends on their
loss.
The investigation was undertaken by a colleague. I would like to thank the Governor
of Bullingdon and his staff for their help and assistance in the investigation. I am
also grateful to the Oxfordshire Primary Care Trust who was commissioned to
undertake a clinical review into the man’s medical care.
One of my Family Liaison Officers wrote to the man’s wife informing her of my
investigation. No issues have been raised by her.
I make one recommendation in respect of the prison’s obligation when a prisoner is
in hospital. There are two points of good practice where Bullingdon has shown
exceptional work in relation to family issues. The Prison Service have accepted the
recommendation and two points of good practice.
This version of my report, published on my website, has been amended to remove
the name of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2007
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CONTENTS
Forward
Summary
The Investigation Process
HMP Bullingdon
Key Events
Issues
Recommendations
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SUMMARY
1. The man died on 4 August 2006 in hospital. He had been diagnosed with
terminal cancer on 28 June.
2. The man had been remanded to HMP Bullingdon from Magistrates’ Court on
in February 2005, charged with a serious offence. He was convicted at a
Crown Court in October and returned to Bullingdon to wait sentencing. His
sentencing date was delayed owing to his poor health and in-patient
admission to the hospital. The man was taken from the hospital for
sentencing at the Crown Court in June 2006. He received a 10 year prison
sentence.
3. From his first remand date in March 2005, the man spent very little time on a
residential wing at Bullingdon. He served the majority of his sentence in
hospital and shorter periods, when discharged from hospital, in Bullingdon’s
healthcare centre.
4. Whilst at Bullingdon, the man refused medication on several occasions and
failed to attend some doctor’s appointments. He was taken to hospital on two
occasions with throat lacerations which were self inflicted. The man denied
he was trying to kill himself. He said he was unable to cope with pain he was
feeling in his stomach. The man was assessed by mental health staff and not
found to be suffering from a mental illness.
5. The man was last admitted to hospital on 30 January 2006 and underwent
investigations into his medical condition. He remained an in-patient from 30
January until his death on 4 August. At all times, he was escorted by two
prison officers carrying out bed watch duties.
6. A compassionate discharge was unsuccessfully applied for following his
diagnosis of cancer. A second application for a compassionate discharge
was in the process of being submitted when the man died.
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THE INVESTIGATION PROCESS
7. The investigation into the man’s death was opened by my colleague,
on 17 August 2006 when she visited Bullingdon and spoke with the Deputy
Governor. Notices of the man’s death and terms of reference for the
investigation were handed to the Deputy Governor by the investigator. My
colleague obtained copies of the man’s prison file and also considered his
medical notes.
8. A review of the healthcare the man received was carried out at the direction of
Oxfordshire Primary Care Trust (PCT). In their opinion, the man’s medical
care was managed appropriately at Bullingdon and his referral to hospital was
timely.
9. On 7 September, my investigator returned to Bullingdon to speak to the Imam,
and to a member of the senior management team and the Healthcare
Manager. The purpose of this visit was to establish the support and
assistance offered to the man and his family.
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HMP BULLINGDON
15. Bullingdon operates both as a local prison and as a category B training prison
for adult males. The primary catchment area includes the Crown Courts at
Oxford and Reading as well as the local magistrates’ courts. Opened in 1992,
Bullingdon is a ‘New Gallery’ style prison by design. It has four main
houseblocks that have been supplemented by a fifth since 1997. It can
accommodate 955 prisoners.
16. The prison has a range of work, education and training opportunities as well
as a broad programme of Offending Behaviour Groups.
17. The prison also maintains a 24 hour healthcare centre that can accommodate
15 inpatients. In April 2005, the provision of healthcare services was
transferred from the Prison Service to the Primary Care Trust. The prison told
my investigator that the centre was fully staffed by appropriately trained staff
and that recruitment is not an issue.
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KEY EVENTS
Events leading to the death of the man
18. The man was received into Bullingdon on 2 March 2005. A first reception
health screen document was completed. This document recorded injuries to
his eye and a minor knife wound to his right side. These injuries related to an
incident, several days earlier, when the offence for which the man was
charged had taken place. The document also recorded that he had alcohol
problems and was receiving medication for a stomach problem due to ulcers.
The man was admitted to the healthcare centre for observation.
19. Until his last and final admittance into hospital in January 2006, the man
attended healthcare on numerous occasions complaining of stomach pain,
nausea and vomiting. The most significant entries from the medical notes are
very detailed. There were several occasions when appointments were made
for him to see the doctor and attend out-patient appointments. The man had
declined to attend these appointments.
20. All hospital out-patient appointments, and time spent as an in-patient, were
under prison escort, with two officers in attendance.
21. On 31 May 2005, the man was examined by the doctor and referral to a
specialist gastroenterologist was noted. On 18 June at 05.50 am,
healthcare staff responded to a call to see the man in his cell where he had
collapsed. On arrival at his cell, a nurse examined the man who was
conscious. His observations were recorded. He told the nurse he had been
feeling unwell, but had never passed out before. The man declined admission
to the healthcare centre and failed to attend an appointment with the doctor
later that morning. Around mid-day he was admitted to the healthcare centre
after vomiting in his cell. The man returned to the wing at 1.45pm.
Healthcare staff informed the wing that he was to attend an appointment with
the doctor after the weekend.
22. On 19 June, the man was examined by the doctor and referred to a hospital’s,
accident and emergency department for assessment and further tests. The
man was admitted and discharged back to Bullingdon on 23 June with an
appointment to attend the out-patient gastroenterology department in four
weeks time.
23. The man was again referred to hospital by the doctor on 4 July. Further tests
were carried out and he received a blood transfusion. He was discharged
back to Bullingdon’s healthcare centre on
9 July.
24. The next time the man was admitted to hospital was on 25 July 2005 following
a discussion between the doctor at Bullingdon and a medical registrar at the
hospital. Whilst in hospital the man received fluids intravenously. He was
diagnosed with a duodenal ulceration gastric outflow on 22 August and
discharged back to Bullingdon healthcare centre. A care plan was activated
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to record the man’s observations and weight. His notes, following his
discharge from hospital, record that he refused some of his medication
against advice from medical staff. He remained in the healthcare centre until
on 7 September when he was seen by the doctor and deemed fit to return to a
residential wing.
25. The man was seen on the wing by a member of the healthcare team on
19 October as he was complaining of pain and being sick. The member of
staff discussed the man’s medication with the doctor. When he was later
seen by the staff member, he refused the medication prescribed by the
doctor. Between 19 October and 20 November, the man was seen regularly
by healthcare staff, who responded to his complaints of pain and vomiting.
His medical notes record that he had been referred to a consultant
gastrologist.
26. On 22 November, the man was taken to hospital following a self inflicted injury
to his throat. The wound was stitched and he was discharged. The man was
examined for a psychiatric assessment.
27. On his return to Bullingdon’s healthcare centre, an Assessment, Care in
Custody and Teamwork (ACCT) form and care plan was opened. (The ACCT
remained opened until the man’s last admittance into hospital in January.)
The assessment noted that he said he had cut himself because of the pain in
his stomach and that he wanted to kill himself. No evidence of mental illness
or clinical depression was diagnosed. The man was placed on appropriate
anti-depressive medication.
28. On 25 November, the man’s medical notes show an entry that he was due for
surgery at the end of January 2006. Before that date, he required an urgent
appointment with a consultant specialist, at hospital. A telephone message
was left for the specialist by the doctor.
29. On 29 November, the man was admitted to hospital where he received
treatment under the care of the specialist. The man was discharged back to
the Bullingdon on 7 January.
30. The man was taken to hospital with self inflicted lacerations to his throat on 12
January. He was treated for his lacerations and was seen by a psychiatric
nurse. The nurse assessed that the man was not mentally ill, but was a to
high risk of repeated self harm because of the pain he was experiencing.
31. The man was discharged from hospital and returned yet again to the
healthcare centre at Bullingdon. An ACCT form and a care plan was re-
opened and activated on his return. He was placed in a ligature-free cell.
Whilst clearing the man’s previous cell, a quantity of ant-sickness medication
had been discovered in the waste bin. A Security Information Report (SIR)
was submitted and healthcare staff informed so they could watch the man
take his medication.
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32. Over the next two weeks, the man was reviewed and cared for in the
healthcare centre with daily notes entered onto his care plan. He had been
making himself vomit because he said of bloating in his stomach. The man
also had a mental health assessment. There was still no evidence to
suggest mental illness and he denied suicidal thoughts. He was prescribed
Temazepan for two weeks to help him sleep and relax.
33. On 26 January, the man was once again admitted to hospital. He continued
to be in pain and had lost weight. The man was fitted with an intravenous
feeding tube. He underwent investigations and tests to ascertain the exact
nature of his illness. As he was not well enough for discharge back to
Bullingdon, healthcare staff and governors regularly visited the man at the
hospital.
34. The Healthcare Manager contacted the specialist’s secretary on 24 April for a
report on the man’s condition. The Healthcare Manager was told that the
specialist would be happy to provide one. On 9 May, the specialist’s
secretary was again contacted by healthcare staff as the report had not
arrived. The staff member was told the specialist was off sick but a clinical
fellow would write the report.
35. In early June, the man was taken from hospital, under prison escort, for
sentencing at Crown Court. He was sentenced to 10 years imprisonment and
returned to hospital at 6.00 pm that day.
36. A ward sister from the hospital spoke to the Healthcare Manager on
29 June and informed her that the man had been diagnosed with terminal
cancer. His prognosis was very poor. The Healthcare Manager made plans
to visit the hospital at a later date to discuss palliative care.
37. On 11 July, the man’s notes record that he would be transferred to another
hospital for chemotherapy. An application for a compassionate discharge for
the man was sent to the Early Release and Recall Section of the Home Office
by the Deputy Governor. On 20 July, the Healthcare Manager noted in the
man’s medical record that the chemotherapy had been cancelled as there
was little confidence it would be effective.
38. The application for the compassionate discharge was refused on 25 July.
The grounds for the refusal were based on the offence for which the man had
been sentenced and issues identified in the Code of Practice for Victims of
Crime.
39. On 30 July, the Healthcare Manager visited the man in hospital. He was
requiring nursing care and was extremely poorly. Soon afterwards, on 3
August, a member of the senior management team was informed by the
hospital that the man had only three to four days left to live. A letter was
available for collection from the hospital to support a second application for a
compassionate discharge.
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40. At 10.10am on 4 August, the man passed away at the hospital. His family
were not present when he died. The Imam was informed and attended the
hospital where he carried out religious rituals in accordance with the Muslim
faith.
41. A remembrance service, at which special prayers were said, took place on 11
August at Bullingdon during Friday prayers.
42. The prison offered full financial assistance to the man’s family for his funeral.
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ISSUES
Clinical review
43. A review into the man’s medical care was carried out by a doctor who is a
General Practitioner and one of the joint acting clinical governance leads for
Oxfordshire PCT. The doctor reviewed the notes in relation to the
management of the ma’s medical care at Bullingdon. He was not
commissioned to review his medical treatment whilst he was under the care of
the hospital.
44. In the clinical review the doctor outlined the chronological events of the man’s
illness leading to his death. He considered the man’s mental and physical
health, documents and entries in his medical notes and communication
between the prison and the hospital. He noted that the man had harmed
himself on two occasions. Each time, a psychiatric assessment was made on
his mental health. With regard to the man’s physical health, the doctor noted
that he was managed appropriately at Bullingdon and their referral to
secondary care (hospital) was timely. The man’s medical records had been
kept in chronological order. The legibility, dating and signing of the medical
record entries were all reasonable. Communication by Bullingdon nursing
staff with the hospital was deemed as good. They maintained regular contact
with the hospital whilst the man was an in-patient.
45. The doctor concluded that there was no area in which Bullingdon’s medical
and nursing care failed the man. Although he had died at a tragically young
age there was no reason to believe that staff at Bulllingdon could have
changed this.
“ It may be that the hospital could have diagnosed his cancer sooner
but it appears from the hospital letters* that all appropriate
investigations were done at the right time. There is no evidence that
his care was affected because he was a prisoner.”
Family Support Issues
46. Bullingdon offered full support and care to the man whilst he was there and
when he was in outside hospital.
47. The Deputy Governor applied for a compassionate discharge when the man
was diagnosed with terminal cancer. This application was refused on grounds
that he had only recently been sentenced for a violent crime and because of
issues relating to the Code of Practice for Victims of Crime. A second
application for compassionate discharge was being considered when the man
died.
48. The Deputy Governor applied to the Assisted Prison Visits Unit for additional
financial assistance for them to travel to see him whilst he was in hospital.
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Extra visits were also allowed. The extra visits and financial assistance were
appreciated by the man’s family. He was also given financial assistance to
purchase television time whilst he was in hospital.
49. Communication between the prison and the man’s family was facilitated
through the Imam. He followed through this support by attending prayers at
the family home on 5 August after the man’s funeral at a Mosque. The Imam
conveyed condolences to the man’s family from the Governor and staff of
Bullingdon during this visit. A letter of condolences was sent to the family on
behalf of the prison by the Deputy Governor on 16 August.
50. Throughout the man’s stay in hospital as a prisoner, Bullingdon provided
necessary care and support. At times resources were stretched by the need
to provide a two officer bed watch. A full bed watch was continued from his
last admittance into hospital on 30 January 2006 until his death on 4 August.
Good Practice
Applying for financial assistance for the man’s family to visit him in hospital
and offering support following his death are examples of good practice.
The Imam’s ongoing support to the man in his last few weeks of life and,
following his death, to his family is also an example of good practice.
Issues relating to the diagnosis of the man’s condition on 28 June 2006
51. A case conference was held at the hospital on 28 June. This was to inform
the man that he had cancer and the illness was terminal. Whilst the
conference was held, one escort officer was allowed to stay in the room. The
second officer was asked to leave the room and wait outside.
52. A member of the prison’s senior management team was duty governor for that
day at Bullingdon, arrived at the hospital to carry out a management bed
watch check. On seeing the officer outside the room, the Governor asked him
what was happening and was told that he had been asked to leave the room.
The Governor waited for 30 minutes then lightly knocked and entered the
room where the man, the bed watch prison officer and hospital staff were
present . She was immediately told to leave by a medical consultant, which
she did.
53. After the conference had finished, the Governor was informed by a
non-medical member of staff from the Patient’s Advice and Liaison Service
(PALS) that they had given bad news to the man about his medical condition.
The Governor asked the PALS officer if the prison had been informed of this
news and was told this had not been done. The PALS officer asked the
Governor how an application could be made for a compassionate discharge
for the man given his condition. The Governor informed her she would have
to make some enquiries.
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54. The Governor completed her management check when hospital staff had left
the room. The Governor offered support to the man and the bed watch
officer, realising that both had found the discussion distressing. On return to
the prison, the Governor briefed the ‘ on coming’ duty governor on the
situation and wrote a report.
55. It is regrettable that hospital staff did not consult with prison healthcare or
senior prison management over the case conference and issues relating to
the man’s diagnosis. The Healthcare Manager had been in regular contact
with the ward. The Healthcare Manager told my investigator that had she
been pre-warned about the case conference she would have been able to
offer support and advice to the man and to prison staff. Being unaware as to
the nature of the case conference, the Governor and the bed watch staff
were placed in a difficult and emotive position. Whilst patient confidentiality is
important, the man was still a serving prisoner at Bullingdon. The prison was
responsible for his care and he was subject to prison regulations.
Communication with the prison before the case conference would have
assisted in preparing Bullingdon for the continued long term bed watch and in
providing support for the man and prison staff. In addition, the question over
the timing of an application for compassionate discharge required a
discussion with senior prison management and the medical consultant before
involvement of other staff based at the hospital.
56. I note that a letter was sent on 29 August to the Governor at Bullingdon by
the, acting chief nurse at the hospital. The acting chief nurse would be
arranging a debriefing session with key staff involved in the man’s care. The
acting chief nurse acknowledged that a number of issues had arisen which
would be likely to influence future nursing and medical management of
patients in custody. He also referred to attempts to manage the situation
were too late, but recognised that should similar circumstances arise in the
future he would know the correct procedures to deal with it.
Recommendation
I recommend that the Governor/Head of Healthcare at Bullingdon liaises with
the hospital to ensure the hospital fully understands the prison’s obligations
when a prisoner is admitted to hospital.
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RECOMMENDATIONS
1. I recommend that the Governor/Head of Healthcare at Bullingdon liaises
with the hospital to ensure that the hospital fully understands the
prison’s obligations when a prisoner is admitted to hospital.
Accepted – The Governor chairs and Clinical Governance forum, which can
review the final report and enter into dialogue with hospital ensuring full
engagement with the PCT
Good Practice
1. Applying for financial assistance for the man’s family to visit him in
hospital and offering support following his death are examples of good
practice.
Accepted- Recognition of this element of good practice is appreciated and will
form part of all plans in circumstances such as those highlighted in the report.
2. The Imam’s ongoing support to the man in his last few weeks of life and,
following his death, to his family is an example of good practice.
Accepted - Recognition of this element of good practice is appreciated and the
relevant staff will be advised. This action will form part of all plans in
circumstances such as those highlighted in the report.
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