Individual at Bullingdon

Investigation into the circumstances surrounding the
death of a man, who was a prisoner at HMP Bullingdon,
at Katherine House Hospice on 20 May 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
October 2006
This is the report of an investigation into the death of a man who died from
apparently natural causes on 20 May 2006 at Katherine House Hospice. He was 75
years old.
The man had a significant medical history of chronic disease, including pancreatitis,
hypertension and arthritis. I would like to add my personal condolences to those
already expressed by my Family Liaison Officer on behalf of this office as a whole.
This investigation has been undertaken by one of my investigators. I would like to
thank the Governor of HMP Bullingdon, and his staff for their participation in the
investigation.
A doctor was identified by North Oxfordshire Primary Care Trust to undertake a
review of the man’s clinical care, and I appreciate his assistance. As is the case in
many of my investigations following a death from natural causes, I amgreatly
assisted by the findings of the clinical review. In the case of the man, the review
identifies a number of learning points for the prison and its health provider. I endorse
the recommendations and learning points made in the clinical review and urge the
Primary Care Trust and prison to develop an action plan to address these in a timely
manner.
I note that following his being diagnosed with a terminal illness, the man was
released on temporary licence to spend the last few days of his life at Katherine
House. This was despite the nature of his offences and the length of sentence he
was serving. I believe this to have been entirely proper and an example of good
practice. In other investigations I have mounted, these factors have proved to be a
barrier to allowing prisoners to die with maximum dignity.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2006
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CONTENTS
Summary 3
The investigation process 4
Background 5
HMP Bullingdon 6
Key events 7
Clinical review 9
Conclusion 10
Recommendations 11
Annexes
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SUMMARY
The man was born in 1931. He was 75 years old when he died in the early hours of
20 May 2006.
The man had been received into custody in 2002, after being sentenced to eight
years imprisonment. He was initially held at HMP Bedford and transferred to HMP
Bullingdon on 27 June 2005.
During his first reception health screen, it was noted that the man had pancreatitis,
hypertension, arthritis and spinal problems. As a result of his health problems, the
man was prescribed a range of medication, which he was apparently allowed to keep
in his possession.
The man was taken to Horton General Hospital on 24 March 2006, where he was
diagnosed as having an inoperable brain tumour. On his discharge from hospital on
12 May, the man was granted release on temporary licence (ROTL) and was
admitted to Katherine House Hospice for terminal care. The man was weak, not
mobile and he continued to deteriorate until his death eight days later.
The clinical review concludes that, overall, the man’s clinical care was of an
appropriate standard. He makes two recommendations, which I endorse. The
reviewer also identifies learning with regard to chronic disease management. I urge
the prison and Primary Care Trust to consider carefully his findings and develop an
appropriate plan of action to improve the management of chronic diseases.
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THE INVESTIGATION PROCESS
1. My investigator studied all relevant prison records relating to the man. These
included his main prison record, his medical records and statements made by
staff.
2. The North Oxfordshire Primary Care Trust identified a doctor to carry out a review
of the man’s clinical care. I am grateful for this review being undertaken in a
most timely manner.
3. My investigator contacted Her Majesty’s Coroner to inform him of the nature and
scope of my investigation and to request a copy of the Post Mortem report. Upon
completion, this report will be sent to the Coroner to assist him in his enquiries
into the man’s death.
4. One of my Family Liaison Officers contacted the man’s family. This gave them
the opportunity to meet with the investigator to discuss the purpose of the
investigation, and to raise any concerns or questions that they would like
explored and addressed. In the event, the family raised no specific matters of
concern about the man’s care and treatment whilst he was in custody.
5. My investigator discussed aspects of the man’s treatment with both staff at
Bullingdon and the clinical reviewer.
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BACKGROUND
6. The man was born in London in 1931. He had been married for over 40 years
and was the father of six children. The man’s criminal history began when he
was aged 10 and he left approved school at the age of 15. At 17, he joined the
Royal Air Force but was later discharged because of his criminal record. The
man had a variety of jobs over the following years. He had his own hire car
business and also ran a shop in Brighton. His last employment was as a
handyman for the Guinness Trust. He retired in 1993 on medical grounds.
7. After he was received into custody, the man suffered a number of bereavements,
losing his wife, granddaughter, and an older brother and, finally, a son. He was
granted permission to attend the son’s funeral.
8. The man suffered poor health and had previously been diagnosed with
carcinoma (cancer) of the breast, requiring a mastectomy in 1997. He was
sentenced to eight years imprisonment in 2002, the first time he had been in
prison since 1977.
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HMP BULLINGDON
9. Bullingdon operates jointly as a local and category B training prison for adult
males. The primary catchment area is the Crown Courts at Oxford and Reading
as well as the local Magistrates’ Courts.
10.Opened in 1992, Bullingdon is a ‘New Gallery’ style prison. It has four main
houseblocks, which have been supplemented by a fifth since 1997, and the
prison can currently accommodate 963 prisoners. The Edgcott wing
accommodates those prisoners defined as vulnerable because of the nature of
the offences they have committed.
11.The Governor recently introduced an ‘Over 60 Prisoner Policy’ that allows for
prisoners over the age of 60 to have their cells open during core hours. The
policy is designed to facilitate a better quality of life and more opportunity to use
the prison’s facilities.
12.Provision of healthcare within Bullingdon is the responsibility of the North
Oxfordshire Primary Care Trust. Overnight and weekend cover is provided by
local GPs who are on call. There is also a clinically qualified member of
healthcare staff on duty at these times. Medication is administered on a weekly
and/or monthly basis to those prisoners who have been assessed as capable of
holding it in their own possession. It is administered on a daily basis to other
prisoners, when they are considered to be at risk or the medication is unsuitable
to be held in their possession.
13.There is an in patient unit with 24 beds and all cells have integral sanitation. This
is staffed by discipline and clinical staff who provide health and social care for
patients with mental health needs, and for some with physical needs who require
a 24 hour nursing presence.
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KEY FINDINGS
14.The man arrived at HMP Bullingdon on 27 June 2005. During the health
screening procedure it was noted that he had pancreatitis (disease of the
pancreas), hypertension, arthritis and spinal problems. It was also noted that the
man had previously undergone a mastectomy for breast cancer. A range of
medications were prescribed to treat his various conditions and he was allowed
to keep them in his possession for self medication
15.The man’s granddaughter was murdered while on her honeymoon in the
Caribbean in December 2002. His wife died after a long illness in April 2003. He
also lost an older brother. One of the man’s sons died in September 2005.
16.On 5 February 2006, the man was admitted to the healthcare centre following an
assessment at an out patient department. It was reported that he had a
temperature and a chest infection.
17.On 27 February, the man was again admitted to healthcare as an in patient. He
was confused, not eating, tearful and experiencing communication problems. He
was discharged the following day.
18.On 24 March, the man was admitted to Horton General Hospital as he was
becoming increasingly confused. He had a CT (Computed Tomography) scan of
his head which revealed an inoperable brain tumour.
19.Whilst he was an in patient at the hospital, a bedwatch was carried out by a
member of prison staff. Nursing staff from Bullingdon kept in touch with the ward
and also visited The man on occasions.
20.In light of the man’s deteriorating health, the prison identified what arrangements
could be made to care for him in the community. Arrangements were made for
the man to be granted release on temporary licence (ROTL) on compassionate
grounds, and he was moved to Katherine House Hospice on 12 May 2006. At
this time he had been refusing to communicate and was also at times refusing to
take his medication.
21.When the man was admitted to Katherine House his condition was described as
very weak. The prison maintained contact with the hospice and staff also visited
the man. However, his condition continued to deteriorate and he passed away in
his sleep in the early hours of 20 May 2006.
22.After Katherine House notified the prison that the man had died, a representative
from the prison’s chaplaincy department contacted the man’s family to notify
them of his death and to offer condolences and support.
23.The Chaplaincy maintained contact with the family and made arrangements for
the man’s funeral, which he later led. The prison provided financial assistance for
the funeral costs.
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24.A post mortem was not carried out, as the man died from a diagnosed condition,
after being released from custody and there was no reason to believe untoward
circumstances were associated with his death.
25.When contacted by my family liaison officer the man’s family did not raise any
concerns about his treatment whilst in custody. The family also said that their
contact with the prison had been positive. I am pleased to record this.
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THE CLINICAL REVIEW
26.The clinical review found that the man had suffered from significant long­term
chronic diseases and noted that he had been diagnosed with a terminal condition
shortly before his death.
27.From the medical records, it is clear that the man was seen regularly by
healthcare staff and, where necessary, referred to secondary care services. The
reviewer concludes that the man generally received a standard of care that was
comparable to that expected in the general community. However, the reviewer
says that one exception to this was the poor control of the man’s hypertension.
He says that the introduction of computerised medical records could improve the
quality of care for chronic diseases, for example hypertension, and also create
an audit trail to demonstrate the service being provided. The care provided to
the man could also have been improved by greater continuity of medical care, as
it appears that the man was seen by at least nine different medical officers while
in Bullingdon.
An electronic patient record system should be introduced as soon as
possible.
Continuity of medical care should be maintained to ensure parents are not
routinely seen by different medical staff.
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CONCLUSION
28.The man died from natural causes in May 2006. He entered his last term of
custody with a very serious undiagnosed physical health problem. Although his
condition was being monitored and assessed regularly by the healthcare centre
at Bullingdon, the underlying malaise was not identified. It was only after his
condition deteriorated that the prison referred him for further investigation at the
Horton General Hospital, where it was established that he had a malignant brain
tumour. The disease was extensive and the prognosis poor. In light of this
development, the prison made timely and appropriate arrangements for his
release on compassionate grounds. I commend the action of managers at
Bullingdon in having made these arrangements.
29.In reviewing the bedwatch log, it is clear that the staff involved with the man’s
care behaved with sensitivity and compassion. The security arrangements at the
hospital seem to have been appropriate, and struck a good balance between
public protection and sensitivity to the man’s circumstances.
30.The clinical review highlights some deficiencies in the continuity of care, the man
having been seen by a number of different medical officers in Bullingdon. I
endorse the two recommendations from the clinical review which need to be
addressed by the North Oxfordshire Primary Care Trust in partnership with the
Governor of the prison.
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RECOMMENDATIONS
Medical
1 An electronic patient record system should be introduced as soon as
possible.
Accepted ­ An NHS collective has begun to develop an implementation plan
for the introduction of electronic patient records. They should be ready to
present a completed plan in 2007.
2 Continuity of medical care should be maintained to ensure parents are
not routinely seen by different medical staff.
Partially accepted ­ HMP Bullingdon accept that continuity of care is best
practice and their situation has been stabilised by having a GP contract in
place that gives the assurances recommended, however this is dependent on
staff/doctors remaining in post, so it is the ideal rather than something that
could be delivered without question in all circumstances.
Good Practice
Ø The prison made timely and appropriate arrangements for the man’s
release on compassionate grounds. I commend the action of managers at
Bullingdon in having made these arrangements.
Ø The staff involved with the man’s care while he was subject to bedwatch
behaved with sensitivity and compassion.
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