Individual at Bullingdon

.
INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING
THE DEATH OF A MAN IN HOSPITAL IN OCTOBER 2004
WHILST IN THE CUSTODY OF HMP BULLINGDON
Report by the Prisons and Probation Ombudsman for
England and Wales
August 2005
This is the report of an investigation into the circumstances of the death of a
man in hospital in October 2004. The man was a serving prisoner at HMP
Bullingdon and, at the time of his death, was four years into a 13-year
sentence.
The post mortem revealed that the cause of death was sepsis, pneumonia
and haemangioblastoma (brain tumour). The man had been taken to the local
hospital on 25 July 2004. On 4 August, he was transferred to another
hospital, where he began a course of radiotherapy. He continued to be unwell
and remained in hospital until he died.
The investigation was carried out on my behalf by one of my colleagues and
my deputy ombudsman carried out the clinical review. The investigator and
one of my family liaison officers met with the man’s elderly mother and the
family liaison officer kept in touch by telephone. I offer my sincere
condolences to the man’s relatives and friends.
The findings of this report speak for themselves. Having recovered well from
brain surgery in January 2001, the man was only required to attend hospital
on a regular basis for scans. In May 2002, a scan revealed a further growth.
No further treatment was deemed necessary at the time but it remained
imperative that regular scans were undertaken to monitor developments.
After Bullingdon failed to ensure his attendance for five rescheduled scan
appointments in 2003-04, his consultant wrote to the prison in February 2004
to express his concerns. When a scan finally took place in June 2004, the
tumour was found to have grown and surgery was immediately undertaken.
However, the extent of the growth meant the man never fully recovered.
I make six recommendations.
Stephen Shaw
Prisons and Probation Ombudsman August 2005
2
Contents
Summary
Investigation methodology
HMP Bullingdon
Events leading up to the man’s death
Issues considered during the investigation
Medical records
Missed hospital appointments
Incentives and Enhanced Privileges Scheme
Release on temporary licence
Contact with the man’s mother
Findings and recommendations
3
Summary
The man died in hospital in October 2004, aged 61. He was serving a 13-year
sentence at HMP Bullingdon. He died from sepsis, pneumonia and a
recurrent brain tumour. At the time of his death, he had been outside of the
prison in two hospitals since 25 July 2004.
In January 2001, the man had been diagnosed with a brain tumour and was
operated on immediately. He recovered well, and by March the only ongoing
treatment required was six monthly MRI scans to monitor any changes. A
scan in May 2002 showed some recurrence, although no treatment was
deemed necessary at that time. However, between July 2001, when the first
follow-up scan took place, and his admission to the local hospital on 15 June
2004, he had had only three scans, the last being on 23 October 2002.
The man did not attend a number of hospital appointments during this period.
Records indicate that on a number of occasions the appointments were
missed because the prison could not staff the escorts.
For some considerable time, he continued to suffer from headaches and other
health problems. Given that he had to go for long periods of time without
being scanned, it is not surprising that, according to his prison visitor, he felt
‘powerless, and just had to wait’.
On 16 June 2004, he had a MRI scan, some 20 months after his last scan.
The imaging revealed a sizeable tumour recurrence and so on 25 June he
underwent surgery for the second time. Unfortunately, his lung collapsed
during surgery and the operation was halted prior to the removal of the
tumour. He declined to have further surgery opting instead to undergo
radiotherapy. He returned to Bullingdon on 2 July. Another hospital
appointment on 14 July did not go ahead as no escort had been arranged.
On 25 July, he had a large rectal bleed and was taken to the Hospital
Accident and Emergency Department. On 4 August, he was transferred to
another hospital and assessed for radiotherapy. This commenced on 16
August. His condition continued to decline.
A clinical review of his treatment found that he was promptly referred to
secondary services when he first began to experience symptoms that proved
to be consistent with abnormal neurological pathology.
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Investigation Process
My investigator undertook a review of all the deceased’s records, including his
medical records. In addition, she visited HMP Bullingdon and spoke with staff
from healthcare and detail. Formal interviews were not undertaken. The
prisons Independent Monitoring Board (IMB) were contacted by telephone and
did not raise any concerns in relation to his case or HMP Bullingdon in
general.
In response to publicity material within the prison about the investigation, the
man’s prison visitor wrote to my office. Subsequently, she has spoken on a
number of occasions with my investigator. In addition, my investigator has
spoken with the secretary of the man’s consultant neurosurgeon and with the
man’s solicitor.
The man’s next-of-kin, his mother, was visited at home by my investigator and
family liaison officer and has maintained contact by telephone. A clinical
review was carried out by my deputy ombudsman and was based on a review
of medical records.
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HMP Bullingdon
Bullingdon Community Prison is a category B local and training prison for
convicted and unconvicted adult male prisoners, serving courts in Oxfordshire
and Berkshire. Opened in 1992, it is a ‘new gallery’ prison by design, with its
four main houseblocks divided into three galleried units. The original house
blocks have been supplemented by a fifth since April 1997. There are single,
double and triple cells. Bullingdon has a healthcare centre that has 22 in-
patient beds and provides 24-hour medical cover.
Edgcott wing, where the man resided, operates as the sex offender treatment
unit and houses a population generally older than the rest of the prison. In
2005, the unit began operating a scheme which allowed the older (over 65)
and infirm prisoners the opportunity to have additional time out of their cells,
over and above association time, so that they could have access to the unit
facilities during the core day. Such a development was prompted by the
concern that in one period of association they were in competition with
younger more able-bodied prisoners for the facilities available. This is a very
welcome development. However, it was not in place when the man was a
resident on the wing.
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The events leading up to the man’s death
The man was received into Bullingdon on 17 June 2000 and underwent a
routine health screen. No physical health problems were recorded. However,
he stated that his optician had told him that he had a tumour behind his right
eye. This was subsequently followed up with a phone call to his optician who
felt that any degeneration seen was likely to be age related.
Court staff had placed him on a suicide and self-harm monitoring system
(F2052SH), because of the serious nature of his offences. During the
reception process, he said that he suffered from depression and was very
distressed to be in custody. He was therefore admitted to healthcare for a
period of observation. On 26 June, he was deemed fit by the doctor and was
placed on wing location. His F2052SH was subsequently closed on 14 July
when the risk was deemed to have passed.
The man first started to complain of suffering from dizzy spells in August
2000. After further episodes of dizziness, vomiting and headaches, he was
referred to a consultant neurologist on 20 November. On 22 November, he
was admitted to healthcare for observation following a spell of vomiting. The
man returned to ordinary location, at his own request, on 27 November. On 2
December, wing staff relayed their concerns to healthcare about him, as he
was very unsteady on his feet, vomiting and losing weight. He was admitted
again on 9 December. On 11 December, the consultant neurologist examined
him in the prison and requested tests that were subsequently carried out.
Unfortunately, there is no letter on file from the doctor and it is not clear what,
if any, was his diagnosis. The man returned to the wing on 15 December.
Records indicate that he preferred to be treated on the wing than stay in
healthcare. This appears to have been because he favoured the relative
comfort of his own cell.
On 1 January 2001, again following concerns expressed by wing staff, he was
admitted to healthcare. On 8 January, the prison doctor contacted the
consultant neurologist and it was agreed that the man needed to be
transferred to the local hospital immediately for assessment. The man was
found to have a brain tumour. The following day a shunt was inserted, and on
16 January a ‘relatively benign’ tumour was removed. The man returned to
Bullingdon on 23 January, having progressed well following surgery. He told
staff that he had no memory of the two months prior to his operation.
The man recovered well. A discharge report from the consultant
neurosurgeon, dated 7 February, stated that the only further treatment
required was monitoring using repeat MRI scans every six months. He was
seen by the consultant neurosurgeon for a follow-up appointment on 28
February and was noted to be much improved since his admission to hospital.
However, he was experiencing some persisting problems with dizziness, poor
concentration and double vision. The surgeon hoped that these symptoms
would gradually settle down.
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In early March, the man was deemed fit to attend his trial. On 5 March, his
solicitors wrote to the prison stating that the Judge had requested that an
alternative, more comfortable, form of transport be arranged. The man had
been finding that travelling in the custodial van was causing him a great deal
of distress due to his recent surgery. The prison replied on 13 March stating
the ‘we have arranged for your client to be transported in a people carrier with
our escorting agency’. It is not clear from when he started to be taken by
people carrier.
In March 2001, the man was found guilty. Again he was placed on an open
2052SH, but this was closed the following day as he was not found to be
expressing any self-harm intentions. On 22 March, following a further
collapse he was referred again to the consultant neurosurgeon. He was
admitted to hospital for three days on 24 March for further tests which did not
reveal any abnormality. His solicitors requested a report from the medical staff
at Bullingdon to assess whether there were any medical implications to
consider prior to the Judge passing sentence. The report concluded that the
man was ‘completely fit to undergo any sentence’ and on 11 April he was
sentenced to 13 years imprisonment.
On 20 April, he was deemed fit for ordinary location. The man continued to
experience problems with his vision, and being unsteady at times, but this was
put down to his earlier difficulties. Following a visit to him on the wing on 26
April, there is an entry in his continuous medical records indicating that he had
been finding it difficult to carry his food plate and manage the stairs. On 7
June, education staff contacted healthcare regarding his worsening double
vision. The man had apparently been told to expect this when last in hospital.
His healthcare notes indicate that wing staff were informed about the double
vision. However, there was no corresponding entry in his wing history sheets.
At this juncture, it is worth noting that the medical records do not provide a
clear record of events. Appointment letters were not always noted in the file
and in some cases it was difficult to know whether appointments were
attended or not. The Local Inmate Data System (LIDS) has been used by my
investigator as a final check to see whether or not the man left the prison. In a
couple of cases this provides the only confirmation of attendance at hospital
appointments. In addition, my investigator spoke with the consultant
neurosurgeon’s office and they were able to provide further confirmation of
attendances.
There is an appointment letter on file for a scan due for 4 July 2001 and an
entry in the IMR which appears to read ‘fit hosp appt’. LIDS indicates that the
man attended the appointment. However, there are no other references to
this appointment or what the results were. The man had another appointment
on 25 July but the prison cancelled this on 9 July, as the hospital had sent the
letter direct to him rather than to the healthcare department. This was entirely
appropriate. According to the medical record, an appointment for 5
September was given over the telephone. However, it seems that he
attended for follow up appointment on 8 August 2001 and the results of the
(July) scan were good according to the report from the escorting officer.
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Consequently, he was asked to attend another scan in six months. Once
again there is no corresponding commentary in the medical record.
A scan appointment on 2 April 2002 again had to be cancelled as the hospital
had sent the appointment directly to the man. The rearranged appointment
went ahead on 20 May. The man had a follow-up outpatient appointment on 7
August 2002. There is no corresponding entry in his continuous medical
record. A letter referring to that appointment, dated 5 September, states that
‘his repeat MRI scan showed a recurrence of tumour. There has been an
increase in size of cystic component with the previous scan done on
04.07.01.’ However, as there was no immediate risk of clinical deterioration it
was felt appropriate to scan again in six months. There is an appointment
letter for a scan on 23 October but no indication in the IMR of him attending.
However, LIDS confirmed that he did attend.
On 15 January 2003, the man attended for a follow up appointment for the
October scan. The hospital escort report, which is completed by the officer
who attends hospital with the prisoner, is detailed and lengthy. It states that
‘as there are no adverse symptoms at present, the tumour will continue to be
monitored, as there are dangers with potential surgery. If there are future
problems such as worsening balance particularly on the left side then surgery
would become necessary. There will be a future MRI scan to be arranged in
summer 2003’. None of this information was transferred to his continuous
medical records.
An entry on 28 January reads ‘ due repeat MRI scan Aug 03 – to watch
symptoms in meantime’. The letter from his consultant neurosurgeon in
relation to the scan states ‘his difficulty with balance, memory and intermittent
confusion continue...at this point in time it is unlikely that we will see any
obvious improvement in that. We have been monitoring his general progress
with repeat imaging and have been aware of some re-growth of the cerebellar
haemangioblastoma on the left hand side...he would rather not have surgery
done at the present time and he would rather wait and see if he should get
any recurrence of symptoms.’ The neurosurgeon finished by saying ‘I have
left it therefore that I will arrange for a repeat scan to be done in the summer
but, should he get increasing problems meantime with balance, difficulty with
his left side, any change in headaches or more confusion, then I would be
grateful if you could let us know straight away then we can deal with it’. An
entry in his medical record on 25 February states ‘on Sat 23.2.03 – sudden
loss of vision left eye – vision came back after 1 hour. Letter to the consultant
NB NO DOUBLE CUFFS’. There is no letter to the consultant on file or any
suggestion that a follow up telephone call was made.
The man reported that he was suffering from constant headaches and nausea
on 23 April. On 25 April, a prison doctor, from Bullingdon, wrote to the
consultant neurosurgeon, explaining that the man had experienced two
periods of loss of vision in February and April. He asked whether it ‘would be
sensible to have an MRI scan of him before you see him on 9 July or sooner?’
There was no reply on file or any indication that healthcare staff made a
follow-up call. There was a letter for a scan on 7 July, which had been
9
crossed out and replaced with 21 July. There are no further entries in the
medical record until 23 July 2003. On that day there is an entry which reads
‘cock up did not attend OPA’. This entry is assumed to be related to the
appointment on 21 July. There was a letter for an appointment for 9 July with
the consultant neurosurgeon which had been crossed out, and 6 August put
in. A note indicates that this was rescheduled by the hospital.
The man was seen at the neurosurgeon’s clinic on 6 August. The letter
relating to this meeting was typed on 3 September. Having missed the MRI
scan in July, the doctor suggests that he review him again after a rescheduled
MRI on 1 September. There is no appointment letter on file for 1 September
or any reference anywhere, so it is unclear whether the prison was aware of
this appointment. There is a MRI appointment letter for 25 September.
Again, this has been crossed out and ‘already booked/needs
changing/cancelled’ written across it. A new appointment for 31 October is
written in. The appointment letter for 31 October has ‘cancelled’ on it and
‘detail can’t staff’. The continuous records indicate that a new MRI
appointment was made for 5 January 2004. A letter for an appointment with
the neurosurgeon for 12 November is crossed out and 10 March 2004 is
written. This appointment is to discuss the results of the scan on 5 January.
Written across the appointment letter for the MRI scan on 5 January is ‘didn’t
go – staff shortages, hospital to ring back with new date’.
On 4 February 2004, the neurosurgeon wrote to healthcare expressing
concern that the man had ‘been sent five appointments all of which have been
cancelled by the prison, many of which I am told on the day of the scan’. He
added that ‘any difficulties regarding this (the next appointment) I would be
happy to speak with Prison Authorities and explain the importance of carrying
out these investigations’. He sent the governor a copy of the letter. The head
of healthcare replied the same day saying ‘we have been unable to escort the
man to hospital due to security issues and/or more urgent medical escorts
being prioritised’. On 19 February the clinical nurse manager, also replied to
the consultant neurosurgeon. Having apologised for the cancellations, she
explained that ‘several of the cancelled appointments have been caused by
staff shortages. This is a problem which we encounter on a regular basis and
have to try to manage through rearranging hospital appointments’. The
clinical nurse manager put an entry in the man’s medical record stating that he
must attend his out patient appointment on 10 March. The man’s mother also
wrote to the prison on 9 March complaining about the missed appointments.
Although there is a reference to a reply in the paperwork, there is no copy of
any letter in the medical records.
The man was seen on 10 March 2004 in the outpatient clinic. However, given
that he had missed his last scan the consultant was unable to monitor any
changes to the tumour. The doctor’s letter explained ‘need to make sure he
attends the next appointment as it is very essential in order to follow up his
tumour. He will be reviewed in the clinic after the MRI scan has been
performed’. There are no further appointment letters on his file.
10
The continuous record sheet indicates that on 31 March the hospital were
telephoned regarding an appointment .The hospital informed Bullingdon that a
new scanner was being fitted and that they would contact the prison in May
with a new appointment. On 13 May, staff rang the hospital again and were
told that there was a backlog and they would receive an appointment within
two months. On 3 June, the neurosurgeon’s secretary was telephoned
directly and a message left asking for help to speed up the appointment for
the man. The MRI scanning unit at the hospital was also telephoned and
prison staff were told that someone would look into the problem.
On the same day, 3 June, the man was seen on the wing and said he had not
eaten for three days. Standing up seemed to make him feel worse so he
remained in bed. The nurse said she would visit him the next day. There was
no mention of a visit taking place in either the medical record or his wing
sheet. In fact, after January 2003 there is only one entry in his history sheet
relating to his ill health and that is on the 6 June 2004, ‘nurse visited him at
treatment time. Was vomiting and had been on a regular basis for 1 week.
Said she would put this to the doctor for tomorrow’. The man was seen by the
doctor on 7 June, but did not want to be admitted to healthcare.
Between 4 and 8 June, prison staff made a number of attempts to get through
to the neurosurgeon’s office. Eventually, on 8 June they did speak to his
secretary and she agreed to speak to the doctor. Following several
conversations, on 15 June it was decided that the man would be admitted to
the local hospital that day. He reported suffering from headaches, nausea
and some unsteadiness of gait. On 16 June, he had a MRI scan. This was
some 20 months after his last scan. The imaging revealed a sizeable tumour
recurrence. The man underwent surgery on 25 June. Unfortunately during
surgery, his lung collapsed and the operation was halted prior to the removal
of the tumour. Post operatively he was treated with intensive physiotherapy
and his lung re-expanded. The man declined to have further surgery and
wanted to try other methods of treatment. He was therefore referred for
radiotherapy to explore whether this was a feasible treatment.
The man was discharged back to Bullingdon healthcare on 2 July. This
seems a somewhat surprising course of action given that healthcare staff
were told on 1 July by hospital staff that he ‘remained unwell. Plan: The man
will remain at the hospital Infirmary until he has had a further scan and his
radiotherapy treatment has been decided’.
On 11 July, the man collapsed in his healthcare cell after losing his balance.
He did not sustain any injuries. On 14 July, he was due to attend a hospital
appointment. This did not happen because ‘no escort was arranged’. On 21
July, the man saw the consultant regarding radiotherapy and he consented to
treatment. It was expected to start in 4 – 6 weeks.
The man remained in the healthcare centre at Bullingdon. Following a large
rectal bleed, he was taken to the Accident and Emergency department of the
local hospital on 25 July. A nurse telephoned his mother to explain about his
admission and passed on the hospital’s phone number. On 26 July, the
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prison undertook a hospital escort risk assessment. It was decided that as the
man was deemed too ill to attempt escape, only one bedwatch officer was
required. On 28 July, the man underwent a laporotomy and the bleeding
artery was sealed. However, he was very weak due to the amount of blood
lost. He was unable to walk or stand unaided and was suffering from painful
pressure sores.
On 4 August, he was transferred to another hospital to undergo an
assessment for radiotherapy. In light of his poor condition, the consultant
wanted to start the radiotherapy as soon as possible and he was admitted to
the Cancer Unit. Given the move to another hospital, a further risk
assessment was undertaken by the prison and it was felt that that the escort
arrangements should remain unchanged. The man remained physically weak
and developed a chest infection. However, he was able to begin his
radiotherapy sessions on 16 August. The bedwatch report indicates that he
was able to leave his bed in a wheelchair for the first time on 25 August.
On 1 September, a Sister visited the man in hospital. The Sister noted that he
had received eleven sessions of radiotherapy and was having physiotherapy.
He was frail and unable to walk. The Sister telephoned his mother after the
visit. The next contact with the hospital was on 13 September by telephone.
It was noted that he was very tired from the radiotherapy, and that
physiotherapy was not being undertaken as he was too weak. On 24
September, a review of the escort arrangement was undertaken following a
view that there was a change in his medical circumstances, as he was bed
bound. The escort remained unchanged. The document indicates that the
reviewing governor had ‘asked the resettlement manager to review the
prisoner’s security category based on his positive behaviour with a view of
downgrading’.
The next entry in his medical record is on 30 September, after he is reported
to have suffered a seizure. On 1 October, release on temporary
(compassionate) licence (ROTL) was considered by the prison and not
recommended. On the same day, an application for him to be re-categorised
from a B to a C category prisoner was considered and rejected. On 5
October, the hospital contacted staff to say that the man’s condition had
deteriorated. The man was unresponsive and the hospital had withdrawn
active treatment. Another review of the escort arrangements was undertaken.
It concluded that the bedwatch officer should no longer stay in the room but
be available for hospital staff if needed. The hospital had contacted his
mother to advise that if she wanted to visit she should do so now. His mother
was able to visit. Her son died on 7 October.
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Issues considered during the investigation
Medical records
The man’s medical records were sometimes difficult and time consuming to
review. The continuous medical record does not provide a commentary of all
that happened to him and on occasions it was difficult to know what
happened.
Missed hospital appointments
In January 2001, the man underwent surgery to remove a ‘relatively benign’
tumour. In May 2002, a further growth was found. The table below shows the
various appointments for both MRI scans and outpatient appointments made
for him from February 2001 to June 2004. The system that the consultant
neurosurgeon, chose to adopt was for him to have a MRI scan and for the
results of this scan and future treatment options to be reviewed in an
outpatient appointment shortly after the scan. It was therefore important for
him to attend the two ‘types’ of appointments. They were scheduled at
approximately six monthly intervals.
Date of
Date of MRI outpatient
Narrative scan Attended? follow up Attended?
08/01/01-
Surgery to remove 23/01/01in
tumour hospital
1st follow up
appointment 28-Feb-01 YES
Admitted to 24/03/2001
hospital for tests for 3 days
2nd follow up NO (hospital wrote
appointment 04-Jul-01 YES 25-Jul-01 direct to the man)
rescheduled
08-Aug-01 YES
NO (hospital
3rd follow up
wrote to the man
appointment 02-Apr-02 direct)
Rescheduled
20-May-02 YES 07-Aug-02 YES
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4th follow up
appointment 23-Oct-02 YES 15-Jan-03 YES
The man
complaining of
headaches and Letter written from Bullingdon to consultant neurosurgeon 25 April 03
nausea suggesting Summer scan brought forward
5th follow up NO (no reason NO (cancelled by
appointment 07-Jul-03 given) 09-Jul-03 hospital)
rescheduled (once) rescheduled
NO (prison error,
stated mis-filed YES (but neurosurgeon
and therefore states needs results of
21-Jul-03 overlooked) 06-Aug-03 scan to assess)
rescheduled (twice)
NO (not clear,
escort staff may
already have been
25-Sep-03 fully booked)
rescheduled (three
times)
NO (cancelled
due to escort staff NO (cancelled due to
31-Oct-03 shortages) 12-Nov-03 escort staff shortages)
rescheduled (four
times) rescheduled
YES (but consultant
neurosurgeon
states needs
NO (cancelled
results of scan to
due to escort staff
05-Jan-04 shortages) 10-Mar-04 assess)
This last cancellation resulted in a letter from the consultant (dated 4 Feb 04) to the in charge
medical officer complaining about the cancellation of five scans and stressing the importance
of the man attending.
Reply from clinical nurse manager apologises for the missed appointments and states that
several of the cancellations were due to escort staff shortages. She indicates that she has
given instructions that the man must attend his next appointment on 10 Mar 04.
The man's mother also wrote (9 Mar 04) to the prison complaining about the hospital
appointments that her son had missed. It is not clear what reply was sent, if any.
The table shows that in 2001 and 2002, the man had two appointments
rescheduled because the hospital had, by mistake, written directly to the man.
Appointments for prisoners to attend hospital are not normally disclosed to the
prisoner until the day of their appointment. This is in order to reduce the risk
of an escape attempt being planned in advance for a particular day. The
man’s last MRI scan in 2002 was on 23 October.
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In 2003, stretching into January 2004, the man had five appointments for a
MRI scan. All five were cancelled by Bullingdon. It is not clear what the
reasons for the cancellations were, but there were several entries in his
medical file indicating that it was due to escort staff shortages. My
investigator spoke to the detail manager (responsible for day to day escort
staff arrangements) and administrative staff who work in healthcare. The
healthcare administrative staff are responsible for providing the detail office
with the paperwork relating to an outside hospital appointment, and the detail
office are then responsible for providing the necessary staff for the escort. My
investigator specifically looked at two of the missed appointment dates with
the detail manager, 31 October 2003 and 5 January 2004. The reply sent by
healthcare to the neurosurgeon’s letter in February 2004, expressing concern
about the number of appointments the man had missed, indicated that the
reason he was not taken to hospital was staff shortages. The detail manager
checked the staffing levels on the two dates and said that staff were available
to take the man to hospital. The detail manager went on to say that even if
there were staff shortages, escorts would not be cancelled. He said that
another element of the prison regime would be curtailed instead.
Whatever the reason, it is unacceptable that the man was not taken to
hospital on any of the five dates on which he had appointments made for him.
The current escort arrangements at Bullingdon allow for two hospital
appointments each day, one in the morning and one in the afternoon, and if
these are already booked healthcare have to try to book another appointment
with the hospital. Problems arise when the appointments are deemed urgent
and it becomes imperative that the prisoner attends. If this is the case, the
paperwork is sent to the healthcare manager or clinical staff and if necessary
a decision has to be made regarding which is the most urgent. Frequently, it
will be necessary for both prisoners to attend their appointments and
negotiations will take place with detail.
Decisions about cancelling a hospital escort versus curtailing an element of
the prison regime in order to free up additional staff should only be taken by
the duty governor. The duty governor should consult with medical staff who
are appropriately qualified to determine the level of urgency of the
appointment.
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Incentives and Earned Privileges Scheme
Some documents in the man’s file indicate that he was on the enhanced level
of the Incentives and Earned Privileges Scheme (IEPS) at the time of his
death. However, upon examination of his file my investigator found that he
was on standard level at the time he was taken to hospital in July 2004.
Consideration of the IEPS is an issue about the quality of life rather than one
thought to have had a direct impact on his death. However, I believe it should
be examined given the nature of the man’s on-going illness which impeded
both his ability to engage in any out of cell activities and to take adequate care
of himself. These factors do not consistently appear to have been considered
when reviewing his sentence planning targets in relation to which IEPS level
he should be on. My investigator, therefore, examined the documents in the
man’s file relating to the IEPS scheme and his sentence planning, as well as
Prison Service guidance and Bullingdon’s own policy.
According to the Prison Service Order (PSO) 4000 (p.17), ‘Incentives and
privileges need to be compatible with sentence planning objectives,
appropriate to the needs and capabilities of the prisoner and set by staff
involved in both activities. In particular when linking incentives and privileges
with sentence planning the following questions need consideration:
• is the sentence plan appropriate in terms of the prisoner’s needs and what
can be realistically expected of him/her?
• have efforts been made to engage the prisoner in sentence planning and
to motivate him/her?
Thus a prisoner who participates in and complies with the sentence planning
and targets set should reasonably expect to advance to, or retain, higher
levels of privilege. Conversely, someone failing to cooperate may reasonably
be downgraded in accordance with local criteria.’ Bullingdon’s own policy
reiterates that the ‘scheme will be linked to assessments, sentence planning
and prisoner compacts’.
On 4 April 2002, the man did achieve enhanced status. This seemed to have
been a controversial decision for some officers on his wing. Eight entries in
his wing history sheet at the time comment on his unsuitability for enhanced
status mainly because he was ‘not addressing his offending behaviour’. At a
review of his enhanced status in June, one officer ticked ‘yes’ to the question
‘is he complying with his sentence planning?’ and ‘no’ to the questions ‘is his
cell/appearance acceptable?’, and ‘is his behaviour to an acceptable standard
of an enhanced prisoner?’ At the next review in July, an officer had answered
‘yes’ to the questions where the previous officer had answered ‘no’, and given
a ‘no’ answer where previously there had been a ‘yes’ answer. There are no
other reviews on file. On 16 October 2002, the man was returned to standard
‘due to refusing SOTP’.
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The man’s first sentence plan in June 2001 set targets for attending courses
associated with his offending. The man was appealing against his conviction.
However, there is no evidence to suggest that this was viewed as
incompatible with attendance on the courses. The man also agreed to attend.
However, at that time these courses were unavailable on his wing within the
prison. Consequently, one of the targets centred on a transfer to HMP Rye
Hill where the courses were available. However, he was on a ‘medical hold’
and therefore unable to be moved until this was lifted.
At his sentence planning review in June 2002, it was acknowledged that none
of his targets had been met due to his health problems. By this stage he had
reached enhanced status. There is no sentence planning review on file for
2003. In his sentence planning review in March 2004, his personal officer
stated that ‘he isn’t a problem on the wing…his health problems are his main
problem and because of this he can’t address his offending behaviour and
also has an appeal pending’. One of the targets set was to reapply for
enhanced status.
Entries in the man’s wing history sheet in October and December 2002
indicate that he was not happy about being downgraded to standard. Records
indicate that he applied again in June and October 2003 and January 2004
and continued to be unsuccessful. In June 2003, enhancement was refused
because ‘he is usually to be found in his bed and rarely leaves the cell’. In
October 2003 and January 2004, his lack of attendance on offending courses
was given as the reason. However, his DCR review in June 2002 stated that
‘due to his health it was felt it was an inappropriate time to attend SOTP’ and
with regard to any long term action plan stated ‘due for operation – no date as
yet. Long term plan very dependent on results of above.’
The man’s record indicates that the last time he applied for enhanced was on
16 March 2004. His wing senior officer recommended his application. On 1
April he was informed that it had been denied ‘due to personal hygiene
reasons. Re-apply 28 days.’ According to Bullingdon’s policy, those on the
standard regime ‘will receive a regime review every four weeks’. There is no
evidence to suggest that he was subject to any further reviews whilst he
remained at Bullingdon.
The tidiness of his cell and his personal presentation were commented on in
his history sheets with varying degrees of emphasis and with some
recognition that at times there were improvements. The impact of his poor
health on his ability to look after himself, and present positively, do not appear
to have been considered or views sought from healthcare. In 2001, records
indicate that wing staff were very proactive in contacting healthcare in relation
to the man’s deteriorating health. However, if advice was sought after 2001, it
is not recorded and therefore difficult to assess whether wing staff were aware
of any behavioural implications of his illness.
I note that in her 2004 inspection report, HM Chief Inspector of Prisons
recorded that the prison had recognised that the IEPS required a thorough
review which it had started to develop. However, HM Chief Inspector said that
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‘there was no consistency across the wings in the standards required from
prisoners or how suitability to be upgraded was decided’. She also found
‘evidence that IEPS reviews were not held regularly’.
Release on temporary licence
Prison records indicate that the man’s release on temporary (compassionate)
licence (ROTL) was considered on 1 October 2004. The form indicates that
‘the man has been seriously ill in hospital for several weeks now with the
minimum of supervision. He is to remain in hospital for the foreseeable future
and poses no threat to himself, victims or hospital staff’. Given that he had
been in hospital since 25 July with the same escort arrangements, it is
somewhat surprising that this had not been considered earlier. Part of the
ROTL process involved gathering information from a number of sources,
including wing staff. The paperwork indicates that wing staff supported the
application for ROTL. The board have to take into account a wide range of
factors and the chair of the board did a ‘for’ and ‘against’ list.
The ‘for’ column listed – 1st custodial, has completed many SOTP (Sex
Offender Treatment Programmes) assessments, is willing to complete OBP’s
(Offending Behaviour Programmes) but has been unable to engage due to
illness, no security information, he is very unwell and incapitated by his illness
and has been supervised by one officer for a long period of time. The
‘against’ column listed – serious nature of offence, only 3 1/2 years into 13
year sentence, cat B until 1-10-05 – awaiting results of review, has not
completed any OBP’s, nature of offence gives rise to concern from security
department and risk protection team – risk of harm to children, duty of care to
him – if he’s left unescorted and comes to harm whilst in our custody, media
interest – potentially negative publicity if media become aware of this, no
contact with outside probation.
On balance, having undertaken the risk assessment, the board did not
recommend ROTL. Given all the evidence available to the board, this was a
risk-averse but not an unreasonable conclusion. However, of concern is that
it is not clear from the document whether the board had an up-to-date medical
assessment or were given any detailed account of his prognosis by medical
staff. There is nothing on file to indicate that they were. Such knowledge
might have altered their decision.
Once the board has made their decision, the form has then to be passed to
the governor in charge for their assessment and recommendation. The form
is not countersigned and therefore it has to be assumed that a governor’s
assessment was not sought. The ‘Notification of Decision on application for
release on temporary licence’ is not completed and, as such, it is not clear
whether the man would have been made aware of the decision.
On the same day, an application for the man to be re-categorised from a B to
a C category prisoner was considered. The document suggests that his ill
health prompted a review of his categorisation. The application was rejected.
The reason given was ‘the man is only 3 and a ½ years into a 13 year
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sentence for a very serious offence. He has not completed any offending
behaviour programmes due to his illness and therefore there has been no
significant reduction in risk.’
Contact with the man’s next of kin
The man’s mother was his next of kin. She is elderly, but had managed to
visit her son in hospital a few days prior to his death and was informed of his
passing by hospital staff. The duty governor faxed the man’s mother local
police station to request that they visit her as he was concerned that she
might be on her own and distressed when receiving the news of her son’s
death. This was sensitively handled by the duty governor. Bullingdon’s
chaplain spoke with the man’s brother who was supporting his mother. A
member of the chaplaincy informed the man’s friends within the prison.
However, the man’s mother told my family liaison officer that she had not
received any further contact with the prison subsequent to her son’s death.
She had not had a letter of condolence or any offer of help with funeral
expenses. By the time my colleagues visited, the funeral had taken place and
his mother was very anxious about how she was going to pay for the funeral.
She then approached the prison and funds were forthcoming. However, it
would have been right for the prison to have made the offer without waiting to
be asked.
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Findings and recommendations
Documentation suggests that a number of hospital appointments were
cancelled due to staff not being available to cover the escorts. However, on at
least two dates, there were adequate staff available in HMP Bullingdon.
The governor, in partnership with the local Primary Care Trust, should
develop and implement a clear policy for attending external hospital
appointments, the circumstances in which an appointment may be
cancelled and the action to be taken in this event.
Regular audits to monitor how many appointments have to be rebooked
and how many are cancelled should be undertaken and staffing levels
adjusted accordingly.
Reviews of the man’s level of incentives and earned privileges did not take
account of information and judgements made in his sentence planning.
In line with it’s own policy, HMP Bullingdon must link the IEPS with
sentence planning and regular audits should be undertaken to ensure
that this is done.
In accordance with PSO 2710, consideration should be given to
communications with the family of the deceased. In this case, this was not
done and his next of kin suffered unnecessary anxiety as a result.
The governor should remind all her managers that contact with the next
of kin must be given high priority and conducted in accordance with
PSO 2710. Consideration should be given to select members of staff
undergoing dedicated training in family liaison.
The clinical review makes two additional recommendations:
All nursing documentation must be completed in accordance with the
NMC Guidelines for Records and Record Keeping. Audits of the quality
and consistency of records and record keeping should be undertaken in
partnership with the Primary Care Trust on a regular basis.
A significant event audit should be undertaken by the prison to establish
why so many appointments were cancelled due to staff shortages, thus
compromising the health of the man and to establish what lessons can
be learnt to prevent recurrence.
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