Individual at Cardiff

Circumstances surrounding the death of a man on 20
October 2006 at Llandough Hospital whilst in the custody
of HMP Cardiff
Report by the Prisons and Probation Ombudsman for
England and Wales
October 2007
This is an investigation into the circumstances surrounding the death of a man on 20
October 2006. The man had been diagnosed with lung cancer on 19 September and
died as a result of his illness. He was a prisoner at HMP Cardiff, and was 76 years
old when he died.
I extend my condolences to the man’s family and to all those touched by his death.
The investigation was undertaken by my colleague. Both my colleague and I would
like to extend our thanks to the Governor of HMP Cardiff, and his staff for their
cooperation during the investigation. Particular thanks go to the prison liaison officer
for gathering all relevant documentation and ensuring it was made available in a
timely way.
The Health Inspectorate for Wales carried out a clinical review into the healthcare
the man received at HMP Cardiff. I extend my thanks to the Inspectorate for
completing the review so speedily and for the recommendations drawn from the
findings.
The man was elderly and in poor health when he arrived at HMP Cardiff, having
been remanded in custody in December 2005. He was described by staff as
someone who generally kept himself to himself, albeit he did challenge the prison
regime on occasion. The man found the adjustment to prison life difficult and chose
not to mix with the wider prison population. He had a history of chronic heart
disease, and was, understandably for his age, frail in appearance.
The man came into contact with healthcare staff regularly between January and
September 2006. He presented symptoms of coughing and breathlessness each
time and had a series of examinations by the prison doctor, followed by prescriptions
to alleviate what were thought to be chest infections. The medication failed to
address his symptoms, and he was referred for a chest x-ray. Additional tests at the
hospital confirmed he had terminal cancer of the lungs. He was admitted to hospital
in October for palliative care.
Hospital staff witnessed a rapid deterioration in his condition during the evening of 19
October. The man died a few hours later, on the morning of 20 October.
In addition to those in the clinical review, I make two recommendations of my own. I
also draw a number of housekeeping matters to the attention of the Governor.
This final version of my report has been amended in light of comments received on
an earlier draft.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2007
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CONTENTS
Summary 4
The Investigation Process 6
HMP Cardiff 8
Key Findings 10
Issues 18
Recommendations 24
3
SUMMARY
The man was charged with arson and criminal damage and remanded in custody by
Cardiff Magistrates’ Court on 22 December 2005. He was taken to HMP Cardiff
where, on arrival, he went through the normal reception process before being
allocated a cell in the Victorian part of the prison.
Healthcare staff determined from police custody documents, and from their own first
reception health screen, that he was a man in poor health with a history of chronic
heart disease and asthma. The nurse who carried out his first health screen also
established the amount and type of medication he was prescribed. It was extensive.
The man was referred to see the prison doctor.
Due to his age and poor physical health, he was allocated a single cell on the ground
floor of A wing. This meant that he would not have to negotiate any stairs to collect
meals and participate in association. The single cell occupancy granted to him was
temporary. The man had not been assessed as high risk and eventually he did have
to share a cell due to population pressures at Cardiff. This was something he initially
resisted but grew accustomed too.
Between January and September 2006, he presented himself in the healthcare
centre with symptoms of coughing and breathlessness. He was also seen on a
number of occasions on the wing, at his request, and at the request of wing staff.
The man was treated for a chest infection and was regularly prescribed antibiotics to
treat the condition. In June, and at the request of wing staff, he was admitted as a
healthcare in-patient for respite care. He remained in healthcare for approximately
two weeks before returning, unwillingly, to his cell in the main prison.
The man displayed a number of behaviours whilst on the wing. These ranged from
anger to anxiety as he struggled to adapt to the marked change in his environment.
His health remained poor, and on 1 September and 18 September he was seen by
the prison doctor in the GP surgery. The man was sent to an outside hospital for a
chest x-ray after his second examination. (He had refused to go after his first
examination.) The x-ray results showed suspected cancer of the lungs and a CT
scan in the weeks that followed confirmed a diagnosis of terminal cancer.
He was transferred back to hospital on 9 October under escort. He spent the first
three days under restraint, and received chemotherapy treatment on 10 October
before the use of restraints was removed. Throughout his time in hospital, he was
on bedwatch with uniformed escort officers. His family visited him on a number of
occasions.
On 19 October, the man’s condition deteriorated rapidly. At approximately 1.50am
on the morning of 20 October, he suddenly died.
The clinical reviewer has concluded that the healthcare he received at Cardiff, up
until his diagnosis was confirmed, was adequate in the main. The clinical review
does highlight that his blood was not monitored for potassium levels and concludes
that his primary care, in this regard, was not adequate.
4
The man was transferred to hospital in a speedy way and, once Cardiff realised he
was to remain in hospital, he was generally managed well. He was left in restraints
to receive chemotherapy treatment despite the doctor’s request for them to be
removed. Having said that, I also recognise that, in the days that followed, Cardiff
reduced his security from two bedwatch officers to one and authorised the removal
of restraints.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 25 October 2006. My investigator began by
requesting all relevant prison records relating to him. These included his
medical and core records covering the time he spent in prison.
2. Notices to staff and prisoners were supplied and displayed around the prison.
These invited anybody with information to talk to my investigator. In this
instance, nobody came forward. My investigator examined the records and
recorded significant events. Given the circumstances, she did not feel it was
necessary to attend the prison and interview staff. However, a visit to
Cardiff’s healthcare centre was made on 3 July 2007 when she discussed the
man’s healthcare with one of the prison doctors.
3. The Health Inspectorate for Wales was invited to undertake a review of the
clinical care the man received while in custody. The clinical review is included
as an annex to this report.
4. The Coroner was informed of the Ombudsman’s investigation. The post
mortem report was not available at the time of the investigation. The Coroner
will receive a copy of this report when it is completed to assist with his
enquiries.
5. One of my Family Liaison Officers, contacted the man’s family to discuss the
purpose of the investigation, and to offer them the opportunity to raise any
concerns or questions about his time in prison. The man’s family raised the
following concerns about his healthcare:
(cid:131) Why was he not reviewed by a doctor as recommended by a Nurse on
20 May 2006?
(cid:131) He was a proud man and not one to make a fuss about his health. It
would have taken a lot for him to admit to feeling unwell.
(cid:131) On 1 September 2006, he complained he was coughing blood.
However, he was not referred for further tests until 18 September, over
two weeks later. It was then another eight days before he received the
results of his x-ray. This process took almost a month. Why were
there such delays?
(cid:131) As well as physical symptoms, there were other signs of his
deteriorating health, such as withdrawing from the regime, being
reclusive and showing aggression towards staff. Why were these not
picked up on?
(cid:131) The clinical review states that standard healthcare checks, such as
blood pressure checks, were not made on him during his respite care
in the healthcare centre. Why were these not carried out given his age
and recent poor health?
(cid:131) He presented as unwell from 20 May 2006, but did not receive any
tangible medical examinations until 18 September.
(cid:131) The first recommendation in the clinical review mentions that
healthcare staff should always request and chase medical notes for
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prisoners who present with illnesses to allow continuity of care. Why
does this not happen as standard?
(cid:131) He had a heart problem and had been in hospital on two or three
occasions prior to going into custody. My report refers to the man
asking for his medication. His family questioned whether he was
referring to his heart medication and felt that, if the prison had made
more of an effort to obtain medical notes, they would have been aware
of this.
(cid:131) The man’s solicitor told his family that all medical records should have
been transferred to Cardiff on his arrival. The solicitor had not
contacted the prison to inform staff how seriously ill the man was when
he first went into custody, although his family first thought the solicitor
had. The solicitor said that it was the responsibility of Cardiff to gather
information on him and request GP records as required.
These concerns have been addressed in the appropriate sections of this
report. I hope my investigation has been helpful to the man’s family in
understanding the events leading up to his death.
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HMP CARDIFF
6. Built in 1827 as a county gaol, HMP Cardiff is a category B local and training
prison located in the city centre. The prison holds adult male remand,
unsentenced, and sentenced prisoners from South East Wales. The prison
has an operational capacity (maximum crowded capacity) of 754 following
extension of three new wings in 1996.
7. In addition to the modern wings, Cardiff has refurbished the original Victorian
parts of the jail. A and B wings now hold convicted prisoners with D wing
specifically for convicted prisoners with enhanced status. C wing is used as a
detoxification unit, E wing holds life sentenced prisoners, and F wing is
reserved for trial and remand prisoners. F wing also has a first night in
custody (FNC) unit on the ground floor and a segregation and therapeutic unit
on A wing.
8. The Healthcare Centre at Cardiff provides 24 hour primary care and has 16
in-patient beds. Clinical care is provided by doctors and nurses employed by
the Prison Service. The latest staffing profile described a team comprising
two general practitioners, a senior nurse, practice manager, three supervisory
grade nurse/senior healthcare officers and 16 healthcare staff (nurses and
healthcare officers). Cardiff and Vale NHS Trust provides the mental health
in-reach team (MHIRT) specialist mental health services.
9. HM Inspectorate of Prisons last inspected Cardiff in February 2005 on a short
unannounced inspection. The Inspectors found that the good healthcare
observed on their previous full inspection in 2003 had been maintained.
However, they were very disappointed that a new build healthcare centre
promised in 2004 had not materialised. (It is due for completion towards the
end of 2007.) Inspectors were also disappointed that their previous
recommendation that ‘a primary care-compatible’ information technology
system should be installed had not been achieved. While praising the work of
the MHIRT, they found that the team was small and lacked the capacity to
meet the needs of the prisoners at Cardiff.
Elderly prison population
10. Prison is not principally designed for the elderly, and it is difficult for an
individual establishment to accommodate an increasingly aged prison
population. A thematic review by HM Inspectorate of Prisons in 2003 found
that, although older prisoners make up a small percentage of the overall
prison population, the number of elderly prisoners had trebled between 1992
and 2002 and was continuing to grow. The study also found that there was
no overall strategy throughout the prison estate for assessing and delivering a
regime that addressed the needs of older prisoners.
11. The thematic review found that some elderly prisoners will inevitably spend
the rest of their lives in prison, and will be housed and managed in the same
way as the general prison population. Early release from prison on medical
grounds for severely or terminally ill prisoners is subject to restrictive criteria,
8
and the thematic stressed that the prison environment must be geared
towards meeting the specific needs of its ageing population.
12. With the exception of a small number of establishments, prisons do not
provide a separate regime for elderly prisoners. At Cardiff, the man was
located on A wing in the Victorian part of the prison. He was allocated a cell
on the ground floor, in recognition of his poor health, but did not take part in
any purposeful activity on the wing.
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KEY FINDINGS
13. When the man arrived in reception at Cardiff on 22 December 2005, he was
assessed as low risk for sharing a cell. The officer completing the first part of
his Cell Sharing Risk Assessment form (CSRA) noted that he had expressed
a preference for a single cell due to his breathing difficulties, but had no
concerns about sharing. Section 3 of the CSRA, completed by a member of
the healthcare team, said “fit for normal location”.
14. He was then health screened as part of the reception process. A brief
medical history of heart disease, asthma, and his current medication was
recorded by the nurse. The nurse also noted that he had no psychiatric
history but presented as “quite frail in appearance”. He was referred to the
prison doctor for physical health reasons.
15. He was located on the first night in custody wing (FNC). An entry in his wing
history book (F2052A) recorded that he was “a bit weak at the knees” and
needed to be located on the lower floor due to his breathing difficulties. The
man was placed in a cell on A1, A wing’s ground floor landing.
16. The following morning, whilst on the FNC, he was inducted into the prison
using an induction passport booklet. He answered a series of questions
which informed officers that he was retired and in receipt of a state pension
and disability allowance. He also said that he had been in custody several
times but approximately 25 years previously. My investigator found that
whole sections of the induction passport had not been completed, including
Section 9 entitled ‘Attitudes and Behaviour’, and the last section which asks
prisoners to sign that they have received induction information on a number of
issues. There was a note in his history sheet stating that he declined to take
part in the full induction programme.
17. Over the Christmas period, the man tried to settle into prison life. Staff
commented in his wing history book that he was quiet and a bit confused,
probably due to his age. An entry by an Officer read, “needs looking after by
staff”.
18. On 10 January 2006, he was seen in triage at the healthcare centre. He was
examined and it was noted in his medical record that he was breathing
rapidly. The man was scheduled to see the prison doctor the next day and
had been asked to bring his inhaler but forgot to do so. An entry by a Nurse
in his medical record said that the man was due to have his medication
reviewed and that staff would ensure he was using his inhaler properly.
19. He saw the doctor on 11 January and said that he had suffered with a chest
infection prior to coming into prison. As a smoker, he was advised to stop.
He was told about the ‘quit smoking’ clinic but declined to attend. He did not
have a medication review and went back to his cell on A1.
10
20. Throughout the remainder of January and February, the man’s mood
fluctuated between being quiet and polite to abusive and anxious. Several
entries in his wing history book reflected that he had become worried about
the possibility of having to share a cell with a new prisoner. Another entry
noted that he did not say much, but would be abusive when he did.
Healthcare staff informed my investigator that he was reviewed by a Doctor
on 27 January.
21. On the morning of 21 March, an entry in the man’s core prison record said
that he had been sent for trial at Cardiff Crown Court. The Prisoner Escort
Record form (PER), to risk assess and record his transfer to and from court,
said that he was remanded in custody again and arrived back in reception at
12.10pm the same day.
22. On 16 April, he showed signs of anger and frustration at an officer and
accused him of deliberately opening and shutting his cell door and playing
‘head games’ with him. His wing history book recorded that he had become
abusive and aggressive towards the officer.
23. Approximately one week later, on 22 April, He was back in court. He returned
to A wing that evening and settled quickly. The PER form recording his
transfer to court and return to Cardiff did not detail the outcome of the court
appearance or when he arrived back in reception.
24. On 20 May, a nurse went to see the man on A1 at his request. The nurse
found that he presented with cold-like symptoms and made an entry in his
medical record following her visit. The entry said, “I feel this man should be
reviewed by the doctor at the earliest opportunity.” The doctor saw him in his
cell later that day and prescribed antibiotics for a chest infection. The doctor
wrote “…..cough, chest relatively clear but in view of PH of IHD for AB,
Amoxicillin 500 tds.”
25. He began to show further signs of anger and anxiety on 31 May. An
extensive entry in his wing history book stated that he pressed his cell bell just
before 6.00pm. When a wing officer responded, he shouted at him and told
him to get his medication. The officer phoned the treatment room and was
told a member of staff would pick them up from the healthcare centre. The
man pressed his cell bell again and, when the officer arrived, the man told him
he would smash his cell up if he did not get his medication. A senior officer
(SO) attended shortly after and was told the same. The man then threatened
the wing officer. The officer recorded that the man had said he would “Do me
and get me out of here, which I took to mean the cell.” The man was later
spoken to by a principal officer (PO) and told his behaviour was not
acceptable.
26. The following day, it was noted in his security file that he used to be a
contractor at Cardiff and knew the prison well. It was also recorded that he
made threats to staff. My investigator could not establish who made the
comments as the record was not signed. On 2 June, a security report was
opened due to the man’s abusive behaviour. Again, it was reiterated that he
11
knew the layout of the prison and should be placed on disciplinary report for
his behaviour. An officer completed the report and further noted that the man
should be transferred to another prison as soon as possible. A governor and
the security manager completed their relevant sections also. My investigator
checked with Cardiff what action followed this report and was told there was
no evidence to suggest he was placed on report or that a transfer was
arranged.
27. On 8 June, the man was told by a wing officer that he would be “two-ing up”
later that evening. This meant that he would be sharing a cell. He did not
take the news well and told the officer that he would not speak to his new
cellmate. The officer reminded the man that he was not a single cell occupant
and noted in his wing history book that he seemed to think he could do what
he wanted. The man was given his evening meal by the landing cleaner. He
threw it down the toilet in his cell.
28. The next day, the man appeared in court. The PER form for this transfer said
that he was received back in Cardiff’s custody at 1.35pm. On his return, he
was admitted to the healthcare centre for respite care. He was seen by a
doctor on 7 June and diagnosed with acute exacerbation of COPD.
Antibiotics were prescribed, and he stayed in the healthcare centre for just
over two weeks, returning to his normal accommodation on 24 June. During
his respite, nursing staff made regular entries in his medical record saying that
he presented no problems throughout that period. The man did not
participate in any meaningful regime whilst an inpatient and remained
reclusive. He took a diet with encouragement from healthcare staff and was
discharged when an urgent admission arose and a bed was needed.
29. The man returned to his previous cell, cell 15 on A1, unhappy with the
discharge. Wing officers monitored him for the next few days. When his new
cellmate arrived, an officer noted that he had made it through the night and
appeared to be “getting on well”.
30. The man went back to court on 7 July. His Prisoner Escort Record form said
that he presented no risk. He arrived at Cardiff Crown Court at 8.36am and
appeared in court No 2 at 10.05am. His appearance lasted approximately 30
minutes and he was sentenced to three years imprisonment. He arrived back
at Cardiff at 3.10pm. He was located back on A wing, this time into cell 16,
with no problems.
31. The man only left his cell occasionally for the rest of July. He was seen by the
doctor on 14 July after again complaining of a cough. He was examined and
prescribed Amoxycillin, an antibiotic, to treat a chest infection.
32. On 6 August, an officer wrote in his wing history book, “[he] seems to develop
a medical problem most days and appears to enjoy the fuss”. The following
day, the man presented as unwell again and was prescribed a different
antibiotic to treat a chest infection.
12
33. He saw the doctor again on 1 September and complained that he was
coughing blood. However, he refused further examination and was again,
prescribed an antibiotic for infection. The doctor made a note that, if his
symptoms persisted, He would need to be referred for exploratory tests.
Healthcare staff told my investigator that the man also refused any referral to
hospital for further exploration into his physical health. This was despite being
advised that his ‘red flag’ symptoms needed a second option and a chest x-
ray.
34. Just over two weeks later, on 18 September, he was again seen by a doctor.
He presented as breathless and the doctor noticed that he had lost his voice.
A PER form showed that he was transferred to University Hospital Wales at
11.40am under escort. On arrival, the man went straight into x-ray and
returned to Cardiff in a taxi at 12.50pm. It is not clear whether restraints were
used to escort him to hospital, and there was no corresponding entry in his
medical record to date and note the referral.
35. On 26 September, the man’s x-ray results were explained to him by a
member of the healthcare team. He was told that the results were not good
news, but in order to determine an exact diagnosis he needed a CT scan
urgently. His medical record noted that he was not in pain and had no
breathing difficulties, but had lost his appetite. Healthcare staff took the
decision not to tell him that his diagnosis from the x-ray revealed a central
obstructing neoplasm (cancer) until a CT scan could confirm the illness.
36. On the same day, a doctor referred him to the Rapid Access Clinic at
Llandough Hospital in writing. In her letter, the doctor explained that the man
required an urgent referral for suspected lung cancer and had presented
himself in healthcare on 1 September with a cough, haemoptysis and a
hoarse voice which he had had for weeks. The letter also explained that he
had initially refused an x-ray but had agreed to one on 18 September. The
doctor asked the hospital to send the out-patient appointment to healthcare
direct, in order for an escort to be arranged. The letter was faxed the same
day.
37. On the morning of 30 September, an A wing officer contacted the healthcare
centre and asked for a nurse to visit the man in his cell. The officer made the
request following an allegation the man had made that the officer had been
victimising him. His medical record said that he claimed the officer was trying
to kill him with paint fumes. The Community Psychiatric Nurse (CPN) who
made the entry wrote that there were no obvious signs of mental illness. This
was the first time the man had seen a member of the mental health in-reach
team.
38. The following day, a B wing officer, asked for the man to be relocated in the
healthcare centre due to the condition of his chest and the allegations made
against the A wing officer. The officer from B wing recorded that, following an
assessment (presumably by the CPN), the man had been refused admittance
to healthcare because he was not “mentally ill”.
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39. It was not clear when the man went for his CT scan as this part of his medical
record was missing from the documentation my investigator reviewed. A scan
result form sent by the hospital suggested the scan was carried out on 6
October.
40. He was given an appointment to see a lung cancer specialist at Llandough
Hospital for 9 October. An escort and hospital risk assessment was carried
out on 6 October in preparation for the transfer. Under ‘specific factors of
concern’, he was assessed as presenting a medium risk to the public due to
his offence. He was also assessed as medium risk of escape and hostage
taking but no known history of either was recorded. Two escort officers were
instructed to use ‘double cuffs and an escort chain’ to transfer him from
Cardiff to the hospital. They were also told that restraints could be removed
for emergencies and medical treatment, but that they could only be removed
with the prior knowledge of the duty governor.
41. At 9.30am on 9 October, He arrived at the Llandough Hospital for an out-
patient appointment in the lung cancer clinic. He was diagnosed with stage
four lung cancer, which denotes an advanced stage of the illness, and was
informed of his condition by the hospital doctor. At 11.50am, the same doctor
decided to admit him as an inpatient. The man became depressed by the
news of his illness and returned to the out-patients department to wait for a
bed. An escort officer rang Cardiff at 12.10pm and told the control room that
the man was likely to stay in hospital for the foreseeable future. The officer
rang again at 1.50pm to confirm his new location in the hospital, which would
be ward West 6.
42. A letter from the Llandough Hospital told the prison doctor that the man’s
prognosis was probably weeks. The letter also explained that the hospital
would explore whether he could be admitted for palliation (terminal illness
care) and would contact Cardiff in due course with regard to setting up a long
term care plan for him. At 3.50pm on 9 October, he was admitted to ward
West 6 and was escorted by two officers. This was the last entry recorded on
his PER form. My investigator could not determine from the man’s records
when his family were told of his stay in hospital and who informed them.
43. A bedwatch log commenced for the man at 9.10 pm that evening. Two
officers were assigned escort duty for that first night in hospital. The log said
that restraints were attached to him and that he was ‘cuffed’ to one of the
officers. The log check list showed that the officers had seen the current risk
assessment and instructions for removing and reapplying restraints.
44. The man had a relatively quiet night in hospital. He took fluids and slept for
long periods. The bedwatch log recorded two periods of restlessness at
2.30am and again at 7.45am. The morning entry noted that he had
“attempted on many occasions to try and slip his hands from the cuffs” and
that the “security cuffs” had been checked every hour throughout the night.
45. At 11.00am on 10 October, he began his chemotherapy treatment which was
scheduled to take two or three hours. The bedwatch log recorded that the
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man was cuffed to an officer using an escort chain at the time of his
treatment. An entry by another officer at 11.50am said:
“Seen by doctor. Moaning about being cuffed. Doctor asked if they
could be removed. Informed her that someone would be visiting from
the prison later today [10 October] and a decision would then be made
as to when, or if cuffs could be removed.”
46. The bedwatch pack issued to staff includes local guidance which details
escort officer duties, when and what to expect from management checks, and
what to do in the event of change in a prisoner’s condition. On the use of
restraints, the local guidance states that escort officers must remove restraints
immediately where a doctor requests removal for emergency treatment or
where restraints impede immediate or ongoing treatment. Where this is
necessary, officers are required to contact the duty governor at Cardiff to
notify them of the changes in security and health.
47. At 1.15pm, the man’s chemotherapy finished. Approximately 15 minutes
later, escort officers opened the emergency escort bag. The bedwatch log
recorded that the bag was opened because he was still in prison clothing. He
was given pyjamas to wear but no slippers were found in the bag.
48. At 2.00pm, an officer contacted Cardiff and reported that there were no
changes to his condition. My investigator found no record of a conversation to
reflect the doctor’s request for removal of restraints and no record that the
officer spoke to the duty governor about that issue. My investigator spoke to
a governor by telephone and was told that, if no record existed, it was
probably safe to assume no conversation took place.
49. An SO carried out a management check at 3.00pm and confirmed that the log
was up to date. The SO also ticked to confirm that the man was in suitable
bed wear and that a risk assessment, signed by a governor, was in place.
The SO’s management check made no mention of the doctor’s request for
removal of restraints during treatment. My investigator did find evidence of a
conversation about restraints between a member of healthcare staff and the
hospital in a significant events form. Unfortunately, the form was not signed.
50. The man had another quiet night. He remained cuffed to an officer, who had
relieved another officer of bedwatch duties that evening. The man slept
throughout the night until staff went off duty at 8.00am on 11 October. At
1.50pm, a governor carried out a management check in accordance with the
local guidelines. The checklist was completed at 2.10pm and recorded that all
was correct. His family visited his bedside at 2.45pm and this was recorded
on the bedwatch log. The governor amended his risk assessment with the
following entry:
“11/10/06 – Risk assessment amended – restraints to be removed.
Restraints can be used if escort staff deem it necessary. Duty
governor to be informed if this happens.”
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51. A hospital watch checklist and handover log for 11 October was made
available to my investigator. The log was completed at 3.05pm by an officer
who took over duties from an SO. The log suggested that the man was no
longer cuffed to an escort officer. It also confirmed that a new bedwatch log
had commenced for another officer’s shift. My investigator discovered that
the bedwatch log for this officer’s shift, between 3.05pm and 8.00pm, was not
completed.
52. Two escort officers took over bedwatch duty at 8.00pm and reported no
problems throughout the night. Both officers went off duty at 8.00am on 12
October and were relieved by two other officers. The bedwatch log for their
shift confirmed that the man had received visits from his family between
11.30am and 12.30pm. An hour later, one of the officers, contacted Cardiff to
confirm that the man would be staying in hospital over the weekend. He slept
for most of the day until his sister visited him in the early evening. He had a
restless night due to developing breathing difficulties.
53. A prison doctor received a further letter from the hospital on 12 October. The
letter was from the Lead Cliniciann, and explained that the man had been
discussed at the lung cancer multi-disciplinary team. The team confirmed that
numerous malignant cells had been found and that his disease was
“extensive”. The next day, his family visited him again.
54. On the afternoon of 15 October, He received another family visit. At 4.25pm,
an officer on bedwatch duty made an entry in the log which said that one of
the man’s visitors objected to officers being present whilst visits took place.
Both officers stepped outside the room and observed him through the window.
He had a restful night with no problems.
55. At 3.30pm on 16 October, the man was placed on single officer bedwatch
following a management check by a governor that morning. Hospital staff
were also informed of the change in circumstances and his risk assessment
was amended to reflect this. An officer remained at the hospital and made
regular entries in the log describing the man as weak and sleeping most of the
time. The following day, he was placed on a drip and seen by a
physiotherapist because of his breathing problems. Nursing staff at Cardiff
telephoned the hospital for updates on his condition and entered them into his
medical record. The record showed that he deteriorated quickly over this
period.
56. On 19 October, a nurse spoke to the Ward Sister at Llandough Hospital and
was told that a case conference had been scheduled for the following
Tuesday. The conference would discuss discharge planning for the man.
The entries in his medical record were not signed.
57. Later that evening, he received a visit from friends and family. The officer on
bedwatch duty, placed himself in the corridor away from the man’s room
because he had picked up an infection. The officer reported this to the duty
governor. Throughout the evening, he took food and fluids but remained
sleepy.
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58. At 1.00am on 20 October, the bedwatch log recorded that the man got out of
bed, fell, and was helped back into bed by the nurse attending.
Approximately 20 minutes later, the same nurse told an officer that the man
had passed away. The doctor pronounced death at 2.00am. An officer
notified the night orderly officer at Cardiff, before returning to the prison at
2.35am by taxi.
Events following the man’s death
59. At approximately 1.30am, a governor was told that the man had died and that
an escort officer had remained at the hospital. The governor agreed to make
his way to Cardiff to start contingency plans for a death in custody, and
arrived within half an hour of receiving the phone call.
60. The governor completed all the relevant paperwork and followed Cardiff’s
local contingency plans. He also drafted a memo to the prison’s governing
governor . In the memo, the governor explained that he had experienced
some difficulty contacting the man’s named next of kin but had managed to
get in touch with his niece and had passed on the news of his death. The
governor asked the governing governor to pass on thanks to the officer on
bedwatch duty, for his invaluable support. The governing governor was also
made aware of the support the SO gave in carrying out the duties required
following a death in custody.
61. At 7.20am on 20 October, the Head of Healthcare recorded in the man’s
medical record that he had died suddenly in the early hours of the morning.
She also told the prison’s Family Liaison Officer of his death. A notice to
prisoners was circulated throughout the prison, informing them that the
chaplain would deliver a service for the man and that all were welcome to
attend.
62. The man’s funeral took place on 31 October. The funeral was arranged by his
family and the cost was met by Cardiff in accordance with the relevant Prison
Service Order (PSO). Cardiff’s chaplain arranged for a wreath to be sent to
the service on behalf of the prison.
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ISSUES
Family concerns
63. Why was the man not reviewed by a doctor as recommended by a nurse on
20 May 2006?
He was seen by a doctor on 20 May 2006 and underwent a chest examination
in his cell. He was prescribed antibiotics for his cough symptoms and was
scheduled for an appointment at the chronic disease clinic.
64. He was a proud man and not one to make a fuss about his health. It would
have taken a lot for him to admit to feeling unwell.
A prison doctor told my investigator that she agreed that the man presented
as someone who did not complain unduly. In her limited contact with him, the
doctor said that he was reluctant to acknowledge the need for further
investigations of his symptoms when this became necessary.
65. On 1 September 2006, he complained he was coughing blood. However, he
was not referred for further tests until 18 September, over two weeks later. It
was then another eight days before he received the results of his x-ray. This
process took almost a month. Why were there such delays?
The doctor saw him on 1 September 2006 after he had reported coughing up
blood and having a hoarse voice over the last few days. The doctor examined
him and advised that his symptoms were of some concern. Then doctor
recommended a chest x-ray as soon as possible and asked the man to
provide a sputum specimen to send for analysis. He was also told that he
should be referred to see a specialist in hospital for further examination. The
doctor told my investigator that the man declined all advice, despite being told
that the underlying cause could be serious. He asked for antibiotics but did
agree to return for a health review two weeks later and then agreed to have a
chest x-ray which took place the same day. The chest x-ray results were sent
to Cardiff a week later and were acted upon immediately. He was referred for
an urgent CT scan on his chest and was also referred to a lung specialist.
These interventions took place within the NHS cancer referral recommended
guidelines of two weeks or less.
66. As well as physical symptoms, there were other signs of his deteriorating
health, such as withdrawing from the regime, being reclusive and showing
aggression towards staff. Why were these not picked up on?
He was reviewed regularly during his custodial period at Cardiff. He had
appointments for both the chronic disease management clinic, as instigated
by healthcare staff, and attended appointments for acute infective
exacerbations of his lung disease, as instigated by the man. Prior to 1
September 2006, no healthcare interventions found any significant
deterioration in his physical or mental health. He was seen by a Registered
Mental Nurse (RMN) in his cell after he displayed what an officer described as
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allegatory behaviour. The nurse concluded that there were no obvious signs
of mental health problems.
67. The clinical review states that standard healthcare checks, such as blood
pressure checks, were not made on him during his respite care in the
healthcare centre. Why were these not carried out given his age and recent
poor health?
The man’s respite care was initiated as a response to his ‘challenging
behaviour’ on the therapeutic landing. It was not initiated as a result of any
concerns over his physical health. The doctor said that no new symptoms
were presented during his respite in June 2006, therefore no medical
interventions followed. His stay in healthcare was undertaken to help alleviate
the behavioural difficulties he experienced on the wing.
68. He presented as unwell from 20 May 2006, but did not receive any tangible
medical examinations until 18 September. His family were concerned that he
could have been suffering during this time and found this quality of care
unacceptable.
The prison doctor confirmed that the man was reviewed on seven separate
occasions during this period. Where he did not refuse medical interventions,
He was treated appropriately for acute exacerbations of his pre-existing lung
disease. As his heart condition presented as stable, on no occasion was it felt
that he deteriorated significantly between May and September. The doctor
said that his symptoms did give rise to medical concern on 1 September. He
was advised appropriately, had a chest x-ray, but initially refused further
medical intervention.
69. The first recommendation in the clinical review mentions that healthcare staff
should always request and chase medical notes for prisoners who present
with illnesses to allow continuity of care. Why does this not happen as
standard?
It is not standard current practice for a prisoner’s GP or hospital notes to be
routinely forwarded to prison establishments when they are first taken into
custody. Where there is doubt about a prisoner’s condition or medication,
previous notes can be requested with a prisoner’s permission. The doctor
said that, in the man’s case, he was able to provide information about his
medical history. Healthcare staff noted this and monitored his chronic
conditions. His condition remained stable in prison up until 1 September 2006
when he presented with new symptoms.
70. He had a heart problem and had been in hospital on two or three occasions
prior to going into custody. My report refers to the man asking for his
medication. His family questioned whether he was referring to his heart
medication and felt that, if the prison had made more of an effort to obtain
medical notes, they would have been aware of this.
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The prison doctor was unable to confirm which episode this concern referred
to but said that the man was receiving medication for his chronic conditions.
He did ask for his medication on the evening of 31 May 2006 and was told it
would be picked up from healthcare and brought to the wing. This was at
approximately 6.00pm, prior to the evening medication rounds. My
investigator could not determine whether the man did or did not receive his
medication that evening.
71. The man’s solicitor told his family that all medical records should have been
transferred to Cardiff on his arrival. The solicitor had not contacted the prison
to inform staff how seriously ill he was when he first went into custody,
although his family first thought the solicitor had. The solicitor said that it was
the responsibility of Cardiff to gather information on him and request GP
records as required.
Then doctor confirmed she was not aware of any contact between the man’s
solicitor and Cardiff’s healthcare with regard to his health. She added that, in
any event, healthcare staff identified his chronic conditions on his initial first
healthcare screening in reception. He was seen by a doctor the same day
and appropriate arrangements were made for a follow up and further
monitoring of his medical condition. He was identified as in need of extra
support within a prison setting due to his age and chronic medical condition,
and was located on the therapeutic landing. The doctor felt that having
access to his medical history prior to custody, or being in receipt of a
solicitor’s letter at the time of his reception at Cardiff, was unlikely to have
made a significant difference to the medical management he received.
72. The man was elderly man and came into Cardiff in poor health. He did not
participate well in the prison regime prior to his diagnosis and found it hard to
settle into prison life. It is clear from his core records that his poor health was
taken into consideration when he was located. Meals were collected for him
so that he did not have to negotiate any stairs. He was permanently placed
on A wing’s therapeutic unit and moved to B wing when the therapeutic unit
was relocated there. Despite these considerations, and in the absence of a
separate elderly prisoner regime, he was managed like any other prisoner on
his wing and found this difficult.
73. He presented himself, and was also referred by wing staff, to the healthcare
centre on many occasions. The symptoms of his physical condition were
treated by the prison doctor, but during his two week ‘respite’ period in
healthcare he did not undergo any further tests. Nor was he given any
restricted or adapted regime by virtue of being an elderly healthcare patient.
It is of little surprise that an urgent case and the need for his bed led to his
return to A wing. Respite care is not a healthcare intervention and staff had
no alternative but to return the man to his wing.
74. The balance between security and the compassionate management of a
prisoner in poor health is a difficult one for any prison to strike. I have no
doubt that, once the man was diagnosed with terminal cancer, healthcare staff
did all they could within their means to refer him to hospital for treatment as
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quickly as possible. Once in hospital, Cardiff’s management of his condition
was generally compassionate and dignified. This is reflected in both
governors’ decisions to remove restraints and reduce the bedwatch from two
officers to one officer for the last few days of his life.
75. Although it must be stressed that there would have been no effect on the
ultimate outcome for him, the investigation has highlighted a number of areas
where practice could be improved. I deal with these below.
Clinical Review
76. The Healthcare Inspectorate for Wales carried out a review of the clinical care
the man received whilst at HMP Cardiff. The review noted that he was in poor
physical health when he was sent to prison, but commented that he was, in
the main, sufficiently tested and monitored when he presented healthcare
staff with his symptoms.
77. The clinical reviewer made the following recommendations:
The man’s primary care medical notes were not requested from the NHS
once he was in prison. Prison healthcare staff should always request
and chase medical notes for prisoners who present with illnesses and
requiring medication, to allow continuity of care.
There was no action taken to monitor the level of potassium in his
blood. The primary care was, therefore, not adequate in this regard.
The Medical Officer should have organised blood tests as a precaution
for him, given the quantity of different medication he was taking.
We have noted … that at least one sheet is missing from the Medical
Record, despite repeated requests for it to be found and sent to us. This
may have been filed incorrectly in the Prisoner Medical Record. Prison
healthcare staff must locate and keep medical records securely and in
the correct file.
Use of Restraints
78. The man remained in restraints from 9 October until approximately 2.15pm on
11 October when a governor authorised their removal. It is clear from the
bedwatch log that, when the man underwent chemotherapy treatment on 10
October, he was still attached to an escort officer despite a request from the
doctor for restraints to be removed. He also complained about being
restrained whilst undergoing treatment. Officers on bedwatch duty have a
pack which provides them with information they need to manage a prisoner in
an outside environment safely and effectively. Cardiff’s local guidelines for
escort staff are attached to each bedwatch log. The guidelines state that:
“When restraints are in use, if a healthcare professional (e.g. doctor,
nurse, ambulance officer, paramedic) asks for them to be removed
because of an immediate risk to the health of a prisoner or because the
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restraints are impeding essential treatment, they must be removed.
The escort staff must notify the Duty Manager immediately, in case
additional security arrangements need to be made.”
The local guidelines to staff also say:
“Similarly, if a healthcare professional seeks the removal of restraints
because, although immediate treatment is not required, they are
impeding examination or treatment, the restraints should be removed
unless there is a risk of the prisoner escaping.”
79. The man’s risk assessment was carried out on 6 October which was three
days before his outpatient hospital appointment. Security staff at Cardiff were
not aware, in advance, that he was to be admitted as an inpatient on the day
he arrived at the hospital, and it is important to place the decisions made over
the risk he posed within this context. However, as a governor confirmed,
there was no evidence in the man’s security file to support the ‘medium’ risk of
escape and hostage taking he was considered to pose in the risk assessment
completed on 6 October. Moreover, the focus on medium risk is clearly
tempered by the inclusion of a measure at the back of the risk assessment
which permits the removal of restraints ‘for medical reasons’ with the authority
of a duty governor.
80. The man’s restraints were removed during the afternoon of 11 October. This
was more than 24 hours after his chemotherapy treatment had finished. The
officer on escort duty on the day of his treatment, 9 October, told the doctor
that the request would be raised with the member of staff responsible for
carrying out a management check later that day. No record of any
consideration or further risk assessment to remove restraints from him was
recorded that day. His log simply said that HMP Cardiff had been contacted
and there were no changes in circumstance. I have taken into consideration
that escort officers may not be aware that, under the local guidance to staff
above, they must remove restraints at the request of the medical profession
under certain circumstances. However, the duty governor should have been
made aware of the medical requests at some point that day.
81. The man was 76 years old and terminally ill. Had the duty governor, been
contacted immediately in accordance with the risk assessment and local
bedwatch guidelines, the man might have received his treatment without the
need for restraints and such close supervision from escort officers. I make
the following recommendation:
The Governor should ensure that officers on escort duty are familiar
with risk assessment procedures and local guidelines to staff on
bedwatch duty. In particular, escort officers must ensure they are fully
aware of their responsibility to consider the requests of medical
practitioners and to notify the duty governor immediately that a request
or change in security arrangement is suggested.
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Healthcare Records
82. Healthcare staff at Cardiff saw him regularly during the last months of his life.
It was not always clear from the record who his primary carers were in the
healthcare centre, and when he was transferred to the outside hospital and
discharged. His medical records were often difficult to read and failed to
record every relevant event. Some entries were not correctly initialled or
signed.
The Healthcare Manager should remind staff that, in accordance with the
Nursing and Midwifery Council’s guidelines for records and record
keeping, all medical records should be legible, up to date and in
chronological order. In addition, audits of the quality and consistency
of records should be undertaken in partnership with the PCT on a
regular basis.
Housekeeping points
83. The man was transferred to hospital for exploratory procedures before being
admitted to ward West 6 at Llandough Hospital on 9 October. Local security
instructions were clearly followed with regard to escorts maintaining regular
contact with the prison to update staff as to his condition. However, there are
some gaps in reporting between 3.50pm and 9.10pm on 9 October and
3.05pm and 8.00pm on 11 October. Bedwatch logs are a valuable
communication tool and, properly completed, allow for early detection of
changes in an individual’s condition and security risk. I draw this to the
Governor’s attention but make no formal recommendation.
84. He remained in prison issue clothing for approximately 24 hours after his
admission to Llandough Hospital. When escort officers did open the
emergency bag at lunchtime on 10 October, they found night clothes but no
slippers for him to wear. Local guidelines to staff on bedwatch duty state that
all prisoners must wear suitable night wear in hospital. I have not been able
to establish why he remained in either prison or hospital issue clothing for this
period. I must assume that officers were either unaware of the requirement
or, due to his unforeseen admittance as an inpatient, did not receive the
emergency bag until the afternoon of 10 October. I draw the Governor’s
attention to this issue but again make no formal recommendation.
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RECOMMENDATIONS
1. The Governor should ensure that officers on escort duty are familiar
with risk assessment procedures and local guidelines to staff on
bedwatch duty. In particular, escort officers must ensure they are fully
aware of their responsibility to consider the requests of medical
practitioners and to notify the duty governor immediately a request or
change in security arrangement is suggested.
The Prison Service has accepted this recommendation.
2. The Healthcare Manager should remind staff that, in accordance with the
Nursing and Midwifery Council’s guidelines for records and record
keeping, all medical records should be legible, up to date and in
chronological order. In addition, audits of the quality and consistency
of records should be undertaken in partnership with the PCT on a
regular basis.
The Prison Service has accepted this recommendation
Additional recommendations are made in the clinical review and are cited in
the text above on page 21.
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