Individual at Chelmsford

Investigation into the circumstances surrounding the death of a man in a
hospice whilst a prisoner at HMP Chelmsford, in September 2005
REPORT BY THE PRISONS AND PROBATION OMBUDSMAN FOR
ENGLAND AND WALES
February 2006
This is the report of an investigation into the death of a man who died in a
hospice at the age of 83, whilst on remand at HMP Chelmsford.
I offer my sincere sympathy and my condolences to his family for their loss.
My office investigates the deaths of all prisoners in custody, including those
due to natural causes. In this case, the investigation was carried out by two of
my investigatorsThey asked the chief executive of the local Primary Care
Trust (PCT) to commission an independent clinical review. The clinical
reviewer’s assistance is much appreciated. I am also grateful to the Governor
and clinical nurse manager of Chelmsford for their assistance during the
investigation.
I note the clinical review identifies a number of learning opportunities for
Chelmsford and hope that the healthcare manager and PCT will see these as
such, and use them to further develop and improve their healthcare services
for prisoners.
During his time at Chelmsford, the man who died was well cared for. Staff in
the healthcare centre liaised with other healthcare agencies to ensure he
received appropriate, sensitive and timely treatment. I commend the
Governor and his team for the sensitive care and management of the man in
the final stages of his illness.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2006
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Contents
Summary 4
The investigation process 5
Background 6
The man who died
HMP Chelmsford
Key findings 7
Issues considered during the investigation 13
The care the man received
Healthcare
Records and record keeping
Recommendations and good practice 16
Annexes:
1 Clinical review
3
Summary
1. The man was born on 10 November 1921 and died at the age of 83 in
September 2005. He spent the last 11 months of his life on remand at
HMP Chelmsford. During this time, he suffered a decline in his
physical and mental health and spent many weeks in hospital. Five
days before his death, he was transferred to a local hospice where he
lapsed into unconsciousness and died.
2. On 9 October 2004, he was remanded into custody having been
charged with attempting to murder his wife. He had made two attempts
to take his own life after the attack on his wife. When he arrived at
HMP Chelmsford, a number of the documents that had been sent with
him flagged up his suicide attempts.
3. This was the man’s first time in prison and he was initially very
distressed. In spite of this, he told staff that he did not intend to harm
himself. However, staff decided to open a ‘self harm at risk’ document
that meant he would be carefully watched and supported. This
remained in place until four weeks before his death, by which time he
was physically very frail and receiving 24-hour nursing care.
4. When he arrived at Chelmsford, the man had a number of health
problems, mostly associated with his age and these were treated
appropriately and in a timely manner. However, in March 2005, his
health deteriorated very markedly. Over the next three months, he
spent many weeks in hospital where his symptoms were investigated
and treated. In June, he was diagnosed as having a fistula (a hole)
between his bowel and bladder. The surgeons decided not to operate
to repair the fistula because the man was so frail and weak. Also, the
man did not want to have the surgery.
5. He returned to prison where the medical and nursing staff did what they
could to make him comfortable and keep him pain free. On 3
September, he was admitted to a hospice where he died five days
later.
6. The clinical review makes four recommendations and highlights an
example of good practice, all of which I thoroughly endorse.
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The investigation process
7. My investigators opened the investigation by letter and then visited
HMP Chelmsford on 5 October. They met the Head of Healthcare, a
member of the Independent Monitoring Board and the chairman of the
local branch of the Prison Officers' Association. The clinical nurse
manager showed them around the healthcare centre. They also
received copies of the man‘s prison and medical records.
8. One of my Family Liaison Officers contacted the man’s family to ask if
they wanted to raise any issues about the man’s time in prison. No
issues were highlighted.
9. A clinical review of the health care the man received was carried out by
a member of the local PCT. Her report is at Annex 1.
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Background
The man who died
10. The man died at the age of 83, from bronchopneumonia (inflammation
of the lungs) in a hospice whilst on remand at HMP Chelmsford. He
had been arrested on 7 October 2004 and charged with attempting to
murder his wife. After the alleged offence, he attempted to take his
own life. His only child, a daughter, had died a number of years
previously, but his son-in-law kept in touch as did his grandchildren.
11. The man spent most of his time in prison in the healthcare centre. His
needs were very different from many of the other patients, most of
whom had mental health problems. Staff allowed him to be out of his
cell as much as possible, and he spent a lot of his time in the day room
reading his newspaper and drinking tea.
12. Staff explored the possibility of transferring him to the Older Persons
Unit at HMP Norwich, but this was not possible as it only accepts
convicted prisoners and has limited capacity.
HMP Chelmsford
13. Chelmsford is a category B local and Young Offender Institution.
Built from 1830 onwards as the county jail, it has been used as a long
term category B prison, a young person's prison and, since 1987, as a
local prison. Two new house blocks were opened in 1996 to relieve
overcrowding.
14. The regime includes provision of education and domestic work in the
gardens, laundry and workshops. There is a Samaritans supported
Listener scheme in place for prisoners who are in distress or who need
to talk in confidence. There is also an Insiders scheme to assist
prisoners through the first few days in prison.
15. The healthcare centre is housed in a purpose-built, two storey building
that was opened in June 2004. It has 12 in-patient beds and a number
of treatment rooms, including a dental surgery and pharmacy. Part of
the ground floor houses a mental health day care centre where
occupational therapy and psychiatric services are provided. The day
care staff are employed by North Essex Mental Health Partnership
Trust.
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Key findings
16. The man appeared at Chelmsford Magistrates’ Court on 9 October
2004, charged with attempting to murder his wife. Whilst there, his
solicitor asked that he be assessed by a member of the Community
Justice Mental Health Team. The team leader spoke to the man. He
informed her that, after the alleged attack on his wife, he tried to hang
himself but the rope broke and he fell to the ground. He denied that he
had any current intention of harming himself. He said that he was an
outpatient of a consultant psychiatrist for older people, but that he was
not on any medication. He listed his physical health problems as
arthritis of the spine and knees (for which he was prescribed pain
killers), high blood pressure and thyroid problems. The team leader
concluded that, at that time, the man was not showing signs of mental
illness. However, his solicitor later informed her that the man had
taken a drugs overdose approximately two weeks earlier. The team
leader recommended that a suicide/self-harm warning notice should be
opened, and, if he was remanded in custody, he should be admitted to
the prison’s healthcare wing.
17. The man was remanded in custody until 15 October, and taken to
Chelmsford prison. The warrant sending him to Crown Court for trial
had a note written at the top highlighting his suicide attempt and then
adding, "suicide watch". In spite of the team leader's recommendation,
the man was not moved directly to the healthcare centre, as no beds
were available. Instead, he was accommodated on D Wing.
18. The continuous clinical record notes that when the man was in
reception he spoke at length about his home life. He denied having
any thoughts of harming himself. When the process of being put on a
suicide and self-harm watch was explained to him, he said that he did
not want this as such thoughts were furthest from his mind. He was
referred to a doctor to have his medication prescribed.
19. However, a further entry at 11:30pm that evening described the man as
extremely upset and wanting to stay on the landing outside his cell all
night. The officer who made the entry attributed this to the fact the man
could not cope because it was his first time in prison. The member of
healthcare who attended D wing contacted the doctor who prescribed a
sleeping pill for the man. Soon after taking this medication, he settled
down and slept through the night.
20. The following day, a first reception health screen form was partially
completed as part of the induction process. It was noted that the team
leader's report and police custody medical and medication forms had
been received by the prison. Also noted was the fact that the man had
recently been treated by his general practitioner for depression. He
also told the member of healthcare staff that he suffered from arthritis
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of the spine and right knee. It was recorded that the man had a
dressing on his forehead, a bandage on his left arm and a bruise on the
back of his head. The question, "Do you think there is any reason why
you might need to see a doctor?" was given a positive answer, but no
reason for this was recorded. Indeed, the remainder of the form was
not completed. Therefore, the sections on planned action and fitness
for normal location and work appear not to have been considered.
Finally, the form has not been signed or dated. These issues are
addressed by recommendations in the clinical review, with which I
agree.
21. The continuous clinical record recorded his current state of health, and
highlighted depression and high blood pressure as problems. The man
was referred to the healthcare centre for crisis intervention with a
review scheduled for 48 hours later, preferably with a psychiatrist. His
current medication was recorded and a review by the doctor was
scheduled for later on that week.
22. At this point a F2052SH self-harm at risk form was opened. This
document is opened when a prisoner has harmed himself or is thought
to be at risk of doing so. There were still no beds available in the
healthcare centre and the Governor was informed. Until a bed became
available in the healthcare centre, the man was moved to a cell on E
wing where vulnerable prisoners are accommodated. A review of the
case should be held within 72 hours of the F2052SH document being
opened and at least every two weeks thereafter. The man 's first
review was held on 11 October, well within the guidelines. The man
attended and told staff at the meeting that he was upset at not getting
bail, but was more concerned about his wife. The support plan that
was drawn up included phone calls to the hospital to check on the
condition of man’s wife and to his son-in-law. It also included referrals
to the healthcare centre and to day care. Staff in the day care centre
provide occupational health and psychiatric services.
23. However, there was still no available bed in the healthcare centre for
the man. The clinical nurse manager liaised with the wing staff to
emphasise the importance of closely monitoring him overnight. The
man was also assessed by staff in the day care centre.
24. On 12 October, the man was assessed by a psychiatrist. He noted that
the man was alert and aware of his surroundings but was very upset
about his wife. He concluded that the man remained at risk of suicide,
should be admitted to the healthcare centre as soon as possible, and
should be watched closely. The man was admitted to the healthcare
centre later that day. Over the next two days, he slept for long periods,
but when awake he chatted easily with the staff. He then returned
briefly to E wing, before being re-admitted to the healthcare centre on
15 October. He returned to court that day and was again remanded in
custody. He told staff that he was tired after being in court all day and
upset at being returned to prison.
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25. On 17 October, the man was told of his wife’s death and was then put
on constant watch. Staff spoke at length with him and continued to
watch him closely. Although he showed signs of distress, he did not
talk about suicide. A note on the record stated that he had spoken
about his wife’s death to a member of staff in the day care unit and he
felt that doing so had helped him.
26. On 18 October, probation staff in a local probation office sent a
Prisoner Warning Notice to the prison highlighting three matters of
concern about the man. Firstly, that his wife had died on 16 October.
Secondly, that his late daughter’s birthday fell on a date shortly
afterwards. Thirdly, that the anniversary of her death was in March.
Receipt of the letter was noted in the continuous medical record.
27. On 27 October, due to pressure on healthcare centre accommodation,
the man was temporarily returned to E wing. However, a week later he
was re-admitted to the healthcare centre where he remained for the
rest of his time in the prison. Staff noted that he had crying spells and
looked disturbed, and they drew up a care plan for him at that point.
Over the next few weeks, he began to have a more positive outlook.
Staff ensured that the man was out of his cell as much as possible. He
spent a lot of time watching television and reading the paper. The
prisoners who worked as cleaners in the healthcare centre kept him
supplied with cups of tea. He was treated by a doctor for a number of
illnesses, including a urinary tract infection.
28. As the date of his wife’s funeral approached, staff noted in his records
that the man would need lots of emotional support before and
afterwards. The funeral passed without incident. On 13 December, the
man attended court where he was again remanded in custody to
Chelmsford. By this time, he was facing a charge of murder as a result
of his wife’s death.
29. On 10 January 2005, the doctor treated him for a bowel problem and
then on 14 March he was prescribed medication for a urinary tract
infection.
30. In the early hours of 22 March, the man rang his cell bell after
discovering that he was bleeding from his rectum. By the time staff
opened the door, he was lying on the floor. He was helped onto the
bed, given oxygen and an ambulance was called. He was taken to a
local hospital, where he was admitted and reviewed by the surgical
team. He continued to bleed and was given a blood transfusion. The
following day, surgeons attempted a colonoscopy, which is an internal
examination of the intestines by means of a fibre optic cable. However,
they had to stop the process because the man was losing too much
blood. He remained in hospital for further tests which showed that he
had diverticulitis, inflammation of the wall of the intestine.
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31. He was discharged from hospital and returned to the prison on 4 April.
Over the next few days, his medical notes recorded that he was very
tired. On 15 April, he told staff it was painful to pass urine, and again
two days later. Staff recorded that he was sleeping for longer periods
and that he was lethargic. On 19 April, a blood test revealed that his
haemoglobin was low, indicating that his body was not making enough
red blood cells. The man was taken to hospital for a blood transfusion.
Six days later, the hospital doctor informed the prison doctor that the
man was anaemic, had an enlarged prostate and possibly acute renal
failure. He also probably had an obstructed urinary system and was
waiting to be assessed by a urology specialist.
32. The man remained in hospital until 13 May when, against medical
advice, he discharged himself. He returned to the healthcare centre at
the prison and an outpatient appointment was made for him for 1
August at the hospital. However, by 16 May the man was again unable
to use the toilet without pain and on the following day he was re-
admitted to the hospital. Over the next two weeks, he had two small
operations and other investigations, but the results were not available
until 17 June. While waiting for the results, healthcare staff regularly
contacted the hospital for information on the man's condition. The
clinical nurse manager visited him three times with different colleagues.
On the first visit she conducted a 2052SH review along with the prison
doctor and the two prison officers who were supervising the man. They
noted that the man's mood was low and tearful.
33. On 17 June, healthcare staff were informed that the man had a fistula
between his bladder and bowel and that there was a non-malignant
tumour in the area. The surgeons discussed the possibility of an
operation with the man. However, they were not sure that he was
strong enough to have the surgery and the man refused to agree to it.
He also refused to have blood tests done that would allow doctors to
assess his overall health.
34. On 21 June, he was discharged from hospital and admitted to a
hospice through arrangements made by hospital staff. However, as the
tumour was not cancerous, the man was unable to remain there and on
27 June he returned to the healthcare centre. The discharge letter
from the hospice staff offered to give advice to the healthcare staff if
they required it. The hospice staff also said that they would consider
re-admitting the man when he reached the final stages of his life.
35. Staff noted that the man was doubly incontinent and a chart was begun
to keep a record of his fluid intake and output. After a risk assessment
was carried out, staff arranged that:
• the man 's cell would be unlocked 24 hours a day
• a care worker would always be present along with another
member of staff
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• a daily review would be held with the deputy governor and head
of healthcare and, whenever possible members of staff from
other departments.
The healthcare staff also arranged for the man's family to visit him.
36. On 5 July, one of the nurses on the afternoon shift noted that she had
been unable to give the man full nursing care because of staff
shortages. The following day, a nurse on the evening shift made the
same observation. In order to meet the man's need for 24-hour care,
the healthcare manager hired agency care staff to supplement her
staff.
37. Over the next two weeks, staff noted that the man was not drinking
enough and on 11 July the doctor recorded that he was refusing fluids.
Two days later, pressure ulcers were noted. Healthcare staff liaised
with the tissue viability nurse and the continence advisor from the local
PCT and took advice on how to treat the man. They obtained an air-
flow mattress and other equipment to improve the man's comfort. The
costs were met from the prison's budget. They looked at the possibility
of obtaining cot sides to improve his safety when in bed, but an
assessment by an occupational therapist was needed first. The clinical
nurse manager tried to arrange this, but was unable to make contact
with the staff in the local NHS occupational therapy unit.
38. The man was due to return to court on 20 July. The day before, his
solicitor faxed to healthcare staff a copy of a psychiatric report she had
commissioned. The psychiatrist had previously seen the man on 9
December 2004, and noted a significant deterioration in his mental and
physical health since then. He described the man as “physically frail
and dependent” and said that he “cannot sustain his attention and
concentration for any period of time”. He concluded that the man was
not fit to stand trial. The medical and nursing staff at Chelmsford
discussed whether the man was fit enough to attend court the following
day. They agreed that he was too frail and faxed this decision to the
court and solicitor.
39. In the early hours of 22 July, the man slipped out of bed onto the floor,
bruising his left eye. Staff put him back into bed and checked him
thoroughly. He had no other injuries. At 11:00am, the prison doctor
was given the man's latest blood test results which showed that he had
an infection. He contacted the hospital and at lunchtime the man was
once more admitted to hospital. Healthcare staff again regularly
contacted the hospital for updates on the man's condition and visited
him. They kept his solicitor informed of events. On 26 July, hospital
staff reported that the man was "very poorly" and was being given
antibiotics because he had sepsis, a serious infection of the
bloodstream. However, over the next few days, he gradually improved.
40. On 1 August, hospital staff told healthcare staff that the man was no
longer on antibiotics and his treatment had been reviewed. They had
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decided that he was "not for further intervention and not for any re-
admissions". The following day, the ward sister at the hospital told
healthcare staff that the man and his family had agreed that he should
not be resuscitated if he had a heart attack. The consultant then faxed
a letter to the prison confirming this information. The man returned to
the healthcare centre later that day. Staff briefed prison management
about the man and stressed the decision not to resuscitate. They also
informed his solicitor.
41. On 4 August, a 2052SH review was held. The man was sleeping when
the review team entered his room. They noted that his health had
deteriorated and he now required and was receiving 24-hour nursing
care. They therefore decided to close the document.
42. Three days later, the man was again found on the floor of his room. A
full physical assessment was carried out, but he had no injuries. The
incident occurred shortly after the healthcare assistant went for her
break. Staff moved the bed to the wall to make it more secure, and
advised the man not to try to get out of bed unaided. An additional
note was made that staff were to encourage him to take more fluids,
but not to force them on him. For the next four weeks, the man grew
weaker. He spent most of his time in bed and slept for a lot of the time.
He was regularly encouraged to drink, but by 2 September the doctor
noted he was more confused and appeared dehydrated.
43. On 3 September, staff asked the doctor to review the man as he was
becoming distressed. He appeared to be in pain - he was restless and
was not sleeping. However, when asked by staff, he denied that he
was in pain. Staff contacted the doctor at the hospice and he agreed
that the man could be admitted at once. By mid afternoon he had been
transferred by ambulance to the hospice. Staff informed his family of
the transfer. Healthcare staff remained in contact with staff at the
hospice and they visited the man two days later, but he was asleep.
The following day they were informed that he was now unconscious.
44. On 8 September, the man's family visited him and later that evening, at
9:15pm, he passed away. On 6 October, the prison chaplain
conducted his funeral and members of healthcare staff attended the
service.
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Issues considered during the investigation
The care the man received
45. The man’s care during his time in custody began at the police station
where he was examined and given medication by a police doctor. At
Chelmsford Crown Court, he was assessed by the Community Justice
Mental Health Team leader. She highlighted the man’s recent suicide
attempts and recommended that, if remanded in custody, he should be
accommodated in the healthcare centre. After his arrival at the prison,
local probation staff alerted prison staff to dates when he might need
extra support. I commend these actions as an example of good
communication between agencies resulting in good care of a
vulnerable person.
46. When the man arrived at Chelmsford, there were no beds available in
the healthcare centre. However, the staff on the wing were alert to his
distress and worked with healthcare staff to ensure that his first night
passed relatively comfortably. For the next month, the man spent as
much time as possible in the healthcare centre, until a permanent bed
was available for him. Staff acknowledged that his needs were
different to many of the other patients and they arranged for him to
spend as much time as possible out of his cell.
47. For almost all his time in custody, the man was on a 2052SH
document, to give him closer supervision and support to prevent him
attempting to harm himself. The review meetings were carried out
regularly and according to the guidelines. The staff who attended the
reviews were drawn from the team that conducts the reviews in the
prison. This provided continuity of care over the months that the
document was open. The suicide prevention co-ordinator took part in
well over half the meetings and chaired the review when it was decided
to close the 2052SH.
Healthcare
48. The man’s illnesses were treated efficiently and healthcare staff liaised
with a number of agencies to ensure that he received prompt and
appropriate care. Once it was agreed that there should be no further
surgical interventions, he received constant nursing care. Agency staff
were hired to help provide 24-hour nursing, and staff arranged that his
cell would always be unlocked. They obtained a specialised mattress
to make him more comfortable and sought advice from specialist
nurses and hospice staff. However, it is unfortunate that cot sides for
his bed could not be obtained as they might have prevented him twice
falling out of bed.
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49. When the man’s condition worsened, staff contacted a local hospice to
arrange for him to go there. The speed with which the transfer was
accomplished was commendable. The relationship and communication
with the hospice was appropriate and timely in the man’s case.
However, the development of a formal multi-agency policy for the
management of terminally ill prisoners would assist in identifying
pathways of care and treatment options for future patients.
The healthcare manager and Primary Care Trust should develop a
multi-disciplinary policy for the management of terminally ill
patients within the custodial environment.
50. The man received a high level of medical and nursing care from
healthcare staff at Chelmsford who ensured that his treatment was
prompt and appropriate. But other members of the prison staff also
contributed to his care. He was also cared for by the staff on the wings
where he spent his first month. The prison’s management contributed
to caring for him by making special arrangements to allow him to be
unlocked for longer periods than usual. The suicide prevention co-
ordinator and his team regularly met with the man and discussed how
his needs could be met.
I commend the Governor and his staff for the excellent care they
gave the man. The ways in which they met his individual needs
are examples of good practice.
51. The clinical review identifies a number of learning points for the
healthcare manager and PCT. These should be seen as an
opportunity to further improve and develop healthcare services for
prisoners.
Records and record keeping
52. Whilst on remand, the man spent approximately 12 weeks in hospital
and the hospice. During these times, he was accompanied by
uniformed prison officers who were responsible for his security. As part
of their duties, they made written observations in two documents:
• The hospital bedwatch occurrence log
• The daily supervision and support record.
53. The front cover of the Bedwatch Log reminds officers of the need to
ensure that the entries they write are factual and respectful. Most of
the entries were well written, and some were very sensitive and caring.
However, I was disappointed to read a number of comments by
different officers that did not reach this high standard. To make
comments of a personal nature is unwarranted and I consider such
entries disrespectful and lacking in common humanity. I have
separately provided the Governor with a list of the inappropriate
comments.
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54. The entries in the clinical records did not on occasions meet the
standards required by the professional bodies for nurses and doctors.
Specifically, they were not always legible, the entry time was not
recorded and the name of the author was not printed next to the
signature. Healthcare staff should be reminded of the expected
standards for clinical record keeping.
I recommend that staff should be reminded of the need to ensure
that entries in prisoner records are accurate, factual, sensitive and
respectful.
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Recommendations
The healthcare manager and Primary Care Trust should develop a
multi-disciplinary policy for the management of terminally ill patients
within the custodial environment.
I recommend that staff should be reminded of the need to ensure that
entries in prisoner records are accurate, factual, sensitive and
respectful.
Good practice
I commend the Governor and his staff for the excellent care they gave
the man. The ways in which they met his individual needs are
examples of good practice.
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