Individual at Elmley

The Death in Custody of a man
HMP Elmley - 12 March 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
March 2006
This is the report of an investigation into the circumstances of the death of a man in
hospital on 12 March 2005. He had been taken to hospital, on 28 February 2005,
following a number of previous hospital admissions. The man had been unwell for
some time with heart related conditions. His death was not unexpected.
The investigation was led by a member of the Fatal Incidents Investigation Group, a
qualified nurse also reviewed the medical care given to the man whilst he was in
prison.
I would like to thank the management and staff at HMP Elmley for their assistance
and co-operation during the course of this investigation.
I would also like to extend my sincere condolences to the family of the man and to
those touched by his death.
This version of my report, published on my website, has been amended to remove
the names of the deceased and the names of staff and prisoners who were involved
in my investigation.
Stephen Shaw CBE March 2006
Prisons and Probation Ombudsman
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CONTENTS
Page
Summary 4
The investigation process 5
Background 6
Events leading up to the man’s death 7
The prison’s response following the death 8
Issues considered during the investigation 9
• Compassionate release
• Transfer to a hospital/hospice with 24 hour nursing care
Conclusions 10
Recommendations 11
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SUMMARY
The man was an 83 year old man who was serving a four year sentence at HMP
Elmley. He died in hospital on 12 March 2005 following a long period of ill health.
His death was not connected to the fact that he had been in prison, nor to the level of
care that he received whilst in prison.
The man was admitted to HMP Elmley on 31 July 2003. His release date was 30
March 2006. He did not enjoy good health, and suffered from various medical
conditions many of which were cardiac related.
HMP Elmley is a local prison which holds both people on remand and sentenced
prisoners. It has a 29-bedded healthcare centre which is in operation 24 hours per
day. The man was located permanently on the healthcare centre due to his poor
general health. As his condition began deteriorating, he required more medical and
nursing input and care.
The man was referred and admitted to hospital on several occasions with congestive
cardiac failure, chest infection and after a possible heart attack. A consultant
physician, wrote to the Senior Medical Officer at the prison stating, “he is in end
stage of heart failure and his life expectancy is poor.” The consultant recommended
that the man should live in “a care home setting with 24-hour input and that
consideration should be given to his release on parole.” Unfortunately, despite
enquiries via Swale Primary Care Trust, there were no vacancies at a local hospital
or at a hospice at that time.
There were some concerns raised by the family regarding the medical and nursing
care and attention that the man received whilst in prison. They were concerned that
the prison was unaware of his heart condition. The man was expected to “do stuff
that he could not do;” for example, “walk up and down stairs.” The family was also
concerned that his angina spray was taken away due to the fact that he overused it.
They also felt that family visits should have taken place in the healthcare centre.
The family also expressed concerns that they were not always informed when he
was taken into hospital.
The man received one-to-one 24-hour nursing care towards the end of his life and
the treatment and care which was given was comparable to that which would have
been available to him in the community.
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THE INVESTIGATION PROCESS
My practice in investigations into a death from apparently natural causes is to
conduct an initial review to determine the extent of the investigation required.
My colleague first visited HMP Elmley on 18 April 2005 and met with the Healthcare
governor. She was given a full briefing about the circumstances surrounding the
man’s death and was informed that members of his family were aware of his poor
prognosis, and had visited him in the hospital. My investigator also met with a Prison
Officers’ Association representative. A notice to staff and a notice to prisoners was
issued by the prison, inviting anyone who might have information relating to the
man’s death, to make themselves known to the enquiry team. No-one came forward
in response to these notices.
My colleague was given photocopies of all the files and records relating to the man.
These included the medical records upon which she based her clinical review.
One of my family liaison officers contacted the man’s family to see if they had
specific questions about his care.
The man’s family did express some concerns about the care that he received whilst
in prison. These concerns were mainly clinical and are listed as follows:
1. The family believed that the prison was unaware of the man’s heart condition
and that he was made to walk up and down stairs.
2. The family said the spray used for the relief of the man’s angina was taken
from him due to overuse.
3. They said that family visits should have taken place in the healthcare centre.
4. The family alleged that they were not always informed when the man was
taken to the outside hospital.
5. They said that, although they had received some of his property, some items
of clothing was still missing.
My colleague revisited HMP Elmley on 18 May 2005 and spoke with Deputy Head of
Security and Operations to discuss the family’s concerns.
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BACKGROUND
The man left school at the age of 14 with no qualifications. He joined the navy and
left when he was in his late 20s. The man married, and he and his wife had six
children. He did not feel that they were a particularly close family as he spent a lot of
time working away in London.
At the time of his conviction, the man had been divorced for seven years. His
accommodation was a bed sitting room which was paid for by housing benefit. The
man’s ex-wife continued to stay in touch and her intention was to assist him to keep
his flat until his release from prison.
The man had no previous convictions. He said he did not use drugs or alcohol, and
had no mental health issues. He was convicted and given a six year prison
sentence on 31 July 2003. The man spent all of his sentence at HMP Elmley, and
due to his poor physical health was given a sitting down job working in the post
room.
On 31 October 2003, he successfully appealed against his six year sentence. This
was reduced to a total sentence of four years.
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EVENTS LEADING UP TO THE MAN’S DEATH
The man was an 83-year old gentleman who was serving a custodial sentence at
HMP Elmley. He began this sentence on 31 July 2003. The man had a number of
medical problems, many of which were cardiac related. He had been prescribed
medications which were entirely appropriate.
There were a number of occasions when he or was seen by the Medical Officer
following complaints of shortness of breath and chest pains, and treatment was
given as prescribed.
From December 2003, the man's condition appeared to worsen when reports of
chest pain and shortness of breath became more frequent. He was admitted to
hospital and remained there for three weeks, was discharged for one day and
readmitted for a further four weeks.
The Medical Officer received a letter on the 2 February 2005 from the consultant
physician at the hospital, stating that the man was in the last stages of heart failure
and that his life expectancy was poor, he recommended that the man would benefit
from being transferred to a care home setting with twenty four hour clinical input.
The consultant physician also wrote that consideration should be given to the man’s
release on parole.
Unfortunately, there were no beds available in the community at that time, and the
man was not eligible for parole or release on license.
He was given one to one continuous twenty-four hour nursing care in the Hospital
wing at the prison. He was admitted to hospital for a final time on 28 February 2005,
but sadly died on 12 March 2005.
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THE PRISON’S RESPONSE FOLLOWING THE DEATH
Elmley has a comprehensive “Death in Custody” booklet which includes an action
sheet and follow up check list, coroner’s address and contact numbers. My
investigator found the booklet both useful and informative.
Notices informing members of staff and prisoners of the man’s death were posted
throughout the prison.
The post mortem was carried out on behalf of the Coroner’s Office, at hospital, and
lists the following as the cause of death:
1. Pulmonary Embolus
2. Deep Vein Thrombosis
3. Peripheral Vascular Disease
A member of Chaplaincy conducted a memorial service and offered prayers for the
deceased and his family members.
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ISSUES CONSIDERED DURING THE INVESTIGATION
Compassionate Release
The man was considered by the prison for early release on medical grounds under
section 30 of the Crime Sentences Act 1997. The general principles governing early
release on compassionate grounds are:
• the release of the prisoner will not put the safety of the public at risk
• a decision to approve release would normally be made on the basis of facts of
which the sentencing or appeal court was aware.
• there is some specific purpose to be served by early release.
Due to the nature of the man`s offence, release on compassionate grounds was not
considered appropriate. I think that decision was correct in the circumstances.
Transfer to a hospital/hospice with 24 hour nursing care
The consultant physician at the hospital, advised that the man should be transferred
to a more appropriate location such as a hospice which would offer 24-hour nursing
care. Healthcare staff therefore contacted the local Primary Care Trust, Swale PCT,
regarding the possibility of finding long term care within the local community. There
were two options available: a hospice, and a local hospital. Unfortunately, neither
was able to offer the man a bed at that time. I consider that the prison did all that
they could to transfer him to a more appropriate hospital setting offering 24 hour
nursing care.
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CONCLUSIONS
I consider that Elmley cared for the man to the best of their ability within a prison
setting. Management and staff were sensitive to his needs and took all reasonable
steps to accommodate them. The care given to the man from medical and nursing
staff is to be particularly commended. He was permanently located on healthcare
from 10 September 2004 due to increasing attacks of angina. Following the
consultant physician’s advice regarding his need for 24-hour nursing care, and the
inability to secure a bed in a hospital in the community, an agency nurse was
employed by the prison for continuous one-to-one nursing care. This continued until
his transfer to hospital on 28 February 2005.
The man was an elderly man who had a significant number of medical conditions,
mainly cardiac in nature. Treatment and prescribed medication was appropriate in
his case.
Initially, the man worked in the post room following a recommendation from the
doctor that he “could be found a sitting down job”. This was appropriately
implemented.
All steps were taken in an effort to transfer the man to a local hospital that could offer
24-hour nursing care. Unfortunately, there were no beds available.
I do not think that he was disadvantaged by remaining in the hospital wing within the
prison.
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RECOMMENDATIONS
1. The Governor should remind healthcare staff of the importance of informing
the families of prisoners when admission to outside hospitals takes place.
2. The Governor should consider what alternative venues he can offer for visits
to take place for prisoners who are elderly or infirm.
3. The Governor should write to the Primary Care Trust to consider devising a
protocol allowing for the transfer of prisoners who are terminally ill to a more
appropriate location.
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