Individual at Erlestoke House

INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING THE
DEATH OF A MAN AT HMP ERLESTOKE IN AUGUST 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2008
This is the report of an investigation into the death of a man. The man, who was in
his early 70s, died from natural causes in August 2007 at the local hospital, whilst in
the custody of HMP Erlestoke. I offer my condolences to his family and to all those
touched by his passing.
The investigation was carried out on my behalf by one of my investigators. A review
of the man’s clinical care was carried out by a Medical Practitioner, who was
commissioned by Wiltshire County Primary Care Trust (PCT). I am grateful to the
clinical reviewer for his assistance. The clinical reviewer has found that the man
received timely and appropriate care whilst at HMP Erlestoke. The man’s medical
and general care was comparable with, and at times exceeded, that which he would
have received in the community.
The man suffered from shortness of breath and chest infections, and tests had
diagnosed the possibility of lung cancer. However, the deterioration in his health and
subsequent death happened before a full diagnosis and a treatment plan were
possible. A post mortem was not requested by the Coroner because the hospital
doctor confirmed that the direct cause of death was bronchopneumonia and lung
cancer was a significant condition.
The man was admitted to hospital five days before he died. He was not subject to a
prison officer escort, but prison staff who were at the hospital for other duties did
spend time with him. I commend those staff for their compassion and decency. In
particular, I wish to mention an officer, who stayed for an extra shift to keep the man
company the night before he died, and another officer who went to his bed when told
that the man was dying and stayed until he passed away. I have been pleased to
learn that the Governor of Erlestoke has already formally recognised the actions of
these two members of staff. I also commend the efforts made by staff at Erlestoke,
in particular the Chaplain, for the way in which they ensured a decent and dignified
funeral for the man when they thought he had no traceable family.
I make no formal recommendations in this report but bring five housekeeping points
to the attention of the Governor and the Head of Healthcare. The Area Manager’s
attention is drawn to the words in the final paragraph of the report. I am pleased to
note that my comments have been accepted.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2008
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CONTENTS
Summary
The Investigation Process
HMP Erlestoke
Key Findings
Issues
Conclusions and Housekeeping Points
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SUMMARY
The man was an elderly man, and already in poor health, when he received a
custodial sentence,. Due to his ill-health, he did not work when he was in prison, but
officers kept his cell unlocked during the day so that he could come in and out of the
association area when he felt able.
During his first three months at HMP Erlestoke, the man required little assistance
from healthcare. However, at the beginning of March 2007, he started to experience
shortness of breath and was diagnosed with a chest infection. This was the first of
what became regular bouts of chest infection and breathing difficulties. The man was
seen quickly and treated appropriately on each of these occasions. His difficulties
continued to give the prison doctors cause for concern so he was referred for a chest
x-ray at the end of April. The results showed some abnormalities and a repeat x-ray
was recommended. The second x-ray determined that there was a possible
malignancy so a computed tomography (CT) scan was requested. The CT scan
took place on 16 July and showed the appearance of possible lung cancer. A doctor
referred him, under the two week wait scheme, to see a chest physician for a full
diagnosis and treatment plan.
Unfortunately, the man’s health deteriorated quickly. On 14 August, he was seen by
a prison doctor who decided that he needed 24 hour healthcare and he was admitted
to hospital later that day.
Initially, the man did not want his relatives to be told that he had been transferred to
hospital. However, after talking to a prison officer at the hospital, he decided to let
his son, sister and a friend know. The addresses given for his next of kin were out of
the local area so the prison asked the Bristol police to make contact. Unfortunately,
his friend did not make contact and the police were unable to trace the man’s
relatives.
The man was in hospital for five days, during which time his condition deteriorated
rapidly. He had been granted release on temporary licence (ROTL) and did not have
any prison escorts. However, there was another prisoner at the hospital who was
being escorted, and his escort staff also visited the man. There was a good
relationship between the hospital staff and the officers. The officers were kept
informed of the man’s condition, and were able to support him accordingly and
ensure that information was communicated back to the prison. This allowed prison
staff to start planning for the man’s transfer to a prison with an in-patients unit or
hospice as appropriate, if he was discharged from hospital.
The man’s condition did not improve, and at 10.30am on 19 August 2007 hospital
staff told one of the prison officers at the hospital that the man was dying. The
officer went to his bedside and sat with him and a nurse until he died.
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INVESTIGATION PROCESS
1. My investigator requested all the relevant prison records including the man’s
medical and core prison records. She visited HMP Erlestoke to see the areas
where the man lived and met wing and chaplaincy staff who knew him.
2. After receiving the initial paperwork, my investigator found that there was a
period between 29 December 2006 and 4 April 2007 for which there were no
medical records. Records are held electronically at Erlestoke and it appears
that the man had two files. The missing records were then sent to my
investigator.
3. Notices to staff and prisoners were sent to the prison to be displayed. These
invited anybody with information to talk to my investigator. In this instance,
no-one raised any matters of concern.
4. Wiltshire Primary Care Trust (PCT) was asked to carry out a review of the
man’s clinical care. A Medical Practitioner carried this out on their behalf.
5. HM Coroner for Wiltshire was informed of my investigation. The Coroner did
not direct that there be a post mortem because a hospital doctor was able to
provide the cause of death. The Coroner will receive a copy of this report.
6. After some delay, the man’s son and sister were formally informed of his
death. One of my Family Liaison Officers spoke to his son to offer him and
his family the opportunity of involvement in the investigation. The man’s son
only concern was that they had not been informed of his father’s death
directly.
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HMP ERLESTOKE
7. Erlestoke is a category C training prison in Wiltshire. It holds adult males
transferred from prisons across England and Wales who are progressing
through their sentence. The operational capacity (maximum number of
prisoners) is 426. Most of the cells are single occupancy.
8. Her Majesty’s Chief Inspector of Prisons last inspected Erlestoke on an
unannounced visit in May 2006. She found that the prison had continued to
perform reasonably well in relation to safety, respect and resettlement. She
also judged staff-prisoner relationships to be extremely good and supportive.
9. Healthcare was one of the services that had improved since the previous
inspection and was reported as set for further improvements. These included
a move to a larger better suited building. At the time the man was in
Erlestoke, the healthcare centre was open between 8.00am and 5.30pm
during the week. Six doctors each work one weekday morning and another
acts as cover in case of absence. There is no in-patient facility or 24 hour in
house cover, but there is access to out of hours doctors as in the community.
The out of hours doctors are provided by Wiltshire Medical Services.
10. When my investigator visited the prison, she was told that there was a
shortage of healthcare staff and, as a result, various clinics such as the
smoking cessation clinic were not running as scheduled. This will be
addressed within the programme of planned improvements to the healthcare
centre. I am told that other improvements include a dedicated pharmacy area
and two separate treatment rooms. The storage for medication and
equipment will also be improved and there will be healthcare provision on
Saturday and Sunday mornings.
Two week wait scheme
11. Under the National Health Service’s two week wait scheme, patients with
specific symptoms, signs or test results which may indicate the presence of
cancer can be referred to hospital through a fast-track route that should
guarantee a clinic appointment within two weeks.
Wing history sheets
12. Wing history sheets provide a record of any issues, concerns or interactions
with an individual prisoner, and every prisoner should have one. The sheet
should contain regular entries by the prisoner’s personal officer, if allocated,
as well as by any other member of staff who has involvement with the
prisoner.
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KEY FINDINGS
13. The man was sentenced to two and a half years’ imprisonment on 12
September 2006. He was initially taken to HMP Bristol. When he arrived he
was seen by healthcare staff for his First Night Health Screen. The screen
records that the man suffered from angina and asthma, for which he was
taking medication. The following day, prison healthcare staff confirmed this
with his general practitioner (GP) and the man’s medication was re-
prescribed.
14. For the first two nights in custody, the man stayed in the healthcare centre,
after which he was considered fit to move onto a residential unit. Special
instructions were given to ensure that he had a ground floor cell and did not
need to use any stairs. The instructions also said that, if the man was unable
to go to the medical treatment hatch, his medication was to be taken to him.
A record of these instructions was put on the man’s wing file. Over the next
three months, the only medical notes related to a skin complaint and allergy.
15. On 8 December, the man transferred to HMP Erlestoke. He was seen in the
healthcare unit as a new prisoner on 11 December, and was noted to have
had chronic obstructive pulmonary disease (COPD) and ischaemic heart
disease. It was also recorded that the man continued to smoke despite
advice.
16. The next entry in the medical record was on 29 December. The man had
been complaining of shortness of breath. On examination by healthcare staff,
he was found to be wheezy and was advised to stop smoking.
17. Each prisoner has a wing history sheet but there are no entries in the man’s
throughout his time at Erlestoke. With the exception of an entry in the medical
record on 19 February 2007 relating to osteoarthritis of the hand, there are no
records to show what or how the man was doing until 6 March.
18. On 6 March, the man was seen by the doctor. He was diagnosed with a chest
infection, cough and shortness of breath for which he was prescribed
antibiotics. The following month (on 4 April 2007), the staff nurse responded
to a call from wing staff to see him as he was again having problems
breathing. The nurse went to see him and telephoned the doctor who
prescribed more antibiotics and advised that the man should see the duty
doctor the following day. (The duty doctor did see him the next day and more
antibiotics were prescribed.) The doctor recorded that the man was still
smoking.
19. Approximately two and a half weeks later, on 24 April, the man again
experienced shortness of breath. Wing staff telephoned for a member of
healthcare staff to go and see him. The staff nurse and a healthcare assistant
attended the wing and took the man’s clinical observations. In the medical
record they described him as being able to speak easily and being in good
spirits. They advised him to improve his inhaler technique with a spacer.
(The effectiveness of an inhaler is reduced if the patient does not use it
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properly. The spacer allows the inhaler to be discharged into a plastic
chamber before being inhaled.) The man was given extra Ventolin (the
medication in the inhaler) in case he ran out during the night. An appointment
was made for him to see the doctor the next day.
20. The man did not attend the arranged appointment, but there is no reason
recorded for this nor evidence to suggest it was followed up. However, he
was seen two days later, again after complaining of shortness of breath and a
cough. More medication was prescribed and a referral was made for a chest
x-ray. My investigator asked the clinical reviewer if the x-ray should have
been arranged sooner. The clinical reviewer replied that an x-ray is usually
only requested if there is a concern that the condition does not respond to
treatment. He believes that the man’s condition was treated appropriately,
and, when there were concerns that treatment was ineffective, an x-ray was
requested in a timely manner.
21. The x-ray took place on 30 April. The results showed Chronic Obstructive
Airways Disease (COAD) – also known as COPD – and possible hilar1
enlargement. A repeat x-ray was recommended for four to six weeks time.
22. Two weeks later, on 15 May, the healthcare manager noted that the man was
wheezing and had shortness of breath. She requested that the doctor should
see him. The doctor noted acute exacerbation of COAD and prescribed
antibiotics and steroids.
23. On 4 June, wing staff asked healthcare to see the man again because he was
experiencing the same symptoms. He was again advised to increase the use
of his inhaler and was given an appointment to see the doctor the next
morning. The staff nurse told the wing officers that, if his condition became
worse or if he became unable to talk, they should call an ambulance. The
man was still smoking. When the doctor saw him on 5 June, the man was
diagnosed with another chest infection and more antibiotics were prescribed.
24. The repeat x-ray took place on 7 June, which was within the recommended
timeframe. Unfortunately, the radiographer did not flag the x-ray as abnormal
or ask for the report to be typed urgently. The report was therefore not issued
until 18 days after the examination, and a further four days passed before the
prison received it.
25. The duty doctor saw the results of the x-ray on 29 June. The results showed
possible malignancy and an urgent CT scan was recommended. The doctor
wanted to see the man to discuss the findings and an appointment was made
for 5 July, but the man did not attend. Again, no reason was recorded.
26. The man did see a prison doctor the next day (6 July 2007). The doctor
logged that the chest x-ray showed abnormalities and concluded that a CT
scan was needed. The man agreed to have the scan and a referral was
1 Hilar: of or relating to or located near a hilum. The hilum is the central area of the lung where the air
passages (bronchi) and blood vessels from each side join up. Swelling of the lymph glands in this
area is often the first sign of lung cancer to show on an x-ray.
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made. The medical records do not show it, but the clinical reviewer has found
that the CT scan took place ten days later.
27. The results of the scan appear to have been received by the prison on 8
August, but the clinical reviewer has found that it was not date stamped as is
usual practice. Nevertheless, an urgent doctor’s appointment was made for
the next day, 9 August.
28. The scan showed appearances compatible with lung cancer. The doctor
made an urgent referral for the man to see a chest physician at the local
hospital for full diagnosis and a treatment plan. The request was for an out-
patients appointment under the ‘two week wait’ scheme.
29. Four days later, on 13 August, a phone call was received by healthcare staff.
It is not known for certain who made the call but it would appear that it was
from wing staff. A prison officer told my investigator that another officer had
seen the man in his cell. He had been vomiting and was struggling to sit up.
The officer tried to lift him, but was unable and called the prison officer for
assistance. They managed to get him to sit upright and then contacted
healthcare. (Although the officer did not know the exact date, it would appear
that it was on 13 August and that it was these staff who contacted healthcare.)
30. Healthcare staff were told that the man’s overall condition had deteriorated.
The out of hours doctor was contacted and arrived to see the man. The
doctor diagnosed a chest infection and prescribed antibiotics and pain relief.
As previously, it was recommended that the man should see the prison duty
doctor the next day. No record of the consultation was sent to the prison, but
it has been confirmed by the clinical reviewer.
31. The consultation was followed up and the doctor saw the man in his cell on 14
August. The entry in the medical record shows that he looked very unwell
and was in pain. He had an irregular pulse, was feverish and was coughing.
The doctor thought that the man needed to be in a 24 hour care unit and
suggested a transfer to a prison with this facility or admission to hospital.
32. A decision was made for him to go to hospital, although there is no record of
who made it. A member of healthcare staff ordered an ambulance, which
arrived later that day to take the man to hospital. Initially, he went under
prison escort which meant he was handcuffed and accompanied by two
officers.
33. During contact with the hospital on 16 August, healthcare staff were told that
the man’s health was not good. He was using a humidifier and receiving
oxygen. That day he had had a scan (the type of scan is not identified) and a
pleural tap, which is a procedure to remove fluid from between the lining of
the lungs and wall of the chest.
34. That afternoon, a governor at the prison asked healthcare to assess the
man’s fitness in relation to his ability and likelihood to escape. The prison was
considering releasing the man on temporary licence (ROTL). The hospital
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confirmed that the man was unable to get out of bed and was breathless even
in bed. They also said that the chest x-ray taken that morning looked worse
than they had expected.
35. The risk assessment for the ROTL is not in his files, but he was in fact granted
ROTL on 16 August which meant that he was not escorted by officers or
handcuffed. Hospital and prison staff recognised, however, that he was
frightened and might receive some comfort from visits by prison staff. The
prison arranged for officers on another hospital escort to spend time with him.
36. Due to the state of the man’s health, the hospital consultant was concerned
and asked who his next of kin were so that nurses at the hospital could
contact them. The prison records show that the man was also asked this by
the prison staff, but at that point he did not want anybody contacted about his
health.
37. Although the x-ray had shown his condition to be worse than initially thought,
consideration was given to discharge plans if his health improved. To this
end, prison healthcare staff recognised that he would need to go to a prison
with a 24 hour care unit until a decision could be made about his security risk
for a future transfer to an appropriate place of care (for example, a hospice).
38. On 17 August, bedwatch officer one was one of the prison officers on the
other hospital escort. She went to sit with the man for a while. She told my
investigator that she would check on him and they would share some jokes
and laugh. The officer spoke to the man about his friends and family and his
reluctance to let them know about his health. The officer told my investigator
that, after discussing it, the man agreed that he should think about what was
fair to them and gave her the details of his son and sister. He did not have
the telephone numbers, only addresses in Bristol. The officer contacted the
prison with these details. The man also gave her the name and address of a
friend in Bristol which the officer also passed on.
39. The addresses in Bristol were some distance from Erlestoke and so the Duty
Governor contacted Bristol police for assistance. This is common practice
when family live some way from the prison itself. The duty governor asked
the police to make contact with the man’s next of kin to let them know he was
in poor health in hospital.
40. The chronology of the police actions is unknown but they contacted the prison
later that morning to say that neither the man’s sister nor son lived at the
addresses given. The prison also passed on the name and address of the
man’s friend. It appears from the records that he was informed of the
situation at 1.20pm and given the prison contact details but did not get in
touch.
41. The staff nurse at the hospital arranged for the hospital’s Roman Catholic
priest to see the man. In a statement by one of the hospital doctors in the
medical records, it was noted that hospital nursing staff were also trying to
notify the man’s next of kin. The prison’s Roman Catholic priest also visited
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the man and liaised with his friend and colleague – the hospital Roman
Catholic priest. The hospital priest would see the man when the prison priest
could not.
42. Through most of the night of the 17 August, the man settled and slept well.
He woke at 3.30am with difficulty breathing, but soon fell asleep again.
43. When the bedwatch officer took over her shift again on 18 August, she wrote
in the escort log of the other prisoner that the man seemed happy to see her,
and that he was joking about not being able to talk very well with his oxygen
mask on. The officer told him that breathing was more important and they
laughed about it.
44. At 2.20pm, the officer told the prison that she had been told unofficially that
the man only had limited time left to live. There was no further treatment
being given apart from pain relief. The man told the officer that he did not
have a will and did not mind what happened to his possessions. He also told
her that he would like to be buried in the large cemetery in Dublin but did not
know the name of it. At 5.00pm, the prison’s Roman Catholic priest came to
see him and gave him the last rites. The priest told my investigator that he felt
the man received these with great devotion.
45. Prison management checks took place for the hospital escorts at 5.50pm.
This is in line with prison procedure. The second prison officer told the duty
governor that she was concerned about the length of time the man had left to
live and did not want to leave him on his own overnight. The duty governor
agreed to speak to the night staff, but the officer took it upon herself to
request permission to remain on duty and stay overnight. Permission was
granted and the officer remained until 7.20am on 19 August.
46. Another prison officer took over the escort shift for the other prisoner and
spent some time with the man. At 8.20am, the officer logged that the man
was sleeping but his breathing was rapid. An hour and a half later, the officer
noted that he had been to see the man again. Although the man looked at the
officer, he made no verbal response. The officer felt that the man’s condition
had deteriorated and spoke to the hospital nurses to ask that prison staff be
kept informed.
47. Two hours later, at 10.36am, the officer was called by nursing staff and told
that the man was passing away. The officer went to his bedside and stayed
with him and a nurse until he died at 10.45am.
Events following the man’s death
48. The man’s next of kin could still not be traced. The evidence shows that the
prison attempted to find them with the help of the police, and that the hospital
had also contacted the local police. There were no next of kin details listed in
the prison records or on the man’s Pinphone numbers and no records of any
visits.
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49. My investigator spoke with the Coroner’s officer to ask if any next of kin
details were known. As with the prison and the hospital, the Coroner’s officer
only knew that the police were trying to trace the man’s son and sister.
50. Due to the services not being able to notify any next of kin, Erlestoke took
responsibility for burying the man and the prison’s Roman Catholic priest
arranged a full funeral. A requiem mass was held at the prison on 23 August
2007 for prisoners and staff who would be unable to attend the funeral.
51. The man was buried on 4 September. The service was taken by the prison’s
priest in his parish church. The Roman Catholic priest had told his
parishioners about the funeral and asked for their support to give the man a
dignified Christian funeral. The priest told my investigator that the church was
full, with approximately 150 people at the service including members of the
prison chaplaincy and management team. The local parishioners had also
arranged for flowers, and prisoners who knew the man contributed towards a
wreath.
52. On 3 November, the prison Roman Catholic priest and members of his parish
held a service and blessed the graves in the cemetery. The priest would like
the family to know that this included the man’s grave, and that one of the
parishioners looks after it and keeps it tidy. It was one of the man’s son’s
concerns that the family did not know of his death and so were not at his
funeral. I hope that they can take some comfort from the knowledge that their
father was given good care and treatment, and a proper burial arranged with
the best intentions.
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ISSUES
Healthcare provision
53. The man was in poor health when he went to prison. My investigations looks
at whether the medical treatment a prisoner receives in prison is comparable
to what he or she could expect in the community. The evidence shows that
the man received appropriate and timely medical intervention.
54. My investigator did note that there was a short delay in referring the man for
his CT scan and asked the clinical reviewer’s view on this. The clinical
reviewer had questioned the doctor. The doctor said that this would have
been the first time the likelihood of cancer had been raised with the man and
therefore he felt he should speak to him himself. This resulted in a week’s
delay which the reviewer said would not have affected the outcome. The
reviewer believes that the doctor’s intention to involve the patient was
exemplary.
Record keeping
Medical records
55. When my investigator received the medical records for the man, there were
no records for the period between 29 December 2006 and 4 April 2007. She
requested these from the prison and discovered that on one occasion when
the man went out for a hospital appointment he was given a new record on
return. The prison sent the extra records but there are only two entries on
them. The first in February related to his osteoarthritis, and the second (on 6
March) was regarding his shortness of breath and a cough. I am pleased to
note that the prison have said they will look into this duplication to stop it
recurring.
56. Both the clinical reviewer and my investigator found that handwritten entries
were at times illegible, unsigned and/or undated. There was correspondence
from other medical providers that was not date stamped. Although I make no
formal recommendation, the Head of Healthcare should remind staff of the
need to stick to the recommended guidelines for completing medical notes.
57. The radiographer at the hospital where the man had his x-ray flagged the
report as urgent for the first x-ray. This is good practice. However, this did
not happen for the second x-ray and the results took nearly three weeks to
reach the prison, thus contributing to the delay in reaching a definitive
diagnosis. The systems for producing these reports are not within my remit,
and the clinical reviewer believes that new systems are set to come into place
that may speed the process. However, the Head of Healthcare at Erlestoke
and the PCT may wish to share my concern with their hospital colleagues.
58. The out of hours doctor did not send a record of the consultation on 13 August
to the prison doctor. The clinical reviewer found that this was because the
prison was not recorded as the ‘surgery’ to which the man was attached.
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There are lessons to be learnt for both services. The Head of Healthcare may
wish to share my report with Wiltshire Medical Service (WMS) so that WMS
can ensure that Erlestoke are recorded as the contact and records are sent to
the prison.
Prison records
59. I commented at the beginning of this report that all prisoners should have
wing history sheets. However, there were no entries made in his wing history
sheet after he arrived at Erlestoke. This is poor practice, and has made it
difficult to find out about the man’s time on the residential units. My
investigator spoke to an officer on the man’s unit who was able to tell her
about his health and his situation. The medical records show that officers
regularly contacted them when the man was unwell and this information
should have also been recorded in his wing history sheet.
60. I am satisfied that officers were aware of the man’s health and monitored him
accordingly. I am also satisfied that on this occasion I do not need to make a
formal recommendation. However, I draw this matter to the Governor’s
attention so that action can be taken to ensure wing history sheets serve their
intended purpose.
Escort logs (Bedwatch logs)
61. The interactions with the man were recorded in another prisoner’s bedwatch
log because the man did not have one. The man should have had a
bedwatch log for the period between 14 and16 August before he was granted
ROTL, but they are not in his file. Ordinarily there would not be a log for a
prisoner who was granted ROTL. But in this case staff were still visiting him,
and therefore the interactions should have continued in his original log if there
was one. It is not appropriate for this type of confidential information to be
kept in another prisoner’s file.
62. Once more, I draw this matter to the attention of the Governor so that he can
share it with staff in the event that a similar situation arises again.
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CONCLUSIONS AND HOUSEKEEPING POINTS
63. I have been pleased to learn of the thoughtfulness and compassion of many
of the staff at Erlestoke. In particular, wing staff ensured that the man was
referred to healthcare colleagues whenever his health deteriorated and made
sure that he was allocated a ground floor cell. When he went into hospital for
the second time, two officers escorting another prisoner made sure that he
was not alone as his life drew to an end. In addition, the prison and the
chaplain took great care to arrange a full and dignified funeral.
64. I make no recommendations in my report, although there are five
housekeeping points that the Governor and Primary Care Trust will wish to
consider. The first concerns the quality of the healthcare records and the
importance of conforming to the guidelines for completing medical notes. I
have also commented on the delay between the man’s repeat x-ray and the
results reaching the prison. Third, I found that the records of out of hours
medical consultations were not sent to the prison.
65. The remaining two housekeeping points relate to prison matters. First, the
Governor will have recognised that the man’s wing history sheet did not
provide a record of the care and attention given to him by wing staff. He will
wish to satisfy himself that history sheets are being completed appropriately.
66. Finally the care and comfort given by officers who were at the hospital for
other duties should not have been recorded in the records for another
prisoner.
.
67. However, I would not wish to conclude this report by writing about things staff
could have done better. For I have been hugely impressed by the actions of
the second prison officer, who stayed for an extra shift to keep the man
company the night before he died, and the third prison officer who went to his
bed when told that the man was dying and stayed until he passed away. I
understand that the Governor of Erlestoke has already formally recognised
the actions of these two members of staff. It may be that the Area Manager
will wish to add his own commendation.
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