Individual at Frankland

Investigation into the circumstances surrounding the
death of a man, who was a prisoner at HMP Frankland,
in November 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2008
This is an investigation into the circumstances surrounding the death of a man
who had been in prison for several decades. He died in his bed at HMP
Frankland, in November 2007. The cause of death was recorded as acute
bronchopneumonia due to dementia.
The man had not been in contact with his family for many years and none of
his relatives could be traced following his death. Nevertheless, I offer my
sincere sympathy and condolences to all those touched by the man’s death
for their loss.
The investigation was carried out on my behalf by one of my colleagues. An
independent review of the man’s medical care in prison was carried out by a
medical reviewer on behalf of the Northumberland Care Trust. I am most
grateful to the medical reviewer for his assistance.
I would also like to thank the Governor and staff of Frankland for their full and
ready co-operation during the course of the investigation. I am particularly
indebted to the head of the business unit for the assistance she provided my
investigator in her role as liaison officer.
I apologise to those affected by this report for the delay in producing it.
I make three recommendations.
Jane Webb
Deputy Prisons and Probation Ombudsman August 2008
2
CONTENTS
Summary 4
The Investigation Process 5
HMP Frankland 7
Key findings 8
Issues 16
Recommendations 20
3
SUMMARY
The man was in prison for several decades, He had lived in a number of
different prisons throughout the country in his first 20 years in custody, before
spending most of the rest of the prison term at HMP Long Lartin.
Following a deterioration in his health, the man was diagnosed with dementia
in 2001 and Alzheimer’s Disease (the most common form of dementia) in
2003. As a result he transferred to HMP Frankland in July 2004 to live on the
elderly and disabled prisoner’s wing, where he could receive more specialist
care.
At the time of his transfer, the man’s memory was already very poor. He was
reluctant to have a bath or shower and would often engage in bizarre
behaviour. His condition deteriorated over time and the man became
increasingly challenging for staff to deal with, particularly with regards to his
personal care.
In June 2006, the man had deteriorated to the extent that staff at Frankland
began to look at alternative care outside of the Prison Service. A number of
different opinions were held as to the most suitable accommodation for the
man, ranging from a low secure dementia unit to the high security facilities at
Broadmoor Hospital. What was agreed, however, was that the man would
never be suitable for release into the community, on account of the underlying
risk factors present.
The man was referred to Broadmoor Hospital in October 2006. After a
lengthy assessment process, he was deemed unsuitable for admission in
June 2007. However, the man was recommended to St Andrew’s Hospital,
Northampton, where, following an assessment, he was offered a place on the
Foster Unit, a medium secure unit for older adults, in August 2007. By this
time, the man had moved to a cell in the healthcare centre inpatient’s unit at
Frankland, on account of his deteriorating condition.
However, before he could take up his bed at St Andrew’s, funding for the
place had to be arranged. Given that the man had been in prison for several
decades, there was some debate over who was responsible for providing the
necessary funding. The Primary Care Trust from his home area agreed to
fund the place, and a contract was sent to them by St Andrew’s early
November. Sadly, the man died mid November, before the contract could be
signed.
The deceased was a difficult and challenging patient for staff at Frankland to
deal with. Nevertheless, I am satisfied that the care that he received was
respectful and, in the main, appropriate. I make three recommendations in
total, including one regarding the future application of a scoring tool to
determine the likelihood of those with non malignant (a severe and
progressively worsening disease) conditions developing a terminal illness.
4
THE INVESTIGATION PROCESS
1. The investigation was opened in November 2007 when my investigator
issued notices announcing the investigation to staff and prisoners. The
notices included an invitation to those who wished to submit information
relating to the man’s death to make themselves known to my investigator.
No prisoners came forward as a result.
2. My investigator visited Frankland late in November. He was given access
to the man’s prison files, which were substantial, and toured the prison,
including visiting the cell in the healthcare centre where the man lived. My
investigator returned to Frankland in February 2008, when he interviewed
four members of staff.
3. A clinical review, examining the medical care that the man received at
Frankland, was carried out by a medical officer on behalf of the
Northumberland Care Trust. I am most grateful to the medical officer for
his assistance.
4. Given the time that the deceased has spent in custody, I have taken the
decision not to investigate events over the whole of his sentence. The
focus of my report will be on the time that the man spent at Frankland,
following the diagnosis of Alzheimer’s Disease.
5
6
HMP FRANKLAND
5. HMP Frankland is one of eight maximum security establishments in
England and Wales. Frankland holds convicted category A and B adult
male prisoners, and also holds high risk remand prisoners. Four of the six
wings hold vulnerable prisoners, including B wing (where the man lived
prior to his permanent move to the healthcare centre in May 2007). The
operational capacity of the prison is 734.
6. Healthcare services at Frankland are provided by the County Durham
Primary Care Trust. The healthcare centre provides 24 hour inpatient
care, consisting of two six-bedroom wards and eight furnished rooms. The
man lived in one of these rooms for the last six and a half months of his
life.
7. The most recent full inspection report by HM Chief Inspector of Prisons,
dated March 2003, describes Frankland as offering a safe environment
based upon good relationships between staff and prisoners. The
inspection found good staff understanding of individual prisoners and their
needs.
8. Following a short unannounced follow up inspection on 25 October 2005,
the Chief Inspector, recorded that healthcare services at Frankland had
improved since the full inspection. However, primary care still needed
development and staffing shortages had hindered progress. Of the 12
healthcare recommendations made during the full inspection, nine had
been fully achieved, one partially achieved and two had not been
achieved.
9. The latest Independent Monitoring Board (IMB) report, for the year 2006-
07, found that healthcare had improved during the course of the year. The
IMB reported that morale amongst healthcare staff, which had previously
been low, had stabilised and improved. They also reported that all
sections of healthcare appeared to be working well.
10. This is the 15th death to have occurred at Frankland since April 2004,
when I began investigating all deaths in custody in England and Wales.
All but two of these have been due to natural causes, as has the one
subsequent death at Frankland.
11. Of those cases that I have previously investigated one involved a man
who, like the subject of this report, would have presented formidable
problems for the nursing team at Frankland. In my report, I concluded that
the care that the man received was “as good as could have been achieved
in the community”. Another case also involved a man with challenging
behaviour. I reported that I was “impressed by the extent to which
healthcare and discipline staff responded to (the man’s) illness and made
his life as comfortable and dignified as possible”.
7
KEY FINDINGS
12. The man arrived at Frankland in July 2004. He was given a cell in the
elderly and disabled prisoner’s unit, on B wing. A reception health screen
took place on the following day, at which the man’s appearance was noted
to be unkempt and frail. He said, however, that he felt “fit and well”. The
nurse who completed the form noted that the man’s Alzheimer’s meant
that he had a very poor memory.
13. Over the following months, wing staff raised concerns regarding the man’s
ability to look after himself. In October, it was reported that he was unable
to bath himself and was often incontinent of urine and faeces. In January
2005, staff reported that the man would sometimes walk around the
landing naked and that he mixed his food inappropriately (by, for instance,
putting custard over chicken).
14. In January 2005, the man was assessed by a locum consultant forensic
psychiatrist. On the following day, the consultant forensic psychiatrist
referred the man to a consultant geriatrician at a local unit specialising in
psychiatry of old age. In his referral letter, the consultant forensic
psychiatrist reported that the man had deteriorated in the last 18 months.
He was now disoriented and his short term memory and knowledge of
current events was poor. The man was, however, still able to recall
historical events, such as the dates of the Second World War and the year
of his imprisonment.
15. The consultant geriatrician replied in March. He reported that there was
no funding in place for psychiatry of old age in-reach into the Prison
Service. The consultant geriatrician therefore said that he was unable to
take on the work “without official recognition and resources”.
16. In April, the man was examined by the mental health team at Frankland.
He undertook a mini mental state examination (MMSE, a brief
questionnaire to test cognition and screen for dementia). The man scored
9/30 on the questionnaire, indicating severe dementia. It was noted that
this represented a dramatic deterioration since the man’s previous MMSE
three months previously (the result of which does not appear to be in the
medical record). The care plans that were in place for memory,
orientation and personal hygiene were discussed with the man, and he
signed them.
17. The man continued to deteriorate over the summer. In July, after a mental
health review, wing staff reported that he was becoming increasingly
violent and aggressive. An example given was that he had recently hit a
member of staff with a bundle of newspapers.
18. In October, the head of prison healthcare services at Durham and
Chester-le-Street PCT, wrote to the chief executive of the PCT. The PCT
chief executive raised the issue of there being no funding in place for
psychiatry of old age. He added that he considered that the man (and
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another prisoner who had also been referred) should be treated the same
as any other patient in the catchment area and that his care should
therefore be covered by the existing contracts that were in place.
19. Around a month later, in November, a mental health support worker, was
told by staff on B wing that the man’s physical health had deteriorated.
The wing staff reported that he was eating very little at present and on
some days was eating nothing. A mental health support worker raised
this with a prison doctor the following day and suggested that the man
might benefit from Ensure (a nutritional supplement). The prison doctor
felt that this wasn’t necessary as long as the man was eating something.
It was, however, decided to weigh the man regularly.
20. Following the chief executive’s letter, a consultant geriatrician was able to
visit Frankland in January 2006 to assess the man. He concluded that the
man was too impaired to be considered for treatment with a
cholinesterase inhibitor (a drug designed to help treat symptoms resulting
from the early and middle stages of Alzheimer’s). However he did
consider that the man was able to cope well with the prison life, due to its
unchanging regime.
21. During an evening in late February, the man slipped in his cell and banged
his head. He suffered no injuries other than a graze to his forehead. A
mental health support worker saw the man the following day to dress his
wound. She discussed his care with wing staff, who told her that the man
refused to bath or shower and only changed his clothes occasionally. The
health support worker said that healthcare staff were unable to force the
man to bathe against his will and that he had no other problems with his
day to day living. They would, however, continue to monitor the situation.
22. The man was admitted to the healthcare centre about mid March, after
developing a chesty cough. He was seen the next day by a prison doctor,
who diagnosed a chest infection and prescribed amoxicillin. The man
experienced another fall during the early hours of four days later. As
previously, he sustained no injury other than a graze to his head.
23. Ten days after the second fall and having considered the man’s case, the
Parole Board recommended that he should not be released on licence
and should remain in closed conditions. In their report, the Board
remarked that
“there is no real way of addressing the risk factors which were certainly
present at the time of (the man’s) index offence and which are still seen
as posing an unacceptable risk……given his history and perceived
level of risk, a continued stay in closed conditions seems the only
realistic option”.
24. It was reported that, during evening association on a day late in March,
the man held a blanket over another prisoner’s mouth and told him to shut
up. The man had been heard to shout abuse at this particular prisoner in
9
the previous few days. He denied the allegation and was warned not to
enter the other prisoner’s cell at any time. Two days later the man
returned to B wing from the healthcare inpatient’s wing. After a couple of
days back on the wing he was said to be coping well with the regime.
25. The man was reviewed by the mental health worker in mid May 2006.
She gave the opinion that he had deteriorated little since she had last
seen him late in February. The mental health worker noted that the man’s
short term memory was poor (he was unable, for instance, to recall what
he had eaten for breakfast that morning) and that he needed continuous
prompting and persuasion to meet his personal hygiene needs.
26. In the spring of 2006, the man’s solicitor instructed a professor of
psychiatry, to prepare a psychiatric report on the deceased for the Parole
Board. After twice assessing the man, the professor wrote to Frankland in
May. In his letter, the professor argued that the man’s dementia was not
as severe as the consultant geriatrician had concluded in January. He
therefore recommended that an anti-dementia drug be commenced. The
professor also recommended that the man should no longer be in
category A conditions as his condition meant that he was not an escape
risk.
27. The professor of psychiatry completed his report early June, and
forwarded a copy to Frankland. On the same day he again wrote to the
senior medical officer at the prison. The professor requested that the man
be referred to St Andrew’s Hospital, Northampton, where there is a low
secure dementia unit. He argued that this was the best place for the man,
given his condition. The letter was copied a consultant psychiatrist at St
Andrew’s, who replied on 19 June. The medical officer wrote that the man
may be suitable for their low secure unit for older men and that they would
be happy to carry out a pre-admission assessment to confirm this.
However, he said that it was first necessary to establish the appropriate
funding authority and to reach an agreement to fund any potential place
taken by the deceased.
28. The prison healthcare development manager at Durham and Chester-le-
Street PCT, replied to the professor of psychiatry’s letter in July. She said
that she had asked the Healthcare Manager at Frankland, to liaise with
the prison doctors and the consultant geriatrician to ensure that the man
received the recommended anti-dementia drugs. The prison healthcare
development manager also wrote that any decision to transfer the
deceased out of the prison environment would rest with the Prison
Service.
29. In mid August, the man was assessed by a second consultant forensic
psychiatrist at Frankland. The man was able to recall the year and place
of his birth, although he did not detail his offence correctly. The consultant
forensic psychiatrist noted that the man was abusive about the prison
officers and said that he did not like to adhere to the rules. The man also
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claimed that he was able to manipulate and influence officers and
governors.
30. The man was found guilty, at an adjudication hearing in mid September, of
using abusive words or behaviour. No details of the specific offence are
available. A segregation algorithm (a means to test whether a prisoner is
suitable to be segregated) was completed by a community psychiatric
nurse. The psychiatric nurse noted that “at the current stage of dementia
he would very quickly deteriorate (if segregated)”. As an alternative
punishment, the man’s earnings were stopped for one week.
31. A consultant forensic psychiatrist at Frankland wrote to the medical
director of Broadmoor Hospital (a high security psychiatric hospital) early
October, to request an assessment. He gave the opinion that the man
was not suitable for conditions of low or medium security, but also
presented the professor of psychiatry’s alternative view. A reply was sent
from Broadmoor’s Referrals and Admissions Panel late October. The
reply said that Broadmoor’s policy was that they could not proceed without
first getting an opinion from the man’s catchment area’s regional secure
unit. They suggested that Frankland should write to the forensic case
manager at a regional secure unit in the man’s home catchment area. He
did so early November.
32. An assessment was subsequently carried out by a consultant forensic
psychiatrist at the regional secure unit in mid December. The psychiatrist
wrote to his counterpart at Frankland in late January 2007 with his
findings. His opinion was that the man’s dementia was moving from a
moderate grade to severe. The consultant at the regional secure unit was
supportive of a move to a therapeutic environment, as he felt that staff at
Frankland were struggling to cope with the deceased and he would only
decline further in future.
33. The consultant at the regional secure unit also wrote about the risk that
the man posed. He felt that the motives for the man’s crimes were still a
matter of speculation and it was therefore difficult to assess the likelihood
that he would carry out similar acts in the future. He went on to say that
he did not think that a transfer to St Andrews was appropriate. He
concluded that the most appropriate location for the man was a high
security therapeutic environment. The consultant forensic psychiatrist at
Frankland subsequently referred the man to Broadmoor Hospital, for a
second time, early February.
34. At adjudication hearings held on two separate dates in February, the man
was found guilty of three offences of using abusive words or behaviour.
He was again found unfit for segregation and instead received a two week
reduction in earnings.
35. The man was assessed by a member of the nursing staff in April,
regarding his current level of personal hygiene. The nurse was told by
wing staff that the man had been sleeping more lately. He was also
1 1
declining all offers of a bath or shower. The man was able to walk to the
healthcare centre, where he again declined the offer of a bath. He
became verbally abusive to healthcare staff and refused to stay for the
assessment.
36. On the following day, the man did agree to go to healthcare and allowed
staff there to help him take a bath. He needed assistance to get in and
out of the bath. It was requested that he be brought to healthcare on
Sundays for regular personal hygiene assessments and a bath.
37. Around two weeks later, on 1 May, the man transferred from B wing to the
healthcare centre inpatients wing. His physical and mental health was
continuing to deteriorate and the man was reportedly not eating and had
lost weight. The move was initially a temporary one for assessment and
to monitor the man’s nutritional status. However, he did not return to B
wing and remained as an inpatient in healthcare for the remainder of his
life.
38. The man was assessed by a prison doctor on the day after his transfer to
inpatients. The prison doctor noted that the man was not managing on
the wing due to poor self-hygiene and poor diet. He also noted that the
deceased looked emaciated (extremely thin through illness or lack of
food). Despite this, however, the first prison doctor remarked that the man
was in good spirits and was chatty and alert. He recommended that the
man take a course of fortisip (a nutritional supplement).
39. The man settled reasonably well into the inpatients wing. He was noted
on a number of occasions to be enjoying the fortisips and to be bright and
alert. However, he was still refusing baths and showers on most days
and, on 18 May, he refused to have a blood sample taken for testing. In
the next fortnight it was noted on two occasions in his medical record that
the man’s legs were swollen. He made no complaint about this, however,
and said that it was normal for him.
40. In June, the chair of Broadmoor Hospital’s admissions panel wrote to the
consultant forensic psychiatrist at the regional secure unit in reply to his
letter of January 2007 and the subsequent referral to the hospital. His
letter was copied to the consultant forensic psychiatrist at Frankland. The
consultant forensic psychiatrist wrote that the admissions panel had
decided not to offer the deceased a bed at Broadmoor, as they could “see
no value in a short term admission to high security, particularly in the light
of his dementia”. He went on to say that the panel’s view was that the
man should be assessed by St Andrew’s Hospital for their opinion on his
suitability for admission there. The consultant forensic psychiatrist at the
regional unit subsequently wrote to St Andrews, in early June, to request
that they assess the man for a potential admission to the hospital.
41. A review of the man’s security category was held late June, at the request
of the director of high security prisons. A report was prepared, which
included a summary of the man’s current circumstances. The Local
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Advisory Panel at Frankland recommended to the director that the man
should remain a category A prisoner. Their reasoning for this was that the
man had undertaken no offending behaviour work, due to his mental
incapacity. The Panel referred to the incident of March 2006, from which
they concluded that the man was “still highly dangerous”.
42. However, the director disagreed with the Local Advisory Panel and
therefore directed that the man’s security category be downgraded to
category B. This meant that the man would, theoretically, have greater
freedom to move around the prison and reduced security on hospital
visits. The following reasoning was given:
“Whilst the director agreed with the local panel’s view that the man
remained highly dangerous and insightless (and he could not foresee a
time when it would ever be considered safe to release him into the
community), he considered that the man’s overall circumstances –
particularly those relating to his age and infirmity – were such to
suggest that he could now be adequately managed and contained as a
category B prisoner.”
43. The man continued to decline showers nearly every day throughout July
and August. There were complaints from staff that he was becoming
more abusive when refusing baths and showers in July, although he
seemed to become more settled in August. Nevertheless, it is apparent
that it was extremely difficult to get the man to engage with personal
hygiene.
44. Late July, the man was assessed for a second time by a consultant
geriatrician, at the request of the healthcare manager. The consultant
geriatrician wrote to the healthcare manager in early August with his
findings. He felt that the man appeared to have changed little since his
last assessment and was very institutionalised. The consultant
geriatrician concluded that it was difficult to see the man ever being
managed outside of prison or a special hospital.
45. The consultant psychiatrist at St Andrew’s Hospital, wrote to the
consultant at the regional secure unit in August, following his referral two
months earlier. The man had been assessed in July by two medical
officers from St Andrew’s. As a result, the consultant psychiatrist at St
Andrews offered the man a place on a medium secure unit for older
adults. He added that a full assessment and treatment plan would be
drawn up and forwarded. It would also be necessary to arrange funding
for the man’s place before he could take it up.
46. The man was reasonably settled through September, although he
complained of abdominal pain and headaches towards the end of the
month. It was established that he had been unable to open his bowels for
some time, and he was prescribed a laxative.
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47. In early October, the community psychiatric nurse at Frankland, spoke to
the consultant psychiatrist at St Andrew’s with regard to the man’s
transfer. She was told that he would be transferred as soon as the next
bed was available.
48. One afternoon late in October, a nurse found the man sitting on the floor
of his cell. He told her that he had missed the bed when trying to sit
down. The man was helped up by staff and examined for injuries, of
which there were none.
49. Around a week later, still in October, the man was again found on his cell
floor in the afternoon, on this occasion by second nurse. The man told the
nurse that he had slipped and had hurt his right arm and shoulder. On
examination, the man was found to have limited movement in his right
arm. He was given a sling by the nurse and an appointment was made
with the doctor.
50. On the following day, the man attended the Accident and Emergency
Department at a local hospital. An x-ray revealed a fracture at the top of
the humerus (the long bone in the arm running from the shoulder to the
elbow). A consultant orthopaedic surgeon decided against an operation.
The man was subsequently discharged with a ‘collar and cuff’ style sling.
However, he usually refused to wear the sling and would take it off as
soon as it was put on.
51. At around 3.00am on 2 November, the man was found lying on the floor of
his cell. He was unable to explain how he had got there. He was helped
back into bed and it was noted that he had received no further injuries.
52. The man was again found lying on the floor of his cell in the early hours of
the morning on both 9 and 10 November. On both occasions he was
helped to his feet and said he had no pain and no further injuries. In the
afternoon of 11 November, he was found sitting on the floor of his cell and
said that he had missed his chair when sitting down. A nurse examined
him and found no new injuries. However, the man said that he had pain in
the same area that he had fractured previously. The nurse made him an
appointment with a prison doctor due to a “deterioration in mobility,
increase in incontinence and general condition”.
53. As a result, the man was seen by a prison doctor on 12 November. The
prison doctor recorded that the man was “non-specifically unwell” and
that, for unspecified reasons, he was unable to examine the man that day.
54. Three days later, the man saw a prison doctor for a second time. He
recorded that the man was “not 100%”. The man refused even a basic
examination and was noted to be alert and pushing the doctor away when
he tried to examine him. The doctor advised that they “watch and wait”.
55. On 16 November, a “named patient agreement” was sent by St Andrew’s
Hospital to the Primary Care Trust covering the man’s home area, who
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had agreed to fund the man’s place at the hospital. This agreement is
essentially a contract which, once signed, would commit the Primary Care
Trust to funding the place.
56. On the following day, the man was noted to be “very poorly” and not
walking about (as he usually did) or talking to anyone. The next morning
he had a shower, but was noted to be very withdrawn and unable to
attend to his own needs. He sat in his chair all day, refused his
medication and had very little to eat. At around 9.00pm that evening, the
man was found lying on the floor of his cell. He was checked over by a
nurse and helped back into bed.
57. At around 9.00am on a day in November, a healthcare support worker
took the man’s medication to his cell. She found the man looking unwell
and unable to speak clearly. The healthcare support worker took the
man’s blood pressure which, at 67/43, was low. She offered him oxygen,
which he declined, and asked the second prison doctor to attend.
58. A prison doctor saw the man in his cell at around 9.05am. He noted that
the man was pale and his breathing was shallow. The doctor suspected
that the man may have a chest infection or urinary tract infection.
However, the man would not allow the doctor to examine him. The prison
doctor referred the man to a local hospital and was told that he could be
admitted in one to two hours once a bed was available.
59. Shortly before 11.00am, the man’s condition deteriorated and he stopped
breathing. The prison doctor was called, and pronounced death at
11.05am.
60. A post mortem examination revealed the cause of death to be acute
bronchopneumonia due to dementia. The man had not had any contact
with his family for a number of years, and no relatives could be traced. As
such, his funeral was arranged by prison staff.
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ISSUES
The man’s proposed move to St Andrew’s Hospital
61. The possibility of the man moving to St Andrew’s Hospital was first raised
by the professor of psychiatry in his report of June 2006. He
recommended that the man be considered for transfer to a low secure
dementia unit at the hospital.
62. A consultant forensic psychiatrist at Frankland did not agree with the
professor. He was concerned about the risk that the man posed, and
referred him instead to Broadmoor Hospital, a high security psychiatric
hospital, in October 2006.
63. In line with Broadmoor’s admissions policy, the man was assessed by a
consultant forensic psychiatrist from a regional secure unit in his home
catchment area in December 2006. The psychiatrist agreed with his
counterpart at Frankland that a transfer to St Andrew’s was inappropriate
and concluded that a high security therapeutic environment was the most
suitable location for the man. As such, the man was referred to
Broadmoor for a second time.
64. In June 2007, the admissions panel at Broadmoor decided not to offer a
place to the man. They suggested that St Andrew’s might be suitable and
a referral was subsequently made. After an assessment in July, a
consultant psychiatrist at St Andrew’s wrote to offer the man a place on a
medium secure unit for older adults, in mid August.
65. Given the amount of time he had spent in prison, the man represented a
unique case. Once his dementia reached the stage where it became
appropriate to consider transferring him to an environment outside of the
Prison Service, it is inevitable that there would be differences of opinion
over the most suitable place for him to live. Whilst the professor of
psychiatry advocated a low secure unit at St Andrew’s, others disagreed
with this view. Given these differences of opinion, and considering that
the man was still a category A prisoner at the time, it was reasonable to
use caution and initially refer to Broadmoor, a hospital with the highest
recommended security level.
66. When the man was declined admission to Broadmoor, a prompt referral
was made to St Andrew’s Hospital. Once he was assessed and offered a
place, it then became necessary to acquire the necessary funding to pay
for the man’s care.
67. In his clinical review, the medical reviewer, for the Northumberland Care
Trust, says that:
“Where it is clear there is a need for a transfer to a different
environment for terminal care, such a transfer should be arranged
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promptly with a minimum delay to enable appropriate planning of
terminal care.”
68. Unfortunately the man was unable to take up his place at St Andrew’s due
to the length of time it took to organise funding for the place. The medical
reviewer describes this delay as “regrettable”. The difficulties in the man’s
case stem from the length of time that he had spent in prison. The usual
scenario would be that the Primary Care Trust (PCT) covering the home
probation area would pay for the placement. However, as the man had
not lived in his home area for over 50 years there was some debate as to
whether the PCT was still responsible for funding.
69. The PCT covering the man’s home area did eventually agree to fund the
place at St Andrew’s. An agreement was sent to them by the funding co-
ordinator at the hospital, in November 2007. Sadly, the man died before
the agreement could be signed.
The deceased’s care at HMP Frankland
70. The medical reviewer notes that the man’s deteriorating condition was
recognised in June 2006. At that point “consideration was given to his
future health and well being within a prison environment”. However, he
goes on to say that:
“Given his weight loss, confusion and mobility problems, likelihood of
his death might have been assessed using a specific tool for patients
with non malignant conditions. Such a tool can predict the likelihood of
death in patients with progressive debilitating diseases……Given the
increasing ageing population of prisoners at Frankland, it is important
that the Prison Service looks at the provision of environments
compatible with terminal care for those with malignant and non-
malignant terminal conditions”.
71. The medical reviewer makes the following recommendations, which I
endorse.
The head of healthcare should consider the application of a scoring
tool to determine the likelihood of those with non malignant
conditions developing a terminal illness.
An assessment should be undertaken of the suitability of the
environment within the healthcare unit for the care of terminally ill
prisoners.
Anti-dementia medication
72. In his letter to Frankland of 24 May 2006, the professor of psychiatry
recommended that the man be started on an anti-dementia drug. In his
clinical review, the medical reviewer notes that it is not clear whether this
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medication was in fact commenced. From the medical record and
prescription charts, it does not appear that this was the case.
73. In contrast to the professor’s view, a consultant geriatrician had, five
months earlier, concluded that the man was too impaired to be considered
for treatment by medication. My investigator contacted the medical
reviewer for his view. He replied as such:
“Given the deterioration over a number of years and the view from one
doctor looking after him that his dementia was too advanced, the
addition of anti-dementia drugs at that stage would be unlikely to have
had any significant beneficial impact on him……he was also poorly
compliant with medication and self care, which would add weight to the
argument against commencing treatment”.
The deceased’s numerous falls in the weeks prior to his death
74. The man was found either lying or sitting on the floor of the cell on a total
of seven occasions in the month leading up to his death. On some
occasions he said that he had missed his bed or chair when trying to sit
down, and on other occasions he was unable to explain why or how he
got to be on the floor. On one occasion, during the afternoon of October
2007, the man fractured his humerus when falling.
75. The medical reviewer notes that “it is likely that the man’s falls were as a
result of his deteriorating mental state, his weight loss, confusion and the
probability of his development of an underlying chest infection”. He goes
on to say that “investigation (of the underlying reasons behind the falls)
would have been unlikely to have altered the outcome, hence continuing
monitoring and support in his prison healthcare environment was not
inappropriate”.
76. A healthcare senior officer, who is also a registered general nurse, told my
investigator that a mattress was put on the floor of the man’s cell to
protect him from further falls. She added that they also considered
attaching cot sides to the man’s bed but, following a risk assessment, this
was deemed unsuitable. However, neither of these actions are recorded
in the medical record, nor is there any record of a formal falls assessment
(a means of risk-assessing and preventing falls in older people) having
taken place.
The head of healthcare should remind nursing staff of the
importance of undertaking and recording a formal falls assessment
for all patients who are at risk of falling.
The morning of the day of death.
77. The medical reviewer considered whether a blue light ambulance should
have been called as soon as the man was taken ill on the morning of the
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day of death.. His opinion is that this would have made “no difference to
the outcome”. The medical reviewer explained that:
“It is clear from the post mortem report that the man had significant
underlying bronchial pneumonia. Given the progressive deterioration
documented in his clinical records, his death could be expected and
occurring within his familiar environment was appropriate”.
78. The medical reviewer concludes that the man’s death was inevitable and
expected, and did not relate to violence or neglect.
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RECOMMENDATIONS
1. The head of healthcare should consider the application of a scoring tool to
determine the likelihood of those with non malignant conditions developing
a terminal illness.
Accepted – The clinical governance lead has been contacted to ask for a
copy of this document and possible training for staff will be looked into.
2. An assessment should be undertaken of the suitability of the environment
within the healthcare unit for the care of terminally ill prisoners.
Accepted – Frankland are establishing assessment and guidance under
the KITE standards for palliative care in conjunction with a Marie Curie
consultant in palliative care. Healthcare staff at Frankland also meet
regularly to discuss any cases with an external palliative care team and
have a named nurse who leads on this area.
3. The head of healthcare should remind nursing staff of the importance of
undertaking and recording a formal falls assessment for all patients who
are at risk of falling.
Accepted – Notice to staff issued and discussed in full staff briefings. The
named mentioned above has been tasked with completing this.
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