Individual at Frankland

Investigation into the circumstances surrounding the death
of a man at HMP Frankland in February 2006
Report by the Prisons and Probation Ombudsman for England and Wales
November 2006
This is the report of an investigation surrounding the circumstances of the death of a
man in February 2006 at HMP Frankland. He was 75 years old and the post mortem
indicates that he died from natural causes.
My colleagues and I extend our sincere condolences to this man’s family and friends
for their loss.
One of my investigators conducted the investigation. I am also indebted to the doctor
who carried out a clinical review on behalf of Durham and Chester­le­Street Primary
Care Trust.
I would like to thank the Governor of Frankland and his staff for their co­operation
and assistance during the course of the investigation. I am particularly grateful to the
member of staff who ensured that all the necessary documentation was made readily
available.
Judged overall, the man was very well cared for by staff at Frankland. However, no
consideration was given to his possible release on licence when his condition
became terminal, and record keeping on the night of his death was not carried out.
My report includes two recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2006
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CONTENTS
Summary 4
Investigation methodology 5
Background 6
HMP Frankland 6
Events leading up to the man’s death 7
24 February 2006 8
Issues arising from the investigation 9
Conclusions 11
Recommendations 12
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Summary
1. The man at the centre of this report died at the age of 75 at HMP Frankland on
the morning of 24 February 2006. He was serving a 25 year sentence
imposed in 1998. He died in his sleep, following a long illness.
2. The man had many medical problems, and was located in the prison’s
healthcare centre where he received 24 hour nursing care. He was located in
a ward, rather than in a single cell, as he had a large electric bed with many
attachments which would not fit into a single cell.
3. The nurse on duty overnight says that the man was physically observed every
15 minutes throughout the night in order to monitor his breathing and check
that his condition had not deteriorated. However, the decision to carry out
these observations was not recorded in the medical record.
4. At approximately 5.05am on 24 February, the nurse says she noticed that the
man had stopped breathing and called for another member of staff to confirm
that this was the case. The Night Orderly Officer was asked to attend the
healthcare unit and the nurse then went into the ward and confirmed that the
man had died.
5. The post mortem found that the man died from natural causes as a result of:
1a Acute pyelonephritis, bronchopneumonia and septicaemia.
1b Idiopathic transverse myelitis.
6. My report makes two recommendations.
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Investigation Methodology
7. My investigator was given access to all the man’s prison records including his
medical records. No formal interviews were conducted during the course of
this investigation, but copies of statements made by staff were considered.
8. Notices to staff and prisoners were sent to the Governor to be displayed
around the prison. These announced the investigation and invited staff and
prisoners to submit to my investigator any concerns or views they wished to
express. My investigator received one letter from a prisoner who said he had
information about the man’s death. However, when the investigator spoke
with himby telephone, it transpired that his information in fact related to other
matters.
9. Durham and Chester­le­Street Primary Care Trust (PCT) was invited to
undertake a review of the clinical care the man received while in custody, and
this was undertaken by a doctor.
10.One of my family liaison officers contacted the man’s widow and her niece to
enable them to be involved in the investigation process. They were asked if
they had any questions or concerns that they would like the investigation to
consider. Both wanted clarification as to the cause of the man’s death. They
also enquired about the return of the man’s possessions, a matter which has
now been resolved by the prison.
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Background
HMP Frankland
11.HMP Frankland is a maximum­security establishment holding Category A and
Category B adult male prisoners. It became part of the high security
directorate of the Prison Service in April 1983. Two further wings were
opened in 1998, bringing the establishment’s certified normal accommodation
(uncrowded capacity) to 653. Prisoners are held in single cell accommodation
in six wings, four of which house vulnerable prisoners. Frankland is one of
only six establishments assessed by the Prison Service as being a ‘High
Performance Prison’.
12. 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.
13. Following a short unannounced follow up inspection on 25 October 2005, HM
Chief Inspector records that healthcare services at Frankland had improved
since the full inspection. Primary care still needed development but staffing
shortages had hindered progress. However, mental health services were
under pressure although the mental health team was well structured with clear
policies and practices. Some prisoners were held in the healthcare centre for
no medical reason. Of the 12 healthcare recommendations made during the
full inspection, nine had been fully achieved, one partially achieved, and two
had not been achieved.
14.The healthcare services at Frankland are commissioned by the Durham and
Chester­le­Street Primary Care Trust. The prison’s healthcare centre has 18
beds, eight in four bed wards and the rest in single cells, all of which are linked
to the office with a call bell system. Adjacent to the centre is the Listeners
suite which is a large and comfortable two bedded room. (Listeners are
prisoners trained by the Samaritans.)
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Events leading up to the man’s death
15. After being sentenced, the man was held first at HMP Exeter, transferring in
March 1999 to HMP Wakefield. He was transferred again to HMP Frankland
on 25 October 2000, remaining there until his death.
16.In 2001, the man developed a neurological condition which was thought to be
transverse myelitis. It left him partially paralysed and requiring considerable
nursing attention, in addition to repeated hospital admissions. In this man’s
case, the condition also resulted in loss of function below the waist with
altered or absent sensation. His bowels and bladder were affected and he
required an indwelling urinary catheter, because of the retention of urine.
17.The man was located in the healthcare centre in a shared ward with two other
prisoners. He made regular visits to outside hospital for treatment and
monitoring of his condition. His nursing care involved frequent turning to try to
avoid pressure sores, monitoring of fluid balance and management of his
urinary catheter. A specialist electrical bed was provided to help prevent
pressure sores. The clinical review records the extent of the man’s illness.
18.On 23 February 2006, the man’s health appeared to be deteriorating as his
breathing became laboured and he was very chesty. He appeared confused
and was slurring his words. He asked to see his wife.
19.An entry that day in the man’s medical record, timed at 8.15pm, by a
Healthcare Officer says, “to monitor situation overnight and contact the duty
M/O (medical officer) if required”.
20.A nurse was on duty overnight and she reports that throughout the night the
man was physically observed by the nursing staff every 15 minutes. This was
to check his breathing and any deterioration in his condition. For security
reasons, the observations were carried out from outside the ward and the
man’s bedside lamp was left switched on. The observations were not part of
the nursing care plan nor were they recorded in the man’s medical record.
21.The nurse says that the ward was unlocked three times during the night so
that the man could be physically examined. My investigator has reviewed the
control room logs where each unlock should be recorded. No entries have
been made.
22.The only confirmation of the 15 minute observations and the three physical
examinations is in the statements made by three members of prison staff after
the man’s death. (Following a death in custody, the staff involved are required
to prepare a statement for the Governor, detailing what has occurred.) Two
officers, as well as the nurse, have prepared statements which state that they
either carried out the checks themselves or were aware of them being done by
the nursing staff.
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24 February 2006
23.According to the statements, the man was checked at 4:50am and seen to be
breathing. At 5:05am, the nurse checked again and it appeared to her that his
breathing had stopped. She asked an officer to look at the man with her to
confirm that he was not breathing. Once they confirmed that this was the
case, they called the Night Orderly Officer, a Principal Officer in the prison.
The PO attended the healthcare centre at 5:10am and unlocked the ward,
allowing the nurse to enter along with the officer.
24. The nurse checked the man’s pulse. Judging that he had died, she asked for
the doctor to be contacted. The doctor arrived at the healthcare centre at
6:00am and confirmed the death.
25.At 6:05am, the PO set in motion the requirements following a death in custody
as required by Prison Service Order 2710. The two prisoners in the ward
were woken up and taken out so that the room could be sealed. They were
advised that the Listeners were available should they be needed. (As noted,
Listeners are prisoners trained by the Samaritans to offer support to other
prisoners at times of distress). The support of the chaplaincy team was also
offered. Neither of the prisoners concerned has asked to speak to my
investigator on the telephone or when he visited the prison. (Although I make
no formal recommendation on this point, the Governor and Healthcare
Manager will wish to consider if there are lessons here in terms of whether
terminally ill patients could be accommodated in single cells or if fellow
patients in a ward can be reallocated.)
26.A governor arrived at the prison and attended the control room to ensure that
the contingency plans following a death in custody had been activated. The
police were contacted at 5.25am; they arrived at the prison at 5.40am, leaving
shortly thereafter. Scenes of Crime Officers arrived at the prison at 9.20am to
take photographs and collect any evidence. Once this had been completed,
the ward was relocked and sealed.
27.The man’s wife was also a serving prisoner. The governor arranged for the
Governor of her prison to inform her of her husband’s death. At 6:40am, she
then held a staff de­brief and advised that the care and welfare team was
available should they be required. She also contacted the chaplaincy teamas
additional support for staff.
28.The undertakers arrived at the prison and removed the man’s body at
10:40am.
29.The post mortem report concluded that the man had died of:­
1a Acute pyelonephritis, bronchopneumonia and septicaemia.
1b Idiopathic transverse myelitis.
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Issues arising from the investigation
The man’s location
30.The man was located on a ward with two other prisoners, rather than in a
single cell. This raised a concern as to whether this was the most appropriate
location for him, and why he had not been provided with more privacy.
However, I understand that the man needed a large electric bed with many
attachments and this was too big for a single cell. Moreover, the single cells
had insufficient power outlets for this type of equipment.
31.The prison did not consider releasing the man on temporary licence, or
transferring him to a hospice. My investigator was told this was because he
had only served eight years of a 25 year sentence and because of the serious
nature of his offences. However, in line with PSO 6330, Release on
Temporary Licence, consideration should have been given to releasing the
man on compassionate grounds to a hospice. (It may well be that the
necessary risk assessment would have found that the man could not be
released, but the procedures should have been correctly followed.)
The Governor should ensure that all terminally ill prisoners are
considered for compassionate release or temporary licence to an
appropriate hospice. The necessary documentation should be
completed and the decision made once all aspects of the application
have been considered.
Quality of clinical care
32.The clinical reviewer judges that the man would have presented formidable
problems for the nursing team. However, the care he received was as good
as could have been achieved in the community. The reviewer comments that
providing such levels of nursing care is not easy when dealing with a patient in
a secure environment. He makes no recommendations, and considers that
the nursing team should be commended for their efforts in caring for the man.
33.My investigator visited the prison to assess whether the night time
observations could be carried out effectively. The visual checks took place
through the door window and a light was left switched on. The investigator
was satisfied that the observations could be carried out clearly and to an
acceptable standard, with minimal disruption to the man or the other prisoners
sleeping on the ward.
Record keeping
34.No record was made of the decision that the man should be visually checked
every 15 minutes, and no records were made when the checks took place.
Furthermore, no record was made of the decision that the man should be
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physically checked three times during the night, and no records were made by
discipline or healthcare staff that the ward was unlocked and the checks
carried out. The absence of any records renders it impossible to confirm that
the checks were actually carried out. The only record is in the statements
made for the prison after the man died.
I recommend that the Governor and Primary Care Trust ensure that staff
are reminded to record their decisions about the level of nursing care,
their observations and when a cell is opened to enable the checks to be
made.
Contact with the man’s next of kin
35.The man asked to see his wife the evening before he died, but unfortunately
there was not enough time to arrange a visit. There were also difficulties
because his wife was not listed as his next of kin. The man’s son was
identified as the next of kin but his location was unknown at the time of the
death. (I understand that his son is in fact also serving a prison sentence.)
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Conclusions
36.My investigator and I concur with the clinical reviewer that the man was cared
for very well over many years by the nursing staff at Frankland. His location in
a ward with two other prisoners was not ideal, but was understandable in the
circumstances.
37. The absence of any records of the care provided for the man on the night of
his death is not satisfactory.
38. I am also concerned about the reasons given for not considering release on
temporary licence or compassionate release.
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Recommendations
Ø I recommend that the Governor and Primary Care Trust ensure that staff are
reminded to record their decisions about the level of nursing care, their
observations and when a cell is opened to enable the checks to be made.
Ø The Governor should ensure that all terminally ill prisoners are considered for
compassionate release or temporary licence to an appropriate hospice. The
necessary documentation should be completed and the decision made once
all aspects of the application have been considered.
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