Individual at Frankland

Investigation into the circumstances
surrounding the death
of a male prisoner at HMP Frankland,
at Bishop Auckland Hospital in February 2005
Report by Prisons and Probation Ombudsman for
England and Wales
December 2005
This is the report of an investigation into the death of a man at Bishop Auckland
General Hospital in February 2005, having transferred to hospital from HMP
Frankland two days earlier. The post-mortem examination established that he died
from cancer of the liver.
I would like to offer my sincere condolences to the man’s family and friends on their
loss.
The man’s health began to deteriorate in December 2004 and, following clinical
examination and tests, it was established he was suffering from liver cancer. In
February 2005, arrangements were put into place to enable his early release on
compassionate grounds. However, the man was too ill to benefit and died while still
in custody.
I would like to thank the Governor and staff of HMP Frankland for their help and co-
operation in completing this investigation. I must also extend my thanks to the staff
at Bishop Auckland Hospital for their assistance, and to the doctor who conducted
the clinical review.
A significant part of this report is devoted to the man’s clinical care.
Stephen Shaw CBE
Prisons and Probation Ombudsman December 2005
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Summary
The man was serving a 12-year sentence imposed in 2001, for offences committed
in 1980. He had been transferred to HMP Frankland in March 2004. On reception,
he complained of abdominal pain and loss of weight. The man was examined and
given medication to ease the pain. However, he continued to complain of abdominal
pain. He therefore underwent a series of tests and examinations over the following
months to establish a diagnosis.
In December 2004, his condition began to deteriorate and he lost a significant
amount of weight. More detailed examinations were carried out at the local hospital.
It was established that the man had cancer. By February 2005, his physical
condition had significantly deteriorated and he was moved permanently into the
prison Healthcare Centre. There he could receive constant medical and nursing
care.
Arrangements were made to allow a compassionate early release, but he was
considered too ill to leave the prison hospital. On 23 February, he was transferred to
Bishop Auckland General Hospital where he died two days later.
Because of the nature of his illness this investigation has concentrated on the clinical
care and treatment. A full clinical review confirms that there were no failures or
shortcomings in the man’s diagnosis, care and treatment. No recommendations
have been made regarding either the clinical, nursing or operational aspects of the
man’s care.
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Conduct of the investigation
Following the man’s death, a member of the prison staff contacted his wife to pass
on the sad news. She was invited to visit the prison, to collect her husband's
property and to speak to members of staff.
The Coroner was informed and the local police began an investigation, as is the
case with any death in custody. The Prisons and Probation Ombudsman was notified
and a Senior Investigating Officer, Mr Dennis Atkins, was appointed to conduct an
independent investigation into the death.
An initial visit was made to Frankland Prison to review all the available
documentation relating to the man and the circumstances leading to his death. A
family liaison officer from the Ombudsman's office contacted his wife and
arrangements were made to meet her and explain the purpose of the investigation.
The Primary Care Trust responsible for the prison agreed to appoint an experienced
clinician to carry out a clinical review into the diagnosis, care and treatment of the
man during his time at Frankland prison. Not for the first time, I am greatly indebted
to the doctor for his report and his co-operation with my investigation.
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HMP Frankland
Frankland Prison was opened in 1983 as the first purpose-built high security prison.
It has been extended over the years and now has a Certified Normal
Accommodation (CNA) of 733, about half of whom are life-sentence prisoners. A
unit for Dangerous and Serious Personality Disordered (DSPD) prisoners was
opened in May 2005.
The most recent inspection by HM Chief Inspector of Prisons was in March 2003.
The subsequent report commented favourably on Frankland’s policy and procedures
for dealing with at-risk prisoners. In particular, the introduction of a 'Safer Custody'
manager and several trained Safer Custody officers, and the post-closure review of
F2052SH prisoners, were mentioned as examples of good practice. Minor
recommendations regarding more comprehensive anti-bullying procedures and
improved 'first-night' facilities for new prisoners were made and have been fully
implemented. Shortly after the publication of this Inspectorate report, Frankland
became one of only five prisons to be awarded 'High Performing Prison' status.
The annual Independent Monitoring Board (IMB) report, published in December
2004, commented favourably on the policy and procedures used to identify, monitor
and care for at-risk and vulnerable prisoners.
Frankland has a clear and comprehensive Suicide Prevention Policy and Strategy
Document, supported by a set of contingency plans for dealing with all deaths in
custody. These were last reviewed in May 2004, and were being further reviewed
whilst this investigation was being carried out.
A Violence Reduction Strategy was recently introduced at the prison and this is
being linked to the Anti-Bullying and Suicide Prevention procedures to create a fully-
integrated strategy for ensuring the safety, support and care of all at-risk prisoners.
Although there have been a number of deaths at the prison since it opened, only two
deaths in the past ten years have been self-inflicted. In the last eighteen months,
there have been six deaths, one self-inflicted and five from natural causes.
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Chronology of Events
The man transferred to Frankland on 16 March 2004. During his healthcare
interview, he complained that he had been suffering from abdominal pain and was
losing weight. A series of tests were carried out, but nothing of significance was
discovered. The man was given medication for his pain, which appeared to help a
little and his weight was monitored. There was no further weight loss and by the end
of the year he had, in fact, gained a little weight.
The man took part in most activities and went to the gym regularly. He sustained
some minor injuries whilst playing badminton and was treated for these with
painkillers, and then a course of acupuncture. However, he continued to complain of
abdominal pain, and began to lose his appetite. From December 2004, his weight
began to drop quickly and his pain increased. The man underwent a full examination
within the prison and arrangements were made for him to be given an ultrasound
examination at Bishop Auckland Hospital on 27 January 2005. This examination
revealed serious symptoms suggesting cancer.
On 3 February, an urgent referral was made to the Gastro-enterology Department of
the hospital. The man was informed that his condition was serious, but no definite
diagnosis could be given at that time. The man became so worried and depressed
that a form F2052SH was raised.
The man was given a chest x-ray at the prison on 8 February. Following this, he
asked to speak to a member of the staff for a full explanation of his situation. The
man was under the mistaken belief that he had a heart problem, and had told his
family that this might be the case. The healthcare officer advised him about his
condition and the fact that it might be terminal. As the full report from the
examinations was not available at that time, he could therefore not give absolute
confirmation of this. The man declined the offer of transfer into the Healthcare
Centre, saying that he would rather be on the wing where he had a good relationship
with staff and prisoners. The man felt he would be more content there.
On 11 February, the man did agree to move into the Healthcare Centre, where he
could be under continuous medical supervision. Although his pain was better
controlled, he began eating less and less and refused to drink on occasions. Despite
the attention of the staff, his condition deteriorated. On 15 February, he was taken to
the University Hospital of North Durham for an ultrasound scan which confirmed the
nature and seriousness of his condition. Arrangements were made for
compassionate release, should his condition continue to deteriorate.
On 23 February, the man was admitted to Bishop Auckland General Hospital on
licence. His family was contacted and advised about the seriousness of his
condition. They visited him the following day. The man died at 2.10am on 25
February 2005.
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Findings and Conclusions
The man was serving a 12-year sentence for offences committed in 1980. His
behaviour throughout his time in prison was good and he gave no cause for concern
at any time.
When the man first arrived at Frankland in March 2004, he complained of stomach
pains and loss of weight. A number of clinical examinations were undertaken, but no
definite diagnosis could be made at that time. He was given medication and his
condition was monitored regularly.
The man continued to complain of abdominal pain, and in December 2004 his weight
began to fall very quickly. More extensive examinations at the prison and at the local
hospital eventually revealed symptoms indicating cancer.
Further examinations were carried out and, in February 2005, he was informed of the
possibility that his condition might be terminal. By this time, his health had
deteriorated considerably. The man eventually moved into the prison Healthcare
Centre on a permanent basis. Arrangements were made for him to be given
compassionate early release, but his illness was too severe to allow him to leave the
hospital.
On 23 February 2005, the man was transferred to Bishop Auckland General Hospital
on licence. His family visited him the following day. At 2.10am on
25 February, the man died.
The post-mortem confirmed that the man had died as a result of a cancer of the liver.
The police investigation confirmed that there were no suspicious circumstances.
The clinical review of his care and treatment indicates that there were no
shortcomings, failures or delay in his diagnosis, nursing care and treatment both in
prison and at the outside hospitals involved in his case.
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Recommendations
I make no recommendations.
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