Individual at Frankland

INVESTIGATION INTO THE DEATH OF A MAN, SHORTLY AFTER HIS
RELEASE FROM HMP FRANKLAND ON COMPASSIONATE LICENCE ON
29 NOVEMBER 2004
REPORT BY THE PRISONS AND PROBATION OMBUDSMAN FOR
ENGLAND AND WALES
SEPTEMBER 2005
This is the report of the investigation into the death of a man who was in the
custody of HMP Frankland when he died due to natural causes on 29
November 2004.
My office investigates the deaths of all prisoners in custody, including those
due to natural causes. In this case the investigation was carried out by one of
my team leaders, Jane Webb. She also commissioned an independent
clinical review which is much appreciated.
The man died in a hospice, four hours after his release on compassionate
licence and after years of treatment for lung cancer. I share the concerns of
my investigator and the clinical reviewer about the late stage at which
compassionate release was considered.
The man had no contact with his daughter or partner whilst in custody and
they have not participated in my investigation. However, I would like to extend
my condolences to them as they come to terms with their loss. I also
commend the prison and the authorities for making it possible for him to see
his daughter shortly before he died.
I am grateful to the Governor of Frankland, and to the liaison officer, for their
assistance during the investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2005
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CONTENTS
Summary 4
Background 5
HMP Frankland 6
Conduct of the investigation 7
Key Findings 8
Recommendations 12
Annex
1 Terms of reference
2 Clinical review
3 North Durham Health Care Trust Integrated Care Pathway
4 Transcript of the interview with the Head of Central Services
5 Transcript of interview with the Healthcare Manager
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SUMMARY
1. The man was convicted of wounding with intent and sentenced to
seven years imprisonment on 18 February 2003. The victim of the
offence was his long term partner, with whom he had a child. The
offence breached the terms of a County Court order, and in prison the
Protection from Harassment Act applied and he was forbidden to have
contact with either his partner or his child.
2. For many years the man suffered from a psychiatric condition (bi polar
affective disorder) and he also abused alcohol. At the time of his
sentence he had already been diagnosed with lung cancer.
3. He began his sentence at HMP Durham, before being transferred to
Frankland in January 2004. Both prisons ensured that he regularly
attended hospital for out-patient treatment. For much of his sentence,
he was monitored under the prison’s suicide and self harm
arrangements. His physical health improved for twelve months from
March 2003, but unfortunately the symptoms returned and continued
treatment was unsuccessful. He became increasingly poorly and frail,
serving most of the last months in the Healthcare Centre at Frankland.
4. As well as the psychiatric and general nursing staff within the
Healthcare Centre, the man was also supported by other professionals
including Macmillan nurses. Whilst each brought their own specialist
expertise to bear, it is not apparent that there was a co-ordinated multi-
disciplinary approach to his situation which could have considered both
the security and medical issues.
5. In October 2004, the man asked about compassionate release and the
following week his request was supported by an entry in the medical
record. The following month the Macmillan nurse raised a number of
concerns about the man’s care and well being. Nearly a fortnight later
he was moved to the Listener suite. On 29 November, a Board met
and recommended compassionate release to a hospice. He was
released the same day at 16.05 and died later at 20.30.
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BACKGROUND
6. Little information about the man’s background is available but it is clear
that his mental health had a profound effect on his ability to maintain
relationships. The psychiatric report for his last offence describes
bipolar affective disorder as "a serious mental illness, which is
characterised by extreme abnormalities of mood. In severe cases
patients can also become psychotic as he has done in some past
episodes." The report goes on to refer to his abuse of alcohol: "also
relatively severe and amounts to a diagnosis of a dependence
syndrome." As well as the assault on his partner, the man had
committed an earlier, similar offence against his brother.
7. When he assaulted his partner, he had stopped taking the medication
for his psychiatric condition and was in the early stages of relapse. By
the time of his arrest he had no fixed address and throughout his
sentence he had no support from family or friends. He gave his details
as a single man with one child and no next of kin.
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HMP FRANKLAND
8. HMP Frankland is a maximum security establishment holding category
A and category B adult male prisoners. It is part of the high security
directorate of the Prison Service.
9. Frankland opened in 1980 as a temporary prison staffed by the army.
It closed for further modifications and reopened as a fully operational
high security prison in 1983. Two further wings were added in 1998,
bringing the certified normal accommodation to 653. Prisoners are
held in single cell accommodation in six wings, four of which hold
vulnerable prisoners.
10. 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 Listener’s Suite which is a
large and comfortable two bedded room. The prison’s Safer Custody
team, rather than healthcare, determine access to this room. When the
man used the Listener’s Suite he was provided with an alarm to
summon assistance.
11. A doctor attends the prison each morning and afterwards a GP is on
call for the Durham cluster of prisons. Nursing staff, with a range of
general and mental health qualifications, and care staff are on duty day
and night.
12. Prisoners in the Healthcare Centre have the same regime as the rest of
the prison and are locked up for the same periods. If they need
attention during this time, they call for staff who obtain permission to
open the cell. The prisoners' medical needs are mixed, including
physical and mental illness. The Healthcare Centre also houses
prisoners whose behaviour is such that they are considered unsuitable
for normal location.
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CONDUCT OF THE INVESTIGATION
13. As well as gathering information from the prison and medical records,
the investigator and clinical reviewer carried out formal interviews with
the prison’s Head of Central Services and the Healthcare manager. A
further interview was carried out with the Macmillan nurse employed by
Derwentside Primary Care Trust who visited the man at Frankland
prison.
14. Staff and prisoners at Frankland were informed of the investigation but
none of them responded to the invitation to contact the investigation
team.
15. The Ombudsman’s Family Liaison Officer made contact with the
authorities responsible for the man’s daughter, who in turn consulted
her to establish that she did not wish to participate in the investigation.
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KEY FINDINGS
16. The man was remanded in custody to Durham on 6 November 2002
and was sentenced to seven years imprisonment on 18 February 2003.
It was his second custodial sentence and he began it at Durham. He
was a category C prisoner. The healthcare reception interview
identified his mental and physical illness. Whilst in police custody, he
had drunk a noxious fluid and the prison opened its suicide and self
harm monitoring form (F2052SH).
17. The F2052SH remained open and there were several occasions when
either ligatures were found in his cell or he was found to have been
secreting medication. Reviews took place regularly and set detailed
objectives which were allocated to specific departments and which
made the connection between his physical and mental health, together
with the stage of his sentence. The F2052SH was closed at the
beginning of March 2003 when it was considered that he was more
settled since he was sentenced. The comment was made in his
personal record that he felt happier as the radiation treatment was
complete and he was able to go back to work. There are some entries
in his security record, but he was given enhanced status as he had
begun to keep his cell in better condition.
18. The man transferred to Frankland on 23 January 2004 and was initially
located on a wing. The records describe him as vague and withdrawn,
but not presenting any discipline problems. He was admitted to the
Healthcare Centre in March after complaining of feeling unwell. There
were signs of deterioration, which suggested a recurrence of the
cancer, and this was confirmed by the hospital after tests the following
month. His mood was low, such that at one point he asked if staff
would hasten his death if the cancer was confirmed. As a result, a
F2052SH was reopened on 30 April and he was also referred to the
Macmillan nurses. The F2052SH and IMR records show that he was a
man in considerable distress with entries such as "awaiting
compassionate release, does not wish to die in prison. Afraid of pain".
Support for compassionate release came from the prison doctor and
the Consultant Oncologist but it was decided not to grant the request
as his condition stabilised in June 2004. He returned to the wing at his
own request, hoping that a change of routine and social contact would
help his mood. This only lasted for a few weeks before his return to the
Healthcare centre.
19. The F2052SH was closed but reopened soon afterwards with entries
such as "wished he had never been born, wished himself dead." He
was seen by the mental health team and psychiatrist, and his mental
health was taken into account as well as his physical wellbeing. In
September, he was suspected of storing medication and said that he
was scared of pain. At the end of the month, the man was described
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by a Macmillan nurse as having deteriorated physically, lost weight and
having difficulty walking.
20. The Macmillan nurse was interviewed as part of this investigation. She
described the difficulty she faced in nursing the man within the prison
where security requirements conflicted with her own professional
values and standards. She believed that there were:
∗ delays before the dietician and the physiotherapist were cleared for
visits
∗ delays before pillows, pressure relieving mattresses and cushions were
allowed in
∗ lack of variety in the food supplements available
∗ information written in his records and passed to the staff on duty but
not consistently carried out.
21. The man had hospital out patient appointments throughout his
sentence and attended them regularly. Each escort from the prison
should have been preceded by an assessment of the risk he would
present to himself and to others. It is the risk assessment that should
provide the opportunity for medical staff to indicate whether there are
any medical objections to the use of restraints. 15 escort forms have
been examined for the period when he was at Frankland, three of
which were accompanied by a risk assessment and only the latter ones
include objections to restraints. Records for a month before his death
show that he was still being strip searched on leaving the prison and
wore handcuffs and a closeting chain. Entries in both the forms appear
to have been made by rote, and without an appropriate assessment
which took into account his increasing frailty. For example, although his
conviction was for an assault on his partner, the forms regularly stated
that he "was a danger to women" although his offence was against a
specific individual. There was no evidence from his criminal or prison
record that he presented a risk to other women.
The Governor should review the use of escort and risk
assessment procedures to ensure that restraints are used
appropriately.
22. The man was being monitored and reviewed as required by the
F2052SH arrangements, as well as by a range of professionals from
the prison and the community. However, it does not appear that his
wellbeing was looked at holistically, that his state of mind was linked to
his diagnosis, or that counselling was considered. Had he been able to
receive the specialist services of the hospice at an earlier stage, he
might have benefited from its compassionate environment.
23. On 28 October, the man began to vomit and was unable to eat or drink.
An obstruction to his throat was suspected and he was admitted to the
hospital as an in-patient. Tests confirmed the diagnosis and he was
told that his prognosis was poor. He refused further treatment and
expressed the wish to have early compassionate release due to his
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illness. The bedwatch records state that he "may be contemplating
ending his own life as he was informed that he would not live to his
parole date". The records of the bedwatch staff are detailed and
informative. Risk assessments were completed for his in-patient stay
and there were medical objections to the use of restraints. These were
respected and he was nursed without them.
24. The man returned to Frankland on 1 November and, on 3 November,
the Medical Officer recorded his support for compassionate release.
This was not achieved until 26 days later.
25. He lived for 28 more days and all but the last four were spent in a single
cell in the Healthcare Centre. His condition was what would be
expected for a person at this stage of a terminal illness. He was weak,
unable to bathe or move from bed to chair without assistance, needed
help to drink and had difficulty eating the prison diet. On three nights
he complained of loud music from other patients. On another night he
asked for assistance to go to the toilet and fell whilst waiting for help to
come. On another occasion, he had to wait for an hour before staff
were available to bathe him. It is some comfort that, as far as can be
told from the records, the man does not seem to have been in pain and
he was lucid and able to communicate his needs.
26. Record keeping is an integral part of nursing practice and is a tool that
should help the care process. Good record keeping helps protect the
welfare of patients by promoting high standards of care, continuity of
care and better communication and dissemination of information
between members of the multi-disciplinary team. Furthermore it should
provide an accurate account of treatment, care-planning and delivery,
with the ability to detect changes in a patient’s condition at an early
stage.
27. All medical records therefore form a vehicle for communication amongst
the team. There is an absence of records, for example he was
admitted to healthcare on 16 April 2004 until 26 June 2004, but there is
no evidence of a care plan or daily nursing notes. Again in July he is
admitted but the medical records do not make this clear and once again
there is no evidence of an appropriate care planning process. There
are entries in the medical record, but these fall short of evidence of an
appropriate care planning process.
28. I am also disturbed about the apparent failings on occasions of staff to
act on instructions entered in the medical record, in a timely manner.
On 5 May 2004, it was identified that the compassionate release
process should be commenced; on 25 May a letter was received from
his consultant supporting this. However, the entry in the medical record
states ‘…physical condition has settled at present, consideration for
compassionate release is not being actively pursued at this time.’ As
the weeks went by it is evident that his condition deteriorated. There is
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no evidence that this was again considered by healthcare or prison
managers.
Healthcare staff must be reminded of the need to keep accurate
and contemporaneous records to promote the welfare of patients
by promoting high standards of care, continuity of care and better
communication and dissemination of information between
members of the multi-disciplinary team. Furthermore, it should
provide an accurate account of treatment, care-planning and
delivery, with the ability to detect changes in a patient’s condition
at an early stage.
27. Each prison is required to develop its own Palliative Care policy which
should be a comprehensive approach to the treatment of serious illness
and focusses on the physical, psychological, spiritual and social needs
of the patient. The document in use at Frankland was developed with
North Durham Health Care Trust and the Macmillan nursing service. It
defines the ideal management for terminally ill prisoners but does not
state how the shortcomings of nursing in a secure environment should
be addressed. The facilities of the Healthcare Centre mean that they
receive prisoners transferred from elsewhere in order that they can
have 24 hour nursing care and so it is likely that this man’s case will not
be unusual.
28. It seems to me it would also be helpful if there were a protocol between
the Macmillan nursing service and the prison to set out the
arrangements for nursing terminally ill prisoners. This should lead to
further improvements in working relationships.
The Primary Care Trust in partnership with the prison and
Macmillan nursing service should develop a multi-disciplinary
protocol for nursing terminally ill prisoners reflecting the NHS
Cancer Plan and which should include:
• Access to the prison by professional visitors
• Timely access to specialist services
• Procedures for compassionate release and release on
temporary licence
29. On 25 November, nearly a fortnight after it was first requested, the man
was moved to the comparative comfort and safety of the Listener suite
where he was given a radio baby alarm so that he could summon
assistance. The same day a Release on Temporary Licence Board,
convened for other matters, had its agenda extended to consider the
man’s release on compassionate grounds. The Board recommended
his release and he was transferred to the hospice with the conditions
that he was:
1) not allowed to visit his home locality
2) not to leave the hospice.
The prison probation officer had made contact with those responsible
for the man’s daughter and confirmed that she wished to say goodbye
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to her father. Arrangements were made for this to happen and she
visited during the few hours that he was at the hospice.
All prisoners who are diagnosed with a terminal illness should be
regularly reviewed by the multi-disciplinary team and considered
for early compassionate release or Release on Temporary Licence
in a timely manner.
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RECOMMENDATIONS
National
All prisoners who are diagnosed with a terminal illness should be regularly
reviewed by the multi-disciplinary team and considered for early
compassionate release or Release on Temporary Licence in a timely manner.
Local
The Governor should review the use of escort and risk assessment
procedures to ensure that restraints are used appropriately.
The Primary Care Trust in partnership with the prison and Macmillan nursing
service should develop a multi-disciplinary protocol for nursing terminally ill
prisoners reflecting the NHS Cancer Plan and which should include:
• Access to the prison by professional visitors
• Timely access to specialist services
• Procedures for compassionate release and release on temporary
licence.
All prisoners who are diagnosed with a terminal illness should be regularly
reviewed by the multi-disciplinary team and considered for early
compassionate release or Release on Temporary Licence in a timely manner.
Healthcare staff must be reminded of the need to keep accurate and
contemporaneous records to promote the welfare of patients by promoting
high standards of care, continuity of care and better communication and
dissemination of information between members of the multi-disciplinary team.
Furthermore, it should provide an accurate account of treatment, care-
planning and delivery, with the ability to detect changes in a patient’s condition
at an early stage.
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