Individual at Frankland

Investigation into the circumstances surrounding
the death of a man in custody at HMP Frankland
who died at University Hospital, County Durham
Report by the
Prisons and Probation Ombudsman
for England and Wales
May 2005
This is a report and findings into the death of a man in August 2004 at University Hospital,
County Durham. In compiling the report, I commissioned a Clinical Review of the care and
treatment received by him at both HMP Frankland and the University Hospital. The review
has been undertaken on behalf of the Durham Primary Care Trust (PCT).
Every death is tragic, but especially so whilst in custody, and I offer my sincere condolences
to the man’s family and friends.
The investigation was carried out by a member of my office. I would like to thank the
Governor of Frankland for providing my investigator with suitable accommodation and
facilities from which to work. I also wish to thank the Liaison Officer for her support and
assistance throughout the investigation.
I note with concern that the Thoracic and General Medicine Consultant treating the man
complained to the Governor about cancelled CT scan appointments and said, this man never
got the assessment of his lung cancer that he should have had with a view to proper
treatment. This report shows that one appointment was cancelled by the prison. The
Consultant treating him believes that at least one other appointment had been made with the
prison, but was not facilitated. My investigation has shown that the hospital's own computer
records do not identify any other appointments. It seems there was a breakdown in
communication, but it is not clear where this occurred.
Other issues of concern include internal communication within the prison, prisoners smoking
in Healthcare, the use of restraints and the use of release on temporary licence (ROTL) for
terminally ill prisoners. I commend the Governor for having issued new instructions in respect
of the latter two matters during the course of this investigation.
The Clinical Review makes no recommendations. The investigation report makes five
recommendations for local action.
STEPHEN SHAW CBE
Prisons and Probation Ombudsman
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CONTENTS
Page
SUMMARY 3
FRANKLAND 4
INVESTIGATION PROCESS 5
FINDINGS 6
RECOMMENDATIONS 11
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SUMMARY
1. On 28 August 2004, the man was admitted to the University Hospital, County
Durham. He died on 31 August, following deterioration of his medical condition. On
15 April 2004, he had been seen by his GP and diagnosed with right basal
pneumonia with pleurisy and treated with Erythromycin. The Clinical Review
describes the ongoing treatment as a history of terminal illness. He had been due to
have a CT scan on 26 July, but this was cancelled by the prison. He had not had a
scan by the time he died.
2. A Consultant in Thoracic and General Medicine at the University Hospital raised
concerns regarding two missed appointments with the Governor. The Governor
passed the letter to the investigation team. The investigation team was able to
establish that one appointment had been cancelled by the prison but that the
University Hospital computer records did not identify any other appointment. The
Consultant’s evidence strongly suggests that there was a breakdown in
communication, but it is not at all apparent where this occurred.
3. The investigation has revealed communication difficulties between Frankland's
Healthcare Department and the Detail Office. Concern is also raised about prisoners
smoking in Healthcare.
4. The investigation has also focused on the use of restraints and ROTL both in the
case of the man and more generally. These matters have been the subject of new
guidelines issued by the Governor, an action that is welcomed.
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HMP FRANKLAND
5. 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.
6. Frankland opened in October 1980 as a temporary prison staffed by the army. After
three months the establishment was closed for further modification. It reopened as a
fully operational high security prison in April 1983. Two further wings were opened in
1998, bringing the establishment’s certified normal accommodation to 653. Prisoners
are held in single cell accommodation in six wings, four of which house vulnerable
prisoners. The establishment’s performance rating is “High Performance”, which is
the highest level achievable.
7. An inspection report by HM Chief Inspector of Prisons (March 2003) described
Frankland as offering a safe environment, based upon good relationships between
staff and prisoners, with appropriate levels of interaction and good staff understanding
of individual prisoners and their needs.
8. The final Standards and Security Audit carried out during February and March 2003
gave an overall “good” rating for both categories. (Good is defined as follows: The
establishment or group performs to a high standard. The evidence gives assurance
that risks are being effectively managed.)
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INVESTIGATION PROCESS
9. The investigation commenced with a meeting between my investigator and the
Governor at the prison, followed by meetings with members of the Prison Officers'
Association (POA) and Independent Monitoring Board (IMB).
10. The Governor appointed a member of his staff to act as Liaison Officer to the
investigator. He also made available a number of documents relating to the period of
the man’s custody. The documents were examined and the investigator identified
whom he would seek to speak to.
11. The investigator commissioned a Clinical Review of the care and treatment of the
man whilst in custody. This was carried out on behalf of the Durham PCT.
12. Following a number of informal interviews and examination of the documents, the
investigator briefed the Governor with his overall findings.
13. The draft report was completed and issued to the Prison Service. One of my office's
Family Liaison Officers, who was in correspondence with a member of the man’s
family, issued the draft report for their comments.
14. His family asked a specific question regarding the extent of his illness and level of the
cancer. The Governor raised a number of questions regarding the report, which the
investigator agreed to review.
15. The report was amended and reissued to the Prison Service and the man’s family, for
any further comment.
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FINDINGS
16. The man was admitted into the University Hospital, County Durham on 28 August and
died on 31 August. A post-mortem was carried out on 1 September at University
Hospital and gave the cause of death as disseminated small-cell anaplastic
carcinoma of the lung. The toxicology report identifies morphine levels consistent
with the therapeutic use appropriate for someone suffering from the terminal stages of
malignant disease. His family asked the investigation team what the level of the
cancer was, but we have been unable to obtain an answer to this question.
17. He had presented on a number of occasions at Frankland’s Healthcare Centre, which
resulted in the medical staff referring him to outside hospital for further tests. The
Clinical Review notes that the history of terminal illness began on 15 April 2004. The
Governor made available to my investigator a copy of a letter from the Consultant in
Thoracic and General Medicine at the University Hospital of North Durham, which
raised a specific complaint regarding the care and treatment of the man whilst at HMP
Frankland. The complaint concerned the cancellation on two occasions of hospital
appointments for a CT scan. My investigator was able to establish that one
appointment was cancelled on 20 July 2004 for an appointment scheduled for 26 July
at 10am. The appointment letter clearly has the entry “cancelled, no staff” written on
it. The investigation team was unable to understand why, some six days prior to the
appointment, sufficient staff could not have been found to undertake the escort. On
examination of the establishment detail records, the Detail Manager on duty at the
time of the investigation was unable to explain why the escort was cancelled, as
sufficient staff were available to take the man to the appointment. The doctor
concluded, he was eventually admitted as an emergency but died just before the third
appointment for a CT scan. This man never got the assessment of his lung cancer
that he should have had with a view to proper treatment. The Clinical Review
comments on this.
18. The investigator wrote to the Consultant seeking clarification of the missed
appointments. She replied on 21 March enclosing a copy of a hand written diary
entry, and a copy of her request for CT scan. The Consultant explained that the
hospital staff said that they would have sent the appointment to the medical officer at
the prison. My investigator contacted the University Hospital Health Records
Department. Their computer records did not show any appointment for the man on
29 June. My investigator was also unable to trace any record that the hospital made
an appointment with the prison for 29 June. My investigator spoke to the prison
Healthcare Administration Manager. She said that the prison receives a large
number of telephone calls from the University Hospital asking why a particular
prisoner has not attended an appointment. Very little appears to have been done to
eliminate this problem.
The Governor and PCT should review communication between external
hospitals and the prison.
19. In his Clinical Review, the doctor writes: had the man been resident in the community;
he would have had a CT scan on 29 June 2004. Both this appointment and his
subsequent one on 26 July 2004 were cancelled and he had still not had the scan
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when he died on 31 August 2004. It would appear that both appointments were
cancelled because of a lack of staff to escort him to appointments, but I can find no
evidence that clinical advice was requested before the appointments were cancelled.
Clinical advice would almost certainly have highlighted the seriousness of his
underlying condition. The University Hospital computer records do not support this
finding. However, the investigation team strongly agree that clinical advice should
always be sought before cancelling a medical appointment.
The Governor should remind staff that clinical advice is sought from the PCT
before any medical appointment is cancelled.
20. The Clinical Review doctor also says: in hindsight, it is apparent that the man’s cancer
had spread and that the outcome was not greatly affected by the delay in diagnosis.
At the time the scan was due, it was not apparent that spread had occurred and at
that stage it was reasonable to assume that an early diagnosis would have led to
treatment which could have improved his quality and quantity of life. I think the
Consultant’s complaint about the cancellation of the scans is fully justified. As noted,
a handwritten diary entry and note from her requesting a CT scan on the dates in
question are available, but the University Hospital computer records do not offer
further support. The investigation team found no evidence of the University Hospital
having made an appointment for 29 June with the prison. I have concluded that there
was a serious breakdown in communication between the hospital and the prison, but I
am unable to say where this occurred.
21. To understand the reasons why the man’s appointment(s) was cancelled, my
investigator interviewed the Detail Manager (responsible for the day-to-day staffing
arrangements) and Healthcare Manager. It became clear that a communication
problem exists between the two departments that requires addressing. The
Healthcare Centre Administration Clerk is responsible for making the appointments
and she then informs the Detail Office. The Detail Office is responsible for providing
the necessary staff. Complications arise when the number of staff profiled to
undertake escorts is exceeded. This results in the Detail staff asking the Healthcare
Centre either to cancel or rearrange an appointment. The clerk will then raise the
lack of staff with the Healthcare Manager, who, if the appointment is urgent, will
contact the Detail Office to say that the escort must go ahead. This in turn leads the
Detail staff to say that, unless they receive an order from a governor grade that the
escort must go out, then the appointment cannot go ahead. The investigator asked
the Administration Manager about the relationship between the Healthcare
Department and the Detail Office. She said,” it’s a waste of time speaking to them”.
Detail staff said that the relationship was good.
22. The Governor has as part of his management team a link governor. The link
governor has responsibility for both the detailing of staff and Healthcare. The
Healthcare Manager informed the investigation team during a recent visit that, whilst
some improvements had occurred recently in communication between departments,
she still experienced difficulties in facilitating prisoner appointments to outside
hospitals. She said that Detail staff still insist that she should contact the Duty
Governor when requesting additional escorts. My investigator spoke to Detail staff
and they confirmed that the Healthcare Manager would be asked to speak to the Duty
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Governor and seek his/her permission to facilitate additional escorts to hospital. They
also said that, once the Healthcare Manager has been directed to the Duty Governor,
they will expect to receive a phone call within five to ten minutes from the Duty
Governor instructing them to facilitate the escort. In anticipation of the phone call,
they begin the process of arranging the escort. The Healthcare Manager is not aware
that, having been instructed to seek the Duty Governor's permission to go ahead with
the escort, the Detail staff are already in fact making the necessary arrangements to
facilitate the escort. This is a waste of the Healthcare Manager’s time, and an
unnecessary bureaucratic obstacle which should cease.
23. Additionally, the Healthcare Manager explained that Detail staff will ask her to
prioritise her appointments and to cancel any non urgent case if an additional prisoner
is required to attend hospital. She said, "I am a nurse, they could all be critical."
24. My investigator asked the Healthcare Manager if she felt she had any authority to
insist that a prisoner be taken to the hospital for an appointment, even if the case was
urgent. It was clear from her answer that she did not have this level of authority or
confidence to insist. Detail staff were asked how they viewed the authority of the
Healthcare Manager. They said that they did not regard her as having any
operational managerial responsibility, and would refer to the Duty Governor for
decisions. It is clear that the Healthcare Manager and Administration Manager feel
isolated and that difficulty with communication exists between Healthcare and the
Detail Office. The Healthcare Manager and Administration Manager said that they felt
disempowered and frustrated. It was evident to the investigator that communication
between the two departments was not on a sound footing, and that this is affecting
the work of the establishment. The investigator discussed this with the Governor. He
was aware of the issues and had held previous meetings to resolve the problems.
The Governor and PCT should seek to resolve the communication difficulties
between the Healthcare Department and Detail Office.
25. Correspondence was received from the Support Organisation for Falsely Accused
People (SOFAP). The organisation forwarded a letter from a prisoner at Frankland,
who wished to remain anonymous, that raised concerns about the care of the man
and about smoking in the Healthcare Department. The concern from the prisoner
regarding medical care referred to the cancellation of the appointment for the man to
undergo a CT scan. The prisoner also referred to the man complaining to him that he
was held in the waiting room whilst other prisoners were smoking, and that this
affected his chest complaint.
26. My investigator visited Frankland’s Healthcare Centre and spoke to nursing staff and
the Healthcare Manager. He found the waiting rooms to be in poor decorative order,
not well lit, with poor ventilation and no signs indicating that smoking was not allowed.
The nursing staff accepted that smokers and non smokers were being held in the
same waiting rooms and that smoking does take place. They felt that they had little
control over the matter and would be vulnerable if they were to tell prisoners to stop
smoking. The Manager accepted that at least one prisoner was smoking on the ward
unchallenged. The Manager made immediate arrangements for no smoking signs to
be fitted in the waiting room. On a later visit to the prison, the investigator found that
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the signs had been installed. However, it was still evident that smoking was taking
place in the room. The investigator discussed this with the Manager. She explained
that not all officers will enter the room to check on the prisoners. She did not
challenge the officers.
The Governor should remind all patrol staff of the need to enter the waiting
rooms and supervise the area appropriately.
27. Observation into the waiting rooms is also poor and requires remedying, as they are
ideal places for bullying to take place. This had been identified in an earlier report by
HM Chief Inspector of Prisons. The Governor had submitted a bid for funding to
improve the observation, which the investigator understands has been successful.
28. My investigator met one of the escort staff who was with the man at the time he died.
He was not under restraint at the time of death. Staff observing him throughout the
night had questioned the need for restraints with the day staff. The man had also
been complaining to the staff about the use of the restraints. The officers
demonstrated an appropriate level of care and concern for him when he was
handcuffed in hospital by raising the matter with the establishment. At the same time,
the Governor, who had returned to duty following the weekend, was briefed of the
man’s condition. Once his condition had become clear to him, he instructed that the
handcuffs be removed with immediate effect. The Governor said that the weekend
Duty Governor should have reviewed the use of restraints in consultation with medical
advice. He has since issued new guidelines to his managers. This is welcomed.
29. My investigator discussed the concerns raised by the Consultant and the use of
restraints with the Healthcare Manager. She described the man as being weak and
dying and said that the use of the chain was in her opinion unnecessary. She did
though acknowledge that it was the prison's responsibility to make the assessment.
She gave an example of a man who attends hospital in a wheelchair and is so ill that
he is not aware that the chain is on his wrist. My investigator raised this with the
Governor and he will be seeking clarification of the circumstances. My investigator
found on a recent visit to the prison that, since the investigation started,
communication between the Security Department and Healthcare Department had
improved, and that the views and concerns of the Healthcare staff are actively taken
into consideration when making decisions regarding the need to handcuff a prisoner.
30. The prison records show that a risk assessment for the man’s release on ROTL was
being undertaken. However, he passed away before the licence was granted. The
investigator discussed this with the Governor and he accepted that the process for
ROTL should have been started earlier. He has since issued new instructions to his
managers. This too is welcomed.
31. My investigator also examined the escort documentation and found that the Hospital
Risk Assessment sheets entitled In Charge are not dated. This makes it difficult to
audit the escort process.
The Governor and PCT should remind staff of the need to date entries on
official documents.
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32. My investigator met with the branch chairman of the POA, who raised no concerns
regarding the care and treatment of prisoners. However, he did cite communication
problems between the Healthcare Department and Detail Office. My investigator also
met a member of the IMB who said that the smoking problems in the Healthcare
Centre had been raised previously during meetings with the Governor. The board
member supplied a written report to my investigator, dated 29 October 2004. The
matter was raised with the Governor. The Governor responded in writing and said
There is no confirmatory evidence that the IMB did raise the matter with me at any
meetings, and that the records of the issue being raised with and by the IMB are not
frequent – one prisoner application in May 2003 and one rota visit report observation
in August 2004.
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RECOMMENDATIONS
1. The Governor and PCT should review communication between external hospitals and
prison.
2. The Governor should remind staff that clinical advice is sought from the PCT before
any medical appointment is cancelled.
3. The Governor and PCT should seek to resolve the communication difficulties between
the Healthcare Department and Detail Office.
4. The Governor should remind all patrol staff of the need to enter the waiting rooms and
police the area appropriately.
5. The Governor and PCT should remind staff of the need to date entries on official
documents.
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