Individual at Garth

Circumstances surrounding the death of a man at a local
hospital, whilst in the custody of HMP Garth,
in December 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2008
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
This is the report of an investigation into the death of a prisoner at HMP Garth who
died from natural causes on 2 December 2007. He was 68 years old.
I would like to add my personal condolences to those already expressed to the
man’s family on behalf of this office by one of the Ombudsman’s Family Liaison
Officers.
The Ombudsman’s investigator and I would like to thank the Governor of HMP Garth
and her staff, especially the Residential Manager, for their assistance. A clinical
reviewer was asked by Central Lancashire Primary Care Trust to undertake a review
of the man’s clinical care and I also much appreciate her help.
The man was taken by ambulance to a local hospital on 20 November and it was
there that he died during the evening of 2 December. I have noted the issues
highlighted by the clinical reviewer and I endorse most of the recommendations
made in her clinical review. I also noted that the clinical reviewer considered that the
man’s care in some instances was not comparable to what he would have received
in the wider community. In particular there was an unacceptable delay of 15 months
before the referral for specialist treatment received attention. The Primary Care
Trust and the prison will develop an action plan to address the matters raised.
Jane Webb
Deputy Prisons and Probation Ombudsman October 2008
1
CONTENTS
Summary 3
The investigation process 4
HMP Garth 5
Key events 6
Issues considered 10
Conclusion 16
Recommendations 17
2
SUMMARY
The man was 68 years old when he died at a local hospital. The man died from
natural causes as a consequence of chronic liver failure.
The man had been received into prison custody as a remand prisoner on 8 October
1969. He was later sentenced to life imprisonment on 30 July 1970. The man
arrived at HMP Garth on 16 December 1996 after being held in a number of prisons.
During his initial health screen at Garth it was noted that the man had been
diagnosed with diabetes and angina.
Ten years later, in May 2006, the man attended a local hospital as he had been
diagnosed with possible oesophageal varices (varicose veins in his throat). The
consultant who saw him recommended that the man be reviewed by a colleague. A
consultant physician and gastroenterologist eventually saw the man on 13 August
2007. He noted that the man’s liver and spleen were both enlarged and he had fluid
around his liver. Blood tests also showed problems with the man’s liver function and
a low platelet count which was consistent with liver disease.
The man was admitted to outside hospital from 4 to 18 October 2007. On his return
to Garth he was placed in the healthcare centre. The man was again admitted to
hospital on 1 November and five days later he had an operation on the varicose
veins in his throat. He discharged himself from hospital on 11 November and
returned to the healthcare centre at Garth.
The man returned once more to outside hospital on 20 November. He was admitted
to the Medical Assessment Unit and was later moved onto a ward. Whilst he was in
hospital the man developed MRSA (methicillin resistant staphylococcus aureus).
This is an infection which is resistant to commonly used antibiotics. The man’s
medication was changed to deal with this new infection. During the evening of 2
December 2007, the man’s condition started to deteriorate rapidly and he died at
11:32pm.
When the man was first an in-patient in outside hospital, a bedwatch was carried out
by two prison officers. The initial security risk assessment, on 4 October 2007,
identified that an escort chain was to be used. However, the risk assessment was
later revised, on 20 November, after the man was again admitted to hospital. The
second risk assessment was that no restraints were to be used. The risk
assessment was revised again on 21 November and the bedwatch was reduced to a
single officer. The man’s family were allowed to visit him whilst he was in hospital.
The clinical review carried out concludes that the man’s clinical care was not in some
instances comparable to that available in the community. I have endorsed five of the
recommendations made in the clinical review. I have written to the Governor about
two of the reviewer’s other recommendations. I have also made a recommendation
that a review takes place of Garth’s death in custody and care team policies are
reviewed.
3
THE INVESTIGATION PROCESS
1. One of the Ombudsman’s investigators opened this investigation on 3
December 2007. He issued notices announcing the investigation to both staff
and prisoners. The notices included an invitation to those who wished to
contribute to the investigation to make themselves known. In the event,
nobody came forward. The investigator also studied all relevant prison records
relating to the man. These included his main prison record, bedwatch logs,
medical records and statements made by staff.
2. The investigator visited Garth on 18 December and 26 February 2008. He
discussed aspects of the man’s treatment with staff at the prison. He met the
Governor, the Residential Manager and the man’s personal officer. The man’s
personal officer was able to provide background information about the man and
his activities whilst in custody. My investigator also interviewed the Head of
Healthcare for Garth, a prison officer and a Principal Officer. The prison officer
and the Principal Officer had been allocated bedwatch duties on the day the
man died.
3. The Central Lancashire Primary Care Trust commissioned a Consultant Clinical
Psychologist/Reviewer to carry out a review of the man’s clinical care. I am
grateful to the clinical reviewer.
4. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of the investigation and to request a copy of the Post Mortem report.
Upon completion, this report will be sent to the Coroner to assist in his
enquiries into the man’s death.
5. One of the Ombudsman’s Family Liaison Officers contacted the man’s family.
This gave them the opportunity to discuss the purpose of the investigation and
to raise any concerns or questions they would like explored or addressed. The
man’s family raised a number of concerns about the treatment he received
while in custody:
• The family felt very strongly that the man would not have died had he
received earlier treatment and diagnosis. They felt that he had not received
appropriate treatment in light of his condition.
• The family were also concerned about the difficulties the man encountered
when making appointments to see his consultant.
The clinical reviewer and my investigator have explored these points and I
hope that my report fully addresses their concerns. The family were very
complimentary about the support they received from Garth towards the end of
the man’s life and after he died. The family also told my family liaison officer
that, when they visited the man in the healthcare wing at Garth, he told them
that he enjoyed being there.
4
HMP GARTH
6. HMP Garth, near Preston, is an adult male category B training prison which
holds over 800 male adult prisoners. It is a purpose built establishment that
sits alongside HMP Wymott on the site of a former Royal Ordnance factory.
7. Accommodation at Garth consists of seven residential units, A to G, most with
dual purposes. F wing is used as a first night centre and induction wing. The
re-integration unit on D wing is used to house some vulnerable prisoners. The
healthcare centre consists of a primary care service and 24 hour in-patient care
with eight beds. Nurse led clinics, including a heart disease management
clinic, are in operation. Prisoners are called to attend for regular check ups
with in-house nursing staff or visiting specialists.
8. The most recent report of a full announced inspection by Her Majesty’s Chief
Inspector of Prisons (HMCIP) was published in 2004. Inspectors found Garth
to be a safe, respectful and improving prison with solid relations between prison
staff and prisoners. The report congratulated Garth for securing an
environment that placed emphasis on purposeful activity, including work,
education and training, for some of the most challenging long term prisoners.
9. HMCIP found that healthcare services had improved since the last inspection in
2001, and that a good working relationship had developed between the local
Primary Care Trust and Garth’s healthcare centre. Healthcare staff were found
to be highly qualified and annually trained in resuscitation. HMCIP reported
that training was carried out in-house by two members of staff who were
Resuscitation Council (UK) trained advanced life support officers. The pre-
inspection prisoner survey results indicated that prisoners felt healthcare
provision was good or very good, especially nurse-led healthcare. This placed
Garth above the average when compared to similar establishments.
10. An unannounced short follow-up inspection was carried out between 5 and 7
July 2007. The inspection found that Garth remained an essentially safe,
respectful and active prison, which had improved its resettlement function.
Relationships between staff and prisoners were generally positive and
supported by a functioning personal officer scheme. The inspection also found
that health services had continued to improve and commended managers and
staff on the continued progress at Garth.
11. The Independent Monitoring Board (IMB) in its latest report for Garth (2004 –
2005) says that overall the prison continues to be well managed. It highlighted
the absence of property storage facilities for prisoners and the additional work
this created for staff.
12. Since 2004, when I became responsible for investigating all deaths in custody, I
have investigated four deaths as a result of natural causes at Garth. There
was no link between the circumstances surrounding this investigation and the
previous deaths at Garth.
5
KEY EVENTS
13. The man arrived at Garth on 16 December 1996 after being previously held in a
number of other prisons in England. On first reception in Garth the man had
two established medical conditions. He had experienced angina attacks since
1994 and he also had diabetes. A range of medication was prescribed for the
man and he was allowed to keep these in his possession for self
administration.
14. On 30 June 2005, the man was taken to a local hospital as he appeared to be
confused and suffering from a weakness on the left side of his face. He was
admitted to the Medical Assessment Unit where he was diagnosed with a
listeria infection. The man was discharged from hospital on 18 July.
15. The man attended an appointment, on 27 October, with a Consultant in
Diabetes and Endocrinology. The consultant noted that the man’s diabetes
was poorly controlled. He recommended the commencement of insulin
treatment and made a referral to a haematologist.
16. In a report dated 1 December, a Consultant Physician in General and Geriatric
Medicine noted the man had the following pre-existing conditions:
• diabetes
• portal hypertension
• hyperthyroidism
• ischaemic heart disease
• angina
• arthritis of shoulders and elbows
• symptoms of Parkinson’s Disease
• iron deficiency anaemia
• raised cholesterol level
• listeria septicaemia.
17. On 10 February 2006, the man attended an out-patients appointment at the
local hospital as he had been suffering from abdominal pain. The cause of the
pain was diagnosed as a possible umbilical hernia and right inguinal hernia (a
hernia is protrusion of an organ through the wall of the area which normally
contains it). A Consultant Surgeon Day who saw the man recommended that
upper and lower gastro-intenstinal endoscopies were carried out. (An
endoscopy is a test that looks inside the body. The endoscope is a long
flexible tube that can be swallowed. It has a camera and light inside it.) The
consultant surgon said that if the result of the endoscopies was normal then the
man’s hernias could be repaired.
18. The man attended a local hospital, on 11 May, for an endoscopy investigation
for possible oesophageal varices (varicose veins in his throat). The result of
the endoscopy was a diagnosis of portal hypertension (raised blood pressure in
the vein which links the stomach and intestines to the liver) and the consultant
who saw the man recommended that he was reviewed by a medical colleague
6
with regard to an apparent ‘hepatic problem’ (a problem relating to the man’s
liver). It was also noted that an ultrasound had shown a small amount of
ascites (an accumulation of fluid) around the man’s liver.
19. In a letter dated 19 December, the consultant surgeon again recommended
that the man’s apparent liver problem be reviewed. The consultant surgeon
commented on the delay in referring the man to the appropriate specialist.
20. On 7 March 2007, the man attended an appointment with a Consultant in
Diabetes and Endocrinology. The Consultant in Diabetes and Endocrinology
made a referral to an optometrist and changed the man’s insulin regime.
21. Two days later, the man attended a local hospital for a hernia operation. Staff
at the hospital informed the prison officers escorting the man that the surgeon
who was due to conduct the operation was unwell. The officers were told that
another surgeon would conduct the operation but he would not arrive until later
in the day. The officers contacted the security department at Garth and were
advised to return to the prison and not wait for the surgeon. The healthcare
department at Garth were unfortunately not involved in this decision. An
appointment was later made for the man to see the consultant surgeon again.
22. In a letter dated 20 June, the consultant surgeon summarised his consultation
with the man on 15 June. The consultant surgeon noted that, although the
man’s hernia was quite large, the concerns about his liver were more
significant. The consultant surgeon arranged for blood and liver tests. He also
made an appointment for the man to see the consultant in physician and
gastroenterologist.
23. In a letter dated 15 August, the Consultant Physician and Gastroenterologist
summarised his consultation with the man which had taken place two days
earlier. The Consultant Physician and Gastroenterologist wrote that the
ultrasound scan had shown evidence of hepatosplenomegaly (enlargement of
the liver and spleen) and ascities. Blood tests had also shown problems with
the man’s liver function and a low platelet count which was consistent with
cirrhosis (liver disease). This consultation took place 15 months after the initial
concern about the man’s liver problems was raised.
24. On 4 October, the man was suffering from abdominal pain and was taken to a
local hospital. Fluid was removed from around his liver and he was discharged
from hospital around noon on 18 October. On his return to Garth the man was
located in the healthcare centre.
25. In his signed statement to an independent researcher, dated 23 October, the
man said:
“I am happy with the treatment I have received for my various illnesses and
have nothing but praise for the way I have been treated here at Garth
hospital.”
7
26. On 1 November, as the man had increased abdominal swelling, he was
admitted to hospital. Five days later, on 6 November, the man had an
operation on the varicose veins in his throat to stem the bleeding. The man
discharged himself from hospital on 11 November and returned to the
healthcare centre at Garth. The self-discharge form identified the following
risks if he did not receive treatment:
• vomiting blood
• encephalopathy (a degenerative disease of the brain)
• further abdominal swelling
• renal failure
• death.
27. During the evening on 19 November, the man was found by staff on the floor of
his cell. He told staff that he might have fainted. Two nurses helped the man
to sit up and measurements of his vital signs were taken. The man was
observed by nursing staff throughout the night and he was taken to hospital the
following morning. Two officers accompanied him in the ambulance. When the
man arrived at the hospital he was taken to the Medical Assessment Unit. After
an x-ray and an electrocardiogram (ECG), the man was moved to a side room.
The man had a Computer Topography (CT) scan the following day. He was
moved to a general ward 26 November.
28. Blood was taken from the man for tests and another x-ray took place on 29
November. The blood tests showed that he had MRSA (methicillin resistant
staphylococcus aureus). This is an infection which is resistant to commonly
used antibiotics. The man’s medication was changed to deal with the new
infection.
29. Whenever the man was an in-patient at the hospital, a bedwatch was carried
out by prison officers. The initial security risk assessment on 4 October
identified that an escort chain was to be used and the man should be
accompanied by two officers. However, when the man returned to hospital on
20 November, the risk assessment was revised. The Head of Security at
Garth, recorded that no restraints were to be used. The following day, the
deputy governor gave permission for a single officer to remain on bedwatch
duty.
30. The Principal Officer recorded in the bedwatch log that, around 7:00pm on 2
December, the man’s condition started to deteriorate. He noted in the log at
7:40pm that nursing staff had to change the man’s bed linen due to the amount
of bleeding. A prison officer came on duty at 9:00pm. The Principal Officer
conducted a handover with the prison officer and waited until he was certain
that the prison officer was settled before leaving the hospital.
31. At around 9:45pm, the man’s condition worsened and he started to vomit blood.
Nurses were in constant attention during this period. This situation was very
distressing for both the man’s sister and the prison officer. When interviewed
as part of this investigation, the prison officer said that they supported each
other during this difficult period and vacated the room after each episode of
8
vomiting to enable the nursing staff to attend to the man. The man’s sister and
the prison officer were both in attendance when the man passed away at
11:32pm. The prison officer immediately informed the prison that the man had
died. The prison later made arrangements for a taxi to take the man’s sister
home.
32. The Residential Manager was appointed as Garth’s family liaison officer. He
contacted the family on the day after the man’s death to offer condolences and
support. The residential manager maintained contact with the family and
assisted with the arrangements for the funeral. The prison offered financial
assistance with the cost of the funeral. The man’s sister was very
complimentary about the support she received from Garth before and after her
brother’s death.
33. The post mortem report records the man’s death as being due to natural
causes as a consequence of chronic liver failure.
9
ISSUES CONSIDERED
Clinical care
34. A review of the man’s medical care was undertaken by a clinical reviewer on
behalf of Central Lancashire Primary Care Trust. The review found that the
man suffered from significant long-term chronic diseases. From the medical
records, it was clear that the man was seen regularly by healthcare staff and,
when necessary, referred to secondary care services.
35. The man’s family had a number of concerns relating to his treatment while in
custody. The family felt very strongly that the man would not have died had he
received earlier treatment and diagnosis. They felt that he had not received
appropriate treatment in the light of his condition. The family described the
man as having suffered an excruciating death.
36. The family drew attention to the fact that the man had been complaining of a
lump in his groin for 18 months prior to his death. They described how the
man's stomach kept getting bigger and bigger until he had difficulty standing,
and eventually collapsed. The man then had to have a large amount of fluid
drained from his stomach.
37. In a statement to the Governor in response to the concerns raised by the
family, The Head of Healthcare at Garth said that the lump in the man’s groin
was a hernia. It had been assessed by a surgeon but no surgery took place
due to the development of problems with the man’s liver. The Head of
Healthcare explained that it was apparent from the man’s medical records that
his liver problem was a result of his diabetes and that this was a common
associated condition. The Head of Healthcare said that the man also had
oesophageal varices (varicose veins in his throat) which were caused by his
liver problems. The Head of Healthcare confirmed that the varices would have
caused the man to bleed from his mouth. She appreciated that this would have
been distressing for those who were present when it happened.
38. The Head of Healthcare said that the man had a large amount of fluid (ascities)
drained from his stomach and this again was a side effect of his liver problems.
His stomach was drained on a number of occasions but she considered that it
could not be treated in any other way. There was no permanent cure because
the man’s liver condition was terminal. The Head of Healthcare confirmed that
the man’s stomach had been large for a number of years but he had been
overweight. She could not establish when the ascities started but explained
that it usually occurs when problems with the liver become pronounced.
39. The clinical reviewer draws attention to the fact that a prisoner’s individual care
is co-ordinated by the General Practitioner (GP) and Medical Officer. They
make the initial referrals for medical investigations to external specialists. The
clinical reviewer notes that a number of nurse led clinics also operate in Garth,
including coronary heart disease, diabetes and mental health. The man
attended the relevant clinics at Garth and his condition was regularly reviewed
by staff. The clinical reviewer says that the Head of Healthcare acknowledged
10
that whilst the prison healthcare service had ensured access to specific health
conditions, less attention had been paid to co-ordinating healthcare across
these specialities. The clinical reviewer recommends that there should be
consideration of a system to co-ordinate methods of monitoring and
investigations across different health specialties. Co-ordination is especially
important when a prisoner has a number of different long term medical
conditions which require different treatments.
HMP Garth should clarify the role of the medical officer within prison
health care.
40. Regarding the man’s diabetes, the clinical reviewer says that the Head of
Healthcare advised her that different prisons have different arrangements for
the management of the condition. Garth had received advice from a dietician
specialising in diabetes which had led to the availability of particular foods. The
Head of Healthcare confirmed that prisoners received three meals a day and
additional food can be bought from the prison shop. The Head of Healthcare
said that the man received specific advice from a diabetic nurse specialist. She
explained that prisoners have hand held kits for testing their blood glucose
levels. Insulin pens are also held in possession and prisoners maintain their
own records which they can discuss with health specialists. The clinical
reviewer recommends that Garth has a clear description of the procedure for
the management of diabetes at Garth and that this is kept in the prisoner’s
health record. The clinical reviewer recommends that there is also a clear
indication in the prisoner’s health record when advice has been obtained from a
nurse specialist.
HMP Garth should develop a clear description for procedures for
management of diabetes which should be kept in the prisoner’s medical
record.
In response to this recommendation Garth said they had, for some time, held a
clear policy for diabetes management. Diabetic records are maintained within
the clinical record and were in the man’s case. However, each prisoner also
has a patient held record as this reflects best practice within the wider
community.
When advice is obtained from a nurse specialist, the action should be
recorded in the prisoner’s medical record.
In response to this recommendation Garth said that when advice is obtained
from a nurse specialist the action should be recorded in the prisoner’s medical
record. Garth considers that this is currently practised as that advice is always
documented within the clinical records and was in the man’s case. The notes
were also clearly signed by the nurse specialist.
Appointments with the consultant
41. The family were also concerned about the difficulties the man encountered
when making appointments to see the Consultant in Diabetes and
11
Endocrinology, as there were no staff available to escort him. In response the
prison said that this paragraph could give the impression that the man had
responsibility for arranging his own hospital appointments. This was not the
case, although the man did write to the Consultant in Diabetes and
Endocrinology on a regular basis.
42. The Head of Healthcare said that there had been an occasional problem with
escorts for the man. On a couple of occasions, emergencies took precedence
and the man had also refused on more than one occasion to travel to hospital.
The Head of Healthcare drew attention to the fact that the man had signed his
own discharge on one of his hospital stays prior to his death.
43. When interviewed by the Ombudsman’s investigator, the Head of Healthcare
said that when the man was referred to a liver specialist part of his preparatory
treatment involved bowel preparation. There were delays caused to the man’s
treatment because he was concerned about being transported in a taxi as his
bowels could open quite easily. The man requested an ambulance, but after
the Ambulance Service refused to provide transport for a non-emergency case,
he relented and travelled by taxi. The Head of Healthcare was aware that a
couple of appointments were cancelled as the man was in hospital at that time.
44. The clinical reviewer recommends that Garth should have a clear policy and
procedures concerning appointments with hospital specialists. There needs to
be clarity about the role of prison staff at hospital appointments and an
indication of what conditions or circumstances constitute a priority for
attendance at a hospital appointment. She also seeks clarity about whether
prison transport, taxi, hospital transport or ambulance should have been
arranged. The clinical reviewer judges that a copy of the policy and procedures
should be placed in the prisoner’s record. There should also be confirmation of
the prisoner’s understanding of these arrangements.
HMP Garth should develop clear policy and procedures concerning
appointments with hospital specialists.
45. In relation to the delays in referring the man to a Consultant Physician and
Gastroenterologist, the clinical reviewer says that it was unclear who should
have initiated a referral. The clinical reviewer notes that the Consultant in
Diabetes and Endocrinology had identified that a ‘haematological’ (relating to
haematology, the branch of medical science which studies the morphology of
the blood and blood forming tissues) opinion was required and reported this to
the Medical Officer at Garth. The clinical reviewer recommends that Garth
consider a system for co-ordinating health care across different specialities,
hospitals and health organisations. The clinical reviewer believes this might be
assisted by a nurse within the prison healthcare service adopting a role, similar
to that of the mental health ‘care co-ordinator’, for prisoners with mental health
problems.
HMP Garth should consider a system for co-ordinating health care across
different health specialities and agencies.
12
46. The clinical reviewer recommends a review of how hospital specialists
communicate with prisoners and vice versa. This should include a review of
the role of the medical officer in initiating and following up referrals to hospital
specialists. The clinical reviewer says that consideration should be given to
whether correspondence is also copied to family members or the prisoner’s
legal representative. She also comments on the value of using ‘ordinary
language’ in correspondence from hospital specialists.
47. The clinical reviewer spoke to the Head of Healthcare about terminal care for
prisoners at Garth. The Head of Healthcare advised the clinical reviewer that
few deaths had occurred at the prison but as the average age of prisoners was
rising, this issue would be an increasing concern. The clinical reviewer
recommends that procedures for providing terminal care for prisoners are
identified where this is feasible and within the capabilities of healthcare staff.
HMP Garth should develop arrangement for providing terminal care at the
prison.
48. The family said that they wrote to the prison to ask if they could do more to help
and were told that Garth was doing everything possible for the man. However,
the family felt that initially Garth did not take the man’s condition seriously
enough.
49. The Head of Healthcare replied that she could not find any evidence that Garth
had failed the man. The man’s condition had been managed externally for a
long time and he had been referred for an operation but this had been delayed
by issues relating to the management of his diabetes. The Head of Healthcare
said that the man had been under the care of three consultants at the local
hospital, a diabetologist, a surgeon and a liver specialist. She said that Garth
did make enquiries about the progress of the man’s medical care. The Head of
Healthcare added that she spoke to the man’s sister on a couple of occasions
as well as writing to her about the care being provided to her brother. The
Head of Healthcare noted that, although the man had chronic health problems,
he wanted to continue working beyond retirement age. He stopped working
only a couple of months before he died.
50. I believe that Garth attempted to deal with issues relating to the man’s medical
care but this endeavour was hindered by poor communication between the
prison and external agencies. In her review, the clinical reviewer recommends
a system for co-ordinating healthcare across different health specialities. I
consider that a delay of over 15 months before the man’s liver problems were
reviewed was not acceptable. In response to the draft report, Garth reviewed
the medical records again and considers that the delays in the referral were
due to the consultant at the hospital. Garth said that whilst the letters received
from the consultant are seen by the doctors at the prison, the follow up action is
assumed to be coordinated at the hospital. On one occasion in May 2007,
when the man complained about the delay in referral this was followed up by
Garth. Therefore Garth considers that whilst there were delays in the man
receiving his treatment for his liver problems those were not solely due to local
systems.
13
51. The family are very complimentary about the support they received from Garth
towards the end of the man’s life and after he died. They visited the man when
he was in the healthcare wing and saw that he enjoyed being there. The family
made it clear that they did not hold the prison responsible for what happened to
the man and understood that there may have been factors outside Garth’s
control which affected his treatment and diagnosis. The family also said that
Garth was one of the best prisons they had encountered.
Role of the bedwatch officer
52. When interviewed by my investigator, the prison officer said that when he
arrived for duty on 2 December the man was still being attended to after
vomiting blood. The prison officer said that the Principal Officer stayed with
him for a while after his shift ended and then left. The prison officer recalled
that when he first saw the man, he appeared not to be aware of the situation or
his surroundings. At one stage, when the man’s sister left the room for a
moment, the man stretched out his arm, called the prison officer’s name and
asked for pain killers. The prison officer said that he found this very disturbing
as he then realised that the man was aware of his surroundings and what was
happening to him. This made the situation very personal for the prison officer
and made him feel hopeless about the assistance he could offer the man.
53. The prison officer said that he was upset at what he witnessed and about what
he was expected to do after the man passed away (still completing the
bedwatch logs, telephoning the prison and remaining with the body). He felt
that there should have been a second officer to share these tasks. The prison
officer said that he had two roles whilst in the hospital, he was there as a prison
officer and he was also there to support the man’s sister. The prison officer
also thought that he should have attended the hospital in plain clothes,
especially as the man‘s condition was terminal. I draw this matter to the
Governor’s attention.
54. The prison officer said that he had not received an immediate offer of support
from the prison although he was permitted to finish his shift early on the day
after the man’s death. The prison officer confirmed that support was offered by
the prison within 48 hours of the man’s death and that he had taken up the
offer.
55. My investigator raised the issue of support for the prison officer with the prison.
Garth replied that a Residential Governor came to the hospital after the man
passed away, to offer support to the prison officer. He stayed with the prison
officer until the man’s body was moved to the mortuary. The prison officer was
then allowed to leave the hospital.
56. I understand the decision making process behind the revision of the risk
assessment which reduced the escort to one officer. I can also understand the
reason why the Principal Officer felt it appropriate to leave the prison
officer alone when he (the Principal Officer) finished his shift. The Principal
Officer had witnessed a single episode where the man had vomited blood and
14
he stayed on to ensure that the prison officer was content with the situation.
The nature of the man's death was very difficult for both the prison officer and
the man’s sister to deal with.
57. I acknowledge that, although it was delayed, support was offered to the prison
officer and that he took up the offer and benefited from it. I was surprised that
the prison officer was scheduled to report for duty on the day following the
man's death. I acknowledge that the prison officer reported for duty earlier than
scheduled that day and that he was relieved from duty early once the impact of
the man’s death was appreciated. I recommend that Garth reviews its death in
custody/care team policy, in case this situation arises in the future, so that
whenever a death (natural or self-inflicted) occurs staff are offered support at
the earliest juncture.
I recommend that a review takes place of HMP Garth’s death in custody
and care team policies.
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CONCLUSION
58. The man moved to Garth in 1996 and, after being transferred to a local
hospital, he died of natural causes in December 2007.
59. In reviewing the bed watch log, it is clear that the staff involved with the man’s
care behaved with sensitivity. The decision to remove mechanical restraints,
following a risk assessment, was right and proper given the circumstances.
The security arrangements at the hospital seem to have been suitable, and
struck a good balance between public protection and sensitivity to the situation.
60. I would like to commend both the Principal Officer and the prison officer for the
support they gave to the man’s sister during her brother’s difficult last hours.
The man’s death was traumatic for all who witnessed it and I am sure that the
man’s sister appreciated the support she received from the officers during that
difficult time.
61. I recommend that Garth reviews its death in custody/care team policy, in case
this situation arises in the future, so that whenever a death (natural or self-
inflicted) occurs staff are offered support at the earliest juncture.
62. Whilst he was in custody the man developed serious medical needs which
required support to be provided by Garth. I consider that his medical care was
not entirely satisfactory and in some instances was not equivalent to the care
he would have received in the wider community. It is not possible to confirm
whether earlier treatment of the man’s liver problems could have led to a
different outcome. The delay in treating the man’s liver problems was
nevertheless not acceptable and action should have been promptly taken to
move this issue forward.
63. The findings of the clinical review and my own investigation highlight that
improvements to medical practices at Garth could be made. I have endorsed
the recommendations from the clinical review. These will need to be
addressed by the Central Lancashire Primary Care Trust in partnership with the
Governor of Garth.
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RECOMMENDATIONS
1. I recommend that a review takes place of HMP Garth’s death in custody and care
team policies.
Accepted - Garth’s death in custody and care team policies were reviewed in
April 2008. Care Team policies are now reviewed at quarterly meetings.
2. HMP Garth should develop clear policy and procedures concerning appointments
with hospital specialists.
Accepted - There is a process in place but this needs to be more clearly
developed and approved via the partnership board.
3. HMP Garth should consider a system for co-ordinating health care across
different health specialities.
Partially accepted - Improvements could be made locally to better co-ordinate the
primary care services at Garth. This will be made easier through the use of
System One; however there is no capacity to co-ordinate this within the hospital
trusts.
4. HMP Garth should develop a clear description for procedures for management of
diabetes which should be kept in the prisoner’s medical record.
Already in place - Garth has for at least six years, had a clear policy for diabetes
management which the clinical reviewer did not request. Diabetic records are
maintained within the clinical records and were in the man’s case, however each
prisoner also has a patient held diabetic record as this reflects best practice
within the wider community.
5. When advice is obtained from a nurse specialist, the action should be recorded in
the prisoner’s medical record.
Partially accepted - This is current practice at Garth. This is always documented
within the clinical records and was in the man’s case. The notes are clearly
signed by the nurse specialist.
6. HMP Garth should develop arrangement for providing terminal care at the prison.
Accepted - Garth does have a palliative care policy but this needs to be further
developed. Difficulties arise when attempting to provide comparative care for
prisoners with child/sexual offences as community services are often unwilling or
unable to offer residential care.
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