Individual at Garth

The circumstances surrounding the death of a male prisoner
In hospital on 26 December 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2005
This is the report of an investigation into the circumstances surrounding the
death of a male prisoner in hospital on 26 December, 2004. The prisoner was
68 years old. At the time of his death, he was serving a nine year sentence of
imprisonment at HMP Garth.
A post mortem examination concluded that the prisoner’s bladder cancer was
advanced and inoperable and that he died of natural causes.
The investigation was conducted on my behalf by my colleague.
I also commissioned an independent clinical review of the management of the
prisoner’s health needs while he was in prison. This was carried out by a
representative of the Chorley and South Ribble Primary Care Trust. A
subsidiary review of the manner in which the prisoner was cared for in
hospital was carried out by a representative of the Chief Executive of the
Lancashire Teaching Hospitals. I am grateful to both agencies for their
generous assistance.
My thanks also go to the Governor and staff at Garth for their help and
cooperation during the investigation.
This publicised version of the report does not include any of the original
annexes which were extensive.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2005
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Contents
1. Summary
2. Investigation methodology
3. HMP Garth
4. The deceased
5. Events prior to the prisoner’s death
6. Consideration of issues arising from the investigation
7. Recommendations
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1. Summary
On 26 October 2001, the prisoner entered Altcourse prison on remand,
accused of a serious drug-related offence. On that day, he underwent a first
reception health screen during which no significant medical issues were noted
other than that he was worried about having prostate problems.
On 11 January 2002, the prisoner was committed for trial at Warrington
Crown Court. On 4 March, he was convicted and sentenced to nine years
imprisonment. Following his conviction, while still at Altcourse, the prisoner
was designated security category B. On 26 March 2002, he was transferred
to HMP Garth.
While he was at Garth, the prisoner developed difficulties in swallowing and
had urinary tract infections. He was admitted to a hospital in August 2004.
Doctors investigated his condition, and on 13 August gave a possible
diagnosis of bladder cancer. The prisoner returned for a short time to Garth to
await surgery. On 25 August, he was readmitted to the same hospital for
further tests. These showed that his swallowing difficulties might have been
caused by the presence of a duodenal ulcer, which was subsequently treated.
Doctors became optimistic that the prisoner’s swallowing difficulties and
gastric problems would improve as a result of the medication prescribed for
his ulcer. They therefore discharged him again to Garth to await surgery on
his bladder.
On 31 August, the prisoner returned to hospital for his operation. He had lost
weight and had continued to experience swallowing difficulties.
On 1 September, he underwent an initial operation, during which doctors
discovered that a large malignant tumour had invaded the bladder. Biopsy
tissue of the tumour was taken for further investigation and tentative plans
were made for him to undergo further surgery.
On 9 September, a further test revealed a minimal opening of the sphincter
muscle at the base of the prisoner’s oesophagus. It was thought that this
might be related to an underlying neurological condition. The prisoner was
subsequently referred to a consultant neurologist at another hospital, where
he was admitted on 20 September. During the following two weeks, the
biopsy tests revealed that the cancer had invaded his pelvic muscles.
Extensive cardiac tests also showed that he had heart failure and a blood clot
on his lung.
Doctors decided that the bladder cancer was inoperable. Treatment options
were therefore discussed with the prisoner. With his agreement, a course of
radiotherapy was commenced on 27 October. The prisoner subsequently
contracted MRSA which was treated with antibiotics.
The results of the investigations into his swallowing problems led to a
diagnosis of two very rare conditions: polymyositis, the weakening of the
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muscles through inflammation, and dermatomyositis, the weakening of the
skin through inflammation.
The prisoner remained in hospital, but he continued to deteriorate. He died
on 26 December 2004. He was 68 years old.
The investigation found that the care given to the prisoner while he was at
Garth and when he was in hospital was appropriate.
I make one recommendation about medical record keeping.
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2. Investigation methodology
The investigation was conducted on my behalf by my colleague.
Notices were issued to staff and prisoners at Garth, inviting anyone who
wished to express concerns about the prisoner’s death to make themselves
known to my investigator. No prisoners or staff took up this invitation.
One of my family liaison officers contacted a close friend of the prisoner after
learning that he was concerned about the way in which the prisoner was
treated in hospital. These concerns were examined as part of the
independent clinical review that I commissioned into the management of the
prisoner’s health needs while he was in custody. The review was conducted
by a representative of the Chorley and South Ribble Primary Care Trust
(PCT). A separate review of the prisoner’s treatment in hospital was
conducted by a representative of the Chief Executive of the Lancashire
Teaching Hospitals.
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3. HMP Garth
Garth is a category B training prison situated near Preston in Lancashire. It
holds nearly 700 prisoners serving medium and long terms. Its
accommodation comprises five wings, a segregation unit and a healthcare
centre. The latter provides 24 hour medical cover and has inpatient facilities
for up to eight prisoners.
The establishment was last inspected by Her Majesty’s Chief Inspector of
Prisons in February 2004. The report of that inspection included five
recommendations about healthcare, none of which are relevant to this
investigation.
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4. The deceased
The prisoner was born in October 1936. He enjoyed a happy childhood within
a close and supportive family. It is understood that both the prisoner’s
parents are dead, but that he is survived by a sister.
The prisoner left school with no qualifications. He led a crime-free life until his
late thirties, when he was convicted of a motoring offence. In the mid-1990s,
at the age of 58, he was imprisoned for 30 months after being convicted of
possessing drugs with intent to supply. He was single when he entered
prison.
Prior to his arrest in October 2001, the prisoner had been living near
Southport. He was arrested on a serious drug-related charge for which he
was later sentenced to nine years imprisonment.
The prisoner told prison staff that he fully accepted responsibility for his crime
which, he said, was motivated by the prospect of financial gain to support his
ailing business. Staff at Garth regarded the prisoner as a level-headed man
who became a father figure to younger prisoners. He had gained the respect
of staff and prisoners alike.
The prisoner died of cancer at the age of 68.
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5. Events prior to the prisoner’s death
The prisoner was arrested on 25 October 2001 on suspicion of possessing
heroin with intent to supply. The next day, he was remanded in custody by
Warrington Magistrates and sent to Altcourse prison.
When he arrived at Altcourse, the prisoner underwent a first reception health
screen. No significant medical issues were noted other than that he was
worried about his prostate problems.
On 11 January 2002, the prisoner was committed for trial at Warrington
Crown Court. He was convicted and sentenced to nine years imprisonment
on 4 March. Following his conviction, the prisoner returned to Altcourse and
was designated security category B. Three weeks later, on 26 March 2002,
he was transferred to HMP Garth.
On arrival at Garth, the prisoner underwent a further reception health screen
during which it was again recorded that he was suffering from prostate
problems for which he was prescribed appropriate medication. He completed
an induction programme and was allocated to C wing where he attained
enhanced status within the local incentives and privileges scheme. During his
sentence, he incurred no adjudications for breaches of the Prison Rules. On
each occasion he was subject to mandatory drugs tests, a negative result was
obtained.
In August 2002, the prisoner was seen by a doctor after complaining of
difficulty in passing urine. This was attributed to his prostate problems.
Nothing of note was recorded for the period between August 2002 and
January 2004.
Between January and April 2004, the prisoner was seen by a doctor on six
occasions because of intermittent urinary tract problems. On 21 April 2004,
he was referred to an Urology department in an outside hospital.
The prisoner was seen on eight further occasions between 25 May and 4
August 2004. During that period he was also referred to the Gastro-
enterology department in a hospital.
On 4 August 2004, the prisoner was admitted to hospital after experiencing
symptoms of dysphagia (swallowing difficulties) during the preceding six
weeks. He told doctors that his food had been sticking half way down his
oesophagus, that he had lost weight, had suffered from a series of urinary
tract infections and had an enlarged prostate gland. The prisoner
commenced a series of clinical investigations, including blood tests, x-rays
and a bladder scan.
On 10 August, an ultrasound scan of his pelvis was carried out. This
identified changes in both the prisoner’s kidneys and irregular changes within
the bladder that were suggestive of a tumour.
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On 11 August, a member of the Urology team saw the prisoner and
gave a possible diagnosis of cancer of the bladder.
On 13 August, a cystoscopy examination (flexible camera scope
into the bladder) identified a widespread invasive tumour of the bladder. A
biopsy was taken and sent for histology examination. The prisoner was
to undergo an operation on his bladder two weeks later. It was agreed that he
was medically fit to return to Garth to await his operation.
On 18 August, the prisoner was discharged from hospital and returned to
Garth to await surgery. He was kept in the healthcare centre.
On 25 August, he was re-admitted to hospital to undergo a gastroscopy
(flexible camera scope which examines the oesophagus, stomach and
duodenum) under sedation. Blood tests showed that the prisoner was
anaemic. An intravenous drip was commenced and, over the following 24
hours, a blood transfusion of two units of blood was administered.
On 26 August, the prisoner was taken to the Endoscopy unit to undergo his
examination. It showed that there was some oedema (swelling of the
oesophagus) as well as a duodenal ulcer. The doctor explained to him that
the ulcer was possibly the cause of his swallowing difficulties and his loss of
appetite. Arrangements were made to carry out further assessments of the
prisoner’s swallowing capacity on the following day, and medication was
prescribed for his ulcer.
On 27 August, a Speech and Language Therapist carried out an assessment
of the prisoner’s swallow. It was noted that he was able to swallow bread and
soft diet. He was therefore to continue with this in the short term, and a
further assessment was to be carried out later in the day. The therapist
returned to see him in the afternoon. It was agreed that he would continue
with a soft and pureed diet with syrupy fluids. The doctors were optimistic that
the prisoner’s swallowing and gastric problems would improve as a result of
the medication he had been prescribed for his ulcer. He was therefore to be
discharged to await his planned bladder operation.
On 28 August, the prisoner returned to the healthcare centre at Garth. He
was re-admitted to hospital on 31 August to undergo the operation on his
bladder. The prisoner continued to lose weight and to experience swallowing
difficulties. The therapist therefore decided that he should undergo a video
fluoroscopy (a swallow study jointly carried out by a radiologist and a speech
and language therapist, using a dye to highlight the gullet) in order to try to
locate any obstruction that might be the source of his distressing symptoms.
On 1 September, before this investigation could be completed, it was
necessary for the prisoner to undergo his operation. He was therefore taken
to theatre. During the surgery it was confirmed that a malignant tumour had
invaded the bladder.
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On 9 September, the planned video fluoroscopy was performed. It
demonstrated a minimal opening of the sphincter muscle at the base of
the oesophagus. It was suspected that this problem might be related to an
underlying neurological condition. The doctor advised that the prisoner
should be fed via a naso-gastric tube until he was strong enough to face
further surgery. The prisoner was subsequently referred to a neurologist
and underwent further tests, including x-rays, blood tests, and CT scans.
On 17 September, a decision was made by the neurologist to transfer
the prisoner to another hospital where further neurological tests could be
carried out. He was transferred on 20 September.
Over the following two weeks, the results of the prisoner’s biopsy
investigations revealed that his cancer had invaded the main muscles of his
pelvis. He was given further blood transfusions and he continued to be fed
via a tube to maintain his nutrition. Extensive cardiac tests revealed that the
prisoner also had extreme impairment of his heart, resulting in heart failure
and a blood clot on his lung. It was difficult for doctors to prescribe anti-
clotting therapy for these conditions in view of the bleeding that was occurring
in his bladder caused by the cancer. The doctors discussed with the prisoner
the treatment options, after explaining that the bladder cancer was inoperable.
On 27 October, a one week course of radiotherapy treatment was
commenced with the prisoner’s agreement. During this period it was
discovered that he had contracted MRSA. This was treated with antibiotics.
The prisoner asked doctors to explain to him the results of the numerous tests
he had undergone. He told them that he did not wish to be resuscitated in the
event of a cardiac arrest.
On 24 December, staff at Garth were informed that the prisoner had only a
short time to live.
On 25 December, the prisoner’s close friend and business partner was
informed of his prognosis by staff at Garth.
The prisoner died in hospital shortly after 10am on 26 December.
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6. Consideration of issues arising from the investigation
Concerns expressed by the prisoner’s friend
The prisoner’s close friend and business partner expressed the following
concerns about his medical treatment:
• He felt that the prisoner should have been kept in hospital rather than
being discharged to Garth;
• He thought that when the prisoner complained that he could not swallow
he was told that he could;
• He thought that the prisoner’s inability to swallow was due to a problem in
his lungs and that this should have been identified sooner;
• The prisoner had growths on his hands and face for some time. The
prisoner’s friend thought that he did not receive rapid attention and
investigation for them;
• He felt that a bed in the hospital should have been
found for the prisoner earlier so that his treatment there could have been
started more promptly.
These issues were examined by a representative of the Chief Executive of the
Lancashire Teaching Hospitals who comments as follows:
• Discharge from hospital to Garth
When the prisoner was discharged from hospital on 28 August, his initial tests
had been completed. The prisoner did not require specialist medical input
and was managing to take small amounts of soft diet. He was awaiting further
investigations and surgical intervention and it was felt that his condition was
good enough for him to leave the hospital for the short period of time between
18 and 25 August.
• The prisoner’s inability to swallow
Several investigations were carried out in an attempt to identify the cause of
the prisoner’s swallowing difficulties. Initially, these were thought to be related
to his duodenal ulcer. However it was finally identified as being caused by
two rare conditions: polymyositis and dermatomyositis.
• Growths on the prisoner’s hands
In view of the seriousness of the prisoner’s other conditions, the growths on
his hands were not ignored but rather monitored and found to be related to his
condition of dermatomyositis.
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• Hospital beds
The Consultant Neurologist works at both hospitals. Therefore there was no
delay in the initiation of the prisoner’s neurological interventions. The doctors
were addressing his condition of bladder cancer and feeding difficulties
caused by his swallowing problems. As soon as a bed was available, the
prisoner was transferred.
The consultant concludes his report as follows:
“I can appreciate why the prisoner’s friend has been so upset by the
death of his friend whose complex conditions caused him to be so ill for
so long. However, there is no evidence to support any suggestion that
the medical and nursing staff did anything other than provide the
appropriate treatment and care to the best of their ability.”
Management of the prisoner’s health needs at Garth
In her clinical review of the management of the prisoner’s health needs while
he was at Garth, the author comments that the care he received from
healthcare staff was quite appropriate. She says that the prisoner’s situation
was complicated by the fact that he developed two serious illnesses. His
urinary symptoms were related to the development of bladder cancer but his
lethargy, weight loss and difficulty in swallowing were due to the onset of two
very rare conditions: polymyositis and dermatomyositis. The author
comments that at this point the healthcare staff at Garth were quite correct in
arranging for the prisoner’s urgent admission to hospital.
Finally, the author draws attention to her discovery of some illegible entries in
the prisoner’s medical record.
I conclude that the management of the prisoner’s health needs while he was
at Garth was professional and correct.
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9. Recommendations
Based on the clinical review, I make the following recommendation.
Documentation/Standards of Record Keeping
The Governor, in conjunction with his Local Primary Care Trust, should draw this
report to the attention of healthcare staff to remind them of the importance of
ensuring that all entries made in prisoners’ medical records bear the clear signature
of the author.
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