Individual at High Down

The death of a man, who was a prisoner at HM Prison Highdown,
on 31 October 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
July 2006
This is the report of an investigation into the death of a man who was a
prisoner at HM Prison Highdown. The man, who was aged 44, died on 31
October 2005 at the Royal Marsden Hospital. The cause of death was
recorded as a squamous cell carcinoma of the tongue. The man had been
diagnosed with terminal cancer in April 2004.
Unfortunately, the man was estranged from his family and none of his
relatives has been traced. Nevertheless, I take this opportunity to offer my
sincere condolences to all of the man’s friends and to all of those touched by
his loss.
The investigation was carried out on my behalf by one of my investigators. An
independent review of the man’s medical care in prison, for which I am most
grateful, was carried out by a panel on behalf of the East Elmbridge and Mid
Surrey Primary Care Trust. I would also like to thank the Governor and staff
of HM Prison Highdown for their full and ready co-operation during the
investigation.
As with many of my investigations following a death from natural causes, my
findings are strongly influenced by the clinical review. In the case of this man,
the reviewers from East Elmbridge and Mid Surrey PCT judge that the level of
care he received was far from satisfactory. It appears no package of health
and social care was put in place to meet the man’s needs. There was no
cancer care pathway or, indeed, much thought about how best to meet the
needs of a terminally ill patient. There are significant lessons here, therefore,
for the Governor and Healthcare Manager.
My report was sent in draft to the Governor of Highdown. I have received a
number of comments from the prison in response, and I have included these
in the text where appropriate.
This version of my report, published on my website, has been amended to
remove the name of the deceased and the names of staff and prisoners who
were involved in my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2006
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Contents
1. Summary
2. Investigation methodology
3. Background
4. HM Prison Highdown
5. Events prior to the man’s death
6. Consideration of issues arising from the investigation
7. Recommendations
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1. Summary
The man who died was initially remanded in custody to Highdown in
September 2003. He was convicted and sentenced to four years
imprisonment in the spring of the following year. At his first reception health
screening, the man reported that he had previously suffered from heart
problems and had had an operation for arthritis.
In January 2004, the man reported that he had bitten the left side of his
tongue. This ulcerated and he subsequently underwent a biopsy. The results
of this indicated a cancerous tumour of the tongue. The man underwent
surgery to remove the tumour on 15 June. This was a success and he did not
therefore require post-operative radiotherapy.
The man was reviewed regularly in the following months, and each time he
was given the all clear. However, he began to complain of discomfort in the
left side of his neck in June 2005 and, following a scan in late July, was
diagnosed with a further tumour. Subsequent analysis led to the conclusion
that removal by surgery was inadvisable on this occasion. The man was
subsequently informed that treatment would involve chemotherapy and
radiotherapy. He also started a course of Oramorph at this time to control the
significant pain that he was experiencing. (Despite the pain, the man declined
admission to the Healthcare Centre at Highdown on a number of occasions.)
His course of radiotherapy was due to commence on 21 September at the
Royal Marsden Hospital. However, the man did not feel comfortable wearing
the plastic mask necessary to cover and support the head during
radiotherapy, and he therefore refused the treatment. Nonetheless, he
continued to receive the palliative care provided at Highdown.
The man’s condition deteriorated further and he was admitted to the Royal
Marsden on 4 October as an inpatient. He was discharged on 11 October
and, on 17 October, was granted permission to keep Oramorph in his cell
overnight due to the extreme pain that he was suffering.
On 12 October, the Parole Board agreed to the man’s early release on
licence. However, suitable release accommodation could not be found due to
the nature of his offence and the difficulties this presented for insurance
purposes. Furthermore, by the time of the Parole Board’s decision, his
condition had deteriorated significantly and he was not well enough to live in
Approved Premises (a probation hostel).
The results of an x-ray on 28 October showed a growing lump, and the man
was again admitted to the Royal Marsden as an inpatient. His condition
deteriorated and he passed away on the morning of 31 October. The cause of
death was recorded as a squamous cell carcinoma of the tongue.
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The clinical review, conducted by the East Elmbridge and Mid Surrey Primary
Care Trust, is very critical of a number of aspects of the nursing care that the
man received at Highdown, and of the standard of medical record keeping.
I make six recommendations.
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2. Investigation methodology
The investigation was opened on 15 November 2005 when my investigator,
visited Highdown and issued notices announcing the investigation and its
terms of reference to staff and prisoners. The notices included an invitation to
those who wished to submit information relating to the man’s death to make
themselves known to my investigator. No prisoners came forward to speak to
my investigator.
On his initial visit to Highdown, my investigator met with the deputy governor
and was given a tour of the prison. He was therefore able to familiarise
himself with the Healthcare Centre and the wing on which the man had lived.
He was also given access to the man’s prison files, including the Medical
Record.
An independent clinical review into the man’s health needs whilst he was in
custody at Highdown was carried out by a panel on behalf of the East
Elmbridge and Mid Surrey Primary Care Trust.
One of my family liaison officers contacted one of the man’s friends, who was
his nominated next of kin, on 23 November 2005. His friend’s view was that
the prison had treated the man well. However, she added that the man had
been very worried about where he was going to live when he came out on
parole.
The report was sent to the man’s nominated next of kin and the Prison
Service in draft. Their comments have, where appropriate, been reflected in
the text.
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3. Background
The man was born in 1961, and was 44 years old at the time of his death. At
the time of his first reception into prison, the man was recorded as being
unemployed.
He was not a heavily convicted man. In 1980, he had been convicted of
causing grievous bodily harm and in 1983 he was convicted of theft. He
received non-custodial sentences for both offences. He was then clear of
trouble until September 2003 when he committed an offence, seemingly under
the influence of a combination of temazepam (a prescription drug used to treat
insomnia) and whisky. The man was remanded in custody to Highdown on 30
September 2003, before being convicted on 19 February 2004. He received a
sentence of four years imprisonment on 2 April 2004.
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4. HM Prison Highdown
Highdown prison, on the outskirts of Sutton in Surrey, first opened in
September 1992. It is a local prison holding both remand and convicted
prisoners. The prison consists of four houseblocks, with a mixture of single,
double and treble occupancy cells. The total capacity is 736.
Healthcare is provided by the East Elmbridge and Mid Surrey Primary Care
Trust. The Healthcare Centre, which is operated by both nurses and
healthcare officers, has an in-patient capacity of 23 beds in single cells.
The most recent report from HM Chief Inspector of Prisons, dated November
2004, reported a significant improvement in the provision of healthcare
services at Highdown. However, there was concern at the high number of
prisoners who failed to attend healthcare appointments.
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5. Events prior to the man’s death
When he was first remanded into custody on 30 September 2003, the man
reported at his first reception health screening that he had previously suffered
from heart problems and had had an operation for arthritis. He also said that
he was suffering from depression and that he had attempted to kill himself in
the past. A suicide and self-harm monitoring form (F2052SH) was raised.
As well as the opening of the F2052SH, the man was admitted to the
Healthcare Centre so that he could be monitored more closely. He
complained of thoughts of suicide and anxiety pre-dating his time in custody,
and said that being in prison had exacerbated the situation.
He was originally placed on a 15 minute watch. However, the man began to
come to terms with his situation and was taken off the watch on 5 October and
subsequently relocated to a houseblock on 14 October. At a case review on
23 October, the man reported that he had no thoughts of self-harm or suicide
and, when these sentiments were repeated at his next case review on 30
October, his F2052SH was closed.
In January 2004, the man reported that he had bitten the left side of his
tongue. There is no evidence that this was done deliberately. He sustained a
laceration which ulcerated, and was subsequently referred to a consultant oral
surgeon at a nearby hospital. The problem persisted and, on 29 April, the
consultant oral surgeon arranged for an urgent biopsy. The results, one week
later, indicated a diagnosis of a moderately differentiated squamous cell
carcinoma (a cancerous tumour of the tongue). The man was informed of the
diagnosis and the need to remove the tumour by surgery with the possibility of
follow-up radiotherapy.
Surgery was arranged for 15 June 2004 at a major London hospital. This
involved the removal of the tumour, along with a left neck dissection which
was reconstructed with a flap from the man’s right arm. The surgery was a
success, with the tumour fully removed, and the man did not therefore require
post-operative radiotherapy. However, in the weeks after surgery, the man
complained of pain and stiffness in his left shoulder, and was therefore started
on a course of physiotherapy.
The man was reviewed regularly in the following months, and each time he
was given the all clear with no sign of recurrence. In June 2005, he began to
complain of discomfort in his left neck and, following an examination at the
Head and Neck Clinic at the hospital on 30 June, it was confirmed that a firm
mass was present. He underwent a CT scan in late July and the result of this
and a fine-needle aspiration (an analysis of cells extracted using a needle)
confirmed a further squamous cell carcinoma on the left side of his neck.
Further analysis concluded that the site and size of the mass made removal
by surgery inadvisable, and the man was therefore informed that treatment
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would involve chemotherapy and radiotherapy. In the interim period, the man
started a course of Oramorph to control the significant pain he was
experiencing in his neck.
On 20 July, the man raised a formal complaint regarding the issuing of his
medication. His complaint was that he should be allowed co-codamol (he
mistakenly referred to this as co-codeine in his complaint form), a painkiller, in
his possession so that he could take it as required at 9am, 2pm and 8pm. In
response, the Head of Healthcare informed him that all codeine based
medication is supervised at Highdown. However, she recommended that he
spoke to the Houseblock Nurse to arrange a more suitable time for his
dosage.
On 23 August, the man was referred to a hospice near the prison, for
specialist palliative care by a prison GP at Highdown. The referral highlighted
pain control as a current problem. The man was visited on 26 August by a
member of the Community Palliative Care Team at the hospice. Adjustments
were made to the administration of his analgesia. It was also agreed that the
man could telephone the member of the Community Palliative Care Team on
a daily basis to discuss his treatment.
Despite the pain that the man was experiencing, he declined admission to the
Healthcare Centre at Highdown on a number of occasions in August and
September. He said that he preferred to remain on the houseblock so that he
could continue to attend education classes and because the Healthcare
Centre was too noisy and had no television.
On 19 September, the man collapsed whilst on the houseblock after suffering
a dizzy spell and was admitted to the Healthcare Centre as an inpatient.
Despite continuing to suffer severe pain, he maintained throughout his stay in
Healthcare that he did not want to be there and was, at times, aggressive and
abusive towards Healthcare staff. No further episodes of dizziness were
recorded and, after being seen by a doctor, the man was discharged and
returned to the houseblock on 20 September.
The man’s courses of radiotherapy and chemotherapy were scheduled to
commence on 21 September at the Royal Marsden Hospital, a specialist
cancer hospital. The planned schedule of treatment was daily radiotherapy
for six weeks, with chemotherapy in the first and fourth weeks. However, the
man did not feel comfortable wearing the plastic mask that covers and
supports the head during radiotherapy, saying that it made him feel
claustrophobic and panicky. Despite attempts to minimise the restrictions
imposed by cutting out parts of the mask, he continued to complain of
discomfort and refused to accept the treatment. However, he was willing to
continue receiving the palliative care provided at Highdown.
On 26 September, the prison GP contacted the hospice with regard to
admitting the man for a short stay for further palliative treatment. This was
agreed in principle by both the prison and the hospice. However, as he was
receiving frequent treatment at the Royal Marsden, it was later decided by the
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member of the Community Palliative Care Team and the prison GP that his
palliative care would not benefit from admission to a hospice.
The man continued to decline treatment and refused to attend hospital
appointments on 30 September and 3 October. It was arranged to admit him
to the Healthcare Centre as an inpatient on 30 September but, on arrival, he
was verbally abusive to staff and refused to stay. He subsequently left the
Healthcare Centre before his admission could be completed.
As well as the constant neck pain he was suffering, the man was now having
difficulty swallowing. Given the deterioration in his condition, he was admitted
to the Royal Marsden Hospital as an inpatient on 4 October. He was
discharged from the Royal Marsden on 11 October and returned to
houseblock 2 at Highdown. By 17 October, the man’s swallowing had
deteriorated considerably and he was now unable to eat normal meals, taking
nourishment drinks instead. On the same day, he complained that he felt pain
in the morning and requested permission to keep Oramorph in his cell for use
in the mornings. This request was granted.
On 12 October, the man was found suitable for early release on licence by the
Parole Board. The Board remarked on how he had shown remorse for his
offence. A Parole Clerk at Highdown, contacted a number of different
organisations to try to find suitable release accommodation for the man,
including the St Giles Trust, the local council, and the Salvation Army. She
said at interview that the major barrier to finding accommodation for the man
was the nature of his offence and the difficulty it presented for the insurance
cover of the premises that might take him. Moreover, by the time he was
granted parole, the man’s condition had deteriorated significantly and he was
not now well enough to take a place in hostel-type accommodation.
On 22 October, the duty nurse was called to the man’s cell at 4.45am as he
was reported to be coughing up blood. The man said at the time that he felt
generally fine, but was worried about the blood. He made no complaints
about being in pain. He was assessed by a doctor later that morning. The
doctor recorded that his appearance was normal. An appointment was made
for the man to have a chest x-ray on 24 October.
The resulting x-ray was seen at the Royal Marsden on 28 October when the
man attended for a scheduled appointment. An assessment of the x-ray
revealed a growing lump, and it was therefore decided to admit him for
immediate treatment. His condition deteriorated over the weekend and the
man passed away on the morning of 31 October. Death was pronounced at
8.45am.
The man’s friend and nominated next of kin was informed of his death over
the telephone by the Head of Residence at Highdown. The Head of
Residence did not recall the time at which he spoke to the man’s friend, but
said it was as soon as he could make contact with her. The man was
cremated on 11 November in a service conducted by the chaplain and
arranged by the chaplaincy.
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6. Consideration of issues arising from the investigation
Quality of care provided at Highdown
The clinical review, conducted by the East Elmbridge and Mid Surrey Primary
Care Trust, is very critical of the quality of nursing care that the man received
at Highdown. In particular, the review highlights a “distinct absence of nursing
intervention throughout the man’s recorded illness”. For instance, the review
notes that, when he complained of extreme pain and a lack of appropriate
pain control, no entries were made in his Medical Record by nursing staff and
care plans were not commenced. Indeed, the reviewers say they found “no
evidence of relevant care plans throughout his stay in prison”. Other
examples noted in the review include the non-recording of the man’s weekly
weights and nutritional status, and a lack of communication between
healthcare staff and hospitals. The review concludes that this has “led to a
complete breakdown in a care pathway that should have been evident for a
man with an initial and subsequent terminal illness”.
The review is critical of the man’s ‘equitable care’ (the extent to which a
prisoner’s medical treatment is the equal of that which would be expected in
the community), providing numerous examples where equity of care was not
achieved. It highlights that on 22 August 2005 Oramorph was suggested for
the man’s pain control. However, it notes that whilst there was an expectation
that nursing staff were able to titrate the dosage to gain maximum effect, “the
current staff do not have this competency”. On the same date, the review
notes that Gebapentin was commenced, yet some doses were missed “with a
detrimental effect on the man’s pain control” and “the nursing staff should
have ensured that there was a sufficient supply of the drug for this man”.
The review also criticises Highdown’s use of the Emergency Nurse
Practitioner (ENP) who was available on site. The ENP had the expertise to
deal with palliative care and to provide continuity of care, as well as to support
and educate both the man and the nursing staff. The review notes, however,
that she was under utilised as a resource.
Communication between healthcare staff at Highdown and hospitals pre and
post operatively is also found wanting in the clinical review. It identifies no
clear pathway for feedback to healthcare staff following outpatient attendance,
and no clear pathway for prisoners requiring palliative care intervention. The
review says that “inadequate communication between the prison healthcare
service and the hospitals had a potentially detrimental affect on the care this
gentleman received”.
The Healthcare Manager, in partnership with the Primary Care Trust and
local secondary care providers, should agree and implement information
sharing protocols to ensure appropriate and timely patient care with the
multi-disciplinary team and the external health and social care partners.
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A local care planning strategy, which includes pathways of care, care
planning, review and evaluation, must be developed and audited to
ensure effective communication within the multi-disciplinary team.
The Healthcare Manager in partnership with the PCT should develop a
locally agreed communication pathway to maximise the
prisoner/patient’s health and social care.
The Healthcare Manager should undertake a training needs analysis to
review the training needs of healthcare staff.
I have received the following comments in response to this criticism from
Highdown:
“A clinical review is solely based on the medical record. Regrettably nursing
and medical staff had omitted to record large sections of the man’s care so
there is little/no physical evidence but this does not mean that good care was
not provided. In fact nursing staff spent considerable time with the man to
ensure that his needs were addressed especially psychological aspects of his
care”.
“Letters of referral from HMP High Down to the secondary care sector always
happen. This is often combined with a telephone call in the case of
emergencies. It is rare however for local hospitals to provide discharge
summaries or feedback following attendance. Usually healthcare staff at the
prison telephone to speak to the appropriate clinician and we ask for a
fax…..There is no difficulty with sharing medical information on a ‘need to
know’ basis for continuity of care, but some individual clinicians within
Secondary Care just do not communicate”.
“A training needs analysis is undertaken every year since 2003, also a skill
mix review. However, funding is an issue. Training needs can be identified
but it can not always be delivered. Every opportunity is taken to deliver
training on site”.
Quality of record keeping at Highdown
As well as noting the absence of records of the man’s pain control, and of
care plans, the clinical review highlights numerous gaps in the clinical records
around the time of his surgery. There was also a lack of entries regarding
hospital appointments, admissions and their outcomes. The standard of
completion of the medicines charts was described as unacceptable.
Furthermore, the man’s weekly weights were not recorded as requested, nor
his nutritional status.
Staff should be reminded of their professional responsibilities to ensure
appropriate and effective record keeping in accordance with the
standards laid down by the General Medical Council and Nursing and
Midwifery Council. The Healthcare Manager should consider the
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introduction of mandatory training to ensure that staff comply with these
responsibilities.
A system of clinical audit must be developed to enable the monitoring
and compliance with agreed standards of record keeping. This should
form part of local clinical governance arrangements.
I have received the following comments in response from Highdown:
“Clinical audit is established. The Healthcare Commission carried out an audit
of medical records on October 2005. Follow up audits have been completed.
On a recent visit by HMCIP and the Healthcare Commission there were no
areas of concern raised regarding notes selected at random. Considerable
work has been done in the last nine months to raise the standards of record
keeping. Clinical audit is an agenda item on the Clinical Governance
committee, which is held every 2 months”.
Medication
It is of concern that appropriate arrangements are not in place to ensure the
administration of medication in accordance with clinical recommendations and
patient need. I appreciate that on occasions codeine-based medication can
be used as a currency by prisoners. However, to deny a terminally ill patient
access to appropriate pain relief is unacceptable.
In the later stages of his care, arrangements were made for the man to have
access to Oramorph overnight. This action is commendable. However, the
response to the man’s complaint in July 2005 was not acceptable, and
alternative arrangements should have been made to ensure that he did not
experience the pain he did.
I have received the following response from Highdown:
“In July the man was not terminally ill, he was vulnerable. The policy of
codeine based medication is not just about reducing the risk of prisoners
trading drugs, but also to protect vulnerable prisoners from having their
medication stolen from them. When the man needed to have Oramorph
throughout the night he was in a single cell. He received his individual dose
containers of Oramorph after other prisoners were locked up and he was
allowed out of his cell before other prisoners in the morning so that un-used
bottles could be returned to healthcare. This was for the safety of the man.”
The allocation of accommodation to the man outside of Highdown
During a telephone conversation with one of my Family Liaison Officers, the
man’s next of kin said that he was very worried about where he would live
after he came out on parole. In granting the man parole on 12 October 2005,
the Parole Board made a condition that he was to live in Approved Premises
(a probation hostel), unless it was necessary for him to go into hospital. The
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Board placed no further restrictions on his accommodation, other than that he
was not to enter a defined area of a large town.
In the weeks leading up to the man’s consideration by the Parole Board, a
Parole Clerk at Highdown contacted a number of organisations in an effort to
find suitable accommodation for him. However, as noted, there were
problems in finding such accommodation. The Parole Clerk therefore also
consulted a number of organisations who would not normally be contacted
over such matters, including the Salvation Army. Discussions were also held
with a nearby hospice, with a view to admitting the man as an inpatient for
symptom control. However, as he was receiving frequent treatment at the
Royal Marsden Hospital, this was not deemed to be required.
It is of concern that more effort to identify suitable accommodation was not
made by healthcare, either by supporting the Parole Clerk or making their own
enquiries. It is unclear why a decision was taken that the man was not
suitable for hospice care. However, other alternatives such as nursing homes
should have been considered.
I consider the time and effort that the Parole Clerk put into finding suitable
accommodation to be commendable, and draw attention to this as an example
of good practice.
Highdown has provided the following comments in response:
“The establishment has tried to arrange nursing home accommodation in the
past but this has to be done through the Continuing Care process. It is
actually quite difficult to arrange nursing home placement for prisoners. The
last time it took (the) healthcare manager 6 months. This was because
nursing home owners are worried about taking ex-prisoners into their home as
they might pose a risk to other residents.”
“The hospice would not be an option for long term accommodation. Beds are
limited and demand is high. If he was not under the care of the Royal
Marsden then the hospice would indeed have been an option for respite
and/or symptom control. This avenue was not followed, a decision made
jointly between medical and hospice staff.”
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7. Recommendations and Good Practice
Recommendations
The Healthcare Manager, in partnership with the Primary Care Trust and local
secondary care providers, should agree and implement information sharing
protocols to ensure appropriate and timely patient care with the multi-
disciplinary team and the external health and social care partners.
A local care planning strategy, which includes pathways of care, care
planning, review and evaluation, must be developed and audited to ensure
effective communication within the multi-disciplinary team.
The Healthcare Manager in partnership with the PCT should develop a locally
agreed communication pathway to maximise the prisoner/patient’s health and
social care.
The Healthcare Manager should undertake a training needs analysis to review
the training needs of healthcare staff.
Staff should be reminded of their professional responsibilities to ensure
appropriate and effective record keeping in accordance with the standards laid
down by the General Medical Council and Nursing and Midwifery Council.
The Healthcare manager should consider the introduction of mandatory
record keeping to ensure that staff comply with these responsibilities.
A system of clinical audit must be developed to enable the monitoring and
compliance with agreed standards of record keeping. This should form part of
local clinical governance arrangements.
Good Practice
The time and effort that the Parole Clerk put into finding suitable
accommodation for the man is commendable.
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