Individual at Holme House

Investigation into the circumstances surrounding the death of
a man at HMP Holme House on 23 July 2005
Report by the Prisons and Probation Ombudsman for England and
Wales
December 2005
This is the report of an investigation into the death of a man who, having
suffered from lung cancer, died in the healthcare centre at HMP Holme House
on 23 July 2005.
My office investigates the deaths of all prisoners in custody, including those
due to natural causes. In this case the investigation was carried out by one of
my investigators. A member of North Tees Primary Care Trust (PCT) carried
out a clinical review of the man's treatment while he was at Holme House. His
assistance is much appreciated.
During his time at Holme House, the man was well cared for. Staff in the
healthcare centre liaised with other healthcare agencies to ensure he received
good and timely treatment. Other staff in the prison cared for him by making
concerted efforts to grant the requests he made in the final stages of his life.
I offer my sincere condolences to the man’s wife and all members of his family
for their loss. I know that the staff and prisoners at Holme House who knew
him share these sentiments.
I am grateful to the Governor of Holme House, and to his staff for their
assistance during the investigation. This is a report that reflects very well both
on Holme House and the Prison Service as a whole. I make one
recommendation in recognition of that fact.
Stephen Shaw CBE
Prisons and Probation Ombudsman December 2005
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Contents
Summary 4
The investigation process 5
Background 6
The man who died
HMP Holme House
Key findings 8
Issues considered during the investigation 11
Recommendations and good practice 12
Annexes:
1. Clinical review
2. The man's request not to be resuscitated
3. Psychiatric report assessing the man's ability to give informed consent
4. The man's thank you note to healthcare staff
5. The man’s widow’s thank you cards to healthcare staff
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Summary
1. The man who died was admitted to hospital on 14 June 2005, suffering
from lung cancer and secondary brain cancer. Doctors told him that
the cancer was incurable and that he had only a few weeks to live. On
30 June, he was remanded in custody to HMP Holme House, Stockton
on Tees, charged with making threats to kill and possession of
firearms.
2. Because of his poor health, he was admitted directly to the healthcare
centre, where staff did all they could to make him comfortable. They
liaised with hospital staff and the MacMillan nurse to ensure that he
received timely and appropriate care.
3. The man informed staff at Holme House that he did not wish to be
resuscitated. This decision was fully documented and reviewed with
him on several occasions thereafter. He was referred to a psychiatrist
who determined that the man had the mental capacity to make this
decision.
4. On 19 July, the man asked for permission for his wife to visit him and
for them to have a service of blessing of their marriage. Governors, the
chaplaincy team and healthcare staff agreed to the request and made
arrangements for the weekend of 23 and 24 July. On Saturday 23 July,
the man’s wife visited him in the healthcare centre, as by then he was
too frail to go to the visitors centre. Because of his failing health, staff
made the necessary arrangements to bring the ceremony forward by
24 hours. After a short while, the man asked to be left alone to rest
before the ceremony. Almost immediately after his wife left the room,
the man passed away and, in line with his wishes, staff did not try to
resuscitate him. His wife sat with him for a while before spending some
time in the chapel.
5. The man received a high level of medical care at Holme House. Staff
were also sensitive and respectful in the arrangements for the meeting
between him and his wife and the planned blessing.
6. The clinical review highlights two actions as examples of good practice.
I fully endorse these and commend other aspects of the care and
humanity the man received at Holme House.
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The investigation process
7. My investigator opened the investigation by letter and then visited the
prison on 8 August. She met the Deputy Governor, a member of the
Independent Monitoring Board, the chairman of the local branch of the
Prison Officers' Association and one of the chaplains. She was shown
around the healthcare centre by a staff nurse. My investigator saw the
room where the man died and received copies of the man's prison and
medical records. The following day, she spoke by telephone to the
head of healthcare, and the other chaplain.
8. One of my Family Liaison Officers contacted the man’s widow to ask if
she had any issues to raise about her husband's time in Holme House.
She replied that she wanted the staff to receive credit for the excellent
care they gave her husband.
9. A clinical review of the care the man received was carried out by North
Tees PCT and the report is at Annex 1.
10. My investigator asked the Teeside Coroner for a copy of the post
mortem report but, at the time of writing, one was not available.
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Background
The man
11. The man was born in1955 and was 50 years old when he died of
cancer only three weeks after his arrival at Holme House.
12. On 14 June 2005, the man had been admitted to hospital where he
was diagnosed with Lung Cancer with Brain (Cerebral) Metastases.
He was informed by doctors that the cancer in his lungs and secondary
tumours in his brain were incurable and that he had only a few weeks
to live.
13. He was arrested on 29 June 2005 and charged with making threats to
kill and possession of firearms. The following day, he was remanded in
custody and sent to Holme House. When he arrived at the prison, he
informed reception staff that he had cancer, and that the doctors had
told him he only had a few weeks to live.
14. The man spent all his time at Holme House in the healthcare centre,
where staff did all they could to make him comfortable. He had been in
prison several times before and told staff that he wanted to have as
normal a routine as possible. He participated in exercise periods and
association as fully as his health allowed. Although he could not take
part, he enjoyed watching other prisoners play football. He was too ill
to work, but he helped staff as he was able - for example, he often
made up the tea packs for other prisoners. He was popular with the
staff and prisoners and was described as an easy man to talk to. He
loved fishing and spoke about how much he missed being able to go
out on his boat.
15. The man appeared to have come to terms with his approaching death.
In conversations with one of the prison’s chaplaincy team he spoke
about dying in an open, unafraid way, as something to face straight on.
He had a positive attitude and had planned his own funeral. A member
of staff spoke of him to my investigator as "A brave man who handled
his illness with dignity."
HMP Holme House
16. Holme House is a purpose built local Category B prison, which opened
in May 1992. It houses unconvicted and convicted male adult
prisoners and unconvicted male young adults. Prisoners are
accommodated in six self-contained living units with integral sanitation,
in a mixture of single and double cells. On 22 April 2005, the
operational capacity was 994. The prison primarily serves the
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communities of Tees Valley, South West Durham, East Durham and
North Yorkshire.
17. Holme House offers a variety of employment opportunities within its
modern workshop complex. These are complemented and supported
by a purpose-built Education Department offering both part and full
time classes.
18. The Prison Enterprise workshops consist of nine individual
work/training areas and offer up to 182 full time prisoner places based
on a five-day week.
19. A first night centre has been established. This is a safer custody
initiative that provides support to prisoners when they first arrive at
Holme House. A Listener scheme operates on a 24-hour basis and is
fully integrated into prison arrangements for those in need of support.
(The scheme, which operates in almost all prisons, is a prisoner peer
group support system, with each Listener receiving training from the
Samaritans.)
20. The healthcare centre has 28 in-patient beds, approximately half of
which are occupied by prisoners undergoing detoxification. They are
kept under medical observation for the first three to five days of
treatment, before moving on to the drug detoxification unit. The head
of healthcare had considerable experience as a palliative care nurse
before joining the Prison Service.
21. The healthcare centre has a Crisis Suite that consists of two rooms at
the end of the ground floor corridor. In one room there are two hospital
beds and lockers; the other is a very relaxing and comfortable sitting
room. It is furnished with a three piece suite, coffee table and
television and there is a rug on the floor. It is quiet and private.
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Key findings
22. The man arrived at Holme House on the afternoon of 30 June. He told
the nurse on duty in reception that he had cancer and listed his
medication. He said that he had last had chemotherapy three weeks
earlier. He also said that he had a hospital appointment the following
day. Because of his medical condition, he went straight to the
healthcare centre and did not spend any time on the wings. Healthcare
staff immediately began a care plan/pathway document for him and set
out an initial plan of action that included liaising with external agencies.
At 10:30pm, the prison doctor gave verbal instructions about the man's
medication for that night.
23. The next day, staff contacted the chemotherapy unit at the hospital to
discuss the man's appointments. He did not have an appointment that
day, but did have appointments scheduled for 8 and 15 July and
needed to have his blood checked before each. The staff at Holme
House said that they would check his blood in the healthcare centre.
The appointment on 8 July was for a chest x-ray and to see the
consultant. On 15 July, he was to attend for chemotherapy.
24. Late in the evening of 3 July, The man told a member of staff that he
felt that he did not have long to live and he hoped the end would be
quick. He also handed over a note that said he did not want to be
resuscitated. The following day staff rearranged his hospital
appointments so that he only had to attend hospital on one day, as he
was due to appear in court on 8 July. On the same day, they referred
him to a psychiatrist to assess his ability to give informed consent
regarding his instruction not to be resuscitated. The man saw a
consultant psychiatrist on 6 July. The psychiatrist concluded that the
man was fully aware of his situation and had the mental capacity to
decide that he did not wish to be resuscitated.
25. The man attended Durham Crown Court on 8 July. He had hoped to
be given bail, but was again remanded in custody and he returned to
the healthcare centre at Holme House that afternoon.
26. On 11 July, the hospital consultant wrote to the prison doctor to say
that the man did not need to attend the chemotherapy session because
he would not gain any benefit from further sessions. The man was
informed of this.
27. Two days later, healthcare staff spoke to the MacMillan nurse
responsible for the man’s care and he gave advice about medication
pain control. (MacMillan nurses give physical and emotional support to
people with cancer.) The nurse visited the man twice and told staff that
they could contact him for advice at any time. On 14 July, staff spoke
to the man about his living will and he again said that he did not want to
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be resuscitated. When asked about hospital care, the man stated that
he was "getting excellent care here and would like to stay".
28. On 19 July, The man wrote to the head of healthcare after she had
raised the question of whether they should try to get him transferred to
a hospital or hospice. The man made it clear that he did not want to go
to either and that he was content to stay in healthcare at Holme House.
He took the opportunity to thank the healthcare staff for their kindness
and care. His letter is at Annex 4. The following day, the man again
wrote reiterating his wish not to be resuscitated. He added a request
that his wife, who did not live in England, be allowed to visit him on the
following Saturday and Sunday. At about this time, the man made an
undated application to have his marriage blessed on Sunday 24 July.
This was agreed on 21 July and a governor and one of the chaplains
began to organise the ceremony.
29. Meanwhile, the man's health was failing. Thus, on 20 July, healthcare
staff drew up an additional care plan: ‘the integrated pathway for the
dying patient’. A section of the pathway dealt with the man’s decision
not to be resuscitated and it was stipulated that this was to be reviewed
not less than every two days. Boxes were ticked to show that the
decision would be reviewed in consultation with the patient, medical
staff and nursing staff. That afternoon, the MacMillan nurse visited the
man and spoke to him and the head of healthcare about how to keep
him free of pain. The following afternoon, the man became breathless
and the doctor prescribed the use of an inhaler. The air-flow bed that
staff had ordered for the man arrived, and he was shown how to use it
and how to alter the pressure to make himself comfortable.
30. Arrangements for his wife’s visit and the marriage blessing continued.
The original plan for the couple to meet in the visitors centre was
changed due to the man's worsening health. It was agreed that they
would use the crisis suite in the healthcare centre where staff would
supervise the visit. The blessing was due to take place in the video link
room on Sunday afternoon.
31. On the morning of Saturday 23 July, the man again had difficulty
breathing. The physiotherapist saw him and recommended that he
should drink plenty of fluids, keep mobile and do breathing exercises.
One of the chaplains spoke to the man and noticed how much weaker
he had become. He told my investigator that the man spoke highly of
his wife and said how important the blessing was to him. At 1:20pm,
the prison doctor prescribed oxygen therapy for the man.
32. The man’s wife arrived with a friend and they were accompanied into
the crisis suite by a member of the healthcare staff. Because of the
man’s rapidly failing health, it was decided to bring forward the blessing
from Sunday to that afternoon. The head of healthcare volunteered to
remain on duty after her shift ended to ensure that the ceremony would
not be rushed. After about 15 minutes, the man brought the visit to a
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close, saying he was not feeling well and wanted to rest before the
ceremony. His wife said she would return to the prison later and left
the room around 2:30pm. She remained outside in the corridor talking
to the head of healthcare while two nurses helped the man. However,
almost immediately and while the man was still in the crisis suite, he
passed away. In accordance with his wishes, staff did not attempt to
resuscitate him.
33. The man’s wife, accompanied by her friend, sat with him until the
doctor arrived. When she left, she spoke to the chaplain who was in
the prison for the blessing. He offered her the use of the chapel and
she spent some time there. The duty doctor then confirmed that the
man had died.
34. The man’s widow returned to Holme House the following day to collect
the man's possessions and she spoke to the Governor at that time.
She later sent a card to the healthcare staff, thanking them for the
kindness and care they gave to her husband. In a separate card to the
head of healthcare, she thanked her for the respect with which she had
treated him.
35. The prisoners in the healthcare centre, especially the cleaners who had
got to know the man quite well, asked for prayers to be said for him.
One of the chaplains held a service for them in the association room in
the healthcare centre.
36. No one from the prison attended the man’s funeral as this was held a
considerable distance away. However, the prison gave his widow
contact numbers for her to call if she needed help with anything.
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Issues considered during the investigation
37. The man received an exceptionally high standard of care from the staff
at Holme House. The head of healthcare and her staff, along with the
doctors ensured that the man received appropriate and timely care.
They also liaised with outside healthcare professionals to provide
continuity of care. They provided the man with a specialised bed to
make him more comfortable. The staff made sure that he understood
the ramifications of his wish not to be resuscitated and that he was able
to give informed consent about this. They respected his wish and did
not try to resuscitate him when he died.
38. Healthcare staff worked with other staff in Holme House to make his
wife’s visit as comfortable as possible. They also organised a blessing
of their marriage and were rearranging it when, sadly, the man died.
After the man’s death, their sensitive treatment of his widow continued.
I regard their actions as in the very highest traditions of public service
and worthy of recognition from the very top of the Prison Service.
The Governor and the head of healthcare are to be commended for
their actions and those of their staff in respect of the man and his
wife, and more generally for the culture of respect and decency that
those actions represented.
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Recommendations
The Governor and the head of healthcare are to be commended for
their actions and those of their staff in respect of the man and his
wife, and more generally for the culture of respect and decency that
those actions represented.
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