Individual at Hull

Circumstances surrounding the death of
A man at HMP & YOI Hull
in July 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2009
This is a report of an investigation into the death of a man at HMP Hull on 11 July
2008. The man was 76 years old and had been terminally ill for some time.
The man was diagnosed with lung cancer in August 2007 and had been receiving
palliative care within the healthcare wing at Hull. His condition slowly deteriorated
and, in July 2008, the healthcare team initiated end of life care. The man had also
confirmed that he did not wish to be resuscitated in the event of becoming
unconscious. On the evening of 11 July, it was discovered that the man had died.
I would like to offer my condolences to the man’s family and to the nursing staff at
Hull who had cared for him in his final days and who I know were saddened by his
death.
My colleague conducted the investigation on behalf of the Ombudsman. I also
asked Hull Teaching Primary Care Trust to conduct a clinical review into the
standard of healthcare the man received. The Clinical Governance Manager carried
this out and her report is attached as an annex.
I would like to thank the Governor of Hull and his staff for their co-operation and
assistance with the investigation. I would particularly like to thank the Head of Safer
Custody at Hull for making all the practical arrangements for my investigator.
I make two recommendations relating to access to dying prisoners and
improvements to accommodation. However, I also comment on the constructive
steps that have been taken at Hull following the recommendations in previous
reports and the positive effect that these had on the man’s care.
Jane Webb
Deputy Prisons and Probation Ombudsman January 2009
2
CONTENTS
Summary 4
The investigation process 5
HMP & YOI Hull 6
Key findings 7
Issues 16
Recommendations 20
3
SUMMARY
The man was sentenced to 12 years imprisonment in 2003. He was 71 years old on
his reception into custody and medical staff did not consider him to be in the best of
health. He had a number of ongoing chronic illnesses that were managed with
medication and had suffered a heart attack in 1997. The man was also reportedly a
smoker and told medical staff that he smoked around 40 cigarettes a day. Despite
his chronic illnesses and continued smoking, the man had little contact with
healthcare during the early part of his sentence.
Following an unsuccessful appeal against his sentence, the man transferred to HMP
Hull in December 2005. At Hull, the man initially had limited contact with healthcare.
In December 2006, he attended the healthcare centre for a routine pneumonia
vaccination. At that clinic, he told the nurse that his ankles were swollen and,
following an examination, she referred him to the doctor and chiropodist.
When a doctor assessed the man on 25 January, he recorded that his legs remained
swollen and he was also “wheezy”. He therefore prescribed medication to be taken
via a nebuliser (a machine that creates a mist of medicine to be breathed in by the
patient through a mask or mouthpiece). Following this, both the doctor and nursing
staff reviewed the man regularly. However, his symptoms persisted and he began to
lose weight. The man was referred to the local hospital for tests to ascertain the
reason for his continued poor health. Over the next three months, these tests
continued in order to rule out stomach or bowel cancer.
The man found it increasingly difficult to cope with life on the residential unit and this
led to him being admitted as an inpatient in the healthcare wing in June 2007. The
investigations into his health problems continued and in July, a computed
tomography (CT) scan (a cross-sectional x-ray of internal organs), which followed an
earlier chest x-ray, confirmed he had a lung tumour.
Over the following months, the healthcare team put in place care plans setting out
how the man’s care would be managed and he attended outside hospital for
palliative radiotherapy. As a terminally ill prisoner, the man was eligible to apply for
compassionate release and, in February 2008, he expressed his wish for the
necessary application to be submitted. However, given the level of risk of him re
offending the application was not supported. A governor explained the reasons to
the man, and although disappointed, he accepted the decision. The man told
nursing staff that if he was unable to leave prison he wished to die within the
healthcare centre with people he knew and these wishes were respected.
As his condition deteriorated, the man was moved to the palliative care suite within
the healthcare centre as it provided a quieter atmosphere. Macmillan nurses and
prison nursing staff continued to care for him and manage his pain relief to ensure
that he was comfortable. On the evening of 11 July 2008 the man died.
It is clear that Hull has made significant progress in its healthcare provision since my
previous report. However, I make two recommendations relating to access to
patients at night and the standard of accommodation provided in the care suite.
4
THE INVESTIGATION PROCESS
1. My investigator opened the investigation on 17 July 2008 on behalf of the
Ombudsman. Hull issued notices to staff and prisoners informing them of the
investigation process and inviting anyone who had relevant information to come
forward. No responses were received.
2. My investigator visited the prison on 3 October. He met the Chaplain and a
member of the Independent Monitoring Board (IMB). He also visited the
healthcare centre where he spoke with a member of staff who had been
instrumental in caring for the man during the last year of his life.
3. One of the Ombudsman’s Family Liaison Officers (FLOs), contacted the man’s
son on 1 August and explained the investigation process. The family did not
raise any concerns about the man’s care whilst in custody. They were very
grateful to the prison for the way that they had been supported since the man’s
death.
4. HM Coroner was informed of the investigation and a request was made for the
investigator to be provided with any post mortem or toxicology reports when
available. A copy of this report will be forwarded to the coroner to assist the
inquest process.
5
HMP & YOI HULL
5. HMP Hull opened in 1870 and has had various roles. It is currently a category
B local prison holding both adult males and young offenders. Hull serves the
courts in East and North Yorkshire and North Lincolnshire. The prison has
eight residential units. There has been extensive work in recent years, which
has provided new wings and a new healthcare centre. The certified normal
accommodation (CNA) is 723, but the maximum number of prisoners that Hull
can hold is 1,044.
6. Hull Teaching Primary Care Trust has responsibility for the provision of
healthcare services in the prison. In addition, a General Practitioner (GP)
service is provided by a local GP practice. The healthcare centre has 18 beds
and provides 24 hour nursing care.
7. HM Chief Inspector of Prisons, Ms Anne Owers, carried out a follow up
inspection of Hull in November 2005. At the time, Ms Owers found that in
general “the healthcare centre provided a good service”. Since the last
inspection, there have been considerable changes, including a new Governor in
the last 18 months. The positive changes and improvements at the prison
culminated in August 2008 with the prison achieving level four status on the
Prison Service performance scale. This signifies that the prison is performing
to an exceptionally high standard.
8. While visiting the prison the investigator talked to representatives from both the
chaplaincy and the local IMB. The investigator was told that neither department
had any concerns with the procedures or processes in place at Hull. The
chaplain, who has been at Hull for over five years, said that he had seen very
positive changes and that these had been beneficial for both staff and
prisoners.
9. The Ombudsman’s office took over responsibility for investigating all prison
deaths in England and Wales in 2004. Since then there have been nine deaths
through natural causes at HMP Hull.
6
KEY FINDINGS
10. The man was sentenced to 12 years imprisonment in 2003 and taken to HMP
Manchester. On reception into prison, he was assessed by a nurse who
recorded that he was taking medication for angina and emphysema. The
healthcare department assessed him on three occasions over the next seven
months, mainly to give advice on using inhalers to aid his breathing. There
were no significant health issues during this time.
11. During his time at Manchester, the man tended to mix with a select group of
people, but was considered by staff to be polite and respectful. He was
encouraged to become involved in offending behaviour groups as part of his
sentence plan, but was adamant that he would not. Staff tried on several
occasions to persuade him, but he continually refused.
12. On 19 July 2004, the man was transferred to HMP Wakefield. On his arrival, a
nurse conducted a health screen. The entry in his medical record reads “does
not enjoy good health”. During the screen, the nurse established that he had
suffered a myocardial infarction (heart attack) in 1997, after which he had
suffered from asthma and emphysema. He also had a history of chronic
obstructive pulmonary disease (COPD), ischaemic heart disease (IHD) and
congestive cardiac failure (CCF). The man also said that he smoked 40
cigarettes a day and had done so for the past 40 years. Following the
screening, he was allocated to a wing.
13. The man decided to appeal against the length of his sentence and, later in July,
the Criminal Appeal Office requested a psychiatric report. Although he could
not understand why they wanted the report, the man was happy to assist. Over
the next 18 months, the man had little contact with healthcare other than for his
medication to be reviewed. He continued to receive favourable reports from
staff on the wing.
14. On 20 December 2005, the man transferred to HMP Hull. The reason for the
transfer was to enable him to access offending behaviour programmes on offer
at that prison as he was still being encouraged to undertake relevant courses.
On arrival, a member of the health care team assessed the man and recorded
his medical problems. The man was located onto a residential unit and settled
in well. Staff regularly recorded in his wing history that he was polite and
respectful, and gave no cause for concern.
15. As at Wakefield, the man initially had little contact with the healthcare team
except to request repeat prescriptions. He did however attend healthcare in
November 2006 to be given a flu vaccination, at his own request. He was also
offered an injection against pneumonia in December but declined as he had
already had one. While in the clinic, the man mentioned that his ankles were
swollen. On examination, it was evident that he had not been attending to his
hygiene and he explained that he was unable to bend down and had no means
to soak his feet. Referrals were made by a nurse for him to be assessed by the
GP and chiropodist. Arrangements were also made for a bowl to be provided
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for the man to retain in his cell or for baths to be taken on the inpatients’ unit in
healthcare.
16. A week later, the man was reviewed again by the nurse who had arranged for
him to have a bath on the inpatients’ unit. However, he said that he would
prefer for a bowl to be made available so that he could wash his feet in his cell.
Following his request, a member of the healthcare team spoke to an officer on
the man’s wing to arrange for him to be provided with a washbowl.
17. Unfortunately, when the man attended for a review in the clinic on 10 January
he said that he had not been provided with the bowl as he had forgotten which
officer he had to ask. The nurse again arranged for one to be made available.
On examination, it was evident to the nurse that the man’s legs were still
swollen. She checked his blood pressure and pulse and although she found
them to be within a healthy range, due to the continuing problems with his legs
the nurse referred the man to the prison doctor.
18. The nurse saw the man again at the clinic two weeks later on 22 January. His
blood pressure was slightly raised and he was breathless at times. Although
the GP referral had been received, the man had still not been given an
appointment. The investigator was told that it was normal for a prisoner to wait
a fortnight to see a doctor unless the referral was urgent, in which case they
would be seen the next day. A doctor eventually examined him on 25 January
and prescribed medication. However, when seen again on 29 January by a
doctor, the man had still not been given the medication. On examination, the
doctor recorded that there was no sign of chest infection but the man was very
“wheezy” and his legs remained swollen. The doctor prescribed medication to
be taken via a nebuliser and said that he would be reviewed in five days.
19. On 2 February, it was recorded in the man’s medical record that he had still not
had his nebulised medications but had received the other medication
prescribed. He was also said to be “still wheezy but slightly better”. Five days
later, the doctor saw him again on the wing and recorded that no nebulisers
were available in the prison. The man said that he felt better but the doctor
considered that he would still benefit from nebulisation when possible, so
arrangements were made for a nebuliser to be obtained from the healthcare
unit.
20. The man’s shortness of breath continued, along with other symptoms including
weight loss. Investigations into the cause were conducted over the next month
with a colonoscopy being carried out on 1 March. On his return from having the
procedure, the nurse conducted a review in the clinic and advised him to
increase his intake of fluids as he appeared dehydrated. The man’s blood
pressure was raised but he assured the nurse that he felt fine and just wanted
to return to his cell and rest. He promised to drink more fluids and the nurse
advised that she would check his blood pressure again the following day.
21. When the nurse visited the man on the wing the following day, his blood
pressure was again raised but he appeared better in himself. The man said
that he had pain in his right hip but was reluctant to take any pain killers without
8
discussing it with the doctor first. In view of this and the fact that his diuretic
medication, which had initially been prescribed as a trial, was about to run out
the nurse made an urgent doctor referral.
22. The prison GP visited the man in his cell that afternoon and recorded in his
medical record that:
“Looks well, not short of breath sitting down but shortness of breath on
slight excursion , COPD (Chronic Obstructive Pulmonary Disorder),
both feet are swollen, pitting oedema (swollen ankles), keeps his feet
hanging all day. To see him again in one month. Has shown me a
cyst on his right deltoid muscle, was given flu jab in 06 on his right.
Refer to Dermatologist.”
23. The nurse reviewed the man again in the clinic on 23 March when he was still
complaining of pain in his hip. His blood pressure was recorded as 120 over 58
and his pulse 80 bpm (these levels are considered to be within the normal
range). The nurse recorded that he would require another blood test the
following week in view of the results of his most recent one.
24. The man continued to be assessed regularly by healthcare staff. In May, he
was referred to outside hospital for investigations to rule out possible stomach
cancer. He was due to attend the hospital in June for the investigations to be
carried out but was prevented from doing so due to problems with transport.
The man had been unable to get into the taxi that had been supplied as he was
in a wheelchair. Following this missed appointment, a senior nurse assessed
the man at the request of the Modern Matron. The senior nurse made notes in
the man’s medical record in which she reflected that this was the first time that
she had been made aware of him using a wheelchair. She went on to write
that:
“On my arrival (the man) was sat on his bed, I observed him
transferring onto his chair which he did with difficulty, using furniture
and was unsteady. He was wrapped up in several layers of clothing
including a towel around his neck. The man expressed that he was
concerned as his right leg is very weak and he said that his muscle has
worn out and gone very thin. On examination, this muscle wasting was
very evident with marked atrophy (wasting) of his right sided
quadriceps. He also expressed that he had tenderness in the base of
his spine.”
25. The senior nurse considered that the man required a full assessment, which
could not be completed in his cell, so she arranged for him to be admitted to the
in-patients department of the healthcare unit. She also recorded that she would
discuss the man with the doctor and his appointment the hospital should be re-
scheduled. The man moved to the in-patients unit the following day.
9
26. On 28 June, a prison doctor, saw the man as part of her surgery in healthcare.
The prison doctor recorded that the man had pain in his right thigh that was
making it difficult to sleep, and pains in his left arm and chest that the man said
were different from the pain he normally associated with angina. The prison
doctor also recorded that he had previously had an endoscopy and
colonoscopy to rule out possible bowel cancer. There was still swelling to the
man’s legs and he appeared slightly dehydrated. During her examination, the
prison doctor noted the muscle wastage previously seen by the senior nurse
and a lump on the man’s right arm. The prison doctor made a routine referral
to a neurologist for further tests.
27. An entry in the man’s medical notes on 29 June refers to a telephone call made
by the healthcare department to the hospital to arrange a new appointment for
the man’s computed tomography (CT) scan. (This scan produces cross-
sectional x-ray images of internal organs.) However, the prison were informed
by the consultant’s secretary that the consultant was unhappy that the man had
not attended his earlier appointment and therefore refused to make another at
this time.
28. Nursing staff reviewed the man daily and conducted blood tests routinely to
monitor his condition. On 2 July, a nurse recorded that a second nurse who
dealt with patients with long term conditions in the community should see him
when she next visited the prison.
29. That afternoon, the first nurse received a call from the detail department (a
department within the prison responsible for allocating staff to different tasks
and providing staffing for escorts) and was informed that the taxi sent to take
the man for his x-ray appointment was unsuitable for wheelchairs. The detail
department said that another taxi could not be provided until 4.00pm and asked
the first nurse if she could contact them to find out if they could see the man at
4.30pm. The x-ray department confirmed that he would still be seen but should
arrive at the department no later than 4.30pm. Unfortunately, the escort arrived
at Hull Royal Infirmary (HRI) 15 minutes late and the man was not seen.
30. The prison made a further appointment for 4 July for the x-ray and rescheduled
the missed CT scan at Castle Hill Hospital for 11 July. A member from the
healthcare admin department emphasised to the detail department the
importance of booking the correct transport for both appointments. They were
subsequently attended without further problems.
31. The second nurse a Community Matron, Long Term Conditions assessed the
man when she visited the prison on 18 July. The man explained that he had
pain in his right leg that had started five months before at the same time as his
weight loss. The nurse recorded that the man had some pressure sores on his
back and that he was having some difficulty with personal hygiene due to his
immobility. The nursing staff had regularly assisted him with his hygiene
throughout his time in healthcare. The nurse also made a referral for the man
to be seen by an occupational therapist to provide a walking aid. When the
nurse made a follow up visit on 1 August, she noted that a hospital style bed
10
had been provided for the man to alleviate the pressure sores that he was
experiencing.
32. The chest x-ray conducted in early July revealed a possible lung tumour and a
following CT scan confirmed the diagnoses. The man was informed of the
findings and fentanyl (opiate-based pain relief) was prescribed in the form of
patches. When he was first prescribed with fentanyl, the man appeared
confused due to the strength of the medication but he was closely monitored so
that changes could be made as required. He also needed to use a nebuliser
(this creates a mist of medicine, which is then breathed in through a mask or
mouthpiece to aid breathing) on a number of occasions.
33. Nursing staff continued to assess the man daily and he also attended outside
hospital for treatment and assessments without further problems. Despite his
poor prognosis, the man remained positive. He attended the “Over 60’s” club in
the healthcare unit on a regular basis and seldom complained about his
situation. Nursing staff told the investigator that he never seemed to let his
condition get him down and, although some days were better than others, he
was always polite and never demanding. Staff provided board games in his
ward to encourage him to interact with other prisoners but at times he was too
tired because of his treatment. On 24 August, he said to a nurse “I feel settled
in my head now because the consultant has told me what will happen to me, I
know I am dying, we all have to. I know my time is soon” the nurse recorded
that despite this he was still very cheerful and was aware that staff were
available to talk to and assist him as much as possible.
34. The man had been experiencing more pain during late August, which caused
problems with his sleep. In view of this, the doctor increased his fentanyl. The
man thanked staff and said that he was looking forward to a nights sleep. It
was noted in his medical record that the man appeared much brighter following
the increase in his pain relief. Care plans were in place that allowed the
nursing staff to ensure that the man’s changing needs could be met and, as
part of this, nursing staff continued to assist him with his personal hygiene.
11
35. On 3 September, a Macmillan nurse (Macmillan nurses provide expert
information, advice and support to improve the lives of people with cancer) and
the doctor again reviewed the man’s medication and decided that he should
start taking oramorph (morphine) for two days and then be reviewed. The
Macmillan nurse also recorded that the man should be advised to be a little
more active each day but that he appeared pleasant in his mood. The man
continued to go to appointments at Castle Hill Hospital and was comfortable on
the ward in the healthcare unit. The Macmillan nurses were in regular contact
with the prisons nursing staff and advised on equipment that they felt would
make the man more comfortable.
36. The man’s condition continued to be closely monitored and, in January 2008, a
governor spoke to him about possible early release on compassionate grounds.
He confirmed that he would like to be considered for release and the process
was started. (The criteria for a prisoner to be released early on compassionate
grounds are standard across the prison estate and focus not only on their
health and life expectancy but also on the risk that they might pose to the
public.) In The man’s case, the decision was taken not to support his
application.
37. On 6 February, a second governor visited the man in the healthcare unit to
explain the reasons for the decision. Both the prison and outside services
considered that the man continued to pose a risk to the public and also thought
that there was a potential risk to him from victims of his offences. Following his
meeting with the second governor, nursing staff spoke to the man and recorded
that he appeared to have taken the news “philosophically”, although it was felt
that he was probably upset so support would be offered as required.
38. The second nurse also spoke with the man on 6 February and recorded on his
care plan that:
“would prefer to die a ‘free man’ but does not wish to return to
Manchester he would like to be released and go to a nursing home
locally. If this is not possible he wants to die in prison and be cared for
by the staff he knows.”
39. The man’s palliative care continued to be delivered effectively within healthcare
and he did not appear to have been affected by the decision not to release him
from prison on compassionate grounds. The second nurse, who saw the man
regularly, recorded in his medical notes that staff had raised concerns about his
pain relief. He did not request additional pain relief during the day but waited
for routine medication to be issued. Another member of the healthcare team
spoke to the man following the nurse’s assessment and discussed with him the
pain relief available.
40. Over the next few weeks, nursing staff and doctor’s reviewed the man’s pain
relief more frequently as his pain increased. In addition, the man was asked
whether he wished to move from the ward into the care suite. (The care suite is
a room on the healthcare landing that had previously been used by patients for
12
association, watching TV and playing board games.) The man initially declined
the move saying that he preferred to stay on the ward. However, on 7 March,
he decided that he would like to move to the care suite as the noise levels had
increased and he needed more nursing intervention at night. The nurse
explained to the man that other patients could visit him at any time and
recorded in his medical notes that he was happy with his move.
41. Over the next two months, the man continued to deteriorate and his increasing
pain was managed accordingly. He was also becoming weaker and frailer but
refused to stay in bed saying that the pain was worse when he did. This
resulted in the man having some minor falls when trying to move around in his
room, which often happened at night. The investigator was told that on a
number of occasions nursing staff and prison managers discussed the
possibility of leaving the door to the man’s room open during the night to aid
quicker access in an emergency. However, it was felt that while he remained
mobile and given the reduced staffing levels in healthcare at night, this would
not be possible.
42. On 30 April, the second nurse, who had not seen him for two weeks, assessed
the man. She recorded in his medical notes:
“Condition seems to have deteriorated in two weeks since previous
visit. Mood appeared down this morning. On questioning, stated that
the falls he has had in the past two weeks have taken it out of him and
the pain in his right arm is worse since then. Also stated that his
confidence has reduced and he does not want to walk around
anymore, even with the staff for assistance. Stated that his pain had
increased over the last two weeks and that his falls were due to feeling
dizzy. I advised him to call staff if he wished to mobilise.”
43. A doctor assessed the man on 13 May and recorded in his medical notes that
he was clearly going downhill and appeared more confused. The second nurse
followed this up the next day. When she assessed the man, she recorded that
he appeared brighter than her last visit and was verbalising well in full
sentences.
44. As part of the man’s care plan, the first nurse spoke with him on 15 May and
discussed his wishes regarding resuscitation. The first nurse recorded that the
man made it clear to her that at the end he did not want this to happen and said
to her “I want to die with dignity and do not want jumping on”. The nurse said
that she would get the doctor to talk to the man about this issue and she would
attend if he wished. The man completed a living will on 29 May in which he
stated that he did not wish to be resuscitated. The doctor and Healthcare
Officer (HCO) witnessed it. The man also expressed a wish for his son to be
contacted after his death but he had always been adamant that he did not wish
his family to be told of his condition any sooner.
45. Reviews of the man’s pain relief and monitoring of his condition continued. He
remained polite, cheerful and spent time watching television and having an
occasional cigarette. The man continued to move around well with the aid of a
13
Zimmer frame. On 27 May, the first nurse discussed with the man his pain
relief and the man made it clear that he did not want to be “doped up”. The
nurse reassured him that this would not be that case and said that nursing staff
would monitor all his medication. The nurse also recorded on the man’s notes
that a Water Low Assessment needed to be carried out the following day (this
is an assessment used to predict a patients risk of pressure sores.)
46. The man’s condition continued to deteriorate but he remained mobile.
However, despite being advised to request staff assistance, he tried to move
around by himself, which led to further falls. On 19 June, the nurse wrote in his
medical notes:
“All staff are aware that at the point he becomes immobile and an
increase in the level of hands on care required, security with nursing
multi disciplinary team will review the decision made regarding his door
being open. At the moment, he is so ambulant and able to walk around
his room and the landing the security process still applies, as it does
with every other prisoner. He is still fully aware of all that he does,
understands why he is in prison and acknowledges that he can be
cantankerous when he wants his own way. Still direct with his wishes
of ‘do not resuscitate’.”
47. At 1.15am on 22 June, the man had another fall and on this occasion needed
to be sent to the Accident and Emergency department at Hull Royal Infirmary.
The man was x-rayed and it was found that he had a slight injury to his hip but
the hospital were unwilling to admit him as there was little treatment that they
could offer. Also, they did not want to interfere with the palliative care the man
was receiving at the prison. On his return to the healthcare wing from hospital,
healthcare staff advised the man that all night time wanderings were to cease.
The man agreed that it would be in his best interests.
48. On 8 July, nursing staff decided that the man would benefit from using a
syringe driver (a small, portable battery-driver infusion pump, used to give
medication under the skin via a syringe, usually over 24 hours) as his condition
had significantly deteriorated. In addition, the Liverpool Care Pathway (LCP)
was initiated. (The LCP was developed to transfer the hospice model of care
for dying patients into other care settings.)
49. Over the next couple of days, nursing staff continued to provide assistance to
the man in tending to his personal hygiene. They checked on him regularly
ensuring that he remained comfortable and that his dignity was maintained.
50. On the evening of 11 July, a staff nurse was making a routine check on the
man at around 10.00pm and noted that he did not appear to be breathing. She
observed him through the observation panel on the cell door which was locked
and she had no keys to enter the room. The staff nurse contacted the night
orderly officer and requested access to the man’s room so that nursing staff
could check him. The night orderly officer went to healthcare, along with a
prison officer. Together with two nurses, they entered the man’s room. The
14
nurses checked the man and no vital signs (pulse, breathing) could be found
and so paramedics and the duty governor were called.
51. The paramedics arrived at 10.30pm and, in view of the man’s wishes not to be
resuscitated, no treatment was administered. Paramedics confirmed the man’s
death at 10.40pm.
52. Following the man’s death, a member of the Care Team (staff volunteers who
provide emotional support to staff), came into the prison and spoke with all the
staff members involved. The duty governor wished to notify the man’s son in
Manchester he was unable to confirm that he still lived at the address listed at
the prison, as the man had not received any visits. In the light of this, the duty
governor asked Humberside Police to liaise with their colleagues in Greater
Manchester with a view to visiting the address and breaking the news to his
son. The duty governor was subsequently informed that the man’s son had
been located and told of his father’s death at 10.15am on 12 July. At 10.30am,
the duty governor spoke with the man’s son who confirmed that he had no
immediate concerns.
53. The duty governor and the prison Family Liaison Officer (FLO), visited the
man’s son after the news had been broken. This gave the family the chance to
ask further questions and be informed about the investigation and inquest
process. The prison stayed in contact with the man’s son and, at his request,
the Prison Chaplain led the man’s funeral.
15
ISSUES
54. Following an investigation into a previous death from natural causes at HMP
Hull, the Ombudsman made a number of recommendations about the care of
terminally ill patients. During this investigation, it was evident that the majority
of these had been implemented to the benefit of the man. I reflect on these in
the following paragraphs.
Consideration for compassionate release
55. The Ombudsman recommended previously that all decisions regarding
compassionate and temporary release should be fully documented had
evidently been implemented in the man’s case. Although it had not been
supported, the application was filed within the medical record and a clear report
on the reasons for the prison’s decision was produced. Most importantly for the
man, the Governor making the decision spoke at length to him personally and
ensured that he understood the process and that the decision would not affect
the quality of palliative care that he would receive.
The man’s wishes regarding his care and where he was located
56. The care plans and medical notes clearly show that the man’s wishes were
respected and documented at each stage of his illness. This included the place
he wanted to die and who he wished to be contacted and when. This again
demonstrates the positive steps made by the prison to act upon
recommendations made from my earlier report, in which the Clinical Reviewer
had recommended that patient’s wishes regarding their care should be explicitly
recorded and reviewed as appropriate.
Delivery and access to care from outside agencies
57. The man was visited and assessed regularly by the nurse, Community Matron,
Long Term Conditions. Macmillan Nurses, who had access to the prison
healthcare as required, also assessed him regularly. Additionally, all outside
agencies were in regular telephone contact with nursing staff at the prison to
get updates on the man’s condition. My earlier case endorsed a
recommendation from the Clinical Reviewer that healthcare staff should
consider what actions could be identified to facilitate the speedier access of
visiting clinicians to healthcare. This appears to have been addressed and the
man benefited from the regular care and input provided by the nurse and the
Macmillan team.
Access to medication and pain relief
58. The medical documentation and the care plans show that the man’s changing
needs regarding pain relief and medication were regularly monitored and
updated. The man was reluctant to request additional pain relief, preferring to
wait for his routine prescription. However, the nursing staff quickly identified
this and advised the man of the additional pain relief that was available. In my
previous investigation, the Clinical Reviewer recommended that the healthcare
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department purchase a Graseby syringe driver and that staff were trained in its
use. This recommendation had been accepted and the syringe driver was in
place and benefited the man in the later stages of his illness.
Accommodation/care suite
59. In the previous case at Hull in which I made recommendations, I raised
concerns about the former association room that had been converted for use as
a care suite, most notably for those patients with terminal illnesses. During this
investigation, my investigator viewed the room and found that efforts had
indeed been made by healthcare staff to make it more comfortable for the man.
A locker had been obtained as well as a table and soft chair and it was clean.
However, the room remained partitioned by a curtain and, due to its size, felt
cold and the decoration very austere. Nursing staff told my investigator that
most of the fittings in the room had been obtained by borrowing from other
areas. Along with the medical equipment and the additional furniture, it is clear
that the healthcare staff have attempted to make the room more suitable for the
palliative care of prisoners. However, in my view, more could be done but I am
conscious of budgetary constraints. I therefore make the following
recommendation:
The Governor of Hull should liaise with Head of Healthcare and the
Primary Care Trust to consider how the care suite can be further
improved and the options for funding such improvements.
The man’s end of life care
60. Since the last death of a terminally ill prisoner at Hull, action has also been
taken to ensure that staff are trained in palliative care and a policy has been
produced. The Liverpool Care Pathway was used very effectively to ensure
that the man’s end of life care was delivered to an equal standard to that which
could be expected in the community.
Staff access to the care suite
61. Nursing staff told my investigator that they were upset that the man died alone
in his locked room and that they had been unable to gain access to him. The
medical notes and care plans show that this was indeed a concern and had
been remarked upon by nursing staff. A meeting between the security
department and healthcare clearly documented the reasons for the door
remaining locked during the night. The reasons given at the time were based
on the man’s continued mobility and as such, the consequent security risks he
posed, which all parties seemed to accept. However, once the man
deteriorated to the stage where he was confined to bed and the Liverpool Care
Pathway was implemented, there does not seem to have been any further
reviews of the closed-door policy. I feel it would have been a comfort to the
man to know that someone was with him in his final hours. It was known that
his death was imminent, so it was unnecessary for him to die alone and
happened due to a lack of communication. I make the following
recommendation:
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When the Liverpool Care Pathway is initiated for a terminally ill prisoner
who has been refused compassionate release or chosen to die within the
prison, the Governor and Head of Healthcare should ensure that daily
meetings are held to assess the prisoner’s condition. These meetings
should be documented and take into account the need for medical staff to
access the prisoner outside of normal operating hours.
Clinical Review
62. The Clinical Governance Manager, Hull Teaching PCT, who carried out the
clinical review into the man’s care, makes no recommendations in her report
but does reflect on the good progress made by Hull in respect of the
recommendations made in the earlier report. In the conclusion to her report,
the clinical reviewer answers the following two questions:
Was the care the man received whilst in custody at HMP Hull appropriate and
comparable to the services he could expect to receive from a Primary Care
Provider in the community?
“The care the man received at HMP Hull Healthcare was broadly
similar to that he would have received in a community setting. The
man had referrals made to appropriate health care professionals, and
had access to advice regarding healthcare issues on request. The
man received care and assistance by nursing and medical staff that
was comparable to care within the wider community and received care
from the long-term conditions team, Macmillan team and occupational
health. He was referred appropriately to the acute hospital trust and
appointments were followed up in a timely manner. The man had a
planned programme of care in which he was able to participate and
received some outstanding care from the inpatients team.”
Would different care have resulted in a different outcome?
“The man’s treatment for his terminal disease was managed within
recommended guidelines. Changes to his care were complete in
collaboration with specialists in the acute hospital setting and within the
scope of this clinical review, it is the author’s belief that different care
for the man would not have resulted in a different outcome, due to the
terminal nature of his disease. The care the man received seems to
have ensured that the man did not suffer and received adequate
psychological support, interventions to maintain his dignity and
privacy.”
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CONCLUSION
63. The man was an elderly man with a terminal illness. It is evident that he
received a high standard of care throughout and I concur with the view of the
Clinical Reviewer that his care was at least equitable to that which he would
have received in the community. I am particularly pleased to note that
throughout my investigation the implementation of recommendations from one
of my earlier reports was of direct benefit to the man and, no doubt, will
continue to be so for other prisoners.
64. The inquest into the man’s death was held on 10 December 2008. After
hearing the evidence provided the jury concluded that the man died as a result
of natural causes brought on by a terminal illness.
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RECOMMENDATIONS
1. The Governor of Hull should liaise with Head of Healthcare and the Primary
Care Trust to consider how the care suite can be further improved and the
options for funding such improvements.
Following the publication of the draft report the prison accepted this
recommendation and are to discuss between both agencies and put in place
costing plans for how to improve the care suite by May 31 2009.
2. When the Liverpool Care Pathway is initiated for a terminally ill prisoner who
has been refused compassionate release or chosen to die within the prison, the
Governor and Head of Healthcare should ensure that daily meetings are held to
assess the prisoner’s condition. These meetings should be documented and
take into account the need for medical staff to access the prisoner outside of
normal operating hours.
Following the publication of the draft report the prison accepted the
recommendation. Once a patient has been admitted to the Palliative Care suite
regular meetings are to be held to discuss individual cases, as the prognosis
becomes critical these meetings are to be held daily between the Duty
Healthcare Manager and Security Manager with regard to access to the suite.
All meetings are to be documented. The prison has set an implementation date
of 31 December 2008 for this to be in place.
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