Individual at Hull

Investigation into the circumstances surrounding the
death of a man at Castle Hill Hospital in February 2008
whilst in the custody of HMP Hull
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2008
This is the report of an investigation into the death of a man in February 2008 at
Castle Hill Hospital, Hull. He suffered from several chronic conditions, and was
treated as a hospital in patient on more than one occasion. He was in the custody of
HMP Hull when he passed away. The loss of any family member is upsetting, but
especially so whilst they are in custody. I offer my sincere condolences to the man’s
family and friends.
The investigation was conducted by two of my investigating officers. In addition I
commissioned a clinical review into the man’s healthcare. My thanks to the Clinical
Governance Manager of Provider Services at Hull Teaching Primary Care Trust, who
undertook this review.
I would like to thank the Governor of Hull and our liaison officer for their assistance
during the course of this investigation.
The clinical review includes a recommendation concerning the importance of follow
up treatment for the man’s pressure sore, which I endorse. I also note the man’s cell
allocation and his access to a wheelchair as examples of good practice. Finally I
commend the prison for removing the restraints from the man during his final hospital
stay, and for allowing him and his family privacy during their final moments together.
I am pleased to see that the Prison Service have accepted the recommendation.
Jane Webb
Deputy Prisons and Probation Ombudsman October 2008
Final report C187-08 October 2008 2
CONTENTS
Summary 4
The Investigation Process 5
HMP & YOI Hull 7
Key Findings 9
Issues 13
Recommendation 15
Final report C187-08 October 2008 3
SUMMARY
The man died whilst in Castle Hill Hospital, Hull in February 2008. He had been
admitted to hospital on 19 February following a long period of ill health whilst he was
in HMP Hull. He was struggling to breathe and the prison’s healthcare centre
requested an ambulance for emergency transfer to hospital.
The man had been in custody since April 2003. He had a long-term chronic chest
condition and persistent obstruction of the airways. He regularly attended prison
healthcare (HCC), as well as the Royal Hull Infirmary (RHI) and Castle Hill Hospital
(CHH) for appointments. He also attended as an in-patient on several occasions.
In view of his health and subsequent mobility problems, the man was allocated a cell
near to both the food servery and the treatment hatch which was also close to the
showers and association area. He also had access to a wheelchair to help his
mobility. Furthermore, the healthcare centre has a lift, so the man did not have to
use the stairs.
My investigators confirmed that the man was not handcuffed when he died and that
authority had been given by a senior manager on 19 February to remove the
restraints. I am pleased that this occurred. At the time that the man died, both
bedwatch officers had withdrawn from the room and remained outside the door,
allowing the man and his family some privacy during his final moments.
The clinical review contains a number of advisory points for the prison and does not
raise any concerns about the care and treatment the man received whilst he was in
custody.
Final report C187-08 October 2008 4
THE INVESTIGATION PROCESS
1. My investigators requested all the relevant prison records relating to the man,
including:
• patient record
• history sheets
• personal records
• wing sick applications
• bedwatch log
• cell clearance sheets.
2. Notices announcing the investigation were supplied by my investigators and
displayed by the prison to staff and prisoners, who were invited to contribute any
relevant information. No prisoners or staff made contact.
3. One of my Family Liaison Officers contacted the man’s daughter to ask if there
were any issues she specifically wanted the investigation to take into account.
She had several concerns which she asked us to consider:
• the man may not have received his medication on several occasions
• he had undressed bedsores on his body when moved to hospital
• he may have sat in his own faeces for some days before he was
bathed
• the family were not informed on each occasion he was taken to
hospital
• he had bruises on his body
• he was very underweight.
I hope these, and any other questions she may have, have been answered in this
report.
4. A clinical review of the man’s healthcare was undertaken by the Clinical
Governance Manager of the Hull Teaching Primary Care Trust (PCT) and I am
grateful to her for the report. She also made herself readily available to answer
any queries during the investigation and her assistance was much appreciated.
The review provides explanations and insight to ensure that, as far as possible,
the full facts are brought to light and any relevant failing is exposed. In addition, it
should help ensure that any commendable action or practice is identified, and
any lessons from the man’s death are learned. It specifically considers the
following questions:
• Was the care the man received whilst in custody at HMP Hull appropriate and
comparable to the services the man could expect to receive from a Primary
Care Provider in the Community?
• Would different care have resulted in a different outcome?
• Are there any learning opportunities following identification of any root causes
and examination of policy and practice?
Final report C187-08 October 2008 5
5. The investigation team visited the prison. They considered the extent to which
the prison complied with local and national procedures for looking after prisoners
with health problems and for dealing with deaths in custody. They were given
access to the man’s records, including his medical records, and spoke to staff at
the prison.
6. My investigator contacted HM Coroner for East Riding and Kingston-upon-Hull to
inform him of our investigation and report. He kindly provided my office with the
post mortem report. The Coroner will receive a copy of this report when it is
completed to assist with his enquiries into the man’s death.
Final report C187-08 October 2008 6
HMP & YOI HULL
7. The prison is located two miles east of Hull city centre and first opened in 1870,
holding male and female prisoners. In 1939 it was used as a military prison and
later a civil defence depot. In 1950 it re-opened as a closed male borstal. In
1969, after extensive security work, Hull became one of the first maximum
security prisons. In February 1986, Hull assumed its current role as a male local
prison and remand centre.
8. In 2002 the prison was expanded and increased in size. Its expansion included
four new wings, a new healthcare centre, a new sports hall, a new multi-faith
centre and refurbishment to other parts of the prison including the kitchen,
education and workshops. Since 1 April 2005, the local Primary Care Trust has
assumed commissioning responsibility for the provision of healthcare. It has an
operational capacity (maximum crowded capacity) just in excess of 1,000.
Healthcare
9. Nursing staff and professions allied to health at HMP Hull Healthcare have
regular performance reviews and supervision to ensure that best practice is
identified and embedded within the organisation. Mandatory and statutory
training is undertaken by healthcare staff, which includes Basic Life Support,
Manual Handling, Risk Assessment, Health and Safety and Managing Diversity.
Staff also have access to learning events hosted by Hull Teaching Primary Care
Trust.
Do Not Resuscitate Notices (DNRs)
10. A Do Not Resuscitate order (DNR) on a patient's file means that a doctor is not
required to resuscitate a patient and is designed to prevent unnecessary
suffering. The United Kingdom medical profession has guidelines for
circumstances in which a DNR may be issued:
• if a patient's condition is such that resuscitation is unlikely to succeed
• if a mentally competent patient has consistently stated or recorded the fact
that he or she does not want to be resuscitated
• if there is advanced notice or a living will which says the patient does not want
to be resuscitated
• if successful resuscitation would not be in the patient's best interest because it
would lead to a poor quality of life.
Previous deaths at Hull
11. There have been 15 deaths at Hull since April 2004. Nine of these have been
from natural causes. None of the previous investigations are comparable to this
one, although in one of my reports I recommended that the Governor should
review the policy of using restraints on every prisoner in hospital. I am pleased to
find that the recommendation has been achieved and that arrangements for the
man allowed the restraints to be removed.
Final report C187-08 October 2008 7
Her Majesty’s Inspectorate of Prisons
12. The latest report, following an unannounced inspection of HMP Hull by HM Chief
Inspector of Prisons dated February 2006, states “Healthcare had improved and
made good use of prisoner forums … The monthly healthcare prisoner forums
actively involved prisoners in healthcare issues.”
Independent Monitoring Board (IMB)
13. In its latest annual report, covering December 2006 to December 2007, Hull’s
IMB does not show any issues which are particularly relevant to this investigation.
On healthcare the report states “Any client with immediate healthcare needs of
an acute nature will be referred to an outside hospital if required or monitored
within the healthcare in-patients unit.”
Final report C187-08 October 2008 8
KEY FINDINGS
14. The man was remanded to HMP Hull in March 2003, and subsequently
sentenced to seven years and six months’ imprisonment in April. He was located
on the vulnerable prisoner wing. It was his first time in prison.
15. According to staff he appeared to be a quiet, polite and approachable individual.
He had health problems prior to his imprisonment and in January 2003, had been
diagnosed with mycobacterium kansasii infection, which is a lung disease similar
to tuberculosis. The symptoms include a chronic cough, weight loss and
discomfort in the lungs. He was still suffering from this disease during the
following year.
16. The man went through a medical screening on reception into prison. Because of
the state of his health and breathing difficulties his record was marked to indicate
that he should only be located on the ground floor. He was put onto I wing so
that he had easier access to the food servery, medication hatch, showers and
association.
17. In April 2003, when discharged from the healthcare centre, the man was
recorded as having various physical problems and being on long-term prescribed
medication. Four days later on 15 April, the man went to healthcare to speak to a
doctor about concerns over his medication. He stated that on several occasions
he believed that insufficient medications had been supplied to him. During this
investigation no evidence of deliberate withholding of medications was found.
The following month, on 2 May, the man was issued with a nebuliser (a device
that administers liquid medication to the airways), for a serious chest complaint.
Due to his condition the nurse advised the wing that he should not have to attend
work whilst in prison.
18. On 5 November, the man was diagnosed, by a consultant physician, with
moderately severe tobacco-related obstructive airways disease and
mycobacterium kansasii infection (treatment for which had started in January
2003). He was due to attend Hull Royal Infirmary for an appointment on 3
December, but informed staff that he did not wish to attend and signed the
appointment letter to the effect that he understood this was done at his own risk.
19. At 11.50am on 12 January 2004, staff on the wing contacted healthcare because
the man was having breathing difficulties. His records give no further information
about the treatment he was given. On 11 March, healthcare staff were called
again because he was having difficulty breathing. Oxygen was given and after a
while his breathing returned to normal. Healthcare staff later returned to the
man’s cell to monitor his breathing.
20. The next time that the man is recorded as having breathing difficulties was on 23
June, when he was taken to HRI. He was treated for a productive cough and
shortness of breath. On 8 July, he was admitted to the healthcare centre with
extreme breathing difficulties. An ambulance had been called to the wing but the
man refused to go to hospital and he returned to his cell later the same day.
21. On 2 November, the man was also diagnosed with severe chronic obstructive
pulmonary disease (COPD), which is a collection of lung diseases including
chronic bronchitis, emphysema and chronic obstructive airways disease. COPD
Final report C187-08 October 2008 9
occurs as a result of damage to the lungs, usually due to smoking, and the
condition is not curable. Treatment mainly relieves the symptoms and the
responses vary from person to person. Some people can experience severe
weight loss, in part because shortness of breath makes eating difficult. During
severe episodes a life-threatening condition called acute respiratory failure may
develop. Contracting influenza or developing pneumonia may markedly worsen
COPD.
22. The man continued to be treated at both HRI and CHH where he was under the
care of a consultant surgeon. There was regular correspondence between the
hospitals and the prison healthcare centre outlining the man’s health problems.
He was regularly reviewed in the chest clinic where his lung function suggested
prominent emphysema. It was thought that he was probably using his nebuliser
too often and so different medications were given. He was also frequently
prescribed antibiotics for reoccurring respiratory tract infections, and had
intermittent steroid therapy when the COPD was particularly severe.
23. It was recorded in January 2005 that the man still had severe COPD but that the
treatment for the mycobacterium kansasii infection was stopped after two years
of combination therapy.
24. Two months later, in March, the man was found to be having trouble overcoming
a recent chest infection. Later in the month, on 22 March, it was recorded that he
had been losing weight recently and had complained of dysphagia (difficulty
swallowing) for about four weeks. He was given regular meals at all times, but
often preferred a slice of toast and liquids. He also ordered Fortisips, which are a
meal supplement. The man attended hospital about once a month for regular
reviews of his condition.
25. On 8 April, the man underwent an endoscopy (a procedure to view inside the
body), which reported normal. He gave up smoking and was put on a waiting list
for a hernia operation. At his appointment on 25 July, he told his consultant that
he had been coughing up blood for a few months. A bronchoscopy (a procedure
to examine the lungs and take a sample of cells for tests) took place on 17
August, which proved normal.
26. The man was also diagnosed with Raynaud’s disease (a condition that causes
some areas of the body – such as fingers, toes, tip of nose and ears – to feel
numb and cool in response to cold temperatures or stress) on 24 October. The
doctor recorded that “His joints had a good range of movement … There are a
few bruises, most likely from steroids.” The man’s daughter has asked about the
bruises on her father’s body and the clinical reviewer advises that steroid
medication can cause the skin to look as though it is bruised.
27. Early the following year, in February 2006, the man’s chest was scanned at CHH
and he was diagnosed with a lump (nodule) in the thyroid gland of his neck.
Three weeks later, on 21 March, it was recorded that he had quite significant lung
disease, a retro-sternal goitre (when the thyroid enlarges downwards into chest)
and a year long history of dysphagia.
28. On 15 June, the man was seen by the prison doctor who recorded that he was
short of breath, was wheezing and could not finish a sentence. He had also lost
weight and the COPD had worsened. Two days afterwards, on 17 June, the man
returned to HCC as he had more difficulty breathing. Oxygen was administered
Final report C187-08 October 2008 10
but he was still having difficulties after an hour and a half and was taken to HRI.
He was treated for the exacerbation of COPD and remained in hospital for ten
days until 27 June.
29. When next seen at the chest clinic at CHH on 29 August, although the diagnosis
of severe COPD remained, there was very substantial improvement to the man’s
condition. However, two months afterwards on 26 October, he was admitted to
CHH suffering from pneumonia and kept in hospital until 31 October.
30. The man continued to visit the hospital as an out patient. On 6 January 2007, he
complained of breathing difficulties and was given emergency oxygen in the
healthcare centre. He was told on 25 June that he had been removed from the
hospital waiting list for a hernia operation because his thyroid gland was
abnormal. A chest infection developed on 14 July and at the HRI four days later
on 18 July, he was found to be suffering from haemoptysis (coughing up of blood
or bloody sputum). It was also recorded that the man was allergic to morphine.
31. The man was admitted to CHH again on 28 September and was diagnosed with
acute exacerbation of COPD, asthma and angina. On 5 October, he had another
bronchoscopy which showed as normal, but he was now having to use a
wheelchair on long distances. He was given his annual flu vaccination on 7
November.
32. On 21 November, the man again complained of difficulty breathing and he was
seen by a doctor on the wing. He was given oxygen which eased his breathing,
but continued to have difficulty and so the paramedics were called. Excess
medication was found in the man’s cell the following day, which was removed
until his return from hospital. He was taken to the Accident and Emergency
Department at the HRI by ambulance at midnight.on 23 November. Following
further investigation and treatment, the man was diagnosed with infective
exacerbation of COPD and he remained in hospital until 30 November.
33. The consultant surgeon again diagnosed severe COPD on 13 December,
together with the previous mycobacterium kansasii infection. The man’s
breathing remained poor and it was suggested that he should have a chest x-ray
in about six to eight weeks time. He was admitted to CHH again from 19
December until 24 December, due to the exacerbation of the COPD.
34. The man was given a formal warning on 4 January 2008, because he had been
found again with excess medication, had requested medication which he was not
entitled to and misused his cell bell. His punishment was subsequently set at
loss of half his earnings, loss of association, and loss of canteen facilities for 28
days. He was admitted to healthcare the same day for medical assessment and
review.
35. On 10 January, the man was admitted again to CHH with infective exacerbation
of COPD. He stayed in hospital for a week until 17 January, and then returned to
the prison. His wing history sheet has an entry for 19 January, which states “Not
a good week as he was quite poorly”. At the end of the month, on 28 January, he
had to be reminded to take all his medication when it was given to him. The
man’s wing history sheet also indicates that he felt that staff were incorrectly
refusing to let him out for association, despite the earlier punishment.
36. At the beginning of February, the man was noted to have a pressure sore on his
sacral area (an area of localised damage to the skin and underlying tissue
Final report C187-08 October 2008 11
caused by pressure, shear, friction and or a combination). On 19 February, the
man collapsed and was found to have low blood pressure and low levels of
oxygen saturation. A nebuliser was administered and an urgent doctor’s review
was requested. The man’s condition continued to deteriorate and an ambulance
was called. He had suffered from incontinence and the staff cleaned him before
the ambulance arrived.
37. The man was admitted to HRI at 11.40 am on 19 February under bedwatch
arrangements, which means that two officers remained with him throughout the
day and night time. Normally a prisoner would be handcuffed to one of the
officers but this did not apply to the man as at 1.30pm a governor authorised the
removal of the restraints at the request of a hospital doctor. On 22 February, the
man was transferred to CHH where his treatment continued. With the man’s
consent, a Do Not Resuscitate notice was made.
38. The following week, on 25 February, medical staff made it clear that the man’s
condition was deteriorating. At 10.30am the bedwatch officers withdrew from his
bedside, with the permission of a governor. This allowed the man and his family
privacy during his final moments. A doctor certified his death at 6.10pm.
39. The prison’s contingency plans were activated after the man’s death. The
Governor, the Coroner and the Independent Monitoring Board were informed. A
family liaison officer was appointed. The bedwatch officers returned to Hull,
where they were spoken to by a member of the care team, and a governor
conducted a hot debrief. A book of condolence was placed in the healthcare
centre.
40. A governor and a family liaison officer visited the man’s daughter on 26 February,
and handed all his remaining property to her. She also visited the prison wing
and the cell that her father had occupied. The prison offered to meet the funeral
costs.
41. A post mortem was carried out at HRI on 27 February. It concluded that the
cause of death was due to natural causes. Lung disease was the immediate
cause of death, with ischaemic heart disease as a contributing factor.
Final report C187-08 October 2008 12
ISSUES
The man’s location at HMP Hull
42. The prison ensured that the man’s social and mobility requirements were met.
He was allocated a cell close to the food servery and medical treatment hatch,
which meant that he did not have to use the stairs. He had the use of a
wheelchair when he needed to get from one part of the prison to another. This is
good practice.
Clinical care
43. The clinical reviewer considered whether the care the man received whilst in
custody at HMP Hull was appropriate and comparable to the services he could
expect in the community. She concluded that it was. Referrals were made to
appropriate health care professionals, and the man had access to advice on
request regarding various healthcare issues. He received care and assistance by
nursing and medical staff, including the long-term conditions team, which the
reviewer judges was comparable to care within the wider community.
44. The reviewer also assessed whether different care might have resulted in a
different outcome. She notes that the treatment for the man’s chronic obstructive
pulmonary disease was managed within recommended guidelines for long-term
conditions. Changes to his care were made with reference to appropriate
specialists. It is the clinical reviewer’s view that different care would not have
resulted in a different outcome.
45. The man’s family asked that this investigation consider whether he had received
the correct medication. The man was concerned about his medications and on
several occasions said that he thought he was not receiving the correct
prescriptions. Explanations for his care and treatment were regularly given to
him. On one occasion he was moved to the healthcare centre for observation
and for his medication to be administered after a cell search identified that he had
been stockpiling his medication. At other times he requested medication which
he did not need. The clinical reviewer found no evidence of withholding or
mismanagement of medication.
46. The man was aware of the system for requesting review by staff at Hull, and on
occasion requested that specific staff attend. He was also aware of the system
for summoning emergency attention when he felt he needed it.
47. The man’s care plans and records appear to be comprehensive and were
regularly updated to address his needs. Communication between health
professional staff was documented and actions and plans were identified and
followed up. Communications between the prison’s healthcare and outside
hospitals were also documented.
48. The exception was that on 23 February 2008 the man was noted to have a bed
sore (also known as a pressure sore or pressure ulcer). His medical record does
not show how bad the sore was or whether an action plan was put in place to
prevent further deterioration. The man did not request further attention for the
sore or complain of any pain and he was not referred to a tissue viability nurse.
Referrals are often not made unless an ulcer is of a high grade or does not
Final report C187-08 October 2008 13
respond to treatment. Although there was no follow up, the clinical reviewer
judges that it did not contribute to his collapse and respiratory distress and
different treatment would not have resulted in a different outcome.
The healthcare manager should be reminded of Hull Teaching Primary Care
Trust’s Protocol for the Prevention and Management of Pressure Ulcers,
utilisation of wound management charts, and referral processes for
specialist aids to prevent further pressure area damage.
Information for the family
49. The man’s daughter was concerned that she was not informed each time her
father was taken to hospital. It is prison policy to inform the family when a
medical condition is thought to be life-threatening. I judge that, in the light of the
prison’s responsibility for the security of prisoners and the community, the policy
is reasonable.
Bedwatch arrangements
50. The man was an ill man when he was taken to hospital for the last time. He was
subject to bedwatch arrangements, escorted by two members of staff, and
handcuffed to one of them. However, soon after his arrival, permission was given
for the removal of the restraints. This was a humane act in the circumstances
and the prison should be commended. Whilst security implications are of prime
importance, removing restraints gave dignity and privacy to the man and his
family. The bedwatch officers left the bedside at an early stage which again, is
good practice and the prison should be commended for doing so.
I commend the prison for their decision to remove restraints and bedwatch
officers when it was deemed safe, thus allowing the man and his family
some privacy during his final moments.
Final report C187-08 October 2008 14
RECOMMENDATION
1. The healthcare manager should be reminded of Hull Teaching Primary Care
Trust’s Protocol for the Prevention and Management of Pressure Ulcers,
utilisation of wound management charts, and referral processes for specialist
aids to prevent further pressure area damage.
The Prison Service have accepted this recommendation. They said that the
protocol for the management of pressure ulceration will be redistributed in
October 2008.
2. I commend the prison for their decision to remove restraints and bedwatch
officers when it was deemed safe, thus allowing the man and his family some
privacy during his final moments.
Final report C187-08 October 2008 15