Individual at Hull

The Death of a Man
in hospital
on 11 April 2004
Report by the
Prisons and Probation Ombudsman
for England and Wales
December 2004
CONTENTS
Page
Foreword 2
Summary 3
Arrival at HMP Hull 4
Time in hospital 6
Information about HMP Hull 7
Conduct of the investigation 7
Findings 8
Recommendation 12
Foreword
This is the report of an investigation into the circumstances surrounding the death of
a man on 11 April 2004. He died at a hospital whilst serving a sentence of 18 months
imprisonment.
All deaths of prisoners in custody are investigated, including those due to natural
causes. The responsibility for carrying out these investigations traditionally fell to the
Prison Service, but has now been passed to the Prisons and Probation Ombudsman
to bring independence and greater consistency to the task. In this case one of my
investigators carried out the enquiry.
The man was sentenced to 18 months imprisonment at Hull Crown Court on 16
March 2004 and was then granted Release On Temporary Licence the day before
his death.
My colleagues and I would like to extend our condolences to his family and friends at
their sad loss. We express particular sympathy to his widow. We would also like to
thank the Governor and other members of his staff who assisted us for their help
throughout the investigation. We found staff very helpful.
STEPHEN SHAW CBE
Prisons and Probation Ombudsman
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SUMMARY
1. On 16 March 2004 the man was sentenced to 18 months imprisonment at
Hull Crown Court and the court also recommended that he be deported at
the conclusion of his sentence.
2. At the time of conviction he was 31 years old. He originally came from
Angola. He arrived at HMP Hull on the afternoon of 16 March 2004. He
reported that he was suffering from Lupus and was awaiting a transplant and
chemotherapy. Hull is able to supply full-time medical attention to prisoners
and he was correctly allocated to the prison’s Healthcare Centre (HCC)
following his First Reception Health Screen.
3. Although he spoke very little English medical staff at Hull obtained critical
information about his medication and medical condition from both his wife
and from doctors in the community who had been treating him. He remained
in the HCC at Hull for the next ten days until 26 March 2004 and on that date
he was transferred to hospital.
4. The man remained under escort in the hospital until 10 April 2004. On 9 April
2004 he was transferred to the hospital’s High Dependency Unit and by
07:00 on the morning of Saturday 10 April 2004 he was described by the
senior officer in charge of the escort as being very poorly.
5. The Governor in charge of the prison that day decided to remove his
restraints and to withdraw the escorting staff from the Intensive Care Room.
During the afternoon of 10 April 2004 the governor was informed that his
condition had deteriorated further and accordingly he granted him
compassionate ROTL as he understood that his death was imminent.
6. He died in hospital at 08:50 on the following evening, 11 April 2004. The
report to the Hull coroner from the Home Office Pathologist, who
subsequently examined the man, identified the cause of death as being
pulmonary fibrosis due to systemic lupus erythematosus.
7. The man’s clinical care was reviewed by the Director of Professional
Development at Eastern Hull Primary Care Trust (PCT). Her review
concludes with an observation that his clinical notes at HMP Hull should
have been more clearly written, signed and dated. The Clinical Director at
Hull and East Yorkshire Hospitals’ Trust submitted a letter which noted that
he was a young man with a very serious systemic illness on profoundly
immuno-suppressing drugs. The Clinical Director considered that his life
expectancy was very limited and it was always a significant possibility that
he would develop a life threatening infection while in prison.
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ARRIVAL AT HMP HULL
8. On 16 March 2004 the man was sentenced to 18 months imprisonment at
Hull Crown Court for conspiracy to defraud and the court also recommended
that he be deported at the conclusion of his sentence.
9. He originally came from Angola and he spoke Portuguese but little English.
10. The Prisoner Escort Record (PER) opened on 16 March 2004 at Hull Crown
Court after the man received his prison sentence indicated that there were
both medical and suicide risks. The section of the form where further
information about risk is recorded refers to “blood disorder - lung problems”
and also states that F2052SH was opened at court. (This is a document
which is opened when a prisoner is thought to be at risk of self-harm or
suicide.) The PER shows that the man was received at Hull at 12:40 on 16
March 2004.
11. Towards the end of this inquiry the investigator received copies of a number
of documents handed over to Humberside Police by Hull on 12 April 2004.
These documents include a Suicide Warning Form opened by staff at Hull
Crown Court at 11.30 on 16 March 2004. The form warned staff receiving
the man at HMP Hull that he seemed very depressed and there was concern
about his reaction to the sentence he had just received. He was described
as tearful.
12. On 16 March 2004 when he arrived at Hull a Self-Harm at Risk form
(F2052SH) was opened. When the prison doctor saw him the next day she
wrote on the form thus:
‘’Not depressed, feels ill and wishes to go home because he is very ill.’’
13. F2052SH remained open until 7 April 2004 when a Senior Officer decided it
should be closed as the man was on a bed watch in hospital and was
therefore being closely watched throughout each 24 hour period.
14. As the man passed through reception processes at Hull on the afternoon of
his arrival, a good deal of information about him was recorded on various
documents. The Personal Summary Sheet in his prison record contained his
home address in Hull and his wife’s telephone number. The summary sheet
also indicated that he spoke little English.
15. A First Reception Health Screen was conducted on the same day. He
supplied the name and address of his doctor in the community and told the
nurse who was screening him that he had seen that doctor recently. He
explained that he received steroids daily and that he was suffering from the
serious illness of lupus which is an ulcerous skin condition, especially one
due to direct infection with tuberculosis. He told the nurse that he was
awaiting a transplant and chemotherapy. He said he was due to start
chemotherapy for his lung in three weeks time and he referred to a lung
biopsy in Angola three years previously. He said he had worries about his
general health due to his breathing difficulty.
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16. In the Additional Information box of the Health Screen document the
following information was recorded:
“Speaks very little English so unable to take full history regarding this man’s
physical/mental health status. States feeling low and may harm himself.
Very concerned about his wife. Obvious breathing difficulties. F2052SH
opened. Will require Portuguese interpreter once on HCC wing, for in-depth
medical history. Admit HCC.”
17. The Continuous Medical Record section of the man’s Inmate Medical Record
indicates that he telephoned his wife on the day of his arrival at HMP Hull
and his sister-in-law confirmed the medication he had been receiving in the
community. His widow is also a Portuguese speaking African lady but his
sister-in-law is English.
18. On 17 March 2004 the Continuous Medical Record notes that the prison
doctor, telephoned the man’s doctor who confirmed his lupus and stated that
he needed to go to hospital every three weeks for an injection. The same
entry by a registered nurse concluded thus:
“Please note that Dr B stated that when he starts to get poorly he
deteriorates rapidly and he will require hospital intervention A.S.A.P. Please
closely observe for signs of deterioration.”
19. The man’s Healthcare Care Plan refers to him being admitted to the prison’s
HCC on 18 March for assessment. On 19 March the prison’s Clinical
Director made further contact with the man’s doctor in the community then
on 22 March 2004 an initialled entry in his Continuous Medical Record states
“Please transfer to A Wing, at the moment feels well.”
20. Although the instructions stated that he should be transferred to normal
location on A Wing, he actually remained in the HCC until 26 March 2004.
Entries on 24 and 25 March 2004 in the Care Plan refer to him spending
most of the day in bed.
21. The last entry in his Medical Record was made on 26 March 2004 and states
he had been unwell for the past three days with complaints of tachycardia,
chest pain and shortness of breath. He was transferred to the Acute
Assessment Unit at a nearby hospital following contact with Dr B at that
hospital.
22. During the ten days that the man spent at HMP Hull prior to his transfer to
hospital two entries were made in the Record of Events section of his prison
record. On 20 March 2004 he was described as a quiet man who created no
management problems at present. On 22 March the entry reads as follows:
“Seen by Diversity Manager. Speaks little English. Speaks Portuguese so
Language Line (translation service) may be necessary if problems occur.
Immigration form filled in for the man.”
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TIME AT HULL ROYAL INFIRMARY
23. From 26 March 2004 until shortly before his death on 11 April 2004 the man
was handcuffed whilst at the hospital and was accompanied by two prison
officers at a time. Information about this period is contained in the Hospital
Watch Occurrence Log. The copy of the log made available to the
investigator begins at 19:40 on 26 March 2004 when he was located on ward
70 at the hospital and concludes at 07:00 on 10 April 2004.
24. The log is maintained by prison officers, not medical personnel, and it
therefore provides relatively few insights into the man’s medical condition or
state of mind. There are many references to checks of the handcuffs and
equipment and there are a number of references to management visits being
paid to the man. The log is also a source of information about visits made by
his wife, family and friends. At 13:30 on 31 March 2004 the man complained
that his handcuffs were too tight but the officer on the bedwatch writes that
he and his senior officer checked the cuffs and decided they were okay and
did not need to be loosened. On 1 April 2004 an officer wrote at 12 noon
that the man had been examined by a doctor who stated that his lung
infection would probably clear up in a few days with the antibiotics.
25. Despite that optimistic prediction the man remained in hospital. At 08:00 on
9 April 2004 another officer wrote in the occurrence log that he had been told
by the medical staff that the man had not been taking his medication. The
medical staff also wanted him to have exercise on a regular basis, short
walks up and down the corridor would suffice. At 13:00 the officer wrote in
the log that escort staff had been told by a doctor of a move to the Intensive
Care Unit later that day.
26. At 13:30 the man was transferred to ward three, the High Dependency Unit
at the hospital. At 20:00 a Senior Officer wrote in the log that the man was
“currently weak, on oxygen, drip and wired up.” At 22:30 the same evening
the Senior Officer wrote of nursing staff indicating that there might be a
possibility that they would want his cuffs to be removed quickly in an
emergency. The last entry in the occurrence log was made at 07:00 on 10
April 2004 by the Senior Officer. He recorded that the man had not slept
well and his condition appeared to have deteriorated during the night. The
officer wrote that he had been polite “but is very poorly.”
27. The weekend when the man’s condition worsened was the Easter holiday.
The Governor in charge of HMP Hull over the weekend of Saturday 10 and
Sunday 11 April 2004 was Mr T. In an e-mail to the investigator he
explained that, as a result of lengthy discussions with the hospital authorities
around the man’s worsening condition, he instructed the escorting staff to
remove the restraints and to withdraw from the Intensive Care room. He
added that this decision was designed to allow the man and his family an
appropriate level of privacy and dignity.
28. During the afternoon of Saturday 10 April 2004 Mr T was informed that the
man’s condition had deteriorated further and he approved compassionate
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Release on Temporary Licence (ROTL) on the basis that the man posed no
further threat to the public or risk of escape given that his death was
imminent. Mr T, with a colleague, visited the hospital and spoke at length
with the man’s wife and family friends to explain the conditions of the ROTL
and to offer any support possible under the circumstances. The licence
document is attached to this report. It indicates that the man was released
from prison on temporary licence from 18:00 on 10 April 2004 until 18:00 a
week later. He was licensed to be in hospital, with Mr T signing the
document on the Governor’s behalf and his wife signing for her husband.
29. The escorting staff were duly withdrawn from the hospital and prison
authorities first learned of the man’s death the following day. At
approximately 21:00 on 11 April 2004 the Night Orderly Officer, who was the
most senior officer on duty in the prison at the time, received a telephone call
from a Senior Staff Nurse who informed him that the man had just died in the
Intensive Care Department. The Staff Nurse reported that the time of death
was recorded as being 20:50 with cause of death probably being heart and
lung failure. The Senior Officer was informed that the man’s next of kin and
his wife were present at the time of death.
INFORMATION ABOUT HMP HULL
30. HMP Hull was opened in 1870 and is now a Category B local prison serving
courts in East and North Yorkshire and North Lincolnshire. Hull receives
prisoners directly from court. A major expansion programme, completed in
late 2002, added 356 places to the prison’s operational capacity and a
further 40 places were added in March 2004. The certified normal
accommodation is 812 but the operational capacity (the maximum number of
prisoners who can be held) is 1071.
31. The HCC at the prison is a new purpose built two-storey building which
opened in April 2003. The HCC provides 24-hour nursing care with the in-
patient unit being located on the upper level of the building.
CONDUCT OF THE INVESTIGATION
32. After the man’s death the investigator visited Hull and obtained all relevant
documentation relating to the ten days that he spent at the prison between
16 and 26 March 2004. In addition to such internal documents as his Inmate
Medical Record and Core Prison Record, the investigator obtained a copy of
the Hospital Watch Occurrence Log which was maintained at the hospital
between 26 March 2004 and 10 April 2004.
33. The investigator wrote to the coroner for East Riding and Kingston upon Hull
and received a copy of the post mortem report. A pathology Professor at
Sheffield University reported to the coroner that the cause of death was
pulmonary fibrosis due to systemic lupus erythematosus The professor
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concluded that the degree of lung disease present was sufficient to account
for the man’s death The professor added that it was a death from natural
causes.
34. My Family Liaison Officer wrote to the man’s widow on 14 June 2004 but,
although the letter was sent to the correct address in Hull, she did not
receive it. A further effort to make telephone contact with her was successful
and the investigator visited her at her home in Hull on 15 July 2004. She did
not speak English well but on that occasion she was accompanied by her
English sister in law and by a Brazilian friend who acted as translator. She
expressed a number of concerns about her husband’s treatment as recorded
in the investigator’s letter to her of 16 July 2004. The investigator
commissioned a clinical review of the case from the Director of Professional
Development at Eastern Hull PCT. I am very grateful indeed to the clinical
reviewer for the review document she submitted to the investigator on
18 August 2004. It is attached to this report.
35. The clinical reviewer additionally commissioned a professional opinion from
the clinical director at Hull and East Yorkshire Hospitals’ Trust regarding the
care given to the man. He reported on the man as follows in a letter to the
clinical reviewer of 2 August 2004
“He was a young man with a very serious systemic illness, on profoundly
immuno-suppressing drugs. His life expectancy was very limited, and it was
always a significant possibility that he would develop a life threatening
infection while in prison. The severity of his illness was recognised as soon
as he arrived at Hull Royal Infirmary and his subsequent management (and
documentation thereof) is good. Unfortunately, despite all appropriate
attempts to treat his infection, he deteriorated and died.”
36. Both the clinical reviewer and the clinical director are highly experienced
clinical professionals who work in complete independence from the Prison
Service.
FINDINGS
37. As soon as the man arrived at Hull on the afternoon of 16 March 2004 he
supplied information about his serious medical condition to Healthcare staff.
38. He was appropriately located in the prison’s HCC following his First
Reception Healthscreen and the prison acted with commendable speed to
find out additional relevant medical information. On the day of his arrival a
phone call was made to his wife to establish the medication he had been
receiving in the community.
39. Prompt efforts were made by the doctor at Hull to make contact with her
colleagues in the community who had been treating the man. By the day
after his arrival at the prison his lupus had been confirmed, the medical
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authorities at the prison knew he needed an injection every three weeks and
they also knew that his condition could deteriorate rapidly.
40. During the meeting that the investigator had with the widow in Hull on 15
July 2004 she expressed a number of concerns about her husband’s
treatment in prison. She spoke of a senior medical lady at the prison telling
her husband that he was too sick to be in prison. In her letter to the
investigator of 13 August 2004 the clinical reviewer wrote that there is no
evidence within the clinical notes of such a conversation. She adds there is
evidence that the prison doctor contacted Dr B at Hull Royal Infirmary for
confirmation of lupus disease on 17 March 2004.
41. His widow also said that her husband became depressed once in prison but
the clinical reviewer comments there is no evidence within the clinical notes
that depression was detected or recorded.
42. The man’s wife expressed concerns about what her husband had eaten and
drunk whilst in Hull Prison. The clinical reviewer reports in her letter of 13
August 2004 that within care plan 1 it is recorded on 24 March 2004 that the
man was reluctant to take the prison diet. An entry on the following day
states that he was accepting light diet only. The clinical reviewer observes
that “there is nothing within written notes that he was refusing fluids or that
fluids were being encouraged.” There is, however, a reference in the
Continuous Medical Record dated 16 March to him having difficulty with
food. The doctor wrote that he should have Fortisip and cranberry juice.
Fortisip is a high energy milk shake-style dietary supplement. There is a
Care Plan 1 entry for 19 March which states that the man accepted his
Fortisip supplement on that date.
43. The Continuous Medical Record reports that on 26 March 2004, after the
man had been feeling unwell for the previous three days, he was transferred
to hospital.
44. He had been recommended for deportation at the end of his prison sentence
and in those circumstances the decision that he should be escorted at the
infirmary by two prison officers was appropriate.
45. At her meeting with the investigator on 15 July 2004 his widow asked why he
had been handcuffed for so long in hospital and felt that he should have
been granted ROTL at an earlier stage. The Hospital Watch Occurrence
Log Notes suggest that his condition deteriorated markedly on Friday 9 April
2004. An entry at 13:30 on that date states that he was moved to the High
Dependency Unit (ward three). A possible indication of a further worsening in
his condition is the entry at 22:30 on 9 April when the nursing staff indicated
to escorting prison officers that his handcuffs might have to be removed
quickly in an emergency. By 07:00 on 10 April 2004 the Senior Officer, who
was in charge of the escort, wrote that his condition “appears to have
deteriorated during the night. He has been polite but is very poorly.” The e-
mail submitted to the investigator by the governor who was in charge of Hull
over the Easter weekend indicates responsiveness to the changing situation
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at the infirmary. The governor’s first decision, after lengthy discussions with
the hospital authorities around the man’s worsening condition, was to
instruct his escorting staff to remove the man’s restraints and to withdraw
from the Intensive Care Room The governor wrote that his motivation was to
allow the man and his family an appropriate level of privacy and dignity. This
was a humane and commendable decision.
46. On the afternoon of Saturday 10 April the governor was informed that the
man’s condition had deteriorated further and, after consulting with the
governing governor at Hull, he approved the man’s ROTL on compassionate
grounds. The governor writes quite openly that the basis for his decision
was his knowledge that the man posed no further threat to the public or risk
of escape given that his death was imminent. This again was a decent and
humane decision on the governor’s part. Despite his widow’s criticism the
available documentation (and in particular the licence document timed to
commence at 18:00 on 10 April 2004) suggests that the governor responded
as quickly as he could to the information he was receiving about the man’s
rapidly changing and deteriorating medical condition.
47. The expert medical contribution supplied by the clinical director at Hull and
East Yorkshire Hospitals Trust, notes that the man was young with a very
serious systemic illness on profoundly immuno-suppressing drugs. “His life
expectation was very limited and it was always a significant possibility that
he would develop a life threatening infection while in prison.”
48. The clinical review submitted on 18 August 2004 concludes by referring to a
Learning Event as follows
“That notes should be clearly written, signed and dated. The person writing
the notes should also print their name and designation.”
49. The clinical reviewer subsequently expanded her advice to the investigator in
a later communication dated 7 October 2004 as follows:
‘’The Nursing & Midwifery Council guidelines for records and record keeping
state that good record keeping helps to protect the welfare of patients and
clients by promoting
• high standards of clinical care
• continuity of care
• better communication and dissemination of information between
members of the inter-professional health care team
• an accurate account of treatment and care planning and delivery
• the ability to detect problems, such as changes in the patient’s or
client’s condition, at an early stage
Thus on reviewing the clinical records these standards should be adopted. ‘’
50. Issues raised by this report were discussed at a meeting held in Hull on 30
September 2004. The meeting was attended by key personnel from Eastern
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Hull Primary Care Trust (PCT), Hull Prison and the Prisons and Probation
Ombudsman’s Office.
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RECOMMENDATION
The Learning Event identified by the Director of Professional Development at
Eastern Hull PCT is drawn to the attention of the Governor at HMP Hull and
to the PCT. The Director provides evidence for her observation in the body
of her clinical review and her recommendation is endorsed by the
investigator. The prison and PCT have already drawn up an Action Plan to
determine how professional performance is to be improved in this area. A
copy of the relevant section of the HMP Hull Prison Healthcare Action Plan,
with a covering letter dated 13 October 2004 from the Assistant Director
Prison Healthcare at HMP Hull, is attached to this report.
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