Individual at Leeds

Investigation into the circumstances surrounding the
death of a prisoner who died in the Leeds General
Infirmary in March 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
August 2005
CONTENTS
Summary
The investigation process
The Prisoner
HMP Leeds
HMP Acklington
Events leading up to the prisoner’s death
Events after the prisoner’s death
Findings and conclusions
Recommendations
This is the report of an investigation into the death of a prisoner who died on
11 March 2005 in Leeds General Infirmary. The cause of death was cancer of
the lung.
The prisoner had been released on temporary licence from HMP Leeds during
the final stages of his illness.
One of my investigators, conducted this investigation. A clinical review into
the prisoner’s care and treatment was requested from the Leeds (West)
Primary Care Trust.
I would like to extend my condolences to the prisoner’s family for their loss. I
would like to thank the Governor of Leeds, and his staff, for their help and co­
operation during this investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2005
Summary
On 11 March 2005, the prisoner died in Leeds General Infirmary, having been
released on temporary licence by HMP Leeds on 28 February on
compassionate grounds. He was 67 years old.
In March 2003, he was sentenced to four and half years imprisonment for
sexual offences and supplying a class ‘B’ drug. This was not his first time in
prison. On sentence, the prisoner was transferred to Leeds and shortly
thereafter to HMP Acklington. On entering prison, the prisoner had been
diagnosed with chronic pulmonary fibrosis. He also suffered from
osteoporosis, for which he was receiving the appropriate monitoring and
treatment. However, from June 2004, he started to complain of chest pain as
well as suffering from a severe shortage of breath. Hospital investigations did
not identify any sinister cause.
Throughout the later stages of 2004, the prisoner continued to experience
chest pain and it was noted by staff that there was a continual deterioration in
his physical condition, particularly weight loss. His deterioration necessitated
24­hour medical care. On 21 January 2005, the prisoner was therefore
transferred to Leeds from Acklington. Whilst at Leeds he was referred for
further investigative tests at Leeds General Infirmary. Whilst an inpatient in
hospital, the prisoner was subject to a bed watch by prison officers because of
the nature of his offences. He was subject to restraints until 18 February.
However, at the end of February, Leeds decided that his physical condition
and the prognosis for recovery was such that further risk to the public was
low. In light of this, the prisoner was released on a temporary licence.
The clinical review concludes that the management of the prisoner’s chest
pain was appropriate. Between September 2004 and January 2005, a lung
cancer developed, but the clinical review concludes that this could not have
been detected earlier. He was a former coal miner who smoked very heavily.
I make no recommendations in this report
The investigation process
1. The investigation was opened at Leeds on 15 March 2005 when my
investigator contacted Leeds. The Governor and his staff produced the
prisoner’s core record, his medical record and a number of other
documents for examination. Notices were issued to staff and prisoners
informing them of the investigation.
2. My Family Liaison Officer, contacted the prisoner’s family on 26 April,
offering them the opportunity to meet with her and the investigator to
discuss the purpose of the investigation, and to raise any concerns or
questions that they would like explored and addressed. The family are
concerned that the prisoner was not receiving the appropriate care and
attention in prison. There is also concern that the lung cancer was not
detected at an earlier stage particularly in light of his physical deterioration.
3. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and the scope of my investigation and to request a copy of the Post
Mortem report. Upon completion, my report will be sent to the Coroner to
assist him in his enquiries into the prisoner’s death.
4. The Leeds (West) Primary Care Trust were asked to provide a clinical
review into the care that was given to the prisoner whilst he was in
custody. Because the prisoner had only recently transferred to Leeds from
Acklington there has been some delay in obtaining the necessary
information from the Northumbria Primary Care Trust in order for the
clinical review to be completed.
The prisoner
5. He was born in April 1938, in West Yorkshire. He had a partner for
approximately 20 years but the relationship broke down about four years
ago. Despite the breakdown, they remained friends. Contact was
maintained through letters, telephone calls and visits. The prisoner also
had an 18­year­old son from this relationship with whom he also
maintained contact.
6. Up until his sentence the prisoner lived in Pontefract, West Yorkshire. For
most of his working life he had been a coalminer in the Yorkshire area and
had also worked as a security watchman on a building site.
7. This was not his first experience of prison. He had previous convictions
dating from 1957 for a variety of offences. In January 2003, he was
convicted by Leeds Crown Court for a number of sexual offences. He
was also found guilty of supplying a Class ‘B’ drug. In addition, he failed
to appear at court whilst on bail resulting in a warrant for his arrest and he
subsequently received a term of imprisonment for this offence. On 14
March 2003, the prisoner was sentenced to four and a half years
imprisonment.
8. On sentence the prisoner went to Leeds prison, but on 26 March 2003 he
was transferred to Acklington where he quickly settled into the regime. He
did not present any disciplinary problems and was described as a quiet,
courteous and polite man. At Acklington, the prisoner took up employment
as a cleaning orderly but due to his breathing difficulties had to give this
up. He did not attend study groups or make use of the facilities and spent
much of his time watching TV in his cell. In light of his good behaviour, the
prisoner was given enhanced privileges.
9. The prisoner’s parole eligibility date was set for 15 April 2005. He had
hoped for parole and understood that this would be dependent upon him
securing a place in an Approved Premises in the Leeds area as well as a
commitment to address his offending behaviour. During an assessment
at Acklington, the prisoner commented that because of his deteriorating
health he did not envisage a long life after his release.
10.Because of ailing health, the prisoner was a frequent outpatient at
Wansbeck Hospital, Northumberland. Prison records indicate that he
attended the hospital 13 times from 4 July 2003 to 8 December 2004 for
chest X­rays and blood tests, primarily in relation to his known respiratory
condition. On each of these appointments, he was subject to restraints
and escorted.
11.In mid July 2004, the prisoner complained of pain in the left side of his
chest. The pain was worse on breathing in. Acklington referred him to
hospital where he underwent some tests on his heart. Nothing was
identified and it was the opinion of the hospital that he had pulmonary
fibrosis that was consistent with his chest condition.
12.By 10 September, he was still suffering pain in his chest and on several
occasions he almost fainted. On 15 September, in conversation with staff,
the prisoner threatened to hang himself because the pain was getting him
down. On the advice of the prison doctor he was prescribed codeine and
observed.
13.On 16 September, the priaoner looked unwell and complained of dizziness
for which he was given oxygen and codeine. He was still complaining of
chest pains and was admitted to hospital once again for investigation. The
tests indicated that the most likely cause of pain was muscoskeletal chest
pain. On 30 September, whilst in the healthcare centre at Acklington, he
again complained of chest pains. He was told that this was pleurisy and
advised to rest.
14.In early October, the prisoner was still complaining of pains in his chest
and the fact that the medication he was on was not strong enough to ease
the pain. He also complained that the health care centre was not doing
enough for him, despite being told by health staff that recent hospital tests
had not identified anything sinister.
15.On 15 October, a letter from Wansbeck Hospital to the healthcare centre
at Acklington about recent tests carried out on himidentified inflammation
and stiffening of the lung due to unknown causes. As a result, he was
given steroids and by 18 October this treatment appeared to be working.
16.However, by 24 October, the prisoner was again asking for more codeine
and was disgruntled that the dosage had not been increased. He had also
threatened to press his cell bell continuously if he did not receive more
codeine. Staff told him that an increased dosage could aggravate his
chest condition and that the pain he was experiencing was consistent with
his known medical condition.
17.Throughout November and December, he was still complaining of chest
pains and was making persistent attempts to obtain a higher dosage of
codeine. Health care staff rejected his requests for more codeine. They
also noted that the prisoner was suffering from insomnia and anxiety. He
requested once again to be seen by an outside hospital. He was
described as looking frail, having lost a significant amount of weight.
18.On 29 November, he threatened to hang himself unless he was taken to
an outside hospital or given stronger painkillers. The prisoner was not
happy with the treatment he was receiving. An emergency appointment
was made for him to see the hospital doctor. He had threatened to harm
himself because of the pain, and he was duly placed on an open
F2052SH, a form to monitor prisoners at risk of suicide or self­harm. His
intention to self­harm was taken seriously and he was subject to
observation. he was asked if he wanted to confide in a prison ‘Listener’
but he declined the offer. The prison doctor also saw himand assured him
that following a series of tests carried out at Wansbeck Hospital in
September, nothing untoward or sinister had been found.
19.Throughout December 2004 and January 2005, the prisoner continued to
lose weight and complain of chest pain. By 6 January, it was noted that he
had lost approximately half a stone in weight in three weeks. He weighed
eight stone. He was skeletal and grey in appearance and looked
exhausted. He was encouraged to take liquid supplements, and it is at
this time that Acklington considered that the prisoner would require 24
hour care because of his deteriorating physical condition. Acklington could
not provide such care and alternative locations in the prison estate were
sought. By 18 January, staff and fellow prisoners at Acklington were
concerned that the prisoner was not eating or able to see to his own
hygiene needs. It was noted that he had spent a lot of time in his cell and
had not changed his clothes. It was becoming more apparent to staff that
he required constant care. A senior manager urged that arrangements be
made for the prisoner to transfer to another establishment where he could
receive such care.
HMP Leeds
20.Leeds is one of the largest local prisons in the country. It has a 24­hour
health care centre with a capacity to accommodate up to 55 patients.
Patients requiring specialist healthcare are identified promptly and referred
to a visiting specialist or the NHS.
21.The healthcare centre at Leeds provides a comprehensive primary care
service with a good medical screening for new prisoners. There is
provision for secondary care consultation and treatment in a range of
specialist and general hospitals in the Leeds area. The relationship
between patients and staff is described as good.
22.It should be noted that the prisoner was transferred from Acklington to
Leeds on 21 January 2005, and only spent eleven days in Leeds before he
was transferred to an outside hospital for investigation and treatment.
HMP Acklington
23.Acklington is a category C prison for convicted adult males, opened in
1972. It is a former RAF station and is the most northerly prison in the
country.
24.There are ten residential units of various designs. The prison can
accommodate up to 882 prisoners, half of whom are vulnerable prisoners.
25.Acklington does not have a full time medical officer and does not have an
inpatient facility. An unannounced inspection by Her Majesty’s Chief
Inspector of Prisons (HMCIP) was conducted in April 2003. The HMCIP
report highlighted some concerns in respect of the needs of older
prisoners, and those with health conditions requiring a level of care that
could not be provided at Acklington.
26.However, the HMCIP report said that good working relationships had been
developed between the establishment and the regional prison health
taskforce. A primary care contract had been agreed with the
Northumberland Healthcare Trust and the delivery of healthcare is to
National Health Service (NHS) standards.
Events leading up to the prisoner’s death
27.The prisoner began his sentence with serious health problems. On
reception at Acklington he was known to be suffering from chronic
pulmonary fibrosis, mainly emphysema, for which he needed inhalers. He
was also taking daily medication for the prevention of osteoporosis. He
was a heavy smoker and continued to smoke despite his breathing
difficulties. Throughout his sentence, he was encouraged to give up
smoking by staff.
28.Initially it was hoped to transfer the prisoner closer to his family and
tentative enquiries were made with HMP Hull. However, a place could not
be found for him. Alternative arrangements were made for him to transfer
to Leeds, which has 24­hour medical care.
29.The prisoner was transferred from Acklington to Leeds on 21 January,
primarily so that he could receive 24­hour care for his physical condition.
His Inmate Medical Record (IMR) was transferred with him to Leeds. A
letter from a medical officer at Acklington addressed to the his
counterparts at Leeds, said that in the preceding months the prisoner had
been complaining of pains around the back of his neck and left side of his
chest. These complaints had been investigated whilst he was at
Acklington but no sinister underlying cause was detected. Indeed, it was
considered that he was suffering from muscoskeletal pain. For this he was
treated with suitable analgesics. The letter said that the temptation to treat
these symptoms with increasing dosages of codeine was resisted by
medical staff at Acklington, because codeine would agitate his respiratory
condition. It also said that the prisoner had a previous history of codeine
abuse. At this time it was noted that he was looking very frail. He was
also experiencing problems with his mobility.
30.The transfer between prisons took place by taxi. Because of his condition
the prisoner was not restrained. A uniformed prison officer and a member
of the nursing staff escorted him from Acklington to Leeds.
31.On arrival at Leeds, he was taken to the health care centre for an initial
health screen and assessment.
32.It was noted that the prisoner was able to speak in full sentences but could
only walk very short distances before becoming breathless. He continued
to complain of a pain in the left side of his chest. He was fully aware that
investigations into the cause of his pain had taken place at Acklington and
the Wansbeck Hospital, and that no sinister underlying cause had been
detected. The prisoner was initially located in the health care centre at
Leeds where he could be observed and treated.
33.By 26 January, he had settled down well at Leeds and it was hoped that
he could be discharged onto a residential wing, provided that an
appropriate discharge plan was in place. The plan included daily blood
pressure and breathing checks, as well as weekly weight checks.
Arrangements were made for himto be moved to a ground floor cell on ‘A’
wing.
34.However, at 6.45pm on 26 January, health care staff were called to the
prisoner’s cell because he was suffering from breathlessness and pain in
his chest. At 12.50am on 27 January, staff were asked to attend his cell
once again as he was still experiencing breathlessness. It was decided to
move his mattress onto the floor of his cell to assist with his breathing and
comfort.
35.On 29 January, the prisoner was still complaining of pains in his chest and
was taking codeine and analgesics for them. He was also being
encouraged by staff to take nutritional drinks in order to build up his
strength.
36.By 31 January, staff became alarmed at his continued physical
deterioration. He was finding it increasingly difficult to move about. It was
apparent that he could not cope on the residential wing and it was decided
that the prison doctor should see him, with a view to transferring him back
to the health care centre. The prison doctor decided that day to refer the
prisoner to Leeds General Infirmary for investigations.
37.At Leeds General Infirmary, he was treated with intravenous fluids to keep
him hydrated. He was also given supplements to build up his weight.
Whilst being treated at hospital, the prisoner was subject to bed watch by
uniformed prison officers. He was restrained by escort chain on the basis
that, because of his offence, it was perceived that he posed a risk to the
community. The system of bed watch supervision continued from 31
January until 28 February. However, in the light of his deteriorating
condition the level of risk that he posed was re­assessed by Leeds. From
18 February, he was still subject to observation by prison officers but was
not restrained.
38.On 24 February, following tests that included a CT scan and a biopsy, it
was discovered that the prisoner had primary pulmonary adenocarcinoma.
No active treatment was possible and the prognosis for a recovery was
very poor. The prisoner was made aware of this diagnosis and palliative
care was suggested. It was proposed that he should receive such care in
a hospice close to his family. Unfortunately, he died before arrangements
could be made to transfer him to a hospice.
39. At the end of February, in light of his deteriorating health, the prisoner was
released on temporary licence (ROTL) on compassionate grounds. At this
time he was seriously debilitated although he could still write letters and
make telephone calls. These were monitored by the prison under the
terms of the licence. His family took the opportunity to visit him whilst he
was in hospital.
40.At 6.40am on 11 March, the prisoner died in Leeds General Infirmary.
Because he had been released on a temporary licence there was no
member of prison staff with him at the time of his death. At 6.45am the
hospital told the duty governor of the prisoner’s death.
Events after the prisoner’s
41.A member of the prison chaplaincy, visited the prisoner’s ex­partner at her
home address and told her of his death. The family had anticipated his
death, although they expressed surprise at the speed of his physical
deterioration. The Chaplain continued to maintain contact with the
prisoner’s family. The family asked him to conduct the funeral. The
funeral took place on 29 March. The prison assisted the family in arranging
the funeral and provided financial assistance.
42.On 26 April, a Family Liaison Officer from my office, contacted the family.
The prisoner’s have expressed some concern in regard to the care and
treatment afforded to him whilst he was in custody, and in particular why
cancer was not detected at an earlier stage.
Clinical review
43.The clinical review undertaken by the Leeds (West) Primary Care Trust
concludes that the prisoner had Fibrosing Lung Disease, possibly related
to his coal­mining career. He was a heavy smoker. He developed a non­
operable lung cancer (not the type normally related to smoking). The
management of his chest disease appeared to be appropriate. He
complained of chest pain on several occasions. This chest pain was
investigated appropriately. As recently as September 2004, he had
detailed examinations of his chest that revealed no cancer. Between
September 2004 and January 2005, a lung cancer developed which
proved inoperable. It is possible that during this period some of his
symptoms related to this but again no abnormality was seen on an x­ray of
his spine and ribs. The clinical review concludes that his medical care was
appropriate and that it was not possible to detect the cancer at an earlier
stage.
Findings and conclusions
44.The prisoner entered custody with very serious physical health problems,
notably a progressive lung disease. This condition was being monitored
and assessed regularly by the healthcare centre at Acklington, with
frequent referrals to Wansbeck Hospital for x­rays.
45.Whilst at Acklington, he had complained of pains in the left side of his
chest. It was a firmly held opinion of healthcare staff that the prisoner’s
worsening health was symptomatic of his known medical condition.
Investigations at Wansbeck Hospital did not identify any other underlying
cause for the pain he was experiencing. Although he requested higher
dosages of codeine to quell the pain, this request was refused primarily
because such medication could have aggravated the prisoner’s respiratory
condition.
46.Acklington does not have a facility for inpatients, and was therefore unable
to provide the prisoner with 24­hour medical care. On realising that his
condition was deteriorating, arrangements were quickly made to provide
him with the appropriate care at another establishment that was close to
his family. His condition continued to deteriorate, and Leeds correctly
referred the prisoner for further investigation at Leeds General Hospital
where it was established that he had cancer of the left lung. The disease
was extensive and the prognosis poor, so palliative care was the only
recourse.
47.The clinical review concludes that, whilst in custody, the prisoner’s chest
pains were investigated appropriately and that the management of his
chest disease was appropriate. Between September 2004 and January
2005, a lung cancer developed that proved inoperable. The clinical review
suggests that during this time it was possible that some of the symptoms
related to the development of cancer, but that no abnormality was seen on
the x­ray of his spine or ribs. It seems that the prisoner’s medical care
was appropriate and that it was not possible to detect the cancer at an
earlier stage.
48.In light of the prisoner’s rapidly deteriorating condition, it was decided to
release him on temporary licence on compassionate grounds at the end of
February. This I hope will reassure the prisoner’s family that he was at
least afforded some privacy and dignity in the last days of his life.
Recommendations
I make no recommendations in this report.