Individual at Leicester

Investigation into the circumstances surrounding the
death of a man
at Leicester Royal Infirmary in June 2006,
whilst a prisoner at HMP Leicester
Report by the Prisons and Probation Ombudsman for
England and Wales
November 2006
This is a report into the circumstances surrounding the death of a man at Leicester
Royal Infirmary in June 2006. Prior to his transfer to hospital, the man was a
prisoner at HMP Leicester. He was 80 years old when he died.
The death of a loved one is always distressing. I would like to add my condolences
to the man’s family and loved ones to those already expressed by one of my Family
Liaison Officers.
The man arrived at HMP Leicester on 22 September 2005, after being remanded
into custody by Leicester Magistrates’ Court. Prior to being remanded, the man had
been an in-patient at Leicester General Hospital and he was returned there, under
escort, just hours after his arrival at the prison. He spent the next month at the
hospital before returning to HMP Leicester on 24 October. He was located in the
Healthcare Centre, where a cell with specialist facilities had been set up in
anticipation of his discharge from hospital. The man was admitted to hospital, on
this occasion the Leicester Royal Infirmary, on 30 May 2006 and, over the next two
weeks, his condition steadily deteriorated. He died in the early hours of 13 June.
The man suffered from a number of serious health problems that presented a
significant challenge to HMP Leicester. I was pleased to find that the prison
allocated extra resources for his care and that staff were recruited solely to cater for
his individual needs. I am more than satisfied that the measures put in place helped
ensure that the man was treated with both dignity and respect at a time of great
vulnerability and ill-health.
I make two recommendations in light of my investigation into the circumstances
surrounding the man’s death, which are directed to the Eastern Leicester Primary
Care Trust. I also cite one example of good practice, which reflects positively on
HMP Leicester and the Primary Care Trust.
I question why a frail elderly man with such deteriorating health and chronic diseases
was given a custodial sentence in the first place. With that in mind, I propose to
share this report with the Department for Constitutional Affairs.
Emma Bradley
Deputy Prisons and Probation Ombudsman November 2006
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CONTENTS PAGE
Summary 4
The Investigation Process 5
HMP Leicester 6
Key Findings 7
Issues 10
Recommendations 12
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SUMMARY
The man who is the subject of this report appeared at Leicester Magistrates’ Court
on 22 September 2005 and was remanded into the custody of Leicester prison.
Upon his arrival he disclosed to the reception staff that he suffered from a number of
physical health problems, including visual impairment, reduced mobility, reduced
physical capacity, difficulty with co-ordination, severe disfigurement and a
progressive condition. After further examination, the prison doctor concluded that
Leicester could not adequately care for him. Arrangements were therefore made for
him to be admitted to Leicester General Hospital, where he had previously been an
in-patient.
On 24 October, the man returned to the prison. In the interim, a package of care had
been put in place to deal with his complex needs. Specialist medical equipment was
acquired and two dedicated nursing staff were employed so that he could be treated
24 hours a day.
Between October and early March 2006, the man settled into a routine and his
health remained stable. On 6 March, he was admitted to Leicester Royal Infirmary,
although he was discharged to the prison the next day after tests concluded that no
medical intervention was needed.
On 17 April, the man experienced a ‘fit’. This caused him to vomit and resulted in
him becoming extremely confused. He was taken to the Accident and Emergency
Department of Leicester Royal Infirmary, where he was admitted a short time later.
He returned to Leicester prison on 19 April.
On 28 April, the man was taken to Leicester Royal Infirmary after clinical tests
revealed that the potassium levels in his blood were dangerously low. He remained
at the hospital until 25 May, by which time his condition had been stabilised.
However, later that day and again in the early hours of 26 May, he suffered further
‘fits’. Healthcare staff were preparing him for a further hospital admission when his
health started to improve. He therefore remained at Leicester prison until 30 May, by
which time his health had deteriorated again.
Over the next couple of weeks, the man’s condition steadily worsened and he died in
the early hours of 13 June. After his death, the prison and local police made
concerted efforts to track down a suitable family member to inform of his death, as
he had earlier stated that he had no relatives. At 1.00pm on 13 June, one of the
prison chaplains informed a cousin of the man’s of his death.
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THE INVESTIGATION PROCESS
1. My investigator considered the man’s prison documentation, including his
clinical records, before formally opening the investigation on 13 July 2006.
2. Prior to my investigator arriving at Leicester, notices were issued to staff and
prisoners announcing the investigation and inviting anyone who had information
relevant to the man’s death to make themself known to the investigator. In the
event, nobody came forward. Informal interviews were conducted with the
manager of the healthcare centre, and three members of his team. Discussions
also took place between my investigator and the Governor.
3. One of my Family Liaison Officers contacted the man’s next-of-kin to offer them
the opportunity to participate in the investigation process. I hope that this report
addresses any concerns they may have about the circumstances surrounding
his death.
4. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of the investigation and to request a copy of the post mortem report.
Upon completion, this report will be sent to the Coroner to assist him in his
enquiries.
5. Eastern Leicestershire Primary Care Trust conducted a review of the care the
man received whilst in prison.
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HMP LEICESTER
6. HMP Leicester is a Category B local prison situated in the centre of the city. It
is a Victorian establishment with an operational capacity of 385 prisoners.
7. The prison was last inspected by Her Majesty’s Chief Inspector of Prisons in
July 2003. In terms of healthcare provision, the Chief Inspector’s report notes
that
‘[p]risoners had good access to healthcare staff through a triage system and by
reporting special sick, and they were seen the same day. Healthcare staff also
visited the wings everyday.’ The report continues,
’the in-patient facility was well cared for, and patients were provided with a
rudimentary regime. The pharmacy provision was excellent, and a pharmacy
technician was present in the prison every week day morning.’
8. Since April 2004, when my office became responsible for the investigation of all
deaths in prison custody, there have been eight other deaths at Leicester: five
apparently self inflicted, two from natural causes and one homicide.
9. Healthcare at the prison is commissioned by Eastern Leicester Primary Care
Trust. The healthcare in-patient unit has 11 beds, ten of which are in shared
cells. The remaining bed is located in a large, single occupancy cell which the
man occupied throughout his time at the prison.
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KEY FINDINGS
10. The man appeared at Leicester Magistrates’ Court on 22 September 2005,
charged with a number of serious offences. His application to be released on
bail was refused and his case was committed to Leicester Crown Court. He
was remanded into the custody of Leicester prison, and arrived there at
1.50pm.
11. Upon his reception at Leicester, the man was subject to a health screening. He
disclosed to the nurse conducting the assessment that he suffered from a
number of physical health problems, including visual impairment, reduced
mobility, reduced physical capacity, difficulty with co-ordination, severe
disfigurement and a progressive condition. Further examinations conducted by
the nurse and a doctor revealed that the man had partial blindness in his right
eye, diabetes, poor memory, limited mobility requiring the use of a wheelchair
and problems controlling his bodily functions. Based on the health screening,
the doctor concluded that “Leicester prison cannot provide the nursing care
required at present”. Arrangements were therefore made to return the man to
Leicester General Hospital, where he had been an in-patient for a number of
months prior to being remanded into custody. The man left the prison at
4.00pm and was located on Ward 6. He was guarded by prison staff and
restrained in accordance with the bedwatch policy.
12. During the morning of 28 September, the man was discharged by Leicester
General Hospital. He returned to the prison, where he was assessed by a
doctor who deemed him fit to appear in court. He was then taken to Leicester
Magistrates’ Court, but returned shortly afterwards, his case having been
further adjourned until 26 October. At 11.15am, the man was taken by taxi to
Leicester General Hospital, where he was once again admitted as an in-patient
under prison escort.
13. The man spent the next month in hospital. Healthcare staff from the prison
maintained contact with the hospital, in order to monitor his progress. On 12
October it was noted that the man’s health had deteriorated and that he needed
two members of nursing staff to assist him with basic tasks such as washing
and dressing. However, his condition stabilised and he was returned to
Leicester prison on 24 October.
14. Due to his chronic health problems, the man needed a dedicated medical care
package that was over and above what is normally provided by the healthcare
centre at Leicester. Before he was discharged from the hospital, the manager
of the healthcare centre managed to secure additional funding, so that a
specialist bed and mattress could be acquired for the man, as well as a number
of other items of equipment that were necessary to care for him properly.
Funding was also secured to employ two extra nursing assistants to care for the
man during the night. The nature of his health needs meant he had to be
turned and treated in his bed at least every two hours.
15. On 27 October, a care plan was drawn up by healthcare staff which detailed
how his health problems were to be managed. Particular attention was given to
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how best to deal with the issue of his confinement to his bed, which gives rise
to medical problems of its own, such as pressure sores. As most, if not all, of
the man’s health problems were degenerative in nature and therefore likely to
get worse over time, the focus of the plan was on making him as comfortable as
possible and ensuring that he did not experience unnecessary pain.
16. Between October and early March 2006, the man settled into a routine that
consisted of him being turned and treated at regular intervals. His physical
condition remained pretty constant over this time, although he did have good
days and bad days. On 6 March, he was admitted to Leicester Royal Infirmary
after an obstruction in his bowels was detected. However, he only stayed at the
hospital for one night before being returned to prison, tests having concluded
that no medical intervention was needed to treat the problem.
17. During the morning of 17 April, the man who is the subject of this report
experienced a ‘fit’. This caused him to vomit and resulted in him becoming
extremely confused. On the advice of a doctor, the man was taken to the
Accident and Emergency Department of Leicester Royal Infirmary, where he
was admitted a short time later. At some point during the afternoon the man
collapsed and fell unconscious. He was moved to the resuscitation unit, where
he was given oxygen. He subsequently regained consciousness and was
moved to a regular ward. He remained at the hospital until 19 April, when he
was again discharged to the prison.
18. On 24 April, the man appeared at Leicester Crown Court, where he received a
sentence of 12 years’ imprisonment. He was returned to Leicester prison later
in the day, and upon his reception to the healthcare centre his mood was
described as “subdued”.
19. As the man was now a sentenced prisoner with a distant release date (the
earliest he could have been released under the parole system was September
2011), Leicester set in motion the process of attempting to transfer him to an
establishment more suited to his needs. HMP Norwich, which has a specialist
unit for elderly and infirm prisoners, was approached on 25 April, but it had no
spaces.
20. During the night of 26-27 April, the man vomited and also showed other
symptoms indicative of an upset stomach. This appeared to resolve itself
without recourse to medication. However, at 5.15pm on 28 April, he was taken
to hospital by ambulance after clinical tests revealed that the potassium levels
in his blood were very low - 1.7 mEq/litre, compared to a usual reading of 3.5 to
5.0 mEq/litre. Low potassium levels are known to have serious effects on the
body, particularly the heart, nerves and muscles. He was treated at Leicester
Royal Infirmary, where he was given potassium supplements and put on an
intraveneous drip.
21. He remained at the hospital until 25 May, all the while under the guardianship of
prison staff. At 7.20pm on 25 May, he arrived back at the prison, when it was
noted that he was “in good spirits”. However, he was observed to have
pressure sores and a possible chest infection. At 9.45pm, he suffered a ‘fit’
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which lasted for about five minutes. For about 20 minutes afterwards he was
described as being “unresponsive”, although he subsequently improved and
became more aware of his surroundings. Healthcare staff contacted the on-call
doctor, who suggested that the man’s medication needed to be reviewed the
following day.
22. At 5.30am the following morning, the man experienced another ‘fit’, this time
lasting for two minutes. He recovered after about five minutes on this occasion.
At 8.30am, he was seen by the doctor, who proposed getting the man
readmitted to hospital if his health deteriorated further. However, over the next
24 hours, his condition improved slightly.
23. Although there was an improvement in his presentation, albeit negligible, the
man’s appetite was limited and he left most of his meals untouched or only ate
a couple of mouthfuls. By 30 May, healthcare staff were sufficiently worried
about the man to get him readmitted to Leicester Royal Infirmary. He left the
prison at 3.00pm and was located on Ward 19 of the hospital, again guarded by
prison staff.
24. He was moved to Ward 23 at 9.45pm and, early the next morning, went for an
x-ray. Over the next week, the man’s physical health continued to deteriorate.
He was visited by prison chaplain on 2 June and again on 5 June. During the
course of the visit of 2 June, the chaplain asked the man if he had any relatives.
He replied that he did not.
25. At 2.25pm on 9 June, the deputy governor authorised the removal of the man’s
restraints as his physical state made it extremely unlikely that he would be able
to escape. Prison staff continued to watch over him though.
26. The man was visited by the prison chaplain on a further three occasions, on 11
June and twice on 12 June. During the course of the second visit on 12 June,
the ‘last rites’ were conducted. At 1.25am on 13 June, he stopped breathing.
He was formally pronounced dead at 1.53am.
27. At 1.00pm on 13 June, the prison chaplain, accompanied a police officer to the
home of the man’s next-of-kin, to personally break the news of his death. The
apparent delay came about because the man had told the chaplain that he had
no relatives and there was nothing in the prison records to indicate otherwise.
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ISSUES
Leicester’s readiness for an elderly prisoner with complex health needs
28. When the man was remanded into custody by Leicester Magistrates’ Court on
22 September 2005, it would be fair to say that Leicester was not in a position
to cater for his complex health needs. Quite appropriately, arrangements were
made to return him immediately to Leicester General Hospital, where he had
been an in-patient for many months prior to being remanded into custody.
29. Although a care package was put in place that appears to have met his needs, I
question why it took more than four weeks for this to be arranged. This concern
is shared by the clinical reviewer, who suggests that there was an unnecessary
delay in the man’s discharge from hospital. The clinical reviewer suggests that
joint care and discharge planning by the Primary Care Trust and the local
hospitals would help ensure a smooth transition between hospital and prison
settings. I would hope that any such arrangement would also speed up the
process. I therefore fully endorse his recommendation that the Primary Care
Trust be formally involved with the local hospitals in planning the discharge and
shared care of prisoners.
Eastern Leicester Primary Care Trust should be formally involved in
planning the discharge and shared care of prisoners located in local
hospitals.
30. In addition, given that elderly prisoners with complex health needs are likely to
constitute an increasing proportion of the prison population in the coming years,
I would urge the local Primary Care Trust to conduct a review of Leicester’s
ability to meet the needs of frail, elderly prisoners.
Eastern Leicester Primary Care Trust should review Leicester’s ability to
meet the needs of frail, elderly prisoners.
The man’s care whilst a prisoner at Leicester
31. Whilst acknowledging that there may have been a delay in the man being
returned to the prison from Leicester General Hospital, I was pleased to learn
from the clinical reviewer that the care he received whilst located in the
healthcare centre was “as good…as a similar individual with his problems
would have received in the community”. Indeed, some of the prison and
healthcare staff spoken to as part of the investigation have suggested that the
man was given a more attentive and dedicated service in the prison, than when
he was in hospital.
32. The healthcare centre not only acquired a specialist bed and mattress for the
man, but the prison and Primary Care Trust jointly arranged funding to employ
two extra nursing assistants to care for him during the night. Having spoken
informally to numerous members of staff in the healthcare team it is apparent
that they knew the man well and took a genuine interest in his well-being.
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Having worked so closely with him over such a long time, some members of
staff were saddened to learn of his death.
33. I therefore commend the healthcare staff team for their dedication in delivering
a high quality nursing service to the man, which can only be seen as an
example of good practice. I hope the Area Manager and Governor see fit to
acknowledge the work, commitment and dedication of the healthcare team in
caring so sensitively and compassionately for the man. The clinical reviewer is
firmly of the opinion that the man’s death could not have been reasonably
prevented or delayed, and my investigation found no evidence to suggest that
anything more could have been done to make his final days more comfortable.
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RECOMMENDATIONS
To Eastern Leicester Primary Care Trust
1. Eastern Leicester Primary Care Trust should be formally involved in
planning the discharge and shared care of prisoners located in local
hospitals.
2. Eastern Leicester Primary Care Trust should review Leicester’s ability to
meet the needs of frail, elderly prisoners.
Eastern Leicester Primary Care Trust has accepted both of these
recommendations and has devised an action plan to implement them by
February 2007.
GOOD PRACTICE
3. The extra resources allocated by the Primary Care Trust and Leicester
prison to care for the man helped ensure that he received a dedicated and
attentive service from healthcare staff.
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