Individual at Lowdham Grange

INVESTIGATION INTO THE DEATH OF A MAN ON
31 MAY 2005 WHILE RELEASED ON TEMPORARY LICENCE
FROM HMP LOWDHAM GRANGE
REPORT BY THE PRISONS AND PROBATION OMBUDSMAN FOR
ENGLAND AND WALES
SEPTEMBER 2005
This is the report of an investigation into the death of a man. This man died
from natural causes at home on 31 May 2005, after being released on
temporary licence from HMP Lowdham Grange.
The man was convicted on 24 March 2003 and sentenced to 16 years
imprisonment, which was reduced to 14 years on appeal. After being
diagnosed with a terminal illness, he was released on temporary licence to
spend the last days of his life at home with his family.
This investigation has been undertaken by one of my investigators. I would
like to thank the Director of Lowdham Grange, and his staff for their
participation in the investigation. Sherwood Primary Care Trust was
commissioned to undertake a review of the man’s medical care, and I also
appreciate their assistance.
The loss of a loved one is always distressing. I would like to add my personal
condolences to those already expressed by one of my Family Liaison Officers,
on behalf of this office.
Whilst I do not feel anything could have been done to prevent this man’s
death, there are lessons to be learnt in the clinical management of patients in
prison. I make two recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2005
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CONTENTS
Summary 3
Background 4
HMP Lowdham Grange 5
Conduct of the investigation 6
Key findings 7
Recommendations 9
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Summary
1. The man was born in 1950 and was 54 years old when he died.
2. He arrived at HMP Lowdham Hall on 11 August 2004, after transferring
from HMP Garth. At his First Reception Health Screen at Lowdham
Grange, the only medical problems recorded by staff were sciatica and
anxiety.
3. On 8 February 2005, he complained to staff in the prison healthcare centre
about not feeling well and this led to him being referred for an x-ray at
Queens Medical Centre.
4. The man was later diagnosed as having adenocarcinoma, a malignant
growth of glandular tissue (cancer), in his right lung. The prognosis was
poor and doctors stated that his life expectancy was a few weeks or
months.
5. Whilst he was an in-patient at the hospital, a bedwatch was carried out by
prisoner custody officers and, due to the nature of his offences, initially he
was handcuffed. When his situation was reviewed, a closeting (escort)
chain was used until shortly before his release.
6. On 12 May, the man was granted release on temporary licence (ROTL) on
compassionate grounds and discharged from hospital. This meant that he
was allowed to return to the family home. While he was at home, the
prison maintained contact with him and was investigating whether he could
be released on parole on compassionate grounds. The prison was in the
process of liaising with relevant parties to try to achieve this aim when he
passed away in his sleep on 31 May.
7. The clinical review concludes that neither the treatment provided, nor the
timescales involved, would have changed the outcome of this man’s lung
cancer. However, he also concluded that the care whilst in prison could
have been managed more efficiently.
8. On 28 June, one of my Family Liaison Officers, contacted the man’s next
of kin. They expressed concern about delays that may have occurred due
to staffing issues, but generally they believed that medical care was given
to him when he needed it.
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Background
9. The man was born in St Helens and had lived with his friend’s parents up
to the age of 17. He had previous convictions for minor offences from the
age of 13 until he was 26, but then settled into a law abiding life.
10. The man had been married for 8 years. His wife had four children when
they met, but he brought them up and regarded them as his own.
Although he was subsequently estranged from his wife, she contacted him
to assist with his release on temporary licence. This allowed him, on
discharge from hospital, to be with his family as his health deteriorated,
and to be in their company when he died.
11. On 31 May 2005, the family contacted the prison to inform them that he
had died during the night.
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HMP Lowdham Grange
12. Lowdham Grange opened in February 1998 and is a privately managed
prison operated by Premier Custodial Group Ltd, part of Serco plc. It
stands on the site of a former borstal that was demolished to
accommodate the new prison. The prison has a largely industrial based
regime, but has seen an expansion of its education provision since it was
opened. It offers a variety of vocational training, domestic and kitchen
work, gymnasium, gardening and offending behaviour programmes.
13. The prison offers single cell accommodation in two identical houseblocks,
comprising four wings arranged in a cruciform shape around a central
control room. Each wing is divided into two landings.
14. The healthcare centre is on a single floor and does not have an in-patient
facility. Nursing staff are directly employed by the prison, and they work a
12 hour shift. Out-of-hours cover is provided by a nurse based overnight
in the healthcare centre. Patients requiring specialist healthcare are
identified and referred to the National Health Service. General practitioner
(GP) services are provided by means of a contract with a local GP who
attends for 15 hours per week and provides out of hours advice.
15. Her Majesty’s Chief Inspector of Prisons (HMCIP) carried out an
unannounced inspection of Lowdham Grange in March 2004. The
inspection report described Lowdham Grange as providing “a secure but
respectful environment for prisoners and staff” and said that healthcare
was delivered “in a respectful and professional way”.
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Conduct of the investigation
16. My investigator studied all relevant prison records relating to the man.
These included his main prison record, Inmate Medical Record (IMR) and
the Bedwatch Logs covering the periods spent in hospital. My investigator
also studied instructions for the arrangements to be followed when
prisoners are escorted outside the prison, including the use of restraints.
17. A Clinical Review was commissioned from Newark and Sherwood Primary
Care Trust. I am grateful to the Director of Public Health for undertaking
this review in a most timely manner.
18. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of my 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 into the man’s death.
19. One of my family liaison officers, contacted the man’s family. They stated
that their only concern was about delays in obtaining medical treatment for
him that might have occurred due to staffing issues.
20. My investigator discussed aspects of the man’s treatment and the issues
raised by his family with staff at Lowdham Grange and the doctor for
undertaking the review. The Primary Care Trust found that the man’s
clinical care was mostly appropriate but drew attention to some minor
issues concerning the management of his care. I have made
recommendations concerning these.
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Key findings
21. The man arrived at HMP Lowdham Hall on 11 August 2004. On 8
February 2005, he approached medical staff as he was having difficulty
sleeping. The medical staff could not find a reason for his discomfort and,
after further investigation, it was decided to refer him to the local hospital
for an x-ray.
22. The x-ray taken on 15 March showed that the man had a pleural effusion
(fluid in his chest) and he was admitted to the hospital on 25 March for
aspiration (withdrawal of the fluids). Unfortunately, no diagnosis of his
underlying condition was made at that time. The man returned to the
hospital again on 5 April and further tests indicated adenocarcinoma in his
right lung.
23. On 21 April, the man returned to hospital and a permanent chest drain was
attached. While he was in hospital, his health deteriorated and it became
clear to the consultant physician treating him that he had a very short time
to live. Both the man and Lowdham Grange were immediately informed of
his prognosis. Lowdham Grange began to assemble the information
required by the Home Office to support consideration of compassionate
release.
24. Once the man was settled on the ward in the hospital, a closeting (escort)
chain was used instead of handcuffs. This was entirely appropriate and
enabled the nursing staff to have easier access when they carried out their
duties. Towards the end of his stay in the hospital, arrangements were
made for officers to carry out bedwatch duties without any physical
restraints. Again, I think this was right and proper.
25. When the man left the hospital on 12 May, he was allowed to return to the
family home as he had been given release on temporary licence. Before
he was due to leave hospital it became apparent that the man would need
a bed downstairs at his family home and a wheelchair. These should
normally be supplied by Health/Social Services from equipment stores
held for such circumstances and arranged as part of the planned
discharge process, but were not. Instead the prison provided a wheelchair
and bought a bed for him.
26. The prison maintained contact with the man while he was at home. He
was regularly visited by senior managers. The prison also continued to
investigate whether he could be released on parole on compassionate
grounds. However, he died at home during the early hours on 31 May
before this could be achieved.
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27. The partner of the man’s estranged wife informed the prison at 3:00pm on
31 May of the man’s death. The Duty Director and a colleague of the
chaplaincy contacted the family to offer their condolences and support.
They also maintained contact with the family and held a memorial service
at the prison on 7 June. Also officiated at the man’s funeral on 10 June
which was also attended by the prison’s Director. The prison provided
financial assistance for the funeral costs.
28. On 10 June, the Coroner confirmed that a post mortem had not taken
place as the man’s GP had certified death.
29. The clinical review concluded that this man’s care while he was in prison
was appropriate and his transfer to hospital timely, but drew attention to
some minor issues concerning the management of his care. These
included action to detect his pleural effusion at an earlier stage and better
maintenance of medical records.
30. My investigator considered the use of physical restraints and I am satisfied
that the decision to remove restraints was taken at the earliest opportunity.
31. In sum, this man developed a very serious physical health problem.
Although his condition was being monitored and assessed by the prison
healthcare centre and the local hospital, the underlying malaise was not
immediately identified. It was only after his condition deteriorated that the
prison referred him for further investigation at the Queens Medical Centre
where it was established that he had adenocarcinoma on his lung. The
disease was extensive and the prognosis poor. In light of this
development, the prison arranged for release on temporary licence on
compassionate grounds.
32. The prison acted appropriately and sympathetically by making
arrangements for him to be released back into the community, and to
spend the last days of his life with his friends and family. I am pleased to
commend their actions.
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Recommendations
I accept the recommendations of the clinical review. I paraphrase those
recommendations in the following terms:
(cid:190) I recommend that all healthcare professionals at Lowdham Grange
should be reminded of the importance of legible, accurate and
thorough documentation.
(cid:190) I recommend that those healthcare professionals should also be
reminded that investigations and tests should be thorough and
where indicated, organised quickly. Test results should be followed
up, documented, filed and acted upon.
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