Individual at Doncaster

Investigation into the circumstances surrounding the
death of a man in outside hospital, whilst in the custody of
HMP Doncaster, in November 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2008
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
This is the report of an investigation into the death of a prisoner at HMP Doncaster,
who died from natural causes on 19 November 2007. He was 47 years old.
I would like to add my personal condolences to those already expressed to the
man’s family on behalf of this office by one of the Ombudsman’s Family Liaison
Officers.
This investigation was undertaken by one of my colleagues. He and I would like to
thank the Director of HMP Doncaster and his staff for their assistance. Doncaster
Primary Care Trust were asked to undertake a review of the man’s clinical care and I
also much appreciate their help.
The man was taken by ambulance to an outside hospital on 17 November and it was
there that he died during the evening two days later. I have made two
recommendations in this report. I have also noted the issues highlighted by the
clinical reviewer and I endorse the recommendations made in her review. The
prison will develop an action plan to address the matters raised.
I have also made two separate recommendations about the management of
bedwatches and hospital escorts. The man had very limited mobility and was in ill
health. He was a most unlikely escape risk. Yet for all of his time in hospital he had
a two-officer bedwatch, and he was cuffed for most of the time too.
Jane Webb
Deputy Prisons and Probation Ombudsman December 2008
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CONTENTS
Summary 3
The investigation process 4
HMP and YOI Doncaster 6
Key events 7
Concerns raised by the family 12
Clinical review 16
Issues 19
Conclusion 20
Recommendations 21
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SUMMARY
The man was born in 1960. He was 47 years old when he died in outside hospital.
The man died from natural causes as a consequence of heart failure on 19
November 2007.
The man had been received into prison custody in March 2007 after he had been
convicted of theft. In April, he was sentenced to 21 months imprisonment at a local
Magistrates’ Court.
The man’s left leg was amputated in 2006 and he had also previously been
diagnosed with diabetes. He had use of an artificial leg and a wheelchair and
required pressure bandaging for his stump. The man had also previously contracted
MRSA (methicillin resistant staphylococcus aureus) and required barrier nursing to
protect others from possible infection. Due to his mobility and health problems, the
man was located on the healthcare wing of Doncaster prison. He remained on the
healthcare wing for the duration of his time in custody.
The man experienced problems with lack of mobility throughout his time at
Doncaster and put on weight due to this and his poor diet. The man was also unable
to visit the gym and library due to problems with access to these services for
prisoners with mobility problems. Due to his weight gain the man was unable to use
his artificial leg and his family brought him a second heavy duty wheelchair.
The man was taken to hospital for treatment on numerous occasions whilst he was
in custody. He was also admitted to outside hospital for eight days in May after
experiencing tightness in his chest. The man was again admitted to outside hospital
from 28 June until 17 July after he developed an infection.
On 16 November, after the man developed an infection in his right foot he was
referred to outside hospital. He was admitted to hospital during the early hours on
17 November. The man’s family were allowed to visit him whilst he was in hospital.
Around 7:15pm on 19 November, the man stopped breathing. Attempts to
resuscitate him commenced immediately. At 7:40pm it was decided that the
resuscitation attempts should stop and death was pronounced by a hospital doctor.
Whilst the man was in hospital, a bedwatch was carried out by prison staff. The
initial security risk assessment was that handcuffs were to be used and two officers
needed to be at his bedside. The risk assessment was not revised and the man
remained in restraints until he died.
The clinical review carried out on behalf of Doncaster Primary Care Trust concludes
that the man’s clinical care was not satisfactory. I have endorsed the six
recommendations made in the clinical review. I have also made two
recommendations in relation to the management of hospital escorts and
bedwatches.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 21 November 2007 when one of the
Ombudsman’s investigators issued notices announcing the investigation to staff
and to prisoners. The notices included an invitation to those who wished to
submit information relating to the man’s death to make themselves known to
my investigator. In the event, nobody came forward. The investigator also
studied all relevant prison records relating to the man. These included his main
prison record, medical records and statements made by staff.
2. The investigator visited Doncaster on 14 February 2008 and discussed aspects
of the man’s treatment with staff at the prison. He also interviewed the clinical
manager at Doncaster. The clinical manager was able to provide background
information concerning the man and his activities whilst in custody.
3. The Doncaster Primary Care Trust commissioned someone to carry out a
review of the man’s clinical care. I am grateful to them for undertaking the
review.
4. 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 in his
enquiries into the man’s death.
5. One of the Ombudsman’s Family Liaison Officers wrote to the man’s family.
This gave them the opportunity to discuss the purpose of the investigation and
to raise any concerns or questions that they would like explored and
addressed. The family had a number concerns relating to the medical
treatment the man received whilst he was in custody:
• The man had the use of an artificial leg before he arrived in custody but
when his family visited him in Doncaster he was using a wheelchair.
• As the man was not using the artificial leg he put on weight and his family
had to purchase another heavy duty wheelchair for him. This caused
problems as the width of the chair meant that it did not fit easily through
doorways.
• The difficulties the man experienced when trying to move around the prison
due to his lack of mobility and the lack of access he had to the facilities at
Doncaster.
• The cessation of certain medication when he arrived in custody.
• The resistance from staff to accommodating the man’s special
arrangements for visits from his family.
• The man not having access to the gym which again did not assist with his
weight management.
• The diet available to the man whilst he was in custody
• The number of hospital appointments for the man which were cancelled by
Doncaster.
• The management of the man’s pain.
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• The application of the man’s pressure bandaging and appropriate hospital
attention.
• The observation of barrier nursing to avoid possible infection.
The clinical reviewer and my investigator have explored these points and I
hope that this report provides the family with answers to their questions.
5
HMP AND YOI DONCASTER
6. HMP and YOI Doncaster opened in 1994 and is a purpose-built Category B
male prison, privately managed under contract by Serco Home Affairs. The
prison is made up of three houseblocks, each with four wings and has a
maximum capacity of 1,145 prisoners. Its principal function is as a local prison
serving the local courts, and the majority of its population are sentenced
prisoners.
7. Provision of healthcare within Doncaster is the responsibility of Serco
Healthcare. The prison has a healthcare unit with provision for up to 29 in-
patients located on the second floor. The lower level is dedicated to the
delivery of primary care services. Resuscitation equipment, including the
defibrillator, is kept in the pharmacy room. A local doctor provides on site cover
21 hours a week and the prison employs two other part-time doctors to provide
a 24-hour service. Prisoners with more serious conditions or clinical needs are
referred to the local hospital. The mental health in-reach team is from the
Doncaster and South Humber Mental Health Trust. It provides a service to a
cluster of prisons in the area. There are also three Registered Mental Health
Nurses and a support worker based in Doncaster. A clinical psychiatrist and a
forensic psychiatrist also attend the prison for regular sessions.
8. An announced inspection of Doncaster took place in November 2005. Dame
Anne Owers, Her Majesty’s Chief Inspector of Prisons, found that HMP
Doncaster ‘was generally well-ordered’. However, the Chief Inspector
expressed concern that ‘prison managers had allowed important areas to slip
below what is safe and decent’ since the Inspectorate’s previous visit in April
2003. A further inspection was conducted earlier this year but the report has
yet to be published.
9. The Independent Monitoring Board (IMB) in its latest report for Doncaster (2006
– 2007) says that overall the prison continues to be well managed. It
highlighted the absence of workshop facilities and the failure to occupy many of
the prisoners in useful and purposeful activity. The report also said that:
“Overcrowding continues to be a serious problem affecting
programmes designed to address such matters as drug addiction,
criminality, and rehabilitation. The Board takes the view that many
prisoners need not be imprisoned for relatively minor offences which
could be more cost effectively dealt with by a properly resourced
Probation Service, be released on bail awaiting trial. Others could be
more appropriately treated in mental hospitals or other psychiatric care
facilities if diagnosis of their mental health problems was adequately
resourced.”
10. There were four natural causes deaths at Doncaster in 2008.
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KEY EVENTS
11. When the man arrived at Doncaster on 27 March 2007, he had a number of
medical conditions. Part of his left leg had been amputated and he had the use
of an artificial leg and a wheelchair. The man also had diabetes and as a result
suffered from neuropathy, whereby the nerve endings in his feet and hands
were damaged. He had also previously contracted MRSA (methicillin resistant
staphylococcus aureus) and required barrier nursing. A range of medications
was prescribed for the man and he was not allowed to keep these in his
possession.
12. The man was located on the healthcare wing at Doncaster due to his lack of
mobility and poor health. Doncaster did not supply a copy of the man’s first
health screen to either the clinical reviewer nor my investigator. However, it
was noted in the medical records that the man had tried to take his own life
within the past five years.
13. When interviewed as part of this investigation the clinical manager at Doncaster
said that he had met the man when he had been serving previous prison
sentences. The clinical manager said that he was fully aware of the issues
relating to the management of the man’s diabetes. The clinical manager
pointed out that, since he had served his last sentence, the man had
undergone surgery on his left leg which had been amputated below the knee.
The clinical manager said that the man had good insight into the management
of his diabetes but did not watch his diet.
14. The man attended a diabetic screening interview on 1 April. It was recorded
that the man was losing his sight, he had ulcers on his stump and pins and
needles in his fingers.
15. On 4 April, the man experienced problems putting on his false leg as his stump
was very painful and swollen. Later, after he returned from a family visit, the
man experienced chest pain and became cold and clammy. An ambulance
was called and, after the paramedics carried out an electro-cardio-gram (ECG),
the man was taken to outside hospital. He returned to the prison the following
day after being seen by a consultant at the hospital.
16. In a letter dated 20 April, a consultant vascular surgeon confirmed that the man
was a poorly controlled diabetic. The surgeon wrote:
“As for the seriousness of his diabetes, it is safe to say that his poorly
controlled diabetes is serious enough to have resulted in vascular and
neuropathic complications leading to limb loss.”
17. The man was sentenced to 21 months imprisonment on 24 April at a local
Magistrates’ Court.
18. The man was taken to outside hospital and an outside Diabetic Centre, on 25
April and 1 May respectively, for review appointments. On 14 May, the man
attended an out-patients appointment at an outside hospital.
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19. On 17 May, after he experienced tightness in his chest the man was taken to
the Accident and Emergency Unit at an outside hospital. He later transferred to
the Medical Assessment Unit before being moved to a ward where he
remained whilst clinical investigations were carried out. The prison was in daily
contact with the hospital to check on the man’s progress. On 24 May, he was
discharged from hospital and returned to the prison.
20. The man refused to attend the dressing clinic on 26 May as he said he was in
too much pain. He also said that he was not getting enough pain relief and
asked to see a doctor. On 29 May the prison doctor wrote that the man’s pain
management was ineffective and he changed his medication.
21. The man attended a hospital appointment on 8 June for a Computerised
Tomography (CT) scan. A letter dated 26 June from a Consultant Cardiologist,
confirmed that the man’s CT scan showed no evidence of angina. On 12 June,
the man attended an out-patients appointment at an outside hospital.
22. On 22 June, the man attended an appointment at an outside hospital for a cast
to be taken of his stump. The man also attended the hospital again on 25 June
for an out-patient appointment. However, no record or explanation was given
in the prison medical record for this attendance.
23. Six days later on 28 June, the man was taken to an outside hospital where he
was later admitted as his condition was unstable. He was administered a
course of antibiotics and remained in hospital until 17 July. He was then
discharged from hospital and returned to the prison.
24. The man attended a review appointment at an outside hospital on 27 July. The
hospital was concerned about the man’s wounds and drew a black line on his
leg. They told the man that if the infection spread to the line, he would need to
go back into hospital. He returned to the hospital, on 3 August, and was
admitted overnight for further intravenous antibiotic therapy as he had cellulites
(inflammation of the deep subcutaneous tissues). He was discharged the
following day.
25. When the man attended the dressing clinic at the prison he told staff that he
was to have a silver dressing on his leg and that the dressing he had on at the
time was only temporary. The nurses at the dressing clinic explained to the
man that they had been sent dressings from the hospital and that they were to
be put on the wound for five days. The man was not happy with this and the
nurse said that she would contact the hospital to discuss the dressings with
them. There are no records to show that this action was taken by the nursing
staff.
26. On 17 August, an accident form was completed as the man said that he had
fallen out of his wheelchair whilst he was in the shower. There was no visible
sign of any injuries but the man told staff that he had pain in his right ribs. Staff
contacted the Health and Safety Officer at Doncaster, who had previously
carried out a risk assessment for the man. The Health and Safety Officer said
8
that it would be up to the Healthcare Manager to assess the man’s disability
needs. On the following day another accident form was completed after the
man fell out of his wheelchair backwards. Again there were no visible injuries.
There was no evidence of further risk assessments being carried out after
these accidents.
27. On 4 September, the man attended an out-patients appointment with a
Consultant Physician and Honorary Professor of Diabetic Medicine. A letter,
dated 6 September, from the Consultant Physician summarised the
consultation. The Consultant Physician recommended that the man would
need some form of compression bandage and that he should continue on
Augmentin (antibiotic medication) until his infection cleared up.
28. On 13 September, the man said that he felt unwell. He was referred to the
prison doctor who saw him the following day. The man told the doctor that he
had not taken his anti-depression medication (Amitriptyline) for three weeks but
he had been given it by mistake for a few nights. One of the side effects of the
man’s medication was that it caused nausea.
29. On 17 September, the man attended an out-patients appointment at a Diabetic
Clinic in an outside hospital. A letter dated 24 September from a Staff Grade
Physician in Diabetes, summarised the results of tests carried out when the
man attended the hospital. A swab of the man’s stump and nose had revealed
MRSA (methicillin resistant staphylococcus aureus). This infection is resistant
to commonly used antibiotics. Further treatment was recommended by the
Physician.
30. The clinical manager confirmed that the clinic nurse would regularly see the
man in the treatment room in the healthcare centre to change his dressings.
The clinical manager pointed out that treatment plans had been in place for the
management of both the man’s diabetes and the dressings for his stump. The
clinical manager confirmed that the clinic nurse liaised with the Consultant
Physician and the Vascular Nurses about the man’s care and she regularly
updated the clinical manager about this. The clinical manager recalled that on
a couple of occasions the man did not attend the treatment room to have his
dressings changed as he was about to receive visits. The clinical manager did
not remember staff raising any concerns about the process of applying the
man’s bandages or dressings.
31. The man was seen by the prison doctor on 3 October. His leg was
unbandaged and the prison doctor said that it was looking better. However,
staff were unable to rebandage the leg until the following day as the treatment
room was being used for other purposes.
32. On 6 October, the man told staff that he had burned his finger a few days
earlier. This had occurred when the man’s hand had fallen against the central
heating pipes whilst he was asleep.
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33. According to the prison medical records, the man did not attend the dressing
clinic on 14 and 20 October. His stump was redressed on 22 October. On 16
October, the man attended an out-patients appointment an outside hospital.
34. The man made a formal complaint on 22 October about being refused Home
Detention Curfew (HDC). On 29 October the Commissioning Manager from
Yorkshire and Humberside Regional Offender Management Service reviewed
and replied to the man’s complaint. He noted that the man had previously
committed offences whilst on bail and had driven whilst disqualified. The
manager therefore considered that the man would find it difficult to comply with
the conditions of HDC and he could not grant it. The manager suggested that if
the man was not satisfied with his response he could take forward this matter
with the Prisons and Probation Ombudsman’s office. There is no record of the
man pursuing this issue further within the prison or with my office.
35. On 26 October, as a result of staff shortages, dressings for the man’s stump
were not carried out. The man did not attend the dressing clinic on 30 October
as he had a visit. The medical records say that the man refused to attend the
dressing clinic on 1 November as he had another visit.
36. On 11 November, the man was referred to the prison doctor as he had
developed large blisters on his toes. The prison doctor checked the blisters
and advised that they should be popped and left to dry out. Swabs for MRSA
were also taken. The results of the swabs were received on 15 November and
showed that the man had MRSA on his right foot blister, as well as in other
places.
37. The condition of the man’s right foot deteriorated over the next few days and it
became apparent that he would need to be referred to hospital for treatment.
On 16 November, the bed manager at the local hospital told Doncaster that
they were struggling to find a bed for the man. The bed manager said that
there were likely to be bed movements and that he would call back. During the
morning, the bed manager rang the prison and informed them that a medic-to-
medic referral would have to be completed. Another prison doctor contacted
the Consultant Physician’s Registrar and arranged the referral. Confirmation
that the man was to be admitted to the Emergency Assessment Unit was
received by the prison later that same day. During the early hours on 17
November, the man was admitted to outside hospital. During his stay in
hospital, the man was visited by his family.
38. Whilst the man was an in-patient at the hospital, a bedwatch was carried out by
prison staff. The security risk assessment identified that a closeting (escort)
chain should be used and two Prison Custody Officers (PCOs) needed to be in
attendance. This was entirely appropriate at that time and enabled the nursing
staff to have easy access when they carried out their duties. The use of
handcuffs for prisoners on escort to hospital has been the subject of recent
case law in relation to the issue of decent and humane treatment. I know that
the Prison Service is currently drawing up new guidance in relation to this
matter. It was in line with standard procedures to have handcuffed the man in
the first instance. At the time the handcuffs were applied, the man was
10
conscious and could have been judged to have posed a security risk. The risk
assessment for the man was not revised during his time in hospital and
therefore restraints were not removed.
39. At 7:00pm on 19 November, two prison custody officers took over responsibility
for the bedwatch duties. The second officer was handcuffed to the man. On
their arrival the man was asleep. At around 7:15pm, the first officer noticed that
the man took a deep breath but thereafter his chest did not move. The first
officer informed her colleague that she was going to get one of the medical staff
as something was not right. The first officer informed a nurse. The nurse tried
to rouse the man and then called the emergency team. The second officer
removed the restraints and the emergency team tried to resuscitate the man.
At approximately 7:40pm, it was decided that the resuscitation attempts had
been unsuccessful. They were stopped and death was pronounced by a
hospital doctor.
40. The first prison custody officer informed the prison that the man had died. The
prison chaplain was identified as the Family Liaison Officer for the prison. He
contacted the man’s family to inform them of his death and to offer condolences
and support. The chaplain was able to assist with the arrangements for the
funeral and on behalf of the Director offered financial assistance towards the
funeral costs. After receipt of the draft report the man’s family stated that it was
not correct to infer that prison staff contacted the family to notify them of the
death. Hospital staff telephoned the man’s ex-wife, to inform her that the man
had passed away. The man’s ex-wife had a good relationship due to the
frequency of her husband’s past treatment. On arrival at the hospital the family
said that no conversation took place between them and the two prison officers.
41. The post mortem report records the man’s death as being due to natural
causes as a consequence of acute cardiac failure (heart failure) caused by
severe coronary artery atherosclerosis (blocked arteries).
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CONCERNS RAISED BY THE FAMILY
42. The man’s family had a number of concerns relating to his treatment while in
custody. The family felt very strongly that the man had not received
appropriate treatment for his health needs. My investigator shared the family’s
concerns with the prison.
43. The family drew attention to the fact that, although the man had the use of an
artificial leg, he been quite mobile before he arrived in custody. When the
family visited the man in Doncaster he was not wearing his artificial leg and
instead used a wheelchair. As the man was not using the artificial leg he had
put on weight, due to lack of exercise. This meant that the family had to
purchase a heavy duty wheelchair to accommodate the weight gain. However,
the family were concerned about the difficulties the man still encountered when
trying to move around the prison. As the new wheelchair was wider, the man
told his family that, when he moved around the prison, the chair had to be
folded and he would have to hop through doorways. The family also felt that
the man was not offered the opportunity to exercise or visit the gym.
44. In his written response on 2 June 2008, the head of internal affairs at
Doncaster said that the man was challenged on 24 April about the use of his
artificial leg. The head of internal affairs said that the man claimed it was too
uncomfortable and he was referred to the prison doctor for a review of
medication to help facilitate mobilisation. The only record of a problem
accommodating the man’s wheelchair was on 9 September but no explanation
was recorded by staff at Doncaster.
45. When interviewed, the clinical manager at Doncaster said that on arrival in
prison the man weighed 20 stone and was overweight for his height. The
clinical manager said that when the man arrived at Doncaster he was using a
wheelchair and he was later given a second wheelchair which was more
robust. The second wheelchair was individually tailored to the man’s needs,
which had changed whilst he was in custody and was required because he had
put on weight. The clinical manager did not recall the man complaining to him
about his artificial leg or actually seeing him use it. The clinical manager said
that staff were guided by the man on whether he was comfortable using his
artificial leg. The clinical manager confirmed that the man’s choice of diet and
lack of mobility meant that his weight increased whilst he was in custody.
46. The clinical reviewer concluded that no appropriate adjustments had been
made with regard to the man’s disability needs. This meant that he was unable
to visit the library, church or gym and this did not assist him with his weight
problems.
47. In response to the draft report the family accepted that artificial limbs do wear
out and it was clear that on the man’s arrival at Doncaster his limb was speedily
removed from him. Their view is that he had worn it to court and it was capable
of further use. They believe he should have had the usage of his artificial leg
whilst the new one was in the course of preparation. The family felt that as a
12
consequence of this the man suffered depression and anxiety (according to his
ex-wife), was unable to exercise and his weight increased considerably.
48. Due to the man’s lack of mobility, special arrangements were made to allow
him to meet his family in the rooms used for legal visits. The family appreciated
that Doncaster arranged for this to happen but recalled that they encountered
resistance from staff who complained about the additional work this caused
them.
49. The officer who is in charge of visits at Doncaster said she had several
conversations with the man’s wife. The officer said that the man’s wife did not
tell her that staff had complained about the additional work. The officer recalled
that the man’s wife told her that it was hard to remember to book the visits for
the weekend.
50. The clinical manager said that a risk assessment had been carried out to
enable the man to see his visitors. This involved him taking a more circuitous
route (avoiding stairs) and using lifts. He was also given dispensation to use
the designated closed visits rooms, which were usually reserved for legal visits,
to see his family. The clinical manager did not recall the man ever having to
use stairs when he visited his family and he said that this could only have
happened if the lifts were not working.
51. My investigator could not find any supporting evidence that staff had
complained about the additional work caused by the arrangements for the visits
by his family.
52. In response to the draft report the family drew attention to a visit the man’s ex -
wife made when she was accompanied by her former father-in-law. She
arrived at the prison at about 4:00pm on a Sunday afternoon not having been
told that visits in the legal visits hall area were subject to time limit. On her
arrival the man’s ex-wife went through the search procedure but was not
admitted to the prison as staff told her it was “too late for the staff upstairs”.
53. The man’s family said that, due to his weight gain, he was measured for
another artificial leg as his old one was no longer able to hold his weight.
However, no appointments were made for fitting inserts to the new leg and so
he was unable to use it. The family were also concerned about the number of
hospital appointments for the man which were cancelled. They did not think
that he received the same level of support with his mobility problems after he
arrived in custody.
54. The head of internal affairs’ response was that limb fitting appointments were
made but had on occasion been cancelled due to security breaches when the
man had found out dates beforehand. The man attended a fitting on 17
October and it was noted that he was wearing his artificial leg on 23 October
but on no other occasions. Other appointments were cancelled due to conflict
of times, for example being superseded by the man already being in hospital.
The head of internal affairs said that the man did attend approximately 12
appointments during his time in custody.
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55. The clinical reviewer believes that there was poor communication between
Doncaster and other parties involved in the man’s medical care. This is
referred to in more detail in her clinical review. Neither my investigator nor the
clinical reviewer find reasons recorded for why some of the appointments were
cancelled or re-arranged.
56. The family said that the diet available to the man did not assist with his weight
management issues.
57. As mentioned earlier, the clinical manager said that the man had a good insight
into his diabetes but did not watch his diet. The clinical manager confirmed that
the man was given healthy food options whilst he was at Doncaster but he
chose not to accept them. The issue of not pursuing a healthy diet did not aid
the man’s diabetes or help him to manage his weight. I cannot comment on
whether the man did choose to purse the option of a healthy diet as his views
on this issue were not recorded.
58. In response to the draft report the man’s family did not accept that he did not
comply with his diabetic dietary requirements. The family described the man as
someone who enjoyed vegetables, fruit and salads but whose blood sugar level
was high irrespective of his diet. The family said that the man described the
meals provided to him by Doncaster as “rubbish”.
59. The family also drew attention to the management of the man’s pain. They did
not think that this was adequately managed as some of the man’s medication
was stopped when he arrived in custody. They said that the man was also
visibly in considerable pain when they visited him at Doncaster.
60. The clinical manager recalled that he saw the man on a daily basis. The man
had occasionally complained about pain relief and the clinical manager said
that healthcare staff had responded to his complaints. The head of internal
affairs said that all medication is prescribed by the prison doctor with the
exception of Zomorph, which was replaced with an alternative analgesia in
accordance with local policy. The prison doctor prescribed Zomorph to the
man after he saw him on 28 March. The man’s medication was reviewed on a
weekly basis and alterations were made accordingly. The head of internal
affairs drew attention to the large amount of medication the man received and
the need for careful consideration of how the medications were combined. The
man was in a lot of pain due to his medical condition.
61. The clinical reviewer considers that the man’s pain medication was
appropriately reviewed and replaced with a stronger analgesia when he was
seen by the prison doctor.
62. The family were also concerned about the application of the man’s pressure
bandaging and the observation of barrier nursing to avoid possible infection.
They did not think that Doncaster were proficient in the application of the
pressure bandages and did not observe the protocols for barrier nursing.
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63. The head of internal affairs said that barrier nursing was carried out at all times
as the prison was made aware of the man’s infection. Doncaster said that their
actions were carried out in accordance with national policies and procedures.
64. The clinical manager referred to a letter dated 6 September from a Consultant
Physician and Honorary Professor of Diabetic Medicine. The letter said that
the man would need some form of compression bandage although the
Consultant Physician did not indicate which type of bandage. This was later
clarified when the man attended the Diabetic Clinic on 17 September.
Dressings were to be changed two to three times a week and then weekly once
the infection had cleared up. When asked whether the man’s dressing was
secure, the clinical manager said that if it came loose, then staff would re-apply.
It had been known for patients to loosen their own bandages or dressings if
they were causing discomfort.
65. The clinical manager said that Doncaster was not directed by the hospital to
adopt barrier nursing for the man. However the clinical manager said that, after
any patient with MRSA was examined in the treatment room, there was a
process to ensure that it was cleaned thoroughly. The clinical manager added
that the prison was directed by the hospital on numerous issues relating to the
man’s care. The clinical manager said that whilst the man was in outside
hospital his clinical care was managed by them and not the prison.
66. The clinical reviewer noted that there were delays in applying the appropriate
bandages and she again refers to this in more detail in her clinical review.
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CLINICAL REVIEW
67. The review of the man’s medical care was undertaken by someone on behalf of
Doncaster Primary Care Trust (PCT). The findings were reviewed by a
member of the PCT’s Professional Executive Committee and the Head of
Quality and Clinical Assurance for the PCT. The review finds that the man had
suffered from significant long-term chronic diseases.
68. The clinical reviewer concludes that there are a number of areas where
improvements are required and makes some recommendations for
improvements to clinical practice.
69. The clinical reviewer notes that the man’s medical records were below the
required standard. Some of the entries were illegible and wrongly dated.
There were also gaps in the records. There was no record of the first and
second health screening interviews and the clinical reviewer assumes that
neither of these screens were carried out. The only records that were available
were for two diabetic screens.
70. The clinical reviewer draws attention to the fact that when the man arrived at
Doncaster he revealed to staff that he had attempted to take his own life within
the past five years, and stated that his mood was low. However, no further
assessment of the man’s mental health needs was carried out. Also, as the
man was a diabetic, he required a special diet but there was no record of a
medical diet order form in his records. The clinical reviewer concludes that,
based on the available evidence, the screening process did not establish the
man’s past or current mental and physical needs.
71. The clinical reviewer recommends that Doncaster should seek medical
summaries for all new prisoners from their registered General Practitioner.
Typically, prisoners do not access primary healthcare whilst in the community
and therefore they suffer from significant health inequality. The clinical
reviewer considers that this could be addressed by the prison healthcare
system.
The Healthcare Manager should ensure that staff seek medical
summaries for all new prisoners from their registered General
Practitioner.
72. The man had previously contracted MRSA and always required barrier nursing
to protect others. However, the reviewer could not find evidence in the prison
medical records to suggest that this was done. The man also missed some of
his appointments at outside hospital and it is not clear, from the prison’s
medical records, why he was not taken to these appointments.
73. The clinical reviewer believes there was insufficient communication between
the prison and external agencies involved in the man’s care. For example, the
man attended an out-patients appointment on 4 September. He was then
supposed to have compression bandages on his feet, but the hospital did not
send details regarding the bandaging. It was not until 19 September, when the
16
man attended a clinic in outside hospital again, that the appropriate bandages
were applied and the prison staff were given details.
74. The head of internal affairs at Doncaster, confirmed that discharge letters and
clinic letters from out-patient appointments were received. However, as the
correspondence was posted, there were delays on occasions before
information and advice was received. Attempts were then made to chase
information but often clinic staff had finished work for the day.
75. The clinical reviewer draws attention to the lack of handrails, ramps or access
to facilities in the prison. The man’s movement throughout the prison was very
difficult. The wheelchair he used was provided by him and could only go
through doors with difficulty. The man had an artificial leg, however, he did not
use this leg whilst in custody. He was not able to go to the library, the church
or the gym because there were no ramps or lifts available. Exclusion from the
gym was a serious difficulty because as a diabetic the man was required to
exercise and had put on three stones whilst in custody. In addition, there was
no ramp to bathrooms and no handrail in the showers. When having a shower
the man had to sit on a plastic chair or on his wheelchair and hold on to the
chair to lever himself up when the shower was finished. On one occasion the
chair slipped and the man fell over, causing severe pain to his ribs.
76. Doncaster’s Disability Policy (Policy Document HMP and YOI Doncaster:
Prisoners with physical, sensory and mental disabilities) concerning residential
accommodation states:
“Prisoners with disabilities will be allocated the appropriate
accommodation in line with their disability, usually on ground floor
level. It is anticipated that one cell per wing throughout the main prison
or a number of specific cells in a designated area will be adapted for
the use of disabled prisoners – a grab rail and portable toilet cradle will
be made available if required. To prevent vandalism, these will only be
fitted when the accommodation has been allocated to a disabled
prisoner.”
77. The clinical reviewer concludes that no appropriate adjustment had been made
regarding the man’s disability and needs. It seems that the care he received
was not comparable with the care he could have expected to receive in the
community. The clinical reviewer draws attention to Doncaster’s Disability
Policy which aims to ensure prisoners with disabilities are not discriminated
against in any aspect of prison life and that equality of opportunity in accessing
all parts of prison life is offered to all prisoners. The clinical reviewer judges
that staff at Doncaster did not follow the policy in this case.
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78. The clinical reviewer recommends that all staff at Doncaster are trained and
kept up to date in the following areas:
• awareness of and familiarity with HMP Doncaster’s Disability Policy
• record keeping
• barrier nursing
• formal referral procedures for secondary care.
The Healthcare Manager should ensure that all staff are trained and kept
up to date in the following areas:
• awareness of and familiarity with HMP Doncaster’s Disability
Policy
• record keeping
• barrier nursing
• formal referral procedures for secondary care.
79. The clinical reviewer also recommends that, in the future, every effort is made
to:
• improve the communication between the prison and external agencies
• carry out regular audits to ensure standards of record keeping have
improved and remain of a high standard
• ensure that first and second screening interviews take place, and that they
are appropriately recorded in the prisoner’s medical record
• ensure that patients are seen in secondary care when medically indicated
and the reason for non-attendance is clearly documented in the prisoner’s
medical record.
The Healthcare Manager should improve communication between the
prison and external agencies.
The Healthcare Manager should carry out regular audits to ensure
standards of record keeping have improved and remain of a high
standard.
The Healthcare Manager should ensure that first and second health
screening interviews take place and that they are appropriately recorded
in the prisoner’s medical record.
The Healthcare Manager should ensure that patients are seen in
secondary care when medically indicated and the reason for non-
attendance is clearly documented in the prisoner’s medical record.
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ISSUES
80. According to Doncaster’s own management responsibilities for hospital escorts
and bedwatches (HMP and YOI Doncaster Security Escorts and Bedwatches –
Hospital escorts and bedwatches management responsibilities 20 July 2007)
the following options are available to the Director:
i. Where the risk assessment indicates that restraints are necessary, escort
and bedwatch with two officers or more with restraints applied.
ii. Where the risk assessment indicates that restraints are unnecessary,
escort and bedwatch with two officers or more, without restraints.
iii. Where the prisoner’s medical condition or lack of mobility is such that he
or she cannot escape unaided, and there is no evidence that an escape
attempt is likely, escort and bedwatch with one officer, without restraints.
iv. If eligible, release on temporary licence under Prison Rule 9 (YOI Rule 6).
v. Exceptionally temporary release remand prisoners to remain in hospital if
they are so seriously ill or incapacitated as to be incapable of escaping
and for who there is no danger of assisted escape (this power is allowed
under Section 22(2)(b) of the Prison Act 1952).
81. Doncaster did not provide my investigator with evidence that the risk
assessment for the man was revised (to acknowledge his limited mobility and
lack of evidence of an escape attempt).
The Director should review HMP Doncaster’s policy for the management
and conduct of hospital escorts and bedwatches.
The Director should ensure that staff adhere rigorously to published
policies on risk assessment of prisoners receiving in-patient treatment in
outside hospital.
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CONCLUSIONS
82. The man arrived at Doncaster in March 2007 and, after being transferred to
outside hospital, died of natural causes in November 2007. From the bedwatch
log, I believe that the staff involved with the man’s care behaved with
compassion and sensitivity.
83. However, the security arrangements at the hospital, although initially suitable,
were not revised in the light of the man’s specific circumstances. Doncaster
had the option of reviewing and revising the risk assessment. There should
have been a careful risk assessment and it should have paid attention to the
man’s severe disability problems. The option of removing restraints and having
two officers on bedwatch duty could have been a more appropriate response in
this case. It is indeed very sad that the man was still handcuffed when he died.
I recommend that the Director of Doncaster reviews the policy for the
management of hospital escorts and bedwatches. This review should consider
the recent case law relating to prison escorts (Mr Justice Mitting’s judgement
on 23 November 2007) and the particular circumstances of this death.
84. Both I and the clinical reviewer conclude that no appropriate adjustment had
been made regarding the man’s disability and needs, and it seems that the
care he received was not comparable with that he could have expected to
receive in the community. HMP Doncaster has a Disability Policy to ensure
prisoners with disabilities are not discriminated against in any aspect of prison
life and that equality of opportunity in accessing all parts of prison life is offered
to all prisoners. It is clear from the evidence that staff in HMP Doncaster did
not follow the policy with regard to the man.
85. The man arrived in custody with serious medical needs which required support
to be provided by Doncaster. I do not consider that adequate support was
given to him. The man’s diabetes and related conditions needed close
supervision. His particular special needs also required individually tailored care
which was not made available. The man’s care was not satisfactory and was
not equitable to that he would have received in the wider community. The
findings of my own investigation, and the clinical review, highlight that
improvements to medical practices and access to facilities at Doncaster need
to be made. I endorse the recommendations from the clinical review. These
need to be addressed by the Director of Doncaster and his healthcare provider.
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RECOMMENDATIONS
Operational
1. The Director should review HMP Doncaster’s policy for the management and
conduct of hospital escorts and bedwatches.
Accepted - This will be reviewed as part of the preparation for the visit by
Standards Audit Unit (SAU).
2. The Director should ensure that staff adhere rigorously to published policies on
risk assessment of prisoners receiving in-patient treatment in outside hospital.
Accepted - Security Unit Managers/Senior Management Team (SMT) to carry out
checks in line with procedures laid down in National Security Framework
(NSF)/Local Security Strategy (LSS).
Medical
3. The Healthcare Manager should ensure that staff seek medical summaries for all
new prisoners from their registered General Practitioner.
Accepted - There is a system in place to carry out this procedure for any
prisoners with chronic illnesses or medication issues.
4. The Healthcare Manager should ensure that all staff are trained and kept up to
date in the following areas:
• awareness of and familiarity with HMP Doncaster’s Disability Policy
• record keeping
• barrier nursing
• formal referral procedures for secondary care.
Accepted - These issues will be added to the annual training plan.
5. The Healthcare Manager should improve communication between the prison and
external agencies.
Accepted - Links with external agencies have improved and we now work more
closely with the PCT to develop information sharing protocols.
6. The Healthcare Manager should carry out regular audits to ensure standards of
record keeping have improved and remain of a high standard.
Accepted - There is now an audit in place to spot check record keeping.
7. The Healthcare Manager should ensure that first and second health screening
interviews take place and that they are appropriately recorded in the prisoner’s
medical record.
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Accepted - This takes place during the reception process.
8. The Healthcare Manager should ensure that patients are seen in secondary care
when medically indicated and the reason for non-attendance is clearly
documented in the prisoner’s medical record.
Accepted - A system is in place to record and monitor any out-patients
appointments that are cancelled or postponed and the reasons for this.
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