Individual at Moorland Closed

Investigation into the death of a man
on 6 September 2006 at a nursing home
whilst in the custody of HMP Moorland
Report by the Prisons and Probation Ombudsman for
England and Wales
August 2007
This is an investigation into the circumstances surrounding the death of a man who
died at a nursing home whilst a serving prisoner at HMP Moorland. The man had
been diagnosed with Motor Neurone Disease whilst a prisoner at HMP Moorland.
He spent the last month of his life in a nursing home and died as a result of his
illness. The man was 59 years old when he died.
I extend my condolences to his family and to all those touched by his death.
The investigation was undertaken by one of my colleagues. Both my colleague and I
would like to extend our thanks to the Governor of Moorland, and to her staff, for
their cooperation during the investigation. Particular thanks go to the appointed
prison liaison officer and to Healthcare Manager, for gathering all relevant
documentation and ensuring it was made available in a timely way.
I would also like to extend my thanks to the clinical reviewer from the Doncaster
Primary Care Trust for undertaking a review into the clinical care the man received.
The man’s condition was undiagnosed when he was transferred to Moorland from
HMP Lindholme. It is clear that the decision to transfer him to a prison with 24 hour
inpatient facilities was a timely one, but I am in no doubt that providing round the
clock care for him was a draining and stressful experience for staff. Motor Neurone
Disease (MND) is a relatively rare condition that affects middle aged men slightly
more than women. It is a devastating, fatal condition that causes muscle wastage in
the limbs, face and throat and can lead to severe problems with speech, chewing
and swallowing. MND is difficult to diagnose and the rate of progression of the
disease varies from patient to patient. The provision of appropriate care and support
for patients with MND is a challenge to any healthcare facility, let alone a prison
healthcare environment.
Despite these challenges, my investigator found that healthcare staff provided
excellent care for the man, and it is a pleasure to commend the doctors and nurses
for their dedication in supporting him for a considerable length of time. I also
commend the healthcare team for the speed with which they obtained and shared
information about the disease and how to manage his condition effectively.
Careful consideration was given to releasing the man under Home Detention Curfew
conditions and then on compassionate grounds but neither proved successful. He
was eventually released on temporary licence and transferred to a nursing home
where he died.
I make one recommendation and highlight three areas of good practice in a report
that generally reflects very well upon HMP Moorland and the Prison Service.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2007
2
CONTENTS
Summary 4
The Investigation Process 6
HMP Moorland 7
Key Findings 8
Issues 16
Clinical Review 18
Good Practice 20
Recommendations 21
3
SUMMARY
The man was convicted of robbery at Leeds Crown Court in 2004. He was
sentenced to three years and 11 months in prison.
He began his sentence at HMP Leeds before being transferred to HMP Lindholme
where he began to experience difficulty walking unaided, and developed symptoms
of slurred speech. The prison doctor felt that Lindholme could no longer provide a
safe environment for him and referred him to Moorland. Lindholme is next door to
Moorland and part of a ‘cluster’ of three prisons in the area. It transfers all prisoners
with inpatient needs to Moorland.
When the man arrived in reception at Moorland in December 2005, he was weak.
The prison doctor examined him and referred him straight to Doncaster Royal
Infirmary (DRI) for further investigation. He stayed in two hospitals over Christmas
and New Year, and was diagnosed with Motor Neurone Disease after he was seen
by a specialist at the Royal Hallamshire Hospital in early January 2006. The man
was returned to Moorland some time towards the end of January and went straight to
the healthcare centre on reception.
He never saw the main prison and did not experience any standard regime
throughout his stay at Moorland. Despite this separation from the general prison
population, healthcare staff made every effort to enable the man to participate in
some form of association and education. He was located in a gated cell, close to the
staff office and his environment was made as homely as possible. The cell next to
his was reserved as storage space for the equipment he needed. The man
befriended another prisoner who was an inpatient at the same time, and they
became chess partners when he was well enough to play.
Between February and August 2006, the man’s health deteriorated on an almost
daily basis. Healthcare staff supervised him around the clock and liaised with
external agencies and organisations to bring in medical aids, mobility equipment and
specialist knowledge. His independence was maintained until he could no longer
care for himself in any capacity. Extra healthcare staff were brought in, and all staff
caring for him attended an awareness raising presentation and further training in how
to manage Motor Neurone Disease more effectively.
Moorland’s healthcare manager and his team also endeavoured to release the man
from custody and into the care of a nursing home in his local area as soon as
possible. In March, a Senior Health Care Officer (SHCO), with support from her
manager, first looked into the prospect of assessing him for release. This became a
lengthy process and the prison experienced a number of difficulties over the coming
months whilst a suitable placement was found.
The man spent approximately seven months at Moorland. His time was split
between the healthcare centre and local hospitals. He deteriorated rapidly. In
August 2006, he was released on temporary licence to his home area and a bed was
secured at a nursing home that provided 24 hour care. He stayed at the nursing
home for approximately one month.
4
On 6 September, he was due for release on conditional licence. His release papers
were hand delivered to him for his signature later that same day by a SHCO. He
signed his papers and was due for release at midnight that evening.
Sadly, the man died at 6.55pm that day.
5
THE INVESTIGATION PROCESS
1. The investigation was opened on 10 September 2006. My investigator began
by requesting all relevant prison records relating to the man. These included
his medical and core records covering the time he spent in prison.
2. Notices to staff and prisoners were supplied and displayed around the prison.
These invited anybody with information to talk to my investigator. In this
instance, nobody came forward. My investigator examined the records and
recorded significant events before visiting the prison. Using the evidence
gathered from the man’s records, my investigator identified a number of key
healthcare staff and interviewed them in November 2006.
3. A clinical reviewer from Doncaster Primary Care Trust (PCT) was invited to
undertake a review of the clinical care the man received while in custody. The
review is included as an annex to this report.
4. The Coroner was informed of the Ombudsman’s investigation. The post
mortem report concluded the cause of death as:
1a Aspiration Pneumonia
2b Motor Neurone Disease
The Coroner will receive a copy of this report when it is completed to assist
him with his enquiries.
5. The man’s next of kin was contacted by one of my Family Liaison Officers to
ask whether she or other members of the family had any comments or
concerns about his death. His family raised no concerns and commended the
prison for the way everything had been handled. The family will receive a
copy of my report.
6
HMP MOORLAND
6. HMP Moorland, near Doncaster, is an adult and young offender (YO) category
C training prison. The numbers held break down into approximately 314 YOs
and 451 adults. It has an operational capacity of 791. Moorland is a
complicated prison that sits on two sites, one establishment for prisoners in
open conditions and one for closed. The closed prison accepts a potentially
challenging population including escape list prisoners, serious offenders and
some life sentence prisoners.
7. The closed site has five houseblocks and, as a training prison, operates a
regime of programmes designed to address offending behaviour, to enhance
thinking and to prepare prisoners for employment on release. Moorland forms
part of a ‘cluster’ of three prisons and is the only establishment in the cluster
with 24 hour inpatient care. Prisoners in need of an inpatient facility from
nearby HMP Lindholme and Moorland (Open) can be transferred into the
closed site’s healthcare centre to receive the appropriate care.
8. Moorland (Closed) was last inspected by Her Majesty’s Chief Inspector of
Prisons (HMCIP), in December 2005. A report published in May 2006
recorded that Moorland was a relatively safe prison, purposeful and able to
deliver a resettlement orientated regime. HMCIP found some areas of prison
life in need of improvement, most notably healthcare provision.
9. The healthcare centre (HCC) is a two-storey building with the lower floor
dedicated to inpatient care. The inpatient facility consists of 18 beds, two
gated cells and one safer cell equipped with CCTV. It has a well placed staff
office or ‘bubble’, large association rooms currently under refurbishment,
shower facilities, and access to additional medical equipment through the
local Primary Care Trust (PCT).
10. The inspection of the inpatient facility found a slight shortage in staffing levels.
The healthcare manager, a Registered Mental Nurse (RMN), is also a
Principal Officer (PO) and as such is detailed to carry out orderly officer duties
across the prison. There are two other dual-qualified members of staff who
carry out both nursing and senior officer (HCSO) duties. Inspectors
commented that whilst prisoners with chronic conditions were well managed,
the regime for patients was limited and staff struggled to cope with additional
inpatients from the other two sites. Agency staff were often used in times of
shortage, but were well inducted. The report recommended that the
healthcare manager should be removed from orderly officer duties, but at the
time of my investigation he still held dual responsibilities.
11. Her Majesty’s Chief Inspector of Prisons emphasised the challenges
Moorland’s population presented to staff. In her summary, she wrote:
“It is to the credit of the Governor and her team that this inspection found that
the prison was, overall, performing satisfactorily”.
7
KEY FINDINGS
12. On 25 October 2005, the man was transferred from HMP Lindholme to HMP
Moorland. Whilst at Lindholme, he had presented with symptoms of slow
speech and had begun to stumble. On arrival at Moorland, he bypassed the
usual reception process and went straight to the healthcare centre (HCC). He
was assessed on arrival and it was noted that he suffered from arthritis in his
spine, hips, knees and ankles, and was reliant on crutches for mobility. He
had certain food allergies and was allergic to penicillin. This was also
recorded at his First Healthcare Screening.
13. The man stayed at Moorland for two weeks before being discharged back to
Lindholme on 8 November. He was seen in reception on arrival and placed
on the doctor’s list to be seen for a prescription. An entry in his medical
record noted that his speech was slurred and unclear at times, but that he
was fit for education. The prison doctor did not see him. He was seen by
healthcare again, prescribed aspirin and, escorted back to his wing and
placed in a single cell.
14. On 8 December, a nurse was called to the wing to see the man and found him
physically tired and “in tears” according to his medical record. The nurse
assured him that she would push for a permanent transfer to Moorland. The
doctor reviewed his suitability for a move and agreed that he needed to be in
an establishment that provided 24-hour healthcare.
15. Moorland accepted the transfer, and on 14 December the man found himself
back in reception at the prison. The doctor saw him in the afternoon and
noticed a weakness on the left side of his body. The doctor also recorded
history of a stroke, slurred speech and weaknesses in his facial muscles.
Following the examination, he was immediately transferred from Moorland to
Doncaster Royal Infirmary (DRI) for further investigation.
16. The man stayed in hospital over Christmas and the New Year. On 15
December, he underwent a computerised tomography (CT) scan of his brain,
and was transferred to a ward the following day. The CT scan results were
normal, and on 28 December he was transferred to the Royal Hallamshire
Hospital (RHH) to undergo tests for Motor Neurone Disease (MND). His
speech and mobility remained limited and on 30 December, he was placed
under the care of an MND specialist at the hospital. After a second opinion
confirmed his diagnosis, the man was moved to another ward and the hospital
prepared for his discharge into the care of the prison. The specialist
prescribed Rilutek and Clexane and arranged for them to be delivered to
Moorland. As the man was still technically in the custody of Lindholme, he
was released on temporary licence under the authorisation of their deputy
governor. His licence extended until 27 January and clearly stated that no
restraints should be used for the duration of his time in hospital.
17. The man left hospital and arrived at Moorland between 21 and 27 January
2006. (It is not clear from his medical records exactly when he was returned to
Moorland.) A post dated Discharge Summary letter dated 19 April 2006 from
8
the consultant neurologist at Sheffield Hospital suggested that he was
discharged from RHH on 23 January, having been diagnosed with an atypical
form of MND. The Escort Risk Assessment form, dated 21 January, stated
that he was returning to Moorland having been on temporary licence for a
number of weeks. He was escorted by one officer shortly after, without the
use of restraints.
18. A SHCO told my investigator that healthcare staff generally get one or two
days’ notice to prepare for the admission of a patient with substantial
healthcare needs. The officer stressed, “we just have to do what we can to
get ready for their admission.”
19. On 27 January, a member of the healthcare team contacted the Sister on the
hospital ward to chase up the man’s medication. It is not clear from the
medical records whom this member of staff was. The Sister explained that,
due to restrictions on the availability of the drugs, delivery could take several
weeks but the hospital would post them to the prison as soon as possible.
The MND specialist would arrange a follow-up appointment to review the
man’s condition in six weeks time.
20. On 29 January, the man pressed his cell bell. When the nurse responded, he
explained that he had fallen from his wheelchair whilst getting ready for bed.
The nurse noticed that he had sustained small lacerations to his head,
examined him for further injuries, and decided no further treatment was
necessary. He was then helped into bed by two members of the healthcare
team and was checked again at 2.00am on the morning of 30 January. An
entry in his medical record stated that he was “ok” and had suffered no ill
effects. The nurse completed the relevant documentation and an F213 form
(which is used to record injuries to prisoners).
21. The following day, an MND specialist nurse at the RHH, contacted healthcare
about the man’s medication order. The SHCO took the telephone call and
was told that the specific drugs prescribed by the MND specialist required
funding. The MND nurse explained that this had caused a delay and she
would contact healthcare as soon as it became available.
22. Approximately two weeks after the man was discharged from hospital,
healthcare staff at Moorland began enquiries about his release from custody
and into either his own home with community support or the care of a nursing
home.
23. On 9 February, another SHCO contacted the man’s physiotherapist to discuss
discharge arrangements. The officer explained that, in order for the man to
be released, he would need the right circumstances: namely, a wheelchair
adapted three bedroom house with support from his local social services
department. The officer asked whether the physiotherapist could contact
Manchester Social Services. The physiotherapist agreed and said he would
ring healthcare back the following day.
9
24. On 10 February, the same SHCO contacted the MND nurse who confirmed
that she would visit healthcare on 24 February to deliver a presentation on
MND, its progression and management of the condition. The nurse also
confirmed that she would liaise with her equivalent in Manchester to prepare
the area for the man’s release.
25. The man fell again on 16 February. He told a nurse that he had stumbled in
the shower and that it was an accident. The nurse recorded his fall in the
medical record. No F213 injury form was found in his records.
26. Over the next week, healthcare staff contacted the Red Cross to arrange for
the loan of hoist equipment to assist with the man’s mobility. A SHCO also
liaised with the Occupational Therapy department at DRI and arranged for a
wheelchair, cushion and bed assessment. The department also confirmed
that they would arrange delivery of specially adapted cutlery to help him
maintain his independence at mealtimes. The MND nurse delivered a short
awareness training session for the healthcare team.
27. The man’s speech therapist reviewed his condition on 28 February. The
speech therapist noticed a decline in his ability to swallow and, following a
discussion with him, referred him to the hospital for an endoscopy to fit a
‘PEG’ feed. The speech therapist told healthcare staff that the man would
have to be placed on a ‘Stage II’ diet. This meant that all food would have to
be mashed and thickened before he could consume it safely. Healthcare staff
were also told to be vigilant at mealtimes as the deterioration in his swallowing
had increased his risk of choking. An entry in his medical record suggested
an open door policy at mealtimes.
28. On 1 March, the occupational therapist (OT) visited the HCC and delivered
hoist training to staff. A SHCO told my investigator that she had previous
experience of PEG feeds, the use of hoist equipment and moving and
handling training. The officer shared her knowledge with staff less
experienced than her and delivered on the job training until the OT arrived.
29. The same SHCO contacted Doncaster Social Services to chase up plans for
the man’s release into community care. A Social Worker at Doncaster,
returned her call and explained that the man’s Probation Officer would be
contacted in due course to discuss what needed to be done to ensure
continuity of care for him on his release back to his home area of Manchester.
The social worker added that he was concerned about the lack of MND
awareness among healthcare staff at Moorland, and the care required to
ensure the man’s safety in a prison environment. The SHCO reassured him
that staff were fully aware of the risk of choking and took every precaution
necessary to ensure the man’s safety. The social worker was also reassured
that, whilst knowledge of the condition was limited, staff knew their
responsibilities and were being trained to use the hoist equipment to move the
man safely.
30. Moorland’s Head of Healthcare was informed by nursing staff that the man’s
needs had increased and that they were unable to cope, particularly at night,
10
with a skeleton staff of one qualified nurse. The Head of Healthcare was also
aware that the man’s condition had increased his risk of choking and he would
need medical intervention day and night. He told my investigator that he
explored the possibility of securing extra nursing cover and introducing a 24
hour open door policy with the head of operations and the deputy governor.
31. The Head of Healthcare then held a series of meetings with his management
team to look at how they could best manage the situation. He secured
authorisation and funding for an extra healthcare assistant and was given
permission to operate an open door policy. A SHCO completed a full risk
assessment and safer system of work assessment, and circulated this
throughout the whole prison.
32. The Head of Healthcare confirmed that the man’s open door policy would
commence on 1 March. An entry in his healthcare log stated that, in order to
comply with the risk and security assessments, staff were to remove his
wheelchair from the cell at 8.00pm and carry out roll checks during the week
and at weekends.
33. A letter dated 1 March from the speech therapist to healthcare confirmed that
the man would need to be referred to DRI’s Endoscopy Deptarment as soon
as possible. The letter also told staff that his Stage II diet could be continued
for a short time after the PEG feed procedure to aid the transition from oral to
non-oral feeding. The speech therapist also provided staff with guidelines to
safeguard against the man choking on his food and asked for him to be
supervised at mealtimes. In addition to his change in diet, the therapist
arranged for a Light writer, a specifically designed typewriter, to be issued to
on a trial basis with a view to long term loan. This would enable the man to
clearly communicate with staff and prisoners in the healthcare centre.
34. The following day, the healthcare centre received confirmation that his
medication would be delivered on a four weekly basis. A SHCO took
responsibility for delivery and signing for the prescription on his behalf. This
was approximately five weeks after he was discharged from hospital.
35. On 6 March, the same SHCO received a telephone call from DRI’s wheelchair
suppliers asking if the man remained in custody and where he was likely to go
on release. The officer told the suppliers that he would probably return to the
Manchester area. The officer then updated his Probation Officer and
confirmed that the man had agreed to nursing home care. The Probation
Officer told her that the house he originally wanted to go to, owned by his
named next of kin, had been assessed and was unsuitable for his healthcare
needs. His next of kin had also stressed that she would not be able to care
fully for him.
36. A SHCO noted in the man’s medical record that the feasibility of applying for
early release on compassionate grounds was also discussed, and a meeting
between healthcare staff and one of Moorland’s governors would be
scheduled in order to reach a decision.
11
37. On 15 March, the man was taken to the RHH. He arrived by ambulance in his
wheelchair, escorted by two uniformed officers. The escort risk assessment
stated that without a wheelchair he was unable to walk, but that “Cuffs can still
be applied.” The assessment also said that he was not an escape risk or a
risk to the public, and that the strength of escort required was due to him
being held in closed conditions. The deputy governor authorised the use of
restraint and gave the following reason for the decision:
“Given [his] lack of mobility, the restraint to be used should be an escort
chain. To be used at all times, excepting Duty Governor’s permission.”
38. The Prisoner Escort Record (PER) form for this journey does not mention the
use of restraints, and it is not clear what type of restraint, if any, was used.
The man saw the MND specialist who took blood samples and confirmed that
she would send a letter to include the results. His PER form said that he
arrived back at Moorland at 5.00pm.
39. The man continued to deteriorate throughout March and a SHCO made
several attempts to check the progress made in releasing him from prison and
finding a suitable community placement. On the morning of 22 March, the
officer contacted Doncaster Social Services Department with the following
questions:
How long before [he] is assessed?
Will he be assessed for a placement in the Doncaster or Manchester area?
When is he likely to be given a nursing home place?
40. Later that afternoon, a member of staff from Doncaster Social Services
returned the SHCO’s telephone call to arrange an assessment. The Speech
Therapist then entered a new plan into his records. The therapist noted that
the Motor Neurone Disease Association (MNDA) would loan the man a
keyboard and he would be able to take it home with him. The therapist further
recorded that he would arrange for a shower chair, a leg splint and a different
wheelchair with wider wheels to be delivered to help maintain his
independence. The therapist arranged to review him again once his PEG
feed had been fitted.
41. On 30 March, the man was sedated and fitted with his PEG feed during a
surgical procedure. He was released on temporary licence, arrived at DRI at
10.00am, and was returned to Moorland at 11.15am. His escort risk
assessment indicated that he was accompanied by two escort officers and
restrained using an escort chain. The decision to use restraints was
authorised by the head of operations. My investigator could not read the
signature on the documentation and it is not clear whether restraints were
used.
42. Throughout April, the man’s condition was monitored, his mealtimes
supervised and equipment ordered to make him as comfortable as possible.
A dietician from DRI visited healthcare to deliver PEG feed training and the
speech therapist carried out a review of his diet. A SHCO contacted Social
12
Services again to chase up his assessment for a nursing home place. The
SHCO also contacted Greater Manchester Probation Area and was informed
that the man was not eligible for Home Detention Curfew, as he was
technically of no fixed abode.
43. On 11 April, the same SHCO explored the possibility of transferring the man
to HMP Manchester as an interim measure, whilst he waited for assessment
and a suitable placement in the area. The officer sought agreement from the
prison doctor at Moorland, and Greater Manchester Probation Area. The
doctor liaised with the healthcare manager at HMP Manchester, but was told
that it would not be possible to transfer him because he was a Category C
prisoner and Manchester was part of the high security estate.
44. On the same day, the Head of Healthcare sent a memo to security, the prison
gate and the orderly officer informing staff that extra nursing cover for the man
was in place. The memo clearly stated the names of the agency nurses to
commence night duty and that cover would continue for the foreseeable
future.
45. On 2 May, an MND nurse, contacted one of the SHCO’s and discussed the
man’s release. The SHCO explained that the man had not yet been assessed
and had no address to go to. The MND nurse said that she was happy with
the care he was receiving at Moorland, but remained frustrated that he was
still in custody. She and the MND specialist were happy to write in support of
his release application.
46. On 6 June, the deputy governor authorised an escort risk assessment and
agreed to release the man on temporary licence (ROTL) to attend a hospital
appointment at the RHH. The risk assessment stated that he would be
escorted by one officer, but that restraints would not be used. The ROTL
allowed him temporary release from 7.00am until 6.00pm on 7 June.
47. On 7 June, healthcare staff prepared him for his appointment at the RHH with
the specialist. However, the ambulance, booked on 5 June, failed to arrive at
the prison gate and the man missed his appointment. The escort officer due
to accompany him recorded this on his PER form. The following day, a
SHCO spoke to the specialist’s secretary who explained that the ambulance
had gone to the man’s old home address by mistake. The officer made
further enquiries and discovered that the ambulance service had used an old
file for information, despite being told by healthcare staff that he was in
custody when the ambulance was booked. Attempts were then made to bring
a new appointment forward, and two days later, the specialist’s secretary
confirmed a new appointment had been made for 5 July. On of the nurses in
healthcare booked an ambulance and escort, and recorded the information.
48. The man saw the prison doctor as part of his morning rounds on 14 June.
The doctor noted a further deterioration in his condition and referred him to
DRI for admission. The man presented as anxious and lethargic. He was
reassured by a nurse before being placed in his wheelchair and transferred by
ambulance to DRI. The doctor wrote a referral letter for the man to take to the
13
hospital. His escort risk assessment indicated that he was to be accompanied
by one officer, without the use of restraints. He was to be released on
temporary licence until 21 June.
49. Whilst in hospital, the man was given a ‘Continuous Care and Nursing Home
Assessment’ by members of Doncaster PCT and DRI’s Outreach Team. A
SHCO made an entry in his medical record following the assessment. It said
that the care team would organise a placement in the Manchester area, but
that funding would need to be secured before he could be transferred. The
transfer would take between four to six weeks.
50. The man remained in hospital for approximately six days. It is not clear from
his medical record when he was discharged back to Moorland.
51. On 30 June, the Neurological Outreach Team sent a letter updating staff on
how to care for him following another review of his condition. The letter was
thorough and provided healthcare staff with new information about his diet,
mobility, and safe movement and handling of him using the hoist and sling.
The letter confirmed that he was no longer able to use the wheelchair on his
own and found it increasingly uncomfortable to sit in. The Outreach Team
scheduled a reassessment of his wheelchair needs for 18 July.
52. The man was released on temporary licence three times throughout July. On
5 July, a SHCO noticed that his chest was ‘rattly’ and asked the prison doctor
to see him. The doctor noted that the man was very tired. Later that day, he
was released on temporary licence for 24 hours to DRI. He was accompanied
by a letter from the doctor, a medication list and a member of the healthcare
team. He went back to DRI and was fitted with a new PEG feed on 8 July.
53. On 11 July, the man attended his rescheduled appointment with the MND
specialist and returned to Moorland at 5.30pm the same day. On 24 July, he
was seen by the doctor because he had been vomiting. The doctor noted that
he had presented as very unwell over the past few days and again referred
him to DRI. The man was seen by the hospital doctor at 6.00pm and was told
he would remain in hospital overnight. In fact, he stayed in hospital until 26
July on a temporary licence.
54. On 28 July, a member of the healthcare staff received a telephone call from
Manchester Social Services confirming that a suitable placement had been
found him at a nursing home.
55. On 31 July, a SHCO arranged for an ambulance to take him from Moorland to
the nursing home on Saturday 5 August. The man’s release on temporary
licence was arranged. The ambulance was booked for 3.00pm and the cost
of the journey was authorised by the Governing Governor. The officer made
an extensive entry in his medical record. It said:
“Healthcare staff will escort him for a full handover. [He] will be ROTL’ed until
his release date in September. Healthcare staff at Moorland are to make
weekly contact with the nursing home. Compassionate release may be
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discussed soon but due to the short length of time until release on licence,
this may not be necessary.”
56. On 5 August, the man was told he would be leaving Moorland for the nursing
home. His care plan noted that he was tearful when told the news. A SHCO
told my investigator that she knew he would be upset and took the decision to
delay informing him of the move for as long as possible. Healthcare staff
prepared him for the long journey and contacted Occupational Therapy to find
out what equipment he could take with him and what had to be returned. The
SHCO came in on her rest day and travelled to Manchester with him. He
settled into his room, and the officer handed the man’s medication and care
plan over before returning home.
57. Between 5 August and 6 September, healthcare staff made regular contact
with the nursing home manager and recorded updates on his condition in his
medical record. A SHCO told my investigator that communication with the
nursing home was difficult at times and that they had a responsibility for
keeping a record of the man’s condition as he was still technically in custody.
58. On 21 August, he was sent to Manchester Royal Infirmary where he was
admitted for treatment. The same SHCO visited him there to renew his
temporary licence. This took him up to the date of his conditional release.
59. At 12.15pm on 6 September, the SHCO and a health care assistant went to
the nursing home with the man’s conditional release papers. He signed the
relevant parts which would release him from custody at midnight. The two
members of staff said goodbye to him and returned to Moorland.
60. At 6.55pm, the manager of the nursing home telephoned Moorland’s HCC
and told a member of staff that the man had passed away. The SHCO was
told of his death when she returned.
61. The SHCO informed the orderly officer of the man’s death and contingency
plans were activated. The duty governor notified the relevant agencies and
Moorland personnel, but had difficulty contacting his next of kin at an early
stage. The governor telephoned both the nursing home and the police before
obtaining contact details. He rang the man’s wife late that evening to break
the sad news.
62. The family liaison officer for Moorland remained in touch with the man’s next
of kin and liaised with Manchester Social Services with regard to funeral
costs. The Social Services Department offered both to arrange and fund Ian’s
funeral with the permission of his family. The nursing home ensured that his
belongings were returned.
63. The man’s funeral took place in Manchester on 26 September. Floral tributes
were sent from Moorland.
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ISSUES
64. The man was a prisoner with significant physical healthcare needs. It is
comparatively rare for prison staff to encounter this level of chronic illness or
be asked to offer the level of care he needed. He was already displaying mild
symptoms of muscle wastage when he arrived at Moorland. He went from
experiencing slight stumbling and slurred speech to almost total immobility in
a relatively short space of time. For healthcare staff, this was the first time
they had nursed a patient with Motor Neurone Disease in a prison
environment.
65. I have no doubt that healthcare staff who came into contact with him did
everything they could, within their means, to make his life more comfortable.
Nursing staff took steps to maintain his independence for as long as possible.
The open door policy, secured early in his illness, enabled him to spend time
out of his cell, engage with staff easily and participate in a limited regime as
his health allowed.
66. It is also clear that the difficulties encountered were not just focused on
providing the high level of care the man needed whilst in a custodial
environment. Healthcare staff evidently felt frustrated at the length of time it
took external agencies to assess him for a suitable placement, and showed
determination and patience in securing his release back to his home area.
67. That said, although there would have been no effect on the ultimate outcome
for the man, the investigation has highlighted a number of areas where
practice could be improved.
Healthcare Records
68. Healthcare staff at Moorland showed great determination and commitment in
caring for the man during the last months of his life. It is clear from his
medical record that nurses overcame difficulties quickly to ensure he was
made as comfortable as possible, and followed the neurological care plan
meticulously. What is not always clear from the record is who his primary
carers were for the duration of his stay in the healthcare centre, and exactly
when he was transferred to outside hospitals and returned. The man’s
medical records were generally well maintained but occasionally difficult to
read, incorrectly initialled and signed, and below the expected professional
standards.
The Healthcare Manager should remind staff that, in accordance with the
Nursing and Midwifery Council’s guidelines for records and record
keeping, all medical records should be legible, up to date and in
chronological order. In addition, audits of the quality and consistency
of records should be undertaken in partnership with the PCT.
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Housekeeping points
69. As the only inpatient facility for the cluster of three prisons, healthcare staff at
Moorland are obliged to receive chronically ill patients, often at short notice.
The healthcare team are then required to adapt to change quickly, and in this
case they did so efficiently. The man was a patient at Moorland for longer
than he should have been, and healthcare staff coped admirably with a
demanding and terminally ill man, in addition to their daily nursing duties.
Staff knew how to access the support offered by the prison’s care team, but
stressed to my investigator that, on reflection, they would have benefited from
receiving acknowledgement that they were under strain and recognition that
they were managing the circumstances well. Staff made it clear that it would
also have been useful to have had more time set apart for reflecting on the
care they provided for him. Again, I make no recommendation, but draw the
attention of the Governor and PCT to this issue.
Use of Restraints
70. The man experienced short and long term stays in hospital on numerous
occasions and was also a regular out-patient. He was released on temporary
licence for every outside hospital admission and appointment whilst in both
Lindholme and Moorland’s care. Whilst it is clear that senior staff
implemented the relevant Prison Service Order (PSO 2300), Release on
Temporary Licence, effectively and efficiently, I have not been able to
ascertain whether restraints were used to escort him to hospital on 15 and 30
March 2006. His PER form makes no mention that an escort chain was
utilised on these dates. It is apparent that, for every journey both before and
after these dates, the relevant documentation said that no restraints were
required. This includes the lengthy stay he had in hospital whilst in the
custody of Lindholme between December 2005 and January 2006. The man
was increasingly dependent on his wheelchair for mobility and, by March
2006, his medical record documents the deterioration in his condition and his
ability to walk. It would be surprising to learn that Ian was, in fact, restrained
for these two journeys, and I must assume that the documents reveal an
inconsistency in record keeping and risk assessment. I draw this point to the
Governor’s attention, but make no formal recommendation.
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CLINICAL REVIEW
71. Doncaster PCT carried out the clinical review of the care afforded to the man.
The clinical reviewer concluded:
“It is clear that the care and management of the man posed prison health
staff enormous challenges. Diagnosis of MND is difficult as presenting
symptoms are often vague and uncertain. The fact that he was in custody
does not seem to have delayed either his diagnosis nor commencement of
treatment.
“His problems before diagnosis would seem to have been appropriately
managed although there did seem to have been some initial confusion
when he was transferred between HMP Lindholme and HMP Moorland.
As his emerging problems required more active treatment and monitoring
by the prison healthcare team, and he started to struggle to cope in normal
prison accommodation, possibly more decisive action could have been
taken and would have resulted in greater continuity and less uncertainty
for him.
“As the man’s mobility and speech problems deteriorated it would appear
he was referred and investigated entirely appropriately … although it may
now seem that his initial problems were indicative of the onset of MND it is
unreasonable to suggest any criticism at the speed with which it was
diagnosed. Indeed the Medical Director at Doncaster Royal Infirmary
commented having reviewed the man’s medical record that his MND was
untypical, therefore was not surprised that his symptoms may have made
diagnosis difficult however he wasn’t concerned that there had in fact been
any delay.
“From the point at which he was diagnosed as having MND, all members
of the immediate prison healthcare team are to be congratulated at the
professionalism with which they cared for him. This must have presented
a very steep learning curve and from interviews with the members of the
Neuro Outreach Team and MND Specialist Nurse they were extremely
pleased with the manner in which the prison health team responded and
were satisfied that he was cared for correctly.
“A decision had been taken at an early stage in 2005 to explore the
possibility of releasing the man under licence for him to be nursed in a
more appropriate environment. Determining responsibility for assessment
and funding however created great difficulty. Between March and July it
would seem there was an unacceptable delay in undertaking an
assessment and facilitating his placement. Accepting the fact that the
circumstances were most unusual the ensuing delay in taking
responsibility was inadequate, the frustration of those involved is clear
from interviews and entries in his IMR”.
“The role of the local Social Services Department in Doncaster, the
Probation Services in Manchester, Social Services in Manchester and
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Manchester Central Primary Care Trust were at times blurred, poor
communication compounding problems. In the final analysis responsibility
for undertaking and funding the placement of a prisoner requiring
placement and continuing care is shared between the Primary Care Trust
and Social Services where the prisoner lives. This was however further
complicated by the fact that the Primary Care Trust in which his General
Practitioner was located is different to the one in whose geographical
patch he lived. It was decided therefore by the Continuing Care manager
at Manchester Central PCT to fund the man’s placement and the issue of
co-funding with Social Services could be negotiated when he had been
released. The issue of which agency takes the lead and who facilitates
placement and negotiation of funding needs to be expedited so as to
reduce any possible delay.
“Motor Neurone Disease is a devastating illness, in any circumstances. It
is difficult to imagine how awful it must be trying to come to terms with and
cope with the distressing and debilitating features of this disease. Caring
for and supporting a patient with MND would be extremely challenging for
any Primary Care team, for a Prison Healthcare team this must have
seemed especially daunting. Once again I believe all those involved both
within and outside prison are to be commended for the way in which they
attempted to care for the man. It is striking from interviews with prison
health staff the close bond that developed with him and is corroborated
with outreach teams working in the prison.
“Collaborative working with all the relevant agencies was absolutely vital to
the outcome of the quality of care for him. I am satisfied that the various
agencies involved with the man worked in a spirit of partnership and
cooperation. The Medical Director at Doncaster Royal Infirmary
specifically commented that the hospital have a good relationship with all
the prisons in Doncaster including HMP Moorland and as such was
satisfied with the way in which the prison interfaced with the hospital.
“It may be helpful for all concerned to have the opportunity to reflect on the
events around the man’s care and undertake an analysis of how his care
was managed. There is an expectation that Primary Care teams will
routinely undertake Significant Event Analysis of the care of patients dying
at home to highlight good practice and explore any lessons to be learned.
Given the challenges faced in caring for him, this would seem to offer a
useful opportunity to review and reflect, enabling staff to explore in a non-
judgemental way what happened and provide some closure.
72. The clinical reviewer has identified six areas for learning and I urge the prison
health partnership to consider his findings and develop an action plan to
address these in a timely manner.
The prison health partnership should develop a SMART action plan to
address the identified learning from the clinical review.
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GOOD PRACTICE
73. Throughout the man’s stay in healthcare, his day to day management was
overseen by one of two SHCO’s. The SHCO who became his primary carer,
managed his transfer to the nursing home, and forfeited one of her rest days
to escort him and settle him into his new home. The SHCO demonstrated an
acute awareness of the importance of providing continuity of care and should
be commended for her actions.
The SHCO should be commended for her personal commitment and
compassion in caring for the man.
74. The Head of Healthcare and his staff, should be commended for securing
both a 24 hour open door policy and additional night duty cover to increase
the levels of care for the man. This was achieved efficiently and effectively
and struck the right balance between security for the prison and quality of life
for Ian.
The Head of Healthcare and the healthcare team should be commended
for their sensitive and compassionate management of the man and his
clinical needs.
75. The senior management team’s use of PSO 2300 Release on Temporary
Licence (ROTL) was implemented efficiently and effectively for each of the
man’s stays in an outside hospital. Licences took into account the rare and
debilitating nature of his condition and were always renewed in a timely way.
I congratulate the Governor and her management team for the speed in which
ROTL was considered and authorised.
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RECOMMENDATIONS
1. The Healthcare Manager should remind staff that, in accordance with the
Nursing and Midwifery Council’s guidelines for records and record keeping, all
medical records should be legible, up to date and in chronological order. In
addition, audits of the quality and consistency of records should be undertaken in
partnership with the PCT.
The Prison Service accepted the recommendation and said the following:
“An instruction to all Healthcare staff will be issued. A check sheet system will be
implemented for Healthcare managers to regularly check quality and content of
all medical records. The PCT Clinical Governance team will be consulted to
identify ways in which they can assist in improving and maintaining standards in
record keeping”.
2. The prison health partnership should develop a SMART action plan to address
the identified learning from the clinical review.
The Prison Service accepted the recommendation and said the following:
“ An action plan will be implemented which has been developed with input from
the commissioning PCT”.
3. The SHCO should be commended for her personal commitment and compassion
in caring for the man.
The Prison Service accepted the recommendation and said the following:
“A Commendation will be given by the Prison Service Area Manager. The PCT
will also issue a letter of thanks”.
4. The Head of Healthcare and the healthcare team should be commended for their
sensitive and compassionate management of the man and his clinical needs.
“A Commendation will be given by the Governing Governor of HMP Moorland.
The PCT will also issue a letter of thanks”.
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