Individual at North Sea Camp

INVESTIGATION INTO THE CIRCUMSTANCES OF THE DEATH
OF A MAN IN DECEMBER 2005 AT AN NHS HOSPITAL
WHILST IN THE CUSTODY OF HMP NORTH SEA CAMP
Report by the Prisons and Probation Ombudsman for
England and Wales
July 2006
This is the report of an investigation into the death of a prisoner at HMP North
Sea Camp. The man died in December 2005 at a hospital near to his home.
The cause of death was recorded as carcinomatosis and a right renal
medullary carcinoma. He was a young man, aged in his early 20s.
The man’s death was particularly sad because, having spent two and a half
years in prison, he was within six weeks of possible release on licence. I wish
to take this opportunity to offer my sincere condolences to his parents and
family, and all of those touched by his loss.
The investigation was carried out on my behalf by one of my colleagues. An
independent review of the man’s medical care in prison was carried out by two
professionals on behalf of the East Lincolnshire Primary Care Trust. I am
most grateful to them all.
I would also like to thank the Governor and staff of HM Prison North Sea
Camp for their full and ready co-operation during the investigation.
The man died from a rare and aggressive type of cancer. I make two
recommendations and highlight three examples of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2006
2
Contents
Summary
Investigation methodology
HMP North Sea Camp
Events prior to the man’s death
Consideration of issues arising from the investigation
Recommendations and good practice
3
Summary
The man was initially remanded into custody on 24 April 2003, before being
convicted and sentenced to five and a half years imprisonment on 2 October
that year. On 27 April 2005, he transferred to North Sea Camp where he was
popular with both staff and fellow prisoners.
On 16 August 2005, he attended the Healthcare Centre at North Sea Camp
complaining of passing blood in his urine. He returned the following day, now
also complaining of vomiting and severe pain, and was referred to A&E
Department at a local hospital. He was admitted to the hospital for three days
where he was diagnosed with a stone in the ureter.
The man continued to experience pain and was therefore re-admitted to the
local hospital on 25 August. He was discharged on 29 August and, at a
follow-up appointment on 5 September, reported that his symptoms had now
resolved.
On 14 October, he again complained of pain in the right loin area and was
subsequently admitted to the local hospitalospital as an inpatient. A urogram
on 17 October found no evidence of a stone, and he was therefore discharged
on 18 October to return on 4 November for a renogram.
The results of the renogram were discussed with him on 21 November. By
now he was also complaining of coughing up blood, headaches and chest
pain. The renogram showed an apparent renal mass in the upper pole of the
right kidney, and he was therefore booked for an urgent CT scan.
On the night of 27 November, he complained of breathlessness and an
inability to lie down, resulting in a night of insomnia. The following morning,
he was again admitted to the hospital, where investigations showed a large
mass in the upper right kidney with deposits in the lungs. A biopsy was taken,
and on 1 December he was diagnosed with a cancerous growth in the kidney
with a very poor prognosis.
The man was transferred to a hospital close to his home on 3 December. His
condition deteriorated and he died in his sleep at 7.20am a few days later.
The cause of death was recorded as carcinomatosis and a right renal
medullary carcinoma. This is a very rare and aggressive form of cancer which
is associated with poor prognosis and outcome.
This report includes two recommendations and draws attention to three
examples of good practice.
4
Investigation methodology
The investigation was opened on 13 December 2005 when my investigator
issued notices announcing the investigation to staff and 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. No
prisoners came forward as a result.
My investigator subsequently visited North Sea Camp on 30 January 2006
and met with the Governor and the prison liaison officer. He also toured the
prison, and was therefore able to familiarise himself with the Healthcare
Centre and the wing on which the man had lived. My investigator was also
given access to the deceased’s prison files, including the Inmate Medical
Record (IMR).
An independent clinical review of the man’s health needs whilst he was in
custody at North Sea Camp was carried out by East Lincolnshire Primary
Care Trust.
One of my family liaison officers contacted the man’s mother and nominated
next of kin, on 16 January 2006. His mother later wrote to our family liaison
officer. Whilst saying that she did not feel that staff at North Sea Camp
contributed to her son’s death in any way, she noted the following concerns
regarding his care whilst at the prison:
• on one occasion in August 2005, when the man was first diagnosed
with a kidney stone, he was transported in a bus whilst in severe pain
with prisoners being dropped off for work before he was taken to
hospital;
• staff appeared to be getting fed up with him frequently visiting
healthcare, and this made him paranoid about going there;
• she telephoned healthcare staff on a number of occasions to express
her concern at her son’s symptoms;
• on one occasion, he was given a prescription by the hospital that was
refused by healthcare staff as it was not prescribed by the prison;
• on the night of Sunday 27 November 2006, her son was awake all night
having difficulty breathing. He was seen by five officers throughout the
night who, when he told them of his problems, answered that they
could not sleep either and he would have to wait until the morning for
an ambulance.
5
HMP North Sea Camp
HMP North Sea Camp is located close to the town of Boston in Lincolnshire.
The prison was established in 1935 as a Borstal, with the original structure
built by staff and trainees from HMP Stafford. In 1988, North Sea Camp
became an open prison for adult males and, at the time of the man’s death,
had an operational capacity of 306.
There are four living units, with multi-occupancy rooms on North and South
Units and single rooms on Harrison and Llewellin (the resettlement units). At
the time of my investigator’s visit, the Healthcare Centre was staffed by a
healthcare manager and one nurse. The most recent report from HM Chief
Inspector of Prisons, dated April 2004, described healthcare at North Sea
Camp as being of a high clinical quality, provided by respectful and very
professional staff.
6
Events prior to the man’s death
When the man was first remanded into custody on 24 April 2003, he reported
that he suffered from sickle cell trait but spoke of no other outstanding issues
at his reception health screen. Over the next two years, he had a couple of
minor complaints, including insomnia, but his health was generally good in this
period.
On 16 August 2005, he attended the Healthcare Centre at North Sea Camp
complaining of haematuria (passing blood in the urine). He was treated with
trimethoprim 200mg and referred to the urology clinic at a local hospital. The
following day, he again attended the Healthcare Centre, this time complaining
of vomiting and saying that he was in a lot of pain. He was seen by the staff
nurse who referred him to A&E Department at the local hospital where, after
examination, he was admitted as an in-patient to Ward 3A. The man was now
complaining of right loin pain and further haematuria, and was diagnosed with
ureteric calculi (a stone in the ureter, the tube through which urine passes
from the kidneys to the bladder).
A further investigation on 18 August revealed no significant obstruction in the
ureter. On 19 August, he underwent a cystoscopy (a visual examination of
the urinary tract with a cystoscope) and right ureteroscopy (an examination of
the ureter with an endoscope). The procedure revealed no evidence of the
stone although, at the end, a miniscule piece of stone was found in a basin
which was thought likely to be his. He was discharged the following day to
await an out-patient review in six weeks time, and was prescribed a five day
course of trimethoprim 200mg.
The man continued to complain of passing blood in his urine and of pain in the
ureter, and was subsequently re-admitted to the local hospital on 25 August.
He was discharged on 29 August. There is no record of any examinations or
treatment provided at the hospital in this period, but the discharge sheet notes
that he was prescribed a further seven days supply of trimethoprim 200mg
plus seven days supply of diclofenac 50mg on discharge.
A follow-up appointment was made for him at the Department of Urology at
the hospital on 5 September. He reported that his symptoms had now
resolved, and therefore no further appointment was arranged. However, a
letter from the Department of Urology dated 29 September stated that the
man failed to attend an appointment on 26 September. There was no
evidence of an appointment letter anywhere in his IMR.
In the afternoon of 14 October, he again complained of pain in the right loin
area and was subsequently taken to A&E Department at the Pilgrim Hospital.
A right renal colic (a severe pain caused by the lodgement or passage of a
stone in the ureter) was diagnosed, and he was therefore admitted as an
inpatient. An intravenous urogram took place on 17 October, which found no
evidence of a stone. He was discharged on 18 October with an appointment
to be booked in three weeks time for a renogram. No medication was
prescribed on discharge.
7
An appointment was made for him on 4 November for a renogram. In the two
days preceding this, he had complained to the prison’s Healthcare Centre of a
chest pain. The results of the renogram were discussed at a follow-up
appointment on 21 November, by which time the man was also complaining of
coughing up blood, and of headaches and sinusitis. The results showed an
apparent renal mass in the upper pole of the right kidney, and he was
therefore booked in for an urgent CT scan. He was also seen by a chest
physician for his symptoms of cough and chest infection, and subsequently
prescribed a five day course of codeine linctus on discharge. This medication
was subsequently altered to paracetemol brufen at North Sea Camp. At
interview, the healthcare manager stated that alternative medication was
prescribed as the codeine linctus was not on the prison’s prescribing list due
to there being no evidence that it is effective.
On the night of 27 November, the man complained of breathlessness to
officers on his wing. He was also unable to lie down, which meant that he
could not sleep. The night orderly officer was called. He spoke to the man
about his medical history and discussed with him whether his condition had
deteriorated since he had seen medical staff. The man stated that the only
deterioration was his inability to lie down. The officer therefore advised him to
report to healthcare in the morning and to contact wing staff if he felt worse
during the night. He also arranged for wing staff to make regular checks on
him through the night.
In the morning of 28 November, the man reported to healthcare and was seen
by the prison doctor. After examination by the doctor, he was again admitted
to the Pilgrim Hospital. Investigations showed the presence of a large mass in
the upper right kidney, with deposits in the lungs. A biopsy of the right renal
mass was taken and, on 1 December, he was provisionally diagnosed with a
medullary carcinoma of the kidney (a cancerous growth in the kidney). He
was subsequently given a very poor prognosis, with the tumour considered to
be so advanced that no effective therapy could be offered.
The man was therefore transferred to a hospital close to his home on 3
December on compassionate licence (a form of temporary release for
exceptional personal reasons) so that he could be close to his family. His
condition deteriorated further and he died in his sleep at 7.20am a few days
later, with his mother and other family members at his side. The cause of
death was recorded as carcinomatosis and a right renal medullary carcinoma.
Following his death, the Governor visited the man’s mother personally to
return his property and offer any help that the prison could provide. A
collection was organised amongst the prisoners at North Sea Camp and the
proceeds donated to his mother. She used this to buy a monument for her
son’s grave, engraved ‘From the Lads at the Camp’, with the remainder used
to sponsor a junior football team that would be named after him.
8
Consideration of issues arising from the investigation
Timeliness of diagnosis
The deceased suffered from an aggressive form of cancer that started in his
kidneys and rapidly affected his respiratory system. Medullary carcinoma is
an extremely rare form of cancer, practically unknown in the UK, which
develops most regularly in young people and has been linked by research to
those with sickle cell trait. It normally presents itself in advanced form at
diagnosis and is highly aggressive leading to poor prognosis and outcome.
The clinical review, conducted by the East Lincolnshire Primary Care Trust,
concludes that the man was referred appropriately to the urology department
by the prison and that there was no delay in diagnosing the cancer.
Family concerns
One of my family liaison officers contacted the man’s mother on 16 January
2006 to find out whether the family had any concerns that the investigation
should take into account. The issues raised by the mother were outlined in
section 2 above of this report and given consideration below.
• The management of the man’s transport to hospital
The man’s mother was concerned that, when he was first diagnosed with
kidney stones in August 2005, he was taken to hospital in the prison bus
whilst in severe pain, with other prisoners being dropped off for work before
he was taken to hospital. The man was first diagnosed with kidney stones on
17 August following his admission as an inpatient a local hospital on the same
day. The staff nurse who admitted him to hospital that morning, stated that he
was offered an ambulance, but refused and therefore travelled in prison
transport instead.
The Deputy Head of Operations at North Sea Camp clarified the procedure
with regard to transporting prisoners to hospital in non-emergency (ie not
requiring a blue light ambulance) situations. He stated at interview that a risk
assessment is taken on each case to determine the most appropriate means
available. The most important aspect considered is the physical health of the
prisoner, with the priority being not to exacerbate the complaint. The second
factor is the transport available at the time. If the prison mini-bus is taking
other prisoners to work, then it is possible that this would be used to transport
another prisoner to hospital. However, he said he was not aware of a
situation ever occurring where workers were dropped off before a prisoner
who needed to go to hospital.
It is clear that, when he was admitted to hospital on 17 August 2005, the
man’s condition was not life-threatening and he did not require a blue light
ambulance. Despite this, I consider it imperative that a prisoner who is in
severe pain and for whom A&E treatment has been deemed necessary should
be transported to hospital as quickly as possible. If a prison vehicle is leaving
9
for other purposes at the time then, as in the man’s case, it would be
appropriate for this to be used to take the prisoner to hospital. However, I
would be very disappointed if it were shown that such a vehicle was diverted
to complete other tasks at the expense of a prisoner who was clearly in pain.
In respect of the deceased, I have no clear evidence on which to confirm or
deny his mother’s account of what occurred.
• The treatment of the man by healthcare staff
The man was concerned that healthcare staff were getting fed up because he
frequently visited the Healthcare Centre, and that this made him paranoid
about going there. The healthcare manager at North Sea Camp stated that
the man would often come to healthcare around the time of his hospital
appointments to check that the appointment was still going ahead and that his
licence was ready. The staff nurse also stated that a number of prisoners,
including him, would often come to healthcare informally just for a chat.
The man did not make any formal complaints about his treatment by
healthcare staff, and there is no evidence of him making any informal
complaints. At interview, the healthcare manager stated that he believed that
the man had a good relationship with (healthcare) staff. I have found no
evidence to support the argument that healthcare staff acted in an
unprofessional manner towards the deceased.
• Telephone conversations between the man’s mother and the prison
with regard to the man’s health
The man’s mother stated that she telephoned North Sea Camp on a number
of occasions to express her concern at the symptoms from which her son was
suffering and the lack of progress in his recovery from them. The final
occasion was on 25 November 2005 when she says that she telephoned the
prison and spoke to a wing officer and a member of healthcare staff. The
officer allegedly said that they would go and see him; the member of
healthcare staff allegedly told her to get her son to come to healthcare. She
was concerned that she could not ask her son to come to healthcare as she
could not call him back, and she did not know what happened after these two
conversations.
The healthcare manager spoke of the procedures that are followed when a
prisoner’s relative contacts healthcare with concerns. He stated that it would
usually be the case that whichever member of staff took the call would find the
prisoner in question and check that they are okay. He also said that, whilst
medical information is never disclosed over the telephone, he would try to
reassure anyone who had concerns.
The staff nurse recalled the mother telephoning on one occasion to express
her concern that the man did not feel well and had not been eating. She did
not recall the date on which she had spoken to the man’s mother. The nurse
stated that she subsequently put a message on the tannoy for the man to
come to healthcare. On arrival, the nurse explained his mother’s concerns to
10
him who referred to it as being “just my mum fussing”. As he had a hospital
appointment in two days time, the nurse told him to keep the appointment and
to come and see her if he got any worse in the meantime.
I sympathise with a parent’s worry and concern for their son’s health when he
is in prison, and understand the frustration when they are unable to have their
concerns answered by healthcare staff. However, staff are bound by the
General Medical Council guidelines on patient confidentiality and are not
therefore at liberty to discuss a prisoner’s health with anyone over the
telephone. It is, nonetheless, important that staff follow up such concerns by
speaking to and assessing the prisoner in question, and I am pleased that
such procedures are in place at North Sea Camp.
The healthcare manager stated that he receives many such calls from
concerned relatives every day, and does not therefore keep a record of them.
There was no record in the man’s Inmate Medical Record (IMR) of his
mother’s telephone calls or of him being seen by healthcare staff following up
those calls. I consider it important that healthcare staff note in the IMR any
conversations that they have with concerned relatives and the follow up
assessments that take place. (I have a number of other concerns about the
standard of record keeping at North Sea Camp which I discuss in more detail
below.)
The healthcare manager should remind staff of the importance of
maintaining records correctly in accordance with the standards laid
down by the General Medical Council and the Nursing and Midwifery
Council.
• The management of the man’s hospital prescriptions
The mother said that her son was once given a prescription by the hospital
that was refused him by healthcare staff as it was not one that was prescribed
by the prison. The healthcare manager recalled that this related to a
prescription issued to the man on 21 November 2005 for a five day course of
codeine linctus. This medication was prescribed to him to treat the cough that
he had developed.
The healthcare manager stated that the medicine prescribed was not given to
him because it is not on the prison’s prescribing list. This is because it is an
‘off the shelf’ medicine and there is no evidence that it is effective. The man
was given paracetemol brufen by prison healthcare as an alternative, this
being the usual medication prescribed for colds at North Sea Camp.
My investigator discussed this situation with the clinical reviewer who agreed
that it was a reasonable course of action to use paracetemol brufen as an
alternative to the codeine linctus.
11
• The man’s care on the night of 27 November 2005
His mother was also concerned by the events of the night of 27 November.
She said in her letter to our family liaison officer that her son was having
difficulty breathing and was unable to sleep. She also stated that her son had
told her that five officers came to his room through the night, telling him that
they could not sleep either and that he would have to wait until the morning for
an ambulance.
The night orderly officer said that he was called to Harrison Unit just after
midnight on the morning of 28 November, as the man was unable to lie down
due to his cough and was having difficulty breathing after going to the toilet.
The man told the officer about his hospital appointments and that he was
taking medication for a chest infection, and stated that his condition had
deteriorated as he was now unable to lie down. The officer said he asked the
man if there was anything that he needed, to which he replied that there was
not. He therefore advised him to see healthcare in the morning. He agreed to
this, but was concerned about his mobility. The officer asked wing staff to
keep regular checks on him through the night and advised him to report to
staff if he felt worse. He said that the man’s condition did not deteriorate
through the remainder of the night, other than a brief increase in discomfort
following a visit to the toilet. The orderly officer’s statement of events is
supported by entries made by a wing officer in the Wing Observation Book on
the night of 27 November.
Given the available evidence, I consider that night staff at North Sea Camp
acted appropriately in dealing with the man’s discomfort on the night of 27
November. Questions were asked of his medical history, and the man was
advised to see healthcare in the morning and to report to wing staff if his
condition deteriorated through the night. (I also note the evidence of the
prison doctor who said that, when he saw him on the morning of 28
November, it initially looked like the man had some kind of viral illness. On
further examination, however, he noticed him to be profoundly short of breath
and in significant discomfort. He therefore arranged for him to be admitted to
hospital.)
I consider the night orderly officer’s actions in asking staff to keep a regular
check on the man’s condition through the night to be an example of good
practice.
The standard of record keeping at North Sea Camp
I have already noted my concern with regard to the failure of healthcare staff
to note in the IMR any conversations that took place with the man’s mother or
the follow-up assessments with the man. In addition, there were a number of
occasions on which the man attended hospital, for both scheduled
appointments and for treatment at A&E, for which there is no record in the
IMR – either of the attendance, or of any diagnosis made, or of any
medication prescribed.
12
There are also very few records of the visits made by the man to healthcare at
North Sea Camp and the subsequent advice, diagnosis and medication that
he received. The healthcare manager stated that these absences were partly
due to staff keeping records of prisoners visiting healthcare in a daily sick
parade diary rather than in individual IMRs. This procedure was reviewed by
the healthcare manager and discontinued on 1 November 2005, with staff
encouraged to write entries in the IMR instead. Nonetheless, the diary
contained no entries whatsoever relating to the man, and there were also
several events absent from his IMR following its closure. Most notably, there
was no record of him reporting to healthcare on the morning of 28 November
and his subsequent admission to hospital.
I repeat my previous recommendation.
The management of prisoners at North Sea Camp on return from outside
hospital
As I have discussed, the man’s IMR contained very scant details of his
hospital appointments. The healthcare manager said that, when a prisoner
goes to hospital, it should be recorded in the IMR. However, on discharge
from hospital the prisoner would go straight to prison accommodation with no
responsibility of reporting to healthcare. If medication is provided on
discharge from hospital, then the onus is on the prisoner to bring this to
healthcare and let them know what medication he has been prescribed.
He added that healthcare staff receive a discharge note from the hospital
which details factors such as medication, follow-up tests and appointments.
However, I note that, in the man’s case, these summaries were often not
written at hospital until over a week after he was discharged, and would
therefore have been received at North Sea Camp any time up to two weeks
after discharge. This represents a substantial period in which healthcare staff
are potentially ignorant of any diagnosis made or medication prescribed to a
prisoner.
The healthcare manager should introduce a more proactive system of
monitoring the status of prisoners discharged from outside hospital.
13
Recommendations and Good Practice
Recommendations
The healthcare manager should remind staff of the importance of maintaining
records correctly in accordance with the standards laid down by the General
Medical Council and the Nursing and Midwifery Council.
The healthcare manager should introduce a more proactive system of
monitoring the status of prisoners discharged from outside hospital.
Good Practice
The Governor personally visited the man’s mother to deliver to her his
property and offer any help that the prison could provide.
A collection was organised by the Governor amongst the man’s fellow
prisoners and the proceeds donated to his mother, which she used to
purchase a monument for his grave and to sponsor a junior football team in
his name.
The night orderly officer arranged for wing staff to make regular checks on the
man’s condition on the night of 27 November when his illness was causing
difficulty sleeping.
14