Individual at Norwich

Investigation into the circumstances surrounding the
death of a man at HMP Norwich
in March 2008
Report by the Prisons and Probation Ombudsman for
England and Wales
September 2008
This is a report of an investigation into the death of a man at HMP Norwich in March
2008. The man who died had a history of poor health including diabetes and in
November 2007 was diagnosed with cardiac failure.
The man’s medical care and support was carried out by a multi-disciplinary team of
health professionals including prison healthcare staff, diabetic specialists and, in the
latter stages of his life, palliative care specialists. My colleagues and I would like to
extend our condolences to his family.
This investigation was carried out on my behalf by one of my investigators. A review
of the clinical care was carried out by an Assistant Director of Nursing at a University
Hospital NHS Foundation Trust, on behalf of Norfolk Primary Care Trust (PCT), and I
am grateful to the Assistant Director for her assistance.
The Assistant Director was asked to review the man’s clinical care in prison and
ensure that it was comparable to that which he might have received in the
community. Both the Assistant Director and I are satisfied that the man received a
good standard of care. I have commented in previous investigations of deaths at
Norwich on the standard of care delivered by the healthcare team and I am pleased
to report again on the level of decency and dignity terminally ill patients receive
under their care.
I make one recommendation jointly to HMP Norwich and HMP Birmingham. I have
also reiterated previously identified areas of good practice at HMP Norwich.
Jane Webb
Deputy Prisons and Probation Ombudsman September 2008
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CONTENTS
Summary
The Investigation Process
HMP Norwich
Probation Approved Premises
Key Findings
Issues
Recommendations
Good Practice
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SUMMARY
The man was 69 years old when he died at HMP Norwich following a terminal
illness. The man had spent 40 years in and out of custodial establishments. His final
period of custody began in 2002 when he was sentenced to seven years
imprisonment. He was already in poor health at this time. In 2006, the man was
released on licence to a Probation Approved Premises (AP), where the Social
Services Department assisted him with his personal hygiene and daily activities. Six
months later, he was recalled to prison because he would not comply with several of
the rules of his licence and those of the AP.
As a result of the recall, the man was taken to HMP Birmingham in December 2006.
He was admitted as an inpatient into their healthcare unit where he remained whilst
at Birmingham. The man did not comply with his diabetic diet and his diabetes was
controlled with medication. He was seen regularly by diabetic specialist nurses.
From July 2007, the man was noted to have increased swelling in his legs and his
diuretic medication was reviewed and increased. Between July and December
2007, the man was admitted to hospital on several occasions due to an increase and
spreading of swelling and variable blood pressure. He was unhappy that he could
not smoke in hospital and always discharged himself.
During a hospital admission in November 2007, the man was diagnosed with heart
failure (biventricular failure) but again discharged himself before further
investigations could take place. There were several more self discharges and the
consequences of refusing treatment were explained to the man. He accepted that
he might die. A psychiatric assessment was carried out to determine the man’s
capacity to refuse medical treatment, and he was judged to have capacity.
Following an appointment with a consultant cardiologist which the man attended in
December 2007, end stage heart failure was confirmed. It was considered that his
condition would continue to deteriorate and that he only had a few months to live.
In March, the man was transferred to the Nelson Unit at HMP Norwich to receive
palliative care. The man received care from the healthcare staff and specialist
palliative care nurses, as well as specialist diabetes nurses, whist at Norwich. His
condition continued to deteriorate and, four days before he died, terminal congestive
cardiac failure was noted and all oral medication stopped. The man was kept
comfortable and pain free until he passed away. As per his wishes, his family were
not informed of his deteriorating condition and resuscitation was not attempted.
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THE INVESTIGATION PROCESS
1. My investigator requested all the relevant documentation including medical
records and core prison records. She visited HMP Norwich during the course
of the investigation.
2. Notices to staff and prisoners were displayed by the prison. These invited
anybody with information to talk to my investigator. In this instance, no-one
raised any matters of concern.
3. Norfolk Primary Care Trust (PCT) was asked to carry out a clinical review.
The review was carried out by an Assistant Director of Nursing at a University
Hospital NHS Foundation Trust on their behalf. Due to the man’s lengthy
periods in custody, it was agreed that the clinical review would concentrate on
the man’s healthcare from the point of his recall to prison in December 2006.
4. The HM Coroner for the district was informed of my investigation. He will
receive a copy of this report.
5. The man’s sisters are recorded as his next of kin. One of my Family Liaison
Officers wrote to them to offer the opportunity of involvement in the
investigation. The Family Liason Officer spoke to one of the sisters who
confirmed that they had both received her letters. During the conversation,
the man’s sister said that they did not have any questions or concerns for the
investigation and added that the contact and assistance received from the
prison was good and helpful. The family have asked to receive a copy of my
report.
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HMP NORWICH
6. Norwich is a city centre prison, predominantly serving the courts of East
Anglia. It has an operational capacity (maximum crowded capacity) of 557,
holding remand and sentenced adult men and young offenders. The prison is
divided into two sections. One area accommodates young offenders and the
healthcare centre and the other is for all other prisoners.
7. The healthcare centre provides 24 hour healthcare cover and has space for a
maximum of 23 in-patients. On the ground floor of the centre is a specialist
elderly patients unit, Nelson Unit. This unit has been designed and equipped
to enable older and less able prisoners to be supported and cared for within
the confines of the prison environment.
8. In previous reports into deaths at Norwich I have highlighted areas of good
practice. Given the function of the Nelson Unit at the prison, the staff are
experienced at providing care for the elderly and for those who are terminally
ill. I have mentioned the following good practice in previous reports and
reiterate them regarding the care of the man who died:
• The cell doors for prisoners at the end of their lives remain unlocked,
allowing quick, easy and regular access to nursing staff.
• There are good links between the prison’s healthcare staff and the
community palliative care services (as well as other specialist
services) which provide good continuity and a multi disciplinary
approach to the treatment of terminally ill prisoners.
9. Her Majesty’s Chief Inspector of Prisons (HMCIP) last inspected HMP
Norwich in November 2006. HMCIP recognised the good links with palliative
care teams and good use of the Liverpool Care Pathway.
Liverpool Care Pathway
10. The Liverpool Care Pathway (LCP) is a key recommendation in the National
Institute for Health and Clinical Excellence (NICE) guidelines for supportive
and palliative care. It is a continuous quality improvement programme for
care for a dying patient. It has been developed to transfer the hospice model
of care into other settings.
11. There is a multi-disciplinary document which provides an evidence-based
framework for end-of-life care. The LCP provides guidance on the different
aspects of care required, including comfort measures, anticipatory prescribing
of medicines and discontinuation of inappropriate interventions. Additionally,
psychological and spiritual care and family support can be included.
Release on licence
12. Prisoners released on licence are supervised by the Probation Service. There
are standard conditions for all licences, which include:
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• Keeping in touch with the probation officer in accordance with any
instructions that may be given.
• Residing at an address approved by the supervising officer.
• Being well behaved, not committing any offence and not doing anything
that could undermine the purposes of supervision, which are to protect
the public, prevent re-offending and help successful resettlement into
the community.
13. Further conditions can be added by the Secretary of State if they are deemed
necessary to manage a person’s risk.
PROBATION APPROVED PREMISES
14. Approved Premises were formally known as Probation and Bail Hostels. They
are approved by the Secretary of State within section 9 of the Criminal Justice
Act 2000. Approved Premises provide a supportive, structured environment
in the community for high risk and difficult to manage offenders. The
management of those accommodated in Approved Premises is governed by
the National Standards for Supervision of Offenders and the guidance
contained in the National Approved Premises Handbook.
15. The purpose of Approved Premises is to provide an enhanced level of
supervision for some of the potentially most difficult and high-risk offenders in
the community. They are not principally an accommodation resource.
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KEY FINDINGS
16. The man was remanded into custody in May 2002. He was sentenced in
June 2002 to seven years’ imprisonment with three years’ extended licence.
During sentencing the judge alluded to the man’s poor health. He was
released in June 2006 on licence and had to reside at a Probation Approved
Premises (AP) and, because of his ill health, enquiries were being made for
more suitable accommodation. Whilst at the AP, the man had regular contact
from the Social Services Department with regards his personal hygiene and
activities.
17. Six months later however, in December 2006, the man was recalled to prison.
He had not been complying with the AP rules and some rules of his licence
regarding offending behaviour treatment programmes. His place at the AP
was withdrawn and he was recalled to prison and taken to HMP Birmingham.
18. The man arrived at Birmingham on December 2006. His medical history
noted that he had diabetes, diabetic retinopathy (damage to the retina) and
heart failure. He did not comply with a diabetic diet and needed medication to
help control his diabetes. The man was reviewed by the specialist diabetic
team at the prison regularly.
19. Whilst at Birmingham, the man stayed in the healthcare unit. His mobility had
deteriorated and he walked with the aid of a Zimmer frame. He was also
taking medication for heart failure and smoked heavily. Through 2007, the
medical records show that the man received various treatment for his
diabetes. From July 2007, he was noted to have increased swelling to his
legs. His medication was varied accordingly.
20. In early November 2007, an urgent cardiac referral was made after the man
was found to have further swelling up to his midriff. Four days later, before an
appointment was scheduled, his blood pressure had dropped and he still had
swelling. The man was taken to the Accident and Emergency department at
the local hospital for further investigations. A diagnosis of biventricular failure
(heart failure) was made and the man was treated with intravenous diuretics.
However, he discharged himself from hospital a day later, because he had not
had tobacco since he was admitted. As a result no further medical
investigations could be undertaken.
21. In November, the man agreed to a hospital admission, but again discharged
himself the next day. A consultant had advised him of the treatment he
needed and that he should see a heart failure specialist, but the man
reportedly refused. He was made aware that his heart was very weak and he
could die without treatment, but he did not change his mind. Initially he
agreed to let the prison contact his next of kin but later changed his mind
about this too.
22. A psychiatric review took place in November, to form an opinion on whether or
not the man had the mental capacity to refuse medical treatment and it was
judged that he did. The man agreed to be admitted to hospital again but as
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before, discharged himself the next day. He continued to refuse treatment,
not attending an outpatient appointment early December, although he did
attend a further appointment five days later. At the second appointment he
was seen by a consultant cardiologist and had an echocardiogram (test which
gives information about the heart). His medication was subsequently
reviewed and altered. By the beginning of January 2008, it was noted that the
man’s swelling had improved.
23. A letter was received by the prison from the cardiologist early January. The
cardiologist confirmed end stage heart failure. The man was also noted to
have poor lung function. Palliative care was the only further care available
and the man’s life expectancy was short.
24. Over the next week staff spoke to the man about compassionate release and
also with the Social Services Department to arrange a care assessment
should he be released. The man agreed to compassionate release, but later
said that he wished to die in prison. Due to his accommodation needs and
risk of offending, finding a suitable placement would not have been easy nor
necessarily granted. No arrangements for his release were in place before he
died.
25. In the middle of January, the man collapsed, but recovered. Two days later
he collapsed again and was admitted to hospital. He discharged himself five
days later but was readmitted the following day because he had low blood
pressure. The man remained in hospital for two nights before discharging
himself.
26. In February, a Community Health Care Coordinator (CHCC) and Social
Worker visited the man to assess his health and care needs. The
assessment found the man’s needs to be complex in nature and
recommended that he had 24 hour access to registered general nurses for a
variety of care including palliative care.
27. The man transferred from Birmingham to HMP Norwich’s Nelson Unit in
March 2008 to receive palliative care. Birmingham produced a transfer
summary detailing the man’s medical history as well as a current medication
list, personal hygiene needs, care plans and dietary needs. The man’s initial
healthcare screen at Norwich noted his diabetes, foot ulcers and possible
gangrene. He had poor mobility and a specialist bed was ordered to relieve
pressure sores. He was also noted to have congestive heart failure and
chronic obstructive pulmonary disease (COPD).
28. The following day he was seen by a Senior Staff Nurse, who noted that the
palliative care treatment needed to start once he was reviewed by the doctor.
The doctor saw the man later that morning and also noted that palliative care
should commence.
29. Later that evening, the doctor, head of healthcare and the senior staff nurse
discussed the man’s deteriorating cardiac condition with him. They talked
about his wishes for resuscitation in the event of a cardiac arrest. Together it
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was decided that the man would not be resuscitated in the event of cardiac
arrest based on the fact that he had been diagnosed with end stage bilateral
ventricular (cardiac) failure and chances of successful resuscitation would be
low or leave him with a poor quality of life. He would however, continue to be
treated for reversible or treatable conditions and to increase his comfort.
30. Over the next five days, the man received personal hygiene care, dressing for
his ulcers, checks for pressure sores, advice about smoking cessation and
general medical observations. He was taking fluids but not eating much solid
food. He had been vomiting so the doctor had been called and the man was
given relevant medication. During the five days, some of his tablets had been
found on the floor and between his sheets. It was also thought that the man
was tending to suck the tablets rather than swallow them. This was noted in
his medical record so that staff could assist him taking his medication. At
approximately 11.20pm on 26 March, the night nurse was checking the man.
She found some more tablets on the floor and asked him about it. The man
told the night nurse that he did not think the medication was doing him any
good and generally did not want any. The night nurse said she would speak
to the day staff about it.
31. The first staff nurse made an entry in the medical record at 2.52pm on 27
March to say that the man had been very sleepy all day. He had eaten little
lunch but had drunk fluids. The record shows that the man did not want his
medication, but had been kept comfortable through the day and turned every
two hours to prevent pressure sores.
32. The Head of Healthcare reviewed the man later in the evening. She had
noted that his condition had significantly deteriorated over the past 24 hours
and that he was in the terminal stage of his disease. The man did not want
his family to be informed of his deterioration, nor did he wish to see the
chaplaincy. At this point, as is common practice for terminal patients in
Norwich, the man’s cell door was left open at all times so that his end-of-life
and healthcare needs could be met.
33. Through the night, the man continued to be checked by healthcare staff. At
4.00am (28 March), he appeared to have been vomiting secretions. Staff
helped to clean him and make him comfortable. Once he was comfortable he
requested a cigarette. Later that morning he was noted to have an “increase
in respiratory secretions” but had become weaker when trying to cough.
34. The man had a palliative care review at approximately 11.20am that morning.
Terminal congestive cardiac failure was noted and all oral medication was
stopped. The man was kept comfortable in accordance with Liverpool Care
Pathway. Through the rest of the day he became increasingly restless and
confused. He was still coughing and vomiting. Norwich healthcare staff
discussed this with the palliative care team who advised that the man be
given a syringe driver (used to continuously administer medication).
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35. Over the next two days, the man continued to receive medication through the
syringe driver. He was given personal care such as washing, dressing and
shaving and remained pain free.
36. A Healthcare Assistant checked on the man at approximately 2.40pm on 31
March. The man appeared peaceful and pain free. The Staff Nurse went to
see him at 3.00pm and found that he had passed away. The Head of
Healthcare was called and, as an authorised person, pronounced the man’s
death at 3.05pm.
37. The news of the man’s death was reported to other prisoners on the unit
individually. Staff were reminded of the PCT Occupational Health Service
which healthcare officers are also able to access, as well as the peer support
available. A memorial service was held, led by the chaplaincy for any staff
and prisoners to pay their respects.
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ISSUES
Transfer between prisons
38. The clinical reviewer questioned the appropriateness of the man’s transfer to
Norwich shortly before his death. My investigator spoke to the Deputy Ward
Manager at Birmingham who confirmed that the facilities for a prisoner in the
dead man’s condition were better at Norwich than those available at
Birmingham. With compassionate release an unlikely option, it was believed
appropriate to transfer the man. Although in the end stages of his life, the
exact timescale would not have been known.
39. The clinical reviewer has also commented that there are no clear documents
for the referral process and subsequent transfer arrangements. My
investigator has however, found a transfer summary outlining the man’s
needs and medical history. The transfer was arranged between the two
prisons and I am satisfied that Norwich is an appropriate prison for prisoners
with terminal conditions, particularly if compassionate release is not an option.
Chronic Disease Management
40. In both prisons, the man was seen by diabetes specialist teams for his
diabetes and resultant foot ulcers. There are documented records of
interactions with these specialists and care from the prison healthcare teams.
However, the clinical reviewer has found that although there was chronic
disease management logged in terms of dietary advice and retinal screening,
there was less recorded evidence of peripheral neuropathy1 testing.
Haemoglobin tests (HbA1c) are also not evidenced to have been carried out
on a regular basis. The clinical reviewer does comment that this may have
been due to the rapid deterioration in the man’s condition. These tests give
clinicians an indication of the patients’ management of their diabetes and staff
were already aware that the man did not control his diabetes adequately.
The tests would not have affected the outcome of the man’s death.
Healthcare staff within both prisons need to ensure that chronic disease
management is comprehensive and any action is clearly documented.
Medication
41. There are several records of the man’s refusal of his prescribed medication
which healthcare staff were told to monitor. He also apparently sucked tablets
rather than swallow them and staff were asked to assist. The medical records
do not log any monitoring of medication, although it should be noted that it
was the man’s right to refuse treatment. On 26 and 27 March he told
healthcare staff that he did not want some of the medication he was
prescribed.
1
Peripheral neuropathy involves damage to the peripheral nervous system (PNS). Infection, injury, nutritional deficiency and disorders such as
diabetes can cause peripheral neuropathy. (explanation taken from the BBC health website)
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42. On 28 March, all oral medication was stopped because he had reached the
terminal phase of his illness. I am satisfied that the man received medication
administered by a syringe driver, which was the most effective means of
keeping him comfortable and pain free during his last days.
Clinical care
43. The man was transferred to Norwich for palliative care. As part of this, senior
members of the healthcare team discussed resuscitation options with him.
The staff explained that, given his condition, if his heart was to stop beating,
the chances of successful resuscitation were poor. The quality of his life
should resuscitation be successful was also discussed and the likelihood was
that he would have a poor quality of life. It was agreed with the man that he
would not be resuscitated in the event of cardiac arrest, but he would be
treated for treatable conditions and for comfort and symptom management.
44. In line with the Liverpool Care Pathway, there were good links between the
healthcare staff at Norwich and the palliative care services as well as the
diabetes specialist team. This ensured that specialist advice, care and
medication were provided to the man during the final phase of his illness.
45. The clinical review found that the man’s condition deteriorated over the last
six to nine months of his life. He understood his condition and prognosis but
frequently refused medical treatment, particularly with regards to hospital
admissions where he was not allowed to smoke. The clinical reviewer felt that
this would have made the man a difficult patient to manage.
46. This said, the clinical reviewer is of the opinion that prison healthcare staff at
Birmingham and Norwich acted within the duty of care and in the man’s best
interests. Both prisons worked to the Liverpool Care Pathway and worked
collaboratively with specialist care teams. The man, therefore, had all his
care needs met and his wishes were respected. The man was able to die
peacefully and with dignity.
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RECOMMENDATIONS
1. Healthcare staff within both prisons should ensure that chronic disease
management is comprehensive and any action is clearly documented.
HMP Norwich and HMP Birmingham have accepted this recommendation.
GOOD PRACTICE
Open door
2. When the man reached the last stages of his illness, his cell door
remained unlocked, allowing nursing staff quick, easy and regular access
to attend to his needs.
Specialist links
3. There are good links between Norwich’s healthcare staff and the palliative
care services (as well as other specialist services). They provided the
man with good continuity and a multi-disciplinary approach to his
treatment, care and support.
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