Individual at Norwich

Investigation into the circumstances surrounding the
death of a man at HMP Norwich in July 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2008
This is the report of an investigation into the death of a man at HMP Norwich
in July 2007. The man died of natural causes two weeks after transferring
there from HMP Leyhill. He was 78 years old.
The man had a history of serious ill-health. In 1974, he was diagnosed with
cancer of the bladder. More recently he had been treated for chronic
obstructive pulmonary disease, heart disease and ventricular tachycardia
(irregular heartbeats), and a recurrence of bladder cancer. In the month
before he died, he was diagnosed with untreatable lung cancer.
Fatal incident investigations conducted by my office attempt, as far as
possible, to address the concerns of family members and anyone to whom the
person who died was close. Sadly, this man had lost contact with his
remaining family over the course his lengthy prison sentence and it has not
been possible to trace any next of kin.
The investigation was undertaken on my behalf by two of my investigators. I
would like to thank the Governors and liaison officers at both Norwich and
Leyhill for the help my investigators received. A representative of Norfolk
Primary Care Trust carried out a review of the care the man received
throughout his time in custody, and I also thank her for her invaluable
contribution.
It is clear that the man had battled for some time with deteriorating health.
Leyhill was not able to offer him inpatient care but did their best to care for
him. He was afforded good multi-disciplinary support to address his needs. I
was also pleased to find that at Norwich, in the weeks before he died, the man
was evidently cared for with dignity and compassion. He was given the
chance to contribute to the care plan devised to make his last days
comfortable, and his wishes were respected. This reflects extremely well on
the staff at Norwich and those working on the Nelson Unit in particular.
I make no formal recommendations, but highlight one housekeeping point and
five areas of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman
May 2008
CONTENTS
Summary
The Investigation Process
HMP Leyhill and HMP Norwich
Key Findings
Issues
Recommendations and Good Practice
SUMMARY
The man was sentenced to life imprisonment in February 1970. He had poor
health during most of his sentence and was treated for various illnesses.
During the 37 years the man was in prison, he moved through several
establishments. He was transferred to open conditions in 2003 and arrived at
HMP Leyhill on 26 March 2003.
In April 2003, the man was diagnosed with chronic obstructive pulmonary
disease, a condition that makes breathing difficult. He was also diagnosed
with heart disease and rapid, irregular heartbeats. He took a number of
medications to control his symptoms.
In the first 15 months he spent at Leyhill, the man was found collapsed on the
floor 30 times. After each incident he was checked by healthcare staff and,
on a number of occasions, he was sent to hospital for further examination.
Despite his various medical conditions, none was thought to be related to the
falls and staff suspected it was a behavioural problem. He continued to fall
right up until his death.
On 17 March 2007, the man collapsed again. He was seen by healthcare
staff who carried out an assessment. During the assessment, a quantity of
his medication was found concealed in a box of washing powder in his room.
He explained that he had stopped taking it because he did not think it was
working. He was therefore admitted to hospital as a precautionary measure.
The prison also opened an Assessment, Care in Custody and Teamwork
(ACCT) document, a form used to monitor and support prisoners who are
considered to be at risk of serious self-harm or suicide. This was closed later
that day when it was established that the man was not trying intentionally to
hurt himself by not taking his medication.
The man remained in hospital for three days. Soon after returning to Leyhill,
he collapsed again on 29 March. He was taken to hospital and admitted,
being discharged two days later. Once again an ACCT form was opened in
order to monitor his compliance with his medication. This was closed on 5
April 2007 when a new system of monitoring the man’s behaviour, a multi-
disciplinary care plan, was introduced.
On 17 June, the man complained that he was experiencing pains in his chest
and numbness in his left arm. He was examined, taken to Southmead
Hospital and admitted. He was subsequently diagnosed with lung cancer
which the consultant considered untreatable. He was discharged nearly a
month later, on 12 July, and transferred to the Nelson Unit at HMP Norwich
for specialist palliative care. His health slowly deteriorated over the next two
weeks and he died during the afternoon of 25 July 2007.
Despite the best efforts of prison staff, it was not possible to contact an
appropriate next of kin to inform them. The man’s funeral took place three
weeks later and was attended by a number of staff from Norwich.
.
THE INVESTIGATION PROCESS
1. One of my investigators opened the investigation into the man’s death on
29 August 2007 at HMP Norwich. He met the Safer Custody Manager,
who provided the man’s prison records. (The investigation was
continued by another of my investigators after the first investigator
completed his secondment with my office.)
2. Prior to the first investigator visiting Norwich, notices were issued to staff
and prisoners announcing the investigation and inviting anyone who had
information relevant to the man’s death to make themself known to the
investigator. No one came forward. Having assessed the man’s
documentation and spoken informally to the Safer Custody Manager, my
first investigator decided it was not necessary to interview staff at the
prison formally.
3. My first investigator also contacted Her Majesty’s Coroner to inform him
of the nature and scope of the investigation and to request a copy of the
post mortem report. Upon completion, this report will be sent to the
Coroner to assist his enquiries.
4. After receiving the clinical review, my second investigator visited HMP
Leyhill. She had the opportunity to look at more evidence and speak to
several members of staff and a fellow prisoner who had regular contact
with the man. She also visited the areas where the man lived and spent
time.
HMP LEYHILL
4. Leyhill is an open prison for adult males in Gloucestershire. It has an
operational capacity of 512 comprising a mixture of life and determinate-
sentenced prisoners. Leyhill has had several refurbishments, and in
1986 prisoners were moved from the original accommodation into new
units providing single room accommodation.
5. Leyhill does not have 24 hour healthcare or inpatient facilities. However,
there is a disabled persons unit, which is more suited to those with
disability needs. For instance, there is better wheelchair access, beds
that can be lowered or raised, audible alarm systems and disability
liaison officers. It is situated for easy access to the dining hall and other
communal areas. There is a day care centre at Leyhill, primarily for
elderly and less able prisoners. It is supervised by healthcare assistants
and affords prisoners time out of their cells to interact with others and
keep mobile.
6. Her Majesty’s Chief Inspector of Prisons (HMCIP), last inspected Leyhill
in March 2007. In her subsequent report, the Chief Inspector praised the
day care centre. She also noted that a healthcare operational support
grade was responsible for booking external NHS appointments, and had
established excellent relationships with the local providers ensuring that
every effort was made for prisoners to attend appointments.
HMP NORWICH
7. Norwich is a multi-function 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.
8. The healthcare centre provides 24 hour healthcare cover and has space
for a maximum of 23 inpatients. On the ground floor of the centre is a
specialist elderly patients unit, the Nelson Unit. The Nelson Unit opened
in 2004 and has been designed and equipped to enable older and less
able prisoners to live a relatively normal life within a custodial
environment. A dedicated team of healthcare workers and prison
officers work on the unit. There are partnership arrangements in place
between primary care and secondary care staff both within and
externally to the prison. In addition, the prison works closely with
palliative care services within Norfolk.
9. The Chief Inspector last reported on Norwich in November 2006. Her
report commented on the good standard of clinical care provided on the
Nelson Unit, albeit that it criticised the lack of purposeful activity. The
Chief Inspector’s report said, “There were good local links to palliative
and Macmillan nurse teams, and good use had been made of the
Liverpool Care Pathway for the dying.”
KEY FINDINGS
10. On 3 February 1970, the man was found guilty of two very serious
offences at Lincoln City Assize and sentenced to life imprisonment.
11. In 1974, he was diagnosed with cancer of the bladder, which was treated
successfully.
12. Between 1970 and 2003, the man secured progressive moves to and
between category C establishments. In March 2003, his security
category was downgraded and he was transferred to open conditions.
He arrived at HMP Leyhill on 26 March 2003 and three days later was
admitted to hospital. A chest x-ray was arranged although there is no
evidence that it was followed up.
13. During his first 15 months at Leyhill, the man was found collapsed on his
residential unit on 30 separate occasions. Each time he was seen by a
nurse, and he was sent to hospital for further assessment on numerous
occasions. No physical cause for the collapses was identified and no
injuries related to a fall were observed. As none of the collapses was
witnessed by either staff or prisoners, some medical professionals
involved in his care speculated that the man deliberately put himself on
the floor in order to draw attention. Incidences of him collapsing and
being transferred to hospital for assessment and treatment continued
until his death.
14. Whilst no direct cause for his collapses was identified, the man was
diagnosed with chronic obstructive pulmonary disease (COPD) in April
2003. This condition makes breathing extremely difficult and painful, and
seriously impacts on the affected person’s quality of life. The man was
also diagnosed with ischaemic heart disease and a fast heart rhythm.
These conditions have less of an impact on a day-to-day basis, but can
prove fatal if not managed properly.
15. The man took a combination of prescribed medications to treat these
conditions. He kept the medicines in his own possession. In April 2003,
a report for the Parole Board indicated that the man had been warned
about not taking his medication and a blister pack was provided for him.
16. The man was taken from Leyhill and admitted, as an inpatient, to the
healthcare unit at HMP Bristol for a week in May 2003. Whilst he was
there, he complied with his medication and there were no occasions
when he collapsed.
17. In July 2004, the head of Leyhill’s healthcare unit wrote to the prison’s
lifer governor asking for the man to be transferred to a prison with 24
hour nursing care. The request was made because he continued to
collapse, occasionally refused to eat, and did not comply with his
medication regime. Some seven months later an application dated 12
December was completed, requesting a move to Norwich. However
there is no other reference to the application, and it does not appear to
have been followed up.
18. The man was diagnosed in July 2005 with a tumour in his bladder and
was operated upon. In September that year, his name was put on the
waiting list for further surgery. He was admitted as an emergency patient
in October 2005 because of symptoms of anaemia. The bladder surgery
was twice postponed and eventually he was assessed to be unfit for
surgery.
19. On 28 September 2006, the man complained to prison staff at Leyhill
that he was experiencing chest pains. He was taken to the Accident and
Emergency (A&E) Department of Frenchay Hospital in Bristol and
admitted as an inpatient. He remained at the hospital for a month for
treatment before being discharged on 26 October.
20. Two weeks later, on 9 November 2006, the man was again taken to
A&E. He was assessed by medical staff and his condition stabilised. He
returned to the prison later in the day. Further urgent visits to A&E took
place on 28 November and 19 December. On both occasions, the man
returned to the prison later the same day.
21. On 17 February 2007, the man’s health deteriorated to the point where
he required an assessment at the local hospital. He was taken to A&E
and admitted overnight. He was discharged to Leyhill on 18 February
after the hospital stabilised his condition. The following day he went to
healthcare to request follow up of the bladder surgery, originally
requested some 17 months earlier. Further emergency hospital visits
took place on 27 February and 6 March, although the man was not
admitted on these occasions.
22. A week and a half later, on 17 March 2007, the man collapsed on the
wing. He was seen by healthcare staff who carried out an assessment.
Whilst the assessment was taking place, a quantity of his medication
was found concealed in a box of washing powder in his room. Staff
asked him why he was not taking his medication as prescribed. The
man said he did not think it was working. Due to the amount of
medication that was found and his apparent collapse, the man was taken
to A&E and admitted as an inpatient. At the same time, Leyhill opened
an Assessment, Care in Custody and Teamwork (ACCT) document, a
form used by the Prison Service to monitor and support prisoners at risk
of self-harm or suicide. It was initially thought that his refusal to take his
medication could have been a deliberate attempt to harm himself. The
assessor completing the ACCT document liaised with prison colleagues
escorting the man at the hospital and concluded that it was not his
intention to self-harm. The ACCT was therefore closed later that
evening. The man was discharged to Leyhill on 19 March.
23. The events of the following ten days are not clear in the man’s records.
His medical record suggests that he returned to Leyhill on 19 March, but
on 28 March it also shows that he was discharged from hospital. It does
not specify when he returned to hospital. The man’s prison movement
sheets suggest that he transferred to Bristol prison for the period
between 20 – 29 March.
24. During this time the lead primary care nurse at Leyhill wrote to one of the
prison governors with her concerns that the man was not taking his
medication and not looking after his personal hygiene. She wrote that he
needed to be supervised on a more individual basis than the healthcare
team at Leyhill could provide.
25. On 29 March 2007, having returned to Leyhill at midday, the man
collapsed again. He was seen by healthcare staff who assessed him.
The medical record notes that the healthcare centre at Bristol would not
take him back and therefore the healthcare staff at Leyhill decided he
needed an ambulance. The man was taken to Frenchay Hospital before
being transferred to the nearby Southmead Hospital, where he was
admitted as an inpatient.
26. The man was discharged again on 31 March. Upon his return to Leyhill,
the ACCT document was reopened. Whilst the man had not
expressed any thoughts of deliberately harming himself, his antipathy
about his medication made him vulnerable. As part of the ACCT, a
separate care plan was drawn up so that the man’s compliance with his
medication could be checked more closely. It ensured that there was a
multi-disciplinary approach to the man’s care, needs and medication
compliance. I commend the staff involved for using their initiative to help
keep the man safe from unintentional harm.
27. On 2 April, the man started being sick. He also complained to staff that
he was suffering from pain in his lower back. He was examined by
healthcare staff who advised that he needed to get out of bed more often
in order to relieve the pressure on his back. No treatment was given for
the sickness and nausea, and the symptoms abated the following day.
28. Three days later, on 5 April, the man’s ACCT was reviewed. In the six
days since it had been opened, staff had developed an observation
booklet called a care plan that could be used to monitor his medication
intake and his changing health and support needs. This meant it was no
longer necessary to keep the man on the ACCT, which had been used
for the same purpose. The ACCT was formally closed at 10.45am. On
the same day, healthcare staff developed a needs plan for the man with
the primary services, and liaised with the doctor to enable care to be
delivered according to his needs. The clinical reviewer comments that
the plan was evidence of good communication.
29. On 6 May, the man was found collapsed on the floor. As Leyhill does
not have healthcare cover at evenings or weekends, officers arranged to
have him temporarily transferred to HMP Gloucester which has an
inpatient facility providing 24 hour care. The man was transferred that
day. He returned to Leyhill from Gloucester on 29 May. During the
intervening three and a half weeks, he had only fallen once. However, it
was recorded that he was eating very little.
30. Upon his return, staff at Leyhill opened another care plan. As a multi-
disciplinary document, the man’s medication intake could be monitored
more closely by all staff, not just by healthcare. The document also
ensured regular contact with the man’s to assess his situation and
needs.
31. My second investigator, visited Leyhill. She found that all the staff she
spoke to knew and remembered the man well. The wing staff were
aware of the extra support he needed and had tried to help with his
personal hygiene. The healthcare assistant told my investigator that the
man would attend the day care centre and, when he did not, staff would
follow up so that they could get him out of his cell. There is good
evidence of information sharing between healthcare staff and operational
staff.
32. The prison doctor met with one of the prison governors on 30 May to
discuss the man’s health. The doctor had examined him that morning
and found the man unable to get out of bed due to back pain. The doctor
was waiting for some test results to confirm bone metastasis (cancer
spread from a part of the body to the bones), but noted that he had lost a
considerable amount of weight and did not appear to be eating and
drinking. A special mattress to help with pressure pain was arranged. It
was the doctor’s opinion that, regardless of the test results, Leyhill no
longer had the facilities to cope with the man’s current condition and he
needed more nursing care. An application for a transfer to HMP Norwich
was made.
33. On 8 June, three members of staff including the senior doctor formally
spoke to the man about what he would like to happen if he experienced a
serious collapse requiring life-saving resuscitation. He said that he did
not want to be resuscitated. His wishes were recorded in his medical
notes. This was followed up on 14 June when he was examined by a
doctor. The man confirmed he did not want to be resuscitated if he
became unconscious. A ‘do not resuscitate’ form was completed and
signed by the doctor.
34. A week later, on 17 June, the man complained that he was experiencing
pains in his chest and numbness in his left arm. He was examined and
taken to Southmead Hospital where he was admitted as an inpatient.
35. Over the next few weeks, the man had a number of medical
examinations and tests. Healthcare staff at Leyhill maintained contact
with their colleagues at Southmead throughout and, on 6 July, the
hospital confirmed that the man had lung cancer. The consultant at
Southmead determined that the man was too frail for cancer treatment,
and thereafter only palliative care was delivered to make him as
comfortable as possible.
36. Confirmation that a space was available at HMP Norwich was received
on 25 June. Southmead Hospital provided Norwich with a discharge
summary of the man’s care and history before he was transferred from
hospital on 12 July.
37. After arriving at the Nelson Unit, healthcare staff drew up a
comprehensive plan to manage the man’s deteriorating health. The plan
covered numerous aspects of his well-being, including hygiene, pressure
area care, weight, nutrition, bowel movements, manual handling,
medication, pain relief and activities to keep him occupied. It was a
multi-disciplinary assessment and a continuous care plan was put in
place. The clinical reviewer comments that there was good liaison and
the man’s own wishes were at the centre of the care he received.
38. The following day (13 July 2007), the man was assessed by a visiting
specialist palliative care nurse from the Priscilla Bacon Centre in
Norwich. In a follow-up letter to the healthcare team at Norwich, the
specialist made four recommendations to make the man as comfortable
as possible. These were carrying out a comprehensive pain
assessment, monitoring his blood pressure, undertaking blood tests, and
giving consideration to implementing the Liverpool Care Pathway. (The
latter is a system widely used in hospices and other specialist care
environments to look after dying patients.) At this point Norwich also
started making efforts to contact next of kin (a friend named by the man).
39. Between 16 July and the early hours of 20 July, the man was found on
the floor by Nelson Unit staff seven times. On each occasion he was
checked for injuries before being helped back to bed. Around 10.30am
on 20 July, he was thoroughly examined by healthcare staff and it was
recorded in his medical notes that he was drowsy and slipping in and out
of consciousness. Later in the day, the man was seen again by the
specialist palliative care nurse who noted that he was dying. As a result,
the Liverpool Care Pathway document was opened. This described in
detail how the man should be cared for and also gave the man the
opportunity to make any last requests. He asked to see a chaplain and
this was arranged in accordance with his wishes.
40. The man slept for the majority of the next few days. Morphine was
started on 22 July and this was steadily increased over time in order to
make him as comfortable as possible. On 24 July, oxygen was given.
41. At 2.44pm on 25 July, whilst asleep and in the company of two members
of staff, the man’s breathing stopped. At 3.07pm, an appropriately
qualified medical practitioner formally pronounced death. The man was
78 years old.
42. Prior to his death, the man had said he wanted a friend to be his next of
kin. After checking, the Safer Custody Manager, found out that the friend
had died a few years previously. The Safer Custody Manager then
attempted to contact the man’s nephew, whom he had identified as his
next of kin earlier in his sentence. Despite checking a variety of sources,
including the electoral rolls and probation records, these efforts were
unsuccessful.
43. The man’s funeral took place on 16 August and the service was led
jointly by two chaplains from Norwich. The Healthcare Manager, the
Head of Offender Management, and the Safer Custody Manager
attended to pay their respects, accompanied by other members of the
chaplaincy team.
ISSUES CONSIDERED
Clinical care
44. The man had a long history of poor health. Whilst at Leyhill he fell
frequently without becoming unconscious or suffering any injuries. His
records contain references to the falls being a means of getting attention,
but he would always be assessed and sent to hospital if deemed
necessary because there was no other clear cause.
45. Due to the number of collapses and hospital admissions, the clinical
reviewer found it difficult to track the records and monitor the man’s
passage through the prison and healthcare systems.
46. The clinical reviewer has found that communication between Leyhill’s
healthcare team and the hospital was insufficient. Not only was further
surgery on the man’s bladder not followed up, but there was no follow up
after the shadow on his lung was confirmed. The clinical reviewer
comments that communications were inconsistent and resulted in
disjointed care. This said, Leyhill now operates a computerised record
system that should highlight any overdue consultations and
appointments. These of course then need to be followed up.
47. The clinical reviewer found more recent evidence of good
communication between Leyhill and primary care district nurse teams.
There was also good communication between both Leyhill and Norwich
prisons and Southmead Hospital during June and July 2007 prior to the
man being transferred to Norwich. I also note what the Chief Inspector
of Prisons has said about the good links being made by Leyhill with the
local NHS.
48. I do not make any formal recommendation regarding follow up
appointments or communication, both which seem to have improved.
Nevertheless, I suggest that the Governor and Healthcare Manager at
Leyhill consider what needs to be done to ensure that the improvements
are maintained.
Medication Management
49. The first report that the man failed to take his medication properly was in
March 2002, but there is no evidence that the risk was assessed at the
time. Similar reports continued throughout his time at Leyhill, yet there
did not appear to be an effective system to manage this. However, in
March 2007, healthcare staff were concerned when they found a quantity
of medication hidden in the man’s cell. As a result, a care plan -
separate to that in the medical record - was devised so that prison and
healthcare staff could monitor his medication intake and general health
needs. The ‘care plan’ is now regularly used at Leyhill to support and
monitor prisoners who need it.
Transfer to HMP Norwich
50. The first request for the man to be transferred to a prison with 24 hour
healthcare was made in July 2004, but there is no evidence that this was
taken forward.
51. At the end of March 2007, a senior nurse told one of the governors at
Leyhill that the man needed more individual care. This was followed up
in May by the prison doctor who felt that the man’s health was
deteriorating. The man was assessed for the Nelson Unit at Norwich
and arrangements were made for his transfer. A space became
available on 25 June, but the man was still in hospital. Upon his
discharge from hospital on 12 July, he went straight to Norwich.
52. The clinical reviewer has noted that, whilst a quicker move might not
have extended the man’s life, he would have been seen by experienced
palliative care nurses. My investigator discussed this with the Governor
of Leyhill who said that consideration was given to the wider perspective
of the man’s care.
53. From accounts by prison managers, wing staff and another prisoner, the
man was happy and well looked after at Leyhill. He knew the people
around him and was closely monitored. The physical environment of
Leyhill is pleasant and less constraining than that of a closed prison
where the man would have returned for inpatient care. There is a
daycare centre, primarily for older prisoners, that the man made use of.
The healthcare assistant told my investigator that, if the man did not
attend, somebody would check to see if he was alright. On the day that
my investigator visited, she spoke to one elderly prisoner who told her
that he himself regularly used the daycare centre. A prison officer had
woken him after lunch to check that he wanted to attend because he was
later going than usual.
54. When the man felt unable to get his meals or medication, arrangements
were made for them to be brought to him. The prisoner whom my
investigator met also told her that, if the man did not want anything from
the menu, he would share his canteen food.
55. The Governor of Leyhill told my investigator that some days the man
was physically better and more able than on others. It was a judgement
call what was in his best interests. I have no doubt that the judgements
were made with the best intentions for the man in mind. When the
healthcare team at Leyhill could not provide adequate care, the man
spent time at other prisons with inpatient facilities and in hospital. In May
2007, the prison doctor advised the Governor that Leyhill healthcare staff
were no longer able to offer adequate support and arrangements were
made to secure him a place at Norwich.
56. I am satisfied that the decision to keep the man at Leyhill took into
consideration his wider care and support. The decision was reassessed
due to medical need and appropriate action taken.
Record Keeping
57. The clinical reviewer found that the entries in the man’s medical record
were at times very difficult to read and follow. Reasons included illegible
handwriting and undated entries. Leyhill now operates a computerised
record system that should remedy these problems.
58. There was one inappropriate entry in the man’s medical record. This
was made in 2002 when he was at HMP Littlehey. My investigator has
spoken to the Head of Healthcare at Littlehey about this. Given the
period of time that has elapsed since the entry was made, and that the
person who wrote it no longer works for the Prison Service, I do not think
there is a need for a formal recommendation or that I should take the
matter further.
RECOMMENDATIONS
1. I do not make any formal recommendations but draw the housekeeping
point at paragraph 48 to the attention of the Governor of Leyhill.
GOOD PRACTICE
1. The man collapsed on numerous occasions, particularly in Leyhill.
Although, it was suspected that this was a behavioural problem the
collapses were dealt with appropriately.
2. Leyhill put in place a multi-disciplinary system to monitor and support
the man. This allowed non-confidential medical information to be
shared appropriately.
3. The man’s doctor discussed his failing health with him. This allowed
him to make an informed choice not to be resuscitated should such a
situation arise.
4. There were good communication links between both Leyhill and
Norwich prisons and Southmead Hospital which enabled Norwich to
prepare for the man’s transfer.
5. At Norwich, the man received equitable end of life care. The staff
followed best practice with the necessary pathways and ensured that
the man died in comfort and with dignity.