Individual at Norwich

Investigation into the circumstances surrounding the
death of a man at HMP Norwich
in September 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2008
1
This is the report of an investigation into the circumstances surrounding the
death of a man at HMP Norwich. The man was found dead by nursing staff in
his cell during the evening. He was 68 years old.
The man was already an elderly man and in poor health when he was
sentenced to three and a half years imprisonment in January 2007. He
moved between Bedford and Littlehey prisons a number of times, before
being transferred to the Older Prisoner Unit at HMP Norwich on 23 August
2007. The man then spent three weeks in an outside hospital. He returned to
Norwich on 18 September where he received end of life care.
The loss of any family member is distressing, but especially so whilst they are
in prison (and in the man’s case, in prison for the first time). I offer my sincere
condolences to his family and friends.
The investigation was undertaken by one of my colleagues. We would like to
extend our thanks to the then Governor of Norwich and his staff for their
cooperation during the investigation. Particular thanks go to the prison’s
liaison officer for gathering all the relevant documentation and ensuring it was
made available.
A medical practitioner representing Norfolk Primary Care Trust, carried out a
clinical review into the care and treatment the man received whilst at Norwich,
Littlehey and Bedford. I am most grateful to her for completing the review. I
have relied heavily on her findings for this report. The other main focus of this
investigation has been Norwich’s management of the man’s stay in hospital
and his return to the Older Prisoner Unit.
Four prisons currently provide specific accommodation for elderly prisoners,
but Norwich is the only one with a dedicated unit that is Prison Service-led. I
have praised the work of the Older Prisoners Unit in several of my reports,
and I am pleased to record here that the man’s last days were made as
comfortable as the circumstances allowed. In the privacy of his own room,
the man received a high standard of 24 hour palliative care. His family was
also fully consulted over his care plan and able to visit him on the day he died.
However, the man’s transfer to an outside hospital has highlighted the
importance of maintaining family contact when prisoners are too ill to
communicate effectively themselves. My investigation has also revealed the
difficult balance to be struck between protecting the public and managing a
prisoner compassionately and with dignity whilst in hospital.
My report makes six recommendations, includes two commendations and
highlights one area of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2008
2
CONTENTS
Summary
The Investigation Process
HMP Norwich
Key Findings
Issues Considered in the Investigation
Recommendations
3
SUMMARY
When the 67 year old man was sentenced to three and a half years
imprisonment in January 2007, he went straight to HMP Bedford. In
reception, he was identified with a number of complaints including heart
problems, arthritis, hypertension and alcohol dependency. He was seen by a
doctor and referred for alcohol detoxification and regular blood pressure
monitoring.
The man stayed at Bedford for 11 days before being transferred to HMP
Littlehey. On arrival he was given another full reception health screen, and
was seen by a doctor the following day. For the next two months, his physical
health began to deteriorate and he appeared confused. Healthcare staff were
concerned about his loss of memory and the difficulty he had looking after
himself. He became concerned about his eyesight and problems he had with
his teeth.
In March, he was seen by a doctor on four occasions. Blood tests were
taken, and he was referred to a diabetes nurse following diagnosis of Type II
Diabetes. The man was also seen by an optician and given a prescription for
reading glasses. Along with his confusion, he developed cellulitis in his legs
and was treated with antibiotics. The following month, he presented with a
fungal nail infection, and a referral was made for him to see the visiting
chiropodist. He got an appointment at the Podiatry Clinic within a week, but it
clashed with a visit from his family and he did not attend.
On 25 June, one of the prison doctors referred him to the local hospital’s
consultant neurologist for tests and scans. This followed symptoms of
continued confusion, tremors in his arms, abnormal reflexes and incontinence
of urine.
A week later, the man was admitted as an emergency to the hospital’s
Accident and Emergency Department. His outpatient appointments were
cancelled.
The man stayed in hospital for four days and was diagnosed as having
suffered a cerebral vascular accident (a stroke). When he returned to
Littlehey, another prisoner was allocated to help him with his hygiene needs
and a full care plan was drawn up. He transferred back to Bedford on 25 July
in order to receive 24 hour healthcare. He saw a dentist prior to his transfer
and requested an appointment with a podiatrist when he got to Bedford. He
stayed in healthcare for two weeks and was relocated in the induction wing
(C1).
After around three weeks at Bedford, the man returned to Littlehey. He
deteriorated again and a request was made for him to be transferred to a
prison with 24 hour healthcare facilities. On 22 August, the Head of
Healthcare at HMP Norwich accepted the request and the man transferred the
following day.
4
Soon after his arrival on 23 August, the man was transferred to the local
hospital. He stayed there for just over three weeks and underwent a number
of medical examinations and assessments. Sadly, he developed breathing,
swallowing and mobility difficulties and was fed by tube. He remained
attached to an escort officer until 13 September, a few days before he
returned to Norwich for end of life care. The man received palliative care in
the Older Prisoner Unit for the last two days of his life.
5
THE INVESTIGATION PROCESS
1. On 26 September 2007, the investigation was opened at HMP Norwich
by one of my investigators. She was briefed about the circumstances
leading up to the man’s death, and requested all prison and medical
files. The investigator began the process of identifying the key issues
and the staff who had interacted with the man during his time at Norwich.
Unfortunately, some documents from HMP Bedford and HMP Littlehey,
including the man’s wing histories, were not located and gaps remain in
his story. The investigator made attempts to find the missing documents
and contacted the Governor’s secretary at Littlehey. Following a search
of relevant departments, the Governor’s secretary confirmed that all
paperwork held at Littlehey had been sent to Norwich.
2. The investigator carried out informal telephone interviews on 16 and 17
January 2008 with a number of prison staff and the Head of Healthcare.
3. A medical practitioner representing Norfolk Primary Care Trust (PCT)
was asked to conduct a review of the clinical care the man received
whilst at Norwich. She agreed to speak with the hospital consultant, and
the Heads of Healthcare at both Littlehey and Norwich. A panel review
took place on 10 January. The clinical review was completed and sent
to my office on 25 January.
4. The Coroner was informed of the Ombudsman’s investigation. The post
mortem report concluded that the man’s cause of death was as follows:
1a Cerebrovascular Accident
1b Cerebral Infarction
The inquest date has been set. The Coroner will receive a copy of this
report when it is completed to assist with his enquiries.
5. One of my family liaison officers (FLOs) contacted the man’s next of kin
shortly after the investigation was opened. The FLO explained her role
and that of my office, and provided information about the investigation
process. She also offered the family the opportunity to meet her and the
investigator to discuss any issues or concerns. The FLO and the
investigator subsequently met the man’s family at their home. During
the visit, the family raised several concerns about the man’s healthcare,
in particular:
• The man had swollen legs and was in pain during family visits to
Littlehey. Did the prison fail to care for him properly?
• The man was discharged from the first hospital after his stroke and
sent back to Littlehey. Was his discharge premature? The family
believe that he might still be alive if he had stayed in hospital.
The family also raised concerns about the use of restraints whilst he was
in hospital and were distressed to learn that he would spend his last few
6
days in prison. The family visited him several times in Bedford and
Littlehey and told my FLO that they were shocked at his appearance.
They also visited him in the Older Prisoner Unit at Norwich, and found this
distressing.
A draft copy of this report was sent to the man’s family and the prison
service. His family made the following comments on the draft:
• Both of his legs were swollen whilst he was in custody.
• His sister was shocked to learn of the non-resuscitation policy at
Norwich and wanted further information about how healthcare
decides which prisoners this should apply to. His sister further
added that she hoped it was not an age-related decision.
• It was a relief to learn that the man was medicated, in accordance
with a palliative care plan, to help ease his passing on the evening
he died.
I address the issue of the non-resuscitation policy in the appropriate
sections of this report and will send the man’s family a copy of this report.
The prison service accepted the recommendations and commendations
and their response can be found on page 28 of this report.
7
HMP NORWICH
6. HMP Norwich is a multi-functional local and training prison, holding both
adult men and young offenders. It also has a remand unit, resettlement
unit and is one of the few prisons in England and Wales with a dedicated
Older Prisoners Unit. Norwich serves the east of England and accepts
both convicted and unconvicted prisoners. It has an operational capacity
of 824.
7. Between 1996 and 2004, Norwich underwent substantial reorganisation
of its wings, some of which were converted into dedicated units. As a
result, the resettlement unit, young offender units and the Older Prisoner
Unit (on the ground floor of the healthcare centre) are all located outside
the main prison.
8. Her Majesty’s Chief Inspector of Prisons has inspected Norwich twice in
the last three years. Her inspection in March 2005 described Norwich as
“an over-complex prison” unable to fulfil its purpose properly. The
unannounced full follow-up inspection in November 2006 focussed on
how well the prison had addressed the problems highlighted and was
able to carry out its multiple roles. Overall, Norwich was doing this with
some success, but HMCIP said the attempts made to fully function as a
community prison were hindered by the high number of prisoners
passing through its gate.
Healthcare
9. As noted, the healthcare centre is located separately to the main prison.
It covers two floors, is well staffed and has an appropriate skills mix.
HMCIP said in her 2005 report that the healthcare centre was
underperforming. However, since Norfolk PCT took over responsibility,
the standard of services had improved. The healthcare centre is
managed by the Head of Healthcare (I Grade nurse), and is supported
by a deputy. The centre currently has a mix of registered general and
registered mental health nurses, senior healthcare officers, healthcare
assistants and prison officers.
10. In her follow up inspection in 2006, HMCIP said that, since Norfolk PCT
had taken over commissioning responsibility for healthcare services,
Norwich had good links to palliative and Macmillan nurse teams. The
palliative care delivered by healthcare staff is taken from the Liverpool
Care Pathway for the dying, which is a gold standard award guide.
11. The SystemOne clinical information system has replaced hand written
medical records at Norwich. It is only compatible with the same system
in other prisons, but where two prisons use the same IT staff at the
receiving prison are able to look at a patient’s medical history and
provide a continuous care record. The SystemOne has been fully
embraced by healthcare staff, so much so that HMCIP commended the
8
healthcare centre for the way it had been fully incorporated into their
prisoner care services.
Nelson Unit (Older Prisoners Unit)
12. Nelson Unit was introduced to address the specific needs of Norwich’s
ageing prison population. The unit holds 15 prisoners, all in single
rooms. It is located on the ground floor of the healthcare centre and is
staffed by prison officers, nurses and healthcare officers. The Chief
Inspector of Prisons found that the unit operated an unlock policy during
the day (staff permitting) and the standard of clinical care was good.
However, Nelson Unit prioritised operational duties over clinical ones
and this left some prisoners unduly waiting for nursing care. If a prison
officer was not available, prisoners were not unlocked irrespective of
how many nursing staff reported for duty.
Elderly Prisoners
13. Prisons are not principally designed for the elderly, and it is difficult for
an individual establishment to accommodate an aged population. A
thematic review by HM Chief Inspector of Prisons in 2003 found that,
although older prisoners (60 years and over) make up a small
percentage of the overall prison population, the number of elderly
prisoners had trebled between 1992 and 2002 and was continuing to
grow. The study also said that there was no overall strategy throughout
the prison estate for assessing and delivering a regime that addressed
the needs of older prisoners.
14. Since the review, the elderly male prisoner population has seen a year
on year increase. The most recent figures, taken from the Ministry of
Justice, Offender Management Caseload Statistics, show that in the last
four years (2002-2006), the population has increased by another 26 per
cent from 1,365 to 1,725.
15. The Chief Inspector’s thematic review concluded that some elderly
prisoners would inevitably spend the rest of their lives in prison. Early
release from prison on medical grounds for severely or terminally ill
prisoners is subject to restrictive criteria, and the thematic review
stressed that the prison environment must be geared towards meeting
the specific needs of its ageing population.
16. A report, Growing Old in Prison, published by the Prison Reform Trust in
2003 quoted a Department of Health study that also focussed on older
prisoners. The study said that out of 203 prisoners aged 60 and over, 85
per cent had one or more major illnesses reported in their medical
records. The most common illnesses were psychiatric, cardiovascular,
musculoskeletal and respiratory.
9
KEY FINDINGS
The man’s time at HMP Bedford and HMP Littlehey
17. When the man arrived at HMP Bedford in mid-January 2007, he was
already taking a substantial amount of medication. As part of the
reception process, his first reception health screen also listed a number
of medical complaints including alcohol problems, high blood pressure,
Chronic Obstructive Pulmonary Disease (COPD), arthritis and an
irregular heart beat.
18. Eleven days later, on 30 January, the man was transferred to HMP
Littlehey. In February, he presented healthcare staff with symptoms of
confusion, low mood and incontinence. In the absence of a 24 hour
healthcare facility, he was managed on the wing and his medication
continued.
19. The following month, the man was diagnosed with cellulitis (of the legs)
and type II diabetes mellitus. His diabetes was discovered after a series
of blood tests and the prison doctor prescribed metformin, an oral anti-
diabetic drug. The man’s cellulitis was treated with a course of
antibiotics but his skin problems continued.
20. In June, following further periods of confusion and incontinence, the man
was referred to hospital for a CT scan. Whilst awaiting this referral, he
deteriorated and was escorted to the hospital’s Accident and Emergency
Department, and from there, to a suitable ward. The man had a CT scan
shortly after he arrived and this revealed a right frontal lobe infarct. In
short, the man had suffered a stroke.
21. The man was discharged back to Littlehey after four days and was
prescribed additional medication. A care plan was drawn up to help him
with his daily routine. As part of the plan, another prisoner agreed to
help him with his personal hygiene needs. The clinical review panel
pointed out that National Institute for Health and Clinical Excellence
(NICE) guidelines were not in circulation at the time of the man’s
diagnosis, and as such there was no best practice for the treatment of
strokes. These guidelines are due for publication in July 2008.
The man’s transfer from HMP Littlehey to HMP Norwich
22. The head of healthcare at Norwich, told my investigator that on 22
August she received a telephone call from her equivalent at Littlehey.
The conversation centred around a possible move for the man to
Norwich’s Older Prisoner Unit and 24 hour healthcare facility. The head
of healthcare at Norwich said that her counterpart provided her with a
brief overview of the man’s condition, and asked whether she would
accept him as a patient. She initially refused to take the man and
explained to my investigator, as she had to her counterpart, that Littlehey
10
was outside Norwich’s catchment area and the man should go to
Bedford.
23. Her conversation with the head of healthcare at Littlehey continued and
he explained that it might not be in the man’s best interest to return to
Bedford. On hearing this, the healthcare manager at Norwich told my
investigator that she agreed to take the man as an inpatient. Both
prisons then made their respective arrangements to transfer him to
Norwich.
24. The following day, a healthcare officer (HCO) from Littlehey escorted the
man to Norwich by car. His risk assessment for the transfer described
the man as “… a confused elderly man with poor hygiene”. The man
was attached to the HCO using single cuffs. He arrived at Norwich just
after lunchtime, bypassed the normal reception process, and went
straight to the healthcare centre. Shortly after his arrival, he was
assessed by nursing staff in much the same way as a patient arriving at
an Accident and Emergency Department. His observations were taken
and he was made comfortable.
25. Later that evening, the man’s confusion and mobility worsened, and a
nurse asked the head of healthcare to assess him. She did so, and
quickly made the decision to send him out to hospital. The head of
healthcare booked an ambulance between 8.00pm and 9.00pm and
liaised with the duty governor and the senior officer (SO) on duty to
arrange an escort to take him to hospital. A risk assessment put
together by the wing SO set out the security arrangements required to
take to the man to hospital.
26. By the time the man was ready to be escorted, the prison had gone from
day duty to night patrol state. This affected staffing levels and, in order
to secure two officers to escort him, the prison rang one of the officers at
home. The first wing officer, together with his colleague, the wing
second officer, made their way to Norwich to begin what the first wing
officer thought was bedwatch duty. The officer told my investigator he
was surprised to see that the man had not left for the hospital, and that it
had turned into an escort and bedwatch duty. The ambulance left
Norwich at approximately 10.15pm. The man was attached to the first
wing officer using double cuffs and an escort chain.
The man’s stay in hospital from 23 August – 18 September
27. On arrival at the hospital, approximately ten minutes later, the man
bypassed the Accident and Emergency Department (A&E) and went
straight to the Medical Admissions Unit (MAU). The head of healthcare
told my investigator that she telephoned the Medical House Officer at the
hospital in advance of the man’s admission. Between them, they
arranged for him to bypass A&E to speed up the process. He went
straight to a ward.
11
28. In the ward, the man was made as comfortable as possible and a nurse
came round to see him within half an hour. The nurse carried out some
basic observations. The first wing officer told my investigator that he got
more involved in the man’s care than usual for a bedwatch, and helped
the nurses to undress him. The officer said that this was because the
restraints used were obstructing the nurse’s ability to do this alone. At
approximately 11.45pm, a doctor took a blood sample. Within the hour,
the same doctor returned and carried out further checks on his condition.
From memory, the officer said that the man remained in double cuffs and
an escort chain throughout these initial interventions.
29. At 1.10am, the man was taken for an x-ray by both officers. The
bedwatch log said that he was compliant with the procedure but
appeared to be “confused and very tired”. There was no record of
whether the man remained in full restraints for the x-ray. My investigator
discussed the x-ray procedure with the first wing officer, and he
confirmed that the radiographer asked him to remove the double cuffs.
The officer did so after a brief consultation with his colleague, the second
wing officer. This officer explained that there seemed little point in
notifying the duty governor in order to obtain authorisation, as the
procedure was to take approximately five minutes. The man was still
attached to the first wing officer (who was wearing a hospital issue
protective apron) via an escort chain, whilst the second wing officer
stood behind the screen. The officer said this was normal procedure.
30. The first wing officer said that the double cuffs were reapplied after the
man’s x-ray, and he was taken back to the MAU. At 3.30am, he was
transferred to the hospital, a stroke ward which is open plan in design.
The man slept for a short time before nursing staff came round at regular
hourly intervals to monitor his blood sugar, blood pressure and
temperature.
31. The principal officer (PO) and the wing SO relieved the bedwatch
officers at approximately 8.30am. The first wing officer told my
investigator that during the handover the PO questioned why the man
was still in full restraints. The officer said that he was following the
instructions in the risk assessment which said “double cuffs and an
escort chain”. In response, the PO explained that this related to the
escort to hospital procedure only, and once the man was admitted he
should have been attached to the first wing officer using an escort chain.
When my investigator spoke to the PO, he could not remember the
conversation or whether the man was attached using double cuffs.
32. Later that morning, the hospital consultant asked the officers to remove
the man’s restraints in order for mobility and response tests to be carried
out. The PO contacted the head of security, and obtained authorisation.
The tests began at 10.45am and took approximately 20 minutes. The
PO made an entry in the bedwatch log which said that both he and the
wing SO remained in close proximity during the tests and had re-applied
the restraints at 11.05am.
12
33. After the tests, the consultant told the PO that the man would need a
number of other examinations including a CT scan. He also said that it
was likely that the man would be in hospital until the following Tuesday
(28 August).
34. Throughout the rest of the day, the man underwent a physiotherapy
assessment and was seen by a speech therapist. The therapists
assessed the man’s ability to walk and swallow. The PO recorded in the
log that the man was still unable to walk when moved from his chair to
his bed, and that it appeared he could not swallow.
35. The man’s next two days in hospital were peaceful. Bedwatch officers
continued to keep a log and did not record any change in his condition.
The man remained attached to one officer using an escort chain. A
review of his risk assessment on 26 August carried out by the duty
governor also recorded no change in his security level. The same
morning, the man was taken to the radiography department for another
chest x-ray. The PO noted on his return to the ward that restraints were
not removed for the procedure.
36. Over the next few days, the man’s alertness fluctuated. The officers on
bedwatch duty described him as agitated and then sleepy and poorly. A
nurse attending to the man on the evening of 27 August told one of the
officers that she was concerned that he was not responding well to the
treatment. Later that evening, one of the escort officers told a nurse that
the man’s toenails looked too long. At 11.00pm, the man tried to get out
of bed and was restless. His airway was cleared using suction but he
remained agitated throughout the night.
37. Following his speech therapy assessment, the man was designated as
unsuitable to take food or drink through his mouth, and was being tube
fed. This information was passed between outgoing and incoming
officers using the handover checklist document. After the man’s restless
night, the checklist also said that the left side of his body was weakening
and that he was trying to get out of bed. The wing SO took over
bedwatch duty at 7.30am on 28 August. His first entry in the log said
that the man was much more active, very confused, and still trying to get
out of bed.
38. The man had another CT scan at approximately 3.00pm. The escort
officer, who was also on duty, knew about the procedure in advance and
contacted the duty governor to obtain permission to remove the escort
chain. The duty governor authorised this in accordance with the risk
assessment provision. The man’s CT scan took around 15 minutes. He
was reattached to the wing SO immediately after the scan. The SO
telephoned Norwich to let communications staff know that the security
level had been restored. The wing SO also recorded that the man had a
tendency to ‘grab’ at nurses during treatment. An unsigned log entry by
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either the duty governor or a principal officer that day reflected that the
man had been quite difficult and was in a confused state.
39. At 6.50pm on 29 August, the man was moved from an open ward to a
side room. Here he seemed more settled and slept for long periods.
The following day, after being made more comfortable by the nurse, he
sat up in his chair. Shortly after 5.00pm, he had his evening meal and
spoke to the officers on duty. The escort officer, who had been on duty
all day, made an entry in the log which said that the man appeared to be
getting better. An hour later, the man was put back into bed in
preparation for an x-ray. He was also told several times that he should
not try to get out of bed. The bedwatch log did not record whether he
had an x-ray that day.
40. The man’s second week in hospital mirrored the first and officers
continued to log his condition as restful, confused or agitated. The man
remained immobile and struggled to eat on occasion. Risk assessment
reviews were carried out on a regular basis by the appropriate members
of staff, and his security level remained unchanged. The reviews did not
give an indication of the factors considered in keeping his security level
the same.
41. During the afternoon of 1 September, one of the nurses attending to the
man’s personal hygiene asked an officer if Norwich had the facilities to
cope with his physical health needs. The escort officer, on duty that day,
told the nurse that she would have to speak to the head of healthcare, to
discuss this further.
42. For the next few days, the man found it increasingly hard to speak. This
was due to the difficulty he had in swallowing. On 4 September, a
member of the physiotherapy team came to see him and made him more
comfortable in bed. The escort officer on duty made an entry in the log
which said the man had been given liquid paracetamol during the day.
The officer also said that the man was lethargic and that there seemed
to be little sign of improvement to his health.
43. The morning of 6 September began as most of the man’s days in
hospital did. He was given a wash and attempts were made to give him
some breakfast. At lunchtime, two physiotherapists lifted him from his
bed to a chair and he sat for about half an hour. One of the hospital’s
nutritionists then attempted to feed him some yoghurt. The man gained
some movement during the afternoon and was seen by a doctor at
4.25pm. The doctor decided he should not take food and fluid orally.
The officer on bedwatch duty, passed on the head of healthcare contact
telephone number to a member of staff in order for the hospital to
discuss the man’s previous medical history with her.
44. The next day, the man was washed and dressed as normal before being
assessed by the speech therapist. At 12.50pm, he had another CT scan
and was escorted back to the ward. The bedwatch log gave no
14
indication of the security arrangements for the scan. In the afternoon,
the man was fitted with a cannula to the nose cavity to help him breath.
At around 5.15pm, nurses experienced some difficulty in finding a
suitable vein to take a blood sample. Approximately 45 minutes later,
the man had another chest x-ray and then slept on his return to the
ward. The head of security carried out a management check at 6.40pm
before the man settled for the evening. He had a peaceful night.
45. The man’s third week in hospital saw a further deterioration in his health.
However, a positive development was the number of visits by his family.
For the first 15 days of the man’s stay in hospital, his family thought he
was still at Littlehey and had been in contact with staff there to arrange
visiting orders so that they could see him. At some point during this third
week, the man’s sister received a telephone call from the PO to say that
her brother was now in hospital. Bedwatch officers were also updated.
The second page of the bedwatch handover checklist for 7 September
was completed by an escort officer. This informed the incoming duty
officer that the man’s brother and sister had been given authorisation to
visit him in hospital.
46. At 3.15pm on 8 September, the man’s family visited his bedside. This
was the first time they had seen him since his transfer from Littlehey.
The man’s family stayed until approximately 5.00pm and the escort
officer on duty that afternoon, recorded in the log that he had responded
well. Shortly after his family left the hospital, the duty governor, arrived
and completed a management check. In the bedwatch pack said that
the risk assessment would remain unchanged, but that the man’s
security level might be reduced at a later stage.
47. The next day, the man became emotional and was seen crying. The
officer on duty thought he was in pain and made a record of this. At
10.30pm, a nurse started a tube feed for him and changed his bedding.
The feed finished at 3.30am the next morning.
48. The man’s risk assessment was reviewed by the head of security at
around 7.20pm on 9 September. Further reviews took place on 10, 11
and 12 September by three different members of staff. The man’s
security level stayed the same as the day he was admitted to hospital.
The documentation gave no indication of what factors were considered
when carrying out reviews.
49. On 12 September, the man’s sister arrived shortly after 2.00pm and
found him unresponsive. She then spoke to nursing staff about his
condition. The second wing officer made an entry in the log which said
that the man’s family had requested a Roman Catholic priest. His sister
and a priest returned to the ward at 3.10pm. Approximately 20 minutes
later, the sister was told by the consultant that he was not likely to live
beyond another week. The duty governor carried out a management
check at 4.50pm and recorded no issues with the escort arrangements.
15
50. The man was given the last rites by the chaplain at 7.00pm that evening.
The escort officer witnessed this before handing over to the night duty
officers. The man’s sleep pattern throughout the night was described as
restless by one of the officers. At 9.00am on 13 September, an escort
officer noted that he sometimes struggled to breathe. The officer made
another entry in the log, 20 minutes later, which said he was breathing
heavily but settled.
51. At 10.25am, the duty governor telephoned the escort officer and ordered
the removal of the escort chain. The officer contacted the
communications staff at Norwich to confirm that the man was no longer
attached to an officer and recorded the change in security level
appropriately. A revised risk assessment was completed by the second
PO. Under the section ‘Medical Information’, the head of healthcare
wrote the following:
“The man is extremely ill and is unlikely to be able to get out of bed.
Medically, he [is] unlikely to live for much longer.”
52. The duty governor provided overall authorisation for the reduction in
security. In agreement with the Governing Governor, he confirmed that
due to the nature of the man’s illness restraints would not be used, but
that two escort officers would remain on bedwatch duty in a supportive
role. Another governor made an extensive entry in the log to instruct
bedwatch officers following the change in circumstances. Officers were
reminded to preserve all paperwork and personal belongings and to
contact the duty governor if the man died. The governor also reminded
officers that the man was not to be left unescorted at any time.
53. The prison chaplain visited the man at 3.45pm that afternoon and offered
prayers. The sister telephoned the ward shortly afterwards to notify staff
that, unless he deteriorated, she planned to visit him the next day.
54. The man did deteriorate. Aside from two family visits on 14 and 15
September, he continued to sleep, had difficulty breathing and was
continuously monitored by nursing staff. During the early hours of 17
September, his breathing worsened due to a build up of fluid in his
throat. One of the bedwatch officers called a nurse and he was made
more comfortable. The nurse confirmed that the man was ‘getting
worse’.
55. At lunchtime on 17 September, the sister came to see him again. He
had not been awake during the morning and continued to sleep. At
3.30pm, the head of healthcare arrived and spoke to the man’s sister.
She explained that the man would be more comfortable if he transferred
back to Norwich and that his family could visit him there. She reassured
her that he would have 24 hour care, privacy and would not be
supervised by prison officers. The head of healthcare also discussed
the ‘no resuscitation’ policy at Norwich with his family. Before the sister
16
left the hospital, she recalled that the man squeezed her hand and she
knew he knew she had been at his bedside.
56. The man slept all evening and throughout the early hours of the 18
September. His transfer back to Norwich was arranged by both the
head of healthcare and operational staff at the prison. At 2.50pm, the
man left the hospital by ambulance, and made the short journey back to
HMP Norwich. He arrived at approximately 3.15pm and was moved
straight to a single occupancy cell in Nelson Unit.
57. In preparation for the man’s return to Norwich’s care, a number of
provisions were put in place. A feeding pump, and the feeds he required
to ensure his nutritional needs, were provided. The Liverpool Care
Pathway, adapted for Norwich prison, was commenced by the
multidisciplinary team, and a care plan, tailored to the man’s specific
needs was commenced. Part of the plan stipulated that the man was not
for resuscitation, in accordance with Norfolk PCT’s policy on
resuscitation. At the draft stage of this report, the head of healthcare
confirmed to my investigator that the reasons given for ‘do not
resuscitate’ were documented as:
1. The patient’s condition indicates that effective CPR is not likely to be
successful;
4. Successful CPR is likely to be followed by a length and quality of life
which would not be in the best interests of the patient to sustain.
The head of healthcare also recorded on the care plan that the man’s
sister could be contacted at any time in the event of an emergency.
58. The senior staff nurse also wrote an extensive note for the attention of
healthcare staff and placed it in the man’s medical records. The note
acted as an admittance plan to Nelson Unit. Staff were told that the man
would have a fixed nasogastric tube fitted to assist with feeding and
medication, a pump and feed. The plan prompted staff to arrange 24
hour open cell access authorisation, and reiterated the no resuscitation
arrangements. The senior staff nurse also confirmed that a palliative
care nurse from the community would visit Norwich on 19 September.
59. In addition, the head of healthcare and the duty governor drafted a
management plan. This gave authorisation for the door to the man’s cell
to remain open during patrol states (when, ordinarily, cell doors would be
locked). The plan explained that the man had suffered multiple strokes
and was receiving end of life care. The open door provision gave
nursing staff on Nelson Unit easy 24 hour access to the man. The
management plan stipulated that he was at risk of choking and needed
frequent assistance with mouth care and pressure sores. The plan also
said the following:
“It is not necessary that an officer is present at the times the man
receives his care.”
17
60. The man was made as comfortable as possible overnight. His care plan
was followed meticulously and he received mouth care at regular 20
minute intervals. He was continuously monitored and nursing staff
recorded his laboured breathing and ‘bubbly chest’.
61. The prison chaplain visited him on 19 and 20 September and prayed at
his bedside. At around 2.30pm on 20 September, the man’s brother and
sister arrived and were escorted to Nelson Unit to see him. They sat
with him privately until approximately 4.00pm. The man remained
unconscious.
62. Shortly after his family left, the man deteriorated significantly. The senior
staff nurse contacted the palliative care nurse and following his advice a
syringe driver was commenced. The first wing nurse and the second
wing nurse started the syringe driver at 5.30pm.
63. At around 6.30pm, the second wing nurse was approached by another
member of staff who asked about the man. The nurse went straight to
his cell and on checking him, thought that he had died. The nurse
contacted the head of healthcare at approximately 6.40pm. She
checked for signs of life, and verified that the man had died at 6.45pm.
64. The head of healthcare contacted the duty governor and other relevant
prison staff who commenced the death in custody contingency plans.
She then telephoned the man’s sister, as arranged, and told her that her
brother had died. The sister expressed her gratitude for the care he
received at Norwich and for the opportunity to visit him there.
Events following the man’s death
65. The Safer Custody Manager at Norwich, is also a trained family liaison
officer (FLO). She kept a log of the contact she had with the man’s sister
from the moment he died up to the last contact she made.
66. In accordance with Prison Service Order 2710, Follow up to a Death in
Custody, the FLO spoke to the man’s sister about funeral arrangements
and explained how Norwich could help with costs and organising the
service. The sister confirmed that her family would arrange the funeral,
and appreciated the offer of financial help. The FLO also spoke to the
sister to arrange the return of the man’s valuables and personal
belongings. His personal effects were then returned by post.
67. The funeral took place and at the request of his family, the prison did not
send a representative to the funeral.
18
ISSUES CONSIDERED IN THE INVESTIGATION
68. As I mention in my introduction to this report, the main focus of my
investigation has been on Norwich’s management of the man’s stay in
hospital and his return to the Older Prisoners Unit. The deceased was
an elderly man who came into prison already in poor health. In the eight
months that he was in custody, he moved between Bedford, Littlehey,
and Norwich. He was admitted to hospital on two occasions. Without
his prison wing history records from Bedford and Littlehey, it has been
difficult to give a full account of his time in custody apart from the
healthcare he received. However, it is clear that his poor health
prevented him from fully participating in prison life and any purposeful
regime.
69. I have also mentioned the exceptional work of the Older Prisoners Unit
at Norwich, and I am pleased to record that the man’s last 48 hours in
the unit were peaceful and comfortable. The care he received, which
closely followed the Liverpool Care Pathway for the dying, was
compassionate, professional and dignified. In addition, the man’s family
was consulted in drawing up his care plan and had access to the unit
whenever they wished to visit. This holistic approach to an elderly and
dying man is something that Norwich has excelled at.
70. I agreed with the clinical reviewer that there was some relevance in
focussing on the healthcare the man received prior to his arrival at
Norwich. I believe the benefits have been two fold. First, it has
enhanced the man’s story. Secondly, the extended focus has addressed
the issues the man’s family raised with my office. It will be necessary for
copies of this report to be shared with the Governors of Bedford and
Littlehey so that they are able to read the clinical review panel’s findings.
71. Not for the first time, it has been a pleasure to write so warmly about the
actions of staff at HMP Norwich. However, the man’s transfer to an
outside hospital, coupled with his long term stay in hospital, has
highlighted where clarity in instructions to staff could improve Norwich’s
performance still further. I deal with these and the issues raised by the
clinical reviewer below.
Clinical care
72. When the man arrived at Bedford, he underwent an alcohol
detoxification course. The clinical reviewer could not find any evidence
that this was followed up with investigations into possible liver damage.
Whilst this is not directly linked to the deterioration in the man’s health,
and would not have changed the outcome for him, the clinical review
panel made a recommendation (which I have reworded as follows):
Bedford’s healthcare staff should ensure that interventions such as
alcohol detoxification programmes are fully documented and that a
follow up with appropriate diagnostic testing is carried out.
19
73. Whilst at Littlehey, the man was referred to a diabetes nurse and the
infection in his leg was treated with a course of antibiotics. The clinical
review panel commented that, whilst a referral was made, there was no
documented evidence that a follow up took place. On speaking to staff
at Littlehey, the clinical reviewer was told that diabetes records were
kept separately from medical records and were not available. The panel
made the following recommendation.
Littlehey’s healthcare staff should ensure that documentation
reflects the care and evaluation of care given.
74. When he transferred back to Bedford in July, the man’s legs appeared to
be an ongoing problem and he was prescribed cream to treat them. His
infection continued to cause him discomfort in the weeks leading up to
his death, and he was referred to a dermatologist whilst an inpatient at
the local hospital.
75. Following the diagnosis of a stroke at the hospital, he was prescribed a
large quantity of medication and sent back to Littlehey. From this point
on, he could not look after himself and a care plan was designed to
assist with his care. The clinical review panel noted that this included
calling upon the assistance of another prisoner to help the man with his
daily personal hygiene. Whilst this helped him in the interim, the clinical
review panel did not feel this was a sustainable arrangement and made
the following recommendation. Again, I have reworded it slightly:
The Head of Healthcare at Littlehey should review how social care
is provided to prisoners who clearly demonstrate an inability to
carry out basic care needs such as washing and dressing for
themselves.
76. Continuous medical records should accompany a prisoner when he or
she transfers between prisons. This enables healthcare staff to see a
recent medical history and to pick up any outstanding appointments.
When the man arrived at Norwich, his medical record accompanied him.
However, it is not clear whether this was the case when he transferred
between Littlehey and Bedford. The man was waiting for podiatry and
dentistry care during the early part of his imprisonment. The clinical
review panel said that he missed two appointments because they
coincided with visits, but his appointment with the dentist at Littlehey fell
when he was transferred to Bedford and was not rescheduled either
there or when he returned to Littlehey. The panel felt that this was not
satisfactory and stressed the importance of continuity of care. I agree
that the man’s appointment with the dentist should have been
rescheduled.
77. The clinical review panel also identified the lack of full follow up care for
the man, after he suffered his stroke. When he was discharged from
hospital to Littlehey, there was no evidence in his medical record that he
20
was referred to a physiotherapist or occupational therapist. When
transferred to Bedford, he was assessed by the nursing staff but there
was no evidence of referral to a multidisciplinary team for post-stroke
care. When he returned to Littlehey from Bedford on 17 August, staff
told the clinical reviewer that they only ‘found out by chance’ that the
man had returned. The panel stressed the following expected outcome
for someone who suffers a stroke:
“Following a stroke, patients should be cared for by a specialist stroke
team and participate in a multidisciplinary programme of secondary
prevention and rehabilitation.”
78. It is clear that, once the man was transferred to the local hospital, he
received multidisciplinary care. The clinical review panel noted that at
present there are no National Institute for Health and Clinical Excellence
(NICE) guidelines on the treatment of stroke patients. These are due for
publication in July 2008. That said, there is existing guidance in NHS
National Service Frameworks. Prison should not be a barrier to the care
someone receives. The review panel recommended the following which
I endorse.
Bedfordshire and Cambridgeshire PCTs should be aware of the
recommendations in the National Service Framework for Older
People following strokes. Appropriate multidisciplinary
rehabilitation should also be provided.
During the draft stage of this report, Norfolk PCT’c clinical review panel
did not feel that the above recommendation, which I edited, fully
reflected the concerns highlighted in the clinical review. In a letter to my
office, received on 7 April 2008, the panel said:
“…we do not feel that this [recommendation] addresses with clarity the
particular issues identified in this review. These were that prisons
should have systems in place to ensure clinical assessments are
undertaken prior to discharge as part of a wider discharge planning
programme, and that staff undertaking these assessments need to have
received training and be appropriately qualified”
Maintaining family contact
79. When the man was transferred to Norwich and then hospital on 23
August 2007, it was two weeks before his family knew where he was.
When previously transferred between Littlehey, Bedford and the hospital,
his sister was kept informed of his whereabouts, albeit not necessarily
on the days he moved. The sister told my FLO that she went on holiday
in August at around the time that the man was transferred to Norwich.
She had sent in a visiting order to Littlehey prior to going on holiday, and
when she telephoned the prison on her return to query the VO she was
told a message would be passed to the man’s wing. Sadly, the man had
already moved on.
21
80. It is unfortunate that the man’s sister did not have the opportunity to visit
him in hospital until 11 September. Learning from the PO that her
brother had been in a local hospital for two weeks must have been
distressing. That said, as soon as the PO received a telephone call from
the VO booking clerk at Littlehey, he contacted the man’s sister
immediately and made the necessary security arrangements so that his
family could visit.
81. Transfers between prisons for non-healthcare reasons are frequent.
Healthcare to healthcare transfers are less frequent but still relatively
common. The man was transferred outside of his immediate area to
Norwich. This presented his family with a greater distance to travel to
visit him.
82. Maintaining family ties has obvious benefits for the prisoner and his or
her family. The man’s family had visited him regularly at Littlehey.
When the PO did speak to the man’s sister, their family links were re-
established. From then on, staff at Norwich (in particular, the head of
healthcare) kept in regular contact. The man’s family telephoned the
hospital and was able to visit. Once plans were made to return him to
Nelson Unit, the head of healthcare reassured the man’s sister that her
family could visit him in his cell, in private, whenever they wanted to.
83. There is no mandatory requirement placed on prisons to contact families
when a prisoner is transferred. The PO told my investigator that the
Prison Service did not inform families over impending transfers for
security reasons. However, where a prisoner is too ill to make contact
himself, and a prison has next of kin details on record, I consider it good
practice for a prison to make contact with a prisoner’s next of kin on his
or her behalf.
84. I make no formal recommendation. However, the Prison Service may
wish to consider if there is further advice that could be offered to
Governors to ensure that families are kept informed when a prisoner is in
hospital, and thus have the opportunity to maintain contact with their
loved ones at the earliest opportunity.
Use of restraints
85. The man was a category C prisoner when he transferred to Norwich, and
as such would normally be escorted using an escort chain. He came by
car and was escorted by a healthcare officer. His risk assessment
clearly indicated the type of restraint used (a single cuff). Hours later,
after the head of healthcare arranged for him to be transferred to
hospital, the man was ‘double cuffed’ and attached to an officer using an
escort chain. The use of a double cuff is more in line with the security
used for a category B prisoner. When informally interviewed, the PO
confirmed the different levels of security normally applied to different
22
categories of prisoner. A category C prisoner, like the man, should
have been escorted with a single cuff and an escort chain.
86. The man’s risk assessment for the hospital escort confirmed that officers
were to use the level of restraints normally applied to category B
prisoners. The SO who completed the risk assessment told my
investigator that it was necessary to treat the man as a category B
prisoner because he was transferred at night. However, there remains
some confusion over why he was subject to a higher level of restraint
when he went to hospital.
87. Unfortunately, the man may have remained in double cuffs for longer
than was intended. The first wing officer followed the risk assessment to
the letter as he should, but wrongly assumed double cuffs were to
remain once the man was admitted to hospital. Once the mistake was
noticed by the PO on the morning of 24 August, my investigator was told
that it was quickly rectified. That said, the mistake was not recorded and
the PO could not remember anything specific when questioned.
88. The first wing officer contacted my investigator on 11 April to discuss
amendments to his statement, dated 17 January 2008. The officer said
that following a discussion with colleagues, the man was double cuffed
for the entirety of his bedwatch duty, which was one 12 hour period,
save for undertaking an x-ray procedure where the double cuffs were
removed and an escort chain used. However, he was not double cuffed
and attached to an officer using an escort chain, as was originally
indicated. The officer confirmed that this was his first bedwatch duty as
an officer. The officer also confirmed he would be amending his original
statement to reflect the level of restraints used.
89. My investigator fed the issue of restraints back to the current Governor
of Norwich. The Governor confirmed that, if the man was left in
inappropriate restraints, this must have been due to a breakdown in
communication as he was not aware of an occasion where a prisoner on
bedwatch would require double cuffs. I make no formal recommendation
but urge the Governor to remind security and bedwatch staff of the need
for clarity in relation to risk assessment instructions.
90. The man was then attached to an officer using an escort chain until 13
September, approximately three weeks after he was first admitted to
hospital. The bedwatch documentation indicated on occasion when the
escort chain was removed for treatment. This was usually at the request
of medical staff. However, the temporary removal of restraints was not
always recorded, and I must assume that the man’s escort chain did
come off when he was taken for CT scans. It would be both physically
impossible and potentially dangerous for staff to remain attached
otherwise.
23
The Governor of Norwich should remind bedwatch officers of the
importance of recording the temporary removal and re-application
of restraints in bedwatch logs.
91. What is also clear is that the man underwent x-ray procedures whilst
attached to one officer. During an informal interview with the first wing
officer and the wing SO, my investigator learnt of the routine officers
follow when escorting a prisoner to the x-ray department. The officers
explained that a protective apron, issued by the hospital, is worn by
officers to protect them against radiation. This was standard procedure
and something the SO, in particular, had experienced many times. None
of the bedwatch staff my investigator spoke to felt that the level of
restraints used was disproportionate to the risk the man posed in an
open ward.
92. My investigator raised the issue with the Deputy Governor. She
confirmed that she was not aware of the routine arrangements for x-ray
and had not experienced this herself.
93. The clinical review panel has recorded that, when the reviewer visited
the hospital, medical staff questioned the use of an escort chain for the
man. The man’s family also raised the issue with my FLO, and stressed
that it was distressing to see him ‘shackled’ and under the constant
supervision of prison officers.
94. I have considered the same two questions as Norwich did in preparing
the man for hospital, and in reviewing his security level once admitted.
One is whether the man posed a significant risk to the public, and
continued to pose a risk. The other is whether the level of restraints
hindered his medical treatment.
95. The man was unknown to staff at Norwich when he arrived. He was
escorted to hospital and remained on a prolonged bedwatch with officers
who also did not know him. However, having suffered a stroke, the man
was in poor health and could not walk unaided, feed himself, or
communicate effectively, whilst in hospital. On the surface, it is difficult
to understand why he was restrained for so long.
96. The man’s bedwatch logs also paint a picture of declining health, but it
was not until the hospital consultant spoke to his sister and to the head
of healthcare on 12 September that his restraints were authorised for
permanent removal the following day. I am pleased to see that once the
duty governor became aware that the man was dying, the escort chain
was removed and the process of transferring him back to Nelson Unit
began.
97. The balance between public protection and the compassionate
management of seriously ill or dying prisoners is a difficult one to strike
and one that I frequently address in my reports. In three recent reports
on deaths of prisoners from HMP Birmingham, HMP Gartree and HMP
24
Maidstone, I have been critical of the lack of flexibility in local policy on
bedwatches. There are, of course, many factors to consider when
arranging a bedwatch, particularly a prolonged bedwatch as in the man’s
case. I also appreciate they involve discretionary judgements.
Moreover, in the man’s case the management checks and risk
assessment reviews were carried out frequently, and in accordance with
the National Security Framework (NSF) guidelines.
98. That said, the NSF does not give explicit instructions on how to deal with
gravely ill or dying prisoners in outside clinical environments. My report
regarding the death of a prisoner in Maidstone’s care in 2007 stressed
that consideration should be given to building this into the Security
Framework so that local practice may become more widespread. In this
case, the restraints were removed once prison staff were told the man
was dying and, as I have already said, the care he received on his return
to Norwich made his last days as comfortable as they would have been
in the community. However, I repeat the thrust of the recommendation I
made in the 2007 Maidstone report:
The Prison Service should ensure that a review of the escorts,
restraints and bedwatch sections of the National Security
Framework takes place with a view to providing advice to staff on
the removal of restraints from gravely ill or dying prisoners on
compassionate grounds when their risk to the public is much
reduced.
99. The clinical review panel made one commendation and highlighted one
area of good practice evident in the man’s care. I echo their findings
below. (Once more, I have re-written the text slightly.)
The healthcare team at Norwich should be commended on the
standard of care given to the man. Documentation was detailed
and provided evidence of good collaborative working alongside
members of the Specialist Palliative Care Team and staff at the
hospital. As a result, the man’s care needs were met and he was
allowed to die peacefully and with dignity.
Arrangements had been put in place to ensure that the healthcare
staff at Norwich had open access to the man’s cell during the
terminal stage of his life. This allowed him to receive appropriate
24 hour care.
100. I am personally aware that the head of healthcare is the author of the
open door access policy in Nelson Unit. I am also aware that she
ensured that the man’s family were authorised to visit him in prison.
These healthcare-led local policies will undoubtedly benefit prisoners
and their families who find themselves in similar situations in future.
I commend the head of healthcare for her vision in ensuring her
staff can provide additional, compassionate end of life care to
25
elderly prisoners. She should also be commended for opening up
the prison gates to families of dying relatives. The man’s family
was able to maintain important links up to the day he died.
26
RECOMMENDATIONS
To the Primary Care Trusts
Bedford’s healthcare staff should ensure that interventions such as
alcohol detoxification programmes are fully documented and that a
follow up with appropriate diagnostic testing is carried out.
The recommendation was accepted. In response, the prison service area
included the following and set the target completion date for September 2008.
All HMP Bedford’s detoxification programmes are now fully documented,
although due to staff shortages, follow up diagnostic testing is not carried out
in all cases. However, funding has now been secured to enable the
recruitment of an additional two Detoxification nurses. Once the additional
resources are in place, follow up diagnostic testing will be carried out in all
cases.
Littlehey’s healthcare staff should ensure that documentation reflects
the care and evaluation of care given.
The recommendation was accepted and has been completed. In response,
the prison service area said the following:
The quality of record keeping has been re - emphasised to staff and
management checks put in place.
The head of healthcare at Littlehey should review how social care is
provided to prisoners who clearly demonstrate an inability to carry out
basic care needs such as washing and dressing for themselves.
The recommendation was accepted. In response, the prison service area
included the following and set the target completion date for July 2008.
To be discussed at the PCT partnership Board in order to review and facilitate
required need.
Bedfordshire and Cambridgeshire PCTs should be aware of the
recommendations in the National Service Framework for Older People
following strokes. Appropriate multidisciplinary rehabilitation should
also be provided.
The recommendation was accepted. In response, the prison service area
included the following and set the target completion date for July 2008.
To be discussed at the PCT partnership Board with a view to identifying
resource implications.
27
To the Prison Service
The Governor of Norwich should remind bedwatch officers of the
importance of recording the temporary removal and re-application of
restraints in bedwatch logs.
The recommendation was accepted. In response, the prison service area
included the following and set the target completion date for May 2008.
Instruction will be issued to staff conducting bedwatches reinforcing the
procedure and their responsibilities.
The Prison Service should ensure that a review of the escorts, restraints
and bedwatch sections of the National Security Framework takes place
with a view to providing advice to staff on the removal of restraints from
gravely ill or dying prisoners on compassionate grounds, when their
risk to the public is much reduced.
The recommendation was accepted. In response, the prison service area
said the following:
The Prison Service is undertaking an urgent review of the existing procedures
in relation to hospital escorts and bedwatch risk assessments in the light of
the ‘Graham’ judgement.
Commendations and good practice
The healthcare team at Norwich should be commended on the standard
of care given to the man. Documentation was detailed and provided
evidence of good collaborative working alongside members of the
Specialist Palliative Care Team and staff at the hospital. As a result, the
man’s care needs were met and he was allowed to die peacefully and
with dignity.
In response, the prison service said the following and set a target date for
completion on 1 June 2008:
Commendations will be passed onto the staff involved and some form of
formal recognition of the work done will be arranged.
Arrangements had been put in place to ensure that the healthcare staff
at Norwich had open access to the man’s cell during the terminal stage
of his life. This allowed him to receive appropriate 24 hour care.
In response, the prison service said the following:
This system will be maintained for future use.
I commend the Head of Healthcare for her vision in ensuring her staff
can providing additional, compassionate end of life care to elderly
28
prisoners. She should also be commended for opening up the prison
gates to families of dying relatives. The man’s family was able to
maintain important links up to the day he died.
In response, the prison service said the following and set a target date for
completion on 1 June 2008:
Commendations will be passed onto to the Head of Healthcare and some
form of formal recognition of the work done will be arranged.
29