Individual at Norwich

Investigation into the circumstances surrounding the
death of a man who was a prisoner at HMP Norwich, who
died at Norfolk and Norwich University Hospital April 2007
Prisons and Probation Ombudsman
for England and Wales
January 2008
This is the report of an investigation into the circumstances surrounding the death of
a man who was a prisoner at HMP Norwich. The man died on 11 April 2007 whilst a
patient at Norfolk and Norwich University Hospital. The post mortem report says that
the man died of pneumonia as a consequence of his oesophageal cancer, heart
disease and chronic obstructive pulmonary disease. The man was 78 years of age
when he died.
The man had no known next of kin, having spent much of his early years under the
care of the National Society for the Prevention of Cruelty to Children. Files indicate
that he had a sister but contact with her had been lost in the 1950s or 1960s. He
struck up a relationship with a woman whilst on home leave from prison but in 1993
contact with this lady seems to have faltered too.
One of my investigators conducted this investigation. I am grateful to the Norfolk
Primary Care Trust who undertook the clinical review into the care and treatment
afforded the man whilst he was in prison. I would also like to thank the Governor of
HMP Norwich, and his staff for their help and co­operation during the investigation.
As when I have investigated the deaths of other very elderly prisoners, I have asked
myself why they were still in custody. I should emphasise that the man received
good care from prison staff, and was heavily institutionalised. However, the reviews
that were undertaken appear not to have addressed the man’s offending risk in a
proportionate and timely manner. This may have resulted in himspending longer in
custody than was necessary or reasonable to protect the public.
I make five recommendations in my report and note one point of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2008
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CONTENTS
Summary 4
The Investigation Process 5
HMP Norwich 6
Key Findings 7
Issues 9
Recommendations 11
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SUMMARY
The man died in April 2007 in the Norfolk and Norwich University Hospital whilst a
prisoner at HMP Norwich.
The man was convicted of murder in 1972 and received a life sentence at Liverpool
Crown Court. In 1982, he was released on life licence into the care of a probation
hostel. However, in 1988 he was found to be in breach of his licence conditions and
was recalled to prison. He was held in a number of prisons in the nineteen years
after his recall in 1988, and arrived at Norwich in November 2005.
Whilst at Norwich, the man was located on a special unit (the Nelson Unit) for elderly
lifer prisoners. The man suffered from many chronic health conditions but during his
time on the Nelson Unit he was well looked after by nursing staff.
In November 2006, cancer of the oesophagus was diagnosed. The man was
referred to the local palliative care services who worked with the prison healthcare
team to give good care to him. The man was too unwell for radical surgery but
consideration was given to alternative treatment (endoscopic mucosal resectioning
of the tumour) that might have been effective for him.
The man was scheduled for the resectioning early April 2007 but this had to be
postponed because there were no beds available at the hospital. The man was
admitted to the Norfolk and Norwich Hospital due to his deteriorating condition in
early April. He died before he could receive the surgery.
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THE INVESTIGATION PROCESS
1. My investigator visited HMP Norwich on 8 May 2007. He was given access to the
man’s prison records. He visited the Nelson Unit where the man was resident
prior to his admission to hospital. He was met there by the Head of Healthcare at
Norwich, and spoke informally to several members of staff. Notices of my
investigation for staff and prisoners were already on display around the prison.
No members of the Prison Officers’ Association (POA) or the Independent
Monitoring Board (IMB) were present or expressed a wish to see my investigator
at this time. The Governor did ask to see my investigator and was keen to ensure
My investigator received all the assistance he required, for which I am most
grateful.
2. Norfolk Primary Care Trust was asked to undertake a clinical review of the care
the man received while in custody. The Head of Clinical Governance and Quality
for Norfolk PCT, undertook the review. She was asked to look at the entries in
the man’s clinical record and their quality. The clinical reviewer was also invited
to judge whether the care the man received at HMP Norwich was the same as he
could have expected to have received in the community.
3. The man was raised in children’s homes and it is not thought he had any
contactable next of kin. Certainly his prison record shows no next of kin. My
Family Liaison Officers were therefore unable to make their usual contact with
family members following the man’s death.
4. My investigator contacted Her Majesty’s Coroner to inform him of the nature and
scope of my investigation and to request a copy of the Post Mortem report. Upon
completion, a copy of my report will be sent to the Coroner to assist in his
enquiries into the man’s death.
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HMP NORWICH
5. Norwich was first opened in August 1887 on its present site on Mousehold Heath,
overlooking the city. It is a multi­functional prison on two separate but adjacent
sites holding up to 823 prisoners. The Victorian prison is a local prison serving
the needs of the local courts. There is also newer accommodation built on the
former barracks that acts as a category C training prison.
6. The Young Offender Institution (YOI) was developed in the mid 1960s. It is on
this site that the healthcare inpatient unit is located. The healthcare unit covers
two floors, the lower level of which is the Nelson unit (L wing).
7. The Nelson unit opened in 2004 and provides specialist care akin to that in a
nursing home. It has been specially designed and equipped to enable older
prisoners to live a relatively normal life within a custodial environment.
Additionally, there is a medical in­patient unit on the floor above the Nelson unit.
8. The Nelson unit has a dedicated team of healthcare workers and prison officers.
There are partnership arrangements in place between primary care and
secondary care staff both within and external to the prison. In addition, the prison
works closely with palliative care services in Norfolk.
9. Ms Anne Owers, Her Majesty’s Chief Inspector of Prisons, last reported on
Norwich in November 2006. Her report commented on the good standard of
clinical care provided on the Nelson unit although she criticised the unit’s lack of
purposeful activity. Ms Owers’ report said that, “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.”
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KEY FINDINGS
The man’s clinical care
10. The clinical review reports on the man’s medical history from the time of his return
to prison in 1988. The man developed chronic arthritis to such an extent that
HMP Lindholme made him a permanent in­patient in their healthcare unit in 1993.
In 1997, the man was transferred to HMP Kingston where he developed further
health problems. In 2002, he was diagnosed as having Type II diabetes
(controlled by tablets) and in 2004 as suffering from Chronic Obstructive
Pulmonary Disease (COPD) which is a breathing difficulty condition. In 2004, the
man suffered mild heart attacks and angina. In 2005, he developed mild
congestive heart failure (an inability of the heart to perform properly) and
dementia. In November 2005, the man was transferred to HMP Norwich because
it was felt he required 24 hour medical care. The Nelson unit has the appropriate
resources to support patients with chronic and palliative care needs. When the
man arrived at Norwich, he did not have a diagnosis of terminal illness but was
considered chronically unwell.
11. The man was admitted to the Norfolk and Norwich University Hospital in June
2006 with a chest infection. He was discharged later the same day after
treatment. He was again admitted in late October 2006 with symptoms of chest
pain and abdominal pain, but was discharged after only a few days with a
diagnosis of constipation. He returned to Norwich prison on 25 October but was
sent back to the hospital on 26 October due to continued pain and vomiting blood
(haematemesis). This was later discovered to be due to an intestinal bleed
caused by non­steroidal anti­inflammatory drugs. The man was given a blood
transfusion and underwent other investigations before being discharged back to
prison on 30 October.
12. On 21 November, the man was seen at an outpatients clinic at Norfolk and
Norwich University Hospital. He was given the news that his earlier investigations
showed he had cancer of the oesophagus. There was some concern over
whether the man understood the diagnosis. When the prison doctor saw the man
on 22 November, he commented in the clinical notes that he was still unsure if the
man had understood his diagnosis.
13. On 3 January 2007, the man was referred to the palliative care team at Priscilla
Bacon Lodge (the local hospice care unit) for community palliative care by
Macmillan nurses. A nurse from this team made her initial assessment visit on 5
February 2007. The Macmillan nursing team continued to support the man and
the nursing team at Norwich prison throughout the coming months.
14. On 5 January, the man was in severe pain and having breathing difficulties. He
was sent to hospital but was returned to prison again the same day. On 6
January, the man again returned to the hospital with the same symptoms. This
time he remained in hospital for three days, receiving treatment for pneumonia.
15. On 12 January, the healthcare team at Norwich prison discussed the matter of
resuscitation for the man. It was decided that, because the man was being
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considered for cancer treatment, he should be resuscitated if the need arose.
This was well documented in the clinical notes.
16. On 19 January, the man appeared still to be suffering from pneumonia with
shortness of breath, delirium and crepitation sounds at the base of the lungs (a
‘crackling’ noise heard through a stethoscope). He was readmitted to Norfolk and
Norwich University Hospital for treatment.
17. When the man was discharged on 25 January, he remained out of hospital
despite generally being in poor health until April 2007. He was suffering from
slight confusion due to mild renal failure and shortness of breath caused by mild
heart failure and oedematous (swollen) ankles, but was carefully monitored and
treated by staff at the prison. However, on the day after he was originally
scheduled for a resectioning of his tumour the man was re­admitted to hospital.
He was suffering from chest pain, nursing staff could not record his blood
pressure, and his pulse was weak.
18. During this last stay in hospital the man was treated for heart arrhythmias and
respiratory failure. He was discovered to have a pleural effusion (a build up of
fluid between the lung and the chest wall) which was treated by inserting a chest
drain. He was also given intravenous antibiotics, physiotherapy, pain relief and
sleeping tablets. In short, he was made as comfortable as possible before his
death later on in April 2007.
The man’s life licence
19. In 1988, the man was returned to prison following the revocation of his life
licence.
20. In 1989, the man’s prison and probation assessments resulted in a
recommendation to the Parole Board that he should be released back into the
community with a condition of residency at a hostel under supervision. I have
been unable to ascertain what occurred in consequence, if anything.
21. In 1997, when he was 69 years old, the recommendation to the Parole Board was
that the man should be sent to an open prison. The aim was to test his resolve to
abstain from alcohol, with a view to release into the care of a hostel. For reasons
that are not entirely clear from the files, the man never reached open conditions.
22. In 2004, the Parole Board was minded to release the man, providing there was a
suitable plan in place for his release. The Board postponed its review until a
release plan could be drawn up in conjunction with the man’s home probation
area.
23. As the man had originally been recalled to prison from around Newcastle, the
Prison Service endeavoured to forge links with that area. There followed a two
year delay in establishing who would take responsibility and fund the release
plans for the man.
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ISSUES
24. The clinical review shows that the man was transferred to Norwich with the
specific aim of improving the care resources available to him. The Nelson unit
provides 24 hour healthcare in an environment designed to support the ongoing
needs of patients with chronic conditions. It endeavours to provide an
environment where the independence, privacy and dignity of individual patients is
respected. According to the clinical review, the man received a mainly good
standard of care during his stay at Norwich. I am pleased to note from the clinical
review that the healthcare team worked collaboratively alongside members of the
Specialist Palliative Care Team and staff at Norfolk and Norwich University
Hospital to ensure that the man’s complex care needs were met and that he was
allowed to die with dignity.
25. There are a couple of exceptions to this good provision of care highlighted by the
clinical review. On 5 January 2007, according to the clinical notes, the man
continued to shout out in pain throughout the night. It was not until 8.00 am the
following morning that staff were able to gain access to his cell. They found him
to be ‘pale, cold to the touch and not responding to verbal stimuli. Blood pressure
was 120/50 [low], pulse 120 and respiratory rate 36 [high indicating he was
having difficulty breathing]. Oxygen saturation levels were 77% [again, low].’ An
ambulance was called and the man was admitted to hospital for the next three
days.
The Governor should ensure that processes for out of hours entry to rooms
on the Nelson unit allow staff ready access to patients.
26. The clinical review also indicates some difficulties with the Liverpool Care
Pathway (LCP), a nursing tool for the management of people in the terminal
phase of a condition. It is clear from the review that at the time of the man’s
deterioration, there was some debate as to whether he had reached a terminal
phase. Staff on the unit were also in a transitional period of training and
implementation of the LCP model.
Practice within the healthcare team at HMP Norwich should be reviewed and
audited by the PCT to ensure it is in line with the Protocol for Palliative
Care. The findings of this audit should be reported to the PCT Clinical
Governance Group and the Partnership Board.
27. The question of whether the man received equitable care from secondary care
services after his diagnosis of cancer is raised by the clinical reviewer. She
concludes that the time taken from diagnosis to treatment should have been less
than one month. However, the man was scheduled for further treatment in early
April 2007. Matters are complicated in that he was assessed as being a high risk
for ordinary surgery of his carcinoma. It was thought that an endoscopic mucosal
resection of his tumour might be feasible. This latter treatment was not
scheduled for some three months.
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The Head of Healthcare should discuss with the PCT commissioners
waiting times for cancer patients and whether the case of this man
demonstrates inequity of service.
28. One final area of concern highlighted by the clinical reviewer was referrals to
other health services, such as dieticians and speech and language therapists.
The reviewer suggested that referrals to both these services would have been
beneficial to the man. In one instance, this referral was never made (the
dietician), in the other (speech and language therapy) the referral was made but
never followed through. Whilst neither of these omissions would have prevented
the man’s death, they may well have resulted in improved care for him.
PCT commissioners should ensure there is a robust system in place for
appropriate prisoner­patient referrals to other multidisciplinary health team
members.
29. The other issue raised by my investigation concerns the very fact that he
remained in prison for nineteen years after his recall from life licence. He had no
relatives with whom he was in touch and had become institutionalised, but I
wonder if more could have been done to secure his release. It is unlikely that
being in prison directly contributed to his death but I am far from clear that the
protection of the public required that he should have died while still in custody.
30. The clinical review says that a geriatric assessment was carried out in September
2005 as part of the parole process. The additional health problems that this
assessment identified showed the man to be suffering from mild congestive heart
failure, restricted mobility, night time falls and a degree of confusion and verbal
aggression. The recommendation was that a medium secure, all male Elderly
Mentally Infirm (EMI) placement with 24 hour care should be found. This
indicates the extent to which the man had deteriorated during his time in prison.
31. I am conscious that there is a growing number of elderly prisoners, many
convicted of very serious offences but who grow increasingly enfeebled while in
prison. This case appears to demonstrate a lack of urgency in securing the
man’s release on licence and the practical impediments that are encountered.
My final recommendation is intended to inject some new thinking into what will
become an increasingly common problem.
NOMS should review the number of elderly prisoners and any impediments
to their release on licence.
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RECOMMENDATIONS
The following recommendations were made in the draft version of the report. The
Prison Service’s and PCT’s responses are included in italics following each
recommendation:
The Governor should ensure that processes for out of hours entry to rooms on
the Nelson unit allow staff ready access to patients.
Recommendation accepted: There is already in place a night routine for accessing
patients on the unit including, for those who are at the end­stage of terminal illness,
an ‘open­door’ policy. It is unclear from records from the night mentioned
why/whether access was not gained as procedures allow for the Night Manager to
attend as required. Staff will be reminded to access the Night Manager as required
in order to deliver care to patients. A Healthcare Notice to staff was issued on
19/11/07.
Practice within the healthcare team at HMP Norwich should be reviewed and
audited by the PCT to ensure it is in line with the Protocol for Palliative Care.
The findings of this audit should be reported to the PCT Clinical Governance
Group and the Partnership Board.
Recommendation accepted: The PCT responded: an audit will be undertaken by the
end of the financial year to establish the level of care currently provided against the
Protocol for Palliative Care. The Prison Service responded: Further training has
already taken place and the Liverpool Care Pathway adapted to the needs of this
patient group. The audit process will form part of the overall PCT audit strategy.
The Head of Healthcare should discuss with the PCT commissioners waiting
times for cancer patients and whether the case of this man demonstrates
inequity of service.
Recommendation accepted: The PCT responded: it is appropriate for a
representative of our service to discuss this with the PCT commissioners before the
new financial year. The Prison Service responded: To be discussed at the next
Prison Health Operational forum by the end of April 2008.
PCT commissioners should ensure there is a robust system in place for
appropriate prisoner­patient referrals to other multidisciplinary health team
members.
Recommendation accepted: The PCT responded: there will be implemented a
robust, auditable referral system to other healthcare providers both within the prison
and the PCT. The Prison Service responded: This will form part of the SLA between
the Prison and the PCT. The timetable for this is scheduled to be before the end
April 2008.
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NOMS should review the number of elderly prisoners and any impediments to
their release on licence.
Recommendation accepted: Together with the Dept of Health, the Prison Service is
looking at all issues surrounding the health and social care of older prisoners.
An Older Prisoners Action Group has been set up by the Dept of Health to target the
problems identified with meeting the particular needs of older prisoner in the Criminal
Justice System. The principle aims of the group are to address the health and social
care needs of older prisoners through specific partnership with the Prison Service,
stakeholders and other networks. This will be ongoing.
Good Practice
I am pleased to note from the clinical review that the healthcare team worked
collaboratively alongside members of the Specialist Palliative Care Team and
staff at Norfolk and Norwich University Hospital to ensure that the man’s
complex care needs were met and that he was allowed to die with dignity.
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