Individual at Norwich

Investigation into the circumstances surrounding
the death of a man, who was a prisoner
at HMP Norwich, in September 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
March 2007
This is the report of an investigation into the death of a man who was a prisoner at
HMP Norwich. The man died at a local specialist palliative care centre in September
2006. His friends and family were at his side.
I offer my sincere sympathy and condolences to all those touched by the man’s
death for their loss. A post mortem recorded the cause of death as metastatic
oesophagael cancer.
The investigation was carried out on my behalf by one of my investigators. An
independent review of the man’s medical care in prison was carried out by the
Norfolk Primary Care Trust. I am most grateful to the clinical reviewer for her
assistance.
I would also like to thank the Governor and staff of Norwich for their full and ready
co-operation during the course of the investigation.
I make two recommendations and highlight two examples of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2007
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CONTENTS
Summary
The Investigation Process
HMP Norwich
Key Events
Issues
Recommendations
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SUMMARY
The man who is subject of this report was initially received into HMP Peterborough
as a remand prisoner on 16 November 2005. Two weeks later, he was sentenced to
six years imprisonment. The man had a history of offending and imprisonment
stretching back to his teenage years. He raised no medical problems at his first
reception health screening.
In April 2006, after transfer to HMP Littlehey, the man began to complain of pain in
his abdomen, particularly when he coughed. He was given pain relief, but returned
to see the prison GP on a number of occasions over the coming weeks. At a review
on 28 April, the prison GP decided that an ultrasound at a local hospital should be
arranged. By the time of his next review, on 23 May, the man had not yet had the
ultrasound. The prison GP therefore asked for the appointment to be re-booked as
urgent. The scan subsequently went ahead on 13 June.
At a review on 10 July, the man said that he had been “gagging” on his food and
bringing up bile over the last few days. An urgent request was subsequently made
to the local hospital for the ultrasound results. The results showed a “small renal
calculus” and, on account of this and his new symptoms, the man was admitted to
the hospital on 11 July.
The man underwent a number of clinical investigations whilst in hospital. These led
to the conclusion that he had cancer of the oesophagus which had spread to the
liver. In a letter of 28 July, the Specialist Registrar estimated that he had between
four weeks and four months to live.
The man was transferred to HMP Norwich on 4 August, so that he could be held on
the specialist older prisoner unit at the prison and receive an increased level of
nursing care. At Norwich, he received additional care from the MacMillan team at a
local specialist palliative care centre.
On 25 August, the man was admitted to a hospital in the city following a bout of
vomiting and dehydration. He was then transferred to the local specialist palliative
care centre on 31 August, for palliative care. The man’s health deteriorated whilst at
the specialist palliative care centre and, by 11 September, his breathing had become
laboured. He died at 6.45pm on 14 September with friends and his ex-wife at his
side. The cause of death was recorded as metastatic oesophagael cancer.
This report includes two recommendations and draws attention to two examples of
good practice.
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THE INVESTIGATION PROCESS
The investigation was opened on 19 September 2006 when my investigator issued
notices announcing the investigation to staff and to prisoners. The notices included
an invitation to those who wished to submit information relating to the man’s death to
make themselves known to my investigator. No prisoners came forward as a result.
My investigator interviewed one member of staff during the course of the
investigation.
My investigator visited Norwich on 12 December 2006. He was given full access to
the man’s prison files, including his medical record.
An independent clinical review of the man’s health needs whilst he was in custody
was carried out by the Assistant Director of Quality and Nursing at the Norfolk
Primary Care Trust.
One of my family liaison officers contacted a friend of the man, whom he had
nominated as his next of kin, on 26 September 2006. This gentleman said that he
felt that the man would have benefited from more medical attention whilst he was at
Littlehey.
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HMP NORWICH
HMP Norwich is located within the city boundaries and holds convicted and remand
prisoners, including adults and young offenders. It is designated as a local prison
and serves the courts of East Anglia. The certified normal accommodation is 591
and the prison has an operational capacity (maximum crowded capacity) of 823.
A car park and road divides the prison into two distinct sections. One section of the
prison accommodates the young offenders and the healthcare centre, which also
includes a specialist older prisoner unit (L Wing). The remainder of the population is
accommodated in the main prison complex.
L wing opened in 2004, and provides specialist nursing home style care for elderly
and infirm prisoners. The unit has been specially designed and equipped to enable
older and less able prisoners to live a relatively normal life within the confines of the
custodial environment. It is managed by a dedicated team of healthcare workers
with support from prison officers. A positive partnership approach has been
adopted, enabling local specialist secondary care providers to attend and support the
full time staff in delivering care appropriate to the needs of the individual.
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KEY EVENTS
The man was received at HMP Peterborough on 16 November 2005, as a convicted
but unsentenced prisoner. No concerns were raised during his reception health
screening (a routine health screen for new arrivals), and the man reported only minor
problems with his health during his time at Peterborough.
On 9 January 2006, the man transferred to HMP Littlehey as a sentenced prisoner.
On reception, it was noted that he had high blood pressure and he was given advice
with regard to this. Over the course of the next three months, the man reported a
couple of minor problems each of which was dealt with at the time.
On 7 April, the man saw the prison GP at Littlehey, and said that his abdomen hurt
when he coughed violently. The prison GP prescribed doxazosin mesylate 1mg (for
the control of his elevated blood pressure). The man returned to healthcare the
following day and again complained of acute pain when coughing. He was given
pain relief by a nurse, and advised to see the doctor again if he continued to
experience pain.
The man saw the prison GP again on 18 April, and complained of getting cramp in
the abdomen. The prison GP thought this to be a side effect of the doxazosin, and
therefore prescribed buscopan instead (buscopan is a medication used to treat
bladder or intestinal spasms). The man again returned to the prison GP on 24 April,
and was given a stronger painkiller.
At a review on 28 April, the man once more complained of abdominal pain, saying
that it “feels like somebody punched (me) in the abdomen”. The prison GP noted
that an ultrasound of the abdomen should be arranged.
The man was not seen again until a review with the prison GP on 23 May. It was
noted that he was still in pain, but that ibuprofen helped. The prison GP recorded
that an ultrasound had been booked “ages ago”, but had not taken place. He asked
for the appointment to be re-booked as urgent.
On 30 May, the man wrote to the Head of Healthcare at Littlehey to say that he had
been in constant pain for over a month and that further medical examination should
take place. He was subsequently seen in healthcare by the Head of Healthcare on 5
June, and reassured that an appointment had been received for a scan. The man
was reviewed by the prison GP on the following day, and was prescribed co-codomol
as pain relief because ibuprofen was no longer effective.
On 7 June, the man lost consciousness on the wing and collapsed. Healthcare staff
were called, and a nurse attended. The nurse recorded that the man was conscious
on her arrival and was experiencing no difficulty breathing. The man complained of
a pain in the neck area. His blood pressure was high (184/115). An ambulance
crew attended, and the nurse spoke to a doctor. It was jointly decided that the man
did not need to go to hospital, and that he should remain in prison for a review the
following day.
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The man finally attended a local hospital on 13 June for the ultrasound scan. He
was reviewed the following day and again on 21 June. On both occasions he said
that the pain was ongoing, but that co-codomol helped. On 26 June, however, the
man reported that the pain had got worse. On account of his ongoing pain, and as
the ultrasound results had not yet been received, the prison GP referred him to the
surgical outpatients department at the local hospital on 5 July.
On 10 July, the man was reviewed by a GP in healthcare at Littlehey. He now
reported that he had been “gagging” on his food over the weekend, and that he had
been bringing up some bile over the last two days. An urgent request was therefore
made to the local hospital for the ultrasound results. They were faxed over on 11
July. The results showed a “small renal calculus on the right side”. On account of
his new presenting symptoms, and following receipt of the ultrasound results, the
man was immediately referred and admitted to the hospital.
The man remained as an inpatient at the hospital until 4 August. He underwent a CT
scan on 17 July, the results of which showed “widespread liver metastases most
probably from a colonic primary”. As a result, the man underwent a colonoscopy (an
internal examination of the colon) on 20 July, the results of which were normal.
A gastroscopy (an internal examination of the upper digestive tract) on 25 July
showed a “malignant appearing lesion in the oesophagus, extending into the
stomach”. The conclusion drawn by the Specialist Registrar was that the man
appeared to have “oesophago-gastric carcinoma with extensive liver metastases”
(cancer of the oesophagus which has spread to the liver). The Specialist Registrar’s
estimated prognosis, in a letter faxed to Littlehey on 28 July, was that the man had
between four weeks and four months to live.
Following receipt of this fax, an application for early release on compassionate
grounds was initiated. Section four of the form, regarding the man’s medical
condition, was completed by a member of the Palliative Care team at the local
hospital, and was based on the Specialist Registrar’s diagnosis and prognosis.
Section five, regarding resettlement and the risk of reoffending, was completed by
the Probation Officer at Littlehey. The Probation Officer noted that the man had a
long history of offending and that he denied the current offence. He concluded that
the man would re-offend were he given the opportunity. The application was not
therefore taken any further.
On 2 August, the man was commenced on a pain relieving syringe driver (a plastic
syringe that delivers small amounts of a drug continuously through a battery
operated pump) so that more effective pain relief could be offered to him. On the
same day it was agreed with the Head of Healthcare at HMP Norwich to transfer him
there. Norwich has an elderly prisoner unit (L-wing) that can provide specialist care
for older and seriously ill patients. The man also had a number of friends in the
Norwich area, which would make maintaining social ties easier.
The man transferred to Norwich on 4 August. On 8 August, the Head of Healthcare,
along with a locum GP and the Clinical Manager, discussed his diagnosis and the
prognosis with him. The Head of Healthcare noted in his medical record that the
man understood his diagnosis and that chemotherapy would not help him. She also
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noted that his condition had deteriorated in the last few days. Resuscitation was
discussed with the man and he agreed that, in the event of cardiac arrest, he did not
wish to be resuscitated. The appropriate forms were signed and completed. The
man also expressed the wish to see his friends (including his nominated next of kin),
and it was agreed that they would be allowed to visit him in Healthcare.
A referral to the Central Norfolk Specialist Palliative Care Service was made on 8
August. The man was visited on 10 August by a Consultant in Palliative Medicine
from a local palliative care centre. The Consultant assessed the man and reviewed
his care plan. The man was visited by members of the MacMillan team at the local
palliative care centre around every three days until 25 August.
On 25 August, the man was admitted to a hospital in the city. This followed a period
of around one week in which he had been vomiting and suffering from dehydration.
The man was accompanied by two officers. He was cuffed to one of these officers
by means of an escort chain at all times, following a security risk assessment.
Over the following days the man’s pain increased and, on 31 August, he was
transferred to the local palliative care centre for terminal care. The security
arrangements were reviewed and a decision was made by the governing Governor
and Security Manager to continue with the escort chain.
The man continued to deteriorate following his arrival at the palliative care centre,
and he was in a lot of pain. Following his visit on 5 September, the governing
Governor gave the order for the removal of restraints, with the condition that they be
re-applied if the man were to leave the room. Two officers remained on escort duty.
The man was visited regularly by friends during this time. His ex-wife was also a
regular visitor, as was the Head of Healthcare. Sadly, his health continued to
deteriorate and, by 11 September, his breathing had become laboured. The man
died peacefully at 6.45pm on 14 September, with friends and his ex-wife at his side.
The cause of death was recorded as metastatic oesophagael cancer.
The man was cremated on 29 September, following a service conducted by a
Salvation Army Minister. The service was attended by the Head of Healthcare and
chaplaincy staff, and all of the costs were met by the prison.
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ISSUES
The clinical review, conducted by the Norfolk Primary Care Trust, concludes that “the
man’s treatment and continuing care needs were met at all stages by the healthcare
teams in Norwich prison and Specialist Palliative Care Services.” The clinical
reviewer goes on to note that the man’s choice of his preferred place of care, the
local palliative care centre, was respected. She records this as an example of good
practice.
The clinical reviewer also considers the timeliness of the man’s hospital
appointments whilst at Littlehey. The prison GP first referred him for an ultrasound
on 28 April 2006. This referral was escalated to “urgent” on 23 May when it became
clear that no ultrasound had yet taken place. An appointment was subsequently
received for 7 June. The appointment was then rearranged for 13 June, the reasons
for which are unclear. The clinical reviewer therefore makes the following
recommendation:
The Head of Healthcare at Littlehey should ensure that, where there is a need
to prioritise a prisoner’s external hospital appointments, clear protocols are in
place to ensure they are prioritised effectively with the rationale documented.
The results of the ultrasound taken on 13 June were not received in the prison until
11 July. The clinical reviewer notes that the results of the ultrasound “did not
indicate any problems with the liver or other sites where the cancer was later found”.
Whilst acknowledging that the delay “would not have changed the outcome for the
man”, the clinical reviewer considers that the results “should have been sent to the
Prison GP service in a timelier manner”. I agree.
The Head of Healthcare at Littlehey should discuss the establishment of formal
procedures with the local hospital to ensure that notification of the results of
investigations is received in a timely manner.
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RECOMMENDATIONS
The Head of Healthcare at Littlehey should ensure that, where there is a need
to prioritise a prisoner’s external hospital appointments, clear protocols are in
place to ensure they are prioritised effectively with the rationale documented.
Accepted – the Clinical Nurse Manager will develop a formalised policy for the
prioritisation of outpatient appointments.
The Head of Healthcare at Littlehey should discuss the establishment of formal
procedures with the local hospital to ensure that notification of the results of
investigations is received in a timely manner.
Accepted – the Head of Healthcare will discuss the process of receiving results
following investigations/appointments with Cambridgeshire PCT.
GOOD PRACTICE
The man’s choice on his preferred place of care was respected. The prison,
Healthcare team and local palliative care centre worked collaboratively to
respect his wishes, meet his care needs and allow him to die with dignity.
An award (Governor’s Commendation) will be made, by HMP & YOI Norwich, in
recognition of the care and professionalism shown by staff at the local palliative care
centre.
An award (Governor’s Commendation) will be made in recognition of the care and
professionalism shown by Health Care Staff from HMP & YOI Norwich.
Head of Personnel to organise commendations.
The Head of Healthcare at Norwich regularly visited the man at the local
palliative care centre in the final days of his illness.
1. An award (Governor’s Commendation) will be made in recognition of the
care and professionalism shown by the Healthcare Manager from HMP &
YOI Norwich.
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