Individual at Norwich

Investigation into the death of a man on 15 February 2006
at a Hospice whilst released on temporary licence from
HMP Norwich
Report by the Prisons and Probation Ombudsman for
England and Wales
September 2006
This is a report of an investigation into the circumstances of the death of a man. The
man died at a hospice on 15 February 2006, whilst released on temporary licence
from HMP Norwich. He was 53 years old at the time of his death.
I extend my sincere condolences to the man’s friends on their loss
The man had been diagnosed with secondary cancer of the pancreas in September
2005, whilst in custody at HMP Wayland. On 20 September 2005, the man was
transferred from Wayland to Norwich, following a period as an inpatient at a hospital.
On 4 November, the man transferred from Norwich’s healthcare centre to L Wing
(this is a wing for older life sentenced prisoners who require intensive nursing care).
On 27 January 2006, the man was released on temporary licence to a hospice for
palliative care. He died three weeks later, with his nominated next of kin at his
bedside. At the direction of the Norfolk Coroner, a post mortem has not been held.
A colleague carried out the investigation on my behalf. She and I would like to thank
the Governors of Norwich and Wayland and their staff for their help and assistance.
I would also like to thank the Norwich Primary Care Trust for the clinical review
conducted as part of the investigation.
This is a report that reflects very well on the care the Prison Service offered to a man
with terminal illness. I make two recommendations and draw attention to one
amongst several examples of good practice.
The recommendations have been accepted by the Prison Service and the Norwich
Primary Care Trust.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2006
Contents
Summary
Investigation process
HMP Wayland and HMP Norwich
The man
Events leading up to the death of the man
Clinical review
Findings and conclusion
Recommendations and good practice
Summary
The man was a life sentence prisoner and had been in custody for 26 years. He died
on 15 February 2006 at a hospice, having been released on temporary licence from
HMP Norwich.
The man had been convicted of very serious offences at Leicester Crown Court on
10 December 1979. He had previous convictions, and between 1971 and 1978 he
had been detained at Rampton special hospital under the Mental Health Act 1959.
However, his life sentence was the first time he had been sent to prison. He served
his sentence in 12 different prison establishments over the following years.
On 19 August 2005, the man was admitted to hospital for tests following a referral by
the prison doctor at HMP Wayland. He had complained of severe stomach pains
over several months and had lost a significant amount of weight. A diagnosis was
made of secondary cancer in his pancreas. The primary cancer was not identified,
but was believed to be in the lung or oesophagus.
The man was discharged from hospital on 20 September, and transferred to HMP
Norwich for medical care in the prison’s healthcare unit. On 4 November, he was
located on L Wing for nursing care (L Wing is a unit specifically created for lifers
requiring dependant nursing care). He attended a hospital on three occasions for
chemotherapy.
On 27 January 2006, the man was released on temporary licence to a hospice for
palliative care. He died there on 15 February.
The man chose two friends to be his next of kin, and they were at his bedside when
he died. Following his death, the Coroner decided not to request a post mortem as
the cause of death was known and he was in a hospice at the time, having previously
been in the local general hospital.
Whilst at the hospice, the man was escorted by one officer at all times. He was
visited regularly by the chaplains of Wayland and Norwich and by his prison visitor
from Norwich.
I conclude that this report reflects very well upon the Prison Service.
Investigation process
The investigation was opened on 23 February 2006, when my colleague visited
Norwich. She reviewed the man’s file and requested copies of documentation from
that file along with his medical notes. Notices were handed to the Safer Custody
Officer, to be issued to staff and prisoners notifying them of my investigation. Neither
a representative of the Prison Officers’ Association (POA) nor a member of the
Independent Monitoring Board (IMB) was present in the prison at the time.
On 1 March, the man’s prison visitor telephoned my colleague to discuss his care.
On 6 March, my investigator returned to Norwich to visit L Wing and observed its
facilities and regime. She later returned to review the man’s extensive files which
date back to the early 1970s. On 11 April, my investigator visited Wayland to view
the staff observation book on the wing where the man had been held. Extracts
relating to him were noted for the purposes of the investigation.
One of my Family Liaison Officers spoke to the man’s nominated next of kin on 13
March. He told my Family Liaison Officer he had serious concerns about the length
of time it took for the man to have his cancer diagnosed. The man’s next of kin was
in receipt of the man’s diaries. These diaries detailed his pain and suffering. The
man’s next of kin was concerned that his friend may not have received medical
intervention at a sufficiently early stage. (On these matters, I am necessarily led by
the findings of the clinical review. I hope the next of kin will be reassured by the
clinical reviewer’s conclusions.)
The man
The man had previous convictions dating back to 1970 and had been sectioned
under the Mental Health Act 1959. This was discharged on 12 January 1981. Three
years earlier, he had been released from Rampton special hospital on licence, after
seven years as an inpatient. In 1979, he was convicted of very serious offences for
which he received a life sentence. The man was employed as a labourer before his
conviction.
He served his sentence in 12 different prison establishments, including periods in
high security prisons. In May 2002, the man was transferred from HMP Littlehey to
HMP Wayland. On 10 September 2004, following a Parole Board review, it was
recommended that he be moved to open conditions and he was allocated category D
status. He was participating in an offending behaviour programme which was
ongoing at that time. He was ready to begin an integration programme in preparation
for his eventual release under licence. It was agreed that his next review would be in
August 2006.
The man transferred to Norwich on 20 September 2005 for full time nursing care after
his cancer had been diagnosed.
The man had lost contact with his blood relatives. His elected next of kin were
friends. He received pastoral care and friendship from the chaplains of Wayland and
Norwich and was supported through the last few months by his prison visitor.
During parts of his sentence, the man displayed inappropriate behaviour which
resulted in transfers to other prisons. In latter years, after completing offending
behaviour programmes, his attitude relaxed and he became a trustworthy member of
the prison community. The man had been granted release on temporary licence for
local town visits at some establishments.
HMP Wayland
HMP Wayland is located close to the town of Thetford in Norfolk. It is an adult male
category C training prison with an operational capacity of 709 prisoners (May 2005).
Two of its eight residential units are designed for those taking part in Sex Offender
Treatment Programmes.
Southern Norfolk Primary Care Trust took over the commissioning of healthcare
services at Wayland in April 2005. There is one full time doctor, one healthcare
senior officer, three healthcare officers and three Prison Service nurses. Healthcare
does not have an inpatient facility. Those requiring inpatient treatment are
transferred to Norwich. Prisoners report on morning unlock to see a doctor on an
appointment basis. The healthcare staff see other prisoners as ‘special sick’. A wide
range of clinics operate from the unit.
The last death at Wayland was in May 2004. The prisoner concerned died from
apparently natural causes.
HMP and YOI 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. One section of the prison accommodates
young offenders and the healthcare centre, which also includes an elderly prisoner
unit (L Wing). The remainder of the population is accommodated in the main prison
complex.
L wing opened in 2004. It provides nursing home care for the elderly and infirm.
There has been one other death from natural causes on the unit this year.
Events leading to the death of the man
On 30 May 2002, the man was transferred to Wayland from Littlehey and participated
in a treatment programme to address his offending behaviour. On 10 September
2004, the Parole Board reviewed his case. The Board recommended that he be
transferred to a prison with open conditions, in preparation for his release on licence.
The man’s next Parole Board date was scheduled for August 2006.
On 8 January 2005, the man’s medical record shows that he was taken to the
healthcare unit with stomach pain and other pain in his right side. He described the
pain as intermittent and as a dull ache. He had no nausea, vomiting, urine or bowel
problems. He was eating and drinking normally. The man was prescribed medicine
for indigestion and was advised to see the doctor if there was no improvement.
The next entry on the man’s medical record is dated 19 May. He had vomited a
brown liquid and had stomach pain. On 25 May, he was examined by a doctor. The
medical notes record him as vomiting 20 minutes after meals. Blood tests were
requested. On 27 May, an entry in the medical record states, ‘see computer, is
allergic to penicillin’.
On 16 June, blood was taken from the man for tests. A test slip in his notes records
that he tested positive for helicobacter pylori, bacteria that grows in the stomach. On
30 June and 6 July, further complaints of abdominal pain are noted in his medical
record. No additional information is provided.
On 12 July, the medical record says that healthcare staff were called to see the man
on the wing. He was again complaining of abdominal pain. On examination, there
was no evidence of vomiting or diarrhoea. His medical notes show that he felt the
doctors were not providing him with good quality care. He was advised on the
amount of medication he could take, as it might exacerbate his abdominal problems,
and was told he was on the waiting list, as an outpatient, for an endoscopy. He was
recommended to apply for a GP appointment.
On 15 July, the man collapsed on the wing. When healthcare staff arrived to
examine him, he was conscious with no breathing difficulties. The man was
complaining of stomach pain and vomiting. He told staff he had lost four stones in
weight and was unable to keep food down. The entry in his medical record notes that
healthcare would keep him under review at the weekend. The next day, the man
was seen on the wing by healthcare staff. His symptoms were no better and he was
looking frail. Medication was given.
On 17 July, the man was again visited by healthcare staff on the wing. His medical
record states he was looking a bit better. Later that day, healthcare staff were again
called to the wing to see him. The entry on his medical record says he was
complaining of pain and feeling ill. He also had cramp in his right leg, which was
relieved by pressure and massage.
On 26 July, the man’s medical notes indicate that a member of staff from healthcare
had a discussion with a governor relating to the man’s medical condition and his
severe pain. It was again noted that he was waiting for an endoscopy. Later that
day, healthcare staff attended the man on the wing following a code blue alert.
(Code blue alert is for medical staff to attend the collapse of a prisoner.) The medical
record describes him as being drowsy but not unconscious, and he improved as
healthcare staff examined him. Another prisoner was recorded as telling the
healthcare member that the man was alright one minute then complained of pain and
became unconscious. Observations were taken from him. It was noted his throat
was very red, possibly due to vomiting bile, and that he needed to see the GP on
Friday.
On 31 July at 11.10pm, an ‘on call out of hours’ doctor attended Wayland at the
request of prison staff to see the man. He had been complaining of severe stomach
pains. The doctor prescribed medication to ease his pain.
On 8 August, the man submitted a formal complaint form. The basis of the complaint
was the constant pain he was suffering, his weight loss, and a feeling of neglect by
the healthcare service and in particular the doctor. The complaint was referred to the
GP, as a Healthcare Senior Officer felt he was unable to answer. Later that day, the
man spoke to a member of the IMB at Wayland. On 9 August, the IMB member
wrote to the Healthcare Manager, with reference to the man's medical condition. In
the letter, the IMB member asked the Healthcare Manager to look into the man's
case as soon as possible, as she felt there was considerable cause for concern.
A report was sent to the IMB member by a governor. The report detailed the man’s
medical history from the start of the year, the interventions from medical staff, and
medication issued to him. The report commented that wing staff had been
concerned about his condition, notably his weight loss. The report closed by stating
that healthcare staff had immediately contacted the local hospital in order to expedite
his referral for an out patient appointment.
On 19 August, the man was admitted to hospital. Over the next 13 days, the man
underwent tests at the hospital and was diagnosed with malignancies. His medical
record has an entry on 2 September recording this information.
On 12 September, a letter from a Consultant in Clinical Oncology at the hospital,
confirmed the man had metastatic cancer in the upper abdomen and an area
surrounding the pancreas. The doctor said that the man should consider an
application for release on compassionate grounds as his illness was terminal. His
estimated life expectancy was three to 12 months, dependent on his chemotherapy
treatment, but no more than 18 months.
The next entry on the man's medical notes is dated 20 September when he was
discharged from hospital to HMP Norwich’s healthcare centre. Wayland requested
the transfer as Norwich’s healthcare is able to provide 24 hour cover. The man was
prescribed a range of medication, including oramorph for pain relief.
Over the next six weeks, he remained in the healthcare centre. His pain relief was
intermittent and he attended the hospital for chemotherapy on 7 October. The man’s
condition was gradually deteriorating and he was becoming increasingly frail.
On 4 November, he was transferred from healthcare to L Wing. This wing is
specially resourced to provide nursing care for older life sentenced prisoners. On 18
November and 9 December, the man attended the hospital for his chemotherapy
sessions. McMillan Nurses were also in contact with the nursing staff and visited him
on L Wing, advising on his pain relief and general nursing care.
On 1 December, the man was assisted in writing a living will. This document was
witnessed by two healthcare staff. In the will, he stated that he wished to die on L
Wing. On 22 December, an entry on his medical notes records, ‘that in the event of
cardio pulmonary arrest the man is not for resuscitation’.
On 30 December, the man was admitted to hospital as an in patient. He was
discharged back to HMP Norwich on 9 January 2006. On his return to Norwich, he
was fitted with a syringe driver to aid his pain relief.
On 15 January, staff on L Wing discussed the man’s pain relief with staff from the
hospice. A new prescription for his syringe driver was authorised by the prison
doctor. On 23 January, a member of staff from the hospice attended L Wing, at their
request, to insert a second syringe driver for him to manage his increased
medication.
On 25 January a Consultant in Palliative Care saw the man on L Wing to discuss his
nursing care and prognosis. The consultant suggested to the man that his pain relief
control would be easier to manage at the hospice. The man agreed to be admitted to
the hospice, despite his earlier living will stating he wanted to die on L Wing.
On 26 January, the man was assisted by L Wing staff to apply for release on
temporary licence to the hospice. This was granted by the Board on compassionate
grounds. At 2pm the next day, he was escorted to the hospice, accompanied by one
officer who remained to provide ongoing support. The man was not restrained.
Over the next 19 days, he settled at the hospice where his pain relief was managed
in a more conducive environment. He was visited regularly by his prison visitor from
Norwich, by the chaplaincy team, duty governors, the Head of Healthcare, and by
his nominated next of kin.
The man died at 6.45pm on 15 February with his nominated next of kin at his
bedside.
His funeral was held on 1 March, with the chaplain of Wayland officiating at the
service. The chaplain of Norwich and the man’s prison visitor, also attended. In
accordance with Prison Service Order 2710, the prison offered financial assistance
towards funeral expenses.
Two memorial services were held for him - one at Wayland and the other at Norwich.
Clinical review
A clinical review of the man's medical care was carried out by the Norwich Primary
Care Trust. The reviewer examined the man’s medical notes and visited the
healthcare units at both Wayland and Norwich.
The man’s diagnosis of metastasic squamous cell carcinoma (cancer) was confirmed
in September 2005. Prior to this diagnosis, he had tested positive for helicobacter
pylori, a bacteria that can grow and survive in the stomach. This infection was
treated with the appropriate medication. The man’s condition continued to cause him
weight loss and pain, although he was receiving appropriate medication for
helicobacter pyloria. Further investigations were ordered by the medical officer at
Wayland. An appointment was made for him to attend as an out patient for an
endoscopy at hospital on 24 August. The reviewer concludes that the man's
emergency admission to hospital on 19 August was timely, taking into account his
failing health.
She further judges that the medical care received by the man was appropriate, as
evidenced in his care and medical notes. Comprehensive risk assessments and care
plans were put in place to monitor, assess and deliver the support and medical
treatment relevant to his needs.
All interventions into his medical care were implemented in line with the Liverpool
Care Pathway. (The pathway is intended as a guide to treatment and aid in
documenting a patient’s progress.) A multi-disciplinary approach to help the man
was facilitated as he entered the terminal phase of his life and was part of his care
plan.
The reviewer said the man's palliative care at the hospice was appropriate and
provided a setting more able to care for terminally ill patients. Following his death,
the staff at the hospice implemented the Primary Care Trust’s Confirmation of
Expected Death Policy and this met the requirements of the Prison Death in Custody
procedures. The reviewer makes one recommendation in relation to this:
The Norwich Primary Care Trust Policy for the Confirmation of Death should be
reviewed to formally incorporate a prisoner dying within care settings external
to the prison.
This recommendation has been discussed with the Head of Healthcare at Norwich
and will be communicated to the Head of Healthcare at Wayland and the Clinical
Governance Lead for Southern Norfolk Primary Care Trust. The recommendation
will be monitored via Norwich Prison and Norwich Primary Care Trust’s Healthcare
Governance structure.
I endorse the recommendation.
The reviewer noted one example of good practice, which I also endorse:
The man was offered a choice where he wished to die. The prison healthcare
team and the hospice worked collaboratively to respect his wishes and allow
him to die with dignity.
Findings and conclusion
The man’s time in Wayland
The man spent nearly three and a half years at Wayland, having been transferred
there from Littlehey in May 2002. He was located on F wing, and was participating in
a treatment programme. My investigator reviewed the staff observation book for F
Wing, starting around the time he began to show signs and symptoms of his illness
(June 2005). There are 18 observations relating to his physical condition and two
entries following his admission to hospital in August 2005.
The extracts describe the man’s medical condition and the pain he was suffering.
They show the concern of wing staff and the referrals they made to healthcare for
medical staff to visit him. From the entries on his medical record and the staff
observation book, the man was obviously in pain and distress caused by his physical
illness. Fellow prisoners and wing staff offered support to him during this difficult
time. A request for an armchair was processed in July. This gesture was welcomed,
offering a comfortable chair for the man to rest in when he was unable to sleep at
night and to make him more at ease during the day.
The IMB member who raised the man’s medical problems acted correctly and with
commendable urgency. I thank her for that. It is a sad fact that IMB members rarely
receive any public acknowledgement for their important work:
I recommend that the Governor of Wayland writes to the IMB member drawing
attention to this report and my comments on her actions.
The man’s time in Norwich
The decision to transfer the man to Norwich was entirely appropriate. Following his
admission to hospital and diagnosis, the healthcare unit at Wayland was unable to
offer him the nursing and medical care that he needed.
The man’s care in Norwich appears to have been compassionate and professional.
He particularly appreciated his time on L Wing as reflected in his living will. He asked
that his belongings and any money left in his account be used for the benefit of
prisoners on L Wing.
The man’s prison visitor at Norwich, expressed his admiration for the humanity and
kindness shown to him. The prison visitor drew attention to the efforts made by
Norwich to ensure he was given food he could digest. On 31 October the medical
officer wrote a short memo to the kitchen requesting jelly and rice crispies for him.
On 15 November, the medical officer again wrote to the kitchen staff for a supply of
food for the man: this included Carnation milk and tinned fruit. He had been
purchasing these foods from his prison earnings and the medical officer felt they
should be supplied by the prison due to his physical condition. I am pleased to note
that the medical officer’s requests were granted.
Finally, I judge that the decision to release the man on temporary licence to receive
palliative care at the hospice, was both timely and caring.
All in all, this report reflects very well upon the Prison Service.
.
Recommendations
(cid:190) The Norwich Primary Care Trust Policy for Confirmation of Death should
be reviewed to formally incorporate a prisoner dying within care settings
external to the prison.
(cid:190) I recommend that the Governor of Wayland writes to the IMB member
drawing attention to this report and my comments on her actions.
Good Practice
(cid:190) The man was offered a choice on where he wished to die. The prison
healthcare team and the hospice worked collaboratively to respect his
wishes and allow him to die with dignity.