Individual at Norwich

Investigation into the circumstances surrounding the
death of a man at
HMP Norwich on 30 November 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2006
This is the report of an investigation into the death of a man at HMP Norwich on 30
November 2004. The man, who was 57, died from heart disease.
I offer sincere condolences to the man’s family and friends in their sad loss.
The investigation was completed by one of my colleagues. I am grateful for the
assistance that she received from the then Governor of Norwich, and his staff,
including the establishment’s Liaison Officer. My thanks are also due to Norwich
Primary Care Trust who arranged for the clinical review. I regret the delay in the
issuing of this report.
A key objective of all my investigations is to make sure that the bereaved family has
the opportunity to raise any concerns and contribute to my inquiries. In this case, the
investigation team was able to meet with the man’s family. I am most grateful to
them for agreeing to this meeting at what must have been a very difficult and
distressing time.
No-one should under-estimate the difficulties of caring in a custodial environment for
a patient like the man who came into prison with a complex range of medical and
psychological problems. This long report documents how HMP Norwich rose to
those challenges. Perhaps inevitably, some things were not done as well as they
could have been. However, I would like to draw particular attention to the views of
the clinical reviewer recorded in the penultimate paragraph of p.27 of this report.
These are that the man’s health actually improved in certain respects while was in
prison.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN September 2006
CONTENTS Page
SUMMARY 4 – 5
CONDUCT OF THE INVESTIGATION 6 – 7
BACKGROUND INFORMATION 8
The man
HMP Norwich
THE MAN’S TIME AT NORWICH 9 – 21
EVENTS OF 30 NOVEMBER 22
CLINICAL REVIEW 23
FAMILY CONCERNS 24
CONSIDERATION AND CONCLUSIONS 25 – 26
RECOMMENDATIONS 27
ANNEXES 28
SUMMARY
1. The man was first remanded into custody at HMP Norwich in April 2002,
charged with various offences alleged to have been committed over a
period of approximately 20 years. On arrival at Norwich, his substantive
health problems of diabetes, heart disease, significant visual problems,
below-knee amputation and hand contractures were identified during the
initial reception healthscreen by the nurse. The man required the use of a
wheelchair. Medical information was obtained from his GP which confirmed
that, in the year or so previously, he had been neglecting his own health
needs. There was evidence that the man had missed out-patients
appointments. In a letter dated 24 April 2002 addressed to the prison’s
Medical Officer, the man’s GP recommended that the prison should keep a
close eye on his mental health as he had previously shown symptoms of
depression.
2. While in Norwich, the man was an in-patient in the healthcare centre on a
number of occasions. Otherwise he remained on a residential wing, mostly
E Wing or A1 landing which were specifically for vulnerable prisoners.
Concern was expressed on more than one occasion by healthcare staff and
others that the physical environment on the wing was difficult for him
because of his mobility problems. Some consideration was given to
transferring the man to another prison but he was put on medical hold on
three separate occasions. This meant that he could not be transferred due
to ongoing medical treatment.
3. It seems that the man’s location in healthcare was able to help him meet
both his physical and emotional needs, but that long term placement in
healthcare was not appropriate. It was considered by healthcare staff that it
would hinder his chances of transferring to another prison if he was seen as
having health problems which prevented him from leaving healthcare.
When the man’s medical needs increased, he was appropriately transferred
to the healthcare centre and was not treated as an in-patient for social
reasons alone.
4. During his time in Norwich, the man was referred to specialist consultants at
Norwich and Norfolk University Hospital in the areas of ophthalmology,
genito-urinary medicine, rehabilitation medicine and diabetes. Before
arriving at Norwich, the man had never previously seen a specialist for his
diabetes. Initial tests at Norwich showed a good level of diabetic control
and the man was followed up in specialist clinics, including seeing a diabetic
specialist podiatrist. He had cataract surgery on 17 November 2003, and
an operation for swollen testicles on 25 November 2003.
5. Records show that the man attended a number of planned out-patient
appointments during the 2 ½ years he spent at Norwich. He missed one
out-patients appointment when a taxi did not collect him on time. He also
spent two nights in hospital between 19 April and 21 April 2002 following his
reporting chest pain.
6. According to his medical record, the man initially suffered a number of
hypoglycaemic attacks (low blood sugar) when he arrived at Norwich. He
appears to have been treated successfully for these. He also suffered a
number of episodes of chest pain, which also appear to have been
managed well by healthcare staff with medication for angina and
reassurances for stress-related symptoms. The man also suffered from
chest infections which were successfully treated. He complained in his own
handwritten notes of physical symptoms associated with vascular disease,
which appear to be related to his existing physical complaints.
7. The man also experienced episodes of low mood during his time in
Norwich. Staff appear to have identified these and provided appropriate
support. He was the subject of suicide prevention procedures for short
periods in May and August 2002 and February 2004. He also spoke to
Listeners on several occasions. (Listeners are prisoners specially trained
by the Samaritans to assist other prisoners.)
8. After the man’s surgery for swollen testicles on 25 November 2004, he was
initially located on E Wing. Shortly after, on 27 November, he was admitted
as an in-patient to the healthcare centre as he was in some discomfort
following the operation. He was monitored by healthcare staff and the
wound was dressed and cleaned on 28 November. He was seen by a
doctor on 29 November. At 8.10pm on 30 November, a Healthcare Officer
was alerted by other prisoners that the man was in distress in the
healthcare ward. Staff responded promptly. Cardiopulmonary resuscitation
was undertaken but sadly was not successful. The man was pronounced
dead at 8.45pm. The cause of death, following the post mortem has been
given as hypertensive and ischaemic heart disease.
9. This report concludes that the man received a good standard of healthcare
while in Norwich, but identifies some record keeping shortcomings. I make
two recommendations.
CONDUCT OF THE INVESTIGATION
10. The investigation was completed by a senior investigator for the Prisons
and Probation Ombudsman (PPO).
11. During the course of initial inquiries, the investigator was shown around
HMP Norwich and visited the cell where the man died. She reviewed all the
relevant documentation and established a chronology of events. Notices
were issued to staff and prisoners telling them of the investigation and
offering them the opportunity of contributing. There were no responses to
these notices.
12. One of my Family Liaison Officers contacted the man’s family and offered
them the opportunity to meet with her and the investigator to discuss the
purpose of the investigation and to raise any concerns or questions that
they would like explored and addressed. They subsequently met with the
man’s family. The family raised a number of concerns, mainly about the
management of the man’s healthcare while at Norwich, particularly his
location on a normal residential wing following an operation. The man had
told his family that, when he was in hospital for the operation, the hospital
had criticised action taken within the prison by a prison doctor. The man’s
wife indicated that he had kept records of occasions where his healthcare
needs were not met in Norwich, that he kept a diary and recorded dates
when he did not receive his medication, and that he had made a number of
formal complaints of this nature. Our records show that none of these
complaints was referred to the PPO, and all were answered locally. The
man’s wife showed my investigator copies of some of these complaints and
a 2003 diary, but said that the 2004 diary was missing. She also said that
her husband made verbal complaints about his healthcare during telephone
contacts and visits with family members. He also complained to her about
other prisoners helping him with his insulin as opposed to medical staff
which led to him suffering a ‘HIV scare’ which his wife said was fully
investigated. The family also compared assessments carried out by the
man’s GP, before and after he was admitted to prison, which they believe
show a decline in his health.
13. More generally, the family felt that Norwich did not cater well for the man’s
basic health and social care needs as he was in a wheelchair and needed
better facilities to accommodate him. The man’s wife said that she had
urged him to demand to see a doctor when he felt unwell, but that he told
her he was afraid of repercussions if he did. She said she asked if he could
see his own GP, but was told by the prison that was not possible.
14. Finally, the family was also upset that they were not informed of the man’s
death until lunchtime the day after and are concerned about this delay.
They said that contact with the prison since his death had not always been
helpful, and they had not received some of his personal possessions back
at the time of our meeting. The concerns and questions raised by the family
are examined further in this report.
15. The investigator wrote to the chair of the local branch of the Prison Officers’
Association (POA), and to the chair of the Independent Monitoring Board
(IMB), to tell them about the investigation process, and to invite them to
meet with her should they wish to discuss any concerns or issues. They did
not wish to arrange a meeting.
16. The investigator contacted Her Majesty’s Coroner to tell him of the nature
and scope of the investigation. The Coroner provided a copy of the post
mortem report of 3 December 2004. The post mortem report recorded the
cause of death as hypertensive and ischaemic heart disease (narrowing or
obstruction of the arteries causing insufficient blood supply to the heart).
There were no signs of any injuries.
17. Norwich Primary Care Trust (PCT), arranged for a clinical review of the
healthcare provided to the man while at Norwich.
BACKGROUND INFORMATION
The man
18. The man was born in 1947, and was 57 years old when he died. He had
first been remanded into custody at Norwich in April 2002 charged with a
number of offences alleged to have occurred over a period of 20 years. He
was found guilty in July 2002 and sentenced to seven years imprisonment.
19. The man had regular contact with his family (wife and children) while he
was in Norwich prison. He was committed to an appeal against conviction
and sentence which he felt was unduly harsh. He was waiting a further
appeal hearing decision when he died, having had earlier appeals
dismissed.
HMP Norwich
20. Norwich is a multi-functional adult prison and young offender institution
(YOI) on two separate but adjacent sites. E wing and A1 landing are
vulnerable prisoner units. Healthcare provides accommodation for 28
prisoners with physical and mental health needs.
21. Norwich had an operational capacity of 823 as of 1 March 2005. The prison
accepts adult men and young offenders, Category B and Category C,
whether convicted or on remand.
22. The last full inspection by Her Majesty’s Chief Inspector of Prisons (HMCIP)
took place in July 2004, and concluded: ‘Norwich is not so much a prison as
a collection of prisons. Mostly it is a local category B prison, holding adult
men on remand or serving short sentences. It also has a Category C
training wing, for longer sentences, a separate unit for young adults (18-21),
an open Category D house for resettling low-risk prisoners and one of the
country’s only two dedicated units for older life-sentenced prisoners. At the
time of the inspection, apart from the small specialised resettlement and
older prisoners’ units, Norwich was performing none of these tasks
effectively. There were unacceptable deficits in safety and key
recommendations from seven recent deaths in custody had not been
implemented. Parts of the prison, notably in the healthcare centre and on A
Wing, were simply unfit for habitation. Custody planning for short-term
prisoners was non-existent and training for longer-term prisoners
inadequate.’
THE MAN’S TIME AT NORWICH
23. In April 2002, the man had suffered a minor angina attack at the
Magistrates’ Court, but recovered by the time paramedics arrived. On
remand into custody at HMP Norwich, a first reception healthscreen was
undertaken by a Nurse.
24. The healthscreen noted that the man had suffered a minor angina attack,
that he was blind in his right eye, had a family history of diabetes and heart
disease, and had been prescribed medication for depression. There were
letters from his GP to his solicitors dated 26 April 2001, 23 July 2001, 21
December 2001 and 15 January 2002. The letter dated 26 April 2001
confirmed that the man was an insulin dependent diabetic, had diabetic
retinopathy (blindness), ischaemic heart disease (narrowing or obstruction
of the arteries causing insufficient blood supply to the heart) and congestive
(chronic) cardiac failure. He had suffered heart attacks in 1993 and 1994
and a back injury in 1995. He had a right below knee amputation, which
had left a displaced stump so he could not wear a prosthesis and was
therefore dependent on a wheelchair. The letter dated 23 July 2001
confirmed that the doctor had not seen the man since 1 February 2001 and
he had failed to attend a follow-up appointment on 10 May. Regarding the
man’s general health, the doctor concluded that it was difficult to be precise.
He noted, ‘He has diabetes and has demonstrated several of the
complications of the condition. I am quite unable to advise whether the
man’s health is going to depreciate in the near future nor am I really able to
give you any idea of his life expectancy. In broad terms, he is very unlikely
to reach the national average age of death.’ The letter dated 21 December
2001 confirmed that since 26 July the man had attended the surgery four
times complaining of chest pain, probably stress-induced angina. On one
occasion, he had called an ambulance to go to hospital because of the
severe pain. He had a problem with the prosthesis and deteriorating vision
because of the diabetes. The doctor said, ‘His general health is
deteriorating quite rapidly and I feel the stress of a court appearance may
well induce further episodes of chest pain. He is under several consultants
but is rather erratic with attending appointments, that is a consultant
ophthalmologist regarding diabetic retinopathy, a consultant physician
regarding diabetes and a consultant surgeon regarding his amputation.’
Finally, the letter dated 15 January 2002 concluded that the man was fit to
attend court, but needed access to toilet facilities every hour and rest
breaks every two hours.
25. During his initial reception healthscreen, the man said that he was not
suicidal and did not have any thoughts of deliberate self harm. He was
admitted to the healthcare centre for observation, assessment and
treatment. There it was noted that the man’s diabetes had not been
regularly monitored, and so was to be monitored from 12 April. It was also
noted that he had been prescribed antibiotics by his GP for a leg infection
but had not taken them on a regular basis. He was to have a complete and
thorough assessment and an adjustment of his medication regime.
26. A cell sharing risk assessment was completed and he was considered as a
medium risk prisoner (that is, the risk to other prisoners would be assessed
if they were to be located in a shared cell with him).
27. On 12 April, the man had a thorough medical assessment by a doctor. He
was noted to be tearful, but he spoke to his relatives on the telephone and
was seen by a prison Listener.
28. On 15 April, the prison received a telephone call from the man’s solicitors
expressing his daughter’s concerns that he was complaining of chest pains
but that nobody had seen him. He had not complained to any member of
the healthcare staff about the chest pains. He was seen and examined by a
member of the healthcare team and said the pain had happened on 13 April
but had soon passed. There is a note in his medical record that he was to
be reviewed by a medical officer. He was subsequently seen on 18 April.
29. On 19 April, the man suffered severe chest pain and was admitted to
Hospital. He was discharged on 21 April. On 23 April, he was referred to a
consultant in Rehabilitation at the hospital, concerning his prosthesis. He
attended an appointment at the hospital on 29 April. The man was unable
to use his artificial leg as he could not extend his knee properly. The man
had been through a physiotherapy programme after the amputation and the
consultant reminded him of the exercises he needed to do to improve the
flexibility of his knee. A follow up appointment was to be arranged for six
weeks time to see if there had been any improvement.
30. On 24 April, the man’s GP sent a patient summary printout for him to the
prison doctor with an accompanying letter. The letter confirmed that the
man suffered from ongoing health problems: ischaemic heart disease,
diabetes, severe peripheral vascular disease (narrowing of blood vessels),
Dupuytren’s contracture (fingers fixed in a bent position) and congestive
(chronic) cardiac failure.
31. On 1 May, the man was tearful and said he might end it all. An F2052SH
was opened by a probation officer at the prison. (An F2052SH is a
suicide/self harm at risk form.) The man was moved to the healthcare
centre and located in a shared ward under close supervision and prescribed
antidepressants. It is not possible to establish when the man returned to
the main residential units due to an absence of completed records. The
F2052SH was closed on 4 May after a case review undertaken by
healthcare staff. The man was considered to be in a ‘natural state of
anxiety regarding his alleged charges.’ He said that he would not harm
himself as he had too much to lose: his wife, children and grandchildren.
The support plan was for healthcare staff to continue to observe his mood
and behaviour and give him the opportunity to discuss his feelings.
32. On 17 July, the man was sentenced to seven years imprisonment. He
returned to Norwich and was located on an ordinary residential wing.
Unfortunately, prison computer records only confirm his cell location from
February 2004. From July 2003 to February 2004, the man’s location has
been pieced together from paper records as far as possible. Because of the
nature of his offence, when on ordinary location the man was placed in
either A1 wing or E wing which are the wings for vulnerable prisoners.
33. On 18 July, there is a note in his medical record which states ‘fit for ordinary
location.’ On 19 July, a plan was drawn up for his care on normal location.
He was collected by healthcare staff for his insulin injection that morning
and it was noted that, because he was partially sighted, testing and insulin
injections needed to be carried out by staff. It was also noted that the man
needed to try to use his crutches. He also felt the heat, and panicked if he
felt he did not have enough air. This in turn caused chest pain for which he
needed his anti-angina medication, GTN spray. Due to fact that he had low
blood sugars at times, staff were to ensure that he had glucose or biscuits
to hand. An assessment was to be carried out over the weekend to
ascertain the best management plan with particular reference to his mobility
and diabetic needs.
34. On 20 July, the man had hot water poured on him by an unidentified
prisoner when spending a short time on E Wing. He refused to take his
insulin and said he would not take it again. There is a note in his medical
record that staff should keep a discreet but close eye on him. A nurse
explained to him that if he did not take his insulin and went into a diabetic
coma, he would go back to A1 landing not healthcare as he wanted. The
nurse noted, ‘The man was, in my opinion, trying to manipulate the situation
saying he would behave himself if he got back to healthcare. At this I
explained it was his choice to take or refuse the insulin, which he accepted.’
35. On 22 July, the then Head of Healthcare, expressed concerns about how
the incident with hot water had been managed. He wrote a letter to the
Governor, and said that the man had told him that he had obtained little help
from wing staff who just directed him to the cold tap. The then Head of
Healthcare indicated that he had previously given instructions to staff that
any scalds should be doused for 15 minutes under cold water. The man
told him that he was not sure if he wanted the police involved, and was
asked by staff to sign some paper which he could not read. He also
expressed his concerns about the man’s treatment generally on A1/E Wing
and said in his opinion that the man needed a prison with a minimum of type
2 healthcare. That is he required an establishment with 24-hour healthcare
on site, and was not considered suitable to be moved to a prison where
healthcare was only provided on a part time basis.
36. The then Head of Healthcare also documented that he discussed the issues
with wing staff and the man was on medical hold, which meant he could not
be transferred to another prison due to ongoing medical treatment. This is
the first mention of the man being on medical hold and the then head of
healthcare subsequently removed him. He concluded that the healthcare
team would need to discuss the man’s health needs with the healthcare
team of the next establishment before any transfer could be considered.
37. On 24 July, the man was moved to a larger cell on A Wing and noted to be
reasonably mobile. There is a note in his medical record that a landing
officer and the Observation Classification and Allocation Unit (OCA) were
dealing with a possible transfer for him. There is no mention of where he
was to be transferred to. A doctor (signature illegible) said that a case
conference did not appear appropriate but that any further problems would
be discussed.
38. On 26 July, the chaplain wrote a letter to the Governor about the man’s
location and treatment on A Wing. She copied the letter to the then Head of
Healthcare. She said, ’I am very disturbed and distressed at the conditions
in which this man is having to live. He has one leg amputated and
consequently he depends on a wheelchair. In the healthcare centre he had
adequate room to manoeuvre and facilities for showering etc. In A Wing he
is in a cell with no room to manoeuvre his wheelchair, to get to the lavatory
or to get out of the cell, there is a step. Because of newspaper coverage
about his case he ... has received abusive behaviour from others on Rule
45 and he has also been attacked with boiling water. He is unable to
shower. It seems now to be the case that in light of the attack, he is locked
up all the time.’
39. That same day, the man submitted a complaint because he had missed a
clinic appointment for his leg because the taxi did not turn up. There is no
record of the prison’s response to this complaint. There is a written note on
the application which states, ‘healthcare staff please inform inmate of
situation’, and another entry states, ‘For attention of landing staff.’
40. On 1 August, it was decided that the man needed to have his testicles
drained of excess fluid and referral to hospital for surgical treatment. This
was subsequently done.
41. On 5 August, the man swallowed a number of painkillers which had been
prescribed for him and which he had stored up. He told staff that he had
subsequently been sick. An F2052SH was re-opened by an Officer. The
man was seen by healthcare staff and his observations were noted to be
normal. He remained on normal location in a shared cell. On 6 August, he
spoke to two different Listeners. He said he was content on normal location
and had no intention of harming himself.
42. On 7 August, an F2052SH review was undertaken and a detailed support
plan was implemented for the man. He said that he felt isolated and lonely
and had nobody to talk to. He added that he could not accept that he was
guilty and had lost his family. He wanted to be transferred to HMP Littlehey.
The support plan was for the man to have regular contact with a prison
visitor and to use a radio as a source of escapism. Wing staff and
Listeners/Samaritans were to offer support, and the OCA was to look at
transferring the man to Littlehey. A Senior Officer wrote a letter to the
Deputy Governor. He said that the man’s health had deteriorated since
being released from healthcare and he asked whether the man could be re-
admitted, not for health reasons but to talk to other prisoners. He noted that
the OCA was having trouble allocating him to another prison due to his
disability and diabetes. The man also made a complaint about his location
on A wing, saying it was not suitable for a disabled prisoner and that he was
not allowed to have his GTN spray for angina in his possession. The
complaint was referred to healthcare and the Governor for consideration. It
has not been possible to establish if there was a written reply to the
complaint.
43. On 8 August, the then Head of Healthcare wrote to the chaplain agreeing
with her memo to the Governor (26 July). The then head of healthcare
agreed with the chaplain’s concerns about the facilities for disabled
prisoners at Norwich, particularly those on Rule 45. The man spoke to a
Listener that day. On 9 August, there is a note in the man’s medical record
that it was hoped he would be transferred to a more appropriate prison. He
was also relocated to healthcare.
44. On 11 August, there was a plan to encourage the man’s mobility and
independence. He was still waiting for his new prosthesis and was
therefore re-referred to the clinic for assessment. There is also a note that
he was unable to see well enough to test his blood sugars or draw up his
own insulin. A care-plan was drawn up for the man to use his crutches on a
daily basis - gradually increasing the length of time - and to be referred for
remedial physiotherapy. Staff were to perform blood sugar tests and set his
insulin pen at the correct setting for him to self-administer. Staff were also
to encourage him to care for his own hygiene needs, make his own bed,
and to keep his environment clean without over-exerting himself.
45. The man attended the limb clinic on 12 August. There is a letter from the
then head of healthcare to the Deputy Governor, ‘Important that the man is
moved to a more appropriate prison. Confining him to a Health Care centre
may only compound the problem, making it difficult for him to be transferred
to another prison. It may well be perceived that the man has health
problems which prevent him from leaving Health Care. If you really do have
difficulties in providing for the man in the adult wing then my comment
would be is there any possibility that he could be admitted to the
Segregation Unit. The Seg has modern facilities which are well suited to
the man’s particular disabilities. Alternatively the man could be
accommodated within the ground floor of B and C Wing which also has
modern facilities. I will leave it for you to discuss the various options with
the man himself.’ The Deputy Governor confirmed to my investigator that
during August 2002 he discussed the man’s case with another senior officer
who worked for him at that time in Norwich. Unfortunately, neither man
could recall this specific case. The Deputy Governor confirmed that any
concerns raised by the Medical Officer would have been case managed by
the Operational Residential Management team in order to ensure the most
appropriate location to meet the individual’s needs, security and the prison’s
overall duty of care. The Deputy Governor explained that E wing (where the
man spent the majority of his time, apart from when he was located in the
healthcare centre) was at that time a small unit caring for approximately 40
vulnerable prisoners in single, double and dormitory style accommodation.
He said that all prisoners in that unit were thoroughly risk assessed prior to
location and he confirmed that the ground floor accommodation, where the
man was located, did accommodate people with disabilities.
46. On 14 August, the F2052SH was closed following a review undertaken by
members of healthcare staff. On 16 August, the man was seen by the
Governor, regarding his application of 7 August. By this time, it appears the
man had been relocated to healthcare, was waiting for a new artificial limb
to be fitted and still hoped to transfer to Littlehey.
47. On 17 September, the man returned from an eye clinic appointment. He
was distressed as he had been told he might go blind. On 19 September,
the man returned to the limb clinic.
48. On 30 September, there is a note in the man’s medical record that he was
back to his cheerful self and helping around the healthcare ward. On 10
October, he again attended an appointment at the limb clinic.
49. On 4 December, the medical record notes he was to be referred to the
diabetic clinic in the first week of January 2003.
50. The man attended the limb clinic on 12 December. A letter from the
consultant, dated 23 December, says that attempts to fit a prosthesis for
him had been unsuccessful. He did not require further surgery but it was
noted that he was to continue using his wheelchair. The man was low in
mood on 24 December because of Christmas. He was reassured by a
nurse. He was again noted to be low in mood on 29 December. On 30
December, it was reported in his medical record that he had improved and
was more relaxed and more social.
51. The man was referred to the Diabetic clinic on 3 January 2003. He
attended his first appointment there on 15 April.
52. On 7 January, the man attended the eye clinic and was said to be low in
mood following his appointment. He was reassured by a member of
healthcare staff (signature illegible). On 16 January, it was noted in his
medical record that he had not been referred to the Physiotherapy
Department, as the doctor wanted him to go to the Diabetic clinic first and to
deal with his problems one at a time.
53. On 24 January, the man had a visit from his daughter which had a positive
effect on his mood. On 7 February, there was an incident between the man
and another prisoner. It is not clearly documented in the man’s records
what this was about, but it appears that he was threatened by the other
prisoner. On 8 February, he was seen by a nurse in his cell as he was
upset about the incident. He believed his food was being tampered with
and refused to eat it. He was reassured by the nurse and landing staff that
they would ensure that his food had not been tampered with. The man
refused to identify who had threatened him.
54. On 9 February, the man said he had diarrhoea early in the morning.
Initially, he refused to take his insulin and oral medication as he said he had
been warned by another prisoner against eating, drinking or cleaning his
cell. He believed his diarrhoea was caused by someone doctoring his food
or drink. He was again seen by the nurse and the landing staff and told
them that cleaners had been told to ignore him. Staff explained to him that
none of that was true and that he must eat and take his medication, which
he eventually did.
55. On 10 February, the man asked members of staff to read a letter from his
wife as he believed that the letter had not been written by her but by a
member of prison staff. An officer and Healthcare Officer read the letter and
compared it with other letters. They considered the letters all had the same
handwriting and style, and in their opinion were written by the same person.
56. On 24 February, the man attended another appointment at the eye clinic.
The man was referred to the Physiotherapy Department on 4 March.
57. On 14 April, the man was told by a member of healthcare that he was to
return to E wing when there was a place available. He was upset at going
back to A1 or E wing, as he said he was abused there before, but he
reluctantly accepted the move. He completed a formal complaint form as
he had been unhappy with the previous accommodation on A Wing. He felt
that the cell was too small, and said he had not been allowed to go on
exercise and had spent three weeks inside his cell. He said that E Wing
was not too bad in comparison and had more space and he could at least
get some exercise in his wheelchair. He was seen by a Senior Officer who
explained that he had to move on and return to E Wing, but the lift on E
Wing was out of order. The man later told a member of healthcare that he
had been trained to manage stairs so the physical aspects of A1/E wing
should not be a problem. He started eating and taking his insulin again.
The man attended a Physiotherapy appointment. This is not recorded on
his movement history, but a letter dated 14 April confirms that he was seen
at hospital.
58. On 15 April, the man attended a Diabetic clinic appointment and was
referred to the ophthalmologist and podiatrist. The consultant’s letter
following the appointment noted that the man had perfect control of his
diabetes. On 17 April, the man’s sister-in-law died. He was seen by the
chaplain and told that he would not be sent back to E Wing at that time.
59. On 22 April, the man telephoned his wife. It was noted that he seemed
cheerful after the call. On 23 April, he was referred to see if the doctor
would again drain his testicles of excess fluid as had been done in August
2002. On 8 May, the GP at Norwich, wrote a letter to the surgical
outpatients department at the hospital about the possibility of a surgical
procedure being undertaken after excess fluid had recurred following
treatment in August 2002.
60. On 21 May, there is a note that the man was on ‘medical hold’. He should
not be transferred to another prison until he attended his appointment at
surgical outpatients for treatment - unless his transfer was to HMP Wayland,
a prison which specifically holds vulnerable prisoners. As the man’s health
deteriorated, he was placed on medical hold again. The prison has
confirmed that OCA had no paperwork or plans to move him. He had by
this time been located in the healthcare centre since August 2002.
61. On 22 May, there is an e-mail from a residential governor for A and E wings,
to a member of staff who works in the administrative section within
probation for the ultimate attention of another member of staff, a Probation
Officer. The residential governor had received a letter from the man’s
solicitors saying he wanted to stay in the healthcare centre. The solicitors
threatened Judicial Review if the man was moved from healthcare. There
was also a telephone call from the man’s son who was concerned about his
father’s welfare as he believed his father was going blind. The man’s son
seemed happier about the situation when the prison spoke to him. He
asked if his father could phone his daughter and that message was relayed
to his father. On 25 May, the Duty Governor spoke to the man about the
reasons for transferring him to ordinary location and said he was still waiting
for a place for him on E wing. The reasons for transferring the man to
ordinary location are not documented.
62. On 27 May, the man attended an appointment at the eye clinic. On 30 May,
he attended an outpatient’s appointment for assessment of his right eye
cataract. Surgery was scheduled for 17 November to remove the cataract.
63. According to his movement history, the man attended hospital appointments
on 10 July and 16 July. It is not clear from his medical record what these
appointments were for.
64. On 22 July, the man was spoken to on E wing by a member of healthcare
staff. There were concerns that he appeared to be low in mood as his
wheelchair could not go through the cell door, but he declined offers of help.
He did not have any sweetener which he needed as a diabetic and his sink
had not been mended. He said he generally felt uncared for and was
finding the prison environment difficult to handle. He felt vulnerable in the
wheelchair and was concerned for the safety of his medication. He also
said he felt as if he was begging when he asked others to get hot water for
him. A care-plan was drawn up for him. He was to be encouraged to talk to
staff, regarding any practical day to day problems. Healthcare staff were to
ensure that his insulin was given to him at the appropriate time in the
morning and that the evening dose was correctly drawn up for him to
administer. An appointment was made for him to see a doctor.
65. The man made a formal complaint, received by the complaints clerk on 22
July, about his location on E wing. He complained that the room where he
was located was too small for him and his cellmate and that he could not
get out through the door unless he got out of his wheelchair. He
complained that he had to rely on other prisoners to set his insulin to the
correct measure and to collect his food for him. (My investigator has found
no evidence of this.) The man said he felt he was better looked after and
more mobile when he was located in healthcare.
66. On 4 August, the man was seen by a doctor on E wing as he collapsed
twice and was anxious and agitated. He was admitted to healthcare for
assessment of his diabetic and other medical needs, including possible
depression. He was to be monitored and if stable would be able to return to
normal location that night or whenever appropriate. It is not clear from the
man’s records when he returned to normal location. It is noted that he
attended a urology appointment on 6 August.
67. According to his movement history, the man attended a hospital
appointment on 20 August. It is not clear from his medical record what the
appointment was for. On 26 August, he attended an eye clinic appointment.
According to his movement history, he attended another hospital
appointment on 4 September. Again, it is not clear from his medical record
what the appointment was for.
68. On 19 September, the man attended healthcare for drainage of a hydrocele
which was carried out on 2 October. On 13 October, he asked for a urology
appointment scheduled for 17 October to be cancelled as he said he
wanted to concentrate on his appeal. This was done.
69. On 28 October, the man attended a follow-up appointment at the Diabetic
clinic. The consultant wrote to the prison and commented that his diabetes
control was excellent. However, he raised concerns expressed by the man
that nobody in the prison was monitoring his blood sugar which he could not
do for himself as his eyesight was poor. The prison responded on 14
November, explaining that the man in fact had assistance from a nurse to
take his insulin.
70. On 30 October, the man attended an appointment at the foot clinic. On 12
November, he attended the eye clinic for a cataract assessment before the
cataract surgery scheduled for 17 November. On 17 November, he
underwent a right cataract extraction. After the surgery, he attended review
appointments at the eye clinic on 25 November and 12 December.
71. On 1 December, there is a note in the man’s medical record that his
medication had disappeared. Healthcare were able to get some of his
medication but not his blood pressure tablets. He was given what
medication was available and the pharmacy dispensed the rest on 2
December.
72. On 4 January 2004, the man submitted a formal complaint listing dates
when he had not received his medication. The Deputy Healthcare
Manager, replied to the complaint on 28 January, having spoken to the man
about it on 27 January. He said, ‘I met with you on the 27th to discuss your
complaint. I agree that it was unacceptable that nobody came to see you
on several occasions. You told me recently that you have had no problems
and are happy with the treatment you are getting. If there is a re-
occurrence in that you are not seen again please will you ask one of the
wing officers to contact me.’
73. On 5 January, it was noted that the man was stressed and worried about his
forthcoming appeal. He attended an appointment at the foot clinic on 6
January. On 12 January, the prison received a request from the Criminal
Appeal Office for a report on the man’s medical condition. A report was
forwarded as requested on 28 January. On 14 January, the man was
referred to the genito-urinary clinic as the fluid in his testicle was getting
worse.
74. On 2 February, there is a note in the man’s medical records that he wrote a
letter, which was subsequently intercepted, in which he said he had not
eaten or taken his insulin for two days. After discussion between wing staff
and healthcare staff, it was concluded that he was possibly trying for a
move to healthcare and had in fact been seen taking his insulin that
morning.
75. On 12 February, the man’s appeal against conviction was dismissed and his
application to appeal against sentence turned down. The man refused to
take his medication.
76. On 14 February, an F2052SH was opened by an officer as the man said he
was going to refuse to eat and take his insulin. After explanation of the
consequences of that course of action, he was noted to have said he did not
want to harm himself and just felt depressed because his appeal had been
denied and felt that nobody was listening to him. The F2052SH was closed
on 16 February following a review. The man was eating again and advised
to seek legal advice about his appeal. He said he had no thoughts of self
harm. The support plan was for the man to use the Listener scheme and
staff support. On 24 February, he attended the foot clinic.
77. On 7 April, the man submitted an application for access to healthcare for a
minor operation on his testicles. He also complained that his right arm was
numb. On 14 April, the prison received a letter from the urology department
asking whether the man still needed to be on their waiting list. On 16 April,
a prison doctor replied to the urology department asking about the
possibility of the man now having an operation to assist with his problem of
fluid on the testicles (the original appointment on 17 October 2003 having
been cancelled so that the man could concentrate on his appeal).
78. The man attended an appointment at the diabetic foot clinic on 23 April. On
5 May, the complaints clerk received a formal complaint from the man that
he was no longer receiving items as part of his diabetic diet. He said he
had not had milk, flora, sweetener, or jam for three weeks. The complaints
clerk responded on 7 May that he would find out what had happened to
these supplies.
79. On 6 May, the man was confirmed as being on the waiting list for a urology
appointment. On 11 May, the man complained about continued pain in his
testicles. The next day, he saw the doctor who drained the excess fluid.
On 16 May, the man made an application for access to healthcare for
trouble he was experiencing with his hands. He was referred to the doctor
on 19 May. On 27 May, he complained of chest pains and shortness of
breath. He was admitted to healthcare for observation and treatment for a
chest infection. It was noted in his medical record that he wanted to go
back to E wing. He therefore returned to E wing the same day.
80. On 15 June, the man attended the Diabetic clinic for an annual review of his
condition. The consultant was concerned that he was not monitoring his
blood sugar levels and had poor diabetic control. According to his
movement history, the man attended a hospital appointment on 18 June.
Again, it is not clear from his medical record what this appointment was for.
81. On 22 June, the man spoke to his grandchildren. This was in breach of
Prison Service Order (PSO) 4000 as he was not allowed to contact any
child under the age of 18 due to the nature of his offences. (His telephone
calls were being monitored for that reason.)
82. On 24 June, the man submitted an application for access to healthcare due
to anxiety attacks. There is no record that he actually saw a member of
healthcare.
83. On 5 July, the man submitted a formal complaint. He alleged that he was
being victimised (presumably by staff) because of his disability. The issue
was discussed with him on 6 July by a Senior Officer (SO). The conclusion
was that the man was feeling down when he wrote his complaint and no
discrimination was found on the grounds of disability. The man decided he
did not want to pursue the complaint. On 7 July, the man asked whether his
grandchildren could be allowed to contact him. This was not allowed due to
PSO 4000.
84. On 21 July, a re-categorisation board was held to consider the man. It was
decided that he should remain a Category C prisoner. He was put on
medical hold again. It is noted that he had a superficial cut to his left wrist.
He was seen by a doctor and the wound was dressed.
85. The man attended an eye clinic appointment on 5 August. On 6 August, it
is known that he attended the dermatology department in hospital. This is
not recorded on his movement history.
86. According to his movement history, the man attended a hospital
appointment on 14 September. It is not clear from his medical records what
this appointment was for.
87. On 22 September, the man submitted an application for access to
healthcare. He complained that his left leg was swollen and his finger joints
were sore. He saw a doctor on 29 September. There was a plan to admit
him to healthcare for intensive blood sugar monitoring for a couple of days
and then for him to attend the diabetic clinic. It was also planned to drain
the fluid on his testicle while he was in healthcare.
88. On 7 October, the man was seen in healthcare complaining of a heavy cold.
On 11 October, he was admitted to healthcare for blood sugar monitoring.
A ‘patient manual handling risk assessment’ was completed concerning his
use of a wheelchair. The conclusion was that the man was self-caring and
independent by means of a wheelchair. No review date was set.
89. According to a letter from the consultant, the man was seen in the eye clinic
on 12 October. This is not recorded on his movement history.
90. On 15 October, a doctor decided not to drain the excess fluid again in
prison and wrote a letter to the urology department at the hospital to pursue
an appointment for surgery. On 16 October, there is a note in the medical
record to say that the man might return to E wing on 18 October and that he
was in fact keen to return there.
91. On 20 October, the man returned to E wing. On 22 October, the man’s
solicitors wrote asking for a letter from healthcare outlining his healthcare
issues and treatment received while in Norwich.
92. Norwich sent a medical report to the man’s solicitors on 28 October. On 5
November, the man asked again for his testicle to be drained as he had
requested a month previously. On 6 November, he made a formal
application to access healthcare for a variety of problems, namely the
problem with his testicle, phlegm on his chest and a swollen leg. He saw a
doctor on 12 November. On 16 November, the man attended the diabetic
outreach clinic.
93. On 24 November, the man was admitted to the hospital’s urology
department for the operation on his testicle. He had the operation on 25
November. He returned to Norwich on 26 November and was located on E
wing. Late that day, he was taken to the treatment room as he was in
severe pain following his operation, was having difficulty breathing, and
appeared to be anxious. His wound was cleaned, he was reassured and
his breathing soon returned to normal. On 27 November, he was again
seen by a member of healthcare staff. He was still experiencing difficulties
after his operation and the wound was still oozing. After discussion with the
doctor, it was decided to admit him to healthcare for a full assessment of the
wound. He was admitted on 27 November and located in H2-17, a
dormitory for five patients. There is a note in the care plan record by a
Healthcare Officer that the man attended an outpatient’s appointment in the
afternoon and appeared stable. There is no record of this on the man’s
movement history.
94. On 28 November, the man complained that he had not been sleeping well
for weeks before his operation. He was quoted as telling a nurse, ‘I don’t
know how I can cope. I feel as though my head is telling me one thing and
my body is saying something else.’ The nurse felt the man was low in
mood, and this was more serious than the trouble adjusting which might be
expected after an operation. He was reluctant to be prescribed sleeping
tablets but said he would welcome somebody to talk to. He was in
discomfort following his operation and his stitches were checked by a
Healthcare Officer. That evening, the man asked to speak to a nurse about
increasing fluid around his back and a general feeling of sickness. He was
seen by a nurse who found him to be of low mood and tearful. He was
referred to see the doctor on 30 November. He actually saw the doctor on
29 November and was prescribed Co-codamol for the pain. The following
day he was noted as being more settled and feeling much better. The Co-
codamol was continued. However, his health deteriorated that evening.
EVENTS OF 30 NOVEMBER
95. On 30 November, at about 8.10pm, a Healthcare Officer was alerted by the
other patients in H2-17 dormitory banging on the window that the man
needed assistance. Before entering the ward, the healthcare officer called
for help from a nurse. The Healthcare Officer then went into the ward and
saw the man sitting in his wheelchair, his head thrown back and gasping for
breath. The Healthcare Officer called out the man’s name and tried to get a
response by shaking his shoulder and patting the side of his face. The man
then caught his breath and his head moved forward, and he appeared to be
orientated for a moment and made eye contact. He then threw his head
back again and began gasping for breath.
96. The nurse had joined the Healthcare Officer in the ward. The nurse then
left and called for an ambulance. She went back into the ward and helped
the Healthcare Officer to move the man from his wheelchair to the floor.
They were then joined by a senior nurse. The nurse and the senior nurse
checked for a pulse but there was nothing.
97. At 8.15pm, a senior officer responded to an urgent radio message for a
Code 2 emergency in healthcare. He contacted the communications room
to summon more assistance, informed the Deputy Governor, checked on
the ambulance response, and cleared the other three prisoners from the
ward along with two other prisoners who were within sight of the ward and
relocated them to the education room. The nurse and Healthcare Officer
commenced cardiopulmonary resuscitation (CPR) at about 8.15pm. The
Healthcare Officer gave two rescue breaths and the nurse started chest
compressions. The senior nurse took over mouth to mouth resuscitation
from the Healthcare Officer with no apparent effect. The Healthcare Officer
then went to fetch the defibrillator from the clinic room. He returned and
placed the pulse/oxygen meter on the man’s finger. He then took over the
mouth to mouth resuscitation from the senior nurse who set up the
defibrillator.
98. The nurse and Healthcare Officer continued with CPR while the defibrillator
analysed the man’s heart rhythm. The senior nurse shocked him twice but
it had no effect. She continued to direct the nurse and Healthcare Officer
with the CPR while she monitored the defibrillator. Paramedics arrived at
approximately 8.25pm and took over CPR until approximately 8.45pm when
collectively they decided to stop the resuscitation.
CLINICAL REVIEW
99. In accordance with procedures agreed with the NHS, the investigation team
advised Norwich Primary Care Trust (PCT) of the man’s death. The PCT
then arranged to undertake a clinical review of the healthcare provided to
the man while at Norwich. The review notes that the man had numerous
physical ailments which appear, in the main, to have been managed
effectively by a multi-disciplinary team of prison doctors and nurses - with
appropriate specialist advice and help when required. The review
concludes that the man’s medical management was appropriate and all
medical areas of care were considered and follow up interventions were
arranged. The information from the man’s GP indicates that his health was
poor before he was located in prison. The man had not seen a diabetic
specialist prior to his imprisonment and the review explains that, following
reception to Norwich, the man’s diabetes was better managed, as was his
heart condition.
100. The clinical reviewer states, ‘By tracking his progress through each
speciality one can see evidence of stability and improvement in that area
where it would reasonably have been expected to have taken place.
Similarly, the incidents of anxiety appear to have subsided over time.
Because of the chronic nature of the man’s conditions it would be expected
that there might be both regressive changes and intermittent fluctuations.
At appropriate times he was located in healthcare. This might be seen as
deteriorations in his health, but the long term picture appears to be one of
effective clinical management. For these reasons I believe the man’s health
improved during his stay in HMP Norwich.’
101. The man had an operation on 25 November when fluid on his testicle was
drained. He was discharged on 26 November. The clinical reviewer
concludes that an early discharge from hospital would have been based on
the clinical need as assessed by the hospital and not something which
would have been decided by the prison.
102. The review notes that not all written medical submissions are legible -
including notes in the man’s Medical Record - and that his medication notes
are incomplete.
103. In relation to the emergency on 30 November, the clinical reviewer
concludes that appropriate action was taken by medical staff to try and help
the man.
FAMILY CONCERNS
104. The family’s concerns about the man’s clinical care while in Norwich have
already been addressed. As far as my investigator is aware, the man’s
family have now received all his personal possessions apart from the 2004
diary which the prison has been unable to find.
105. The man’s family are concerned that they were not advised of his death
until the next day. According to prison records, the man had nominated his
daughter as his next of kin. There is no other address or contact number
listed. At the time of the man’s death, the local protocol for HMP Norwich
was to inform the local police nearest to the next of kin to inform them of a
death in custody. The man’s daughter was therefore contacted by the
police and advised of her father’s death. This is no longer the case and the
local protocol at Norwich is now for the prison to contact the next of kin in
these circumstances. (As I note below, I strongly welcome this change.)
CONSIDERATION AND CONCLUSIONS
106. The man’s health was clearly poor before he arrived at Norwich in April
2002. He required the use of a wheelchair, and had problems associated
with diabetes, leading to significant visual difficulties, and a below the knee
amputation. He also suffered with heart disease. While in prison, he was
treated for swelling of his testicles.
107. This report has set out in some detail the medical treatment that the man
received while he was in Norwich. Each of his physical disorders appears
to have been effectively managed. His occasional low moods were
identified, and in May and August 2002 and February 2004 concern was
such that he was subject to suicide prevention procedures. There were
occasional areas of difficulty in his medical care – for example, there is a
record of an outpatient appointment being missed in July 2002, there was
an incident of scalding that same month that does not appear to have been
well handled, and in December 2003 there was a problem getting the man
all his medication. But overall it would seem that he did receive appropriate
medical treatment. This view is supported by the clinical review. The
clinical reviewer states, ‘Concerning his medical management it is my view
that the man was appropriately treated. All medical areas of care were
considered and follow up interventions arranged.’
108. The man complained that other prisoners assisted him to take his insulin.
There is no documentary evidence that this was the case. On the contrary,
the medical record shows that the man was assisted by nurses to
administer his insulin.
109. Both my investigation and the clinical review have identified some problems
with record keeping. Hospital appointments were not all documented on the
man’s movement history record. Not all written medical submissions are
legible and the man’s medication notes are incomplete.
Healthcare staff should be reminded of the need for clear, concise and
contemporaneous record keeping in accordance with the NMC
guidelines for records and record keeping. A clinical audit system must
be put in place to monitor compliance with standards for records and
record keeping.
110. The man’s complex physical health were such that caring for him in prison
was challenging. He spent much of his time in healthcare. The man
encountered significant problems on the main residential wings, mainly due
to his inability to move around. It is apparent that he was much happier on
E wing than on A wing as the cells are larger. However, there is no audit
trail concerning any discussion which was had about transferring him to
another prison, despite references to discussions between various staff
members about this issue.
The Governor should remind all staff of the need to ensure that
contemporaneous prisoner records are maintained and updated
particularly to reflect decisions taken or considered and all prisoner
movements.
111. The local police delivered the news of the man’s death to his daughter
according to the local protocol at the time. My strong preference is that,
wherever possible, a senior manager from the prison where a prisoner has
died should break the news to the family. Where this is not possible,
consideration should be given to asking a senior manager from a prison in
the nearby area to visit the family and break the news. The Prison Service’s
newly revised guidance Liaison with Bereaved Families Following a Death
in Custody (Prison Service Order 2710) explores these issues. It
recommends that the news is broken to a family as soon as possible after
the death, face to face, by a dedicated Family Liaison Officer, along with the
chaplain, Governor or most senior individual available. It is welcome that
Norwich has a new local protocol reflecting these arrangements.
112. The man was clearly very ill prior to his location in Norwich. I note the views
of the clinical reviewer that his health actually improved while there.
113. I consider that on 30 November 2004 all appropriate action was taken by
medical staff to try and help the man.
RECOMMENDATIONS:
OPERATIONAL:
The Governor should remind all staff of the need to ensure that
contemporaneous prisoner records are maintained and updated particularly to
reflect decisions taken or considered and all prisoner movements.
HEALTHCARE:
Healthcare staff should be reminded of the need for clear, concise and
contemporaneous record keeping in accordance with the National Medical
Council guidelines for records and record keeping. A clinical audit system
must be put in place to monitor compliance with standards for records and
record keeping.
The Prison Service has accepted all the recommendations. There were no
comments from the man’s family.