Individual at Parc

Investigation into the circumstances surrounding the
death of a man at HMP Parc in June 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
April 2007
This is the report of an investigation into the death of a man who was a prisoner at
HMP Parc. The man died in the prison’s healthcare centre on 11 June 2006. He
was 49 years old. A post mortem recorded the cause of death as
bronchopneumonia due to carcinomatosis due to carcinoma of the lung.
I offer my sincere sympathy and condolences to all of the man’s family and friends
for their sad loss.
The investigation was carried out on my behalf by one of my colleagues. An
independent review of the man’s medical care in prison was carried out by the
Healthcare Inspectorate Wales. I am most grateful to the reviewer for her
assistance.
I would also like to thank the Director and staff of Parc for their full and ready co-
operation during the course of the investigation.
The clinical reviewer commends healthcare staff at Parc for the consideration and
support they provided for the man. I concur with her view. This is a report that
reflects well on all staff at Parc for the kind and respectful way in which they cared
for the man.
I make two recommendations and also highlight one example of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2007
2
CONTENTS
Summary
The Investigation Process
HMP Parc
Key Findings
Issues
Recommendations
3
SUMMARY
The man was received into HMP Cardiff on 4 May 1998 as an unconvicted prisoner.
He was sentenced to 15 years imprisonment on 16 April 1999.
The man raised no concerns at his reception health screening, other than that he
had suffered from inflammation of the vertebrae in the past. On 1 June 2000, he
was diagnosed with high blood pressure. He reported various stomach and back
pains during his first seven years in custody.
On 5 May 2006, the man attended the healthcare centre at Usk and complained of a
lesion to the right side of his neck. He was reviewed on 10 May, and it was noted
that the lesion was two to three centimetres in diameter. An appointment was made
for a biopsy at the Royal Gwent Hospital, Newport, on 17 May.
At his appointment, the man told the consultant that he had been suffering from
stomach and back pains for five weeks and had lost weight. The consultant
suspected that the man had cancer of the stomach and discussed this with him. The
results of the biopsy, a week later, confirmed an adenocarcinoma (a cancer of a
gland or glandular tissue, or in which the cells form gland-like structures).
Following his provisional diagnosis, the man transferred to Parc on 19 May. This
meant he would be able to receive 24 hour inpatient care in the prison’s healthcare
centre. He began to feel nauseous on a regular basis, was eating little and
continued to lose weight. His pain was well controlled through adjustments to his
analgesia (pain relief) on 19 May whilst still at Usk, and on 29 May when in Parc.
In June, the man’s health worsened, although his pain continued to be well
controlled. Following discussions with the Probation Service, his children were
informed of his illness by a social worker on 9 June. Sadly, the man continued to
deteriorate and, at around 7.12am on 11 June, he was found to have stopped
breathing by a member of the nursing staff. In accordance with an instruction given
four days previously, cardio pulmonary resuscitation (CPR) was not attempted.
The clinical reviewer commends healthcare staff at Parc for the considerate care
they provided for the man. She makes a recommendation with regard to a hospital
appointment which the man missed due to a breakdown in communication with the
hospital following his transfer. I make a further recommendation regarding contact
with the man’s family.
4
THE INVESTIGATION PROCESS
The investigation was opened on 13 June 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 was given 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 Investigations Manager at the Healthcare Inspectorate Wales.
One of my family liaison officers contacted two of the man’s children, on 15 June
2006. His daughter expressed concern that, when she was told of her father’s
illness on 9 June 2006, the seriousness of his condition was not explained to her.
5
HMP PARC
Parc is a modern category B local prison on the outskirts of Bridgend. The prison
opened in November 1997 and is the only private prison in Wales. It is managed by
Group 4 Securicor Justice Services (G4S), and has capacity for 839 male prisoners.
The provision of healthcare within the prison is the responsibility of Primecare
Forensic Medical Services. They employ a team of three doctors and 25 nurses and
provide a 24 hour primary care service. The in-patient ward area has 17 beds, all
with integral sanitation. The latest report from HM Chief Inspector of Prisons, dated
9-13 January 2006, describes a good therapeutic and structured environment for in-
patients, with a very high level of respectful and constructive contact between staff
and patients.
6
KEY FINDINGS
The man was received as an unconvicted prisoner at HMP Cardiff on 4 May 1998.
At his reception health screen (a routine health screen for all new arrivals into prison)
on the same day, the man said that he had suffered from spondylitis (inflammation of
the vertebrae) but reported no other concerns about his physical or mental health.
Following his reception to HMP Maidstone on 28 May 1999, around one month after
the man had been sentenced to 15 years imprisonment, he said that he had
previously been a very heavy drinker.
During his first seven years in prison, the man complained of various back aches,
stomach pains and infections, each of which was dealt with at the time. On 1 June
2000, he was diagnosed with hypertension (high blood pressure) and subsequently
prescribed bendroflumethiazide to treat this. The man received monthly checks on
his blood pressure following this diagnosis. In the spring of 2002, he began one to
one sessions with a psychologist, in a bid to address his offending behaviour.
On 24 May 2005, the man transferred to Usk, having spent time at HMP
Wandsworth and HMP Parc in the previous two years. His history of hypertension
was recorded at his reception health screening. At a hypertension clinic on 3
January 2006, the man’s blood pressure was noted to be rising. He was prescribed
lisinopril, in addition to bendroflumethiazide, to control this.
On 20 March 2006, the man attended the healthcare centre complaining of
shortness of breath and pain in his lower back. He also complained of coughing up
frothy sputum. The man’s blood pressure and pulse were taken, and he was
escorted back to his cell. He was reviewed 15 minutes later, when it was noted that
he was less short of breath. However, later that day the man’s shortness of breath
increased. He was sent to the Accident and Emergency Unit at a local hospital for a
review. The man returned to Usk the same day, having been diagnosed with a chest
infection. He was prescribed amoxicillin (an antibiotic) by the prison doctor.
On 5 May, the man attended healthcare and complained of a lesion on the right side
of his neck. He was prescribed a course of erythromycin (another antibiotic) and
advised to return for a review if it did not settle. At a review on 10 May, it was noted
that the lesion was now two to three centimetres in diameter. The man was
subsequently referred to a larger hospital on 12 May, and an appointment was made
for him to return on 17 May for a biopsy.
The man was seen in Usk’s healthcare on 15 May. The lesions were now reported
to have spread to both sides of his neck, his back and his right arm. He attended the
hospital for his biopsy on 17 May and was seen by the Consultant ENT and Head
and Neck Surgeon. As well as the lesions, the man told the consultant that he had
had stomach and back pains for the last five weeks and was losing weight. The
consultant suspected a stomach malignancy (cancer of the stomach), and discussed
this with the man. The man then returned to Usk. The results of the biopsy, a week
later, showed a moderately differentiated adenocarcinoma (a cancer of a gland or
glandular tissue, or in which the cells form gland-like structures).
7
The man was reviewed in healthcare on the morning of 18 May. He was very upset
about the thought of having cancer. He said that he was not eating, as he felt
nauseous and was vomiting after eating solids. As a result, he was encouraged to
take Fortisip (a dietary supplement drink). The man was also having difficulty
walking due to his pain, which was noted to be uncontrolled. He saw a prison doctor
the following day and was prescribed MST continus (a morphine based slow release
painkiller).
Usk is a small prison with no in-patient wing and only a part-time doctor. As a result,
healthcare staff decided that they would be unable to provide the level of care and
assistance required by the man following his diagnosis and increasing pain. A
transfer to Parc was therefore arranged following the review on 18 May, and the man
transferred on 19 May. On arrival at Parc, he was located in the healthcare centre
as an in-patient and a full care plan was written by the healthcare team. The care
plan contained five objectives: to maintain the man’s hygiene standards; to maintain
intact pressure areas of skin; to reduce sickness; to reintroduce diet; and to control
pain.
The man’s pain was quite severe on 20 May, although he was able to walk around
the wing unaided during association. His pain had reduced the following day, and he
became more settled and talkative over the next couple of days. On 24 May, he
attended the hospital for a CT scan, but missed an out-patient appointment on the
same day because the hospital had sent the notification to Usk rather than to Parc.
That appointment was re-scheduled for 31 May.
The man’s pain began to increase again over the next few days. He was also feeling
nauseous and not eating very much. By 29 May, his pain was severe and he was
vomiting frequently. A prison doctor, was contacted in the evening and gave a
verbal instruction for diamorphine to be administered.
Following a further biopsy on 31 May, the man was diagnosed with an advanced
malignancy. In a telephone conversation on 1 June, a Consultant in
Gastroenterology advised about palliative care (symptom control was the only
possible way forward given his diagnosis). A referral to the Palliative Care
Consultant at a nearby hospital was made on 5 June by the prison doctor.
The man’s pain was well controlled during the first days of June, although he was
eating very little and often feeling nauseous. After a review on 4 June, he was put
down to see the doctor every day due to deterioration in his general health. He was
having difficulty taking his medication on account of his nausea and, on 6 June, all of
his medication was stopped apart from his painkiller and an antiemitic (a drug used
to control nausea).
On 7 June, following a review, the prison doctor noted that the man’s health had
clearly deteriorated. The doctor considered that the man was no longer mentally
competent to contribute to decisions with regard to his management. He
recommended that the man be seen more by the palliative care specialist, and that
cardiopulmonary resuscitation (CPR) should not be attempted were he to suffer a
collapse. The doctor noted that the man did not appear to be in any pain.
8
The man was visited and reviewed by a Consultant in Palliative Medicine on 8 June.
The consultant praised the nursing staff at Parc for dealing with the man’s needs
“very appropriately”. She went on to say that his deterioration might be consistent
with him entering the terminal phase of his illness, but that this was not necessarily
the case. Later that day, the man fell out of his bed. He was disoriented but did not
suffer any injuries.
On 9 June, the man’s daughter was contacted and informed of his illness by Social
Services. Prison staff had been advised not to break the news themselves because
of the nature of the man’s offence. Blood tests taken on 9 June were reviewed the
following day. They showed that the cancer had spread to the man’s liver, his
kidneys were starting to fail and he had a raised white blood cell count as a result of
his chest infection. His condition was deteriorating and he was confined to his bed.
Nursing staff continued to check on him regularly through the night.
At around 7.12am on 11 June, a nurse checked on the man and found that he was
not breathing and had no pulse. In accordance with the prison doctor’s instructions
four days previously, CPR was not attempted. The duty doctor was called and
pronounced death at 8.26am. A post mortem carried out on 14 June showed the
cause of death to be bronchopneumonia due to carcinomatosis due to carcinoma of
the lung.
One of the prison chaplains spoke to the man’s daughter on 11 June to break the
news of her father’s death. The chaplain had previously spoken to her on 9 June
after she had been told of his illness. Two of the man’s sons and two of his sisters
visited the prison on 13 June. The funeral was organised by members of the
chaplaincy team, and all of the costs were met by the prison.
9
ISSUES
Issues raised in the clinical review
The man transferred to Parc on 19 May 2006, shortly after he was diagnosed with
cancer. A full care plan was written on his arrival, and his pain appears to have been
well controlled. The clinical reviewer commends the healthcare staff at Parc for their
“considerate care” of the man.
The clinical reviewer notes that, on 2 June 2004 and 18 February 2005, blood test
results indicated that the man had raised blood lipids (fats) which, if abnormally high,
have been associated with heart disease. This was not picked up on by medical
staff at Usk. A further blood test on 3 January 2006 again showed high blood fat
levels, as well as a chronic iron deficiency. Anaemia is sometimes a sign of chronic
disease, and could have been caused by the man’s lung cancer. Again, these
results were not noted by medical staff at Usk. The reviewer considers that, whilst
these failures would not have affected the progression of the man’s cancer, “prison
medical teams should be alert when results come back from laboratories”.
On 24 May 2006, the man attended hospital for a CT scan. However, he missed an
out-patients appointment on the same day, apparently because the hospital had sent
the notification to Usk rather than to Parc. The hospital did not appear to have been
informed of the man’s transfer to Parc five days earlier. Given that it is the sending
prison that holds details of the prisoner’s contacts and appointments, I consider it to
be their responsibility to inform the hospital of any transfer. The clinical reviewer
makes the following recommendation, which I endorse:
Healthcare staff at the sending prison need to inform the relevant NHS hospital
if a prisoner’s location changes, so that communication is not delayed and
appointments are kept wherever possible.
Contact with the man’s family
Following his transfer to Parc on 19 May 2006, the man expressed the wish that his
children be told of his illness. Staff from the Probation Service met with him on 7
June and discussed his wishes. It does not appear that the man had had any
contact with his family following his imprisonment. A chaplain at Parc told my
investigator that chaplaincy staff were prepared to break the news to the man’s
family, but were asked not to do so by the Probation Service due to the nature of his
offence. As a result, one of the man’s daughters was informed of his illness by a
social worker on 9 June.
Given the seriousness of the man’s offences, and the lack of contact with his
children following his reception to custody, I consider it appropriate that a social
worker rather than prison staff broke the news of his illness to them. However, the
man’s daughter felt that the seriousness of her father’s illness was not explained. It
might have been helpful if she had been given the contact details of a healthcare
professional at the prison with whom she could discuss the nature of her father’s
illness in more detail, and possibly even arrange a visit.
10
The Director should ensure that, when next of kin are given news of a
relative’s serious illness, a telephone number of a member of healthcare staff
is provided so that they have the opportunity to discuss the circumstances in
detail.
11
RECOMMENDATIONS
Healthcare staff at the sending prison need to inform the relevant NHS hospital
if a prisoner’s location changes, so that communication is not delayed and
appointments are kept.
Fully accepted – All nurses will be informed of the required action and the relevant
hospitals informed if a patient move to another prison.
The Director should ensure that, when next of kin are given news of a
relative’s serious illness, a telephone number of a member of healthcare staff
is provided so that they have the opportunity to discuss the circumstances in
detail.
GOOD PRACTICE
Healthcare staff at Parc should be commended for the care provided for the
man in the last few weeks of his life.
12