Individual at Isle of Wight

Investigation into the circumstances surrounding the death
of a man in September 2006
at a hospital on the Isle of Wight
whilst a prisoner at HMP Parkhurst
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2007
This is the report of an investigation into the death of a man who was 40 years old,
when he died in September 2006, at a hospital whilst a prisoner at HMP Parkhurst.
The man died of acute lymphoblastic leukaemia. He had been diagnosed with
leukaemia in March 2006 and, although treated, it did not respond to chemotherapy.
My colleagues and I would like to extend our condolences to the man’s family for their
loss.
This office investigates all deaths of prisoners in custody, including those due to natural
causes, and this investigation was carried out on my behalf by one of my investigators.
The clinical review was carried out by a doctor, on behalf of the Isle of Wight Primary
Care Trust, and I am grateful for his help. Both the doctor and I are satisfied that, apart
from health service transport difficulties, the care provided was equivalent to that he
would have received in the community.
I commend Parkhurst for their efforts to move the man nearer to his mother’s home. It
is sad to report that this did not happen, despite their best efforts.
Emma Bradley
Deputy Prisons and Probation Ombudsman March 2007
CONTENTS
Summary 4
HMP Parkhurst 5
The investigation process 6
Key Findings 7
Issues considered during the investigation 11
Recommendations and good practice 12
Annexes
1. Clinical Review
Evidence Considered
Personal prison record and history sheet
Security file
Inmate Medical Record
Bedwatch logs
Family liaison logs
Prison wing observation records
OASys and sentence planning reports
Post Mortem
SUMMARY
The man had been in prison since 1996, and he had transferred to HMP Parkhurst on
21 November 2003. Whilst in prison, he saw medical staff for several complaints,
including narcolepsy, urine infections and many instances of back pain.
In March 2006, he was diagnosed with leukaemia, and began a course of
chemotherapy treatment at a mainland hospital, with support from an island hospital,
and the prison healthcare team.
The man’s health began to deteriorate further in August and he was not responding to
the chemotherapy. He remained in hospital and was given palliative care. Parkhurst
applied for release on compassionate licence, with a view to the man returning to his
mother’s home. Compassionate release was granted on 6 September, however due to
National Health Service transport difficulties, the man could not return to his mother’s
home and he passed away at the island hospital.
Contact between the prison and the man’s family was good and although, the man did
not return to his mother’s home, his family were able to be near him when he died.
HMP PARKHURST
1. Parkhurst is one of three prisons on the Isle of Wight. It is a Category B prison for
long term and life sentence prisoners, and also holds those remanded by the Isle of
Wight courts.
2. The healthcare provision for all three prisons is clustered and managed by
Parkhurst. Parkhurst has the only in-patient healthcare facility. E3, the allocated
healthcare wing and primarily manages prisoners with psychiatric illnesses. It is on
the third floor with the only fire exit being the main staircase.
Bedwatch arrangements
3. Bedwatch is the term used by the Prison Service to describe when a prisoner
requires in-patient treatment at an external hospital. The procedure includes a risk
assessment, to decide on the level of security required for the individual prisoner. In
most cases the prisoner is accompanied by two prison officers, and remains
attached to one of the officers throughout, by means of an escort chain. The chain
can however be removed to administer treatment or when deemed medically
necessary.
Compassionate release
4. Early release from prison on compassionate grounds may be considered on the
basis of a prisoner’s own medical condition or as a result of tragic family
circumstances. Prison Service Order 6300, states that the Secretary of State only
grants compassionate release in the most exceptional cases.
THE INVESTIGATION PROCESS
5. My investigator requested all the prison records relating to the man, which included
his medical records and core prison record. My investigator also visited the prison.
Unfortunately the records were not received in the Ombudsman’s office until five
weeks after the man’s death, which has delayed this investigation. The wing history
files do not give much information about the man’s history in Parkhurst apart from
health issues, which is therefore what this report will focus on.
6. A doctor undertook the clinical review on behalf of the Isle of Wight Primary Care
Trust and his report is annexed. My investigator met with the doctor to discuss the
clinical review process.
7. The Isle of Wight Coroner was informed of the Prisons and Probation Ombudsman’s
investigation. He kindly provided my office with the post mortem report. The
Coroner will receive a copy of this report when it is completed to assist him in the
inquest.
8. One of my Family Liaison Officers made contact with different members of the
man’s family, to offer them the opportunity to raise questions or concerns for our
investigation to consider. The man’s sister told my Family Liaison Officer that, once
the man’s condition had been diagnosed, she believes that the prison did all they
could to look after him. However, she did question whether his condition might have
been diagnosed earlier, as he had been unwell for some time beforehand. The
Clinical Review considers this question further. Copies of my report will be made
available to the man’s family at all stages.
9. Notices to staff and prisoners were supplied and displayed by the prison. These
invited anybody with information to talk to my investigator. In this instance, no-one
raised any matters.
KEY FINDINGS
10. During the year preceding the man’s diagnosis of leukaemia, he was seen regularly
by healthcare staff, primarily for shoulder and back pain. An entry in the wing
observation book on 7 November 2005, by his personal officer noted that the man
had asked to see a doctor, but does not give a reason why. He noted further that,
when the man was told he would not be able to see a doctor for two days, he was
unhappy and asked to see a governor and be taken to the island hospital.
11. The man was seen the following day and was reported to be complaining of lower
back pain, which was apparently travelling down both kidneys and legs. He was
taken to the Accident & Emergency Department at the island hospital but, after a full
examination, no diagnosis was made and he returned to Parkhurst. The man was
prescribed painkillers and a muscle relaxant, in an attempt to manage his pain. He
was seen by the medical officer on 9 November. At this consultation his smoking
and weight were discussed, the man was considered to be morbidly obese. He was
advised about these health risks and received regular medication reviews.
12. On 6 December, he agreed to go on a low fat diet, in an attempt to lose weight.
Over the next three months, the man continued to receive advice about his diet and
back pain. His wing records show that the back pain was affecting his job as a
cleaner and by January the man had to give this job up.
13. On 23 December, the man made a formal complaint about the care he was
receiving for his back pain. It is recorded that on one occasion he refused to wait to
see the doctor. The nurse later went over to see the man and offered him some
paracetamol, which he also refused.
14. By January 2006, the man was managing to lose weight, and had lost 15kg. He
continued to be prescribed pain killers for his back pain, although there were some
concerns that he was storing his medication. On one occasion the man refused to
take any more of a course of treatment.
15. On 4 March, wing staff asked healthcare to see the man. He was asked to produce
a sample pot of phlegm, which was noted to contain a small amount of blood. The
man’s blood pressure was taken and he was given more information about stopping
smoking (he had been smoking when healthcare staff entered the cell). The
healthcare worker told the man that he would see the doctor on Monday 6 March.
The member of staff recorded in his medical record that he did not note any acute
change in the man’s condition.
16. When the man saw one of the prison doctors on 6 March, he was noted to be very
pale and unwell. The man told the doctor that he had noticed blood in his mouth
and nose over the past two to three weeks. A subsequent letter sent by the man’s
solicitors said that the blood loss had in fact continued over a longer period. the
man was also noted to have an itchy rash on his abdomen and legs.
17. The prison doctor recommended urgent admission to hospital, and the man was
taken to the island hospital, where blood tests revealed the presence of leukaemia
cells. Leukaemia was diagnosed, and the man was transferred to a mainland
hospital, the following day. An entry in his medical record shows that on 9 March,
he had a bone marrow biopsy and ultra sound. It was agreed that depending on the
results of these tests, chemotherapy would be started. Chemotherapy began on 11
March. On 15 March he was said to be tolerating it well.
18. As a result of the man’s diagnosis, the prison appointed a manager to act as a
liaison between the prison and his family. The contact was intermittent at first, but
became more frequent as his condition deteriorated.
19. A Senior Primary Care Nurse (SPCN) from the prison visited the man in hospital on
6 April. He noted in the medical records that the man was due to have a lumbar
puncture and further bone marrow biopsy. The results of the tests would determine
whether he could receive the second course of chemotherapy back at the island
hospital. The hospital medical team told the SPCN that it was likely that the man
would need ongoing treatment for the next two years.
20. The man went back to Parkhurst on 13 April. He was allocated back on normal
location, but as he was vulnerable to infection, he was not allowed contact with
anyone with coughs or colds. My investigator asked why the man was not allocated
to the healthcare centre; she was told that it was unsuitable. In the event of an
emergency, it would have been difficult for someone of the man’s size and health to
be able to get out quickly. His medical record gave instructions for an immediate
transfer to the mainland hospital if he became acutely unwell.
21. A letter from the mainland hospital was circulated to all staff on 14 April, which
concerned the man’s vulnerability to infection and the need to ensure that any risk
was minimised. The same day a dietician was contacted about provision of a
neutropenic diet. The diet helps protect individuals with a weak immune system,
from some bacteria and harmful organisms found in food. It was readily available as
prisoners have several daily menu choices which are pre-ordered and a neutropenic
diet can be constructed from these.
22. On 8 May, the man was admitted to the mainland hospital again. Between this date
until the day he died, he spent considerable periods of time, in both the mainland
hospital and the island hospital and his mother was able to visit him in both. There
was an occasion however, on 12 July when the man refused to go from the prison to
the island hospital, saying that he would only go to the mainland hospital. He was
advised of the consequences of not attending the hospital appointment, and later
changed his mind. Healthcare staff believe that he initially refused, because he was
unable to smoke at the island hospital, whereas he was occasionally allowed to
smoke at the mainland hospital.
23. Throughout July, correspondence between the mainland hospital and the prison
shows that the man’s white blood count was too low for chemotherapy to take place.
He continued to have blood tests, which were unsatisfactory, and on 2 August he
was readmitted to the mainland hospital. On 7 August, he was deemed well
enough to continue the treatment, although he was in a lot of pain with sciatica. The
hospital contacted the prison on 12 August to inform them that the man felt unwell
and was to have a blood transfusion, platelets and a course of antibiotics.
Chemotherapy was stopped and a morphine pump was put in place, to relieve his
pain. The bedwatch logs show that the man was informed on 21 August that his
treatment had not been effective and his condition was terminal.
24. The man returned to the prison the next day. His ongoing care was to be given by
the island hospital, with weekly blood and platelet transfusions. On this occasion
he was located in the healthcare centre.
25. After just two days back in the prison, the man returned to the island hospital, but
this was not noted in the medical records. There is an entry on 30 August, which
notes that the man’s mother wanted to discuss his care plan with her own doctor.
The entry also records that she hoped her son could be discharged into her care, at
her home. The following day, the doctor at the island hospital gave a prognosis that
the man had two weeks to live, and said that he too wanted to discharge him to his
mother’s home or to a nearby hospital.
26. The SPCN noted in the medical records on 4 September 2007, that the man was
receiving palliative care. Parkhurst applied for his early release on compassionate
grounds, which was to be considered by National Offender Management Service
(NOMS) on behalf of the Secretary of State. Pending this decision, it was decided
by the hospital and prison, that the man should remain in hospital. This would
facilitate an easier transfer to a hospital or hospice closer to his mother’s home.
This was explained to the man.
27. There is conflicting evidence about the man’s early release. It is clear that NOMS
approved his compassionate early release on 6 September, but the bedwatch
officers believed that it was refused and he was to be released on temporary
licence. They informed the man to this effect. There are no entries in the man’s
medical records regarding the arrangements being made for his release. The
information has had to be gathered from various other sources. However, there is a
release pack amongst the man’s prison documentation, which included information
on benefits and community care.
28. On 7 September, it was recorded that the man was due to transfer to his mother’s
home that day. When the prison telephoned the hospital to find out the time of
transfer, they were told that the ambulance service refused to transport him as he
was not going to another hospital. However, other evidence, including a summary
from the hospital consultant and discussion with the head of prison healthcare,
suggests that the relevant health authorities in Wales were unhappy to take
responsibility for the man’s care.
29. An entry in the man’s prison medical record makes it clear that the prison did not
think that the ambulance service responded compassionately. Enquiries were made
about other arrangements. The St John’s Ambulance Service in Newport was
approached, but was unable to help for four days. The prison also tried to arrange
transport by a private car, accompanied by two members of staff and a trained
nurse. However, as the man was very weak, it was agreed that he would not be able
to manage such a long journey in a car. The prison also liaised with the local
hospice, who were prepared to admit the with a view to transferring him to the area
where his mother lived when his health stabilised. However, the man and his
mother wanted him to return straight to her home.
30. On 8 September, plans were made for a private ambulance to transfer the man to
his mother’s home, where the family doctor was to meet him. The medical records
do not show why this did not happen, but an entry in the bedwatch log indicates that
the relevant health authority could not provide the necessary support at her home
over the weekend. It remained unlikely that the man would return to his mother’s
home until 11 September.
31. The Prison Family Liaison Officer, contacted the man’s family to inform them of the
difficulties and suggested that, in the light of his deteriorating health, they may wish
to be with him at the hospital. Permission was given by senior managers at the
prison to assist the family with some of the costs associated with their travel and
accommodation. The man’s family arrived at the hospital late that evening.
Although they were not at his side, they were nearby when the man passed away at
1.00am on 10 September.
32. Parkhurst contributed to the cost of the man’s funeral and held a memorial service
locally for those staff and prisoners unable to attend.
ISSUES CONSIDERED DURING THE INVESTIGATION
Clinical Care
33. The man developed a terminal illness and, after initial treatment with chemotherapy,
palliative care was all that could be provided for him. After he was diagnosed with
the lymphoblastic leukaemia, he was mainly cared for in outside hospitals, until he
died on 10 September 2006.
34. The clinical reviewer has noted that had a more robust care plan between the
specialist health providers and the prison been put in place, it might have meant that
they could have planned more effectively to enable the man to return to or near his
mother’s home as per their wishes. This apparent lack of effective and timely care
planning meant that when they wanted to transfer the man to his mother’s home,
they were unable to secure transport before he died.
Healthcare providers should ensure that a robust multi-disciplinary care plan
is in place for all terminally ill prisoners.
Communication
35. Throughout the man’s hospital stays the communication between the hospitals and
the prison was generally good. The prison’s Family Liaison Officer worked well to
keep the family informed and listen to their concerns. However, the records about
early release and the man’s move to his mother’s home are poor. The information
is held in different places and confusing, with different staff given and passing on
different information. A detailed multi-disciplinary care plan, as proposed by the
clinical reviewer, would help to address this issue.
All staff should be reminded of the need to keep accurate and
contemporaneous records to ensure effective communication.
GOOD PRACTICE
The following were considered to be areas of good practice.
1. When the man was initially diagnosed with leukaemia, the prison appointed a Family
Liaison Officer and the records indicate that the family were very grateful for the
support and assistance they received.
2. The prison provided further support for the man’s family by meeting some of their
travel and accommodation expenses, and the funeral costs.
3. Prison and Healthcare staff made several attempts to ensure that the man was able
to die close to his family and with dignity. It is sad that, despite their extensive
efforts, he was not able to return to his mother’s home.
4. A release pack including information on benefits and community care was prepared
for the man.
5. RECOMMENDATIONS
1. Healthcare providers should ensure that a robust multi-disciplinary care plan
is in place for all terminally ill prisoners.
Parkhurst have accepted this recommendation and a protocol is being drawn up in
conjunction with the PCT and implemented on an individual basis.
2. All staff should be reminded of the need to keep accurate and
contemporaneous records to ensure effective communication.
Parkhurst have accepted this recommendation and staff will be reminded and
trained in appropriate recording systems.