Individual at Stocken

Investigation into the death of a man
at a hospice in Leicester, whilst on temporary release
from HMP Stocken
Report by the Prisons and Probation Ombudsman for England
and Wales
November 2006
This is the report of an investigation into the death of a man. He died at a hospice in
Leicester whilst on temporary release from HMP Stocken.
The man had been estranged from his family for some time. However, prior to his
death he re-established contact with a former partner and their daughter. My
colleagues and I would like to extend our condolences to them and to all those
touched by his passing.
The post mortem shows that the man died as a result of bronchopneumonia and
lung carcinoma. He had been diagnosed with lung and bone cancer in December
2005, and was transferred from prison to hospice on 15 April 2006 and remained
there until he died.
This investigation was carried out by a member of my team. She and I would like to
thank Principal Officer of G Wing for his assistance as Liaison Officer.
I have made four recommendations, all of which are consistent with the findings of
the independent clinical reviewer. However, I have also highlighted eight areas of
good practice. The overall treatment of the man at the centre of this investigation, by
both staff and prisoners at Stocken, was characterised by dignity and respect.
Although as with everything in life one or two things could have been handled better,
taken as a whole this is a report that reflects very well upon the Prison Service and
Stocken prison. I would be grateful if the Governor would share that judgement with
his staff.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2006
2
CONTENTS
Summary 4
The Investigation 5
HMP Stocken 6
Key Findings 7
Issues Considered 11
Recommendations 12
3
SUMMARY
This man was remanded into HMP Nottingham on 15 November 2002. He was
sentenced on 19 December 2002, and transferred to HMP Stocken on 23 January
2003.
In February 2003 he complained of back pain and was treated with ibuprofen and
physiotherapy which continued for four months. Between August and November
2005, he had a recurrence of his back pain and also complained of pains in his
chest. He received painkillers and physiotherapy again. However, in the middle of
November 2005, a doctor noted that he might have secondary bone cancer and
coincidental Bell’s palsy. The man had a chest x-ray, the results of which suggested
pulmonary disease.
Several multi-disciplinary meetings were held to discuss concerns over the man’s
deteriorating health. Issues such as how to cater for his diet, how to store his strong
medication, and where he should be located, were taken into account.
The man was diagnosed with cancer on 6 December 2005; it was found in his lungs
and in his ribs. A meeting was held to discuss appropriate treatment. The cancer
was incurable, but he could be treated to slow the process. Over the next few
months, the man had radiotherapy and chemotherapy. He lost his hair and his peers
in the workshop made him a hat. There was good communication between prison
healthcare and outside hospital and the man was visited by Macmillan nurses.
Applications for early compassionate release and parole were refused in March
2006. When the man became seriously ill in April, a referral was made to the
hospice. A place became available on 15 April and he was released there on
temporary licence.
Although this transfer was made on a temporary basis, the hospice had space
available and was able to keep the man for a longer period. He was still at the
hospice when he passed away.
4
THE INVESTIGATION
1. My investigator requested all the relevant prison records relating to the man. Formatted: Font: 12 pt, Font
These included his medical records and core prison record. She also visited the color: Auto
prison and interviewed several members of staff. Formatted: Font: 12 pt, Font
color: Auto
2. Melton, Rutland and Harborough Primary Care Trust (PCT) was asked to carry Formatted: Font: 12 pt, Font
color: Auto
out a clinical review. Due a change of roles however, the clinical reviewer was
Formatted: Font: 12 pt, Font
changed in the course of the review. This inevitably caused some delay in its
color: Auto
being received by my investigator. Both reviewers made themselves readily
available to my investigator to answer any queries, and their assistance is much
appreciated. Formatted: Font: 12 pt, Font
color: Auto
3. HM Coroner for Rutland and North Leicestershire was informed of my office’s Formatted: Font: 12 pt, Font
investigation. He kindly provided my investigator with the post mortem report. color: Auto
The Coroner will receive a copy of this report to assist him with his enquiries. Formatted: Font: 12 pt, Font
color: Auto
4. Notices to staff and prisoners were supplied and displayed by the prison. These Formatted: Font: 12 pt, Font
color: Auto
invited anybody with information to talk to my investigator. In this instance, only
Formatted: Font: 12 pt, Font
those staff already identified by my investigator made contributions.
color: Auto
Formatted: Font: 12 pt, Font
5. One of my Family Liaison Officers spoke to the man’s former partner to ask if she color: Auto
had any particular comments or worries. She did not raise any concerns Formatted: Font: 12 pt, Font
although she did wish to pass on her thanks to the prison and the hospice. She color: Auto
wanted to thank the prison’s Family Liaison Officer, in particular. The family have Formatted: Font: 12 pt,
English (U.K.)
asked to see a copy of this report when completed.
Formatted: Font: 12 pt,
English (U.K.)
6. A draft copy of this report was issued to the man’s family and to HMP Stocken for
Formatted: Font: 12 pt,
them to make any comment. The man’s family have not made any comments.
English (U.K.)
HMP Stocken have commented on the recommendations and their response is
Formatted: Font: 12 pt,
included in the recommendation section. English (U.K.)
5
HMP STOCKEN
6. Stocken prison was built in 1985 and has been expanded on four occasions. It
now accommodates over 600 convicted adult men. The emphasis is on training
and resettlement. The accommodation consists of single cells. Cell sharing is
limited.
7. G wing is an enhanced status wing. This is for prisoners who comply with the
prison rules and participate in the regimes. The rooms are not locked and have
en-suite bathroom facilities.
8. There is no inpatient healthcare facility at Stocken. Prisoners can be transferred
to nearby prisons with this facility or to outside hospital, if necessary.
6
KEY FINDINGS
14. The man started complaining of back pain in February 2003, and was initially
prescribed ibuprofen. This has not been entered in his medical record but is
noted on his prescription chart. On 12 March, he was seen by a physiotherapist,
because the pain had worsened. He continued to see the physiotherapist for four
months. Over the following two years, his contact with healthcare was primarily
for skin and earwax problems.
15. Between August 2005 and November 2005 the man experienced chest pain and
recurring back pain. He received painkillers and physiotherapy. He had an
electrocardiogram (ECG) in August, which came back as normal. On 17
November, he saw the doctor who noted that he had a right facial palsy. It was
also noted that he might have had bone metastases (secondary bone cancer)
and coincidental Bell’s palsy. The man was referred for blood tests and a chest
x-ray. The results of the chest x-ray were reviewed and showed lung markings
throughout both lungs, suggesting chronic longstanding pulmonary disease. As a
result of this the man was referred to the ‘two week wait’ clinic. (This is a clinic
where urgent referrals will be seen by a specialist within two weeks in
accordance with the government guidelines/targets for cancer referrals.)
16. The following day, the x-ray findings were explained to the man by his doctor.
The clinical reviewer has noted that, the day after, the man was seen again and
given stronger medication and treatment for constipation. However, the prison
pharmacy was unable to provide the later medication and so a private
prescription was written and staff collected it from a local pharmacy in the
community.
17. Concerns over the man’s failing health were discussed at a meeting between
healthcare and wing managers. Whilst there was no proper diagnosis of the
man’s condition at this stage, he was being prescribed strong opiate-based
painkillers. The meeting considered which wing would be most suitable for him,
and also the security and personal safety implications of having such medication
in possession.
18. The man had expressed a wish to stay on G Wing. He did not have any
particular friends on the wing, having been described as a bit of a loner.
However, he was very comfortable with his peers and surroundings. Staff were
willing to support this wish, and obtained a secure, lockable cabinet for the safe
storage of his medication. Prisoners were also supporting the man, for example
by cleaning his clothes. It was agreed that his condition would be monitored by
healthcare on a daily basis, and interventions would be put in place as
necessary.
19. The man was diagnosed with lung cancer and bone cancer in his ribs on 6
December 2005 (the cancer was found to be in both lungs, but the primary
cancer had not been identified). He was told that it was not curable, but there
were treatments available to slow the process. A case conference was
scheduled for 9 December to determine appropriate care and management
plans.
7
20. Over the following two days meetings between healthcare, wing managers and
internal probation took place to discuss the man’s health plan and needs.
Thought was given to transferring him to a prison with 24 hour healthcare cover.
The healthcare manager tried to facilitate a place at HMP Leicester, but there
was no space at the time. It was again noted that the man felt happy on G Wing,
although he said he did not want to die in prison. At one of the meetings,
compassionate release was discussed. However, with no friends or family with
whom he could stay, the only option was a hospice. It was agreed that this was
not currently necessary but would be considered later if appropriate. It was also
agreed that staff would make regular checks on the man through the night to
monitor his condition.
21. A planned admission to outside hospital was arranged for 13 – 16 December, for
further tests and investigations. The day before this, the healthcare manager
suggested that a resuscitation policy be discussed with the man when he
returned from hospital. Nothing seems to have happened with this until the new
year. The day he was due to be discharged from hospital, the man was in pain
and so remained in hospital. The records show there was good contact during
this admission between the prison and hospital staff.
22. Biopsy results on 21 December showed that the man had had a good response
to radiotherapy, and was awaiting admission to the oncology ward at Leicester
Royal Infirmary to decide on further treatment. He returned to Stocken late on 24
December at short notice, which caused healthcare staff concerns about his
medication regime. As a result, he missed a dose of his opiate analgesia on 25
December because there was only one member of nursing staff who could not
administer a controlled drug on her own. Procedures were put in place to ensure
that over the holiday period two trained nurses could administer these drugs to
him.
23. Over the next four months, the man regularly attended the Leicester Royal
Infirmary for treatment. He also had contact with MacMillan nurses. During this
time, the Governor supported an application for compassionate release and the
man applied for parole. A letter dated 8 March refused early release. The man
had been given a 12 month life expectancy, which is longer than is considered
appropriate for early release given the seriousness of his offences and the fact
that he had not completed any offending behaviour work in relation to them.
24. A letter dated 10 March also refused the man parole for the same reason of not
addressing his offending behaviour; he was understandably distressed by this.
As noted, wing staff, knowing he had previously attempted suicide, felt it was
appropriate to open a F2052SH so that he could be monitored more closely. This
was closed three days later when the man’s mood had improved.
25. Usually, if a prisoner is on an F2052SH, he will not remain on G Wing because
there are no emergency cell bells. However, staff were again sensitive to the
man’s health and desire to remain on the wing and put in place extra monitoring
systems to ensure he was safe.
8
26. There was confusion about the man attending an appointment on 21 March 2006.
No healthcare or discipline staff knew that he was due to attend an appointment
until he alerted them on the day. An escort was arranged and the man attended
the appointment accompanied by a member of healthcare, although he arrived
late. The clinical reviewer has looked into this error and it would appear that the
hospital had relied on the man telling the prison, rather than informing them
themselves.
27. The man began experiencing difficulty and pain when eating the standard meals
prepared by the prison. A nurse liaised with the kitchen staff to organise a soft
diet for him, but this request was met with some resistance. Eventually, a
Principal Officer, who is in charge of G Wing, intervened and the man was given
meals such as omelettes which were easier for him to eat. Due to the treatment
the man was receiving, his appetite was also affected and he would not
necessarily want to eat at the set mealtimes. Staff on the wing took the initiative
to keep his meals back and microwave them when he was ready to eat. The staff
would also keep porridge and some soft foods in their kitchen, so that the man
would always have something available, and to ensure he kept his strength up.
This shows treatment of the man that was caring, compassionate and decent –
and went well beyond the norm.
28. Wing staff called healthcare on 12 April because they were concerned that the
man was in pain. The following day, officers reported that during the night he had
been in pain and vomiting. A doctor went to see him and felt that he needed to
be transferred out of the prison. He then made a referral to the hospice. It was
agreed that the man would be transferred to the hospice on 15 April, when a
space would be available.
29. The doctor and the man discussed resuscitation in the event of cardiopulmonary
arrest. This was witnessed by the nurse and it was recorded that the man was
not to be resuscitated. At the time, however, Stocken did not have a formal
resuscitation policy and the Governor’s view was that staff would have been
expected to attempt to resuscitate. A policy has now been drafted but has not yet
been implemented.
30. The man was released on temporary licence (ROTL) to the hospice on 15 April
(ROTL meant that he did not need to be restrained or escorted by prison
officers). However, this man was the first prisoner that the hospice had admitted
and they were initially uncertain as to the procedure and risk that a prisoner might
bring. An agreement was made that two officers in civilian clothes would stay
with the man but he would not be restrained. After two weeks the staff at the
hospice had a better understanding about caring for a prisoner, and were
comfortable with the man, so the officers were withdrawn.
31. Several staff visited the man whilst he was at the hospice. There was no formal
requirement for some of them to do so and this is another example of the care
and decency afforded to him by staff at Stocken.
32. The man expressed a wish to see one of his children, a daughter whom he had
not seen for several years. One of the prison’s probation officers contacted his
9
external probation office to ask them to check the last known address for his
daughter. They said they did not believe it was in their remit and so the prison
staff asked the prison chaplain if he could help. He contacted an external
chaplain who went to the address and spoke to the man’s former partner. She
visited him with their daughter and he was able to spend time with them before
he died.
33. Originally the man was to stay at the hospice for two weeks and contingency
plans had been agreed with nearby HMP Gartree that, should he need 24 hour
healthcare which Stocken could not provide, he could be transferred there.
However, the hospice had a space available and was able to let the man stay.
He remained there until he passed away.
34. On 5 June the Governor wrote to the staff on G Wing following a Reward and
Recognition Committee meeting in May. The man had nominated the staff on G
Wing for a recognition award for their “compassionate support beyond duty”. The
nomination was agreed by the Governor and the staff received a hamper for their
tea bar.
10
ISSUES CONSIDERED
Early release on compassionate grounds.
35. Appropriate consideration was given to early release on compassionate grounds,
a referral in conjunction with Prison Service Order 6000 having been made. This
application was refused for the reasons stated earlier. Sadly, the man’s health
deteriorated rapidly over the next two months. Stocken granted release on
temporary licence to enable him to go to a hospice, where he was able eventually
to reside unescorted. In this way, his request not to die in prison was met.
Stocken’s healthcare provision
36. Stocken does not have an in-patient facility. Consideration was given to
transferring the man to Leicester prison although, at the time, there was no space
available. There is no evidence that any other prison was considered then, for
instance Gartree (who were subsequently willing to take him from the hospice if
necessary). This said, there is also no evidence to suggest that at that time it
was essential for the man to have 24 hour healthcare.
37. The man could have been moved to a wing closer to the healthcare centre.
However, the general perception is that G wing is a calmer wing with more
mature prisoners. The man had already expressed a wish to stay on this wing,
where he knew people and they were aware and supportive of his needs. With a
few minor exceptions, the good multi-disciplinary working approach ensured that
the man still had appropriate medical intervention whilst he was on G wing.
38. The clinical review reports on the man’s medical care in more detail. Overall, it
concludes that a good quality of care was delivered by the healthcare team.
However, there were some areas of confusion regarding appointments,
resuscitation and dispensing medication. The clinical reviewer has made several
recommendations which I endorse:
The Prison and PCT should develop a joint communication plan, including
the identification of prison-hospital link managers in both establishments.
The PCT, in conjunction with the prison, should develop and implement a
controlled drugs policy and consider including guidance in relation to the
care of patients requiring palliative care including high doses of opiate
analgesia.
The Governor and Healthcare Manager should agree and implement the
draft resuscitation policy.
G Wing
39. It would appear that the man had very good care and decent treatment whilst on
G wing at Stocken. Wing staff were aware of his poor health and monitored him
well, and ensured his medication could be kept safe on the wing - thereby also
keeping him safe. They kept food back for him, as he did not necessarily want to
11
eat at the same time everyday. Staff also brought in porridge and other soft
foods so that he would always have something available. Several staff visited the
man whilst he was in the hospice. Prisoners on G wing were also sympathetic to
him, cleaning his clothes, changing his bedlinen and pushing his wheelchair if he
needed it.
40. The man was also allowed to continue going to the workshops when he felt able.
Sometimes, he would just go to have a chat with people but he was still getting
paid. He had a good rapport with those in the workshop and they made him a hat
to cover his loss of hair caused by the chemotherapy.
Meals
41. Due to his poor health and the medical treatment, the man was finding it difficult
to eat solid foods. A nurse tried to arrange a soft diet through the kitchen, but
was met with resistance. In the end it took a Principal Officer and a letter to a
Governor before anything was sorted. I appreciate that the kitchens are busy,
but the duty of care to a prisoner is everybody’s responsibility and I recommend
that they are reminded of this.
The Governor should remind kitchen staff of their role in meeting the non-
clinical needs of prisoners who have chronic illness or who are terminally
ill.
Multi-disciplinary working
42. There are some very good examples of multi-disciplinary working. This
encompasses communication between wing, healthcare and probation staff and
liaison with the hospitals and the hospice. There were a few occasions when this
broke down but overall the approach worked very well in caring for this man.
Family contact
43. The man had not remained in contact with his family. However, before he died
he wished to see one of his children again. The probation department were
trying to deal with this with the assistance of the external probation office.
However, it would appear that it was not straightforward in terms of getting written
permissions and risk assessments. The prison chaplain became involved and,
through a priest in the community, was able to contact the man’s former partner
and mother of his daughter. This enabled him to see his former partner and his
daughter before he died.
12
RECOMMENDATIONS
1. The Prison and PCT should develop a joint communication plan,
including the identification of prison-hospital link managers in both
establishments.
HMP Stocken have accepted this recommendation and will meet with the PCT
to develop a joint communication plan. The first meeting is scheduled to take
place on 15 December 2006.
2. The PCT, in conjunction with the prison, should develop and implement
a controlled drugs policy and consider including guidance in relation to
the care of patients requiring palliative care including high doses of
opiate analgesia.
The prison have accepted this recommendation and it will be progressed in
consultation with the PCT. As above the first meeting is scheduled for the 15
December 2006.
3. The Governor and Healthcare Manager should agree and implement the
draft resuscitation policy.
This recommendation was accepted and the draft policy is currently being
circulated for consultation and will be published by January 2007.
4. The Governor should remind kitchen staff of their role in meeting the
non-clinical needs of prisoners who have chronic illness or who are
terminally ill.
This has been actioned.
GOOD PRACTICE
1 There was good evidence of a multi-disciplinary approach to the man’s
care.
2 Early compassionate release was applied for and when this was refused
ROTL was granted so that the man went to a hospice and therefore did
not die in the prison.
3 Wing staff took the man’s depression history into account when he was
refused parole and compassionate release and opened a F2052SH so
that he was monitored closely until his mood lifted.
4 Once arranged, the man was able to have a soft diet at times which
suited his appetite.
5 Staff were commended by the Governor for their supportive treatment of
the man, at the man’s own request.
13
6. Healthcare staff saw the man regularly and ensured his needs were met
as much as possible, despite the difficulties of providing good palliative
care within a prison environment. On one occasion when he needed
medication that was not available, healthcare staff wrote a private
prescription and went to collect it for him.
7. Medical record keeping displayed good practices, particularly after the
man had been diagnosed with cancer.
8. Good work to try and find one of the man’s children led to him being
able to see her before he died.
14