Individual at Wakefield

INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING
THE DEATH OF A MAN AT
HMP WAKEFIELD IN SEPTEMBER 2005
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 HM Prison
Wakefield in September 2005. A post mortem examination conducted by a
Home Office pathologist, concluded that the man died of carcinomatosis and
carcinoma of the colon.
I offer my sincere sympathy and condolences to his family for their sad loss.
The investigation was carried out by two of my colleagues. I also
commissioned an independent clinical review of the management of the
man’s health needs for the period he was at Wakefield. The review, for which
I am most grateful, was carried out by three professionals on behalf of the
Wakefield West Primary Care Trust.
I would also like to thank the governor and staff at Wakefield for their full and
ready co-operation during the investigation.
The clinical review team make five recommendations regarding local practice
and procedure at Wakefield (I have made one additional recommendation of
my own). They have also drawn attention to the high standard of care
received by the man who died and have highlighted five areas of good
practice. I concur with their findings. I should also like to add my own
commendation to the staff at Wakefield for the kind and respectful way in
which they cared for the deceased.
The final version of my report has benefited from comments I received from
the Wakefield Hospice that have enabled me to correct previous inaccuracies.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2006
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Contents
Summary
Investigation methodology
HM Prison Wakefield
Events prior to the man’s death
Consideration of issues arising from the investigation
Recommendations and good practice
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Summary
The man was convicted of murder and sentenced to life imprisonment in
1996. He transferred to Wakefield in 1997. Towards the end of October
2003, he began to complain of abdominal pain and an inability to open his
bowels. On 31 October, when medication prescribed by healthcare staff at
Wakefield proved to be ineffective, he was transferred to a local hospital. A
cancer of the sigmoid colon was diagnosed, and he underwent surgery to
remove a tumour on 2 November.
On 9 December, it was discovered that the cancer had spread to his liver and
was inoperable. He subsequently commenced several courses of
chemotherapy, the first of which took place on 20 January 2004. These initial
cycles were successful, and his condition and prognosis improved.
On 7 January 2004, the man’s solicitor applied for his release on
compassionate grounds. The application was refused by the Home Office on
8 June as he had failed to meet the full criteria. The solicitor subsequently
applied for Judicial Review to contest the decision to refuse his release. On
12 November, this application was also refused. A subsequent appeal to the
Court of Appeal failed on 28 January 2005.
After his condition had stabilised for around nine months, a CT scan on 16
September 2004 showed a progression of the cancer in his liver. As a result,
his consultant recommended that chemotherapy would no longer be of benefit
to him. He therefore had no further cycles. The man’s condition remained
stable until February 2005 when it was noted that he was becoming weaker.
He subsequently moved into the palliative care suite at Wakefield on a
permanent basis on 19 March.
A second application for compassionate release on medical grounds was
made on 7 April 2005. His deteriorating condition now meant that he fulfilled
all the criteria for release, with the exception of that relating to ‘adequate
arrangements for the prisoner’s care and treatment outside prison’. Hospice
admission was not deemed to be appropriate by his MacMillan nurse as he
was being cared for well in HMP Wakefield’s palliative care suite and she did
not consider that he had any specialist palliative care needs that would
warrant hospice in-patient care.
The man’s condition continued to deteriorate throughout the Spring and
Summer of 2005. At 2.02am one morning in September, during a routine
check of his syringe driver, the man was discovered to be showing no sign of
life. The duty doctor was called, and the man was subsequently pronounced
dead at 3.08am. The cause of death was recorded as carcinomatosis and
carcinoma of the colon.
I make six recommendations and point to a number of examples of good
practice.
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Investigation methodology
The investigation was opened on 15 September 2005. My investigators met
with the deputy governor at Wakefield, the chair of the prison’s Independent
Monitoring Board, and a member of the local branch committee of the Prison
Officers’ Association, to explain the nature and scope of the investigation. My
investigators toured the prison and familiarised themselves with the
healthcare centre in which the man had been located since 19 March 2005.
On the same day, notices announcing the investigation and its terms of
reference were issued to staff and prisoners at Wakefield. The notices
included an invitation to those who wished to submit information relating to the
man’s death to make themselves known to my investigators.
An independent clinical review into his health needs whilst he was in custody
at Wakefield was carried out by professionals on behalf of the Wakefield West
Primary Care Trust. The review team interviewed a number of healthcare
staff who were involved in the man’s treatment and palliative care at
Wakefield.
My investigators were given access to the man’s prison files, including the
Medical Record.
On 11 October, one of my family liaison officers wrote to the man’s mother to
ascertain whether she had any concerns for the investigation to address. His
mother told the family liaison officer that she had no concerns and that she
thought the care her son had received at Wakefield had been good.
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HM Prison Wakefield
Wakefield is a high security prison. At the time of the investigation, Wakefield
held up to 580 adult male long term prisoners.
The prison provides workshops and an education department offering both full
and part time education. The programmes department offers a range of
offending behaviour courses, including FOCUS (anti-drug taking programme),
the Sex Offender Treatment Programme (SOTP) and the Enhanced Thinking
Skills programme (ETS)
Healthcare is commissioned by the West Wakefield Primary Care Trust. The
healthcare centre provides 24 hour cover and has inpatient beds for up to 21
prisoners. The centre also has a Palliative Care Suite, which is an en-suite
single room in a converted dormitory. A Specialist Palliative Care Service is
provided by Mid Yorkshire Hospitals NHS Trust.
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Events prior to the man’s death
The man was transferred to Wakefield in January 1997. At the time, he
suffered from back pain for which he was taking medication. He had a history
of operations on his back.
In July 2000, he complained of frequent urination and thirst. A blood sugar
reading was taken and found to be 14.2mmol/L, well above the normal range
of 3.5-5.8mmol/L. This reading is also well above the diagnostic threshold for
diabetes. Despite this evidence, and a family history of diabetes, no such
diagnosis was made at the time.
A further examination was made on 15 January 2002 following a healthcare
review at which the man’s previous abnormal results were noted. A blood
sugar reading was taken and found to be 23.8mmol/L. At the same time, he
complained again of frequent urination and thirst. Diabetes mellitus was
diagnosed, and appropriate treatment commenced.
In May 2003, he raised a claim for clinical negligence against Wakefield on
account of his mis-diagnosis and a delay in referring him to a diabetic
consultant following diagnosis. A settlement of £30,500, including costs, was
reached in May 2005.
On 29 October 2003, the man complained that he was experiencing
abdominal pain and that he had been unable to open his bowels for five days.
He also complained of nausea. He was admitted to the healthcare centre for
reassessment two days later. In the meantime, he was given a course of
Micralax Enema to help him open his bowels.
On 30 October, the man complained that he had vomited overnight and during
the day, and that he had a lot of pain in his lower abdomen. The Micralax had
proved ineffective as he remained unable to open his bowels.
On 31 October, he felt tenderness in his abdomen. He was still unable to
open his bowels and was therefore prescribed a phosphate enema in the
morning. At 2.30pm that day, after the enema had proved to be ineffective,
he was referred to the Accident and Emergency department at a local
hospital. A cancer of the sigmoid colon was diagnosed.
On 2 November, the man underwent surgery to remove a tumour, which
resulted in the formation of a colostomy. By 15 November, he had recovered
sufficiently to be able to return to the prison.
In the days after his return to Wakefield, he spoke of being sad and fearful for
his future following diagnosis. He dreaded the thought of having to undergo
chemotherapy. He also experienced regular pain, particularly in his lower
abdomen, for which he was initially given paracetamol before starting a
course of co-codomol on 21 November.
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On 9 December, the man was seen by an oncologist who discovered that the
cancer had spread to the liver. This was deemed inoperable. He was offered
oral chemotherapy. He was seen on a weekly basis by a palliative nurse, with
whom he was able to discuss his fears of chemotherapy. A prognosis by a
doctor, on 23 December, gave him just three to six months to live. Following
this, on 7 January 2004, his solicitor wrote to the Lifer Review and Recall
Section (LRRS) of the Home Office to apply for his release on compassionate
grounds.
The man was reviewed by a dietician on 15 December 2003 with regard to the
dietary supplements that he was taking as a result of his diabetes. She
recommended that he continued to take two litres of full fat milk and a serving
of Ensure Plus (a nutritional supplement) per day. This was again reviewed
on 9 January 2004, by the dietetic manager at a local hospital, who deemed
the man’s dietary supplements to be sufficient.
On 20 January, the man commenced a course of chemotherapy at the
hospital. Despite having reservations in the weeks leading up to the
treatment, he was more cheerful and optimistic immediately after
chemotherapy, and was surprised at how well he had coped with the first
session. At a review, mistakenly noted by the senior medical officer at
Wakefield, as being on 17 January (it is not clear on which date this review
did take place), he was noted to have tolerated the first treatment cycle
extremely well. At a further review with the palliative care nurse on 30
January, he was recorded as asymptomatic.
A second cycle of chemotherapy commenced on 17 February, after which he
was again optimistic and pleased by his progress. His consultant noted that
he had experienced a significant reduction in pain since commencing
chemotherapy. Further courses commenced on 16 March and 13 April,
complemented by palliative care at Wakefield, and the man was again
recorded as responding well to the treatment.
The response by him to his first cycles of chemotherapy also had a positive
impact on his prognosis. On 15 March, his consultant gave a prognosis of six
to twelve months, a view that was repeated by another doctor on 30 March.
On 15 May, the man was placed on disciplinary report after an incident in the
healthcare centre in which he brandished a pool cue at staff. He was
subsequently placed in segregation from 19 May for a period of 11 days. In
the weeks preceding this incident, the man had made a number of informal
complaints with regard to his treatment by staff, none of which was
substantiated by any evidence when investigated internally. During his time in
segregation, he was seen by healthcare staff on a daily basis. He reported no
concerns - other than slightly worse pain in his back, legs and feet on 20 May.
On 8 June, his application for release on compassionate grounds was refused
by an LRRS caseworker. The reasons for the refusal are discussed in section
6 of this report. Although the application was refused, LRRS asked the
governor to monitor the man’s situation closely and, if there were a change in
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his circumstances, to consider submitting a new application. An application
for Judicial Review to contest the decision to refuse release was submitted on
15 June by the man’s solicitor.
The man attended the local hospital on 15 June for review following a CT
scan. The results showed that he had responded well to chemotherapy. It
was therefore decided to continue with the treatment. It was also noted that
he was feeling much better and had reduced his intake of painkillers. The
consultant therefore prescribed a further four cycles of chemotherapy. He
commenced the first of these the following day, and the second on 11 July.
The man was due to attend an outpatient’s appointment at the hospital on 24
August in order to commence a further course of chemotherapy. However, he
failed to attend the appointment. There is no record of the reason for this
omission. The man again failed to attend a clinic on 7 September, and he
therefore missed the cycle. He underwent a CT scan on 16 September, the
results of which showed a progression (deterioration) of the disease in the
liver. His consultant subsequently wrote to Wakefield to express her “extreme
disappointment” that they had not facilitated the man’s attendance at the
previous clinics. She also stated that, whilst she “cannot say that this has
been detrimental to his treatment … the fact that he has now shown
progression after what was a responsive chemotherapy raises the question
that if he had had his chemotherapy on time would he have continued to have
benefit from it?”
As a result of the progression, the doctor recommended that he had no further
courses of chemotherapy. He was reviewed regularly in the following months
by his Macmillan nurse who wrote to his consultant on 17 January 2005 to say
that the man’s condition had remained stable following the termination of his
chemotherapy.
On 12 November 2004, his application for Judicial Review was refused. His
solicitor successfully sought permission to appeal against this decision. The
appeal was heard at the Court of Appeal on 28 January 2005 and was
dismissed.
On 1 February, it was noted that the man was now weaker and was
“beginning to fail”. He was also experiencing nausea and pain in his right
lower abdomen. On 5 February, the man reported to the healthcare centre
with these symptoms, having vomited five times overnight. He was advised to
put himself down for sick parade, and he subsequently returned to his cell.
There is no record of him having seen a doctor on this occasion.
The man then collapsed on the wing on the morning of 9 February. He was
seen by a healthcare officer and complained of pain in the abdomen and an
inability to keep down his food. The healthcare officer subsequently arranged
for him to be seen by a doctor in the afternoon for further assessment. When
he saw the doctor that afternoon, the man reported that he had been vomiting
on and off for the last six weeks and that his bowels had not been opening
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properly. The doctor recorded that if the pain increased he should be
admitted to hospital.
The next day, 10 February, the man reported an increase in pain and that he
was still vomiting. The doctor therefore instructed that he be admitted to A+E,
and he was subsequently taken by ambulance to the local hospital. The man
was admitted as an inpatient and remained at the hospital until 19 February
when he was discharged back to the prison.
On his return to Wakefield, he declined admission to the healthcare centre on
a number of occasions. However, on 19 March, he consented to admission
after his condition had deteriorated quickly, and was given a room within the
palliative care suite. He had become increasingly frail and was beginning to
experience some confusion regarding his surroundings. On 22 March, he
made it clear to nursing staff and to the prison’s medical officer, that he did
not wish to be resuscitated. The appropriate forms were therefore completed.
Following his admission to the palliative care suite, the man was visited
regularly by his mother. No restrictions were made on the number of visits
she could make, and she did not have to go through the formal procedures of
booking a visit. His mother was also allowed to stay with her son for as long
as she wanted on each visit.
On 7 April, a second application for compassionate release on medical
grounds was received by LRRS. However, a decision with regard to release
was never made in response to this application, as the criteria referring to
“adequate arrangements for the prisoner’s care and treatment outside prison”
were not fulfilled. His case was discussed by a local hospice on 18 May, at a
weekly multi disciplinary meeting held between themselves, the local hospital
and the community specialist palliative care teams. At the meeting his
MacMillan nurse, said that he had no specialist palliative care needs that
would warrant a hospice in-patient bed. This was confirmed in a follow-up
conversation between the director of Patient Services at the hospice, and the
prison’s medical officer.
Following his admission to the healthcare centre, the man’s condition
improved a little. However, he was continuing to experience pain, nausea and
confusion, and was becoming increasingly weak. Moreover, in a letter dated
25 April, his consultant stated her belief that the man was approaching the
terminal phase of his illness and that his life expectancy could now be
measured in days and weeks.
The man continued to deteriorate slowly over the following three months,
becoming frailer and weaker as time went on. At times, he also had difficulty
sleeping as he was frightened at the prospect of dying while he was asleep.
Despite this, his mood remained reasonably positive. He often engaged in
conversation with other prisoners in the healthcare centre. On 14 July, the
man experienced a two-minute long seizure after falling to the floor when
attempting to get out of bed. He had recovered within 10 minutes, but had no
recollection of the event and suffered bruising to his right temple and cheek.
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He was subsequently given diamorphine for his pain and reported no further
discomfort that day.
The man experienced a second fall on 17 July, this time without suffering any
injuries. His condition was now beginning to deteriorate more significantly.
He had difficulty breathing on occasions and was becoming increasingly weak
and frail. By 29 August, he was in considerable general pain. It was therefore
arranged for a syringe driver (a plastic syringe that delivers small amounts of
a drug continuously through a battery operated pump) to be provided so that
more effective pain relief could be offered to him. This commenced on 7
September. As a result, he remained settled and comfortable for a while.
A few days later, shortly after 2.00am, during a routine check of his syringe
driver, the healthcare officer found that the man was showing no signs of life.
The HCO contacted the duty doctor and telephoned for an ambulance. The
man was pronounced dead at 3.08 am. The cause of death was recorded as
carcinomatosis and carcinoma of the colon.
At 3.30am, his mother was telephoned by the duty governor, and the news of
his death was broken to her. His mother had been expecting to hear of her
son’s death for several days, and the duty governor telephoned so that the
news could be passed on as quickly as possible. She had written to the
governor in July 2005 to ask that news of her son’s death did not appear in
any newspapers when it occurred. This request was passed onto the Press
Office on the morning of his death.
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Consideration of issues arising from the investigation
Quality of healthcare provided at HMP Wakefield
The clinical review, conducted by Wakefield West Primary Care Trust,
comments that the man was very well cared for by a dedicated and
professional team. The review found no significant failings or inadequacies in
the man’s healthcare and clinical management. The review team
commended the good quality of palliative care and effective team working.
They also identified five areas of good practice, each of which I endorse.
The clinical review also comments on the use of the Medical Record as a
communications device at Wakefield, and notes that nursing assessments
and plans were generally adequate and accurately recorded. It argues,
however, that the Medical Record was overused as a means of clinical
communication rather than as a device for recording significant clinical events.
The review also comments that some of the clinical entries are illegible, that
clinical records were not filed in date order and that they lacked a clear
structure.
Healthcare staff should develop a more effective and rigorous means to
communicate clinical team decision-making within the nursing process,
rather than using the medical record as the main channel for
communicating clinical events. Also, the clinical director should seek to
undertake an audit of clinical record keeping.
The clinical review also considers the advice given at the man’s review on 30
August 2005, when it was recommended that a syringe driver be considered
for his pain relief. The syringe driver was, however, not commenced until 7
September. The review notes that this delay was caused by confusion as to
the appropriate route by which the device could be obtained.
A procedure for accessing syringe drivers in HMP Wakefield should be
developed in collaboration with Wakefield West Primary Care Trust.
Healthcare staff should ensure the consistent and effective use of an
evidence-based pain assessment/scoring tool for the care of those with
palliative care needs and other patients with pain control needs.
The clinical review also comments on the standard of some of the nursing
notes at Wakefield. For instance, the nursing assessment completed on 15
November 2003 is noted by the review team to be partially completed to a
reasonable standard. However, the review notes that there is a “focus on
retrospective recording of clinical events rather than a proactive approach to
the nursing process”. The review also specifically identifies sparse
management plans entered into the man’s Medical Record on 16 June 2004.
Healthcare nursing staff should seek to develop and improve their
practice and understanding of the nursing process, specifically the
nursing assessment, care planning and review, and evaluation of
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nursing care, and how this process is recorded in the nursing
documentation.
The review team also considered the décor and environment of the healthcare
centre at Wakefield, in particular the inpatients area and palliative care suite,
to be of a poor standard.
The décor and general environment of the Healthcare Centre,
particularly the inpatients area and palliative care suite, should be
improved.
The man’s missed hospital appointment on 24 August 2004
The man was due to attend an outpatient’s appointment at a local hospital on
24 August 2004 in order to commence a course of chemotherapy. However,
he failed to attend the appointment and was therefore unable to take the
course. There is no record in his Medical Record of the reason why he failed
to attend the appointment.
A specialist registrar in oncology at a hospital in Yorkshire wrote to the doctor
at Wakefield on 5 August, following a consultation with the man on 3 August.
The registrar clearly confirmed at the end of the letter that the man’s next
appointment was for 24 August. There is, however, no record in the
healthcare centre diary at Wakefield to indicate that an appointment was
booked for this date.
The healthcare manager should review procedures for recording future
outpatient appointments and reasons for failure to attend scheduled
appointments
The man’s application for compassionate release on medical grounds
On 7 January 2004, the man’s solicitor wrote to the Lifer Review and Recall
Section (LRRS) of the Home Office to apply for his release on compassionate
grounds. The Lifer Casework Manual sets out the following criteria for
compassionate release on medical grounds for those prisoners serving a life
sentence:
• the prisoner is suffering from a terminal illness and death is likely to
occur very shortly (although there are no set time limits on life
expectancy, three months may be considered an appropriate period for
an application to be made to LRRS), or the lifer is bedridden or
similarly incapacitated, for example, those paralysed or suffering from a
severe stroke; and
• the risk of re-offending (particularly of a sexual or violent nature) is
minimal; and
• further imprisonment would reduce the prisoner’s life expectancy; and
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• there are adequate arrangements for the prisoner’s care and treatment
outside prison; and
• early release will bring some benefit to the prisoner or his/her family.
The man’s application was refused on 8 June 2004 by an LRRS caseworker
as it failed to meet a number of the criteria set out above. In particular, the
man’s medical reports showed that it was difficult to reach a consensus on his
life expectancy, with estimates of up to 12 months in March 2004.
There were no arrangements in place for him to take a hospice place on
release, and there was no suggestion that his treatment in prison was any
worse than that available in the community. There were indications that the
man presented a risk of re-offending, because of his failure to address
aspects of his offending behaviour. Although the application was refused,
LRRS asked the governor to monitor the man’s situation closely and, if there
were a change in his circumstances, to consider submitting a new application.
On 15 June, the man’s solicitor submitted an application for Judicial Review to
contest the decision to refuse release. The grounds submitted were that the
man’s illness entitled him to release, and that the failure of LRRS to refer the
case to the Parole Board amounted to a breach of Article 3 (the right not to be
subjected to torture or to inhuman or degrading treatment or punishment) of
the European Convention for Human Rights. This application was refused on
12 November 2004 by a Justice who found that detailed consideration had
been given to the case. The Justice also found that there had been no breach
of Article 3, as there was no obligation to refer such a case to the Parole
Board if it had been decided that the prisoner was not fit for release.
The man’s solicitor successfully sought permission to appeal against the
decision to refuse this application. The appeal was heard at the Court of
Appeal on 28 January 2005 and was dismissed. The Court again found that
there was no breach of Article 3.
On 7 April 2005, a second application for compassionate release on medical
grounds was received by LRRS. This application was supported by the
governor who judged the man as unable to sustain any concerted attempt at
violence and as presenting a low risk of re-offending. However, the governor
expressed reservations as to whether appropriate accommodation could be
found for the man.
A decision with regard to release was never made in response to the man’s
second application. As a result of his deteriorating condition, he now met all
of the criteria for compassionate release with the exception that there were no
adequate arrangements in place for his care and treatment in the community.
The prison had held discussions with a local hospice with regard to admitting
him. However his MacMillan nurse was of the opinion that the man had no
specialist palliative care needs that would warrant hospice in-patient
treatment. This view was shared by the prison’s medical officer who
confirmed that, with the support of his MacMillan nurse, the man was being
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managed well in the healthcare centre at Wakefield. A formal referral for his
admission to the hospice was not therefore made.
It is clear that, when the man’s initial application for compassionate release on
medical grounds was received and considered, he did not meet the specified
criteria and an appropriate decision was therefore made. The second
application was supported by the governor. However, a decision was not
reached on this second application as the man did not have the specialist
palliative care needs to warrant hospice in-patient treatment necessary. I
consider that the palliative care received by the man at Wakefield to be
exemplary.
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Recommendations and good practice
Recommendations
The governor should consider the following recommendations, of which
numbers 1-5 are highlighted in the clinical review:
1. The décor and general environment of the Healthcare Centre, particularly
the inpatients area and palliative care suite, should be improved.
2. Healthcare staff should ensure the consistent and effective use of an
evidence-based pain assessment/scoring tool for the care of those with
palliative care needs and other patients with pain control needs.
3. Healthcare nursing staff should seek to develop and improve their practice
and understanding of the nursing process, specifically the nursing
assessment, care planning and review, and evaluation of nursing care, and
how this process is recorded in the nursing documentation.
4. Healthcare staff should develop a more effective and rigorous means to
communicate clinical team decision-making within the nursing process, rather
than using the medical record as the main channel for communicating clinical
events. Also, the Clinical Director should seek to undertake an audit of
clinical record keeping.
5. A procedure for accessing syringe drivers in HMP Wakefield should be
developed in collaboration with Wakefield West Primary Care Trust.
6. The healthcare manager should review procedures for recording future
outpatients appointments and reasons for failure to attend scheduled
appointments.
Good Practice
The Clinical Review highlights the following examples of good practice:
1. Good quality of palliative care nursing and medical care delivered by the
prison healthcare team, the local NHS palliative care team and Macmillan
nurses, the Consultants in Oncology from local hospitals.
2. Effective and considerate care/custodial management interface within the
establishment, in particular the man’s effective yet kindly custodial care
management, especially during the latter part of his life.
3. Ensuring effective pain control was maintained during the man’s last few
weeks.
4. Ensuring that the man’s nutritional needs were effectively met through
liaison with an external professional dietician.
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5. Ensuring that the man’s mother could spend time with her son at the prison
during his last few days.
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