Individual at Wandsworth

Circumstances surrounding the death of a prisoner in March 2005 in
hospital whilst a prisoner at HMP Wandsworth
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2005
This is the report of an investigation into the circumstances of the death of a
prisoner at HMP Wandsworth. The man who is the subject of this report was
aged 59 when he died in March 2005 in hospital. At the time of his death, he
was serving a 20 year prison sentence at HMP Wandsworth.
I would like to extend my condolences to the man’s family and friends for their
loss.
The man who died had been diagnosed with lung cancer in October 2004. He
was undergoing chemotherapy when he developed a chest infection six days
before he died.
The investigation was led by one of my Investigators. A clinical review into his
care and treatment was undertaken by a qualified nurse who works in my
office.
I am grateful to the Governor and staff of Wandsworth for their co-operation
with this investigation. I have made no recommendations but have been
pleased to identify two examples of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2005
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Contents
Summary .........................................................................................................4
Investigation.....................................................................................................5
HMP Wandsworth............................................................................................6
The Man...........................................................................................................6
Events leading up to the man's death..............................................................8
Issues considered..........................................................................................10
Conclusion.....................................................................................................11
Annexes.............................................................................................................
Annex A – Notice of Investigation...........................................................12
Annex B – Terms of reference ...............................................................13
Annex C – Clinical Review......................................................................16
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Summary
The man who is the subject of this report was 59 years old when he died in
March 2005 at in hospital, while in the custody at HMP Wandsworth. He had
been seriously unwell since October 2004, when he was first diagnosed with
lung cancer. The man was undergoing chemotherapy with a view to
commencing radiotherapy when his condition deteriorated. He was taken to
hospital from Wandsworth in March, having developed a chest infection. He
died there six days later with his family with him.
According to the Clinical Review, it appears that the man received appropriate
care for his health while in prison. He had first consulted a doctor in
Wandsworth on 21 March 2003 about a cough. He reported a history of
asthma and the doctor treated him accordingly so that his condition improved.
His breathlessness on exertion was attributed to obesity, and he was advised
about diet.
The man did not consult the doctor again until October 2004. On this
occasion, he presented with an apparent allergic reaction causing facial
swelling. When it failed to resolve swiftly, he was sent to hospital as a medical
emergency. He returned to Wandsworth the next day, having been diagnosed
with inoperable cancer of the lung. A plan of treatment by chemotherapy was
put in place.
There are no recommendations arising from this investigation. The clinical
review raised no concerns, recording that there appears to have been no
difference in the care received by the man from that from which he would have
benefited had he not been in custody. The post mortem indicates that he died
from lung cancer.
I conclude, on the basis of the evidence I have seen, that his death was
unavoidable and that he was well cared for. I identify two examples of good
practice on the part of the prison.
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Investigation process
My practice when notified of a death from apparently natural causes is to
conduct an initial review to determine the extent of investigation required.
My colleague, visited HMP Wandsworth. She was provided with the man’s
prison record, and copies of the notices, reports and other records associated
with his death.
My investigator also gathered details of his next of kin and made contact with
the Coroner’s officer. One of my Family Liaison Officers, subsequently
contacted the man’s brother.
A qualified nurse was commissioned to carry out a clinical review.
Notices to staff and prisoners were distributed and displayed, telling them that an
investigation would be taking place the man’s death, and inviting anyone who wished
to see the investigator to make themselves known. No responses were received.
No formal interviews with staff were conducted. This report is based upon a thorough
review of all relevant records, and consideration of the findings of the clinical review.
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HMP Wandsworth
Wandsworth is a large category B local prison for men. It has a Certified
Normal Accommodation (CNA) of 1,173, with an operational capacity
(maximum crowded capacity) of 1,462. The prison currently functions at or
near this latter figure.
The main prison has five wings, and there is a separate vulnerable prisoner
unit of three wings. The jail holds a mix of long and short term prisoners, plus
those on remand.
The most recent inspection by Her Majesty’s Chief Inspector of Prisons was
conducted in May 2004. The Chief Inspector found that Wandsworth had
made progress since an inspection a year earlier. However, significant work
remained to be done to ensure a safe and respectful environment, providing
purposeful activity and meeting prisoners’ resettlement needs.
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The Man
The man who is subject of this report was born and brought up in an area of
Hertfordshire. He later settled in Kent, where he and his wife raised a family.
His wife died in December 1996. However, he remained close to his brothers
and mother, who supported him until his death. He was aged 59 at the time of
his death.
The man who died was serving a sentence of 20 years. He had first been
received into custody on remand at HMP Pentonville on 2 November 1994.
He spent some time at HMP Brixton, before moving to Wandsworth on 25
January 1996. Apart from a three week period at Belmarsh in 1999, he had
remained at Wandsworth since that time.
The man was a Listener (a prisoner who is trained by the Samaritans to
support other prisoners) and had many friends on his wing.
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Events leading up to 9 March 2005
The man’s first reception health screen was completed by a nurse at
Pentonville on 2 November 1994. It noted that his general health was good,
but that he had a history of being asthmatic.
There is no record of any significant health events while he was in Pentonville
or subsequently, during his trial, in Brixton. He first went to Wandsworth on
25 January 1996. Between 1996 and March 2003, the man consulted
healthcare about minor ailments, and was treated accordingly.
On 21 March 2003, he reported with what is described as a productive cough
(a cough producing phlegm). According to his medical records, because of
his previous history of asthma, he was treated with steroids and an inhaler. A
week later he was noticed to be much better, although still breathless when
climbing stairs. This was linked to him being overweight. He had been
advised that he needed to lose three stones in weight.
The man remained essentially well until 18 October 2004, when he saw the
doctor complaining of a swollen face. On 27 October, he was no better and
complained of breathing difficulty. He was treated for allergy with
antihistamines. When he continued to show no improvement, the doctor sent
the man to the medical emergencies department at the local hospital, for
investigations. On 17 November, he returned to the prison with a verbal
diagnosis of inoperable lung cancer. A comprehensive regime of medication
was prescribed and a stent (a fine tube) was inserted in the superior vena
cava – a major vein in the upper body - to improve blood flow.
Chemotherapy treatment began on 6 December 2004, the first of four planned
cycles. The second cycle of chemotherapy followed on 6 January 2005. The
third cycle of chemotherapy was hindered by an infection, which aggravated
the man’s asthma, for which he was treated in hospital from 3 to 7 February.
On 7 February, a doctor at the local hospital alerted the Health Care Manager
at Wandsworth that he had missed one or more clinic appointments. The
Health Care Manager acted swiftly to ensure there was no repetition. A third
cycle of chemotherapy was completed on 21 February.
At the beginning of March, the man developed another chest infection. In
view of the recent similar episode and his chemotherapy, the doctor at
Wandsworth transferred him to the hospital as a medical emergency. The
next day, his condition deteriorated due to a blockage in the stent. He had to
be artificially ventilated in the intensive care unit. He had surgery to remove
the blockage from the stent on 3 days later, but did not improve or regain
consciousness.
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The man’s initial bed watch consisted of two officers and restraints were used.
However, a review of the situation two days later resulted in the restraints
being removed and the bed watch being reduced to one officer.
He was visited by relatives on three occasions between his entry to hospital
and the day he died. His mother and two brothers were with him when he
died at 4:00 pm.
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Issues considered during the investigation
Wandsworth followed its contingency plans relating to deaths of prisoners.
Statements were taken from staff, the IMB were informed and notices to staff
and prisoners were issued. The post-incident response was fully compliant
with Prison Service instructions and policies on managing a death in custody.
The decision to review the use of restraints was entirely appropriate given the
circumstances. I think the Governor made the right decision, and commend
him for it.
There was evidence of effective liaison between doctors and nurses in the
primary health care service in the prison and with the secondary care services
in the hospital.
Consultation with the family during the preparation of this report raised no
concerns about the man's illness and death, or the way they were treated.
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Conclusion
The clinical review did not find any deficiencies in the man’s medical treatment
while at Wandsworth. It seems clear that he had a serious condition that could
have become acute at any time.
The man seemed settled in Wandsworth. I have seen no evidence to suggest
that he had any other problems that were affecting his mental or physical
health. Wandsworth acted quickly to get him to hospital when he weakened,
and ensured his family were aware and able to be with him when he died.
In conclusion, there appears to have been no difference in the care received
by the man from that which he would have received had he not been in
custody.
Good Practice
The prison took action to make sure he was able to attend all his outpatients’
appointments.
It was also good practice that, as the man’s health deteriorated, the prison
removed his restraints and reduced the number of staff providing the bed
watch.
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