Individual at Whatton

Investigation into the circumstances surrounding the
death of a prisoner at HMP Whatton,
in December 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2008
This is an investigation into the circumstances surrounding the death of a
prisoner at HMP Whatton. The man died on 26 December 2007 at a hospice
local to the prison. He was 49 years old. The cause of death was recorded
as acute bronchopneumonia due to metastatic carcinoma of the oesophagus.
He was a vulnerable man who was in poor health for much of his time in
custody and he received commendable care from all the staff at the prison.
Much thought, imagination and attention to detail was given to ensure the
man’s comfort and safety.
The man had not been in touch with his family for some years and none of his
relatives could be traced following his death. Nevertheless, I offer my sincere
sympathy and condolences to all those touched by the man’s death for their
loss. I also apologise to those affected by this report for the delay in
producing it.
The investigation was carried out on my behalf by one of my colleagues.
Unusually, my investigator had himself met the man and so is able to verify at
first hand that he was comfortable, although clearly very ill. An independent
review of the man’s medical care in prison was carried out on behalf of the
Nottinghamshire County Teaching Primary Care Trust. As ever, I am most
grateful to the clinical reviewer for his assistance.
I would also like to thank the Governor and staff of Whatton for their full and
ready co-operation during the course of the investigation. I am particularly
indebted to the prison liaison officer for the assistance she provided my
investigator.
I make two recommendations concerning the arrangements for terminally ill
prisoners and highlight one example of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2008
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CONTENTS
Summary 4
The investigation process 5
HMP Whatton 6
Key findings 7
Issues 15
Recommendations and good practice 18
3
SUMMARY
The man was remanded into custody on 11 October 2005. The following year
he was convicted and sentenced to five years imprisonment. The man had a
number of health problems when he was first received into prison, including
chronic obstructive pulmonary disease and asthma. Initially he did not settle
well into prison life, and in the first half of 2006 was monitored by the prison’s
suicide and self-harm procedures.
Following his transfer to HMP Whatton in September 2006, the man settled
better into prison life. At the time of his transfer, he began to complain of
persistent vomiting and abdominal pain. The man was referred to a local
hospital, where he underwent an examination on 29 November. The initial
examination was unable to find a cause for the man’s symptoms and a further
appointment was made, for a gastroscopy (an examination of the stomach
using a fibre optic camera), for 14 December.
Before the man could undergo this procedure, he was admitted to the local
hospital on 12 December, having experienced severe vomiting and abdominal
pain that morning. The gastroscopy went ahead two days later, and the man
was diagnosed with cancer of the oesophagus (the tube that connects the
mouth to the stomach).
The man remained as a hospital inpatient until 10 April 2007. In that time he
began a course of chemotherapy which, due to a gastro-intestinal bleed and a
chest infection, he was unable to complete. The man also underwent an
oesophagectomy (surgical removal of the part of the oesophagus where the
tumour was situated). This procedure was a success and, after a slow
recovery, the man was able to return to Whatton.
Around a month after his discharge from hospital, the man began to report
pain in his right arm. Following a biopsy in early July, he was diagnosed with
skin cancer. He subsequently underwent radiotherapy on 31 July, which
reduced his pain over the next few weeks.
Over the next four months, the man lived on the wing at Whatton and was
cared for by healthcare staff. His health gradually deteriorated over this time,
although he was usually in good spirits and enjoyed a good relationship with
staff. On 11 December, the man was released on temporary licence and took
a bed in a local hospice. His condition continued to deteriorate and he died at
2.55pm on 26 December.
My report shows that the man received commendable care from the
healthcare staff at Whatton. However, I make recommendations in two areas.
Firstly, whilst the clinical review concludes that the provision of medication to
the man was adequate, there were times when his regime had to be changed
due to suspected bullying for his analgesia (pain relief). Secondly, I consider
whether the man might have benefited from full-time inpatient care.
4
THE INVESTIGATION PROCESS
1. The investigation was opened on 9 January 2008 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 did not interview
any members of staff during the course of the investigation. He hoped to
interview the former healthcare manager, although was unable to do so as
she is no longer employed at the prison. My investigator was, however,
able to tour the prison, including the room in which the man lived.
2. My investigator was given access to the man’s prison files, including the
medical record. An independent clinical review of the man’s health needs
whilst he was in custody was carried out on behalf of the Nottinghamshire
County Teaching Primary Care Trust (PCT).
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HMP WHATTON
3. Whatton is a category C prison located around 20 miles from Nottingham.
It is a specialist establishment for adult male sex offenders who are
required to participate in the Sex Offender Treatment Programme.
Additionally, prisoners should not require the services of a full-time
medical officer.
4. Healthcare in the prison is commissioned and provided by the
Nottinghamshire County Teaching PCT.
5. There are no inpatient healthcare beds and no 24 hour healthcare service
in the prison, with no medical staff on site during the evening or overnight.
An out of hours service is provided under contract by Nottingham
Emergency Medical Services (NEMS).
6. Medication is administered on a weekly and/or monthly basis to those
prisoners who have been risk assessed as suitable to hold it in their own
possession. It is administered on a daily basis to other prisoners, when
either they are considered to be at risk or the medication is considered
unsuitable to be held in their possession.
7. Whatton was last inspected by Her Majesty’s Chief Inspector of Prisons,
Ms Anne Owers, in January 2007. Ms Owers found that, whilst the
healthcare unit was a clean and clinical environment, “waiting times for the
GP were unacceptably long and a major concern”. In response to my draft
report, the Governor has commented that waiting times to see a prison
doctor are now 24-48 hours.
8. The Independent Monitoring Board (IMB) annual report of 2006/07 raised
a number of concerns regarding the provision of healthcare at Whatton.
Significantly, one of these concerns regarded the availability of palliative
and social care for a terminally ill prisoner.
9. This is the 12th death to have occurred at Whatton since April 2004, when I
began investigating all deaths in prison custody in England and Wales. It
is the tenth due to natural causes. There has subsequently been one
further death of a prisoner at Whatton, again from natural causes.
10. Of the previous cases that I have investigated at Whatton, three were of
patients suffering from terminal cancer. In one of these cases I
recommended that the Governor and PCT should develop a protocol to
ensure palliative care for patients is kept under review. This
recommendation was accepted in January 2008.
6
KEY FINDINGS
11. The man was remanded into custody to HMP Nottingham on 11 October
2005. A first reception health screen (a routine health screen for all new
arrivals into prison) was carried out following his arrival at the prison. At
his reception health screen, the man revealed that he had recently had
tuberculosis (TB). He also said that he was asthmatic. As a precaution,
he stayed overnight in the healthcare centre’s inpatient’s unit, until he
could see the prison doctor on the following day.
12. The following day, the man’s doctor in the community was contacted. He
confirmed that the man had been diagnosed with TB in January 2005.
The doctor also detailed a history of alcoholism, chronic obstructive
pulmonary disease (COPD, the restriction of airflow to the lungs due to the
narrowing of airways), asthma, learning difficulties and acute bronchitis.
13. The prison doctor wrote to the consultant ophthalmologist (eye specialist)
at a hospital in the man’s home area on 28 October, to clarify details of
some eye problems that the man had reported. The consultant replied on
2 November, detailing a history of chorioretinitis (inflammation of the
retina) from December 2004. He added that the man required follow-up
within the next few weeks, and agreed with the prison doctor’s suggestion
that referral to a hospital local to the prison was appropriate. An
appointment was subsequently made at the eye clinic at this hospital on
22 November.
14. The man had taken a cell on the Vulnerable Prisoners’ Unit (VPU) at
Nottingham, due to the nature of his offence. He was initially noted to be
settling well into prison life and was interacting well with his fellow
prisoners. However, on a number of occasions in late 2005 he
complained of breathlessness and a chest infection. He was prescribed a
course of antibiotics by the prison doctor.
15. The good start to the man’s prison life did not last, however. On 6
February 2006, an Assessment, Care in Custody and Teamwork (ACCT,
the form used by the Prison Service to monitor and support persons
deemed to be at risk of suicide or self-harm) form was opened after the
man made small lacerations to his left arm with a razor blade. He again
made superficial cuts on five further occasions in February and on one
occasion in March. The man also received a number of warnings about
his abusive behaviour towards staff.
16. The ACCT document was closed on 27 March, but re-opened just five
minutes later when the man again made superficial cuts to his arm. He
transferred to HMP Woodhill on 7 April, with the ACCT document still
open. It was closed sometime during the man’s time in Woodhill, although
I am unfortunately unable to say when as the necessary documentation is
missing.
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17. On 12 April, the man was seen by a prison doctor, after complaining of
having a cough which produced a green phlegm. He was prescribed a
course of amoxicillin (an antibiotic). Around a month later, on 15 May, the
man was seen again by the doctor. He continued to complain of a painful
phlegmy cough and was diagnosed with bronchitis. The doctor now
prescribed a course of doxycyclin (another antibiotic).
18. Following his conviction on 19 May and subsequent sentencing on 29
June, a progressive transfer to HMP Whatton was arranged for the man.
Before a prisoner is transferred to Whatton, a nurse at the sending
establishment is required to complete a healthcare assessment form. In
the man’s case, it was completed by a nurse from HMP Woodhill on 9
August. She described his medical history, including COPD, and referred
to his history of self-harm.
19. The man subsequently transferred to Whatton on 5 September. His
medical history was detailed at a reception screen. An F2052SH (the
suicide/self-harm monitoring form that preceded ACCT as Whatton had
not yet introduced the ACCT system) was opened as the man said that he
was very nervous and concerned about his safety at Whatton. He also
said that he was depressed and anxious about his physical health.
20. Two days later, the man saw a prison doctor and complained that he had
been vomiting since the previous day. The symptoms continued and over
the course of the next week the man also experienced dizziness and
abdominal pain. He was not eating well and was put on a course of
Fortisips (a nutritional drink).
21. The F2052SH was closed on 21 September, as the man had settled well
at Whatton. However, he continued to complain of vomiting and
abdominal pain, and was reported to have lost 3kg in weight over the
course of the previous week. A request was therefore made to the kitchen
for the man to have a soft diet (soup, rice pudding etc) in addition to the
Fortisips.
22. An urgent gastroenterology (the branch of medicine concerned with the
digestive system) referral was made by a prison doctor on 27 September.
The doctor described the man’s symptoms as “several weeks of recurrent
vomiting after eating” and a “vague sharp central abdominal pain”.
23. Having heard nothing following his initial referral, the prison doctor made a
second referral on 9 October. He wrote that the man’s exact diagnosis
was unclear and he had not responded to any interventions that they had
made so far. Following the second referral, an appointment was made for
the man to see a consultant gastroenterologist at a local hospital on 29
November.
24. An ACCT document (Whatton had by now converted to the new system)
was opened on 23 October, as the man had made a minor cut to his left
arm. He was low in mood and said that he was distressed because his
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stomach problems were preventing him from eating. The document was
closed around three weeks later, on 15 November.
25. The man duly attended his appointment at the hospital on 29 November.
The Consultant Gastroenterologist was unable to determine a cause of
the man’s vomiting and weight loss from his initial examination. He
therefore requested that a gastroscopy (an examination of the stomach
using a fibre optic camera) be arranged. An appointment was
subsequently sent through for 14 December.
26. On 12 December, a nurse was called to the man’s cell as he had been
vomiting profusely and was complaining of abdominal pain. The nurse
took clinical observations, including the man’s blood pressure which, at
85/65, was low. On account of this, and the severe pain that the man was
in, an ambulance was called and he was transferred to the local hospital.
He was admitted as an inpatient on arrival.
27. The man remained as a hospital inpatient for four months until 10 April
2007. He underwent the gastroscopy as planned on 14 December 2006,
when a tumour of the oesophagus (cancer of the oesophagus, the tube
that connects the mouth to the stomach) was diagnosed. The man began
a course of chemotherapy on 27 January 2007. Unfortunately, due to a
gastro-intestinal bleed and a chest infection, the course had to be
abandoned.
28. Because Whatton has no inpatient provision, discussions were held with
other prisons in the area with regard to accommodating the man on his
discharge from hospital. Both HMP Lincoln and Nottingham were unable
to take the man, although healthcare staff at HMP Leicester thought that
they might be able to accommodate him.
29. A nurse from Leicester subsequently visited the man in hospital to assess
whether they could care for him. Prior to her visit, the man took a turn for
the worse. It was now thought that he would die within the next three
months. He was receiving medication through a syringe driver (a plastic
syringe that delivers small amounts of a drug continuously through a
battery operated pump) and was deemed to need full time nursing care.
On 15 February, Leicester reported that they would be unable to admit the
man as their staff could not manage the syringe driver or the nursing care
that he needed.
30. The then healthcare manager at Whatton wrote to the ward manager at
another local hospital (to where the man had been transferred) on 20
February, following a meeting on 16 February. The healthcare manager
wrote that it was clear that the man would be most appropriately cared for
in a nursing home, and that it had been agreed that staff at the hospital
would arrange this via the Social Services Department.
31. On 15 March, the man underwent an oesophagectomy (surgical removal
of the part of the oesophagus where the tumour is situated). The
9
operation was a success and the tumour was fully removed, although the
man’s post-operative recovery was difficult due to another chest infection.
32. The man eventually recovered well from the surgery and improved
considerably. It was therefore agreed to discharge him back to Whatton,
rather than to a nursing home or hospice. He returned to Whatton on 10
April following a discharge review at which it was agreed that the man did
not need any specialist care at the present time. The man settled back
well at Whatton. He did not need help with physical activity but staff had
to cajole him into eating properly.
33. Following his discharge, the man was prescribed a substantial quantity of
medication. This included oromorph (a strong morphine based painkiller)
and salbutamol (for COPD) to take as required. He was also prescribed a
number of other painkillers, including fluoxetine (an antidepressant),
olanzapine (an antipsychotic), diazepam (a sedative), procyclidine (used
to control the side effects of antipsychotics), lansoprazole (to reduce acid
production in the stomach) and paracetamol (a painkiller). A care plan
was produced that determined that the man’s medication would be
prepared and dispensed by two nurses in healthcare, once in the morning
and again in late afternoon. The care plan also indicated that medication
should be locked in the man’s cell cupboard.
34. Concerns were raised on 19 April that the man’s carer (a prisoner who
helped him when necessary with cleaning his cell and fetching meals)
may have been taking some of his morphine from him. The carer was
subsequently replaced. Despite this, the man was in good spirits. On 27
April, the man was taken off oromorph following a review as it was
determined that he no longer required it.
35. The man reported pain in his right arm on 22 May. The prison doctor
suspected either an abscess (a collection of pus) or metastases (cancer
cells that have spread). He referred the man for an x-ray, the results of
which, on 31 May, were normal. However, the man continued to complain
of pain in his arm and his stomach.
36. At a review with a prison doctor on 15 June, the man said that the pain in
his arm had increased further. The doctor therefore increased his
morphine. At a nursing review three days later, the lump on the man’s
arm was noted to be growing and painful to touch. The following week,
the man reported that the pain in his arm was worse still. An appointment
was therefore arranged at one of the local hospitals for a biopsy on 2 July.
The results, which were received on 6 July, confirmed a squamous cell
carcinoma (skin cancer).
37. The healthcare manager contacted other healthcare managers at
Nottingham, Leicester and Lincoln prisons again on 5 July. She asked if
they had any beds available for the man in the event of his deterioration
and need for further nursing care. All three prisons said that they were
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unable to offer any accommodation. It does not appear that the
application to the three prisons was taken any further.
38. Over the following few weeks, the man continued to experience pain in his
arm. His morphine was increased on 20 July when he said at a review
that he usually woke up in the morning in a lot of pain. At a further review
on 30 July a second prison doctor, noted an obvious increase in the size
of the man’s tumour.
39. The man attended outside hospital the following day for radiotherapy (the
use of high energy x-rays to destroy cancer cells in the treated area) to his
upper arm. In the days after his radiotherapy, the man reported that the
pain in his arm had decreased. At a nurse review on 5 August, the man’s
arm was noted to be more swollen than previously. There were also
blisters forming on his skin due to burns from the radiotherapy. The nurse
called the out of hours service for advice, and antibiotics were prescribed.
40. By the middle of August, the man said that he was feeling much better
and his pain control was much improved. Nevertheless, the second
prison doctor referred him to a local hospice and specialist palliative care
cancer unit, on 21 August. In her letter, the second prison doctor
requested advice on the man’s medication. She also raised the possibility
of the man being cared for at the hospital should he deteriorate further.
41. Towards the end of August, the man’s pain began to increase again. He
was visited by two Macmillan nurses from the hospice on 5 September.
The first of the nurses wrote to a prison doctor, the following day, in which
she made suggestions for changes to the man’s medication. This
involved increasing the man’s dose of MXL (a morphine based painkiller)
so as to provide adequate pain relief.
42. The man was initially happier with his new medication, and reported on 8
September that he was relatively pain free. An entry on 11 September
indicated that he attended for his evening medication and was not given
opiate analgesia (Sevredol) to take away “as per area manager [who was
actually acting healthcare manager, not area manager] who does not
support this”. At the time, the man was issued with Sevredol on a daily
basis, to take as he required. The next entry, on 14 September, notes
that the man was issued Sevredol to take as required, together with his
other prescribed medication.
43. Over the following days, the man continued to complain of pain. However,
he was noted to be using the Sevredol to good effect. It is also clear that
he had Sevredol in possession, as was detailed on his prescription chart.
The man was seen again by the Macmillan team on 20 September,
followed by a multi-disciplinary meeting also attended by the prison doctor
and a consultant in palliative medicine at the hospice. The doctor from the
hospice wrote to the prison doctor the same day to summarise the main
issues. He requested that Whatton arrange a hospital style bed and
pressure relieving mattress, so that the man could be as comfortable as
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possible. The doctor added that the hospice would be willing to accept
the man as an inpatient when he reached the terminal phase of his illness
and was bed bound.
44. The doctor from the hospice also emphasised the importance of the man
having access to his full PRN (as required) medication to deal with his
pain control. It was thought that the man may have been at risk of bullying
from other prisoners regarding this medication (particularly Sevredol).
The Head of Residence, therefore agreed to explore options for storing
the man’s medication. At the time, the man collected his Sevredol from
healthcare on a daily basis.
45. The hospital bed arrived on 5 October but, due to its size, it had to be put
in a cell on A wing rather than B wing, where the man lived at the time.
The man said that he was happy to move to A wing, but that he would
miss his friends on B wing. The same day that the bed arrived, the
hospice doctor visited the man again. He noted that the man seemed
much brighter than he had done previously and that his pain was very well
controlled at present. He also noted that the man was able to shower and
dress himself but that his fellow prisoners were helping him with his
personal care. In a follow up letter on 8 October, the hospice doctor
confirmed that they would be able to take the man when he was bed
bound and in the last few days of his life.
46. At a nurse review on 9 October, the man said that he had been
approached by a prisoner on B wing the previous day. The prisoner had
asked for some of the man’s medication. At a review the following day,
the man said that he had been approached twice in the past for his
medication. It was agreed that his Sevredol would now be delivered to the
man’s cell by healthcare staff and locked in a cupboard in his cell. The
key to the cupboard would be held by staff in the wing office.
47. At lunchtime on 19 October, healthcare staff were called to A wing to see
The man, as he was feeling unwell. The nurse who attended noted that
the man was hot and sweaty, his chest was rattling and he looked very
unwell. The nurse contacted the on-call doctor, who visited the man later
that afternoon. The doctor noted that The man had markedly deteriorated
and suspected bronchopneumonia. He arranged for the man to be
admitted immediately to a local hospital.
48. The man was discharged from hospital four days later on 23 October,
having been treated during his inpatient stay with intravenous antibiotics.
He was discharged with a further course of oral antibiotics, with no
changes made to any of his other medication.
49. Three days later, the man was reported to have fallen in his cell overnight.
He went to healthcare and, whilst no bruises were noted, he appeared
pale and unwell. Due to the man’s frailty, he was escorted back to the
wing in a wheelchair. The following day, a nurse went to the man’s cell to
issue him with medication. She found the man looking unkempt and
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noted that his cell was in a mess. The nurse again issued the man’s
medication on 29 October. On this occasion she noted in his medical
record her concern that wing staff were struggling to cope with his
deteriorating condition.
50. The prison doctor reviewed the man on 29 October. She noted that the
tumour to the man’s right arm had increased in size. On the same day,
intelligence was received that the man was selling his Sevredol for
cigarettes. The prison doctor made it clear that the man’s medication
should not be reduced in case he had pain at night. It was decided to try
giving the man extra tobacco in the hope that this would discourage him
from trading.
51. The man was reviewed again by the prison doctor on 1 November. She
noted that his level of mobility had decreased and he was now having
difficulty getting out of bed by himself. The hospice was asked whether a
bed was available for the man should he deteriorate further. The prison
doctor was told that they were currently full, but that a bed might be
available in the next week should it be necessary.
52. In early November, the man was weakened by a serious bout of
diarrhoea. Despite this he was still able to potter about the wing, although
he also began to report difficulty swallowing his medication. As a result,
his tablets were changed to capsules, which he found much easier to
swallow. The man’s hygiene needs were now being met by a healthcare
assistant who had been assigned to look after him. The healthcare
assistant was funded by the local PCT and would sleep in a room on the
wing overnight, attending to the man as necessary.
53. A room at the hospice became available on 9 November. However, as
the man was still able to walk around it was decided that he did not
warrant the hospice bed yet. The man improved over the next week or so,
and he was noted to be more alert, brighter, and more mobile. His
medication was changed on 20 November, following concerns that the
man had to ring his cell bell at night to get wing staff to open his locker to
get the medication. By 28 November, the man’s pain control was reported
to be much better and he was now using less Sevredol.
54. The pain remained reasonably well controlled in the first week of
December. Following discussion with the Macmillan team at the hospice,
a full air mattress was provided on 6 December, as the man had been
experiencing pressure sores. The man remained in good spirits and was
comfortable once his mattress was in place.
55. On 10 December, a side room became available at the hospice. It was
arranged for the man to move in the following day. He was therefore
released on a temporary licence on compassionate grounds on 11
December. A risk assessment was completed to determine the level of
security required. The then Governor in charge of Whatton wrote that “the
nature of his offences mean that he must be accompanied by staff”. The
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man was therefore accompanied by a prison officer throughout his time at
the hospice but handcuffs were not used. The officer was instructed to
wear civilian clothes.
56. In response to my draft report, the Governor of Whatton wrote that the
officer accompanied the man at the hospice “more for support than
security”.
57. By 19 December, the man’s condition had deteriorated and a syringe
driver was now being used for his pain relief. He died at 2.55pm on 26
December. A post mortem report revealed the cause of death to be acute
bronchopneumonia due to metastatic carcinoma of the oesophagus.
58. The man’s next of kin was his brother. He was also believed to have a
sister-in-law, the wife of a brother who had died. Sadly neither relative
could be traced. The man’s funeral was therefore arranged by prison staff
and took place on 10 January 2008.
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ISSUES
Quality of care provided at Whatton
59. The clinical reviewer comments on the difficult challenge of managing a
patient with a terminal illness in a prison setting. Nevertheless, he
describes the medical care that the man received at Whatton as “entirely
appropriate”. He describes the healthcare staff’s record keeping as
“accurate and contemporaneous” and remarks on how this enabled
continuity of care to be achieved.
60. The clinical reviewer goes on to say that he “cannot find any significant
shortcomings in how the man was managed whilst at Whatton”. Indeed,
he praises the nursing and healthcare staff for accommodating the man as
much as they could, and recommends that they are commended for their
diligence.
The Governor should commend healthcare staff for the diligent and
professional manner in which they cared for the man.
Medication
61. The clinical reviewer comments in his clinical review that “providing in-
possession controlled drugs to a patient with terminal care is fraught with
problems in the prison setting”. There are a number of examples of staff
at Whatton encountering difficulties in providing the man with his
medication. This is particularly the case with Sevredol, which is an opiate
based painkiller and hence is highly valuable to other prisoners.
62. On several occasions in September and October 2007, concerns were
raised that the man may have been being bullied for his medication.
Indeed, on 10 October, the man said himself that he had been
approached twice for his medication. There was also intelligence that the
man might have been trading his medication for cigarettes.
63. Following the allegation of bullying on 10 October, it was agreed that
healthcare staff would deliver the man’s Sevredol to his cell, where it
would be locked in his cupboard. The key would be kept by wing staff.
Prior to this, the man had collected his Sevredol in person from healthcare
and had held it in possession (with the exception of one incident on 11
September 2007 when, confusingly, the man was denied his in-
possession medication). A more imaginative initiative was to try giving the
man extra tobacco to reduce his need to trade his medication.
64. The decision to hold the man’s Sevredol in a locked cupboard in his cell
appeared to work well in reducing any alleged bullying. However, there
were still some difficulties accessing the medication at night because staff
held the key. This led to a change in his medication on 20 November.
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65. The clinical reviewer concludes that “nursing and discipline staff both tried
to make the best of things but it is the reality of prison life that not all
prescribed medication will end up where it is intended”. He goes on to say
that, despite these difficulties, “the provision of medication to ease the
man’s suffering was adequate”.
66. It is clear that healthcare staff at Whatton encountered difficulties in
ensuring that the man was able to access his required medication.
However, each problem was dealt with sensibly and quickly.
Nevertheless, it would be wise to try to prevent such problems from
occurring in the future.
The Healthcare Manager should create an action plan to cover the
provision of medication for terminal patients.
Suitability of Whatton to house a terminal patient
67. When the man’s health deteriorated and he entered the terminal phase of
his illness he was able to take a bed in a local hospice on 11 December
2007. The clinical reviewer describes the man’s admission to the hospice
as “entirely appropriate”. A bed had been available for the man in early
November. However, he was still mobile at the time and it had been
agreed with the hospice that admission would not be arranged until the
man was bed bound.
68. As I have commented earlier, the clinical reviewer says that the medical
care that the man received at Whatton as “entirely appropriate”. However,
he goes on to consider the lack of inpatient facilities at Whatton. The
clinical reviewer comments that:
“The availability of a bed in a healthcare department to cover overnight
and weekend care is essential when diagnosed terminal care patients
are under the charge of a prison. The inexorable deterioration in health
and inability to self-care is all too predictable…These patients require
individual care and security assessments and if their needs cannot be
fully accommodated by changes in procedures, without discriminating
other prisoners or placing staff at risk, then they should be transferred.”
69. The healthcare managers at Leicester, Lincoln and Nottingham, prisons in
the area that do have inpatient facilities, were twice asked by the
healthcare manager if they would be able to take the man. On the first
occasion, in February 2007, a nurse from Leicester assessed the man in
hospital. They later said that they would be unable to take him, as they
did not have the facilities to manage the syringe driver that it was thought
that the man would need on discharge. On the second occasion, in July
2007, all three prisons decided that they were unable to offer
accommodation.
70. Whilst the care that the man received at Whatton was entirely appropriate,
it is likely that he would have benefited further from the full time care that
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would have been available had he lived on an inpatients wing. I accept
that the appointment of a healthcare assistant in the last weeks of the
man’s time at Whatton was beneficial to him and, effectively, led to there
being 24 hour healthcare cover available to the man. However, this does
not disguise the fact that staff twice attempted to arrange a transfer to a
prison with inpatient facilities, but were unsuccessful.
71. The reluctance of other prisons in the area to take the man is
disappointing. There are a number of factors that the receiving
establishment must consider in such circumstances, including the
availability of a bed in their healthcare centre. However, I would expect a
terminally ill prisoner to be a high priority in assigning beds. I do not
consider that a terminally ill patient should be in a prison without 24 hour
medical care, unless there are exceptional circumstances.
72. Prison Service Order (PSO) 3050 considers the continuity of healthcare
for prisoners. It provides details of the information that should be shared
between establishments once the transfer of a prisoner with significant
health issues is agreed. However, there appears to be no national
guidance on how to arrange such a transfer, or the responsibilities of the
Service as a whole to those who are terminally ill.
The National Offender Management Service should review its
policies and practices in respect of prisoners requiring 24 hour
medical care who are currently in establishments with no inpatient
facilities.
73. The Governor of Whatton submitted the following in response to my draft
report:
“The prison has now extended its healthcare hours to cover the new
core day, and believe that it is possible to deliver a standard of nursing
care which is equivalent to that offered in the community through
responding flexibly to individual patient need, rather than being a
necessity to extend its cover to 24 hours. A palliative care lead nurse
has been appointed, and Whatton now holds a monthly multi-
disciplinary palliative care meeting to review patients with cancer
diagnosis, and those on Liverpool Care Pathway. Towards the end of
the man’s life, his care was being led by a nominated nurse who liaised
regularly with the wing staff to ensure that the man was cared for with
dignity and respect, giving a more positive end of life experience
among people he knew. It is felt that location in a 24 hour prison health
centre would not have improved his care or personal experience.”
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RECOMMENDATIONS
1. The Healthcare Manager should create an action plan to cover the
provision of medication for terminal patients.
Partially accepted – rather than develop an action plan, the prison/PCT
have already put in place a new policy for medicines management, a
policy for managing controlled drugs and a policy for the delivery of
medication by syringe driver.
2. The National Offender Management Service should review its policies
and practices in respect of prisoners requiring 24 hour medical care
who are currently in establishments with no inpatient facilities.
Local response – at HMP Whatton, the man received the same level of
care, if not better, than he would have had in a community setting. “24
hour” inpatient care was not required as extra staff were used to
support him during the night, and when he required further specialist
care he was transferred to the Hospice. The idea that 24 hour care
units are on a parity to the NHS is not the case. The treatment plan
devised by the prison’s healthcare and the prison demonstrate that
when the man required support from Hospice service he was
transferred and that, throughout, he was supported in a sensitive and
wholly appropriate way by staff.
National response – transfer of patients to another prison to provide
additional care should only occur if it is totally essential. Although there
is currently no policy on the transfer of patients, it should occur on a
case by case basis taking into account the level of necessity. If NOMS
were to review this it should be in consultation with Offender Health.
GOOD PRACTICE
3. The Governor should commend healthcare staff for the diligent and
professional manner in which they cared for the man.
Local response – the report commends the care and support provided
for the man by the Health Team, but does not mention the managers
and prison officers on A8 who were exceptional in their understanding,
care and support for the man.
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