Individual at Whatton

The death in custody of a prisoner
HMP Whatton – 24 April 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2004
This is the report of an investigation into the circumstances of the death of a
prisoner at HMP Whatton on 24 April 2004.
All deaths of prisoners in custody are investigated, including those due to
natural causes. The responsibility for carrying out these investigations
traditionally fell to the Prison Service itself, but has now been passed to the
Prisons and Probation Ombudsman (PPO) to bring independence and greater
consistency to the task.
In this case a member of the PPO’s staff has carried out the investigation. An
independent clinical review was commissioned from the Director of Public
Health at Rushcliffe Primary Care Trust.
The prisoner died in Queens Medical Centre (QMC), Nottingham, during his
treatment for an inoperable aggressive pancreatic tumour. He was serving a
five­year prison sentence at Whatton Prison at the time of his death.
My colleagues and I would like to extend our condolences to the prisoner’s
family for their loss. I would also like to thank the acting Governor in charge of
Whatton Prison at the time of my investigator’s visit, and the other members of
his staff who assisted us. My investigator found staff especially helpful. In
particular, all the documentation he required had already been gathered
together for him.
Stephen Shaw
Prisons and Probation Ombudsman
July 2004
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Contents
CONTENTS......................................................................................................................................3
SUMMARY.......................................................................................................................................4
BACKGROUND...............................................................................................................................5
INVESTIGATION PROCESS..........................................................................................................6
THE EVENTS LEADING UP TO THE PRISONER’S DEATH.....................................................7
POST INCIDENT RESPONSE.......................................................................................................7
LEVEL OF COMPLIANCE..............................................................................................................8
FINDINGS........................................................................................................................................9
CONCLUSIONS...............................................................................................................................9
RECOMMENDATIONS...................................................................................................................9
GOOD PRACTICE...........................................................................................................................9
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Summary
The prisoner died at the age of 58 at Queens Medical Centre (QMC),
Nottingham, while undergoing treatment for an aggressive pancreatic cancer.
He was serving a five­year prison sentence atWhatton Prison. His death was
not connected to the fact that he was in prison or to the level of care that he
received there.
The prisoner was a person with multiple medical problems, including jaundice,
DVT, multiple pulmonary emboli, pneumonia and pancreatic cancer.
This was the prisoner’s first conviction and, though he was not familiar with
prison life, he appeared to settle well. The prison describes him as a quiet but
determined man, with good custodial behaviour.
The report includes one recommendation.
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Background
The prisoner was born in December 1945 and was 58 years old when he died
on 5 April 2004.
He served as a Paratrooper in the British Army, but was discharged in 1971
following an accident in which he sustained serious burns.
The prisoner had been married three times, but was living with another partner
at the time of his arrest. He was the father of seven children – two girls and
five boys. On reception to prison the prisoner gave his next of kin as his
second wife.
This was the prisoner’s first conviction and was imposed on 16 October 2002
at York Crown Court. He was given a five­year prison sentence for rape.
At the time of his death, he had been in Whatton Prison since 19 December
2002.
The prisoner was well known to the staff at Whatton Prison, and particularly to
the healthcare staff who had dealt with many of his physical problems.
The prisoner was admitted to the QMC on 16 January 2004, following
complaints of abdominal pains, indigestion and jaundice.
In the meantime the QMC treated the prisoner for two episodes of chest
infection. He was subsequently re­admitted to hospital in late February with a
further chest infection and then developed a blood clot on the lung.
During this time, he was found to be suffering from pancreatic cancer that was
ultimately deemed inoperable. He remained in hospital until his death on 24
April 2004.
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Investigation process
All the indications were that this was a death from natural causes. The
Ombudsman’s Terms of Reference permit in these circumstances, that it may
be sufficient for a clinical review to be carried out by an independent health
care professional, rather than a full investigation. My approach in cases of
apparent natural cause deaths has been to conduct an initial review to
determine if a full investigation is justified. In this prisoner’s case, I decided
that the circumstances did not require a full investigation.
I did so after the investigator visited Whatton Prison and had a very helpful
discussion with the Deputy Governor1 as well as the Healthcare Manager.
The investigator recommended that a full investigation was not warranted and
I agreed that this procedure should apply in this case.
The investigator visited the Unit where the prisoner spent much of his time in
prison. He met the Chairman of the local Prison Officer’s Association (POA),
and the Chair of the Independent Monitoring board (IMB). Neither the POA nor
the IMB had any issues they wished to draw to the investigator’s attention.
The investigator was given access to all the prisoner’s prison records,
including his medical records, and was given copies of everything that was
required.
The Deputy Governor had spoken to his ex­wife 2 the recorded next of kin, and
explained that there would be an investigation. His ex­wife was sent a letter
by the investigator inviting her to get in touch to make any comments or ask
questions if she wished. She wrote to me, with copies of entries in her
husband’s diary. This is a record kept by the prisoner regarding his medical
treatment.
The Director of Public Health, of the Rushcliffe Primary Care Trust carried out
the clinical review. A medical report sent to him, from the person who was in
charge of the prisoner’s care at QMC, is also available.
1 The Governor was absent from the establishment at the time of the visit.
2 The second of the prisoner’s three wives.
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The Events Leading up to the prisoner’s Death
The prisoner was admitted to QMC on 16 January 2004, following complaints
of abdominal pains, indigestion and jaundice. At the time, it was thought that
the jaundice could be caused by an obstruction due to cancer, but further tests
were required.
In the meantime, the QMC treated the prisoner for two episodes of chest
infection. He was not happy about his treatment at the QMC, as he felt he
needed further hospital treatment. However this would have been for his
chest and not for the troubles in his stomach.
The prisoner was subsequently re­admitted to hospital in late February with a
further chest infection and then developed a blood clot on the lung.
During this time, the prisoner was found to be suffering from pancreatic
cancer, which at first was thought to be operable and was admitted in early
April to the QMC for surgery. Shortly after this, the prisoner’s cancer was
deemed inoperable and he remained in hospital until his death on 24 April
2004.
Throughout these periods at the QMC, the prisoner was still in prison custody.
Due to the nature his offence, he was not eligible for Release on Temporary
Licence. However at the time of his death, the prison were attempting to
secure a compassionate release, possibly to a hospice.
Regrettably he died before a decision was reached.
Post Incident Response
All the necessary information was gathered together for the purposes of the
investigation, and arrangements were made for the investigator to see the
relevant members of staff so that we could satisfy ourselves as to the way the
prisoner had been cared for.
The Duty Governor of the prison broke the news of the prisoner’s death to his
ex­wife, whom he had named as his next of kin. This seems to have been
appropriately and sensitively handled.
As the prisoner died in hospital of cancer, the hospital did not appreciate the
significance of informing the Coroner that he was in prison custody. This was an
oversight from the Hospital that the Coroner has addressed.
An autopsy was not carried out for the same reason.
The prison informed the Coroner by letter on 26 April 2004. This letter was returned
some weeks later as undelivered on 26 May 2004 and a copy was immediately re­
sent. The Coroner's Office then contacted the prison on 1 June 2004 and an
explanation was given. The coroner then contacted the prison on 3 June 2004
indicating that he was not intending to hold an inquest. This was for the sake of the
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family. The funeral had taken place, and the Coroner was satisfied with the hospital’s
opinion on the cause of death.
Level of Compliance
Standards of healthcare in prison are intended to mirror those available in the
outside community.
The prisoner’s prison records indicate that, while in custody he was being
given an appropriate level of care, and his medical and social needs were
recognised and adequately dealt with. The medical aspects of his care are
described in the independent clinical review. The Director of Public Health
concludes that due care was given to the prisoner in the diagnosis and
treatment of what turned out to be a terminal illness.
The prison was compliant with the current version of PSO 2710 – Follow Up to
Deaths in Custody, as it does not specify that establishments telephone
Coroner’s offices when prisoners die in outside Hospitals. However, despite
an early attempt to inform the Coroner by letter, the Coroner was not aware
that the deceased was a prisoner at the time of his death for about six weeks.
Apart from the communication breakdown between the Prison and the
Coroner, the post­incident response was fully compliant with Prison Service
instructions and policies.
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Findings
The prisoner died of natural causes as a result of an aggressive cancer of the
pancreas. The decline was rapid, with 3 months from diagnosis to death. This
appears to be entirely consistent with this type of cancer.
The prisoner was not happy about his treatment at the QMC, as he felt he
needed further hospital treatment. However, the independent clinical review
concludes that this would have made no difference to the outcome, as this
centred on his chest, and not the stomach.
The Coroner was not aware that he was a prisoner at the time of his death. This
clearly compromised the Coroner’s position regarding a post mortem and an inquest.
Conclusions
The prisoner was well cared for in Whatton Prison, and in my judgement
received an equivalent level of healthcare when he was there as he would
when he was outside in the community.
The prison attempted to confirm details with the coroner by letter.
Unfortunately this letter was returned, but a second letter did reach the
Coroner. Good practice would be to report such a death by telephone, and
confirm by letter.
Recommendations
I recommend that, at an appropriate time, PSO 2710 be amended to remind
governors of the need to inform Coroners of the deaths of prisoners who die in
outside hospitals.
Good Practice
A full investigation might have revealed aspects of the prisoner’s treatment
that amounted to good practice. In this case, where the death was clearly due
to natural causes, the more limited type of investigation that has been
conducted has not brought these to light.
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