Individual at Woodhill

Circumstances surrounding the death of
a man who was a prisoner at HMP Woodhill
in February 2007
Report by the Prisons and Probation Ombudsman for
England and Wales
November 2007
This is the report of an investigation into the death of a man. The man had been a
prisoner at HMP Woodhill and died from natural causes on 9 February 2007 at a
local hospice. He was 46 years old. At the time of his death the man had been
released on temporary licence (ROTL) and therefore was no longer in custody.
I would like to add my personal condolences to those already expressed to the
man’s family on behalf of this office by one of my Family Liaison Officers.
This investigation was undertaken by one of my investigators. She and I would like
to thank the Governor of HMP Woodhill and his staff for their assistance. A doctor
was asked by Milton Keynes Primary Care Trust to undertake a review of the man’s
clinical care, and we also much appreciate her help.
As is the case in many of my investigations following a death from natural causes, I
am much influenced by the findings of the clinical review. I have noted the issues
highlighted by the clinical reviewer and there are clearly lessons to be learned in
terms of the clinical management of patients at Woodhill. I endorse the
recommendations made in the clinical review and urge the Primary Care Trust and
Woodhill to develop an action plan to address these in a timely manner.
In addition to my recommendations, I have been pleased to draw attention to two
examples of good practice.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2007
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CONTENTS
Summary 3
The investigation process 4
HMP Woodhill 5
Key events 6
Concerns raised by the family 9
Clinical review 10
Conclusion 11
Recommendations 12
2
SUMMARY
The man was born in 1960. He was 46 years old when he died on 9 February 2007
in a local hospice.
The man had been sentenced to one year’s imprisonment at Northampton Crown
Court in 2004, and he was originally released on licence later that same year. His
licence was revoked and he returned to custody in May 2005. The man was
released a second time on January 2006, but his licence was revoked again in
August 2006. The man returned to custody at HMP Woodhill in August 2006.
On 28 November 2006, the man was diagnosed as having cancer of the rectum. His
prognosis was poor and he was told that he had less than six months left to live.
On 18 January 2007, the man was transferred to a local hospice. Whilst he was at
the hospice, the man was accompanied by one member of prison staff and was not
restrained. He passed away at the hospice at 3.40am on 9 February 2007.
The clinical review concludes that the man’s clinical care was not entirely
appropriate. I have endorsed the two recommendations in the clinical review.
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THE INVESTIGATION PROCESS
1. My investigator studied all relevant prison records relating to the man. These
included his main prison record, medical records and statements made by staff.
2. The Milton Keynes Primary Care Trust identified a doctor to carry out a review
of the man’s clinical care. I am grateful to her for undertaking the review.
3. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation and to request a copy of the Post Mortem report.
Upon completion, this report will be sent to the Coroner to assist him in his
enquiries into the man’s death.
4. One of my Family Liaison Officers contacted the man’s family. This gave them
the opportunity to discuss the purpose of the investigation and to raise any
concerns or questions that they would like explored and addressed. Members
of the family said they were frustrated by the lack of communication they
experienced regarding the man before his death. They felt that they should
have been told sooner that the man was terminally ill, thus allowing them to
spend more time with him.
5. My investigator discussed aspects of the man’s treatment with staff at Woodhill
and with the clinical reviewer.
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HMP WOODHILL
6. HMP Woodhill is a core local prison located on the outskirts of Milton Keynes.
It is one of eight high security prisons holding category A prisoners, and it
serves courts in Northamptonshire, Hertfordshire, Buckinghamshire and
Bedfordshire. Woodhill holds a maximum of 807 prisoners in several units
comprising both remand and convicted adults, young offenders, juveniles and
vulnerable prisoners.
7. Woodhill underwent a full inspection by Ms Anne Owers, HM Chief Inspector of
Prisons, in February 2002, with an unannounced follow-up inspection in August
2005. In her report of the follow-up inspection, Ms Owers said the prison had
made progress in its induction arrangements. However, she noted that the
regime in the healthcare centre had deteriorated, though this was being
addressed by the Primary Care Trust.
8. Provision of healthcare within Woodhill is the responsibility of the Milton Keynes
Primary Care Trust. Healthcare facilities include a 24 hour in-patient unit and a
visiting specialist service. Prisoners have access to a doctor 24 hours a day
and those with more serious conditions or clinical needs are referred to the
local hospital.
9. Medication is administered on a weekly and/or monthly basis to those prisoners
who have been risk assessed as suitable for holding it in their own possession.
It is administered on a daily basis to other prisoners, when either they are
judged to be at risk or the medication is considered unsuitable to be held in
their possession.
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KEY EVENTS
10. The man arrived at Woodhill on 21 August 2006 after his licence had been
revoked a second time. During the health screening procedure at the prison,
he complained about his haemorrhoids. He was advised to make an
appointment to see the prison doctor. It is not clear if this took place.
11. On 2 September, the man reported he was experiencing problems with passing
urine and opening his bowels. He was examined by a prison doctor who found
that the man had an enlarged prostate gland and no evidence of internal
haemorrhoids. The doctor diagnosed that the man had prostatitis
(inflammation of the prostate).
12. On 21 September, the man complained of rectal pain and bleeding. An urgent
referral was made to a local hospital on the following day. On 23 September,
the man was admitted to hospital with acute urinary retention. He was started
on antibiotics and given an out-patients appointment for 10 November. The
man was discharged from hospital on 24 September and returned to Woodhill.
After they received the draft report of this investigation, the family pointed out
that they had not been informed by the prison of the man’s admission to
hospital. The family said that they were contacted by a nurse at the hospital
who informed them of his whereabouts. The family feared that the man could
have died in hospital and they would not have known that he was there.
13. On 5 October, another prison doctor noted that the man had symptoms of
prolapsed internal haemorrhoids. The following day, the prison doctor
requested an urgent follow up appointment at the local hospital because the
man was suffering again with acute urinary retention. Woodhill contacted the
hospital again on 9 October to follow up the referral. The hospital confirmed
that they had received the urgent referral and that it was with their Consultant
Surgeon.
14. On 10 October, a letter was received from the Consultant Urologist at the local
hospital. The Consultant Urologist suggested a trial of Tamsulosin (a tablet) to
relieve the urinary retention.
15. On 23 October, Woodhill contacted the hospital again to chase the appointment
for the man’s rectal bleeding problem. The hospital said that an appointment
had already been booked for 10 November with the Consultant Urologist. The
prison informed the hospital that the Consultant Urologist was dealing with the
man’s urine retention, not his rectal bleeding.
16. On 10 November, the man attended an out-patient’s appointment and was
listed for a cystoscopy on 27 November. (This is where a visual examination of
the urinary tract is carried out with a cystoscope. The latter is an instrument
that allows a doctor to see inside the bladder and to remove tissue samples or
small tumours.)
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17. On 19 November, the man expressed concern about his bowel problems. The
following day, a prison doctor wrote to the colo-rectal surgeons at the local
hospital and asked them to see the man when he attended the hospital on 27
November.
18. On 27 November, the man had a cystoscopy performed during which a
possible rectal tumour was discovered. On 28 November, a colonoscopy
revealed a large inoperable infiltrating rectal tumour. An operation was carried
out two days later to relieve obstructions to the man’s bowels. The man was
told that his prognosis was poor and that he had less than six months to live.
Whilst the man was in hospital in November and December, a bedwatch was
carried out by prison staff. The initial security risk assessment was that
handcuffs were to be used. He was discharged from hospital on 9 December
and returned to the healthcare centre at Woodhill.
19. On 19 December, the man started chemotherapy treatment in the local
hospital. He returned to the healthcare centre at Woodhill two days later.
20. On 10 January 2007, it was noted at the palliative care multi-disciplinary
meeting that the man was experiencing difficulty accepting his diagnosis and
prognosis. After receipt of the draft report, the family disputed this. They felt
strongly that the man had accepted his diagnosis and prognosis and that he
had felt frustrated that he was unable to go anywhere or see his friends and
family until the end.
21. On 11 January, the man was granted release on temporary licence (ROTL) on
compassionate grounds due to his terminal prognosis. (ROTL permits
prisoners to be released for temporary purposes, although there is no right to
this. A security risk assessment must be carried out before a licence can be
issued. The risk assessment for the man said that he should be accompanied
by one member of staff and that restraints should not be used.)
22. The man attended the local hospital for further chemotherapy treatment on 16
January. On 18 January, he was admitted to hospital with acute urinary
retention and widespread vein thrombosis. After treatment, the man
transferred to a local hospice later that day.
23. Following his transfer, contact was maintained between the prison and the
hospice by both staff visits and by telephone. A Healthcare Officer (HCO)
visited the hospice during the afternoon on 18 January. The HCO gave staff at
the hospice copies of the man’s medical records, care plan and treatment
chart, as well as his cancer medication.
24. The HCO visited the man on 19 January. The man asked the HCO if both his
sister and partner could be kept informed about his condition. During his visit
the HCO noted that the man was in a lot of pain which was being treated by the
nursing staff at the hospice.
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25. On 23 January, the HCO visited the hospice again. He was told by the man
that the doctor at the hospice had stopped his cancer medication and was
making him comfortable with pain relief. The man also now spoke about the
possibility of his death occurring. When the HCO spoke with the doctor after
this third visit, the doctor was pleased that the man was accepting his
prognosis as up to that point he had only talked about getting better.
26. When the HCO visited the man on 25 January, the doctor at the hospice told
him that the man was not well and his condition was deteriorating. The doctor
also said that the man was now in denial once more regarding the final
outcome of his condition. The doctor thought it might be possible that the man
was aware of his prognosis but did not want to admit it.
27. On 30 January, the HCO visited the man but did not speak to him as he was
asleep. The prison officer who was on duty at the hospice told the HCO that
blood tests had identified that the man’s calcium levels were high and were
causing him to be sleepy. On the following day, Woodhill were informed that
the man had deteriorated overnight and was now difficult to manage. He had
pulled out his drips and was acting erratically. The man had calmed down by
the late afternoon but was then very sleepy and withdrawn.
28. On 5 February, the hospice told Woodhill that the man was now under sedation
to control his pain. It was likely he would remain sedated until he passed away.
The man remained stable but was very poorly. His family was with him. The
man died at 3:40am on 9 February at the hospice.
29. The prison’s family liaison officer made contact with the man’s family shortly
before his death. He maintained contact with the family and assisted with the
arrangements and some of the expenses for the funeral.
30. A post mortem was not carried out as the man had died from a diagnosed
condition after being released from custody, and there was no reason to
believe untoward circumstances were associated with his death.
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CONCERNS RAISED BY THE FAMILY
31. When contacted by my Family Liaison Officer, the man’s family said they were
frustrated by the lack of communication they experienced before his death.
They felt that they should have been told sooner that the man was terminally ill,
allowing them to spend more time with him. The family also said that the man
had complained to them that when he told staff that he was in pain they had not
been helpful or assisted him.
32. My investigator has discovered that the family was informed on 30 November
2006 that the man was in hospital. They were also told of his terminal
diagnosis on 1 December. The Head of Healthcare at Woodhill wrote to the
family on 16 January 2007. In her letter, the Head of Healthcare apologised on
behalf of the prison for any undue distress caused by the lack of
communication concerning the man’s illness. The Head of Healthcare went on
to say that permission to make contact had only just been given by the man,
and that prior to this the man himself was contacting his family members. The
Head of Healthcare added that, without his prior consent, the prison was not
permitted to make this contact themselves.
33. When my investigator contacted the Head of Healthcare, she said that
healthcare staff were aware that the man was in contact with members of his
family, but it was not clear if he was discussing his illness in the early stages.
The Head of Healthcare added that they would not be able to release
information without the man’s consent. After the family received the draft
report, they said that the man had asked them to speak to the person in charge
and request a disclosure form. The family did contact the prison to request this
and were told they would be called back, however, this did not happen.
34. Although the prison says that every effort was made to respect patient
confidentiality, the family feel strongly that the man had actively advised them
regarding disclosure and that the prison had failed to assist them with this. I
appreciate that efforts should always be made to ensure that relatives are
made aware of serious health concerns. However, this is not always possible.
Healthcare staff need to respect patient confidentiality as well as the patient’s
own wishes. Not everyone wants their loved ones to know about the state of
their health. In this case an additional factor was the man’s alleged denial of
his prognosis, although this is something the family strongly deny. It would
appear that all these issues conspired to delay notification to the family of the
seriousness of the man’s condition. I commend the efforts that Woodhill made
after the diagnosis and the support given to the man’s family after his death.
After receipt of the draft report, the family wanted to draw attention to the
positive support given by staff at the hospice to the man. I am happy to reflect
their views in this report.
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CLINICAL REVIEW
35. As I have reported, a review of the man’s medical care was undertaken by a
doctor on behalf of Milton Keynes Primary Care Trust.
36. The clinical review concludes that ‘’it is unlikely that the care received by the
man in Woodhill contributed to his death.’’
37. However, the reviewer also says that, although attempts were made by
Woodhill to access rapid clinical care for the man, there was a delay of several
weeks before he was seen for the problem of rectal bleeding. The reviewer
suggests that the man’s care could have been expedited if the Cancer Two
Week Wait referral system had been used instead. The reviewer judges that it
is not clear whether healthcare staff at Woodhill are aware of the standardised
routine Two Week Wait system for possible cancer referrals.
Prison healthcare should review their system of record keeping. It may
be timely to examine the merits of introducing a computer based system
in line with current NHS practice to facilitate exchange of information and
improve healthcare information storage.
Prison healthcare should refresh the knowledge of all staff about the
cancer Two Week Wait system and the national guidance supporting it.
38. The reviewer also commends the co-operative working between the healthcare
staff at Woodhill and the Milton Keynes Palliative Care Team who between
them provided terminal care for the man.
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CONCLUSION
39. The man arrived at Woodhill in August 2006 and died from natural causes in
February 2007. Following his arrival at Woodhill, the man was diagnosed with
cancer and told that his prognosis was poor.
40. In light of the findings of the clinical review and my own investigation, I conclude
that the man’s medical care was not entirely satisfactory. However, I have
noted in a subsequent investigation into a death in March 2007 that Woodhill
was then using the Two Week Wait system. I commend Woodhill for moving
forward on that issue so rapidly.
41. I have endorsed the two recommendations from the clinical review. These
need to be addressed by Milton Keynes Primary Care Trust in partnership with
the Governor of Woodhill.
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RECOMMENDATIONS
1. Prison healthcare should review their system of record keeping. It may be
timely to examine the merits of introducing a computer based system in
line with current NHS practice to facilitate exchange of information and
improve healthcare information storage.
Recommendation 1 was partially accepted. The Prison Service agree that a
computer based medical records system would be beneficial, but this needs to be
as part of a national system. The Primary Care Trust have received budgetary
allocation to introduce a nationally agreed system.
2. Prison healthcare should refresh the knowledge of all staff about the
cancer Two Week Wait system and the national guidance supporting it.
Recommendation 2 was partially accepted. Prison healthcare currently use the
two week cancer referral system, however the man’s preliminary diagnosis was
unclear because of ongoing medical problems. The GP services at Woodhill are
under a new contract and are aware of the referral system. All relevant
healthcare staff will be made aware of this new system
Good Practice
1. I commend the co-operative working between the healthcare staff at
Woodhill and the Milton Keynes Palliative Care Team who between them
provided terminal care for the man.
2. Healthcare staff at Woodhill neither forgot nor abandoned the man when he
was admitted to the hospice. A Healthcare Officer visited the man on five
separate occasions during the 12 days between 18 and 30 January. The
Governor should consider whether the Healthcare Officer’s actions should
be formally recognised.
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