Individual at Wymott

A death in custody at
HMP Wymott on 26 July 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2005
This is the report of an investigation into the circumstances of the
death of a man who died on 19 June 2004 at the Marie Curie
Centre, a hospice in Liverpool. At the time of his death the man
had been serving a four-year prison sentence at HMP Wymott. His
cause of death was disseminated (widespread) cancer.
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.
The investigation was carried out by one of my colleagues. A clinical
review to look into the man’s clinical care and treatment has been
carried out by the Director of Public Health at Chorley and South
Ribble Primary Care Trust.
We would like to extend our condolences to the man’s family for
their loss. I would like to thank the Governor in charge of HMP
Wymott, and his staff for their help.
This report commends a Healthcare nurse for her proactive response
when noticing that the man appeared unwell. The prison’s
involvement in ensuring that he was near to his family during the
final days of his life is also noted.
Stephen Shaw
Prisons and Probation Ombudsman
January 2005
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Contents
SUMMARY.............................................................................................................................................4
INVESTIGATION PROCESS..............................................................................................................5
THE MAN...............................................................................................................................................6
HMP WYMOTT.....................................................................................................................................7
EVENTS LEADING UP TO THE MAN'S DEATH...........................................................................8
AFTER THE MAN'S DEATH..............................................................................................................9
LEVEL OF COMPLIANCE.................................................................................................................9
FINDINGS............................................................................................................................................10
CONCLUSIONS...................................................................................................................................11
GOOD PRACTICE..............................................................................................................................11
RECOMMENDATIONS.....................................................................................................................11
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Summary
The man was born on 6 December 1930 and was 73-years-old when
he died on 26 July 2004 from disseminated (widespread) cancer. At
the time of his death the man was serving a four-year sentence at
HMP Wymott, a category C prison near Preston.
The man had appeared to be in good health up until the middle of
June 2004 when he consulted healthcare with symptoms which
prompted the Healthcare doctor to refer the man to hospital. At
hospital he was diagnosed with cancer, following which he was
transferred first to a hospice in Preston and from there was
transferred to another hospice in Liverpool. It was at the hospice in
Liverpool that the man died.
My investigator spoke by telephone to one of the man’s daughters
who was his next-of-kin.
HMP Wymott assisted in ensuring that the man was close to his
family during his final days. A Healthcare nurse is to be commended
for instigating a doctor’s consultation for the man.
This report makes two recommendations in relation to Healthcare
services at HMP Wymott. These are in connection with the issue of
non-prescribed medication and in the provision of Well-man clinics.
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Investigation Process
My practice in cases of apparent deaths from natural causes is to
conduct an initial review to determine the extent of investigation
required.
My investigator visited HMP Wymott on 29 July 2004 when he spoke
informally with a number of staff to outline the facts relating to the
man’s treatment at Wymott, his transfer to hospital, and his
subsequent transfers to hospices in Preston and Liverpool. My
investigator was given access to the man’s records, including his
medical records.
The investigator spoke to a representative of the local Prison
Officers’ Association (POA) and to a representative of the
Independent Monitoring Board (IMB). Neither had any issues which
they wished to draw to the PPO’s attention.
My investigator telephoned the man’s daughter. She said that her
father’s cancer was diagnosed only shortly before his death and she
wondered whether the diagnosis could have been made at an earlier
stage.
A doctor from Chorley and South Ribble Primary Care Trust carried
out a clinical review.
No formal interviews with staff were conducted. This report is based
upon a review of all relevant paperwork, including the man’s clinical
records.
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The Man
On 25 October 2002, the man appeared at Liverpool Crown Court
where he was convicted on three counts: false imprisonment,
indecent assault, and assault occasioning actual bodily harm. He
was sentenced to four years in prison. Following his conviction, he
was first received into HMP Liverpool where he remained until
transferred to HMP Wymott on 20 December 2002. He had been in
prison on two earlier occasions, but this had been 50 years
previously.
The man was a widower, his wife having died in 1984. He had six
children, many grandchildren and a number of great grandchildren.
One of the man’s daughters was contacted by my investigator. She
said that her father had seemed reasonably well for most of the time
that he had been at Wymott, apart from having some problems with
his eyes (glaucoma) and with his legs (oedema). He had then
suddenly, and obviously, become very unwell and had then gone on
to die within a short space of time. She said that her father had
smoked in the past and had once been a mineworker. She also
acknowledged that her father had been a person who would
generally avoid consulting doctors if possible. However, even
allowing for her father’s reluctance to consult doctors, she did
wonder whether he had received appropriate treatment at Wymott
given that his cancer had probably been developing for quite some
time before being diagnosed.
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HMP Wymott
HMP Wymott is a category ‘C’ training prison which opened in 1979
and which has accommodation for around 1,000 adult males. At the
time of the last prison inspection report, 18.5 per cent of prisoners
were 50 years-of-age or older. The training regime at Wymott
includes provision of farms, gardens and workshops.
The prison’s Healthcare unit contains no in-patient beds. When
prisoners require in-patient treatment they are referred to outside
hospital.
The newly appointed Healthcare manager told the investigator that,
at prescription dispensing rounds, prisoners can ask for certain non-
prescribed one-off medications, for instance a two day (16 tablets)
supply of paracetamol. The only prescription charts available at
dispensing rounds would be those relating to prisoners due to
receive a prescribed medication. For those prisoners seeking non-
prescribed one-off medication, their prescription charts would need
to be noted at a later time that non-prescribed medication had been
issued. The Healthcare manager acknowledged that this was not a
foolproof system for ensuring that all medicines issued to an
individual prisoner will always have been recorded. The Healthcare
manager went on to say that this system was due to change. In the
future, ad-hoc issue of non-prescribed medication will cease.
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Events Leading Up To The Man’s Death
Upon his conviction on 25 October 2002, the man was taken initially
into HMP Liverpool. At his first reception health screen at Liverpool,
it was recorded that he had problems with bronchitis and angina.
On arrival at HMP Wymott on 20 December 2002, he had a further
health screen and then on the following day he was seen by a
Healthcare doctor. From these two examinations it was noted that
he was known to suffer from angina and asthma, also that he was
using eye drops for his known condition of glaucoma, and that he
had symptoms indicative of oedema.
After that initial contact with Healthcare staff on 20 and 21
December 2002, no further entries were made in the man’s health
record for over 18 months. On 14 June 2004, a Healthcare nurse
was on the man’s landing on other business when she noticed the
man’s jaundiced complexion. The Healthcare nurse arranged a
doctor’s consultation for 16 June. However on 15 June the man’s
appearance indicated a deterioration over the previous 24 hours, so
he was seen by a doctor that same day.
At the consultation on 15 June, the Healthcare doctor noted that the
man had symptoms of one week’s duration of loss of appetite and
lower back pain, a discolouration of his skin (jaundice) for an
unknown period of time, and mild constipation during the previous
fortnight. Blood tests showed, among other things, that his
haemoglobin (Hb) level was 7.2, a level which for a man is indicative
of severe anaemia. The doctor referred the man to Chorley Hospital
that same day requesting further investigations.
Following these investigations, a hospital consultant wrote to the
Governor at Wymott on 7 July to advise him that the man had been
diagnosed with terminal cancer, that he was deteriorating rapidly
and was too unwell at that time to be moved out of hospital. The
consultant added that it would be inappropriate for the man to
return to prison. Instead, he should either remain in Chorley
Hospital or move to a hospice when well enough.
On 10 July the man was transferred to a hospice in Preston.
However, at the request of his family, HMP Wymott arranged for him
to be further transferred to a hospice in Liverpool where all the
family are based. The transfer took place on 20 July and HMP
Liverpool agreed to supply bed-watch officers. The man remained in
the hospice in Liverpool until his death on the early morning of 26
July.
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After The Man’s Death
The man died at 6.05am on the morning of 26 July. Hospice staff
contacted the man’s family to break the news to them and the bed-
watch officer from HMP Liverpool notified HMP Wymott. The man’s
family came to the hospice at 8.00am that morning. HMP Liverpool
arranged for both the principal bed-watch officer, and a Governor
grade officer, to be present at the hospice to speak with the family.
When my investigator visited the prison, all the necessary
information had been gathered together for the purposes of the
investigation. Arrangements had been made for the investigator to
speak to relevant members of staff.
Level of Compliance
Standards of clinical care in prison are intended to mirror those
available in the outside community. The man’s records indicate that
while at Wymott his health care needs were dealt with adequately.
In particular, there was no delay in his transfer to hospital once the
severity of his condition was recognised.
The post incident response by HMP Wymott was fully compliant with
Prison Service instructions and policies on managing a death in
custody.
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Findings
The man’s daughter has said that her father was a person who was
reluctant to seek medical advice and his health care records amply
confirm that. Following his obligatory health screen on arrival at
HMP Wymott in December 2002, almost 19 months elapsed before
the man next consulted a Healthcare doctor. It had been a
Healthcare nurse who instigated the consultation for 15 June 2004
when she noticed the man’s jaundiced complexion. At that
consultation, his symptoms and blood test results led to him being
referred to hospital that day for further tests, resulting in a
diagnosis of terminal cancer. The man’s condition deteriorated
rapidly and he died on 26 July 2004, a mere six weeks after his
Healthcare consultation.
The question that the man’s daughter has understandably asked is
whether her father’s cancer could reasonably have been diagnosed
at an earlier stage. We know from the man’s health records that he
did not consult a doctor between the time of his arrival at Wymott in
December 2002 and the consultation of 15 June 2004. The notes
made by the doctor that day indicate that most of the man’s
symptoms had been of brief duration and so it seems that he was
largely symptom free during the time his cancer was developing.
Having said that, I am very conscious of the daughter’s assessment
of her father’s response to illness and it might well be that he chose
to ignore, or diminish in his mind, the potential significance of
certain symptoms. We shall never know the answer to this. We do
know, though, that when the man did consult Healthcare the
response was to refer him to hospital without delay.
Although there is nothing to suggest any deficiencies in the care and
treatment provided to the man, two matters have arisen in this case
that are of concern to me. The first matter is the practice of ad-hoc
issue of non-prescribed medication. The concern here is that a
prisoner who prefers to avoid consulting doctors might choose to
deal with his symptoms by taking paracetamol tablets. A
breakdown in recording systems might then result in a failure to
record issue of the drug in the prisoner’s prescription chart possibly
masking the onset of a serious clinical condition.
The second matter of concern relates to Wymott’s ageing prisoner
population. The man was a 73-year-old man who had not had a
clinical consultation for 18 months between arriving at Wymott in
December 2002 and the consultation in June 2004.
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Conclusions
The man was well cared for in Wymott, the healthcare he received
there was probably at least as good as it would have been outside in
the community. There were no indications that the man had a
developing condition that ultimately proved to be fatal.
Good Practice
I commend the Healthcare nurse, for her diligence in first making,
and then bringing forward, a doctor’s consultation for the man when
she noticed his jaundiced complexion.
The prison’s assistance with the man’s transfer to a hospice close to
his family was an example of good practice.
A full investigation might have revealed other aspects of the man’s
treatment that amounted to good practice, but 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.
Local Recommendations
1. If the system has not already been changed, I recommend that
ad-hoc issue of non-prescribed medication should cease.
2. Healthcare should establish a Well-man clinic and actively
encourage all prisoners, especially older prisoners, to have a
periodic check-up.
3. I recommend that Healthcare nurse, receive a letter of
commendation.
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