Individual at Wordsworth House

Circumstances surrounding the death of a man at Lincoln County
Hospital on 8 February 2006, whilst a resident at Wordsworth House
Approved Premises in the Lincolnshire Probation Area
REPORT BY THE PRISONS AND PROBATION OMBUDSMAN FOR
ENGLAND AND WALES
AUGUST 2006
This is a report into the circumstances surrounding the death of a man at
Lincoln County Hospital on 8 February 2006. The man, who was aged 60,
was a resident at Wordsworth House Approved Premises in Lincoln.
He had been at Wordsworth House since July 2005 when he was released
from HMP Bullingdon after serving an eight year prison sentence. He
suffered from a multitude of chronic health problems throughout his time in
prison and these continued after his release. In January 2006, his physical
well­being deteriorated rapidly and he was admitted to Lincoln County
Hospital on 2 February. Various tests and scans were conducted which
revealed that he was suffering from an advanced form of cancer. He died
from natural causes in the early hours of 8 February.
The death of a loved one is always painful and shocking. I would like to offer
my sincere condolences to the man’s family and loved ones to those already
expressed by one of my Family Liaison Officers. Tragically, the family was
already mourning the loss of the man’s younger brother, just five weeks
earlier.
This investigation has been undertaken by a member of my team. I would like
to thank the Senior Probation Officer in charge of Wordsworth House and his
staff for their co­operation and active participation.
I consider that the staff at Wordsworth House treated the man with dignity and
respect throughout his stay, and his supervising officers also took practical
steps to assist him. However, I do have concerns that the man was seen by
both his General Practitioner and paramedics in the days before he was
admitted to hospital, yet no action seems to have followed to explore further
his failing health. Indeed, it was only after a public health nurse visited
Wordsworth House and expressed her concerns to the man’s doctor that he
was finally admitted to hospital. My terms of reference preclude me from
conducting any sort of investigation into the care provided by those other than
the services within my remit. I will therefore be sending a copy of this report
to the West Lincolnshire Primary Care Trust, encouraging them to review its
findings and consider establishing a local inquiry into the care afforded to the
man who died to see if lessons can be learned.
I make one recommendation and draw attention to three examples of good
practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2006
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Contents
Summary 4
The investigation process 5
Background
The man who died 6
Wordsworth House Approved Premises 7
Key findings 9
Issues arising from the investigation 14
Good practice 15
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Summary
1. The man who is the subject of this report was sentenced to a term of 11
years imprisonment in September 2000. The following year, a
successful appeal resulted in the sentence being reduced to eight years.
He served time in a variety of prisons before being transferred to HMP
Bullingdon, a Category C training prison.
2. He was released from Bullingdon in July 2005, and took up a place at
Wordsworth House Approved Premises in Lincoln. He settled in well and
enjoyed good relationships with both staff and fellow residents.
3. In early January 2006, the man started complaining of acute pain in his
teeth and gums. He saw an emergency dentist and obtained a
prescription for antibiotics. However, his pain persisted and he
experienced considerable discomfort when attempting to eat. In late
January, he went to his General Practitioner and was prescribed more
medication.
4. On 31 January, the man who later died was seen by a public health
nurse who works specifically with those supervised by the Probation
Service. She identified that his pulse was significantly faster than it
should have been, that he was experiencing chronic abdominal pain and
that his food and fluid intake was extremely poor. She measured the
man’s weight and found that he had lost three kilograms in the six
months he had been at the hostel. She also found that his teeth and
gums, which were giving him so much pain, were giving off an
unpleasant smell.
5. The combination of these complaints caused significant concern to the
nurse, who wrote a detailed letter to the man’s doctor in advance of his
scheduled appointment on 2 February. On 2 February, the man saw his
doctor who immediately recommended that he go to the Accident and
Emergency Department at Lincoln County Hospital. He was admitted in
the early afternoon and was transferred to a ward later in the day.
6. Between 2 February and 7 February, the man was subject to a range of
clinical tests and examinations. By 4 February, it was suspected that he
had cancer. Sadly, his condition deteriorated considerably during the
afternoon and evening of 7 February and he died in the early hours of 8
February.
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The investigation process
7. My investigator considered the man’s probation documentation, including
records held by Wordsworth House Approved Premises, before formally
opening the investigation on 6 April 2006. He met the Senior Probation
Officer in charge of the hostel and formally interviewed one member of
staff and the visiting nurse practitioner who saw the man on 31 January
2006. He spoke informally with various members of the team at
Wordsworth House and one former resident, with whomthe man was
friendly. My investigator also studied the man’s medical record relating
to the period he was in prison.
8. Prior to my investigator arriving atWordsworth House, notices were
issued to staff and prisoners announcing the investigation and inviting
anyone with information relevant to the man’s death to make themself
known to the investigator. In the event, nobody came forward.
9. One of my Family Liaison Officers contacted the man’s next­of­kin to
offer them the opportunity to participate in the investigation. They raised
concerns about how staff atWordsworth House dealt with the man’s
deteriorating health and about the quality of care provided by his doctor.
I hope this report will go some way towards answering the first question.
However, my remit does not extend to passing comment on the quality of
care provided by General Practitioners and consequently I am unable to
address the family’s concerns in this area. (The family has been
provided with the details of the appropriate body that looks into such
matters.)
10. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of the investigation and to request a copy of the Post
Mortem report. Upon completion, this report will be sent to the Coroner
to assist him with his enquiries.
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The man who died
11. The man who died received an 11 year prison sentence on 15
September 2000 for a range of serious offences. He subsequently
lodged an appeal against the length of his sentence and succeeded in
having it reduced to eight years on 26 March 2001.
12. After initially struggling to come to terms with his imprisonment, he
settled into prison life and progressed through the system. He was
transferred from HMP Rye Hill to HMP Bullingdon, a Category C training
prison, on 30 December 2003 and was released from Bullingdon on 13
July 2005.
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Wordsworth House Approved Premises
13. Wordsworth House is an 18­bed Approved Premises for men, run by the
Lincolnshire Probation Area. It is staffed 24 hours a day by probation
employees who provide support to residents and ensure their
compliance with the hostel rules and licence and bail conditions. The
resident group comprises a mixture of those on bail and convicted
offenders who are at the hostel as a condition of a court order or as a
requirement of their release from custody. The overwhelming majority of
residents fall into the latter category, and the hostel provides a relatively
stable environment as they settle into the community.
14. All residents are registered with a local doctor, although different
residents can be allocated to different surgeries. This can create
problems for residents with mobility problems who may find that they are
registered with a surgery situated further away from the hostel than their
more able­bodied counterparts. It also creates difficulties for the hostel
itself because some services, such as medication delivery, become
logistically difficult. The manager of Wordsworth House has made a
representation to the local Primary Care Trust, which currently allocates
patients to surgeries, that a better system would be for all hostel
residents to be under the care of one surgery. This would help to ensure
effective communication and improve the quality and consistency of care
given to residents. West Lincolnshire Primary Care Trust’s view is that
the high turnover of residents would make it impractical for them all to be
registered with one surgery, and that the current arrangements are not
detrimental to residents’ health.
I recommend that the current system for allocating residents to
General Practitioner services be subject to on­going review by West
Lincolnshire Primary Care Trust in conjunction with Lincolnshire
Probation Area.
15. All offenders supervised by Lincolnshire Probation Area, including those
accommodated at Wordsworth House as a requirement of a court order
or prison licence, are eligible to receive health services provided by the
Healthy Living project. The Healthy Living project is a service unique to
Lincolnshire Probation Area and which aims to improve offenders’
access to health and welfare services. (It is known that offenders use
community­based services far less than the rest of the population.) The
project is funded by National Lottery money and employs a total of six
staff including qualified nurses. Although the project is run by the local
Probation Area, it is entirely independent upon and governed by the
same standards as other community­based health services. This
extends to ‘patient confidentiality’, which means that practitioners are not
permitted to disclose medical information to anyone else without the
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patient’s consent unless there are exceptional circumstances involving
the patient’s life or the life of others at risk. I commend this initiative.
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Key findings
16. The man who is the subject of this report was given an 11 year prison
sentence at Lincoln Crown Court on 15 September 2000, having pleaded
guilty to a series of serious offences. Two days prior to being sentenced,
he had taken an overdose of temazepam medication which had been
prescribed to help him cope with feelings of acute anxiety. He was taken
to hospital and placed on a secure ward where medical staff managed to
stabilise his condition. As a result of this incident of self­harm, he was
placed on an F2052SH document (the Prison Service’s system for
managing prisoners who pose a danger to themselves). In June 2003,
the man harmed himself again when he cut himself with a razor blade.
17. On 25 March 2004, whilst still a prisoner at Bullingdon, the man who died
was lancing an infected spot on his chest with a needle when he was
momentarily distracted. Apparently the needle disappeared and the man
became convinced that he had accidentally inserted it into his body.
However, subsequent x­rays failed to corroborate this belief and no
foreign body was ever found in his upper abdomen.
18. In December 2004, the man received two injections of depo­medrone, a
widely­used treatment for carpal tunnel syndrome, a condition which
causes pain in the sufferer’s thumb and wrist. It would appear that he
reacted badly to the medication. He wrote a letter to his legal
representative stating that he thought the prison doctor was trying to kill
him. It is outside of my remit to investigate this matter, although the
Coroner has been informed that the man made an allegation about the
conduct of the medical officer.
19. The man who later died was released from Bullingdon on 13 July 2005.
A condition of his release was that he should reside at Wordsworth
House Approved Premises in Lincoln until such a time as his supervising
probation officer gave him permission to live elsewhere. The conditions
of his residence at Wordsworth House, and therefore his release from
custody, were that he:
· comply with the curfew hours (11.00pm until 7.00am)
· pay his rent
· keep appointments with his probation officer and keyworker, and
· maintain acceptable standards of behaviour at all times.
He arrived at the hostel as directed on 13 July, and received an induction
from a Probation Service Officer (PSO). The rules of Wordsworth House
were explained, and he was allocated to a keyworker, another PSO.
(Each resident is allocated to a keyworker upon their arrival, and this
member of staff acts as their primary point of contact for sorting out
practical issues, such as claiming benefits.)
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20. Due to his history of depression and self­harm, the man was made
subject to self­harm prevention procedures as a precautionary measure.
He was checked by staff at two­hourly intervals throughout the night and
was spoken to regularly throughout the day. This is an example of good
practice, and clearly demonstrates that staff at Wordsworth House were
sensitive to the potential impact of moving from a prison environment to
an Approved Premises after a lengthy custodial sentence. In the event,
the man settled in well and the ‘Risk Of Self­HarmForm’ was closed on
19 July.
21. On 27 July, a ‘Health Screening’ was undertaken with the man which
resulted in a referral to the Healthy Living project. He attended for an
assessment with a nurse from the Healthy Living project on 3 August.
She identified that he was suffering from a multitude of health problems,
including chronic back pain, arthritis, post­traumatic stress disorder, neck
problems, breathing difficulties, a history of alcoholism, occasional use of
cannabis and mobility problems. He was also a long­term recipient of
anti­depressant medication and disclosed that he was one of a number
of claimants who had brought a case against Bullingdon for alleged
exposure to silicon dust. On the basis of this assessment, the nurse
jointly drew up a plan with the man for making his day­to­day life more
comfortable. This focussed on maintaining his mobility and pursuing a
healthier diet. He was offered vaccinations for Hepatitis B and a
programme of bereavement counselling, but he chose not to accept
either of these. He was offered further one­to­one sessions with the
nurse, but he also declined this intervention and support.
22. The next few months of the man’s stay at Wordsworth House were
relatively unremarkable, as he established himself in the community. He
reliably kept his appointments with both his supervising probation officer
and his keyworker. From late August onwards, he was given permission
to spend time away from the hostel in order to stay with his family.
During the course of these periods of approved leave, he carried out do­
it­yourself jobs and re­established his links with his family at the home of
one of his siblings.
23. On 6 November, the man once again met the nurse from the Healthy
Living project. This appointment was requested by the man so that the
nurse could prepare a letter to a local housing provider outlining his
various medical conditions. He did not bring any new health issues to
the nurse’s attention, and therefore the letter she wrote to the housing
provider only detailed those complaints that had been identified in their
earlier meeting of 3 August. The man who later died saw the nurse
again on 6 December when she showed hima draft copy of the letter
she had prepared in support of his housing application. He did not
mention any new medical issues during this appointment with the nurse.
24. On 20 December, the man had a supervision session with his probation
officer, during the course of which he mentioned that he had been to see
his doctor and had had his lung capacity tested. He informed his
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probation officer that the outcome of this assessment was positive. His
doctor had informed him that his lung capacity was equivalent to that of a
52 year old. This was despite the fact that he had been a heavy smoker
for many years and was actually 60.
25. The man’s younger brother died on 6 January 2006. According to the
man’s keyworker, the man was “absolutely devastated” when he heard
the news and, over the following days and weeks, he lost some of his
enthusiasm for life. He went off his food and was visibly more
withdrawn.
26. When the man met his supervising probation officer on 11 January, he
disclosed that, in addition to his feelings of grief, he was experiencing
acute pain in his teeth. He said that he was going to see a dentist for an
emergency appointment. It is known that the man saw the dentist at
some point between 11 January and 13 January, because during the
morning of 14 January he complained to his keyworker that the
medication he had been prescribed by the dentist was making him feel
unwell. The man was assured by his keyworker that this was a known
side­effect of this particular medication, a fact that the keyworker found
out from reading the information leaflet that came with the tablets.
27. Over the next couple of weeks, the man’s intake of food continued to be
poor, which hostel staff attributed to the unfortunate combination of his
bereavement and on­going dental problems. On 27 January, the man
had his first supervision session with his new probation officer. During
this meeting, he expressed a view that the antibiotics he had been
prescribed did not seem to be having any effect on his gum infection.
The probation officer telephoned NHS Direct during the session to seek
medical advice as to the most appropriate course of action. The
outcome was that the man was advised to go and see his doctor, which
he did the same day. He was prescribed more medication for his gum
infection.
28. Due to the concerns of staff at Wordsworth House about the man’s
failing health, they agreed with himthat staff would enter his room
periodically to check on his well­being. This is not normal practice for
Approved Premises and reflects positively on the professionalism of the
staff involved who clearly had the man’s best interests at heart. The only
comment I have to make on this arrangement, which was informal in
nature, is that the details of these interactions were not routinely
recorded in the hostel log. For this reason, my investigator has not been
able to establish how frequently the man was seen throughout the nights
in question. The only exception to this is an entry made at around
3.00am on 28 January, when the man was seen by a member of staff
who engaged him in conversation and found him to be feeling a lot better
than he had during the previous evening.
29. At curfew (11.00pm) on 29 January, the man who is the subject of this
report once again informed the night staff that he was feeling better.
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However, he was still not eating and the next day he was visited in his
room by the in­house chef at Wordsworth House to see whether he
wanted soft or pureed food specially prepared. The man agreed to this,
but his food consumption continued to be negligible.
30. On 31 January, the man’s condition appeared to be deteriorating and the
nurse from the Healthy Living project, who was visiting the hostel to see
other residents for pre­arranged appointments, was asked by the man’s
keyworker, to examine him. The health screening, which lasted for over
an hour, revealed that the man’s pulse was very high (100 beats per
minute compared to a normal rate of 70) and he was three kilograms
lighter than when he was measured in August 2005. His breath was
noted to be extremely unpleasant. The man described to the nurse a
sensation of abdominal pain which started low down and worked its way
up to his chest.
31. The nurse took into consideration the man’s extremely poor appetite, his
low fluid intake and his general state of weakness. She suspected that
he might be suffering from blood poisoning. However, due to patient
confidentiality the nurse was not able to inform Wordsworth House staff
of her specific concerns, although she felt able to dispel the notion that
his physical presentation was related to underlying feelings of
depression. After seeing the man, she prepared a letter to his doctor, in
advance of his scheduled appointment on 2 February, outlining her
findings.
32. On 1 February, the man continued to look unwell and was still suffering
from pain. Due to his concerns about the man’s condition, the hostel
manager contacted the nurse to seek medical advice. The manager then
telephoned the man’s General Practitioner and asked the doctor to visit
the hostel and examine the man. Apparently the doctor was unable to
visit him, but instead arranged for a paramedic unit to come to
Wordsworth House and conduct an assessment.
33. The paramedics from Lincolnshire Ambulance Service arrived at 9.42am
and spent over an hour with the man, before recommending that he take
Ibuprofen painkillers, that he attend his scheduled doctor’s appointment
on 2 February and make another appointment to see the dentist.
According to the Patient Report Form completed by one of the
paramedics, the man’s presenting complaint was a “dental infection”.
34. Around 7.50pm on 1 February, the nurse from the Healthy Living project
returned to Wordsworth House where she showed the man a copy of the
letter she had prepared for his doctor. He agreed that he was happy for
the letter to be sent on his behalf. According to the nurse, he looked
slightly less distressed than when she saw him on 31 January.
35. At 9.00amon 2 February, the man had a discussion with hostel staff and
disclosed that he had had a bad night. His doctor’s appointment was
scheduled for 9.30am and, at 9.15am, he was driven to the surgery by a
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member of staff, accompanied by one of his friends. It not normal
practice for the staff of Approved Premises to drive residents to
appointments of any sort. However, given the state of the man’s health
at this point, this should be recognised as another example of good
practice.
36. The man saw his doctor as planned. After reading the nurse’s letter and
conducting his own examination, the doctor immediately recommended
that the man should go to the Accident and Emergency Department at
Lincoln County Hospital. He was driven to the hospital by the member of
hostel staff and admitted at some point between 12.45pm and 3.10pm.
His relatives were informed of his admission to hospital and, in
subsequent days, they would regularly call the hostel to informthem of
any changes in his condition.
37. From 2 February onwards, the man was subject to a number of tests and
examinations in order to find out what was wrong with him. Wordsworth
House maintained contact with the hospital by telephone but, because
the staff are neither family members nor next of kin, they were not able to
obtain much information from the medical staff. On 4 February, the man
was visited by a member of his family, who contacted Wordsworth House
and disclosed that the hospital was exploring the possibility that he had
cancer.
38. On 6 February, the man was visited in hospital by his keyworker. He
says that he found the man to be quite chirpy, but that he was obviously
unwell. He was still undergoing scans and various tests at this time and
was moved to the Oncology Ward, the specialist cancer treatment unit.
39. On 7 February, residents and staff at Wordsworth House signed a ‘Get
Well’ card for the man and, at 8.15pm, it was taken to himat the hospital
by a member of staff. Sadly the man had taken a turn for the worse
since the previous day and his prospects for recovery were bleak. He
died in the early hours of 8 February.
40. After news of the man’s death was received at Wordsworth House later
in the morning, staff made sure that his fellow residents were informed.
Four members of staff attended his funeral, as did one resident and one
former resident.
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Issues arising from the investigation
The man’s care by staff at Wordsworth House
41. The man’s family expressed two main areas of concern that they wanted
considered as part of the investigation into his death. The first related to
how staff at Wordsworth House attempted to deal with his deteriorating
health. My findings in relation to this reflect positively on the staff team
at Wordsworth House. I consider they acted with great professionalism
and dedication throughout the last few weeks of the man’s period of
residency, when his health was obviously failing.
42. For the record, it needs to be stated that Approved Premises staff are not
clinically trained and, over recent years in particular, their roles have
changed from helping and directly assisting residents to monitoring their
behaviour and enforcing the rules. Given this significant shift in ethos, it
is encouraging that staff felt confident enough to use their initiative and
apply commonsense and compassion whilst attempting to make the man
as comfortable as possible.
43. One of the rules of Wordsworth House is that visitors are prohibited from
going into residents’ rooms. The primary purpose of this rule is to ensure
that behaviour cannot take place in areas which are not routinely
monitored by staff which could potentially compromise the safety of staff
and residents. On this occasion, permission was given to a former
resident, to whomthe man was particularly close, to go into his room and
sit with him, ensuring he was provided with support and company.
44. There is no doubt in my mind that this gesture, relatively minor in itself,
will have afforded the man a degree of comfort at what must have been a
time of great distress and alleviated some of his feelings of isolation.
When the in­house chef went to speak to the man on 30 January to
discuss ways of making his meals more palatable, this illustrated that the
whole team, not just his keyworker or allocated probation officer, were
sensitive to his changing needs and growing vulnerability.
Quality of care provided by the medical professionals involved
45. My terms of reference preclude me from looking into the quality of clinical
care provided by the doctor, dentist and paramedics who saw the man
prior to his admission to hospital. However, a copy of this report will be
sent in due course to the Primary Care Trust responsible for providing
General Practitioner services to the residents of Wordsworth House.
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Recommendation
46. I recommend that the current system for allocating residents to General
Practitioner services be subject to on­going review by West Lincolnshire
Primary Care Trust in conjunction with Lincolnshire Probation Area.
Good practice
47. My investigation has highlighted three examples of good practice by the
Lincolnshire Probation Area. I would be grateful if the first two and my
comments thereupon are drawn to the attention of all staff at Wordsworth
House:
1. Opening a ‘Risk Of Self­Harm Form’ on a resident with a history
of self­harm but whose current emotional state is unknown and
whose circumstances have changed significantly is an example
of good practice.
2. Arranging for the man to be driven to his appointment with his
doctor and relaxing the rules regarding visitors entering his
bedroomare two examples of staff being sensitive to his
increasing frailty and his changing needs.
3. Providing health services directly to those subject to probation
supervision, in this case under the auspices of the Healthy
Living project, is an example of best practice.
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