Individual at Parc

Investigation into the death of a man
at HMP & YOI Parc in December 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2011
Ashley House, 2 Monck Street, London SW1P 2BQ Tel: 020 7035 2876 Fax: 020 7035 2012
E-mail: mail@ppo.gsi.gov.uk www.ppo.gov.uk
The man died in Bridgend Hospital while in the custody of HMP Parc. He had
been suffering from cancer. He was 65 years old. I offer my sincere sympathy
and condolences to his family and friends affected by his death. I apologise for
the delay in issuing this report and any additional distress this may have caused.
The investigation was carried out on my behalf by my colleague. A clinical
review of the man’s healthcare was undertaken by the Healthcare Inspectorate
for Wales. I would like to thank her for the review, but must note that its late
arrival delayed my report.
I would like to thank the Director of Parc and her staff for their co-operation and
assistance. Particular thanks go to the Head of Safer Custody and Violence
Reduction for his help throughout the investigation.
The man was transferred from an Irish prison in 2007, having lived there for a
number of years. He was initially sent to HMP Cardiff, before moving to HMP
Parc in December, via a number of other prisons. The man came into prison with
a number of ailments but no serious illnesses. In February 2009, he was referred
to the urology department of the local hospital having passed blood in his urine.
In May, the first prison doctor who saw the man was told that the man was
suffering from cancer. The man began chemotherapy at the end of June, but his
health declined further in mid-December. When he was seen on the morning of
20 December, the doctor noted that he was in pain and had spent a bad night.
The man’s condition worsened and, the next morning, he was transferred to
hospital. The man died the following evening. Following his death, the prison
arranged a pagan funeral in accordance with his wishes.
Although staff supported the man throughout his illness, the clinical reviewer
assessed that his medical care fell below appropriate standards in some areas. I
make four recommendations regarding palliative care, record keeping and pain
assessment, and highlight one area of good practice.
The 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.
Jane Webb
Acting Prisons and Probation Ombudsman March 2011
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CONTENTS
Summary
The investigation process
HMP Parc
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was born in March. He was charged with a number of serious offences
and arrested in Ireland in October 2006. He was returned to the United Kingdom
and remanded to HMP Cardiff on 3 August 2007. He told staff of his high blood
pressure and prescribed medication, but said that he had no serious illnesses.
He moved to HMP Swansea later in the month where staff continued to monitor
his blood pressure.
The man was transferred to HMP Parc on 12 October and then, in December,
moved briefly to Usk and Cardiff before returning to Parc. Once back at Parc, he
again told staff of his high blood pressure but did not mention any severe
ailments. In early 2008 he complained of suffering from a chest cold. Later that
year, he applied for a promotion in the prison privileges system but this was
rejected due to the number of written warnings he had received.
In December 2008, the man complained of passing blood in his urine. Blood
tests were ordered, but were not followed up. It was not until February 2009 that
the man was referred to hospital. He complained of chest problems around that
time. Following tests, it was confirmed in May 2009 that he was suffering from
lung and bladder cancer. The man took the news stoically, and said that he was
happy to remain in his usual cell rather than move to the healthcare unit.
Unusually, staff decided that the man’s wife should be contacted each time he
went to an outside hospital to allow her to accompany her husband. Officers and
healthcare staff told the man to ask staff whenever he needed more pain relief
medication. He underwent chemotherapy in the summer, but began to suffer
more pain in the autumn. The man’s application to be released early from prison
as a result of his ill health was unsuccessful because of the risk associated with
his offence.
The man underwent palliative radiotherapy in an attempt to aid his swallowing
but his condition continued to deteriorate throughout December. He was very
weak by 20 December and, following a bad night, it was decided to transfer him
to hospital the following day. His family were informed and were with him when
he died on 22 December. The prison contributed to the cost of the funeral and
arranged for a pagan chaplain to conduct it.
The clinical reviewer assessed the quality and timeliness of the man’s care as
falling below appropriate standards in a number of areas and I make four
recommendations regarding palliative care, record keeping and pain
assessment, and highlight one area of good practice.
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THE INVESTIGATION PROCESS
1. My colleague was appointed to undertake the investigation. On his initial
visit to the prison, my colleague met the Director, the man’s cellmate, his
personal officer and the senior officer on his wing. My colleague was
shown the man’s cell. Notices were issued to prisoners and staff to alert
them to the investigation. No-one came forward in response to the
notices.
2. My colleague wrote to Healthcare Inspectorate Wales to request a review
of the clinical care the man received while in prison custody. The clinical
reviewer was provided with all of the relevant documentation to assist her
review. The clinical review was not completed until September 2010
which has resulted in a delay in issuing this report.
3. One of the Ombudsman’s family liaison officers spoke to the man’s wife to
discuss the investigation and any issues or concerns. The man’s wife was
interested in the details of the medical care her husband received, and
wanted some of his property returned to her. My colleague and the
Ombudsman’s family liaison officer visited her on 2 June to discuss the
investigation. My colleague and the clinical reviewer travelled to Parc on 9
June to discuss the man’s wife’s concerns with the Head of Healthcare.
My colleague returned to the prison on 21 September to clarify some
outstanding issues.
4. The man’s wife responded to the draft report and made a number of
comments on it. The final report has changed in the light of these
comments and, where the report has not been amended, I have written to
the man’s wife to explain why. The National Offender Management
Service also responded to the draft report. They identified no factual
inaccuracies, and I include their response to the recommendations at the
end of the report.
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HMP & YOI PARC
4. HMP & YOI Parc is a category B local prison near Bridgend in Wales.
This is a closed prison for prisoners who do not require maximum security,
but for whom escape needs to be made very difficult. It holds
approximately 1,200 male adults and young offenders. The prison opened
in 1997 and is managed by G4S on behalf of the National Offender
Management Service (NOMS). At the time of the man’s custody,
healthcare services at Parc were provided by Primecare and included a 24
bed in-patient centre.
Incentives and earned privileges (IEP) scheme
5. The IEP system is intended to encourage and reward good behaviour in
prison. Prison Service Order (PSO) 4000 describes it as follows:
“The IEP scheme complements the discipline system by rewarding
good behaviour. In addition to any local aims, it is intended to
encourage prisoners and YOs [young offenders] to behave
responsibly, to participate in constructive activity, and to progress
through the system. This will foster a more disciplined and
controlled, and therefore safer environment for prisoners and staff.
It should also contribute to the reduction of re-offending by
encouraging prisoners to lead law-abiding, productive and healthy
lives.”
6. Prisoners are able to move up a level (basic, standard or enhanced) and
earn various privileges. Poor behaviour can result in moving down a level
or losing privileges. Privileges include association time and extra visits.
Restraints
7. Restraints or handcuffs are frequently used on prisoners who are required
to leave the prison environment. Before they are used a security risk
assessment is completed to ascertain the level of risk that a prisoner
poses with regard to their potential to escape. The assessment informs
the decision about the number of escorting officers and the type of
restraint to be used (single cuffs or two metre long escort chain with cuff at
either end). It also determines the circumstances and the authority
required for the restraints to be removed.
Independent Monitoring Board (IMB)
8. Each prison has an Independent Monitoring Board (IMB) made up of
members of the community whose role it is to ensure that the prison is
properly run and that prisoners are treated decently. Each Board
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produces an annual report, the most recent of which for Parc is dated
March 2008 to February 2009. The report commented on the need for the
personal officer scheme to be effectively managed and for more places to
be available for both work and education.
9. The IMB’s report referred positively to palliative care at Parc:
“The Healthcare team have continued to provide excellent
treatment and support to prisoners suffering from terminal illnesses,
and such prisoners have been treated in a caring and appropriate
manner during their final days.”
10. The overall judgement of the Board was that:
“HMP & YOI Parc has again made conspicuous ongoing efforts to
ensure that all prisoners felt safe and were treated humanely, with
dignity and fairness by all those charged with their care.”
Her Majesty’s Chief Inspector of Prisons
11. Her Majesty’s Chief Inspector of Prisons conducted a full unannounced
inspection of Parc from 7 to 11 July 2008. The report said that the prison
was reasonably safe but suffered from a lack of education or work places
for its population. The report notes that, although the prison had areas of
concern, it had improved since the last inspection. However, the report
said that the two key areas that needed to be addressed were the training
of staff and the need to resource the prison effectively. The report said
“Overall, we found that prisoners had good access to a wide range of
clinical services, which were at least comparable with those found in the
community.”
Previous deaths at HMP & YOI Parc
12. Parc experienced two other deaths from natural causes in 2009, one of
which was also due to cancer. This death also occurred in an outside
hospital.
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KEY FINDINGS
13. The man entered HMP Cardiff on 3 August 2007 charged with a number
of serious offences. He went to the healthcare unit due to his status as a
Rule 45 prisoner. (This is when prisoners who feel vulnerable either
because of the nature of their offence or other reasons can be separated
from the rest of the prison population.)
14. No significant issues were noted in the man’s reception health screen,
although he asked to see a doctor due to high blood pressure. He was
assessed by the doctor on 8 August and discussed his history of
hypertension and peptic ulcer. He also mentioned recent headaches and
lower back pain. He was prescribed paracetamol and lisinopril (to treat
high blood pressure and cardiac issues) and given a cell in the healthcare
centre so that he could be monitored.
15. As there were no other clinical matters, it was deemed unnecessary for
the man to remain any longer in the healthcare department. As a Rule 45
prisoner, he could not mix with other prisoners on a residential wing and
so he was segregated on 20 August for his own safety. Staff conducted
the checks to identify any healthcare concerns to prevent him staying in
the segregation unit, and the man’s segregation was reviewed regularly
16. On 21 August, the man was assessed by a prison doctor who requested a
check of the levels of urea and electrolytes in his blood. The doctor noted
that, until the results came back, the man’s prescription of lisinopril should
not be increased. However, if the results were satisfactory, the
prescription could be increased to 10 milligrams (mg). The man’s high
blood pressure was noted in his medical record before he transferred to
HMP Swansea on 22 August. His blood pressure was recorded as 155/92
with a pulse of 81. (This is quite a high blood pressure reading. A normal
reading would be approximately 130/80. The pulse reading is normal.)
17. During the man’s reception health screen at Swansea, he mentioned to
the first nurse who saw him that he suffered from bad headaches and
stomach ulcers but nothing of any further significance. He was not given
lisinopril as the nurse wrote in his record that he was not allowed it until
his urea and electrolytes levels had been checked. (The man was given
lisinopril for the first time at Swansea on 30 August, and was subsequently
given it every day from 3 September.) His blood pressure was high during
his latter time at Swansea, and the doctor referred him to the chronic
disease clinic.
18. On 12 October, the man transferred back to HMP Parc where he told the
first officer during the induction assessment that he was glad to have left
Swansea. The nurse who reviewed him noted his prescriptions and ulcer.
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The man was seen by the doctor the following day who prescribed his
medication and asked for blood tests to be undertaken. A nurse who saw
him later that day noted his high blood pressure. The man was seen by a
prison doctor on 6 November who prescribed him further medication and
requested blood tests to be taken. These were completed the following
week, and the results revealed no problems.
19. In mid-December, the man was briefly transferred to HMP Usk and then
Cardiff but returned to Parc on 21 December. His health was again
assessed during his reception health screen. The man said that he had
recently seen a doctor for a repeat prescription. His medication was listed
as Omeprazole (to control stomach acid), paracetamol,
Bendroflumethiazide (to treat hypertension), lisinopril (to treat
hypertension and cardiac issues), Beclometasone (to treat asthma and
sinus conditions). He had no concerns about his physical health and the
healthcare worker noted nothing of significance. The man told the nurse
that he drank socially but did not use drugs. He did not acknowledge any
mental health issues and said that there was no reason to see a doctor.
20. The man received a written warning on 28 December from a second
officer for being in another prisoner’s cell against the unit rules. The
officer noted in his wing history sheet that he warned the man prior to
issuing the written warning. The man moved cells in January after telling
staff that he was concerned about his cellmate. It was noted in the wing
history sheet that the man thanked staff for facilitating the move.
21. In early 2008, the man complained of a chest cold which had lingered for a
while. He was given Amoxicillin 500mg (an antibiotic) three times a day
and Prednisolone (an anti-inflammatory medication) 20mg daily and
reviewed by a prison doctor. Staff attempted to collect sputum but he
could not produce a sample. He was sentenced to 12 years in prison at
the end of February.
22. The man applied for enhanced status under the IEP scheme on a number
of occasions in 2008 but was turned down. He refused to engage in any
behavioural programmes and had received a number of written warnings.
One written warning concerned the man having another prisoner’s
property in his possession against unit rules on 20 March 2008. A third
officer noted in the wing history sheet that the man admitted purchasing a
T-shirt. The officer later wrote that the man denied purchasing it and said
that he was frustrated as the warning would inhibit his chance of achieving
enhanced status. The third officer noted that the man suggested that staff
were attempting to prevent him achieving enhanced status. The officer
wrote in his wing history sheet:
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“He does not see that his behaviour may need altering in order to
attain his targets.”
23. The third officer noted in the man’s wing history file on 2 April that a visit
with the man’s family was allowed to go ahead despite the confirmation
slip bearing the date of 7 April and not 1 April as the man had thought.
His application for enhancement was not supported on 10 April by the
third officer who wrote:
“The man is not a disciplinary problem on the unit but he does not
seem to understand that his behaviour results in him not achieving
his targets. He does not see that only he can change this to reach
his goals. Despite being told about query times, the man will
always try and manipulate staff into dealing with them at the most
inopportune times.”
24. Two weeks later, the officer noted that the man attempted to talk about the
failure of his application for enhanced status again shortly before prisoners
were locked in their cells. He tried to speak to officers again on 3 March
about enhanced status. The third officer wrote in the man’s wing history
file that he would now need to submit an application to talk to officers as
he always began the conversations at inopportune times.
25. On 11 May, the third officer wrote in the man’s wing history file that:
“spoke to the man who now says that he has come to the
realisation that he will not be getting his enhancement at present.
He now states that he wishes to participate in all programmes open
to him. A sudden change of heart now that he realises he needs to
address his behaviour in order to gain enhancement.”
26. The man applied for enhanced status again in June. However, it was
noted by the first officer in August that the man continued to attempt to
monopolise staff time. A fourth officer wrote in the man’s wing history file
that he contacted the IMB in August to ask about his application for
enhancement but was told that, without undertaking the required courses,
he would not be eligible.
27. On 17 August, the man wished to telephone his family in the evening.
This was refused as a prisoner on the standard regime does not have
association time on weekend evenings. He asked the first officer to
telephone on his behalf from the office which was also refused as the
number requested had not been cleared by security.
28. A further written warning was issued to the man on 14 September by a
fifth officer:
10
“Despite two warnings last week in which I informed you of correct
time for telephone use and advised you that if you need to use the
telephone to ask a member of staff. Regardless of this you still
ignored unit rules and used the telephone at an unauthorised time.
Furthermore when challenged you became argumentative and tried
to justify your behaviour. You have been on the unit long enough to
be aware of unit rules and was reminded of these only days ago.”
29. The man told a nurse on 11 December that, for several weeks, he had
passed blood in his urine. He was seen by the prison doctor the following
day who confirmed that the man had an enlarged prostate and was
passing blood in his urine. The doctor ordered blood tests, although the
sample taken could not be tested. There is no evidence that this was
followed up.
30. The fifth officer recorded in the man’s wing history file on 31 December
that he had refused to go to hospital because of being handcuffed. The
officer explained to the man that it was standard practice to cuff a prisoner
for an outpatients’ appointment. The investigator asked about this issue
and was told that it was standard practice for category B prisoners.
31. On 1 January, the man complained of a problem with his chest again and
an appointment was made for him to see a second prison doctor on 4
January. At that appointment, the doctor noted that he had a cough and
was wheezing. The man was given smoking cessation advice and
prescribed Becofide and Salbutamol (medication used to aid breathing).
There is no evidence that the outstanding matter of the urine sample taken
in December was followed up at this appointment.
32. The man’s chest problems continued into February and he complained of
his chest feeling tight. The second prison doctor saw the man on 17 and
24 February and noted that he was short of breath and continued to pass
blood in his urine. From the records, the second doctor could see that this
had not been effectively investigated since December. The man was
referred to the urology department of the local hospital on 24 February.
33. Less than a week later, the man went to the Princess of Wales Hospital for
tests. Staff at the hospital were concerned that he might have a bladder
tumour and he underwent further surgical procedures at Abertawe Bro
Morgannwg University NHS Trust. He returned to Parc on 17 April.
34. The man applied for enhanced status again in December 2008 which was
granted in April 2009.
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35. In May, the prison received correspondence from the hospital that
confirmed that the man was suffering from cancer. The tests revealed that
he was suffering from cancer in his lungs and bladder. A sixth officer
recorded that the man took the news relatively well and staff did not
consider there was need for suicide prevention procedures to be put in
place. The officer offered the man the opportunity to telephone his wife,
but he declined. The prison chaplain also visited the man and offered him
her support. She arranged for the man to have a telephone call to his
family. She visited the man again at the start of June and, although she
offered him an opportunity to see a pagan chaplain, he told her that he
was happy with the support offered by the prison.
36. On 3 June, the man went to hospital for a bronchoscopy (a procedure
where an instrument is inserted through the patient’s nose or mouth to
examine the lungs and airways). Upon his return, staff wanted him to
spend the night in the healthcare unit so that he could be monitored.
However, the man was determined to return to his usual cell and signed a
disclaimer to confirm this. He returned to his cell that evening.
37. Four days later, on 7 June, the man felt ill and the alarm was raised via a
code blue alert. (A code blue indicates a medical emergency relating to
breathing.) He complained of sudden chest pain. The notes in the
medical record described the man as cyanosed (blue skin) and suffering
from haemoptysis (coughing up of blood). He was wheezing and
described as cold and clammy. His pulse was high, 78 beats per minute.
The man was taken to hospital, and staff telephoned his wife to tell her
that he was there. He returned from hospital two days later, on 9 June,
but was unhappy that the medication the hospital had prescribed for him
was not available at the prison. He spoke to the doctor the following day
to resolve this.
38. The man told staff in mid-June that he was not taking his pain relief as he
did not feel it was necessary. He was taken to hospital on 25 June after
becoming unwell but returned that day. A multi-disciplinary case
conference was held on 26 June to discuss the man’s care. This was an
opportunity for a range of people responsible for the man’s care to discuss
any issues or concerns. It was decided that the prison chaplain would tell
the man’s wife whenever he was taken to an outside hospital so she could
accompany him. (This would not normally happen because of practical
and security constraints.) The man was told to press his cell bell
whenever he needed pain relief so that staff could provide it for him.
39. At the end of June, the man told staff that he was suffering from pain at
night. Arrangements were put in place for the night nurse to give him pain
relief medication every night. Chemotherapy was begun on 30 June, and
often left him tired. The man had been given an information leaflet about
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his therapy. He was concerned about his temperature rising so staff
arranged for it to be taken when the medication was administered at night.
A second nurse wrote in the man’s medical record that he was happy with
this arrangement.
40. The man went to hospital on 8 July to have an X-ray and MRI [magnetic
resonance imaging] scan. A note was made in the PER relating to the
issue of restraints:
“Permission given by the Head of Safer Custody and Violence
Reduction for closet chain to be removed for scan.” [The Head of
Safer Custody and Violence Reduction was required to authorise
such decisions.]
41. On 21 July, the man was taken to Velindre Hospital. However, on arrival
he was told his blood tests results from the day before meant that he
would not be able to have chemotherapy on that day. The hospital
contacted the prison to arrange another date.
42. The first prison doctor carried out a full assessment of the man on 12 and
13 August. He noted that, although the man had suffered from diarrhoea
and had a tender stomach, his clinical observations (that is pulse,
temperature and blood pressure) were within normal limits. The man
returned after a day of treatment at hospital on 19 August and, again, his
prescribed medication was not available for him in the prison. The man’s
wife telephoned the hospital, who told her they had contacted the prison to
let them know that he had been given more medication. The medication
was found in the admissions department of the prison. A third nurse told
the man that, in future, he should see a nurse in the prison admissions
department on his return from hospital to ensure that he had his
medication.
43. Another case conference was held on 3 September. Nursing, safer
custody and chaplaincy staff attended. A senior nurse recorded in the
man’s medical file that he raised no concerns about his care, and it was
noted that his wife continued to attend all of his outpatient appointments.
The fourth officer, in the man’s wing history sheet, described him as “a
polite and mature inmate”.
44. On 7 September, the hospital told the man that he would not be able to
have his chemotherapy until he had a blood transfusion. A note was also
made in his medical file regarding the contact details of the lead palliative
care nurse at the Princess of Wales Hospital in Bridgend, saying that she
was available on the telephone if required. The prison had further contact
with the lead palliative’s colleagues at the end of the month.
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45. A letter sent to the second prison doctor on 6 October by a doctor
explained that the man was reviewed during a hospital appointment in
early October. It confirmed that the pain was caused by his tumour and
he should continue to take Oramorph (liquid morphine) when required. On
7 October, the third nurse recorded that the man was suffering from more
pain but the Oramorph was helping.
46. The man’s condition was reviewed by the lead palliative nurse on 22
October. She noted that he was clear about his prognosis and graded him
as five to six on the pain scale. (This was described by the clinical
reviewer as a scale of zero to ten with zero being no pain and ten being
the worst pain.) He continued to take Oramorph when in pain. The lead
palliative nurse noted that she was scheduled to see the man again in four
weeks time, but offered further support should it be required.
47. On 13 November, the man was sick in the morning, but told a fourth nurse
that he was not in pain.
48. A third prison doctor reviewed the man two days later as he had
developed a large swelling on his neck. He was referred to the oncology
department of the hospital as it was feared that it might be cancerous.
49. The fourth officer had noted on 2 November that the man has said that he
was considering applying for release on compassionate grounds.
However, the second prison doctor confirmed on 24 November that the
man was still physically active. He described the man as in “remarkably
good health” for the type of problems he had. This meant that he posed
too great a risk and so the application for release on compassionate
grounds was not supported by the prison. A seventh officer was asked by
the man to take over as his personal officer on 29 November.
50. The man attended the outpatient clinic at Velindre Hospital on 26
November. It was decided that, although further chemotherapy would not
be of benefit, radiotherapy could improve his swallowing. The palliative
lead nurse telephoned to say that she thought that the man was
deteriorating and might only have months to live. It was noted that the
palliative lead nurse would be invited to the next case conference.
51. On 1 December, the man applied for release on temporary licence (ROTL)
on special purpose leave on 24, 25 and 26 December to try to spend his
last Christmas with his family. This type of release is described in PSO
6300 as:
“This is a short duration temporary release, often at short notice,
that allows eligible prisoners to respond to exceptional, personal
circumstances and to wider criminal justice needs.”
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52. On 3 December, the prison chaplain said she supported the ROTL
application on compassionate grounds, but understood the security
implications.
53. A note was made in the man’s medical record by the third prison doctor on
5 December that he had no complaints, and was awaiting his first session
of radiotherapy. The man went to Velindre Hospital on 9 December for a
CT (computerised topography) scan. The Head of Safer Custody and
Violence Reduction gave permission for cuffs to be removed during the
scan.
54. A case conference was held on 9 December with the palliative lead nurse
to discuss the man’s application for release on temporary licence. The
man was not present at the meeting. The application was not supported
by the man’s unit manager or his offender supervisor as the man was still
mobile enough to be considered a security risk. The seriousness of his
index offence was also taken into consideration. The staff agreed to
suggest that the man move to a single cell. They agreed that the man
should move to an outside hospital if his health deteriorated any further. It
was noted that the man saw healthcare staff twice a day and was able to
contact Macmillan nurses on the telephone if he wished to. (Macmillan
nurses specialise in cancer and palliative care.)
55. The outcomes of the case conference were discussed with the man the
following day. He said that he was happy with the care he had received
and preferred to stay in his cell as he got on well with his cellmate. The
man’s cellmate told the investigator he had been happy with this
arrangement. He acknowledged that he could speak to the Macmillan
nurses on the telephone should he wish to. The seventh officer wrote in
his wing history sheet that he received a visit from his family on 16
December which he said he enjoyed.
56. From 16 December, the man’s health began to deteriorate. The seventh
officer wrote in his wing history sheet that he was “starting to go downhill a
bit, health wise”. The man signed a form confirming consent for a flu and
swine flu jab, which he received on Thursday 17 December.
57. On 18 December, the man’s application for ROTL was rejected due to
concerns regarding security and the victim of his offence:
“Due to the fact there are victim issues, community local issues, the
risk is too high for the man to be considered at this stage, any
further applications must be passed through Offender Supervisor
as Social Services and victim liaison would also have to be
contacted.”
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58. The second prison doctor requested an extra mattress for the man as he
was becoming incontinent at night. The following day, a note was made in
his record for all staff to monitor him as he was becoming increasingly
frail. My investigator spoke to the man’s cellmate who said that he
continued to look after the man and assist him in his daily routine at this
time.
59. On the morning of 20 December, it was recorded by an eighth officer that
the man had not had a good night. He had been in pain but his cell-mate
kept staff aware of any changes in his condition. He was reviewed by the
third prison doctor and assessed as deteriorating and becoming
disorientated. It was also noted that, while he denied it, the man was
clearly in pain when he moved. The doctor noted that he was again
offered the opportunity to go to the healthcare centre, but he wished to
stay where he was. The doctor wrote that the man would not want to go
to hospital but “wants to stay where he is”. The sixth officer recorded that
a visit was organised for his family in the care room on D wing as the man
was too ill to go the visits hall.
60. The man deteriorated further the following morning and was unable to get
out of bed. Healthcare staff, having reviewed the man, decided to transfer
him to hospital. The second prison officer spoke to the Princess of Wales
Hospital to arrange the move.
61. The prison undertook a risk assessment for the man’s transfer to hospital.
In the section ‘Approval of Head of Security or Head of Operations’, it was
recorded that restraints were not to be used. A later assessment at
3.30pm confirmed that restraints were not to be used “due to serious
nature of his illness”. The second assessment also reduced the level of
the escort to one staff member.
62. The prison chaplain telephoned the man’s wife to tell her that her husband
was being taken to hospital. He was escorted to the Princess of Wales
Hospital in Bridgend at 10.30am. His family were told, and arrived at the
hospital at 11.20am. The prison chaplain came to the hospital at 3.50pm.
The man died the following day at 6.35pm.
63. Following the man’s death, other prisoners were informed and offered
support from Listeners and chaplaincy. (A Listener is a prisoner trained by
the Samaritans to provide emotional support to other prisoners. It is
confidential, but is not a counselling service.)
64. The man’s cellmate was told individually and staff kept a close eye on him.
The officers were offered support from the care and support team and
chaplaincy.
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65. The prison organised and contributed to the cost of the funeral. The man
was a pagan so the prison chaplain, arranged for a pagan chaplain to
carry out the service. She also returned the man’s property to his wife.
The prison held a memorial service to which prisoners and the man’s
family were invited.
17
ISSUES
Clinical issues
66. The clinical reviewer assessed the overall medical care received by the
man in prison. She finds that there were several areas where it could
have been improved. I make a number of recommendations based on the
findings of the clinical reviewer, and also include some recommendations
directly from the clinical review. I include in this report the key areas of
interest from the review and encourage the Head of Healthcare to closely
study all the findings and recommendations in the clinical review.
Quality and timeliness of care
67. The clinical reviewer makes reference to a number of occasions when the
quality and timeliness of the man’s care fell below appropriate standards.
A number of recommendations are made with regard to this, and I would
encourage the Head of Healthcare to review them.
68. When the man was seen by the second prison doctor in December 2008
there were delays organising blood tests to assess the symptoms the man
was presenting with. The clinical reviewer was concerned by these delays
and commented that the:
“Blood test should have been repeated and other results should
have been followed up. An indication of cancer may have been
diagnosed at this time and treatment commenced. It would seem
likely that even if an earlier diagnosis was made the final outcome
would likely be the same, however it would have allowed the man
to be assessed by specialists and allowed the appropriate
management of his pain, care and treatment at an earlier time.”
69. This oversight is worrying and may have meant that the man experienced
more discomfort than was necessary. The clinical reviewer did not make
a specific recommendation regarding this issue, but I would encourage the
Head of Healthcare to consider the implications.
70. The clinical reviewer also considers that the man did not receive
appropriate pain relief medication at various points during his time in
custody. With regard to the pain in his chest, she writes:
“Over time, the man experienced a physical pain in his chest which
was complex in nature. Overall pain management was reactive
and the type of pain experienced, location, and severity, were not
routinely assessed once the prognosis was clear. It is evident that
there was informal discussion with the man and that this prompted
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some changes and increases in his analgesia however there was
no regular pain self assessment such as the VAS (Visual Analogue
Scale - a pain self rating out of 10) nor a specific assessment
documenting the sites, number, and types of pain.”
71. In light of the clinical reviewer’s findings, I make the following
recommendation:
The Head of Healthcare should ensure that healthcare staff use
relevant pain assessment guides to ensure appropriate provision
and effectiveness of pain medication, in accordance with current
guidance.
72. The man’s wife told the investigator that no Macmillan nurses visited her
husband, despite his wish for them to do so. Macmillan nurses were
involved in his care although it does not seem that they visited him at any
point. The contact details for Macmillan nurses were put into the man’s
medical record at an early stage to allow for consultation. They were also
involved in the case conference held on 9 December. It is a matter for the
Macmillan nurses to decide whether to visit a patient and I am satisfied
that the prison did not put any obstacles in their way. The clinical reviewer
also comments on palliative care services for the man:
“Whilst a review of the care he required was undertaken on 15th June
2009, no contact was considered or made to access palliative care
services or support for the man until September 2009. Staff did not
collaborate with Clinical Nurse Specialists, Palliative Care Specialist
Nurses, or voluntary organisations to access specialist advice and
support to ensure he received the best possible care.
73. I agree with the clinical reviewer. I make the following recommendation:
The Head of Healthcare should ensure that patients requiring
palliative care are treated in accordance with the prescribed
pathway, including visits from the Macmillan nurses.
Sharing information
74. The clinical reviewer refers to a number of occasions where poor
communication and liaison affected the care provided to the man.
75. When the man returned from his chemotherapy sessions he was provided
with medication by the hospital. This was not always provided to him and
did not appear to get through the reception area of the prison. The man’s
solicitor was obliged to contact the prison to alert them to the man not
receiving the correct medication. The clinical reviewer was also
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concerned about the man’s visits to hospital not being effectively recorded
in the prison’s clinical records:
“On a number of occasions, no entries were made in the prison
clinical record of the man‘s attendance at hospital for clinic
appointments or his admission into hospital detailing the
appointments, the outcomes or actions required.”
76. I agree with the clinical reviewer regarding the importance of effective
communication, and make the following recommendation:
The Head of Healthcare should ensure that all hospital visits are
documented in the medical notes to ensure effective continuity of
care.
Record keeping
77. In her clinical review, the clinical reviewer criticises the standard of record-
keeping by healthcare staff at Parc. She specifically notes that the reason
for lisinopril not being administered at Swansea was not noted on the
man’s medication chart, and no prescription charts appear to have been
completed after 30 July 2009. She described the record keeping in the
following manner:
“The clinical records were generally in poor order, with entries
being illegible, abbreviations used throughout the records and lines
left blank between entries.”
78. I endorse the clinical reviewer’s recommendation:
The Head of Healthcare should ensure that the entries made by
healthcare staff in medical and nursing records are legible, signed,
lines are not left blank and that abbreviations are not used in
accordance with the standards set out in the NMC [Nursing and
Midwifery Council] Guide to Record Keeping.
Concerns about a particular doctor
79. The man’s wife was concerned that one of the doctors at Parc did not
provide the right care to the man. Unfortunately, she did not give the
name of the doctor. The man received medical care from a number of
healthcare staff, including several doctors during his time in the prison.
He did not make any formal complaints about his medical care, nor is
there any record that he mentioned to staff that he was unhappy. In fact,
when he was told of the outcome of the ROTL case conference on 9
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December 2009, the man told staff that he was happy with the care he
had received to date.
80. Although I am not able to identify the doctor to whom his wife referred, the
clinical review considers the man’s care overall. It takes into account the
conduct of every healthcare professional who he came into contact with.
At no point in the review is an individual’s conduct specifically called into
question, although over-arching issues are identified. In light of the fact
that the man did not raise his concerns with staff and in line with the
clinical review, I make no comment on the conduct of any individual doctor
in this report.
The swine flu jab
81. The man’s wife was concerned that her husband received flu and swine
flu vaccinations at the same time on Thursday 17 December. She
explained that she spoke to him the following day, when he seemed very
ill. She was concerned that, since his immune system was already
compromised by his treatment, he should not have been given the
injections.
82. The clinical reviewer examined this issue and consulted colleagues. She
wrote in her report that:
“We have sought the views of a consultant oncologist in this matter,
and he has concluded that taking into account the man’s condition,
and the fact that his chemotherapy treatment had been concluded
three months previously, receiving two flu injections at the same
time would not have compromised the man’s condition or speeded
up his death.”
83. When the investigator spoke to the man’s cellmate, he explained that they
voluntarily put their names forward for the vaccinations. The cellmate said
that he suggested that the man discuss it with the pharmacist. The man
told his cellmate that the pharmacist described the jabs as “not a bad
idea”. The man signed a form acknowledging his decision to undertake
the injections. Given that the man made the decision voluntarily, and the
clinical reviewer has identified no risk with the procedure, I think it was
reasonable to give him the flu and swine flu jabs at his request.
Whether a nurse saw the man on the morning he went to hospital
84. The man’s wife wanted clarification as to whether the man saw a nurse on
the morning that he was taken to hospital. I can confirm that healthcare
staff did attend the man to help him get out of bed. They decided to
transfer him to hospital.
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Whether the man should have been admitted to hospital earlier
85. The man’s wife felt that he was sufficiently ill to have been admitted to
hospital earlier. The clinical reviewer had sympathy with this opinion
saying:
“Whilst it is clear that given the man’s condition it would have been
appropriate to admit him to hospital on 20 December, the decision
by the doctor and prison staff to respect the man’s wishes at this
time was reasonable, particularly as to do otherwise would have
caused the man more distress as he was adamant that he did not
want to be admitted to the Healthcare unit or to the hospital.”
86. The man told his cellmate and staff that he was adamant he did not want
to go to hospital before he had to. Given his strong personal desire to
stay at Parc as long as possible, it is clear that staff there sought to fulfil
his wishes. It is very difficult for staff in this type of situation to balance the
medical needs of a patient with their previously stated wishes.
87. I think it is worthy of note that the clinical reviewer identified that any
earlier transfer of the man may have caused further distress. I do not
criticise the prison for the difficult choice they made because it is clear that
they reached it with regard to the man’s wishes. The clinical reviewer also
judges it to be reasonable under the circumstances.
Good practice
88. The prison chaplain contacted the man’s wife when he was taken to
hospital on 7 June 2009. In the subsequent case conference, they agreed
that the chaplain would contact his wife each time he was taken into
hospital for treatment. This allowed his wife to see him relatively regularly
and was appreciated by her. This contact was continued up to and
including the man’s final transfer to hospital. This is an example of good
practice.
Prison transfers and the complications arising from them
89. The man’s wife was upset by his frequent moves to different prisons
following his initial arrival into custody. The moves also complicated
matters such as telephone calls, visits and money. I understand that the
man exchanged correspondence with a number of prisons regarding the
money and telephone call issues.
90. Moving between prisons can be difficult for prisoners and their families. It
is unfortunate that this was true for the man. However, the prison
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authorities and processes require prisoners to transfer for a variety of
reasons such as population pressures, security matters and court
appearances, even if it is inconvenient for those concerned. My remit
means that I have not considered all the transfers at the start of his time in
custody but I can provide some information. The man moved to Usk in
December 2007 while serving a short sentence. Usk is unable to hold
remand prisoners so he transferred to Cardiff later in the month once that
sentence was complete and he was on remand again. However, Cardiff
was unable to take vulnerable prisoners so the man was transferred again
to Parc.
Refusal of enhanced status
91. The man was not granted enhanced status in 2008 due to a number of
written warnings. His wife disputed the validity of these warnings following
her husband’s death. The investigator has looked into this issue and
found nothing irregular in the application or consequence of these
warnings. The warnings were issued for a number of reasons including
using the telephone at unauthorised times. Although the man’s wife
expressed her belief that there were mitigating circumstances regarding
the use of the telephone, the nature of a prison wing with 120 prisoners,
each with their own individual circumstances, means that the prison can
often not exercise such discretion. I conclude that it was reasonable for
officers to refuse enhanced status.
92. It is clear from his records that the man struggled, at first, to adapt to the
requirements of the regime at Parc. However, this changed as the man
changed his behaviour. He achieved enhanced status and was described
as polite and mature by an officer.
Compassionate release
93. Prisoners who are suffering from a terminal illness and for whom death is
thought likely to occur soon can be released from prison by early release
on compassionate grounds. In order to be released, an application must
be sent to the Public Protection Unit in National Offender Management
Service. The form includes sections to be completed by the Governor, a
prison doctor and an offender manager. A full prognosis must also be
provided. Once the form is submitted, caseworkers in the Public
Protection Unit determine whether the application meets the criteria set
out in PSO 6000 (the instruction that deals with the release and recall of
prisoners). In making this decision, they consult with the Parole Board
and specialist medical advisors in the Department of Health. PSO 6000
states:
“The criteria applied in medical and tragic family circumstances
cases are as follows:
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(i) Medical
- the prisoner is suffering from a terminal illness and death is likely
to occur soon; or the prisoner is bedridden or similarly
incapacitated; and
- the risk of re-offending is past; and
- there are adequate arrangements for the prisoner's care and
treatment outside prison; and
- early release will bring some significant benefit to the prisoner or
his/her family.”
94. The man applied for compassionate release toward the end of his life but
it was rejected. I understand that this was due to the medical opinion that
the man was still well enough to re-offend. The man subsequently applied
for temporary release on special purpose licence in an attempt to spend
his last Christmas at home. This type of release is described in PSO 6300
(Release on Temporary Licence) as follows:
“This is a short duration temporary release, often at short notice,
that allows eligible prisoners to respond to exceptional, personal
circumstances and to wider criminal justice needs.“
95. Following a case conference on 9 December, the man’s application was
rejected on 18 December due to security and victim concerns. The verdict
noted that any further applications would need to involve Social Services
and victim liaison. The investigator was told by the prison during the
investigation that such liaison could not begin before the man’s health
deteriorated. Although the man was keen to be released, it is
understandable that the prison was cautious about doing so due to his
offences and reasonable level of health up until very near to the end of his
life.
Authorising a visit to the man
96. The man’s wife said that she was upset by the delay in allowing her
daughter’s fiancé to visit the man. She explained that in June 2010 they
wanted the two men to meet but the prison took time to authorise his visit.
The investigator has seen a letter from the man’s solicitor sent on 24
August requesting the visit be allowed. The Head of Operations at Parc,
responded the following day granting special dispensation for the man’s
daughter’s fiancé to visit the man.
97. Despite this authorisation, the man’s wife told the investigator that the first
visit did not occur until 1 November, more than three months later.
However, the man’s wife did say that part of the delay may have been
caused by the family’s solicitors neglecting to tell the family that her
24
daughter’s fiancé had been given approval to visit her husband. Although
the delay is regrettable, since the Head of Safer Custody and Violence
Reduction replied to the letter from the man’s solicitor, I consider him to
have fulfilled his obligations in this regard.
98. The man’s wife, while acknowledging the possible delay on the solicitor’s
behalf, said that officers repeatedly refused to allow the man to arrange a
visit for his daughter’s fiancé until November. My investigator looked into
this and asked the prison to review the authorisation process. The
investigator was told that the prison was unable to check whether there
was any delay in the authorisation of the visit following the decision taken
by the Head of Safer Custody in August. It is regrettable that there is
insufficient evidence to answer this question fully.
The use of restraints during the man’s hospital visits
99. The man was restrained while he was escorted for hospital appointments.
He was unhappy with the level of restraint and the differing approach
escort officers took to the issue. The man’s solicitor wrote to the prison to
request that restraints to be removed to allow private consultations with
the hospital staff. I understand that the prison responded by agreeing to
use a longer escort chain that secured the man but meant he could meet
with hospital staff in more privacy. This allowed greater privacy without
removing the restraint entirely.
100. I understand that restraints are an emotive issue, particularly during
medical visits, due to the impact they have on prisoners’ dignity.
However, the prison has a responsibility to the public to ensure that
prisoners are restrained during any time spent out of direct prison custody.
The prison responded to the request from the man’s solicitor and I am
pleased that they allowed him to consult hospital staff privately without
compromising their responsibility for security.
Liaison with the man’s family
The funeral
101. I am pleased that the prison not only paid for the funeral but also arranged
it. The man was a pagan, and the prison chaplain helped locate a suitable
person to conduct the funeral. This level of involvement is to be
welcomed, and is an example of the efforts made by the prison chaplain to
support the family after the man’s death.
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The man’s property
102. The man’s wife told my investigator that she wanted some computer discs
that the man had been writing his life story. The investigator spoke to the
prison on her behalf but was told that the prison had no such discs. This
is, of course unfortunate and I remind Parc of the vital importance of
ensuring that all property is returned to the bereaved family.
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CONCLUSION
103. The man spent a number of years in custody before becoming terminally
ill. Although the clinical review outlines a number of issues that could
have been improved upon regarding the man’s clinical care, I believe that
staff sought to care for his clinical and personal needs. His wish to stay in
his cell was respected, and he was supported by discipline and chaplaincy
staff. I am pleased that the prison informed the man’s wife of his hospital
appointments which allowed them to attend together. This type of support
was continued by the chaplain after the man’s death. I realise that the
man’s wife has a number of concerns regarding his care, and I hope that
this report provides further information about his time in custody.
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RECOMMENDATIONS
Recommendations
1. The Head of Healthcare should ensure that healthcare staff use relevant
pain assessment guides to ensure appropriate provision and effectiveness
of pain medication, in accordance with current guidance.
The National Offender Management Service accepted this
recommendation:
“New pain assessment guides are currently being reviewed
collectively with GP practitioners, Medical Director and Pharmacy
supplier. To be discussed and taken forward in our Medicines
Management meetings.”
2. The Head of Healthcare should ensure that patients requiring palliative
care are treated in accordance with the prescribed pathway, including
visits from the Macmillan nurses.
The National Offender Management Service accepted this
recommendation:
“Links with Macmillan Nurses have been made and our Healthcare
department will be visited and reviewed with MacMillan in order to
develop working practices. Plans are under development to
provide a palliative care suite on our new Older Persons Unit.”
3. The Head of Healthcare should ensure that all hospital visits are
documented in the medical notes to ensure effective continuity of care.
The National Offender Management Service accepted this
recommendation:
“A new policy will be implemented to ensure that all secondary care
provision/ interactions are kept and documented in the IMRs and an
audit trail provided from referral to discharge from secondary care.”
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4. The Head of Healthcare should ensure that the entries made by
healthcare staff in medical and nursing records are legible, signed, lines
are not left blank and that abbreviations are not used in accordance with
the standards set out in the NMC [Nursing and Midwifery Council] Guide
to Record Keeping.
The National Offender Management Service accepted this
recommendation:
“Defensible documentation training will be provided for all medical
staff. All staff are to receive a copy of NMC guidelines and policies
and procedures.”
Good practice
1. Telling the man’s wife of his upcoming hospital appointments allowed her
to be with him, and is an example of good practice.
The National Offender Management Service noted this good practice:
“This good practice continues to be carried out wherever possible.”
29