Individual at Chelmsford

Circumstances surrounding the death of a man at
Hospital, on 8 October 2007 whilst a prisoner at HMP
Chelmsford
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2008
This is a report into the death of a man at Hospital on 8 October 2007. The
man, who was 74 years old, was a prisoner at HMP Chelmsford. He died
from natural causes, having been admitted to hospital ten weeks before his
death.
The man had no registered next of kin and I was therefore unable to contact a
family member to inform them of my investigation.
The man had been recalled to prison in June 2004, having been released on
life licence. When he arrived at HMP Chelmsford in November that year, he
was identified as suffering from ischaemic heart disease. He had previously
undergone cardiac surgery, including a valve replacement. His health
deteriorated during his time in custody, and he was further diagnosed with
cancer. The Coroner has confirmed that the cause of his death was
bronchopneumonia and cancer.
This investigation has been undertaken by one of my investigators. I would
like to thank the Governor of Chelmsford, and his staff for their co-operation
and active participation.
Mid Essex Primary Care Trust conducted a review of the care the man
received whilst in prison. Unfortunately, due to staffing problems within the
PCT, there were significant delays in completing this review. Nevertheless, I
would like to thank the clinical reviewer for her contribution to the
investigation.
As is the case in many of my investigations following a death from natural
causes, I am greatly influenced by the findings of the clinical review. In this
case it appears that the man received exemplary care from both clinical and
discipline staff at HMP Chelmsford. Given that the prison has not had the
happiest recent history, I might mention that this is not the first investigation I
have carried out at Chelmsford where a high level of medical and nursing care
has been highlighted.
The clinical report makes three recommendations and highlights two areas of
good practice that will be shared with the Mid Essex Primary Care Trust. Of
those recommendations, one relates to the impending introduction of a
computerised records system for healthcare. The computerisation of medical
records across the prison estate is much to be anticipated and welcomed.
My own investigation includes one recommendation (relating to when a
prisoner’s next of kin should be informed of emergencies). I also highlight
three areas of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman
July 2008
2
CONTENTS
Summary 4
The investigation process 6
HMP Chelmsford 7
Key findings 9
Issues 16
Recommendations and good practice 20
3
SUMMARY
The man was received at HMP Chelmsford on 29 November 2004, having
been recalled to prison for breach of his life licence. He arrived at Chelmsford
with a long standing illness - ischaemic heart disease(a disease of the blood
vessels supplying the heart muscles with oxygen which is severe enough to
cause temporary strain on the heart, or even permanent damage to the
muscle). He had previously undergone cardiac surgery, including a valve
replacement.
A month after arriving at Chelmsford, the man started to experience ill health,
and pains in his prostrate gland. He was transferred to the local hospital in
Chelmsford and, after a number of consultations, was diagnosed as having
urethritis (inflammation of the tube that conducts urine from the bladder to the
exterior) in April 2005.
The man’s condition worsened and he experienced continual abdominal and
prostrate pain. As a result of his ailments, he had ample contact with prison
healthcare staff and was referred to hospital on numerous occasions for
treatment. As his condition deteriorated, he was given a catheter (a thin,
sterile tube inserted into the bladder to drain urine) by the hospital to try and
relieve some of the pain he was experiencing. Despite this procedure the
man continued to experience episodes of abdominal pain and urinary
infections. This resulted in his frequent admissions into hospital care.
In a bid to resolve the man’s complaint, he was added to the hospital
operation waiting list to receive green light laser prostatectomy surgery
(treatment delivered using a high powered laser to destroy surplus prostate
tissue which is blocking the bladder).
Unfortunately, during this period, the man contracted bleeding piles (piles,
also known as haemorrhoids, are swellings on the inside of the anal canal)
and again had to be referred to the hospital for treatment. In June 2006, the
man underwent his prostatectomy. Approximately three weeks later, he once
more started to experience pain and urinary problems.
Over the next year, the man’s ill health continued. The hospital carried out
further tests and procedures to ascertain the underlying cause of his urinary
and haemorrhoids problems. He was cared for by nurse specialists at the
hospital, and they and the prison healthcare team made attempts to make the
man more comfortable and reduce the pain he experienced.
In June 2007, the man was again admitted to hospital for treatment of his
haemorrhoids. He also suffered from anaemia (a deficiency of red blood
cells), and had to have a blood transfusion. He remained in hospital, where a
number of further tests were carried out daily to identify the cause of his
bleeding, abdominal pain and anaemia.
The man was discharged from hospital on 5 July 2007. Prison healthcare
were informed that, if he had any recurrence of bleeding piles, they should
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contact the hospital surgeon. Two weeks later, the man was admitted again
for this very reason.
The man had only been out of hospital for about a week, when he was
readmitted on 28 July. He had complained of feeling dizzy, was pale in colour
and had a swelling on his left scrotum. The hospital urology nurse specialist
arranged for the man to have an ultrasound and clinic appointment.
Following receipt of daily progress reports from the bed watch prison officers,
the prison conducted a risk assessment. It was confirmed that the man now
posed no security risk due to his ill health and his restraints were
subsequently removed. He was also reduced to a single prison officer escort.
The man continued to undergo a number of tests in hospital. He was
diagnosed with ischaemia of the bowel (cancer), and received appropriate
surgery for this condition. Consideration was given by the prison to whether,
should the man’s condition improve, they could arrange his transfer to HMP
Norwich (which has a unit for older lifer prisoners located on the ground floor
of its healthcare centre). Unfortunately, he continued to deteriorate and
remained weak and incoherent most of the time.
By September 2007, the man’s cancer had started to spread and he was later
moved to a private side room on the hospital ward. Hospital staff informed the
prison that the man’s prognosis was very poor and he now needed constant
care. They were trying to locate a hospice or community hospital bed. The
deputy governor said that consideration would be given to whether the man
could be released early on compassionate grounds.
Unfortunately, within a short time the man started to experience periods of
rapid, intermittent and then shallow breathing. Sadly, on the morning of 8
October 2007, the man stopped breathing. He was examined by the doctor
and his death was certified at 8.00am.
5
THE INVESTIGATION PROCESS
1. My investigator considered the man’s prison documentation, including
his clinical records, before formally opening the investigation on 22
January 2008.
2. Prior to my investigator arriving at Chelmsford, notices were issued to
staff and prisoners announcing the investigation and inviting anyone who
had information relevant to the man’s death to make themself known to
the investigator. No one came forward. My investigator interviewed one
member of staff.
3. Whilst in prison the man had no listed next of kin. He did however have
a friend, a former prisoner, who continued to visit him up until his death.
4. 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 with his enquiries.
5. Mid-Essex Primary Care Trust (PCT) conducted a review of the clinical
care the man received whilst in custody. It is attached to this report as
an annex. The review was slightly delayed but I thank the clinical
reviewer for her detailed contribution.
6
HMP CHELMSFORD
6. HMP Chelmsford is a category B local prison that serves the courts of
Essex and surrounding areas. It predominantly holds sentenced and
unsentenced adult male prisoners, but almost a third of the population is
made up of young offenders aged between 18 and 21. The
accommodation is split between the original Victorian wings and newly
built residential units. Like most local prisons there are constant
population pressures, and the jail is one of the most overcrowded
prisons in England and Wales.
7. HM Chief Inspector of Prisons, Ms Anne Owers, inspected Chelmsford in
a full, announced inspection in July 2007. Ms Owers found a prison
suffering a range of difficulties. The population was very fluid, with
prisoners staying a relatively short time and with insufficient activity to
occupy them. Staff turnover was high and shortages were a constant
feature.
Healthcare
8. Healthcare at Chelmsford is provided in a spacious, modern and well-
equipped two-storey building completed in 2004. There is an inpatient
unit with 12 large individual cells, fitted with safe furniture except for two
cells that have hospital-type beds. Two cells are fitted with CCTV. The
building has full disabled access, including a lift and toilet, with
accessible bath and shower facilities in the inpatient unit. Treatment
rooms are also on E, F and G wings. G wing was where the man was
located.
9. Patients with long-term conditions can be referred to the gymnasium for
specific exercise programmes. The man had been a regular gym
attendee until his health deteriorated.
10. Primary care staff include both nurses and doctors. Paper-based clinical
records are used in all departments. A healthcare administrator
manages prisoner outpatient appointments in conjunction with
healthcare staff using a traffic light prioritising system.
Personal officer scheme
11. All prisoners at Chelmsford are assigned a personal officer. Their role is
to meet the prisoner on a regular basis and to discuss any issues or
concerns the prisoner may have.
Bed watch
12. If a prisoner is admitted to outside hospital, they will generally be
escorted by two officers who will stay beside their bed at all times. Two
or three daily shifts of officers will stay with the prisoner until treatment is
completed. However, depending on the circumstances, the bed watch
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may be withdrawn if the prisoner is terminally ill or nearing the end of a
sentence. The number of staff may also be increased or decreased if
the risk assessment warrants it.
13. The prisoner may be handcuffed whilst in bed. This is usually done by
means of a closeting chain, which allows the prisoner to be attached to a
member of staff. The chain must not be attached to a bed.
Compassionate release on medical grounds
14. Chapter 12 of Prison Service Order 6000 sets out the following criteria
for compassionate release on medical grounds:
 The prisoner is suffering from a terminal illness and death is likely to
occur soon; or the prisoner is bedridden or similarly incapacitated
 The risk of re-offending is past
 There are adequate arrangements for the prisoner’s care and treatment
outside prison
 Early release will bring some significant benefit to the prisoner or his/her
family.
8
KEY FINDINGS
Prior to arriving at HMP Chelmsford
15. On 26 May 1960, the man was convicted of manslaughter and
sentenced to six years imprisonment. He was released five years later,
but was convicted of murder and armed robbery on 11 March 1966. He
was sentenced to life imprisonment.
16. The man started his life sentence at HMP Wandsworth and continued to
serve his sentence at no fewer than 17 prison establishments. During
this time, the man had nine Parole Board reviews. He was eventually
released on life licence on 26 November 1999, after spending 33 years
in continuous custody.
17. On 24 June 2004, the man was stopped in his car by the police and a
firearm was found in his possession. He was arrested and charged with
possession of the weapon. He was held in police custody and appeared
at Basildon Magistrates’ Court on 26 June. His life licence was revoked
and he was recalled to prison, arriving at HMP Belmarsh later that day.
Given his long experience of prison life, he settled into the regime
without any concerns.
The man’s arrival at HMP Chelmsford
18. On 29 November 2004, the man was sentenced to seven years
imprisonment for the firearms offence and transferred to HMP
Chelmsford. When he arrived he went through the normal prison
reception process. It was recognised that he suffered from ischaemic
heart disease and had previously undergone cardiac surgery, including a
valve replacement. His condition was now stable with medication and he
was referred to the prison doctor for a review of his medication needs.
No other concerns were raised.
19. A little over a week later, on 9 December 2004, the man was
experiencing pain caused by his prostate gland (an organ that is located
at the base or outlet of the bladder). He was seen by the prison doctor
and later rushed to the local hospital. Following a number of
consultations, in April 2005 the man was diagnosed by a consultant at
the hospital as having urethritis (inflammation of the tube that conducts
urine from the bladder to the exterior).
20. Over the next 12 months, the man attended the hospital on a number of
occasions. He had experienced several bouts of pain whilst on the
prison wing. A principal officer told my investigators that the man did not
really wish to be admitted into the healthcare unit, and received the
majority of his treatment on the wing. Aware that he had healthcare
complaints, staff tended to him and liaised with the healthcare staff as
appropriate. They visited the man in his cell on a regular basis. The
man also attended the GP clinics in the prison. The healthcare team
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liaised with the hospital to ensure he was receiving the right treatment
and kept them abreast of changes to his condition.
21. In a bid to try and resolve the pain he had been experiencing, the man
attended hospital on a number of occasions to try the use of a catheter
(a thin, sterile tube inserted into the bladder to drain urine). But following
this procedure he continued to experience episodes of abdominal pain
and urinary infections, and was treated with antibiotics accordingly.
Prison healthcare staff maintained their communication with the hospital
and, as and when necessary, the man was returned to hospital for
treatment.
22. One of the problems that arose was that the man’s catheter became
blocked from time to time. As the procedure to remove a catheter could
not be carried out in the prison, the man would be transferred to hospital.
As his condition was monitored and no improvement seen, his name was
added by the hospital consultant to the operation waiting to receive
green light laser prostatectomy surgery (treatment delivered using a high
powered laser to destroy surplus prostate tissue that is blocking the
bladder).
23. During April 2006, the man continued to experience pain. By this time
he had contracted numerous urinary infections. Not happy that the
man’s problem had become more frequent, the prison doctor wrote to
the hospital to request that his operation be brought forward. The
hospital subsequently responded and a date of 21 June was scheduled.
24. Prison wing and healthcare staff monitored and managed the man’s
discomfort and pain as best they could, and he was referred to hospital
as necessary to unblock his catheter. He also started to experience
piles which were bleeding and again had to be referred to the hospital for
treatment.
25. On 21 June 2006, the man was admitted to hospital to undergo the
prostatectomy. He returned to prison soon after. Three weeks later he
again had pain and urinary problems. The prison nurse contacted the
nurse specialist at the hospital in a bid to bring forward his review. In the
meantime, prison healthcare staff provided the man with antibiotics to
help combat his urinary infections.
26. The man received his hospital appointment on 2 August, and was seen
in the Urology Clinic. He was given medication to ease the urinary
problem and placed on a waiting list for a procedure called flexible
cystoscopy (when a thin telescope is passed into the bladder via the
urethra, allowing a doctor to see around bends). His piles continued to
cause him problems and he was again referred to the hospital where he
later received external haemorrhoid injection treatment.
27. On 30 December, the man attended hospital for a gastroscopy (an
examination of the inside of the stomach). No abnormalities were
10
detected. Two days later he was seen on the wing by staff, complaining
of abdominal pain and tenderness. He was also unable to pass urine
and was dribbling fresh blood. Healthcare staff were alerted, and the
man was immediately transferred to the local hospital’s Accident and
Emergency Department where he was treated and prescribed antibiotics
on trial without his catheter. He returned to prison soon after.
28. Throughout January 2007, the man was still experiencing discomfort
caused by his piles. Once again, the prison doctor referred him to
hospital for further assessments. He was then seen by the surgeon and
placed on the hospital waiting list for a sigmoidoscopy (a procedure to
confirm the cause of his rectal bleeding). Throughout the man’s care,
healthcare staff asked wing staff to keep on eye on him and to inform
them of any changes in his condition.
29. On 30 May 2007, the man attended the hospital’s Urology Clinic for an
appointment where the nurse specialist taught him self-catheterisation.
It was hoped this would ease his problem of being unable to empty his
bladder fully. When he was returned to prison, the healthcare nurses
checked on him regularly in his cell.
30. After a few days had passed, the man complained to a nurse that he felt
unwell. He had a headache and felt shivery. The man was examined
and found to have contracted another urinary infection. He was given
antibiotics and paracetamol to control the pain. His sigmoidoscopy
appointment had to be cancelled because of his poor health.
31. The man’s personal officer told my investigator that in prison the man
was a likeable person who was always very polite and respectful. He got
on well with everyone, although he tended to keep himself to himself. In
his early days in Chelmsford, he was employed as a gym orderly but this
had to cease as his health declined. The man’s personal officer said
that, despite the man being aware of his ill health, he was reluctant to go
prison healthcare or indeed to outside hospital. However, his attitude
changed as his health further deteriorated.
32. The urology nurse specialist contacted prison healthcare on 19 June
2007. The man had recorded an abnormal blood test result when he
was last at the hospital, and it was requested that he be re-tested. Soon
afterwards, the man had to be admitted again into hospital for treatment
of his piles. Four days later, the hospital contacted prison healthcare to
inform them that the man needed a blood transfusion as he was
suffering from anaemia.
33. The man remained an in-patient at the hospital. Tests were carried out
on him daily to assess his condition. Surgeons also performed the
sigmoidoscopy and gastroscopy procedures to try to identify the cause of
his bleeding, abdominal pain and anaemia.
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34. During this time, as per prison bed watch procedures, the man was
supervised by two prison officers and restraints were applied. The
officers kept an occurrence log to record important events and kept in
contact with the prison on a regular basis (approximately every four
hours) to report on the man’s condition.
35. On 5 July, the man was discharged from hospital with the instruction that
he should be referred to the hospital surgeon if his piles continued to
bleed. Prison nursing staff, as usual, checked on him that evening in his
cell. The man was comfortable and raised no concerns. His prison
medical records noted that during his hospital stay the following
procedures had been undertaken and diagnoses made:
 colonoscopy – colonic polyps
 GI Endoscopy – duodenitis (examination of the stomach)
 reflux oesophagitis
 abdominal U/S – abdominal aortic aneurysm
 prostate minimally enlarged.
36. Following examination on 18 July by the healthcare nurse, the man was
again found to be experiencing rectal bleeding. He attended hospital the
next day when it was found he had possible rectal prolapse (piles)
problems. He was treated and told his condition would be reviewed over
the next three months. If necessary, he would receive a prolapse
surgical procedure to rectify his problem.
37. When the man was examined in his cell by nursing staff on 21 July 2007,
he reported no problems. His catheter was in place and working well.
However, two days later, he complained of feeling unwell and had a
swelling on his left scrotum. He was examined by the healthcare nurse,
and the hospital urology specialist nurse was asked for advice. The man
was prescribed a course of antibiotics later that evening. The nurse
specialist subsequently arranged for the man to have an ultrasound at a
clinic appointment.
38. On 28 July, whilst awaiting his hospital appointment, the man
complained of feeling dizzy and was pale in colour. He was examined
by healthcare nurse who found that his piles were clearly visible from his
bowels. The prison doctor made an urgent referral to the surgical team
at the hospital and the man was admitted as an in-patient straight away.
39. The man had been admitted to hospital now on numerous occasions,
and his health appeared not to be improving. The prison’s senior
management reviewed the daily progress reports on his health
(submitted by escort officers), and conducted a risk assessment. On 30
July, a second governor confirmed that the man no longer posed a
security risk due to his ill health, and his restraints could be removed.
He would also be reduced to a singleton prison officer escort.
12
40. The principal officer told my investigators that the man had become ill on
and off in the months prior to this admission to hospital. When the man
was in hospital, the principal officer carried out several bed watch duties,
and sat with him on various occasions whilst he received treatment.
41. Throughout August 2007, the man underwent a number of tests whilst in
hospital. During this time, it was identified that he had ischaemia of the
bowel. As a consequence, he underwent abdominal surgery and
required intensive support for an embolic event to his right leg (a term
used to describe a sudden onset arterial event that leads to oxygen
deprivation of a limb). Afterwards, mobility became difficult for the man.
42. The hospital continued to telephone to update prison healthcare staff on
the man’s condition. Healthcare staff also visited the hospital regularly to
keep abreast of the man’s condition and the treatment he was receiving.
This was coupled with the escort officer’s progress report to prison
management. Consideration was given to the possibility of the man
being transferred to HMP Norwich should his condition improve.
However, his state of health was described now as poorly, with no
known indication of when he could be discharged from hospital.
43. The man’s health continued to deteriorate. During September, a bone
scan revealed he had multiple metastases consistent with metastatic
cancer of the prostate (the spread of cancer from one part of the body to
another). He was now immobile and slept most of the time. When he
was awake, he was often in pain and incoherent. He was subsequently
moved to a private side room on the hospital ward that offered more
privacy.
44. The hospital contacted the prison healthcare team on 4 October to
inform them that the man’s condition was worsening. The following day,
a prison healthcare nurse accompanied by the deputy governor attended
the hospital to visit the man. They spoke with the man to ask if there
was anything they could do for him. He responded that there was not.
45. Whilst at the hospital, the deputy governor met with the ward sister who
disclosed that the man’s prognosis was extremely poor, and that he now
needed constant care. He had been examined earlier in the day by one
of the hospital medical professors. Given his condition, they were trying
now to find a hospice or community hospital bed. It was possible that
this could take between two and four days. It was also noted on the
man’s medical records that deputy governor would look into the
possibility of the man being released early on compassionate grounds.
46. Following this, the hospital doctor faxed a letter to the prison confirming
the man’s prognosis. Since the man’s admittance into hospital in July,
he had had a complicated stay including a bowel operation and removal
of his spleen. It had also been found that he had metastatic cancer
which probably originated from his prostate.
13
47. The principal officer told my investigator that, during the entire time the
man had been in hospital, no family members ever visited him. The only
person who visited was a former prisoner from Chelmsford with whom
the man had become friends while in prison. The former prisoner visited
the man on a daily basis.
Events from 7 October 2007
48. The principal officer arrived at the hospital at 8.10pm to carry out his bed
watch duty. He relieved a prison officer who gave him a full handover on
the man’s condition. The man was asleep when he arrived and
remained so throughout the night. The principal officer was informed by
hospital staff that the man was receiving pain killers that were
automatically given by a machine. He was in a very poor condition and
his life expectancy was not long. During the night, the man displayed
periods of rapid and shallow breathing and occasionally noises came
from his chest.
49. At around 7.00am the following morning, the man opened his eyes. The
principal officer attempted to talk with him but got no response. At
7.10am, the man’s rapid breathing ceased and was replaced by shallow,
very intermittent breaths. The principal officer told my investigator that at
around 7.30am the man appeared to stop breathing. At that stage he
went out into the main ward to inform a nurse who returned to the man’s
room with him.
50. The nurse and the principal officer sat at the man’s bed, with the nurse
indicating that the man’s life was imminently coming to end.
Approximately ten minutes later, the nurse confirmed that the man had
died and she left the room to alert the doctor. When the doctor arrived,
he examined the man and certified his death at 8.00am on 8 October
2007.
After the man’s death
51. The principal officer immediately contacted the prison and informed the
deputy governor and the duty orderly officer of the man’s death. As per
the prison contingency plans, he remained with the man until he was
taken to the hospital mortuary at 11.10am. When the principal officer
returned to the prison, he made a note of events to give to the duty
governor.
52. The prison activated its death in custody contingency plans. A central
element in those plans is that the deceased’s next of kin should be
informed as quickly as possible. However, the man had no one officially
recorded as his next of kin. Prison staff knew that he did have a
daughter, but there had been no contact with her for a number of years.
The man was not in contact with any other members of his family (a
brother and sister), and was only ever visited in prison and hospital by
the former prisoner with whom he had become friendly.
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53. The Coroner was informed that the prison had no recorded next of kin for
the man. The prison subsequently made preparations for the man’s
funeral. The principal officer was one of three members of prison staff
who attended the service, together with the man’s friend. The man was
cremated. A memorial service was later held in the chapel and was well
attended by both prisoners and staff.
15
ISSUES
Quality of care afforded to the man
54. After being recalled to prison in June 2004, the man was both treated on
his residential wing and referred to hospital on many occasions due to
his illnesses. The clinical reviewer comments that the care the man
received within the healthcare centre and in HMP Chelmsford generally
was exemplary. This included healthcare staff maintaining contact by
telephone and in person with the hospital nurse specialist during the
man’s admission.
The healthcare team at Chelmsford made good use of the
knowledge and expertise of the nurse specialist to ensure the best
of care was offered to the man, including frequent contact with the
local hospital.
55. Other members of prison staff also contributed to the man’s care -
including the staff on his wing where he spent most of his time when not
in hospital. When the man was in the local hospital, information about
his health was cascaded effectively by bed watch officers. The prison’s
management also took appropriate action in removing restraints as soon
as it was known that the man’s health had deteriorated. Unfortunately,
the good intentions of the hospital to find a hospice space did not
materialise in time.
I commend the Governor and his staff for the excellent care they
gave to the man.
56. The clinical reviewer says that the time the man had to wait to receive
surgical procedures was comparable to waiting times in the community.
She also judges that the treatment received by the man was prompt and
appropriate.
57. The clinical reviewer does comment that the prison environment was not
conducive to managing a urinary catheter, and this may have contributed
to the numerous infections the man suffered. There are clear
indications, however, that both prison healthcare and hospital staff
ensured the man was able to self-care for his catheter. This was also
evidenced by way of a patient leaflet regarding catheter care in the
man’s healthcare record.
Removal of restraints
58. The man was escorted, under restraint, by two officers whilst an in-
patient at the local hospital until 30 July 2007. The serious deterioration
of his health was reported back to the second governor. A risk
assessment was undertaken, and the escort was reduced to one officer,
and the restraints removed. From this time until the man’s death, the
security measures remained at a single officer escort without restraints.
16
I commend the Governor for his timely risk assessment and the
removal of restraints that allowed the man some dignity before his
death.
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Next of kin details
59. The man had not officially recorded anyone as his next of kin (it is not a
requirement for any prisoner to provide such details).
60. HMP Chelmsford does not have a policy in place whereby, if a prisoner
is admitted to outside hospital for a serious illness, the next of kin is
informed. (If a prisoner requests contact to be made with next of kin, I
understand this would be done.)
61. In the man’s case, such a policy would have made little difference.
However, in my judgement it should be routine for next of kin to be
contacted when prisoners are in hospital with serious illnesses, unless
there are overwhelming security objections. This should certainly occur
in all instances (subject to security requirements) when it looks as
though a prisoner is likely to die.
Chelmsford should review the system currently in place of when to
inform next of kin if a prisoner is transferred to hospital.
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CONCLUSION
62. Treating serious illnesses in a prison environment presents evident
difficulties. I am pleased to record how hard the staff at Chelmsford
worked to look after the man whilst he was in their care. This is
evidenced within the man’s medical records and by the numerous
contacts and referrals made with the local hospital.
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RECOMMENDATIONS
1. Chelmsford should review the system currently in place of when to
inform next of kin if a prisoner is transferred to hospital.
Good Practice
2. The healthcare team at Chelmsford made good use of the knowledge
and expertise of the nurse specialist to ensure the best of care was
offered to the man, including frequent contact with the local hospital.
3. I commend the Governor and his staff for the excellent care they gave to
the man.
4. I commend the Governor for his timely risk assessment and the removal
of restraints that allowed the man some dignity before his death.
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