Individual at Lincoln

Investigation into the death of a man who died in
hospital whilst in the custody of HMP Lincoln in
February 2006
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2008
This version of my report, published on my website, has been amended to
remove the names of the man who died and those of staff and prisoners
involved in my investigation.
This is the report of an investigation into the death of a man in hospital in
February 2006. The man was on remand at HMP Lincoln for the murder of
his daughter. He had refused food on and off for over a year and eventually
died as a result of starvation. The post mortem has given the cause of death
as bronchial pneumonia and severe under-nutrition.
The man had written an advance directive refusing all food and most medical
intervention. This was eventually upheld as a legally binding document by the
High Court in August 2005. The advance directive meant that the man was
deemed to have the “capacity” to decide to refuse food and medical
intervention.
I would like offer my sympathy to his family and friends. They remained
steadfastly supportive throughout the time he spent in prison. I must sincerely
apologise for the delay in producing the report into this most complex case.
The investigation was undertaken on my behalf by one of my colleagues. An
independent review of the man’s medical care while in prison was undertaken
by two medical practitioners of Bassetlaw Primary Care Trust (PCT) who were
appointed by the then West Lincolnshire PCT. I am grateful to them both for
their assistance and for a clinical review that tremendously assisted the
investigation. Lincolnshire Teaching PCT provided an additional report and I
must also thank their clinical reviewer for her commitment to the clinical
review process.
It is rare but not unknown for prisoners to kill themselves by starvation. This
report explores the circumstances of the man’s death and the legal and moral
issues raised by it. I believe important lessons can be learned at national
level from what occurred in this case and have been very impressed by the
professionalism and sensitivity demonstrated by staff and management at
HMP Lincoln.
I formally recognise three issues of good practice. I must commend Lincoln’s
senior management team and the West Lincolnshire Primary Care Trust for
their pioneering care of the man who is the subject of this report. I make four
recommendations and I agree with the six recommendations made by the
clinical reviewers.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2007
2
Contents
Summary
The Investigation Process
HMP Lincoln
Key Events
 The man’s remand and initial period in custody
 The man’s food refusal and sectioning under the Mental Health Act
 The man’s return to Lincoln prison and the High Court judgement
 Authenticity of the advance directive dated 10 October 2005
 Events during 2006 leading to the man’s death
Issues
 Clinical review
 Family contact
 Advance directive
 Sectioning under the Mental Health Act 1983
 Did the man’s case have to be referred to the High Court?
 Facilities in the healthcare centre and the management of
the man’s food refusal
 Constant supervision
 Role of the observer in constant supervision
 Transfer between Lincoln prison and the Hospital
 Staff support
Recommendations
Good Practice
3
SUMMARY
The man was arrested by police after allegedly murdering his daughter with
whom he had been living after his marriage broke down. The murder
attracted significant media attention. The man was taken to Lincoln prison on
18 August 2004 and was immediately located in the healthcare centre and
placed on an intermittent suicide and self harm prevention watch.
The man was reluctant to talk or engage with other staff or prisoners initially
and spent most of his time in his cell watching television. He spent two days
on a normal residential unit but quickly returned to the healthcare centre. He
said he had been threatened by other prisoners. On 13 November, half a
mug of pills was found in his cell and he admitted to staff that he intended to
take an overdose. He was immediately placed on constant supervision and
relocated into a gated observation cell within the healthcare centre. A few
days later some shoelaces were also found in his cell. His tablets were
replaced with liquid medication to reduce the opportunity of his storing it up.
He was assessed as being at risk of suicide throughout November and
December 2004 and the constant supervision continued.
On 24 December, the man declined to eat or take his medication. This
continued over the next couple of weeks. At an ACCT case review on 12
January 2005 the prison doctor explained to the man that if he continued to
refuse all food his physical condition would deteriorate and he could die.
(ACCT stands for Assessment, Care in Custody and Teamwork and is the
term used to describe the system for monitoring and supporting prisoners
considered to be at risk of self-harm or suicide.) The man said that he
understood this but wanted to die in this way. The doctor suggested that he
should contact his legal team and ask them to draw up an advance directive
to say that he did not want to be force fed, or treated in the event of becoming
unconscious through food refusal. The doctor then contacted a consultant
psychiatrist and asked him to assess the man’s ‘mental capacity’ to make
such a directive.
The psychiatrist assessed him on 14 January 2005. While he considered that
the man was competent to refuse food and drink and enter into the advance
directive, he could not rule out the possibility that he was suffering from a
mental illness that required him to be assessed. In contrast, the doctor’s
opinion was that the man was not suffering from a mental illness. However,
the two doctors agreed that he should be assessed under the Mental Health
Act 1983 for a period of assessment. The signed advance directive was sent
to the prison by the man’s solicitor on 16 January 2005.
The doctor discussed the man’s case with a forensic psychiatrist at a medium
secure unit. He advised the prison that they might be required to treat the
man within the terms of his advance directive and allow him to continue his
food refusal. He also recommended an urgent independent assessment. On
20 January, the man moved to the high dependency unit within Lincoln’s
healthcare centre. That evening, two consultant forensic psychiatrists,
assessed him to establish whether he was suffering from a mental illness and
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whether he had the necessary mental capacity to refuse food, drink and
medical treatment. They jointly concluded that the man should be detained
under the Mental Health Act for the treatment of his depressive condition.
They also concluded that his illness meant he could not “rationally weigh
information in the balance regarding his healthcare and wish to die”.
The man was extremely upset at being told that he was to be detained. He
understood that this meant he would be treated in hospital if he continued to
refuse food and fluids. The man therefore agreed to start eating and drinking
again.
The man was transferred to the medium secure unit on 24 January 2005.
Staff at the secure unit found it difficult to assess him because he refused to
engage with their efforts. After several months it was decided that, although
he suffered from personality disorders, he did not fulfil the Mental Health Act
criteria for a detainable mental illness. He had been transferred to hospital as
a result of a mental illness which had to be resolved with treatment. It was
therefore decided that he should be recommended for transfer back to prison.
The man returned to Lincoln on 27 July 2005. The first entry in his clinical
record reads, “on arrival the man expressed his intention to kill himself by
starvation and clearly stated that there is nothing we can do to stop him.” The
man was put back in the healthcare centre, on constant supervision in a gated
cell. No advance directive was in place. The doctor recorded that the man
needed to be seen again by the two forensic psychiatrists so that they could
reassess his capacity.
The two psychiatrists did not agree over whether the man had capacity to sign
an advance directive. West Lincolnshire PCT sought a declaration of capacity
from the family division of the High Court. Another psychiatrist was instructed
by West Lincolnshire PCT to provide a third expert assessment of the man’s
capacity and did so on 8 August. Her opinion was that the man had capacity
to refuse food and treatment and the High Court therefore judged that the
man’s advance directive, dated 10 August 2005, was a valid legal document.
Staff at the prison were informed of the judgement and a note was made in
the man’s record, “The man stated that he is now at peace.” The Healthcare
Principal Officer (PO) encouraged him to reconsider his advance directive and
said that he could change his mind at any time. The man stated his desire to
carry out his advance directive in full.
Over the following months, the man remained under constant supervision in
the gated cell in the healthcare centre. He spoke to staff regularly about his
past and his desire to die through food refusal. In November 2005, his
condition deteriorated and arrangements were made for him to be transferred
to hospital. However, while he continued to refuse food, he began to
consume fluids and as a result, his condition then improved and it was not
until February 2006 that staff made arrangements for him to be transferred to
the hospital. The man was transferred to a private room in the local hospital
where he died.
5
THE INVESTIGATION PROCESS
1. One of my colleagues was appointed to lead this investigation on my
behalf. She and I visited Lincoln on Friday 3 March 2006. We met with
the Governor and her Deputy Governor. We were briefed about the
man’s condition while he was at Lincoln and the management decisions
that were made about his care. We were given a tour of the healthcare
centre and met the Head of Healthcare and the Head of Clinical
Governance for West Lincolnshire PCT. We met with representatives of
the Independent Monitoring Board (IMB) and with the prison’s family
liaison officer.
2. Notices were issued inviting prisoners and staff who had any matters
relevant to the investigation to make themselves known to the lead
investigator. One member of staff made himself known to the
investigation team, through the Prison Officers’ Association (POA). No
prisoners responded to the notices.
3. One of my Family Liaison Officers contacted the man’s identified next of
kin. The next of kin was pleased to be told about the investigation
process, but had no concerns about the man’s care in the prison. He
thought that the prison had done everything that they could for him. The
family did request to see a copy of my report and I hope that it has
answered any outstanding questions they might have.
4. The lead investigator attended Lincoln with another colleague from my
investigation team in May 2006. They interviewed prison, healthcare and
probation staff. The team examined the man’s prison files, including the
constant observation files and records relevant to the High Court
proceedings. The investigator also liaised with Prison Service’s Safer
Custody Group, visiting their offices on two occasions. I would like to
thank them for their co-operation and assistance in this investigation.
5. West Lincolnshire PCT was commissioned to undertake a clinical review
of the man’s care at Lincoln. To increase the independence of the
clinical review, the PCT approached a neighbouring Trust, Bassetlaw
PCT, to conduct the review on their behalf. Two representatives from
Bassetlaw visited HMP Lincoln with my investigation team and
conducted joint interviews. I received their final clinical review on 29
November 2006. I would like to thank them for their active participation
in the investigation and the clinical review. Following receipt of the
clinical review, the lead investigator wrote to Lincolnshire PCT (as West
Lincolnshire PCT had merged into a larger county-wide PCT) with a
number of issues on which she required further guidance. A solicitor
wrote a comprehensive reply to the investigator’s letter on behalf of
Lincolnshire PCT. This was received in this office on 22 January 2007. I
would like to reiterate what I have said in my foreword to this report and
thank Lincolnshire PCT for their professional contribution to this
investigation.
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HMP LINCOLN
6. Fronted by an impressive Grade II listed gate building, HMP Lincoln is a
Victorian category B adult male local prison that overlooks the city of
Lincoln. The five narrow wing buildings can currently hold up to 490
prisoners. A-wing has been closed for refurbishment since it was
devastated by a riot in October 2002.
7. The modern administration block situated at the front of the prison is
abutted by the healthcare centre. This can hold up to 14 prisoners in
normal cells over two floors. The healthcare centre has one gated cell
with a transparent door and a recently refurbished high dependency unit.
There are good links between the healthcare centre and the local
hospital.
8. The Annual Report from the IMB in 2005 recognised Lincoln as a prison
that had successfully resolved many of the problems it faced in the
aftermath of the riot. The report concluded that while there remained
some concerns, “the Board detected an air of change occurring within
the establishment and a more positive sense of purpose in all areas of
the prison.”
9. HM Inspectorate of Prisons published a report in early 2006 of an
inspection that they carried out in September 2005. This did not reflect
such a positive view of Lincoln. While the Chief Inspector identified
some “green shoots of recovery”, following the jail’s “troubled history”,
she concluded that it was not performing satisfactorily and that Lincoln
was not a safe prison.
10. Significantly for the purpose of this investigation, the Chief Inspector
found that 20 of 23 of her recommendations for Lincoln’s healthcare
centre had been addressed since the last inspection in 2002. The
Inspectorate report concluded that the healthcare provision had
considerably improved. Overall, work in healthcare was found to be of a
high standard.
7
KEY EVENTS
The man’s remand and initial period in custody
11. Following the murder of his daughter, the man went missing for a
number of days until he was discovered by police. He was taken in for
questioning, charged with his daughter’s murder, and remanded to the
custody of Lincoln prison on 18 August 2004.
12. A healthcare assessment noted that the man “does have a noticeable
tremor of his head”, due to Parkinson’s disease. It indicated that he had
seen a psychiatrist at the age of around 25. Following the healthcare
assessment, he was prescribed chlorpromazine (a drug commonly used
to treat psychotic disorders).
13. A letter was received by the prison from the man’s solicitors on the day
of his arrival to indicate that he was suicidal. The letter asked that
consideration be given to placing him in a mental health hospital. Given
the nature of the charge against him and the circumstances of his arrest,
an application was made for him to be put in a safer cell in the healthcare
centre on the day of his arrival. The man was appropriately identified as
being at risk of self-harm and was made subject to ACCT procedures.
(ACCT stands for Assessment, Care in Custody and Teamwork and is a
system used for managing and assisting prisoners who are considered to
be at an increased risk of suicide or self-harm.) He was placed on the
second level of observations which meant that he was considered a
medium risk and was checked intermittently, several times an hour.
14. By the next morning, the man’s ACCT ongoing record noted that he was
feeling overwhelmed by the number of visitors he had received and that
he wanted some space. He told staff that he was worried about those
whom he had hurt but that he did not have the courage to hurt himself.
The man was located in a cell with a camera fitted for continuous
observation on 20 August, but he was not subject to continuous
supervision at that time. His monitoring was intermittent, at around 30
minute intervals. The prison received information from the police in their
case summary to indicate that he had “suicidal intent”.
15. The man’s solicitor wrote to Lincoln on 3 September to express her
concern that the man was suffering from clinical depression and perhaps
the onset of Parkinson’s Disease. She also questioned the
appropriateness of his legal visits taking place in the visits area where
their conversation might be overheard. The details of the murder and his
family history had been the subject of significant media attention in the
previous weeks. The letter was placed in his medical record and staff
continued to monitor him closely.
16. From 9 September 2004, staff assessed that the man was to remain
subject to intermittent observations. An officer wrote:
8
“The man is still very emotional and presents as being unsure of his
future.”
17. On 13 September, he told a member of staff that he “hates waking up in
the morning and seeing the light – he wishes God would take him in his
sleep so he could be with his daughter.”
18. A note was made in his wing history record on 19 September that he was
experiencing problems with another prisoner in the healthcare centre
who was asking about his offence. The man requested that he be
allowed to go back to his cell during association to avoid the prisoner.
(“Association” is the opportunity for prisoners to spend time out of their
cell, mixing with other prisoners and participating in recreational
activities.)
19. A consultant psychiatrist assessed him on 24 September. He found that
the man had a “strong wish to be dead. Intention to kill himself when
opportunity presents itself. Does not believe efforts should be made to
keep him alive.” The psychiatrist concluded that the man was depressed
and recommended that he should remain subject to continuous
observation. He also prescribed him anti-depressants. According to his
ACCT record, he was in fact still subject to intermittent observations at
this time. This level of observations continued. The man complained
that the anti-depressants caused him to feel dizzy and shortly afterwards
he refused to take them.
20. The man walked out of a self-harm review meeting on the morning of 30
September after he was asked if he was going to self-harm. A further
ACCT case review took place on 7 October. It was recorded that the
man remained “resilient” to any questions about his index offence but
was not posing any problem to staff. The man expressed his concern at
being in healthcare where there was little activity in his daily regime and
he was not being stimulated. This sentiment was echoed in a letter,
dated 8 October, from his solicitors to the Governor of Lincoln. They
were particularly anxious that the man was yet to receive his spectacles
and more generally that he was located in healthcare with little to occupy
him. They suggested that he should have a radio to pass the time.
21. The man had a “traumatic” legal visit on 11 October during which his
solicitors made him aware that the full facts of the offence might emerge
as a result of the ongoing criminal investigation. The man remained
reluctant to discuss with prison staff the details of the charges against
him. An ACCT case review took place following the visit and he was
encouraged to associate with other prisoners.
22. The Governor replied to the man’s solicitor saying that the man would
receive his spectacles as soon as payment had been received for the
optician’s fees. The solicitors replied on 15 October stating that they
would do so. The governing Governor also reassured the solicitors that
9
the man was not located in a strip cell and that he was getting the
opportunity to live a “stimulating life” in the healthcare centre.
23. The man had a radio and television in his cell for most of his time in the
healthcare centre. He particularly enjoyed watching television. Staff
tried to get him to associate with other prisoners, saying that they would
review whether he could have a television in his cell unless he agreed to
come out of his cell during association periods. So important was the
television to him, that later he spent a good deal of time planning his
viewing schedule in great depth with the member of staff who was
observing him. However, he preferred not to associate with other
prisoners. The charge against him was high profile in his local area and
nationally and he did not want to speak about the circumstances. The
man would chat with the member of staff carrying out his observations
and watch television for most of his days.
24. On 18 October 2004, the man was assessed as fit to be transferred out
of the healthcare centre and was moved to a normal wing in the prison.
Whilst on the wing, the man received a visit from the Lifer Manager and a
bereavement counsellor. Just two days later he was returned to the
healthcare wing. He was experiencing stress, sleep deprivation and
headaches and his suicidal ideation continued. The doctor told my
investigators during interview that the man experienced some
threatening behaviour from other prisoners on the wing, probably as a
result of his high profile.
25. At his ACCT case review on 21 October, he was recorded as “tearful”
although it was felt that he had “no firm intention” to self-harm. During
the review, he was initially reluctant to engage but went on to speak quite
freely about his concerns. He alluded to childhood abuse and suggested
that revelations at his upcoming trial might lead to the imprisonment of
another family member. The man remained subject to intermittent
observations.
26. The man’s third nursing care plan was drawn up on 27 October 2004 and
related to his diagnosis of Parkinson’s Disease. Nursing staff were to
encourage him to discuss any difficulties and monitor his physical
condition. All changes were to be reported to a prison doctor.
27. Observations were continued intermittently, about every 15 minutes,
following the next ACCT case review meeting on 28 October 2004. The
review recorded that the man was increasingly anxious about the
forthcoming court hearing. He was apparently confused about the
amount of “fuss” being made about the hearing, considering his intention
to plead guilty.
28. The Governor responded to concerns raised about his mental health by
his solicitors on 18 August 2004 in a letter dated 3 November. In her
letter, the Governor reassured his solicitors that he was subject to
suicide prevention strategies, including intermittent observations, and
10
that his mental health would be subject to review by psychiatrists.
Indeed, the consultant psychiatrist reviewed the man’s condition two
days later (5 November). The man reported hearing voices. The doctor
thought that the voices were not a symptom of a psychotic process but,
more likely, a result of his sleep deprivation and stress levels. Again, the
doctor suggested that the man should remain subject to constant
supervision. The man was actually subject to intermittent observations
at that time and these continued. The man was taking medication for
suspected Parkinson’s Disease, as well as medication for his headaches
and an anti-depressant.
29. The man continued to refuse to associate with other prisoners on the
healthcare centre. On 10 November 2004, staff advised him to use his
association times as an opportunity to get out of his cell.
30. Staff searched his cell on 13 November and discovered half a mug of
“pills”. When questioned by staff, the man admitted that he was going to
take an overdose the following night and that he had written a letter
absolving Prison Service staff of any responsibility for his suicide. The
man was placed on a constant supervision immediately. This meant that
he was relocated into a different cell in the healthcare centre (a gated
cell). On the day of his cell move, a record of a telephone conversation
between the man and a friend was noted in his wing history sheet. The
man had said that he couldn’t do “it” now that he was being watched.
31. The cell used for constant observations has a glass door which is
transparent from floor to ceiling. There is a metal gate between the glass
door and the rest of the healthcare centre. Staff observing him sat in the
corridor just outside of the cell, continuously monitoring him and writing
notes at least every 15 minutes. There is a normal (not gated) cell
immediately opposite which directly overlooks the gated cell.
32. A further search of the man’s cell was made on 14 November but nothing
was discovered. Officers were informed two days later that there were
shoelaces in the man’s personal mail.
33. The doctor countersigned a psychiatric nursing assessment dated 14
November. The assessment described the man as suffering from a “Low
mood, feelings of abject hopelless [hopelessness], sadness and apathy.”
His communication was assessed as poor unless prompted, although he
said that he spoke to his daughter, his alleged victim, every night. The
assessment suggested that he was “in denial concerning his relationship
with family and in particular his daughter. Is unwilling to accept that he
felt any anger towards his family.” The man particularly complained that
he “feels like he is in a goldfish bowl, everyone talking to him.”
34. The doctor wrote to the Governor on 16 November 2004 for the
Governor’s information only. He passed on concerns from all of the staff,
himself included, as follows:
11
“He [the man] has expressed his intention to end his life on several
occasions. Only this afternoon, shoelaces have been found in his cell.
He is on constant watch and I see no imminent change to this, just so
you are aware from a staffing viewpoint.”
35. The man was found to be saving his medication again on 25 November.
Three days later, he was observed storing medication in his mouth. The
man became abusive to staff on 29 November 2004 when they informed
him that he would not be coming off the constant supervision in the
“foreseeable future”. The man’s frustration at being on constant
supervision continued and, on 3 December, the Healthcare Senior
Officer (HCSO) recorded that the man seemed “desperate to get off” the
constant supervision. The HCSO went on to report that the man had
asked a fellow prisoner, who was working as a cleaner on the healthcare
wing, for a shoelace. Following his several attempts to store his
medication, staff changed the man’s medication to a liquid form. He
remained in the gated cell and was subject to continued constant
supervision.
36. The man expected to go to court on 9 December, but did not appear on
the court list. A note was made in his Daily Record of Nursing Care that
he was “unhappy about this situation”. The following day, his solicitors
informed him that his case would be heard in his absence in January, but
the man was reportedly “concerned and confused” by this information.
The man also told his solicitor that he was concerned about the lack of
privacy, given his constant supervision.
37. On 16 December, a case conference was held to discuss his repeated
attempts to store medication. Staff were concerned that he was
attempting to store medication in order to take an overdose as an
attempt at suicide. The case conference was attended by the Governor
and healthcare staff, but the man refused to engage with the meeting.
He would not discuss his reasons for storing medication and walked out.
38. The consultant psychiatrist reviewed him on 17 December. The man
maintained that he wanted to die. The psychiatrist concluded that he
was still at risk of suicide. According to his medical records, he had a
“usual day” on 18 December. He had a legal visit in the morning. It was
recorded in his Daily Record of Nursing Care by an officer that the man
was trying to “obtain shoelaces” and might have been storing his
medication again. The entry went on to state that the man “has made no
secret that he wants to be with his daughter at Christmas”. Another
room search was conducted but nothing was found.
12
The man’s food refusal and sectioning under the Mental Health Act
39. A nurse wrote a Nursing Care Plan in the man’s clinical record on 28
December 2004. The trigger for this Care Plan was the following need,
as identified by the nurse:
“Declining to eat and accept medication since 24/12/04, possibly
catalysed by a dispute with Aramark, but no explanation given. Also
angry re:- current situation (constant watch, trial coming up).”
(Aramark is the private contractor that runs the prison’s shop from which
prisoners may purchase food and other goods.)
The nurse went on to describe nursing interventions aimed at preventing
the decline in the man’s physical health. He suggested that staff should
give him a daily opportunity to vent his feelings. Staff were to offer food
and medication to him and document whether he accepted the food or
not. A urine test, carried out on 4 January, tested negative for ketones.
(Ketones are often found in the urine when the body has not had enough
carbohydrates to digest. This is turn might suggest that an individual has
not been eating.) Despite the lack of ketones in his urine, clinical
observations showed that he was rapidly losing weight at that time. The
nursing care plan about his food refusal was reviewed on 5 January
2005. No change was made to his planned care. The man initially
declined to see his solicitor on 5 January 2005. He was encouraged by
staff and eventually agreed to meet with her. The Healthcare PO
recalled that, after the visit, the man initially seemed agitated but soon
settled down.
40. An ACCT case review took place on 12 January which the man and the
doctor attended. During the review, the doctor explained to him that if he
continued to refuse all food his physical condition would deteriorate and
he could die. The man understood this, but expressed his wish to die in
this way. The doctor suggested that the man contact his legal team to
draw up an advance directive. (An advance directive is a document, in
which a patient sets out how medical decisions affecting them are to be
made.)
41. The doctor wanted to establish whether the man might be force fed were
he to lose consciousness. If he did not want to be force fed or treated,
he would have to set this down in an advance directive or staff would be
obliged to treat him. In order to write a valid advance directive, it had to
be established that the man had the mental capacity to enter into that
directive at the time of writing it. To this end, following the care review,
the doctor contacted the consultant psychiatrist to assess the man’s
capacity.
42. On 13 January 2005, the Nursing Care Plan was reviewed and a note
was made by Health Care Senior Officer (HCSO) as follows, “Review.
May decline to take fluids. Will review if and when.” The same day the
13
man discussed signing “paper work for no medical intervention to save
his life” with the nurse that was his key worker at that time. (A key
worker is someone who acts as a support and the main point of contact
for the prisoner-patient.) A care planning meeting was arranged to
discuss the matter with the Governor. The nurse reported that the man
was more “settled in himself now the decision is made”.
43. On 14 January, the consultant psychiatrist examined the man to
determine if he had the mental capacity to make the decision to refuse
food, fluids and treatment. The psychiatrist concluded that the man was
competent to refuse food and drink and to enter into an advance
directive. However, he was unable to rule out the possibility that he was
suffering from a mental illness that might require detention. The doctor
recorded his own view that the man was not in fact suffering from a
mental illness. However, the two medical professionals came to the
agreement that the man should be assessed under the Mental Health
Act 1983. The reason given by the consultant psychiatrist to section him
was:
“Impossible to provide proper assessment and treatment with the
facilities available at HMP Lincoln.”
44. On 16 January, the man apparently told staff that he had only a matter of
days to live. The following day, the man expressed his intention to end
his life through the refusal of food and fluids. His solicitor passed the first
draft of the advance directive setting out this intention to healthcare staff.
45. The man was due to appear in court on 17 January. Staff in the
healthcare centre encouraged him to attend court but he declined
because he felt “vague and dizzy”. The Healthcare PO faxed the court
to suggest that it was inappropriate to force him to attend court given his
physical condition. The PO’s entry in the daily record of nursing care
went on to say:
“… he is now aware that he may be sectioned under the MHA [Mental
Health Act] and possibly forced to be given diet. Not at all happy with
this arrangement.”
46. The doctor went on to discuss the man’s case with a forensic psychiatrist
based at the medium secure unit. The psychiatrist’s advice was to treat
him within the terms of his advance directive should he be unable to
make decisions for himself and to allow him to continue his food refusal.
The doctor explained to the man the physical consequences of his
continued food refusal, but agreed that he would not feed him artificially if
he became unconscious. The doctor agreed that he would only treat him
for pain and physical distress.
47. On 19 January, the man was seen by the mental health in-reach team.
He said that he had felt a sense of peace since deciding to end his life.
The man raised concerns about being transferred to a mental health
14
hospital. His key worker wrote a nursing care plan on 19 January 2005,
aimed at preventing the decline in his physical condition. At this time,
the man had not eaten for nearly a month and had stated that he would
soon stop drinking. The care plan encouraged staff to talk to him about
his “fears and anxieties”, to continue to offer food and drink, and maintain
the constant watch. In addition to the nursing intervention discussed in
the previous nursing care plan, staff were to liaise with the doctor “as
appropriate” and provide access to the chaplaincy if the man requested
such support.
48. On the morning of 20 January, his key worker recorded in his Daily
Record of Nursing Care that the man was “now officially refusing fluids”.
She also noted:
“The man has signed the care plan relating [to] his care in the final
stages of his life.”
49. It was agreed that the man would be transferred to hospital if he lost
consciousness. The Head of Healthcare told my investigation team that
she did not think the prison healthcare centre would have adequate
facilities to help him through the last moments of organ failure. In the
meantime, he was transferred to the high dependency unit within
Lincoln’s healthcare centre.
50. The high dependency unit was a brighter room, with a fully adjustable
bed and in-cell sanitation. Staff felt that the room better served his
clinical needs, as his physical condition was deteriorating through the
self-starvation. The man was given his last rites by a Roman Catholic
minister in the chapel. The service was attended by staff.
51. That evening, following a request by healthcare staff at the prison, two
forensic psychiatrists assessed him to establish whether he had the
necessary capacity to refuse treatment and whether he should be
detained under the Mental Health Act. Before his assessment, the lead
psychiatrist liaised with the man’s solicitor who had expressed her
concern at her client’s refusal to eat or drink. The assessment was
carried out jointly and concluded that the man should be detained for the
assessment and treatment of his depressive condition. The psychiatrists
found that his illness was such that it meant he could not “rationally
weigh information in the balance regarding his healthcare and wish to
die”. They felt that the man did not have sufficient capacity to refuse
treatment, they strongly advised staff against following his wishes as laid
out in the advance directive dated 14 January 2005.
52. The Healthcare PO made the following entry in the man’s Daily Record
of Nursing Care at 7:15pm on 20 January:
“The man has been seen by two forensic psychiatrists and they have
doubted his capacity to meet all the criteria due to his depression. He
will, once a bed has been found, be transferred under s48 of MHA 83
15
[Mental Health Act 1983]. IF HE BECOMES UNCONCIOUS (although he has
now agreed to take fluids only) THEN HE IS TO BE TRANSFERRED TO
HOSPITAL IMMEDIATELY AS PER ANY EMERGENCY. The man is extremely
upset at being sectioned, wants to be with his daughter.”
53. The doctor met with the man and explained the outcome of the
assessment and the decision to section him. He understood that he
would be treated if he continued to refuse food or fluid and would not be
left to die, so he agreed to start eating again. The doctor remembered
him eating four meals in a short space of time. The doctor reflected that
it was not good for a patient to eat so much so quickly after a prolonged
period of starvation, but on balance it was to be expected from someone
who had denied himself food for so long.
54. An observation made in his daily record of nursing care on 22 January
noted that he recognised he could be aggressive but that he did not
mean to be. The officer explained to him that his aggressiveness might
be related to his urea level and caffeine withdrawal. Following this
discussion, he decided to drink two cups of tea a day. That day the man
started to eat and drink again.
55. On 22 January, he had a visit from his two sisters and his brother-in-law
at around 2.00pm. It was reported to staff that he became angry during
the visit and said “Right you’ve told me, now get out!”
56. That afternoon, his key worker made an entry in the Daily Record of
Nursing Care. The man had told an Operational Support Grade (OSG)
that he had been abused as a child:
“e.g. being made to drink his own urine and forage for food in bins.”
57. The following day, his key worker explained to the man “what can be
done under the Mental Health Act”. She explained how long people can
be detained for and “the right to enforce medication”. She advised him to
pay more attention because a lack of concentration “can appear to be
indicative of a depressive condition”. She recorded this conversation in
the Daily Record of Nursing Care. During interview, she told my
investigators that she felt the man was not clear about the sectioning
process because staff were fearful that he would become angry once he
had understood its implications. She said that the man was only angry
because he felt he had been misled about the sectioning process until
she had explained it to him.
58. The man was transferred to the medium secure mental health unit on
Monday 24 January 2005. No care plan was in place at the time. The
care that the man received at the medium secure unit falls outside of the
remit of my terms of reference. Two Care Programme Approach (CPA)
meetings were held whilst the man was at the Unit. Prison and PCT
representatives attended those meetings to co-ordinate the care that the
man received between the medium secure unit and the prison.
16
59. The first CPA meeting was held on 18 March 2005. It was attended by
the Governor and the prison doctor, representing the prison. At the
meeting, the doctor told the review team:
“I said very clearly that he was not coming back to HMP Lincoln without
a certificate of capacity.”
60. A further CPA review took place on 22 July 2005, attended by the multi-
disciplinary team from the medium secure unit, social services, medical
advisors, as well as the Governor and the doctor. A clinical psychology
report, nursing report, nursing risk profile and medical report were
compiled in readiness for the review.
61. At the meeting it was noted that it had been difficult for staff at the
medium secure unit to assess him, as he refused to engage with their
efforts. The man was assessed as having a pre-morbid personality
disorder, with borderline and dissocial personality disorders.
Nonetheless, it was decided that he did not fulfil criteria set out by the
Mental Health Act for mental impairment, although he did suffer from a
psychopathic disorder. Legally, remand prisoners can only be
transferred for treatment if they are suffering from a diagnosable mental
illness as defined by the Mental Health Act or severe mental impairment.
The man did not fall into either category and it was recommended to the
Home Office that he be transferred back to prison. During this meeting,
the clinical team discussed with prison staff the risks that the man posed
to himself. The prison staff said they felt that they would be able to
provide the necessary supervision and management. Finally, those
present at the meeting concluded that he had capacity to refuse food and
treatment and understood the effects of such a refusal.
The man’s return to Lincoln prison
62. The doctor wrote to the Mental Health Unit at the Home Office on 22 July
2005 to inform them of the outcome of the CPA Review. No care plan
was drawn up to determine how the man was to be treated when he
returned to Lincoln. Between that meeting on 22 July and the man’s
discharge on 27 July, staff at the medium secure unit reported that he
had been acting more threateningly towards them and, on one occasion,
had struck a member of staff although no serious injuries were
sustained. This information was not passed on to staff at Lincoln, either
in a verbal or written handover at the time of discharge.
63. A warrant for the man’s transfer back to prison was issued on 26 July.
He was transferred back to HMP Lincoln on 27 July 2005. His
Continuous Clinical Record was started again on 27 July. The first entry,
made by his key worker, noted:
“On arrival the man expressed his intention to kill himself by starvation
and clearly stated that there is nothing we can do to stop him.”
17
64. As part of the admission process for the Healthcare Centre, in line with
West Lincolnshire Primary Care Trust policy, the key worker carried out a
risk assessment. She concluded that, although he had no current mental
health problems, he was a very high risk to himself and a moderate risk
to others.
65. A number of nursing care plans were completed on 27 July looking at
measures to care for his food refusal and his self-harming behaviour, as
well as providing him with enough support to promote his independence.
At 3.00pm that day, the Healthcare PO carried out an assessment of the
man’s intention to self-harm, and the linked decision to place him in the
healthcare centre, despite recording that he asked to go on ordinary
location. The second part of the assessment was completed by the
doctor a couple of hours later. The doctor found him to be more frail
than when he left Lincoln in January and agreed with the PO that the
man should be located in the healthcare centre. The PO noted:
“He remains at high risk of completed suicide. Level III obs (constant
watch) is the only justifiable course of action.”
66. The man was placed on constant supervision in the gated cell in the
healthcare centre. It was the same cell that he had been in prior to his
transfer to the secure unit. Overnight, he discussed with staff his
intention to sign an advance directive. A note was made in the
continuous clinical record that the Governor had been informed of his
food refusal.
67. The Governor emailed the Home Office Legal Advisers Branch on 28
July 2005, requesting advice about what action the prison should take to
ensure they discharged their duty of care to the man. In her email she
referred to a case heard the previous week where a prisoner was found
by the High Court not to have capacity to refuse food and was
administered food intravenously despite his stated desire to die through
food refusal. The doctor noted that the man needed to be seen again by
the two forensic psychiatrists so they could reassess his capacity to
continue to refuse food and drink and to write an advance directive. The
PCT was notified.
68. On 29 July, the man’s legal representatives faxed a letter for the
attention of the Governor, covering a handwritten advance directive
signed by the man and dated 28 July 2005. The same day, the
Governor received a response from the Home Office Legal Advisers
Branch to clarify what a prison’s obligations are to a prisoner refusing
food. She was advised that if two psychiatrists assess the prisoner as
having the capacity to refuse food, if he is given the opportunity to revoke
the advance directive at any time, and his mental capacity is kept under
constant review, the prison has discharged its obligations.
18
69. The Healthcare PO described this time as particularly difficult for the
man. It marked a year since his daughter’s death and a time of great
uncertainty as to his own fate. The PO told my investigators that he did
not feel that there was any way to enhance the level of care that the man
was receiving because staff were so attentive to his needs anyway, but
he did remind staff to be sensitive to him over these few days. The
actual anniversary of his daughter’s death happened to fall over a
weekend and the Healthcare PO was not scheduled to work. He made it
clear to staff they were to contact him if the man was finding it hard to
cope. The PCT gave healthcare staff a forensic psychiatrist’s on-call
contact details in case the man needed extra psychiatric support that
weekend.
70. Staff suggested to the man that he ate and drank until his assessment by
the two forensic psychiatrists, which had been arranged for 2 August, in
order to appear mentally well during their assessment. The man agreed
to drink until he was assessed, but made it clear that he would refuse
food and fluid after 2 August. This decision was recorded in a nursing
care plan, written by his key worker and added to by the Healthcare PO
on 1 August 2005.
71. Following a clinical assessment on 2 August, the forensic psychiatrists
disagreed about whether the man had capacity to enter into an advance
directive. One psychiatrist felt that the man did have capacity to refuse
food and drink and to enter into an advance directive. The other
psychiatrist concluded that the man did not have the capacity to make
treatment decisions. This was based on the fact that there was evidence
to suggest that his ability to weigh things in the balance was impaired by
factors relating to guilt and a sense of bereavement. During the
assessment the man described how his daughter would have “double the
justice” if he were to die in pain and said, “I deserve to die in pain, her
mother will get justice.” During interview, the psychiatrist described how
the psychiatrist arrived at his conclusion:
“It was my view that the man did not have the ability to weigh things in
the balance. I took the view that factors related to guilt, bereavement,
as evidenced by his attitudes towards death and the afterlife, a wish to
punish himself by dying in as painful a way as he possibly could, could
still be – could be argued to still be signs of an underlying residual
depression. And then following discussions between, lengthy
discussions really between ourselves, prison staff, the legal
representatives, it was judged that this matter should be referred to the
consideration to the High Court of Justice Family Division in London.”
72. On 2 August, a multi-disciplinary meeting was held to discuss the man’s
care, which the PCT had scheduled to coincide with the clinical
assessment. The purpose of the meeting was to ensure there was clear
understanding between the prison and the PCT about the man’s care.
During the meeting, West Lincolnshire Primary Care Trust made known
to Lincoln prison their intention to seek either a declaration of capacity
19
from the High Court or interim directions to allow time for a further
independent psychiatric assessment of the man’s mental capacity.
Email correspondence on 3 August confirmed that the Secretary of State
for the Home Department was to be a joint applicant in any such legal
proceedings.
73. A consultant physician at the local hospital examined the man at the
prison on 3 August. The prison doctor had requested that he come to
the prison because the man was too ill to attend an appointment at the
hospital. The physician found that the man was frail but otherwise well
and alert. He anticipated that if the man refused fluid he would die within
five to ten days. He went on to say that the man would die within six to
seven weeks if he were to refuse food and nutritious intake but continued
to take fluids.
74. An ACCT case review took place on 4 August. The man refused to
attend the review and the meeting went ahead in his absence, a pattern
which would recur throughout his time in healthcare. He was eating and
drinking small amounts at that time and those who attended the case
review described him as being in “reasonable spirits”.
75. West Lincolnshire PCT and the Home Office jointly instructed a medical
practitioner to assess the man’s mental capacity to refuse food, drink and
medical treatment and to enter into an advance directive to this effect on
8 August. The medical practitioner interviewed the man and wrote a
report for the court. She was able to interview him in private but with a
prisoner officer outside the gated cell. The doctor concluded that there
was no evidence of mental illness or impairment during the interview.
She advised the court of her opinion that the man did have the capacity
to refuse food and treatment.
76. On Friday 12 August 2005, the High Court handed down a judgment that
the man had capacity to refuse food and medical intervention and that
his advance directive, dated 10 August 2005, was a valid document.
Staff were informed of the judgment and offered the opportunity to
approach the Healthcare Manager if they had any concerns.
77. The record of the man’s weekly case review the following day (13
August) opens, “The man stated that he now is at peace.” The PO who
co-ordinated the case review, noted that he encouraged the man to
reconsider carrying out his advance directive and reminded him that he
could change his mind at any time. The man stated his desire to carry
out his advance directive in full. He was offered the opportunity to see a
Roman Catholic priest, but declined. The man was reportedly “in good
spirits” at the review.
78. The Liverpool Care Pathway Plan is a clinical framework that provides a
palliative care pathway for dying patients. It is opened only when a
patient is dying and co-ordinates the different aspects of care, including
comfort measures, anticipatory prescribing of medicines and
20
discontinuation of inappropriate interventions. Psychological and
spiritual care and family support are also included in the framework. The
prison doctor opened the Care Pathway to manage the man’s care on 12
August 2005.
79. On 15 August, prison managers, the NHS trust and PCT met to agree
the criteria that were to be reached before the man would be admitted to
hospital. He was once more moved back to the high dependency unit
after discussion with a governor. The governor on duty reminded the
man of the option to take up treatment at any time. The man confirmed
that he had not eaten for three days and his condition was notably
worse. The prison doctor met with the man and again explained the
physical impact that refusing food and fluid was having on his body.
80. The man was very anxious about his brother and his sister-in-law’s
visiting on 18 August. He repeatedly told staff that he was nervous that
they would try to persuade him not to go through with the advance
directive. That said, the family visit went ahead. Shortly after, the man
told staff that he did not want to see his family any longer. The man felt
that it was too distressing for them to see him.
81. Between 12 and 17 August, the man refused both food and fluids,
although he did take some medication to assist his sleep. Staff observed
that he was reflective and emotional during this time, talking about his
childhood, his time as a miner and his family. At about 5:45am on 17
August, the man woke up after a good night’s sleep complaining that he
was suffering from dryness. He accepted a cup of tea. Later that
morning at around 8:55am, the PO spoke to the man who said that he
wished to revoke his advance directive. The Healthcare PO observed
that the man felt as if he had let his daughter down because he promised
he would be with her.
82. The man saw his solicitor over the lunch period and, on his return, told
staff that he did now not want to formally revoke his advance directive.
He had been informed by his solicitor that the advance directive did not
preclude him from taking food and fluid if he chose to do so, but if he
wanted to resume his food refusal the advance directive would still stand
and he could, once again, still refuse clinical interventions. Clinical
records were immediately amended to instruct staff that the man should
be treated like any other prisoner. The man started to eat and drink
again.
83. A weekly case review took place on 18 August. The record of this
meeting mentions the man’s “revival”, referring to his decision to eat and
drink again and that he looked much better following a haircut and a
shave. However, he was to remain on constant supervision until after his
court appearance the following month.
84. On 23 August, the man finally agreed to speak about the circumstances
leading to the charge against him. The prison doctor arranged for a
21
Registrar of one of the Consultant Forensic Psychiatrists, to visit the man
the following day. By then, the man had spoken with his solicitor and
told the visiting doctor that he had been advised not to talk about the
charge he faced.
85. On 24 August 2005, the solicitor produced another advance directive that
was dated 22 August. The advance directive refused consent for
resuscitation including Cardio Pulmonary Resuscitation (CPR),
intravenous (IV) fluids and drugs. The prison doctor made it clear to the
man that the advance directive only applied where his condition had
deteriorated through food and fluid refusal. The man would be
resuscitated following any other attempt at suicide or self-harm.
86. The man attended another weekly case review meeting on 25 August, a
record of which was taken by a staff nurse , as follows:
“Spoke quite openly about feelings, states categorically that he will not
hunger strike again, and that were he going to use other methods he
would have done so by now. Appeared quite convincing in this … keen
to lose Level III status. All members of staff felt that this would be
appropriate, although accept that this decision currently rests with other
parties.”
87. On 7 September 2005, the staff nurse wrote a nursing care plan,
apparently triggered by that fact that the man was charged with the
murder of his own daughter. The aim of the plan was to keep the man
safe and monitor his mental health.
88. The next day, a case review made reference to the man’s case being
scheduled for Crown Court the following week. Despite this, the man
was recorded as being in good humour. In fact, the case review
recorded that the only reason that the man’s observation level could not
be reduced to “reflect his state of mind” is due to “senior management
intervention”.
89. On 13 September, the man appeared at the Crown Court via video link.
It was noted in the record of his case review, dated 15 September, that
he had been upset by his appearance on video link. The man retreated
under his bedclothes and wanted to “go to sleep permanently”. Mention
was made that his case might be brought to the Crown Court on 17
October and that the man felt “that his family want to kill him”. Staff
reassured him that they would support him through the trial.
90. During a conversation with the prison doctor, the man said that he just
wanted to be in the dark and on his own. He told the doctor that he
would not end his life because so many staff had become so close to
him. He repeated that he thought he would be reunited with his daughter
when he died. The doctor’s entry in the clinical record concluded that he
had to be kept under constant watch until his court case.
22
91. Staff were concerned over the man’s “buoyant” and “compliant”
behaviour in the build up to his trial. Despite being keen to attend the
case review where this matter was being discussed, the man walked out
when he was asked about whether he was experiencing suicidal intent.
A cell search carried out that day saw the marked change in mood
continue. He was angry about the cell and personal search conducted
by staff.
92. The man asked to make a call to his solicitor from the telephone in the
staff office on 30 September. When his key worker advised him that this
was not prison policy, and that he had to use the payphone and his PIN,
The man claimed that the PO always allowed him to use the office phone
for privacy. A note was made on his self-harm register that he had been
told that only a governor grade could authorise use of the office phone.
93. Later that same day (30 September), the key worker made another entry
in his continuous medical record. The man claimed to be stashing drugs,
“in such a way the drug dog won’t be able to find them” and hiding laces
in order “to plait them to make a rope”. He also claimed that staff in the
healthcare centre were giving him privileges he was not entitled to. The
man’s cell was searched with dogs but nothing was recovered except a
slither of concrete that the man had removed from another part of the
centre and left on the window sill to be discovered by staff. The man
complained that his slippers were damaged during this search.
94. A SO sent a message to all staff on the constant supervision on 2
October, reminding them not to watch television while they were
observing him. The man’s habit of turning the television around for staff
while he slept was recognised as potential conditioning of staff not to pay
close attention to what he was doing.
95. The man’s room was searched again on 4 October, as he claimed that
he was hiding drugs in his room. Nothing was found, but he remained on
constant watch. He barely communicated with staff and spent much of
the time under his blanket.
96. The man’s agitation at his cell being searched was echoed in the record
of a Case Review that took place on 6 October 2005 with the Healthcare
SO, a member representing probation, and a representative from
Lincoln’s chaplaincy. The prison doctor contributed to the review. The
man had told the doctor that he was having vivid dreams and intense
visions. Although the man was not eating or drinking, it was not
understood to be a formal food refusal at that stage. The doctor made a
note in the man’s clinical records that the man was showing some
depressive symptoms:
“Declined to attend review today. Has been quite agitated this week
because of what he regards as excessive cell searches – a result of
SIRs [Security Incident Reports] and an unexpected court appearance
at which extracts from his daughter’s diary were read out. He has
23
declined to eat again and refused his medication. He has also given all
his personal bits and pieces to other prisoners, he states he doesn’t
want the Prison Service to give him anything.
“Constant watch continues.”
97. The man was particularly distressed by a legal visit on the morning on 7
October. His legal team asked him to take his daughter’s diary, which
agitated him. Staff advised him that he was not obliged to take the diary.
He continued to refuse to eat or drink and refused food and medication
over the next few days.
Authenticity of the advance directive dated 10 October 2005
98. A final version of the man’s advance directive was signed and dated by
him and witnessed by his solicitor on 10 October 2005. It confirmed that
the man refused all treatment, except the use of glycerine sponges for
his mouth, pain relieving medication and measures required to avoid
getting bed sores. The prison doctor made a note in his clinical record to
the effect that, in his opinion, the man’s capacity to refuse treatment had
not changed since the High Court decision a few months before. The
prison doctor asked one of the forensic psychiatrists to assess the man
again as quickly as possible to establish whether or not the advance
directive was valid.
99. Two days later, the psychiatrist attended the prison and assessed the
man. The High Court had said that there would have to be a substantial
deterioration in his mental state for the decision about his capacity to
change. The psychiatrist found that the man’s frame of mind had not
deteriorated since the court judgment, in fact he seemed better within
himself. The man said that he would drink fluids but not eat food. He
thought that this would be less painful, although he realised that it would
mean it would take longer for him to die. The psychiatrist advised him to
start taking his anti-depressants again in case his mental state
deteriorated. The psychiatrist concluded that there was no evidence to
overturn the previous findings of the High Court, namely that the man
had capacity to make an advance directive.
100. The Treasury Solicitors wrote to the governing Governor with a copy of
the recently redrafted advance directive that same day. This instructed
that the man did not want to be resuscitated in any event. This was an
amendment from the previous version of the advance directive, in which
he had said that he did not want to be resuscitated “in the event of a
heart attack, stroke or any other ailment which results in a loss of
competency and/or capacity”.
101. A daily care checklist was started on 13 October, tailored to the man’s
personal needs. The checklist comprised 15 actions, for example, staff
should offer food or supplements at mealtimes or spiritual support. A
staff member entered their initials in a chart each time each of these
actions was completed. The man was in a noticeably improved mood.
24
The prison doctor explained the consequences of his refusal to take food
and the effect that it would have on his body.
102. On the morning of 13 October, the Healthcare SO and a member from
Probation carried out a case review. The man refused to attend. A
record of the case review taken by the Healthcare SO read as follows:
“Has just signed a new ‘Advance directive’. This time he will drink but
not eat! However requesting ‘build-up’ drinks. Court case has been
put back until Mar ’06. No doubt this gamesmanship will continue until
then.”
103. An officer completed the man’s weekly healthcare review on 19 October.
She noted that he was suffering from mood swings and that, although he
had previously refused medication as well as food, he had started taking
his medication again. Later that day, he was seen by a psychiatrist for
the prosecution team in the healthcare centre.
104. A further case review took place on 20 October with a senior healthcare
officer, a probation worker and a representative of the chaplaincy. The
man refused to attend because it was “pointless”. It was recorded that
he was refusing meals but drinking and taking medication.
105. West Lincolnshire PCT had maintained regular contact with the local
hospital since the High Court decision on 15 August. On 25 October, the
prison doctor formally wrote to the Medical Director at the hospital to
alert him to the fact that the man had started to refuse food again.
Although the doctor did not feel it was necessary to transfer him at that
time, he wanted arrangements in place so that as soon as the man’s
condition deteriorated he could be transferred without complication. The
doctor noted that the man had now lost about 10 kilograms in weight.
This meant he was now 56 kilograms.
106. A nursing care plan dated 27 October was drawn up in response to the
advance directive that the man signed on 10 October, with the aim of
providing support and maintaining a safe and comfortable environment.
As usual, the man refused to attend his weekly case review, but he
agreed to see the Reverend from the chaplaincy who then passed on his
thoughts to the case review meeting. The man had apparently pored
over his daughter’s diary in the early hours of the morning and become
agitated.
107. During his meeting with the chaplain, the man reported having difficulty
swallowing and the doctor undertook a medical assessment of him later
that day. The man’s Care Pathway communication log was
recommenced on 27 October following the previous “few days” of food
refusal and a noticeable deterioration in his physical condition. The man
had been abusive to staff the previous night and continued to be
aggressive towards the doctor and the PO. The man was described as
very shaky and experiencing difficulties swallowing. The doctor noted
25
that the man was going through the “expected loss of mental clarity,
calling into question his capacity for decision making. I consider his
advance directive to be active now.” The doctor alerted the PCT and the
Duty Governor of the change in the man’s condition.
108. The man was located in a constant watch cell with a clear door and
lockable gate. His toilet and bed would have been clearly visible to a
prisoner in the cell directly opposite. Members of staff were located
outside the man’s cell 24 hours a day, in shifts, to carry out the constant
observations. On 28 October, the Healthcare PO discussed a move to
the high dependency unit with the man but he refused to go. The man
also declined a mattress used to alleviate pressure sores, although he
did accept some medication. The man refused to have his medical
observations taken (blood pressure, weight and urinalysis). He also
refused food and food supplements but did drink coffee, despite advice
that coffee would dehydrate him.
109. A risk assessment was faxed from West Lincolnshire PCT to the
Healthcare PO on 31 October. Clear reference is made to the PO
contributing to the risk assessment and action plan. The assessment
identified the following risks:
- the patient losing capacity to revoke his advance directive despite
indicating that he wanted to;
- public/professional scrutiny;
- staff stress;
- efficiency of the healthcare centre;
- hospital might refuse admission when it is necessary;
- caring for distressed or unconscious patient in a healthcare setting.
110. The assessment rated the severity of the risks. It determined that the
risk of public scrutiny and referral to a professional body was the
greatest, shortly followed by the risk of staff stress. The risk assessment
identified several actions to manage each risk, attributing a lead for each
of the actions and recorded the action status. All of the relevant actions
were in progress or completed, including advising staff that they could
elect not to care for the patient in order to reduce stress.
111. On 31 October, an officer recorded that the man had become aggressive
towards staff and that he was “fed up of being in a glass case”.
Unusually, the man consented to giving a urine sample on the same day.
The sample showed that he now had ketones in his urine. Healthcare
Officers and the prison doctor held a case review which the man again
refused to attend. They discussed his condition and noted that the food
refusal was beginning to “take its toll in terms of physical appearance
and mental clarity”. However, just the next day, the doctor noticed that
the man was still “physically robust” when walking.
112. On 4 November, the man was recorded as swearing at staff because
they were moving him from cell to cell. The member of staff who made
26
this entry suggested that this might have been a dream. A later entry,
following a chat with him, suggested that this was either a dream or a
hypnagogic episode brought on by toxicity from food refusal and that he
once again appeared rational.
113. During the next few days, the man was asked on a regular basis whether
he had changed his mind, as well as being reminded of the effects of not
eating. It was noted on 10 November that he appeared very weak and
that he was unable to stay awake when sitting in a chair.
114. At his ACCT case review meeting on 11 November, it was agreed that
the man was getting as much care and attention that he would allow, but
despite this was “looking quite haggard”. He had apparently had a few
outbursts towards staff, especially unfamiliar staff. He was also refusing
all offers of help and support.
115. The situation was unchanged by the next weekly case review held on 17
November. The man was still refusing food, but drinking small amounts
and taking medication.
116. A note was made in the man’s nursing care plan on 18 November that he
wished to work but that the work had to be minimal due to his physical
condition. A brief note was made of his weekly case review that took
place on 24 November, reporting that his condition remained the same.
His weight was noted to have dropped to 50 kilograms.
117. The man was noted to be pleasant and continuing to refuse food but
drinking lots of orange squash and coffee. The man was refusing pain
relief at this time. During conversation with an officer on 29 November,
The man said that he had no regrets, “… he knows his time is coming
and he has sent out all letters etc to his family.”
118. Following discussion between the prison doctor and the Governor, an
instruction to healthcare staff was issued the same day. The instruction
clarified actions that needed to be taken by staff if there was to be a
sudden deterioration in the man’s condition or if they were to discover
that he had died in his cell. If he was to start eating again, he was to be
transferred to the local hospital so that they could manage his care.
119. A Governor’s Order was issued to Prison Service staff on 29 November
2005 notifying them of a “small risk of [the man’s] sudden death”. The
Order suggested that if no signs of life have been detected for one hour,
efforts should be made to check his vital signs. The Order clearly said
that such efforts should not be intrusive or cause him to wake should he
be trying to rest. The clinical record indicates that the doctor considered
a transfer to hospital would be required in the near future for an
enhanced level of nursing care.
120. One of the forensic psychiatrists came to review the man on 30
November. The man refused to be interviewed, so the doctor simply
27
observed him from outside his cell. The prison doctor said that the man’s
mental health had not suffered a serious deterioration and that there
were no grounds to admit him to a mental health unit. He displayed no
psychotic symptoms. The forensic psychiatrist did not make any
recommendations about the man’s future care.
121. The Governor’s Order was discussed at the man’s multi-disciplinary
weekly case review on 1 December, and it was recorded that his physical
condition was noticeably declining.
122. The man’s solicitor met with him in a side room of the healthcare wing on
2 December 2005. An officer recorded that he “appeared to be ok” after
this visit. The man was apparently shocked by a news broadcast on 5
December when his name was mentioned in connection with being found
in a wooded area.
123. It was recorded in his weekly case review for 8 December that he was
being visited daily by the doctor and the Governor. Both his mental and
physical condition were noted as being under constant review. The
man’s calorific intake had increased because he chose to drink orange
juice. He was still reminded daily about the physical impact that refusing
food was having on his body. On 9 December, an oficer observed that
the man “has become very talkative and funny’”.
124. The Treasury Solicitors wrote a letter of response to a telephone
conversation with governor on duty on 13 December. The letter
contained the advice that as there was no formal policy about leaving
food in the prisoner’s cell when they are refusing food, food should not
be left in his cell. The letter referred to the possibility that such a practice
might amount to a breach of human rights as it could be interpreted as
inhuman and degrading treatment. No opinion was given as to whether
leaving food in a cell does constitute such a breach, but the possibility
was recognised.
125. The brief note of the weekly case review meeting made by a duty nurse
on 15 December said that the man “continues on course of action to
refuse food to end his life”. The doctor and the Healthcare PO visited
him to ask him who he would like to visit him in hospital.
126. The man chatted to an officer on 16 December about the Roman
Catholic Church. The man particularly remarked on how helpful the
chaplaincy had been to him during his time at Lincoln. The Roman
Catholic Chaplain told my investigators that it is part of the chaplaincy
regime to visit healthcare every day. She said she spent quite a lot of
time with the man and that he was “not difficult or reflective in behaviour”.
127. The man “declined as usual” to attend his weekly case review on 29
December. It was recorded that he continued to refuse all meals but that
mentally he was “very alert”. It was agreed that the reviews should now
28
take place fortnightly unless his situation changed. The man continued
to drink orange juice.
29
Events during 2006 leading to the man’s death
128. On New Year’s Day 2006, the man’s principal concern was his dwindling
stock of orange juice. Staff observations showed that he could talk of
little else. He mentioned his worry to a governor who carried out the
Duty Governor visit on that day and promptly arranged for 96 cartons of
orange juice to be delivered to him. He was apparently “Elated!” at the
delivery of his orange juice.
129. Somewhat at odds with his prolonged food refusal, the man was
recorded by an officer as talking constantly about food on 3 January.
Over the next few weeks, he was often observed watching the television
programme ‘Ready, Steady, Cook!’ and chatting to staff about their
evening meals or his favourite subject, orange juice. One member of
staff even recommended that he write a book about orange juice.
130. When the man was advised that his solicitor had come to visit on 6
January 2006, he refused to see her because he would have to attend
the legal visits area in a wheelchair. Staff later helped him to write a
letter to his solicitor, apologising for refusing to see her and explaining
the reasons for not wanting to go. That afternoon, he rang his solicitor to
explain why he had refused to see her. According to observations in his
constant supervision records, the man was concerned that prison staff
might get into trouble because he refused to see his solicitor and he
wanted to ensure that staff would not be blamed.
131. An SO remarked that on 7 January he noticed a real change in the man’s
attitude towards staff as he was “very concerned about staff welfare …
there really does seem to be a change in his character since I last had
dealings with him.”
132. His key worker and a member of the prison’s probation team met for his
case review on 12 January and a brief record was made of the meeting
which recorded that “no significant change” had occurred. The man
continued to drink only orange juice.
133. On one of her several visits to see the man, the Governor made a note
on 13 January that he was “quite bright” and ”mentally alert”. The man
described his routine to her and told her how much he was enjoying
drinking orange juice. He said that he was still waiting for his glasses,
which should have been sent to Lincoln when he was transferred back to
the prison from the medium secure unit in July 2005, six months
previously.
134. After being quite depressed about an apparent shortage of orange juice,
the man told an officer during the evening of 14 January that he did not
think he had any longer than a month to live. The following day, he
expressed his concern to an officer about the levels of hygiene of a
prisoner a couple of cells away from him. The smell was affecting his
30
comfort and he was also worried about using the bath after that prisoner
had used it.
135. Later that day, he also complained about the prisoner in the cell opposite
his gated cell. The observation panel for the opposite cell directly
overlooked the one that the man was in. He was concerned that the
prisoner opposite always stared at him, even when he was using the
toilet. Within an hour or two, the prisoner opposite him was relocated to
another cell and the man was reported as being relieved and grateful.
136. An officer observed him as subdued and “very down” and made the
following entry on 16 January in his constant watch record:
“talking about his family wanting him to hurry up the process of his
death. He said they aren’t sending him any money and it has hurt him
as he knew he was [dying], but he wanted to die with no pain.”
137. The man’s intake of orange juice steadily increased, and on 18 January
the Healthcare PO arranged with kitchen staff for him to have three litres
a day. The PO also discussed the matter with the Governor’s secretary
who agreed to purchase an additional one litre a day of tropical juice for
him.
138. The same day, the man was given a new job to enable him to earn
money and buy some more orange juice. The man was “a lot happier”
because he had been given something to do. He was asked to make up
new prisoner medical records, so that the blank files would be ready to
be used by healthcare staff. He was able to carry out this work in his
cell.
139. The man refused to attend the weekly case review on 26 January, as
had become the norm. He was recorded as drinking three litres of
orange juice a day, but not eating any food. The chaplain helped him to
write to his sister on 27 January. The last daily care checklist on file took
place on 29 January. On the same day, the man reached for his orange
juice and slipped off his chair.
140. An officer recorded that the man’s general condition had deteriorated
between 30 January and 3 February. The officer noted that he continued
to work despite the apparent deterioration in his condition. The officer
also recorded that the chaplain was helping him to deal with his sadness
because some members of his family had appeared to stop writing to
him.
141. The man received his glasses on 31 January 2006. The occasion was
marred because his canteen (order from the prison shop) had been
miscalculated and, as a result, he was running low on orange juice.
142. The officer who was carrying out the constant watch on 1 February,
noted:
31
“[t]alked at length about how much longer he has to live. He thinks
about March perhaps April. Spoke about which type of coffin he will be
buried in (cardboard) lot cheaper. Doesn’t seem bothered about
dying.”
143. The contemplative mood continued into the afternoon shift when an
officer made several poignant entries:
“Says he cannot remember when he stopped eating. Says he would
prefer to go to sleep and not wake up that’s why he does not want
visits. Says he is happy that way … says he finds it easier now to open
up and talk to staff. Talking about when he goes to the hospital that his
family will be able to visit and that it would give them some comfort.”
144. Later that afternoon (1 February), the man received Holy Communion
“with great reverence” according to the entry made in his Daily
Supervision and Support record.
145. On 4 February, the man was given his last box of medical records to
make up, a task which he spent all day completing. His deteriorating
concentration meant that the day ended in frustration and healthcare
centre staff decided to withdraw the work. By this time, he could not
dress himself without assistance. It was recorded in his Daily
Supervision and Support record on 5 February that he was seeing
double.
146. When the prison doctor reviewed the man on 6 February, he found such
a significant deterioration in his condition that he wrote to his solicitors to
inform them that he would no longer be fit to go to the visiting area. The
doctor discussed the matter with the Governor and they were in
agreement that any required legal visits should take place in the
healthcare centre. In a letter to the Governor to confirm their discussion,
the prison doctor suggested that, in his opinion, the man would soon be
transferred to hospital to be nursed through the last stages of his life.
The doctor tried to persuade the man to move to the high dependency
unit, but to no avail. The officer who was carrying out constant
supervision, was moved to make the following entry in the man’s Daily
Supervision and Support record:
“this is VERY UNDIGNIFIED FOR HIM HAVING SOMEONE WATCH
WHILST HE STRUGGLES TO GET ON/OFF TOILET.”
147. During interview, the officer said that he felt “uneasy” watching the man
struggle with a basic function like going to the toilet. He said that the
man did not complain to him about being observed so closely, preferring
to chat about the television, cigarettes and juice.
148. When the Governor went to visit the man that day, they discussed his
pressure sores and his swollen feet. The Governor spoke to the man
32
about moving into the more spacious and modern high dependency unit
further down the corridor. According to the Governor’s entry in his ACCT
record, the man said that he would prefer to stay in his current cell
because he did not like the bed in the high dependency unit. My
investigators spoke to some staff who speculated that the man liked to
be in a higher position than the member of staff observing him as a
matter of control. The set up of the high dependency unit required that
staff carrying out the constant watch would have to do so from a higher
viewpoint than his bed, and some suggested this was at the root of his
reluctance to move cells. Others thought that the man felt the room was
too cold. Other staff members thought that he felt ‘at home’ in the cell he
had spent so many months in.
149. Entries made in his observation record on 9 February suggest that the
man had mixed feelings about being transferred to hospital. He
expressed doubts about his pending transfer. Following his rounds, a
governor wrote the following entry in the man’s ACCT record:
“Spoken to him at length about being admitted to hospital. He has a
few concerns about visitors and his smoking in hospital. I have
reassured him that procedures will be put in place for him to receive
visits by his named visitors.”
150. The man’s reflective mood continued into the evening:
“Said he is ready to die, he can’t take the situation he is in anymore,
said he is hoping to die soon and everything has been arranged but not
til he has seen his family”.
The man would repeat countless times over his last few weeks that he
would like to see his family, his brother, sisters and nieces and nephews,
before he died.
151. The deterioration in his medical condition was noted in his weekly case
review on 10 February. In his record, the Healthcare SO mentioned that
the healthcare centre was going to be closed for refurbishment on 17
February and staff were beginning to plan for his transfer to hospital
before that date. According to his ACCT record, the man also had a
legal visit on 10 February. On the same day, the man was chatting to
staff about how he might go “any time now but hopes to get his visits
from brothers and sisters first at the hospital].” He was chatting about
what facilities he wanted and the arrangements for him to be able to
smoke.
152. The man received Holy Communion on 11 February. Following his Holy
Communion, he was in a chatty but gloomy mood. An officer recorded
the following:
33
“Another long chat. The man telling me to enjoy my life as time goes
so quick. He became a bit melancholy. Appeared to be thinking about
his life.”
153. Apparently adjusted to the fact that he would be transferring to hospital,
an entry in the ACCT dated 12 February noted that the man “says he
knows he won’t be there for long may be two weeks at the most”. Later
that day the man commented that he felt “peaceful that his family will
visit”. However, he did suggest that some of his letters had gone
missing.
154. An officer reported that, at 8:53pm on 13 February, the man was
becoming “agitated” because of the “antics” of the prisoner in the cell
opposite. By 9.10pm, the prisoner had been moved to another cell in the
healthcare centre and the man was observed as being “more settled”.
155. A number of nursing care plans were completed in respect of his care on
13 February. The identified needs were to prevent pressure sores, to
maintain his dignity while offering him diet and maintaining his safety, to
monitor his mental state and keep him company, to minimise pain, and to
maintain his personal hygiene. Nursing interventions were identified to
manage each of these needs.
156. In the early hours of 14 February, the man was using the toilet when he
told an officer that he was “embarrassed” because he had wet himself in
bed and he had not realised until he had woken up. The officer informed
the nurse but he was unwilling to have the sheets changed until later in
the day. A staff briefing took place during the afternoon of the 14
February between an officer and the key worker. The man seemed to be
upset that he was being visited by a doctor and his solicitor the following
day and would be asked the “same old” questions. He accepted that it
was being done for his own good.
157. The following morning, the Governor visited the man and he told her
about being visited later in the morning by the prosecution’s psychiatrist.
His appointment with the psychiatrist lasted just 25 minutes.
158. In the early hours of 16 February, the man used the toilet many times.
According to the officer on duty, the man was “waffling” and “making no
sense” for around three-quarters of an hour. The man was asked
whether he would be willing to transfer to hospital. He said he did not
want to transfer because he would not be able to smoke at the hospital.
The hospital was contacted and told that the man’s admission was to be
delayed.
159. At 9.00am that day, after a visit by a Muslim minister, the officer made an
unusual entry stating that the man thought he was going back onto a
wing. By this time, the man’s physical state had deteriorated so much
that he could not possibly have been transferred to ordinary location.
34
This comment would appear to be due to his declining mental state at
this time.
160. Around midday, an entry in his Daily Supervision and Support Record
stated:
“Started talking about being found in the forest, and sleeping in the
ditch. Also about, D-Day coming, states if he wakes up he does, and if
he doesn’t no problem.”
161. Despite experiencing difficulty passing urine and having a heavy fall in
the early hours, on 17 February 2006 The man reported feeling “in good
health”. He estimated that he had “about 6 weeks left”. He
acknowledged that he was likely to lose his power of speech soon, but
reported “being at peace with God”. He told the officer who was carrying
out the constant watch that “all is in order when [the] time comes”.
162. When a Physical Education Officer (PEO) came on shift at midday, the
man had moved onto discussing his refusal to transfer to hospital. The
PEO entered into the man’s ACCT record that it seemed the reason for
this refusal was the smoking restrictions. The man discussed with the
Deputy Governor who he would be able to receive for visits. The
governor reassured him that the prison had a list of his approved visitors.
163. In the course of trying to go to the toilet in the early hours of 18 February,
the man again fell heavily to the floor. He said that he was okay and
managed to get to the toilet and use it. He smoked a cigarette and went
back to the toilet for 40 minutes. An hour and a half after the fall, he was
checked by the nurse who reported that he seemed alright.
164. There followed a morning of being his usual talkative self, discussing
what he was going to watch on television and balancing the merits of
certain types of fruit juices. In the afternoon, he reported that he was
“feeling the cold more” and warmed himself up with a coffee and a
change of tracksuit bottoms.
165. A governor chatted to him about visits on his rounds later that day. The
Deputy Governor suggested that he might be too weak to have visits in
the visitors centre and that he might need to talk to medical staff about
allowing visits on the healthcare centre. An officer described a
conversation that he had with the man:
“… he knows that he’s approaching his final weeks he can feel it in his
body. That’s why he wants to have his visits.”
166. A further nursing care plan was completed on 19 February in response to
the man’s increasing incontinence. The aim of the plan was to maintain
his dignity and to prevent a further deterioration of his pressure areas.
35
167. On 21 February, most of his afternoon was spent with the chaplaincy. He
was also visited by the prison doctor and a governor on their respective
rounds. The prison doctor again explained to him that he was dying and
suggested that he should be transferred to hospital. Again, the man
refused.
168. The man had a visit from his sister and other family members on the
afternoon of 22 February. In his ACCT record, the officer described it as
“very emotional for them all.” The visit lasted one and a half hours and
took place in the staff room in the healthcare centre. The man told staff
he had had a good visit.
169. The same day, the man fell over twice: once in his room when trying to
get to the toilet and once when he attempted to get out of the bath by
himself. The Healthcare SO recorded in his multi-disciplinary progress
notes that the man appeared increasingly frail, but continued refusing to
be moved to the high dependency unit or the local hospital.
170. The chaplain made an hour long pastoral visit on the afternoon of 23
February. She helped him write a letter to his niece. She described him
as being “relaxed” but “slower” during the course of writing the letter.
The chaplain said the letter reflected the man’s words but he was not
physically strong enough to write it. The man was recorded as being
very tired that day. He finally agreed ‘in principle’ to transferring to the
hospital in two days time.
171. On 24 February, an officer wrote in the man’s ACCT record that,
“mentally he appeared to be aware of his surroundings and time and
place.”
172. The officer described him spending eight minutes being deeply focussed
on opening a plastic bag in order to empty his ashtray into it. He told the
officer that he kept the ends to give to people who needed them. The
officer remarked upon the fact that every action was “slow and
methodical”. Uncharacteristically, the man did not chat with staff much
that afternoon. In fact, he spent it in a state that the officer described as
“almost catatonic”, although the man did respond when spoken to.
Again, he was feeling cold and was assisted with putting another jumper
on.
173. Towards early evening, the man resumed his usual chat about television
schedules and orange juice. He was visited by a governor that
afternoon. The man needed a nurse’s assistance to go to the toilet and
to make coffee. Much later on, a PEO that had taken over the constant
watch from another PEO and noted that the man seemed “very confused
and disorientated”.
174. The man then commenced rolling a cigarette, during which he fell asleep
eight times. It took him well over two hours to roll a cigarette. Until this
evening, his usual routine would be to go to bed at around 1.00am and
36
then wake up around 5.00am. The PEO noticed how remarkable it was
that the man, while dozing off occasionally, did not stop talking all night.
With the assistance of a nurse, the PEO finally got the man into bed at
4.10am.
175. The man then slept all the way through until 8.10am when the duty
healthcare nurse checked him. An officer was on the constant
supervision shift that morning. The officer noted in the observation
record that the man said he was “not too bad”, although he noticed that
his “speech was laboured and slurred”.
176. The man went back to sleep for an hour, until the duty nurse entered his
cell at around 9.00am with a drink of orange juice. She rolled him a
cigarette and sat him on the edge of the bed so that he could enjoy his
drinking and smoking.
177. Around three-quarters of an hour later, the man had to be wheeled to the
bathroom and lifted into the bath. His bath took half an hour, after which
he returned to his room and sat smoking a cigarette. The prison doctor
visited him with the chaplain, from whom he received Holy Communion.
178. The man offered to clean up his cell but was discouraged by the officer
on duty who was concerned that he was not strong enough to do so and
feared that he might fall. He spent the morning looking through a
television magazine and dozing. Just after 2.00pm, the ambulance
arrived to transfer him to hospital. Two officers accompanied him and
they arrived at 2:25pm. The man was immediately admitted to the
specialist ward. In the interests of privacy, he was located in a side
room. No restraints were used for his transfer to the hospital because of
his fragile physical state.
179. The man was asleep throughout his transfer to hospital. Pillows were
used to make him comfortable throughout the afternoon in the hospital
and he continued to sleep. A nurse visited him at 4:30pm to check if he
was comfortable or whether he wanted his position to be adjusted.
According to his observation record, he ”very slowly” said no.
180. A governor visited him at 5.15pm and confirmed that his solicitors had
been told of the transfer to hospital. After this visit, nursing staff offered
him orange juice but he “feebly” shook his head in response. At 6.00pm,
nursing staff and HMP Lincoln were informed of a deterioration in the
man’s condition. Staff called the nurse at 6.13pm because they thought
he had “gone”. After the nurse attended, a priest arrived to perform last
rites and the doctor was called. A doctor arrived at the man’s bedside
and pronounced him dead at 6.31pm.
181. An escort officer contacted Lincoln to tell them that the man had died and
his time of death. The bedwatch staff were told by nursing staff that the
Coroner would be informed the following Monday (30 January). The
37
Duty Governor at the time contacted the man’s brother who had been
due to visit him the following week.
38
ISSUES
Clinical Review
182. All of my deaths in custody investigations are informed by a clinical
review. Ordinarily, in accordance with my terms of reference, I
commission the clinical review from the PCT responsible for delivering
healthcare in the prison in whose custody the prisoner was in at the time
they died. However, West Lincolnshire PCT (now part of Lincolnshire
PCT) was instrumental in the delivery of care that the man received at
Lincoln. With this in mind, I approached the Head of Offender Health at
the Department of Health, to see if a more independent arrangement
might be reached.
183. After some negotiation, West Lincolnshire appointed two medical
practitioners of Bassetlaw PCT to undertake an independent clinical
review. The clinical reviewers reviewed the man’s medical records and
met with my investigator, with West Lincolnshire PCT and with prison
healthcare staff to determine the parameters of their investigation. They
joined my investigation team for many of the interviews and visited
Lincoln’s healthcare centre. They produced a clinical review that was
sent to Lincolnshire PCT for their consideration in August 2006. After
protracted negotiation, my investigator was sent the final agreed version
of Bassetlaw’s clinical review at the end of November 2006. The clinical
reviewers have identified six areas of learning to improve clinical
services.
184. The reviewers observed the healthcare facilities at HMP Lincoln. They
found that the facilities to provide in-patient care were not of comparable
standard to that of the mainstream NHS.
Clear accountability for ensuring working conditions [in Lincoln’s
healthcare centre] are safe and fit for purpose is required.
185. The clinical reviewers thought that a consensus should have been
reached about the man’s capacity before he was discharged from the
medium secure unit. In their opinion, the High Court decision should
have been sought before his discharge and then a care pathway could
have been drawn up and begun straight away. In response to the draft
report, Lincolnshire PCT wrote that all present at the CPA meeting
before the man’s transfer back to prison agreed that he had capacity to
choose to refuse food, drink and medical treatment. The CPA meeting
resulted in a plan and clarification that further psychiatric services could
be accessed in the event of any deterioration following transfer back to
prison.
When a prisoner is being returned from prison after a time in a
mental heath secure unit under the Mental Health Act, a discharge
process should be agreed by all relevant parties, to enable a care
pathway plan to be drawn up as soon as possible.
39
186. Staff told the clinical reviewers that locating the man in a gated cell for
such a long time did not allow him sufficient dignity. However, they
recognised that, when he did express any discomfort about the prisoner
located directly opposite his cell, the other prisoner would be promptly
moved.
A patient under long-term constant supervision must not be held in
a cell where he may be watched from a cell opposite.
187. The clinical reviewers thought that the high dependency unit was not set
up for constant observation. It did not have a transparent door and the
observing officer would have to sit on an elevated chair to carry out
constant supervision.
Consideration should be given to making the high dependency unit
suitable for constant supervision.
188. The clinical reviewers found that the man’s transfer to hospital was
appropriate. Nevertheless, they make the following recommendation:
There should be a clearly documented decision with the patient’s
preferences of where they want to die stated. Any reasons these
cannot be complied with (eg security or ability to care) should be
stated. This situation was appropriately dealt with in this case.
While I do not disagree with the principle behind this recommendation, I
later commend the efforts made by staff to involve the man in choosing
his place of death.
189. Constant supervision was carried out by prison officers. The clinical
reviewers commented on discrepancies that emerged during interviews
between some officers’ understanding of their role as observer.
While not a key point, some clarity on the role of the observers in
these situations [long-term constant supervision] is required. As
the patient becomes frailer in the latter stages it may have been
more appropriate to use a member of healthcare staff.
190. I am grateful to the clinical reviewer for their clinical review and concur
with their recommendations. Overall they found that “the standard of
care provided to the patient by Lincoln was excellent.”
191. After submission of the clinical review, my investigator wrote to
Lincolnshire PCT to request more detail on some outstanding matters. I
would like to thank Lincolnshire Primary Care Trust for the full response
that was received in this office at the end of January 2007. I have
referred to this document in my subsequent consideration of issues.
40
Family contact
192. Lincoln enabled the man’s family to visit him in the healthcare centre
when he was too frail to get to the visitor’s centre. The Deputy Governor
reassured him that his approved visitors’ details had been passed to the
hospital ready for his transfer during the last stages of his life. These
efforts with the man’s next of kin continued when the man had died. The
governing Governor and the Deputy Governor met the man’s brother at
the hospital on the night that the man died. Another senior officer
continued with the family liaison and provided a single point of contact.
193. My family liaison officer was told by the man’s brother that he was
content that Lincoln did everything that they could for his brother. He
said that the man was determined to die and so he did. He raised no
particular concerns for consideration during the investigation. However,
he was interested in seeing a copy of the investigation report and I hope
it has addressed any outstanding concerns.
Advance directive
194. An advance directive is a statement of instruction about how a person
wants to be treated in the future should they lose the capacity to make
informed decisions about their own care. Around Christmas 2004, the
man told the prison doctor that he was not eating because he had no
appetite. By early January 2005, the man said he was not eating with
the intention of ending his life by starvation. In line with Prison Service
policy, the doctor suggested that the man contact his solicitor to
formalise his refusal of food and treatment.
195. Adults with capacity have the right to refuse food, fluid and treatment,
both at the time it is offered, and in the future using an advance directive.
If treatment is forced, it is a breach of the patient’s right to life, self-
determination and liberty. It can also be considered a criminal offence to
treat someone against their informed will.
196. The man had to have the capacity to make an advance directive, in order
for it to be legally valid and implemented by staff. The presumption in
law is that a patient who wants to make an advance directive has
capacity unless it can be proven otherwise. A person lacks capacity if
some mental health condition causes him or her to be unable to make a
decision whether to consent to or refuse treatment. There are three
stages to assess, if someone’s capacity is called into question:
 the patient must be able to understand information relevant to
the decision
 the patient must be able to retain that information
 the patient must be able to weigh that information in the balance
in order to make their decision.
41
197. The man had been treated for varying degrees of depression and had
been diagnosed with a borderline personality disorder since arriving at
Lincoln. The prison doctor and the consultant psychiatrist both felt that
the man had capacity to refuse treatment. However, the consultant
psychiatrist could not rule out that the man had a mental illness that
would affect his judgement.
198. The prison doctor told my investigators:
“There was a prison protocol from the management of food refusal and
it’s that document that recommends two psychiatrists to certify mental
capacity and an advance directive to prevent artificial feeding.”
199. The prison doctor contacted two consultant forensic psychiatrists from
the medium secure unit, for their expert opinion. The two psychiatrists
attended the prison together and jointly assessed the man. They found
that he had a depression that warranted urgent treatment and made it
difficult to assess whether he could effectively weigh information in the
balance. The second forensic psychiatrist told my investigators:
“I mean it was quite clear that my colleague and myself had the view
that he had an agitated depression, he needed treatment. Obviously
the issue of not eating and drinking was judged to be part and parcel of
his depression and my colleague, again who you may well interview at
some later stage, I think had a fairly robust view which was that treating
him against his wishes if necessary by force feeding would be justified
under common law and under the Mental Health Act if necessary but
as it transpired that didn’t prove to be necessary when he was
transferred he did eat and drink, albeit to various degrees.”
200. The Governor sought advice from the Prison Service and the Legal
Adviser’s Branch at the Home Office about what action she needed to
take, given the man’s circumstances. During interview, she could not
remember who she spoke to at the Prison Service or at Treasury
Solicitors. She expressed her extreme frustration at the lack of speedy
advice and support. She told my investigators:
“I was not supported and had to work extremely hard to get any kind of
sensible advice from anybody that would listen to me.”
201. When faced with such an extreme case as this one, Governors must
have ready access to advice about how to effectively discharge their duty
of care.
The Prison Service should review the role of the regional Safer
Custody Advisers to ensure that they provide relevant and timely
advice in sensitive cases.
42
The Prison Service and the Department of Health should prepare a
briefing about the pathway of care for a prisoner who is determined
to die through food refusal.
Procedure under the Mental Health Act 1983
202. The decision to detain the man was made after the consultant forensic
psychiatrists assessed him as suffering from severe depression in
January 2005. The man was detained in accordance with the Mental
Health Act. The clinical review says:
“… the decision to detain him for assessment under s47 and s 28 of
the Mental Health Act was based upon the opinion of the consultant
forensic psychiatrists that the man was suffering from severe
depression of a nature and degree which made it appropriate for him to
be detained in a hospital for medical treatment and that he was in
urgent need of such treatment.”
203. The key worker said that the man was not happy about being detained
under the Mental Health Act. She felt that no one had fully explained the
sectioning process to him and the reasons that he was being detained.
She told my investigators that she explained to him why he was being
detained and what would happen to him. She said that once he
understood what was happening to him, he accepted the situation.
204. The clinical review team say of this decision:
“It would not have been clinically appropriate or in the man’s best
interests for him to remain within the prison setting at this time and in
light of his assessed need for treatment within a hospital setting.”
205. The prison doctor said that the man was angry when he was told about
being detained under the Mental Health Act:
“Prison tends to disempower people anyway and really the only power
that sometimes people are left with is the power to choose to eat, drink
or take medication and we were basically removing even that power
from him by placing him under the Mental Health Act and he
understood that while he was under that Act, it would be possible to
feed him against his will, so he was utterly disempowered, that would
make me angry.”
206. The prison doctor said he explained to him that the psychiatrists could
not say that he had capacity at that time and that he needed to be
treated for depression before his advance directive could be put into
force. The doctor said that, once the man understood that his sectioning
was necessary to bring about the validation of his advance directive, he
was co-operative.
43
207. I am satisfied that it was appropriate for him to be detained under the
Mental Health Act at this time. In the two days between the decision
being made to detain him and his transfer to the medium secure unit, the
matter was explained to him and he understood the process and the
reason it was being done.
Did the man’s case have to be referred to the High Court?
208. At a CPA meeting before the man’s transfer back to Lincoln, it was
agreed that at that time he had capacity. This was 22 July 2005. Upon
his return, the Governor contacted the Prison Service for urgent advice
and they confirmed that, for the advance directive to be valid, two
psychiatrists had to agree that the man had capacity at the time of
drafting. Two psychiatrists were asked to assess the man’s mental
capacity again to determine whether the advance directive was valid. On
2 August, the two psychiatrists assessed him. One psychiatrist felt that
the man had the capacity to make a valid advance directive. The other
psychiatrist assessed him as unable to weigh information in the balance.
It was the West Lincolnshire PCT and their legal representatives that
suggested his case be referred to the High Court. They and the Treasury
Solicitors on behalf of the Home Office petitioned for a legal judgment as
to whether the man had adequate capacity to make a valid advance
directive.
209. Lincolnshire PCT said that, when the man was in the medium secure
unit, he expressed no intention to die and ate and drank a little food. It
was their view that the man’s situation had changed upon his transfer
back to Lincoln, whereupon he immediately stated his intention to kill
himself through food refusal.
210. My investigators spoke with the second psychiatrist during the course of
the investigation and he said that he did not feel the man had the ability
to weigh information in the balance during his assessment on 2 August.
He thought that his guilt and perpetual desire to ‘be with his daughter’
may have been signs of a residual depression. He said that there were
lengthy discussions between himself, the prison and legal
representatives, and the decision was made to refer the man to the High
Court.
211. All staff reported that there was a sense of relief once the High Court had
handed down its judgment. When asked whether staff found the
situation easier once the High Court judgment had been made, the
prison doctor said:
“Absolutely, there was considerable anxiety in the time before because,
as you alluded to earlier, it was unclear whether he should be
resuscitated, it was unclear how he should be treated if he were to
have an accident and there was a good deal of anxiety. After the court
in turn decreed that he was capacitous, that eased very considerably.”
44
212. Although it was unfortunate that the man’s case had to be referred to the
High Court, it provided staff and the man with the clarity they needed.
The man was described as “euphoric” after the High Court decision. I
think that, balancing the rarity of the situation and the lack of certainty
about his capacity, there was no option but to refer his case to the High
Court for confirmation of the legal status of the advance directive.
Facilities in the healthcare centre and the management of the man’s
food refusal
213. The man was located in the healthcare centre for the great majority of his
time in Lincoln. During an interview with the Head of Healthcare, she
was clear that the healthcare building at Lincoln was not fit for purpose.
The clinical review team describe the facilities within the healthcare
centre as “totally inadequate”. She told my investigators that, since
taking over the delivery of healthcare in April 2004, the PCT was
responsible for providing necessary equipment while the Prison Service
retained responsibility for the building or ‘the estate’. The Head of
Healthcare was clear that she had experienced no problems with
obtaining equipment. She said that Prison Service staff have to
electronically test the equipment and they were prompt and efficient in
doing so. However, she said that she has made representations about
the inadequacy of the healthcare building. She said she had discussed
her concerns with the Chief Executive of the PCT and brought to her
attention that she considered the building to be dangerous for health and
safety reasons and because it had failed its infection control audit.
Having said this, Lincolnshire PCT felt that the conditions in the
healthcare did not affect the man’s treatment.
214. Lincolnshire PCT had agreed to spend a substantial sum of money to
improve the fabric of the healthcare centre at Lincoln. In order for the
work to be completed, a similar sum had to be provided by the Prison
Service. My investigators were told that, at the time of the investigation,
the work had been postponed because the Prison Service was not able
to offer the necessary funds for the refurbishment. While I appreciate the
pressures placed on the Prison Service’s resources, I am very
disappointed that the refurbishment of an inadequate healthcare facility
that can be described as “dangerous” was not prioritised.
215. The man was in a gated cell in the healthcare centre. He described it to
staff as a “goldfish bowl”. The cell had a Perspex door and was
overlooked by another cell located directly opposite. On two occasions,
he complained about the prisoner located opposite looking into his cell.
It is recorded that, on both of these occasions, the prisoners were moved
to a different cell within hours. The Healthcare SO said that he thought
“more effort was made because of him [the man], because we knew it
was going to be a long term thing.”
216. The man elected not to move to the high dependency unit, which is
situated at the far end of the healthcare centre and which would have
45
afforded him more privacy. His key worker described how the man was
so desperate for privacy that he would often spend 20 minutes on the
toilet in the morning because it was the only time he had by himself. The
high dependency unit was the only alternative to the gated cell.
However, the prison doctor said he did not want to move principally
because he liked his room. He added:
“He was a strange character and cared about the staff who were
looking after him and he didn’t want the constant watch officer to be
sitting on a high chair looking in through a window, he much preferred
them to be across a gate from him.”
217. When I opened this investigation, staff kindly took me to see the cell
where the man spent most of his time at Lincoln. I shared the view that
the location of the gated cell gave him no privacy. However, given his
refusal to move to the high dependency unit, I can see that staff had little
option but to keep him safe in that cell.
218. It is very rare that prisoners die as a result of refusing food. In fact, only
three other prisoners in the last 15 years have died in this way. Prison
Service guidance says that prisoners refuse food either as a means of
protest or as a result of a serious mental disorder. However, the man
told staff from the outset that he wanted to die through food refusal. In
January 2005, when he first mentioned his intention, the prison doctor
explained to him what would happen to him as a result of such actions.
219. If a prisoner uses food refusal as a means of protest, or a bargaining
tool, Prison Service guidance suggests that staff must try to find
“constructive ways to meet the underlying need”. The man expressed no
ulterior motive. He told staff that he simply wanted to die in order to be
with his daughter. The man did not fall within the ‘usual’ category of food
refusal as protest.
220. Prison Service guidance on food refusal places the responsibility with
individual prisons to decide whether to initiate suicide prevention
procedures for prisoners refusing food. The ACCT procedures involve
regular multi-disciplinary reviews of a prisoner’s circumstances, to
promote communication about the reason for the food refusal and to
identify actions which may dissuade a prisoner from refusing food
further.
221. However, the man repeatedly told staff that he intended to die. I think
the ACCT process gave staff who came across him in different
capacities the opportunity to share their views about how his care could
best be managed. One example of this in practice was when staff who
carried out constant supervision on him were concerned that he was
anxious about money and bored. Healthcare staff suggested that he
start a job constructing blank medical records. This is a good illustration
of the ACCT process working to improve communication between
different groups of staff and care planning. It is unfortunate that the man
46
declined to attend so many of the reviews. This meant that he did not
have as much input into his care as he could have done.
222. The man wanted to die through his food refusal. I believe his food
refusal was appropriately managed through ACCT suicide prevention
procedures and improved the multi-disciplinary care planning and
communication.
223. When it had been agreed that the man had capacity and therefore fell
within the minority of cases of prisoners intending to die through food
refusal, the rarity of his case meant that there was little guidance for staff
on the day to day management of his care. For example, legal advice
was sought as to whether staff should continue to place meals in his cell
every mealtime. Legal advice was that this might constitute “inhuman
and degrading treatment” and it was immediately stopped.
224. The prison doctor spoke to the man every day that he worked at Lincoln
prison to ensure that he understood the consequences of his food
refusal:
“It’s a question of explaining that food refusal would eventually lead to
his death by organ failure, that he might be in considerable pain
because of muscle wasting, explaining that his advance directive
prevented us from treating him to prolong or save his life but his
advance directive allowed us to treat him for comfort and dignity as
best we could and I told him regularly in the last four weeks that in my
opinion he was now doing irreversible damage so he was very well
aware of that. He was seen every day by a doctor…”
I commend the sensitive management of the man’s food refusal in
the healthcare centre.
225. Although I think the ACCT process was the most effective way to
manage the man’s care, I am concerned that people who sat in on case
reviews did not always know him. Case reviews are multi-disciplinary in
order to ensure that staff have a full picture of the prisoner’s risk factors.
It is difficult to understand what contribution a member of staff who had
not had contact with a prisoner could have made to the ACCT review. It
is also important that those who attend case reviews are empowered to
alter a prisoner’s care plan. Staff interviewed by my investigators did not
feel able to alter his observation status and said that the meetings
became more of an update about his condition. I understand that
healthcare staff did not feel able to override a senior management
decision about whether his observation status could have been reduced.
(I say more about this in the following section of this report.)
226. I commend the work of the Safer Custody Group (then part of the
National Offender Management Service, now part of the Prison Service)
who are about to pilot a training package in how to work with prisoners
who are subject to constant supervision. The training package
47
encourages meaningful involvement rather than simply monitoring. It
also requires staff to try to engage a prisoner in activities that reduce the
amount of time they spend being observed in a gated cell. For example,
staff might try to encourage the prisoner to attend education or receive
tuition in their cell.
227. As well as the ACCT process, nursing staff ran a care planning process
and there were also multi-disciplinary notes recording the man’s time at
Lincoln. While I cannot fault the committed approach to recording and
planning his care at Lincoln, such a prolific amount of paperwork might
lead to confusion or important observations being lost.
The Governor and PCT should consider streamlining the paperwork
required for a prisoner determined to die through food refusal, so
that all staff involved in an individual’s care have an overview of the
prisoner’s condition and health and social needs.
Constant Supervision
228. Constant supervision is where a prisoner is supervised by a designated
member of staff on a one-to-one basis, remaining within sight at all
times. It is most commonly used when there is an immediate and
imminent risk of suicide or serious self-harm. There are only two places
within the healthcare centre at Lincoln where a prisoner can be
constantly observed – a gated cell with a perspex door or the high
dependency unit. The man was located in a gated cell in the healthcare
centre on 13 November 2004. Excluding the six months that he spent in
the medium secure unit, he was subject to constant supervision from
September 2004 until his death in February 2006.
229. Prison Service Order (PSO) 2700 sets out instructions for prisons caring
for prisoners at risk of suicide and self-harm. The section concerning
prisoners on constant supervision describes constant supervision as “a
temporary measure, intended to manage acute suicidal crisis”. The
Order stresses the importance of staff interacting with a prisoner, rather
than merely observing their well-being.
230. At paragraph 4.2.2, the PSO says:
“In those exceptional cases where this level of crisis lasts beyond 24
hours, further case reviews must be held at least three times during
that establishment’s core working day. Acute suicidal crisis is usually
temporary and the aim of the case reviews should be to reduce the
level of supervision progressively as the prisoner’s condition improves.
The temporary nature of this level of supervision must be reflected in
the support plan.”
231. In fact, the Healthcare SO told my investigators that constant supervision
was “very rare” at Lincoln. He went on to say: “normally it’s very short-
term, sort of over emergency or some sort of crisis in somebody’s life.”
48
However, the Healthcare SO went on to reflect that the man was on an
“artificial constant watch”. He said that staff felt obliged to “cover their
backs” by keeping him on constant supervision.
232. When a prisoner is on constant supervision, staff should hold reviews
every four hours, or at least three times in a core working day. As stated
above, the purpose of a case review for a prisoner subject to constant
supervision is “to reduce the level supervision progressively as the
prisoner’s condition improves”. Staff at Lincoln held case reviews
weekly. A number of staff who took part in the man’s case reviews told
my investigators that the meetings were held but no active discussion
took place about how to reduce his observation level. The staff attending
the case reviews felt that the matter was out of their hands. The member
from Probation described it as “a given” that the man should remain on
constant supervision.
233. My investigators spoke to the Governor about the decision to keep the
man on constant supervision for such a prolonged period. The Governor
said that she did not have any direct involvement in the man’s level of
supervision. She said that she understood the decision would have been
made by the case review team and reviewed by them on a weekly basis.
She knew that the prison doctor was overseeing the man’s care, and she
passed on her concern that he had to be cared for as a “very, very high
risk and we need to be careful because he’s going to do it”.
234. The prison doctor told my investigators that he felt the constant watch
was “intrusive”. During interview, he said:
“The man gave his word to me on several occasions that he would not
attempt to end his life by any other means than starvation.”
235. The prison doctor said he felt “he had no other option” than to keep him
on constant watch. He said that he was advised by governors at the
prison that Safer Custody Group had told the prison “get him to court
alive”. The murder of his daughter had high profile media coverage and
the doctor understood that, if the man were to die before his trial, the
prison and the Prison Service might be open to some criticism.
236. My investigators met with representatives from the Safer Custody Group,
in London. Safer Custody Group told my investigation team that they
were kept informed of the man’s case and were copied into a key
submission in August 2005 that confirmed that he had the capacity to
refuse treatment and therefore to elect to die by food refusal. They were
not aware of the length of time that the man was subject to constant
supervision. There is no record that advice was given to anyone at
Lincoln prison by Safer Custody Group or by the regional Safer Custody
Adviser for the East Midlands.
237. Bassetlaw PCT’s clinical review found:
49
“As long as the patient did not have the right to refuse food, he
appeared to be a high suicide risk. It was therefore entirely appropriate
that he was under constant observation until the judgment. As this was
a prolonged period, we felt it would have taken a brave decision
following establishing capacity, given the profile of the case, to reduce
the watch status. This was despite the fact that the patient appeared to
be at a reduced risk. We cannot say for certain, but if capacity had
been established earlier it may have been made easier to reduce the
status. Either way, it would have helped his management in this case.”
238. Lincolnshire Primary Care Trust responded that at no time did the man
not have the right to refuse food. However, because of his severe
depression he was assessed as not having the ‘capacity’ to make that
decision with a view to ending his life.
239. As discussed above, Prison Service guidance on food refusal suggests
that an ACCT Plan “may allow for a better continuity of care”. I think that
the man was appropriately managed through the ACCT system which
encourages a multi-disciplinary approach to the support of an at-risk
prisoner. I understand that the man expressed his determination to die
and therefore could be assessed as an ongoing acute risk of suicide.
240. Although the man had stated that he would not take his own life by
means other than food refusal, it would have been unwise to rule this out
from an operational management perspective. It would have been
impossible to exclude the possibility that he might have awoken one
night in severe pain and decided to take his life by much quicker means.
The man clearly wanted to die and was extremely determined to do so.
This determination did not seem to waiver the closer he got to the end of
his life. He was a high profile prisoner because of the nature of his
alleged offence. Whether senior managers at the prison had been
explicitly told by Safer Custody Group to “get him to court alive” or not, I
can fully understand the feeling that the prison had no option other than
to keep him under constant supervision. As the clinical review has
highlighted, he had already been under constant supervision for a
prolonged period before it would have ever been appropriate to consider
reducing that level of monitoring. It would have been a brave decision to
have done so and one which, in my view, would have to have been
supported by the prison doctor, the PCT, the governing Governor, Safer
Custody Group and the Area Manager.
241. A review of PSO 2700 is underway led by Safer Custody Group. As part
of the review, the PSO section on constant supervision is being
strengthened to provide clearer guidance to prisons on the management
of acutely suicidal prisoners. The guidance has been drafted because
concern has been raised by Governors and PCTs that a large number of
people are being placed under constant supervision. It encourages staff
to think of other alternatives to constant supervision, for example location
in a care suite.
50
242. The revised Order also has a tiered approach to caring for a suicidal
prisoner. Constant supervision should only be used as a crisis
management tool. Safer Custody Group have introduced a secondary
system that is triggered after a prisoner has been under constant
supervision for eight or more days, when the prisoner is considered to be
“particularly challenging” for the purpose of the Order. At that stage, an
‘enhanced’ case review team should meet, with multi-disciplinary
representatives at a higher level of operational manager than a typical
case review team. The case review team should then identify a single
member of staff who becomes that prisoner’s key worker. Between
them, the case review team and the key worker must devise a plan that
encourages the prisoner to break his behaviour pattern and reduce the
level of observation.
243. I am pleased to learn of the Prison Service’s plan to reinforce that
constant supervision should only be used as a short-term, crisis
management measure.
In cases of prolonged constant supervision, a high level care
planning meeting should be convened involving, where necessary,
the Governor, Area Manager, Safer Custody Group, Primary Care
Trust, and senior healthcare staff, including mental health
professionals.
244. In the man’s case, I am satisfied that senior managers within the prison
and the PCT were made aware of his condition and played a role in the
care planning process.
Role of the Observer in Constant Supervision
245. Bassetlaw’s clinical review team considered the role of the observer in
constant supervision as part of their review. Almost all of the prison
officers who carried out the constant supervision told my investigation
team that they had volunteered to do so. One officer said that she began
to feel uncomfortable with the supervision towards the end of the man’s
life when he became frail and looked to be in pain. She said that she
easily removed herself from the constant supervision list. It is clear from
the ACCT records that there were a select few officers who did repeated
shifts with the man. My investigators spoke to several of these officers.
While some described him as a private man who did not openly share his
thoughts with them, others said that they often chatted with him about his
personal history and his decision to end his life.
246. Department of Health guidance, ‘Mental Health Observation, including
constant observation – Good working practice for healthcare staff
working in prisons’, refers to the management of prisoners who have an
assessed mental health problem or who are awaiting assessment and
require formal observation. This guidance would have only applied to
the man in the brief time he was at Lincoln before he was detained under
the Mental Health Act. However, this document contains some useful
51
guiding principles for staff managing a prisoner with a prolonged acute
risk of attempted suicide. It suggests that prisoners can either be
monitored from arm’s length or within eyesight. The least intrusive level
of observation should always be adopted to preserve a prisoner’s dignity
and privacy. The man was observed within eyesight at all times that he
was under constant supervision. Staff sat outside of his cell with the
Perspex door between them and the man. Staff engaged him in
conversation and there are many insightful notes of conversations
between the observing officer and the man in his ACCT record.
247. The clinical review team concluded:
“We discussed the benefits of having constant observation, in terms of
building relationships with the staff looking after him and have made
brief reference to these. We did not feel it was an appropriate function
of the constant watch to perform specific therapeutic actions and did
not therefore include this in the review. Our recollection is we did feel
the benefits of building a relationship were similar, whether there was a
healthcare officer or a discipline officer. We also felt there were other
ways to build these relationships and surely a patient who was based
on the healthcare wing for many months with frequent contact would
gain this, without the need for constant observation. In short, we
thought this would be gained either way.”
248. Lincolnshire PCT go further to suggest that, although a member of
discipline staff may not be qualified to deliver therapeutic interventions,
they could request the assistance of healthcare staff at any time.
249. Although the prison doctor told my investigators that he felt the constant
supervision was intrusive for the man, he acknowledged that the man
began to enjoy their company:
“… it must have been unpleasant although he enjoyed talking to the
constant watch and they became his companions really.”
250. The Department of Health’s guidance says that staff who perform
constant supervision should “be appropriately briefed about the prisoner,
including their history, background, specific risk factors and particular
needs. Prison officers undertaking observation duty should be
considered to be a part of the care team…”
251. On balance, I agree with the clinical reviewers that constant supervision
can be used as a positive way to engage and support a prisoner,
whether by healthcare staff or discipline staff. I have seen sufficient
evidence to conclude that staff performing the observations were
appropriately skilled in engaging with the man and encouraging him to
talk about his worries with them. All staff received a handover from the
preceding shift and all felt well briefed about his condition. Staff felt able
to ask healthcare for support. This is illustrated by one of the Physical
Education Officers (PEO) on the morning that the man died who
52
acknowledged the great assistance that he received from a nurse after
the man had fallen from the toilet. I think that the man’s care is a good
example of how prison officers and healthcare staff can work together to
care for at risk prisoners.
Transfer between Lincoln prison and the Hospital
252. Once the High Court decision had been made, Lincoln chose to adopt
the Liverpool Care Pathway, intended for patients who are at the end
stage of their lives. This palliative care model focuses on the
psychological and spiritual needs of the patient. It is meant to care for
patients who are in the last 48 to 72 hours of their life. The man was not
at that stage when the pathway was implemented, but healthcare staff
adapted the documentation to meet his needs. As part of the Liverpool
Care Pathway, practitioners are encouraged to discuss with the patient
their preferred place of care and death.
253. The High Court handed down its judgment on Friday 12 August 2005.
The man’s advance directive was valid and he had the capacity to
choose to refuse food and medication. On Monday 15 August, a third
strategic case review was held, attended by members of the prison’s
senior management team, the PCT Medical Director and the Head of
Clinical Governance, healthcare staff from the prison, including the
prison doctor and the PO, and staff from Lincolnshire Hospitals Trust.
The man did not attend that meeting. Security measures were discussed
and agreed for the Hospital to put in place so that the man would be
protected from press intrusion. The prison doctor pointed out that,
although it was “technically possible” to care for him within the healthcare
centre, “the prison and healthcare staff did not want this”. At that
meeting, it was agreed that the man should be transferred from Lincoln
to the local hospital “when staff saw evidence of confusion”. However,
this agreement was made a long time before the man met the criteria
and was transferred. No further meeting was held to review this
arrangement, although there is evidence of continuous liaison between
the healthcare centre and the hospital about his condition.
254. The man initially expressed a desire to die in hospital. When asked to go
to the local hospital on 16 February, he did not want to go because he
would not be able to smoke as much as he would like. The hospital was
notified that the man wished to delay his admission. He refused again
on 21 February. On 23 February, he agreed in principle to transferring to
the hospital in two days’ time.
255. This arrangement stayed in place until the man was eventually
transferred on 25 February 2006. Staff at Lincoln liaised with the
hospital to plan a side room for him when he went there. Hospital staff
were briefed and updated about his condition as the months passed and
all staff were made aware of the advance directive.
53
I commend the proactive approach to planning the man’s transfer
to hospital, which avoided delay and possible security breaches
and ensured dignified continuity of care.
256. The man died at the local hospital. He was transferred around three
hours before he died. The man seemed to have mixed feelings about
being transferred to hospital towards the end of his life. An officer told my
investigators that the man “was very worried about” transferring to
hospital. She said that his main concern was that he would not be
allowed to smoke. Originally, he had agreed to go to hospital when his
condition deteriorated because he understood he would be allowed to
smoke there. The officer said:
“The next time I came [to do constant supervision shift] he said that the
smoking had been overruled, he wouldn’t be allowed to sit and smoke,
‘cos he was a smoker wasn’t he, heavy smoker and that to him was
like, ‘oh I am not going then’.”
257. Other officers said that the man did not seem to mind being transferred
to hospital. The prison doctor said he spoke to him on numerous
occasions about his preferred place of death. The doctor told my
investigators that he was happy for the man to die in prison if that was
what he wanted. The doctor and the governing Governor discussed the
matter “at length”. The Governor told my investigator that if the man had
said that he did not want to go, then she would not have insisted on him
transferring to hospital. However, she said that ultimately she did not
want him to die in prison for two reasons. First, she said that she was
concerned “just in case there was something else that the services
available could do”. Secondly, she was worried about the effect that
watching a prisoner die in prison would have on her staff. The doctor
said that members of the management team at the prison felt that the
man should be transferred for “perhaps political reasons which I find
entirely understandable”.
258. The man was transferred to hospital hours before he died. He agreed
with the doctor that he would be transferred to hospital and the doctor
said that “he was quite happy to be transferred on the day that I
transferred him”. An officer said that he “did not think that [the man] was
in the frame of mind because of his condition to realise what was going
on.” The officer said that the man did not react at all when the
ambulance arrived and described him as being “half asleep”.
259. Whatever their own preference, the Governor and the prison doctor
agreed that the man would not be transferred against his own wishes. In
fact, it is clear from his advance directive that he wanted to die in hospital
not in prison.
I commend the involvement of the patient in determining his own
place of care and death.
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Staff support
260. During the man’s life, staff in general felt well supported by the
management team at HMP Lincoln. Healthcare briefings were held
regularly and there is evidence of communication at every significant
change of the man’s condition or care. Nearly all of the staff who carried
out constant supervision shifts were volunteers. An officer told my
investigators that, as soon as she felt uncomfortable doing the shifts
because of the man’s deteriorating condition, she was able to opt out.
261. One prison officer reported that he felt he was put in a difficult position
towards the end of the man’s life when his frailty meant that he needed
more support to perform his daily functions. The clinical reviewers
suggested that, when his physical condition deteriorated and he was
prone to falling, constant supervision might have been more
appropriately carried out by healthcare staff. I agree that this might well
have been more appropriate.
262. The key worker felt that she was not well supported by the healthcare
management team. She felt that the PCT was “intrusive” and said that
she had raised the matter for the attention of her line manager.
263. The prison doctor and the Head of Healthcare said they felt well-
represented in Lincoln’s management team. The doctor reported that he
felt he could speak with the Governor any time that he had a concern.
264. It seems to me that, overall, staff felt well supported and clear about their
role in the man’s care. In this respect as in others, there is much to
commend.
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RECOMMENDATIONS
I agree with the recommendations made in Bassetlaw’s clinical review.
Clear accountability for ensuring working conditions [in Lincoln’s
healthcare centre] are safe and fit for purpose are required.
The recommendation was accepted. Refurbishment plans are agreed,
awaiting funding and start date.
When a prisoner is being returned from prison after a time in a mental
heath secure unit under the Mental Health Act, a discharge process
should be agreed by all relevant parties, to enable a care pathway plan
to be drawn up as soon as possible.
The recommendation was partially accepted locally. The Prison Service
responded as follows:
“This recommendation is directed largely at the discharging mental
health secure unit and outside the jurisdiction of the Prison. However,
please note the comments of one of Consultant Forensic Psychiatrists
who felt that the discharge process was effectively handled in this
case.”
While I appreciate that the role of the discharging mental health unit is crucial,
the recommendation was directed at the Prison Service because community
health services are outside of my terms of reference. The investigation team
did not have access to clinical records or consider the care that the man
received at the medium secure unit. I am pleased that the Prison Service has
accepted the recommendation.
A patient who under long-term constant supervision must not be held in
a cell where he may be watched from a cell opposite.
This recommendation was partially accepted. The Prison Service said:
“Wherever possible, locally, this would be complied with however it
would be dependent on prisoner numbers in the healthcare centre.
Across the prison estate this would not always be possible due to
resource and security issues. The revised PSO 2700 which is now
available on the Prison Service Intranet provided guidance on
preserving prisoner dignity during constant supervision.”
Consideration should be given to making the high dependency unit
suitable for constant supervision.
This recommendation was not accepted. The Prison Service responded,
“there are privacy issues for those prisoners requiring palliative care which
would be compromised by these alterations.”
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There should be a clearly documented decision with the patient’s
preferences of where they want to die stated. Any reasons these cannot
be complied with (eg security or ability to care) should be stated. This
situation was appropriately dealt with in this case.
The recommendation was accepted. The Prison Service responded:
“Locally already complaint. The practice in this case was commended
under good practice. Nationally, draft food refusal guidelines being
drawn up by Offender Health, state that the wishes of patients should
be under constant review. End of life care should occur in line with
NICE guidelines.”
While not a key point, some clarity on the role of the observers in these
situations [long-term constant supervision] is required. As the patient
becomes frailer in the latter stages it may have been more appropriate to
use a member of healthcare staff.
This recommendation was accepted. Response as follows:
“The revised PSO 2700 offers guidance for all staff about how to
undertake a constant supervision. A period of constant supervision
can only be authorised by a doctor or nurse or by a Duty Governor (in
consultation with a doctor or nurse). A requirement of ACCT, which
would be opened for every prisoner under constant supervision, is that
regular multi-disciplinary case reviews are undertaken and PSO 2700
recommends that a doctor or senior nurse be included. The care of the
prisoner would be discussed at these reviews including the need for
observations to be undertaken by residential or medical staff according
to the individual need.”
I make the following four additional recommendations to improve prisoner
care:
The Prison Service should review the role of the regional Safer Custody
Advisers to ensure that they provide relevant and timely advice in
sensitive cases.
This recommendation was accepted. The Prison Service responded:
“The role of the Area Safer Custody Adviser (ASCA) is regularly looked
at by Area Managers and Safer Custody Group, and this
recommendation has been discussed at the SCG/ASCAs meeting in
September 2007. ASCAs provide timely advice and guidance to Area
Managers, Governors (Directors of private prisons) and staff on a range
of safer custody matters. Prisons lead on the management of individual
cases but the ASCAs’ advice is sometimes sought and given.”
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The Prison Service and the Department of Health should prepare a
briefing about the pathway of care for a prisoner who is determined to
die through food refusal.
This recommendation was accepted. Draft food refusal guidelines are being
drawn up by Offender Health at the Department of Health.
The Governor and PCT should consider streamlining the paperwork
required for a prisoner determined to die through food refusal, so that
all staff involved in an individual’s care have an overview of the
prisoner’s condition and health and social needs.
This recommendation was not accepted by the Prison Service, who
responded: “There is no delegated authority to deviate from national policies
on the management of prisoners subject to ACCT documentation.
The PCT wrote the following, in their response to the draft report:
“The PCT acknowledges that documentation for the ACCT process and
documentation held by healthcare pertaining to a patient’s risk of self
harm can duplicate each other in some respects. However, the multi-
disciplinary notes which form the patient’s medical records are held in
medical confidence. It would therefore be inappropriate to include the
level of detail which may be reflected within them regarding mental
health status, within the ACCT documentation which is more freely
available to a range of staff. For this reason, the PCT does not feel
that this recommendation is appropriate.”
In cases of prolonged constant supervision, a high level care planning
meeting should be convened involving, where necessary, the Governor,
Area Manager, Safer Custody Group, Primary Care Trust, and senior
healthcare staff, including mental health professionals.
This recommendation was partially accepted. In response, the Prison Service
wrote the following:
“Constant supervision is normally used as a temporary measure in
order to assist a prisoner during a period of suicidal crisis (usually no
more than 72 hours). The man’ case is extremely unusual and
presents many previously unconsidered issues. Safer Custody Group
is always willing to give advice to prison staff about the management of
at risk prisoners, as happened in this case.”
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GOOD PRACTICE
Overall, the management of the man’s care presented a considerable
challenge to senior managers, healthcare staff and officers at Lincoln. The
prison worked hard to protect his rights and preserve his dignity until the end
of his life. I have identified the following areas of good practice:
I commend the sensitive management of the man’s food refusal in the
healthcare centre.
I commend the proactive approach to planning the man’s transfer to
hospital, which avoided delay and possible security breaches and
ensured dignified continuity of care.
I commend the involvement of the patient in determining his own place
of care and death.
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