Individual at Isle of Wight

Circumstances surrounding the death of a man, a former
prisoner at HMP Camp Hill, in February 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2009
This is the report of an investigation into the death of a man who died from natural
causes at his family home in February 2008. He was 64 years old. He had been
released on temporary licence from HMP Camp Hill before being granted release on
compassionate grounds by the Secretary of State. 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.
Before his death, the man’s family had already contacted my office as he wanted to
raise a number of concerns. These centred on the care he had received whilst in
prison and the events surrounding his release from custody. My Terms of Reference
provide authority to investigate, to the extent appropriate, the deaths of those
released from custody (either temporarily or permanently). The death of the man is
one such case. I would like to add my personal condolences to those already
expressed to his family on behalf of this office by my senior family liaison officer..
The investigation was undertaken by one of my investigators. I am grateful for the
assistance he received from staff at HMP Camp Hill. In particular, I would like to
thank the Governor and his staff for all that they did to assist my investigation. I
would also like to thank the Chief Officer of the relevant Probation Area, and his staff
for their assistance.
The man was diagnosed with terminal cancer in October 2007 and was granted
release on temporary licence two months later. In January 2008, he moved from the
prison’s local hospital to a local hospice. He then moved to another hospice a week
later. The man was granted release from custody on compassionate grounds on 13
February 2008. He returned to the family home a week later and died on 25
February.
The initial conditions of the man’s compassionate release from custody meant that
he had to stay within the grounds of the hospice and he was not allowed to return to
his family home. This came as a surprise to him and his family. After additional
work was carried out by staff of the relevant probation area, the conditions of the
licence were revised and he was allowed to return to his home. It appears that
information about the initial conditions of his release was not fully explained to him
and his family. This led to a very difficult relationship between the Probation Service
and the man, and his family. There was also poor communication between staff
from a second probation office and Camp Hill leading up to the man’s release from
custody. I have made a recommendation about improvements to communication
between the Prison and Probation Services.
A doctor was appointed by the Primary Care Trust to undertake a review of the
man’s clinical care and I appreciate his assistance. The clinical reviewer raises a
number of learning points that the prison health partnership will need to consider
seriously. I trust the Primary Care Trust in partnership with HMP Camp Hill will
develop an action plan to address them in a timely manner. I must apologise for the
delay in issuing this report.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2009
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SUMMARY
The man was born in 1943, he was 64 years old when he died at home with his
family on 25 February 2008. He died from natural causes as a consequence of a
metastatic gastric adenocarcinoma (a malignant growth of glandular tissue in the
stomach).
The man was sentenced to four years imprisonment at Crown Court in April 2007.
He had been initially remanded into custody at HMP Lewes on 6 November 2006.
He transferred to HMP Camp Hill on 1 May 2007.
During his first reception health screen on 6 November 2006, he saw a doctor about
problems with his prostate. It was also recorded that he had previously been
diagnosed with emphysema and suffered from depression.
On 3 February 2007, he collapsed while his family were visiting him at Lewes. After
he was seen by a prison doctor he returned to the visits hall.
Following a blood test on 2 July, the medical officer at Camp Hill suspected the man
might have gastrointestinal cancer. A referral was made to the local hospital, and he
was seen at the hospital on 19 July 2007. As the possibility of cancer was
considered to be high, it was planned that a colonoscopy (telescopic examination of
the large bowel) would be first carried out, followed by a computer topography (CT)
scan of his abdomen.
The man attended the local hospital for a colonoscopy on 16 August. At this
examination no cancer was detected but he was diagnosed with diverticulitis. (The
diverticulum is a small sac-like structure that sometimes forms in the walls of the
intestines. Diverticula can trap particles of food and become very inflamed and
painful; this condition is called diverticulitis.)
He had a CT scan of his abdomen on 4 September. The results of the procedure
suggested upper gastrointestinal (stomach) or pancreatic cancer. On 23 October,
the man was told he had cancer and was informed that his prognosis was very poor.
A course of palliative chemotherapy began.
He was admitted to the local hospital on 11 December. Whilst he was in hospital, a
bedwatch was carried out by prison staff. The initial security risk assessment was
that handcuffs were to be used and two officers needed to be at his bedside. After a
further risk assessment it was decided that handcuffs were no longer to be used and
the escort was reduced to one officer. A final revision of the risk assessment led to
the man being allowed to stay in hospital without an escort. He was also given a
mobile telephone by his family so that he could keep in contact with them and the
prison. His family were allowed to visit him whilst he was in hospital.
On 14 December 2007, as the man’s life expectancy was a matter of months, he
was released on temporary licence (ROTL). He was transferred to a local hospice
on 18 January 2008, before moving the following week to a second hospice nearer
to his family. An exclusion zone was created around the area where the victim of the
man’s crime still lived. The conditions of this exclusion zone were that the man was
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to remain within the grounds of the second hospice and he was also not allowed to
contact his victim.
The man was granted release on compassionate grounds by the Secretary of State
for Justice on 13 February. However, the conditions of his compassionate release
from custody came as a surprise to both him and his family. He had to remain within
the grounds of the hospice and was still not allowed to enter the exclusion zone
although his family home was within the zone. The family had expected that he
would be immediately released from the hospice and be able to return to the family
home. Staff at the local probation area explained the conditions of his licence.
During the following week probation staff reviewed the conditions of his licence so
that he could enter a revised exclusion zone which included the family home.
The man returned to the family home on 21 February 2008. During the following
weekend his condition deteriorated and he passed away at 10:15pm on 25 February
in the company of his family.
The clinical review carried out by an appointed doctor and a panel of his colleagues
identified issues relating to the care for the man. The clinical review concludes that
the care he received whilst in custody was not comparable to what he would have
received in the community. The review also highlights areas of practice that could
be improved. The review makes a number of recommendations for service
improvement and I have endorsed six of them. I believe it is important that the
prison health partnership consider the findings from this report and develop an action
plan to address these learning opportunities. I have also made a specific
recommendation about improving communication between Camp Hill and the
probation area.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 13 March 2008 when my investigator issued
notices announcing the investigation to both staff and prisoners. The notices
included an invitation to those who wished to contribute to the investigation to
make themselves known to him. One prisoner asked to see him. My
investigator also studied all relevant probation and prison records relating to the
man. These included his main prison record and his medical records.
2. My investigator visited Camp Hill on 25 April and discussed aspects of the
man’s treatment with both staff and prisoners. He interviewed the Head of
Offender Management and an officer. My investigator also interviewed two
prisoners who had both shared a cell with the man. They were able to provide
background information concerning him and his care whilst in custody. My
investigator also interviewed two members of staff from the relevant probation
area. These staff had dealings with the man and his family after he moved to
the second hospice.
3. The Primary Care Trust (PCT) commissioned a doctor from the PCT’s Public
Health Department and a panel of his colleagues to carry out a review of the
man’s clinical care. I am most grateful to them for undertaking such a thorough
review.
4. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation and to request a copy of the Post Mortem report.
Upon completion, this report will be sent to the Coroner to assist him in his
enquiries into the man’s death.
5. In mid-February 2008, before he died, my office was contacted by the man’s
because he wanted to raise a number of concerns about the care he had
received whilst in custody. His family also had concerns about how his release
from custody had been handled. My terms of reference provide me with the
authority to investigate the deaths of those prisoners who have been released
from custody (either temporarily or permanently). Once my office had been
officially notified of his death, I decided to investigate using my discretionary
powers.
6. My senior family liaison officer and my investigator met the family to discuss
their concerns. These were:
 The family recalled that in February 2007 the man had collapsed in the visits
hall at Lewes prison. The family said that neither he nor his family were
given an explanation about what was wrong with him on this occasion.
 The family said that the man felt he did not get the care he needed from
Camp Hill’s healthcare centre because he was under the care of the prisons
local hospital.
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 The family said that there were conflicting diagnoses following the possibility
of cancer being raised. Having initially been told the man had cancer, they
were then told that it was not cancer but diverticulitis.
 The family said that there were problems with hospital procedures not being
carried out and appointments being cancelled.
 They pointed out there was an occasion whilst in hospital, after the man’s
bedwatch staff had been withdrawn, when he slipped on water, fell to the
floor and hurt his head.
 The family had concerns about the man’s medication. They said that
management of his pain control was not consistent and there were delays in
him receiving his pain medication/relief. They had concerns about the
withdrawal of his anti-depressant medication and the effect that this had.
The family pointed out that he did not get his antibiotics for a urinary tract
infection.
 They felt that he had not been supported by staff at Camp Hill on an
occasion when he had been vomiting blood.
 The family also said that they were told that Camp Hill told staff in the local
hospital that they could not cope with the man’s condition and that he should
not return to prison.
 The family also raised a concern about Camp Hill not informing them when
he was admitted to hospital.
 The family said they had been distressed by an officer coming to risk assess
the man and the hospice, and taking photographs of him as he was taken
out of the ambulance when being rushed to the hospice. Whilst they said
they understood the security issues, they felt that this was insensitive when
he could barely walk.
 The family were not happy with the treatment both they and the man
received from staff of their local probation area.
 From the family perspective, the issue of the man’s release from custody
after he moved back to their area, was not handled well and his return to the
family home was delayed. Due to the fragility of his health the family did not
fully accept the extent of the exclusion zone.
 Whilst the family had concerns about his care at Camp Hill, they were also
keen to compliment staff whom they felt had been very supportive to them
before and after the man’s death. They named the Head of Offender
Management, members of the chaplaincy and a particular officer. The family
were also extremely grateful to fellow prisoners for all they had done to care
for and support the man whilst he was ill.
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7. The clinical reviewer, the clinical review panel and my investigator have
explored the points raised by the family and I hope that this report provides
them with answers to their questions.
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HMP CAMP HILL
8. Camp Hill is a category C training prison situated near Newport on the Isle of
Wight. The prison was built in 1912 using prisoner labour from nearby
Parkhurst. Camp Hill has a varied regime with education and various offending
behaviour programmes. At the time of the investigation the prison could hold
up to 595 adult male prisoners.
9. There are nine residential units, ranging from Victorian style galleried units to
single corridor buildings. Some of the units have specific functions. St
Stephen’s holds prisoners who have reached the enhanced level of privileges.
There is also a segregation unit that can hold up to 19 prisoners.
10. Health services at Camp Hill and the other two prisons on the Isle of Wight are
commissioned by the Isle of Wight NHS Primary Care Trust. The prison’s
healthcare is clustered with HMP Albany and is provided by HMP Parkhurst.
Parkhurst provides healthcare to the 1,500 or so prisoners on the island and
has a 12 bed in-patient facility (mainly providing psychiatric treatment).
Prisoners’ medical needs are catered for by way of out-patient clinics and core
day primary nursing cover. There are three nurses on duty from 7:30am
to 5:30pm, Tuesday to Friday, and from 7:30am to 5:30pm, Saturday to
Monday. During weekends and evenings, one member of healthcare staff is on
duty. General practitioners (GPs) from Medina Healthcare, a local community
practice, attend Camp Hill for four sessions of three-hours each week.
Evenings and weekends are covered by on-call doctors from the local PCT.
There is no nursing or healthcare cover at Camp Hill during the night.
11. The most recent report of a full announced inspection by Her Majesty’s Chief
Inspector of Prisons was published in January 2007. She found that the
healthcare service at the prison offered a broad range of clinical services for
prisoners and there was good chronic disease management. However, Her
Majesty’s Chief Inspector of Prisons said that prisoners were unhappy with the
delivery of care from the doctors, dentist and optician, particularly the waiting
lists. The Chief Inspector also said that staffing levels were barely adequate
and prohibited the introduction of additional nurse led clinics.
12. In its latest report (2006-2007), the prison’s Independent Monitoring Board
(IMB) drew attention to the problem of recruitment of staff and the impact this
had on the induction of new prisoners. The report also drew attention to the
number of prisoners with mental health problems who were located in the
segregation unit whilst awaiting assessments.
13. Since 2004, my office has investigated two deaths through natural causes at
Camp Hill. There was no link between the circumstances surrounding this
investigation and the previous death at Camp Hill. There was also no link in
the recommendations made here and those in investigation reports into deaths
through natural causes at Parkhurst and Albany.
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KEY EVENTS
14. During his first reception health screen as a remand prisoner at HMP Lewes on
6 November 2006, it was noted that the man had seen a doctor about problems
with his prostate. It was also recorded that he had previously been diagnosed
with emphysema and suffered from depression. A referral was also made to
the mental health in-reach team as he told staff that he had previously tried to
commit suicide. He was allowed to keep his medication (Venlafaxine to treat
his depression and Tamsulosin for his prostate problems) in possession.
15. At around 10:10am on 3 February 2007, the man collapsed in the visits hall at
Lewes in front of his family. He told staff that he did not have any chest pain
and, after being given oxygen, he walked to the healthcare centre. He saw one
of the doctors who told him to “take things easy” and an appointment was made
to return to see the doctor on 6 February. He returned to the visits hall at
around 11:00am.
16. On 12 February, the man attended the healthcare centre as he still felt unwell.
He told staff that he thought he had either a bladder infection or kidney stones.
An appointment was made for him to see the doctor the following day. A test of
his urine was carried out when he saw the doctor. It was negative for protein
and blood.
17. The man was given enhanced prisoner status on 2 March under the Incentives
and Earned Privileged Scheme (IEPS). There are three tiers to the IEPS –
Basic, Standard and Enhanced – and the incentives include in-cell televisions,
more private cash, wearing own clothes, more time out of cell and community
visits.
18. On 11 April 2007, the man was sentenced at Crown Court to four years
imprisonment. He arrived at HMP Camp Hill as a category C sentenced
prisoner on 1 May.
19. On 2 July, following the result of another blood test, a referral was made for
suspected gastrointestinal (stomach) cancer. It was recorded on the referral
form that the man had suffered from constipation since November 2006 and
had increasing abdominal pain and tenderness. A fast track referral form was
faxed to the prisons local hospital, the following day. He was due to attend the
hospital on 5 July but this appointment was cancelled by the prison. The
reason for the cancellation was not recorded and my investigator could find no
further information about it.
20. The man went to hospital on 19 July and a sigmoidoscopy was performed to
look inside his colon. (A sigmoidoscope is a long flexible tube that can be
swallowed and allows the surgeon to see inside the body.) As the possibility of
cancer was high, a colonoscopy (a telescopic examination of the large bowel)
was to be carried out first, followed by a computer topography (CT) scan of his
abdomen.
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21. The man returned to hospital again on 16 August for the colonoscopy. At this
examination no cancer was detected but he was diagnosed with diverticulitis.
The CT scan of his abdomen followed on 4 September. The results suggested
upper gastrointestinal or pancreatic (stomach) cancer. On 13 September, a
colorectal cancer multi-disciplinary meeting decided that a liver biopsy was
necessary to clarify his diagnosis.
22. During the afternoon of 7 September, the man was seen by a senior nurse as
he had a slightly raised temperature. On 10 September, he was seen by a
prison doctor who prescribed antibiotics.
23. On 23 October, the man saw a colorectal nurse specialist at the hospital. He
was informed of the results of the CT scan. He was also referred to the
Macmillan Nursing Service as he had experienced problems with abdominal
pains.
24. A guided liver biopsy was carried out on 29 October. The biopsy showed
adenocarcinoma (a type of cancer). The man began to receive palliative
chemotherapy but suffered significant side effects which required in-patient
admission to the prisons local hospital.
25. Four days later on 2 November 2007, the colorectal nurse specialist wrote to
the Governor of Camp Hill summarising the man’s prognosis. She said that,
although it was difficult to predict his life expectancy, it was not expected to be
more than a year and possibly less if he did not respond to treatment. The
colorectal nurse specialist informed the Governor of the man’s nutritional
needs. She also confirmed her support on compassionate grounds for any
action which would assist him or his family.
26. The man went to the prisons local hospital on 6 November for an endoscopy of
his stomach. (An endoscopy is a test that looks inside the body. The
endoscope is a long flexible tube that can be swallowed. It has a camera and
light inside it.)
.
27. On 15 November, the consultant surgeon made a referral to the consultant in
clinical oncology. On 26 November, the consultant in clinical oncology wrote to
the consultant surgeon about the review he had carried out with the man the
previous day. He said that the man remained rather weak and tired with some
intermittent abdominal pain and vomiting. He confirmed that the man wanted to
try palliative chemotherapy again. He was aware that this would not cure his
cancer but it might improve his symptoms and prolong his life. The consultant
in clinical oncology concluded that the man’s life expectancy was in the region
of three to six months although it could be shorter or slightly longer if he
responded well to chemotherapy
28. The consultant in clinical oncology wrote on 6 December to a doctor at Camp
Hill, about another consultation with the man the previous day. He also wrote
to the Governor of Camp Hill. In his letter he summarised the man’s prognosis
and treatment. The consultant in clinical oncology wrote that he was in no
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doubt that the man’s condition was terminal and he supported his release from
custody on compassionate grounds.
29. On 11 December, the man was admitted to the prisons local hospital as he was
vomiting, had severe abdominal pain and was dehydrated. Whilst he was in
hospital, a bedwatch was carried out by prison staff. The initial security risk
assessment on 11 December was that handcuffs were to be used and two
officers needed to be at his bedside. This was revised on 14 December; only
one officer was to be at his bedside and restraints were no longer to be used.
Later that same day he was released on temporary licence (ROTL). He was
also given a mobile telephone by his family so that he could keep in contact
with them and Camp Hill. The man’s family were allowed to visit him whilst he
was in hospital.
30. The man was discharged from hospital on 2 January 2008 and returned to
Camp Hill. He returned to hospital two days later when he became ill again.
On his return to hospital the security risk assessment was that he no longer
required officers at his bedside.
31. On 7 January, the consultant in clinical oncology wrote to the prison doctor
about the man’s consultation at his clinic on 3 January. He said that he had
told the man that further chemotherapy was unlikely to have a significant effect
on his cancer. He had therefore stopped his chemotherapy. The consultant
undertook to try further treatment if the man’s condition improved significantly
but he did not think that this was likely. If his vomiting continued, he thought
that he should be re-admitted either to hospital or to the local hospice.
32. When interviewed as part of this investigation, a deputy team manager and a
probation officer from the relevant probation area were able to clarify what
happened around this time. The probation officer was the man’s offender
manager. (The offender manager is responsible for post-release supervision of
the prison licence which includes assessing an offender’s risks and needs,
planning manage these risks, considering the victim’s perceptive and risk
issues and deciding what activities need to be carried out and how they will be
delivered. They are also responsible for reviewing the offender’s progress
against their sentence plan and for adjusting the plan in the light of changing
circumstances.)
33. The probation officer said that, from a Probation Service point of view, nothing
of note was learnt after the man was sentenced until 2 November 2007 when
staff received a phone call about him. A member of the Public Protection Team
at Camp Hill had telephoned to inform them that the man was seriously ill and
in hospital. Up until that point probation staff had not known that he was
seriously ill and did not have information about his illness. The member of the
Public Protection Team had asked whether the man could be released on
temporary licence. The victim liaison officer (VLO) for the victim of the man’s
offence, expressed concerns about release on temporary licence (ROTL) being
granted and the head of the Public Protection Team at Camp Hill was informed
on 2 November of the victim’s concerns. He stated that he would recommend
to the Governor that the man should not be granted ROTL. There was no
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further contact between the prison and staff of the probation area until 4
January 2008.
34. On that day (4 January), the probation officer contacted Camp Hill and was told
that the man had already been released on temporary licence to the prisons
local hospital. The Deputy Team Manager said it was normal practice for the
prison to inform staff at the probation area whenever a prisoner was considered
for temporary release so that a risk assessment could be carried out. This did
not happen in this case. He also stressed the importance of the victim of the
man’s crime being briefed by the VLO about what was happening. The prison
informed the probation officer that the man was unable to get out of bed
unaided and that his death was imminent. The probation officer retrospectively
agreed to ROTL being granted with conditions that the man did not contact the
victim of his crime and was excluded from certain geographical areas. She
was also informed by Camp Hill that the Governor was in the process of
applying for what she referred to as a “Royal Prerogative”, that is the Secretary
of State for Justice would remit the man’s custodial sentence and he would be
released subject to licence conditions.
35. Around 5:45pm on 5 January, the man fell over and cut his head. Hospital staff
carried out neurological observations until midnight.
36. A week later, on 11 January 2008, a probation officer based at Camp Hill,
contacted the probation officer to inform her that the man was still in hospital.
He said that the man would be transferred HMP Lewes the following week with
the intention of releasing him from there to a hospice. The probation officer
expressed her concerns about moving him to a hospice in the proposed area
as the victim of his crime still lived there. She informed the probation officer
based at Camp Hill that she would be requesting an exclusion zone so that the
man was not allowed to be near his victim. The probation officer based at
Camp Hill also informed the probation officer that the prison was no longer
applying for a “Royal Prerogative” for him.
37. A fax was received by the probation staff from Camp Hill on 15 January. The
prison asked whether the exclusion zone could be reduced as the man was
going to move to a hospice near his family. The VLO was asked to consult the
victim about his living within the exclusion zone.
38. The prison’s head of offender management, contacted the probation officer on
17 January. She explained that the man was very ill and she was trying to
arrange for him to be released to a hospice near his family. The probation
officer explained the victim’s issues and the fact that the hospice was very
close to the victim’s address and within the exclusion zone.
39. The probation officer based at Cam Hill contacted the senior probation officer
(SPO), on 18 January to say that the man was going to be moved to the
prisons local hospice. He said the intention was that the man would then move
into another hospice, at one of two areas near where his family were living.
The senior probation officer gave the probation areas preferred area and asked
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for the probation office based at camp hill to keep the VLO up to date with any
developments.
40. Later that day, the Deputy Team Manager contacted the probation officer
based at Camp Hill and reviewed the man’s position. He had taken over
responsibility for the man and his release from custody whilst the probation
officer was on leave for two weeks. The probation officer based at Camp Hill
said that the intention was that the man move to a hospice in either in two
areas close to where his family were living, but not the area that the probation
area preferred. The probation officer based at Camp Hill told the Deputy Team
Manager that the man was no longer receiving treatment for his condition and
was only having pain relief. The Deputy Team Manager explained the licence
conditions that his team recommended:
 The man was to remain in the hospice/hospital grounds
 There was to be no direct or indirect contact with the victim
 The man was not to enter the exclusion zones.
41. The probation officer based at Camp Hill named the proposed hospice. When
interviewed by my investigator, the Deputy Team Manager said that the
probation officer based at Camp Hill was dismissive of the probation area’s
influence over the choice of hospice. The probation officer based at Camp Hill
said that this was the decision of medical consultants. The Deputy Team
Manager did not agree with this. He said that the consultants should be
informed of the exclusion zone and then work out where the man could be
cared for.
42. The Deputy Team Manager then spoke to the Head of Offender Management
about the prison’s intention to move the man to a hospice and where this would
be. He stated that this was contrary to the exclusion zone recommended by
the VLO and was without the agreement of the probation area. He added that
there was no current risk assessment package to protect the victim. The Head
of Offender Management explained that the medical director of the prisons
local hospice and consultant in palliative medicine had chosen that hospice in
the family’s local area so that the man could be near them. The Deputy Team
Manager expressed his concern about the proximity of the hospice to the victim
and repeated the view of the VLO. He asked the Head of Offender
Management to consider a hospice in another area as this would enhance the
safety of the victim and give more assurance. He said that it would also only
be a minor journey for the family to visit the man. The Head of Offender
Management agreed to look into this.
43. The Deputy Team Manager then spoke to the VLO who requested that the man
be excluded from the family’s local area and ideally move to a hospice in a
neighbouring area. He also contacted his manager who agreed that the
preferred option was a hospice in the neighbouring area. The head of public
protection said that, if Camp Hill decided to select a hospice in the family’s local
area then the licence condition would have to say the man could:
 Not leave the grounds
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 Not have direct or indirect contact with the victim
 Not enter any part of an identified holiday park.
The Deputy Team Manager faxed this information to the Head of Offender
Management.
44. The Head of Offender Management also wrote to the Early Release and Recall
Section of the Ministry of Justice on 18 January. She enclosed an application
for early release on compassionate grounds for the man. Staff at the probation
area were not informed about this action. On the same day the man was
transferred from the prisons local hospital to the local hospice.
45. On 21 January, the probation officer based at Camp Hill telephoned the Deputy
Team Manager to inform him that the man was now in the prison’s local
hospice. He told him that the Head of Offender Management had informed the
medical director of the said hospice that the man could not move to a hospice
in the area where his family loved. The probation officer based at Camp Hill
said that the medical director was not happy about the situation and suggested
that the Deputy Team Manager was to blame. The Deputy Team Manager did
not accept this, saying that the licence conditions were suggested by his office
and that Camp Hill had accepted them. He said that the Head of Offender
Management was in a position to balance all the issues. She thought the
family’s local area exclusion zone was inappropriate and she had the final
decision about where the man moved to. He said that he was not in a position
to consider all the factors as he had not received all the medical assessments.
The probation officer based at Camp Hill also confirmed that the issue of a
“Royal Prerogative” was still being sought, although he had previously said (on
11 January) that this was no longer the case. The probation officer based at
Camp Hill suggested that, if this was granted, the man could move to the area
where his family lived. He was unable to clarify if this was the case when
pressed by the Deputy Team Manager. The probation officer based at Camp
Hill phoned back later the same day to say that the man was going to move to
a hospice in the neighbouring town to where his family lived. The Deputy Team
Manager sent a fax to the Head of Offender Management summarising his
discussions about the case and his understanding of what had been agreed.
46. On the following day, the medical director of the prisons local hospice wrote to
the medical director of the hospice based in the family’s neighbouring town. He
summarised the man’s treatment and prognosis and thanked him for accepting
the man as an in-patient.
47. The probation officer based at camp Hill telephoned the Deputy Team Manager
on 24 January and informed him that the man was going to move to the other
hospice the following day. He said that the man would be released on
temporary licence and that the nursing staff at the hospice would not know that
he was a prisoner. He confirmed that the medical director of the new hospice
did know that the man was a prisoner. The Deputy Team Manager asked what
procedures were in place by which either Camp Hill or the probation area would
be informed if the man left the hospice. The probation officer based at camp
Hill was unable to confirm what procedures were in place so the Deputy Team
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Manager contacted the Head of Offender Management. He said that the man
was not under the direct supervision of the probation area whilst he was on
ROTL, and asked her what involvement she expected from his team. The
Deputy Team Manager said that, as his team had not visited the hospice in the
family’s neighbouring town, he was unable to inform her of any specific factors
that needed to be considered as part of her ROTL risk assessment. He also
asked whether the medical director of that hospice and his staff had been
advised to contact either Camp Hill or the relevant probation area if the man left
the hospice.
48. The probation officer contacted the Head of Offender Management on 4
February to inform her that she had returned from leave. She discussed the
Deputy Team Manager’s fax, sent on 24 January, and requested answers to
the issues he raised. The Head of Offender Management replied that the
man’s ROTL was being reviewed on a weekly basis, he was being visited by
staff from Lewes prison every week, and there was no need for staff from the
probation area to visit him. The Head of Offender Management said that all the
staff at the hospice to whom she had spoken were aware that the man was a
serving prisoner. If anything happened, they would inform her or staff at Camp
Hill. They discussed how long it would take for the agencies to be made aware
if the man left the hospice grounds. The Head of Offender Management
informed the probation officer that this was not known and it would depend on
how much time staff at the hospice took to inform her. The Head of Offender
Management confirmed that both the man and his family were aware of the
licence conditions and the consequences of him leaving the hospice.
49. When interviewed as part of this investigation, the Head of Offender
Management said that the man had been confined to hospital, was in a
wheelchair, had lost six stones in weight and could barely walk or put his
slippers on. The Head of Offender Management confirmed that he was also
receiving morphine through a syringe driver (a drip inserted into his stomach).
She felt that the probation area were not basing their risk assessment on the
risks that the man posed. The Head of Offender Management said:
“… he was a very, very poorly man with not a lot of strength and not a
lot of will and he was just wanting to spend his last days with his family,
his last few days and this was relayed to the Probation Department.
We had physically seen him, we encouraged them to go and physically
see him, but they were intimating they still had major concerns about
his ability to pose a risk to the victim and their concerns that the victim
had raised with them about him being in the vicinity of that borough
again. We felt these were mitigated by his current healthcare condition
and we made that known to the Probation Area and I was very
disappointed with their response in terms of getting him home as fast
as possible they ought to have done really.”
50. On 5 February, the probation officer received a telephone call from the new
hospice asking how long it would take to get the “Pardon” agreed. The
probation officer was informed that the hospice only accepted short term
patients and that the man would need to move on. The probation officer said
14
she did not know when the “Pardon” would be granted and advised the caller to
contact the Head of Offender Management for more information. The Deputy
Team Manager advised the probation officer to clarify with the Head of
Offender Management what further involvement she wanted from the probation
area. The probation officer was unable to contact the Head of Offender
Management as she was not getting a response to her messages.
51. Around noon on 12 February, the Head of Offender Management contacted the
probation officer to tell her that the man had been granted release on
compassionate grounds. She said that the hospice wanted to discharge him as
soon as practicable. The probation officer pointed out the licence conditions
and said that she did not understand why the Head of Offender Management
was saying that the hospice wanted to send the man to his family home which
was within the exclusion zone. The Head of Offender Management told the
probation officer that she would need to apply for licence conditions to the Early
Release and Recall Section either directly or through her.
52. The Deputy Team Manager then spoke to the staff nurse at the hospice to find
out their understanding of the situation. He was informed that the Head of
Offender Management had already told them about the man’s “Pardon” earlier
that morning. The staff nurse thought that the man would now be able to leave
and return to the family home. The Deputy Team Manager explained that he
was to be released early on a probation managed licence. Probation were
asking for the same licence conditions (the exclusion zone, not to leave the
hospice and not to contact the victim) to continue. The staff nurse thought that
the man would be surprised by this and the Deputy Team Manager offered to
visit the hospice, with the probation officer, later that day. The Deputy Team
Manager said it appeared that both the man and the staff at the hospice
expected him to receive a “Pardon” with immediate release and no conditions
attached.
53. The Deputy Team Manager then spoke to a member of staff at the Early
Release and Recall Section. He said that the Secretary of State had not yet
signed the papers granting compassionate release. The Deputy Team
Manager explained that the probation area had only recently found out that the
man was not allowed to remain long term at the hospice. The Deputy Team
Manager told the member of staff at the Early Release and Recall section that
his team had not visited the hospice or the man’s family home and still did not
know where it was within the area. He said that they wanted to continue with
the current licence conditions. The member of staff at the Early Release and
Recall section agreed that the compassionate release would not be forwarded
to the Secretary of State for signature until the Deputy Team Manager had
visited the man.
54. The probation officer and the Deputy Team Manager then visited the hospice
where they met the staff nurse and asked about the man’s general wellbeing.
The staff nurse confirmed that the man got on well with his daughter who would
do anything for him. When the probation officer and the Deputy Team Manager
met the man they explained the conditions of his release. When interviewed,
they recalled that he was very surprised as he was under the impression that
15
he would be released without any conditions. They also agreed to meet the
man’s family to explain the conditions of his release from custody. It became
apparent to them that he did not appear to have empathy with the victim. He
told them that anyone would have given the victim “a good kicking after the way
he was talking to me”. The man’s confirmed to them, in their view, he should
not be allowed within the exclusion zone without specific probation permission.
Towards the end of their visit, the man told them the address of his family home
which was within the exclusion zone.
55. The probation officer later rang the man’s wife to explain the situation with
regard to his release on licence. When interviewed, the probation officer
recalled that the man’s was very distraught. She said that the Head of
Offender Management had told her that the “Pardon” had been granted and
that her husband would be home in a couple of days. She added that the Head
of Offender Management had told her the exclusion zone would be reduced so
that he could come home and it was just a question of “rubber stamping” the
papers. The probation officer confirmed that, although she had not spoken to
the Head of Offender Management about the situation, her manager had. The
probation officer said that she was under the impression that the Head of
Offender Management would be in contact to explain the misunderstanding.
She also mentioned during her conversation with her that the man would be
able to move out of the hospice into a nursing home in the same area, or
another neighbouring town.. The probation officer was given the address of the
family home and agreed to meet the man’s wife the following day (13
February).
56. The following day the probation officer completed Multi-Agency Public
Protection Arrangements (MAPPA) paperwork and recommended MAPPA level
one due to the man’s ill health. (MAPPA involves the assessment and
management of the serious offenders. The aim is to ensure that a risk
management plan is drawn up for the most serious offenders that benefits from
the information, skills and resources provided by the individual agencies,
including the police, co-ordinated through MAPPA.)
57. There are three levels of MAPPA:
 Level three - Anyone subject to level three is considered as being the
highest risk case, where more than one agency will take responsibility for
the management of the person concerned.
 Level two - As with level three, anyone who has been identified as falling
into the level two heading would be managed by more than one agency,
very often limited to probation and the police. However, it is possible to
involve more agencies if the circumstances warrant it.
 Level one - An offender on level one MAPPA is normally managed by a
single agency. This is the lowest monitoring procedure available under the
MAPPA system.
16
58. The probation officer also contacted the Adult Protection Team to check the
history of any domestic violence incidents which might have occurred at the
family home. This is a standard check when a licensee is hoping to move into
a specific address.
59. Around 11:00am on 13 February, the Head of Offender Management rang the
Deputy Team Manager. She told him that the man’s wife had phoned her and
was very distressed. The man’s wife had told her that the probation officer had
said her husband would not be allowed to live at the family home. The Deputy
Team Manager confirmed that, from his understanding, this was not what the
probation officer had told her. The conversation between the Head of Offender
Management and the Deputy Team Manager then centred on the man’s licence
conditions. The Head of Offender Management felt that the licence conditions
should now be relaxed whereas the Deputy Team Manager thought that they
should stay in place.
60. The Deputy Team Manager contacted the member of staff at the Early Release
and Recall Section after his telephone conversation with the Head of Offender
Management. He confirmed that the Secretary of State agreed the early
release on compassionate grounds on the basis that the victim’s issues were
considered. He told the Deputy Team Manager that three licence conditions
would be imposed:
 No victim contact
 Not to enter stipulated areas
 To reside as directed.
The Deputy Team Manager noted in the contact log that this was a suitable
balance of the rights of the victim and offender. He recorded that it was
unfortunate the man and his family had been, “led to believe they would get a
full pardon and have no restrictions upon him and that we [Probation] did not
know they had been told this”.
61. The probation officer then took a copy of the licence to the hospice so that the
man could sign it. Prior to her meeting with him, the probation officer was
informed by a member of staff that the Head of Offender Management had
spoken to the man and his wife, and they were expecting good news. The
probation officer explained that nothing had changed from the previous day and
that the man was to be released with conditions in place. There then followed
what the probation officer described to my investigator as a very difficult
meeting with them. The man’s wife made it very clear to the probation officer
that, from her conversations with the Head of Offender Management, she had
been given the impression that her husband would be allowed to return home.
She also indicated to the probation officer that she would be taking the matter
further. After the man had signed his licence the probation officer informed him
that the Deputy Team Manager would visit him at the hospice on 15 February.
62. The probation officer then had a meeting with the Deputy Team Manager and
they discussed trying to accommodate the man’s move to the family home.
The probation officer contacted the VLO to enquire whether the exclusion zone
17
could be revised so that the man could return to the family home. The Deputy
Team Manager also discussed this with the man’s wife. He explained the
importance of balance between the rights of the victim and offender, and the
risk of accidental contact between the man and his victim. The man’s wife then
contacted the probation officer who confirmed that they were investigating
whether her husband could go home. The probation officer told the man’s wife
that she would need to meet senior managers and carry out a home visit, and
the process might take some time. The man’s wife told her that she would tell
the hospice not to pursue the option of moving her husband to a nursing home
as he would get better care at the hospice. The probation officer indicated that
she was happy for the man to move into a nursing home until a decision about
the exclusion zone had been reached.
63. After the visit the Deputy Team Manager also sought a medical view from the
hospice as to whether the man could be adequately cared for at the family
home. He wrote:
“During our visit to see [the man] on Tuesday this week [the probation
officer] and I learnt that he would like to move to live with his wife rather
than enter a nursing home and since then we have looked into this
possibility. We are working as quickly as possible and hope to conduct
the necessary home visit and conclude the assessment by Wednesday
20th February, or earlier if possible. To aide our assessment would
you please tell me your assessment as to the whether it is feasible for
the man to live at [family address] and what medical support would be
needed and if, and by whom, this could be provided. I would also
appreciate your view as to the likelihood of the man needing to be
moved back into a nursing home at a future date and where this could
be too. This is because for geographical reasons [named
establishments] remains a problematic nursing home for him. [The
probation officer] and I are available on the telephone for most of today
for further discussion and I would be grateful if your assessment could
be faxed to this office when available”
64. On 14 February, the probation officer and the Deputy Team Manager met the
VLO and they agreed a reduced exclusion zone. They noted that the hospice
would have to confirm that a care plan could be put in place to care for the man
at home. The Deputy Team Manager contacted the family to confirm that the
probation officer would carry out a home visit the following day. He informed
them that he would also check with the hospice that the proposed move was
medically possible and that arrangements could be made to meet his clinical
needs at home. He said that he intended the process to be completed by the
following Wednesday (20 February).
65. The probation officer and her colleague made the home visit on 15 February.
They were met by the man’s wife and her daughter, who showed them around
the house. They also confirmed that the man’s two granddaughters lived at the
house. The probation officer explained that the purpose of her visit was to
assess risks and she explained the revised licence conditions. She
18
emphasised that the man would not be allowed to enter the exclusion zone,
and the consequences if he did not abide by the licence conditions. The man’s
wife and daughter explained how they intended to care for him after he
returned home. The probation officer outlined the further action she would
need to take to try to accommodate his return home and informed the family
that this should be completed by 20 February.
66. On 18 February, the probation officer contacted Social Services who confirmed
the following day that they had no concerns about the man returning to the
family home. On the following day, she contacted the Early Release and
Recall Section to inform them of the revised licence conditions.
67. The probation officer received the revised licence for the man on 20 February
and she immediately informed his wife. She told her that the Deputy Team
Manager would visit the hospice for the man to sign the new licence and that
he would be allowed to leave the hospice the following day. She explained that
the hospice would arrange transport to bring him home and that they would
travel outside the exclusion zone.
68. The man was duly moved from the hospice to his family home on 21 February.
69. On 25 February 2008, the probation officer visited the man at home. She
spoke to him, his wife and daughter. His daughter asked them about the
Ombudsman’s office as they wanted to discuss their concerns about her
father’s care and he also wanted to tell “his side of the story”. The probation
officer suggested that they contact my office with a view to the man being
interviewed. The probation officer noted in the contact log after the visit that,
when the man was moved from the hospice, they gave a “Do not resuscitate”
sign to the ambulance staff. This had clearly upset the family and the probation
officer noted that the man had deteriorated since his last visit. Around 10:15pm
he died at the family home. After receipt of the draft report the man’s family did
not agree with the probation officers recollections of events. They said that the
man was unconscious all day, and indeed died later that evening. The family
said she did not visit or speak to him, or his family, on that day.
70. The post mortem report records the man’s death as being due to natural
causes, as a consequence of a metastatic gastric adenocarcinoma (a
malignant growth of glandular tissue in the stomach). An inquest did not take
place as there were no suspicious circumstances surrounding his death.
19
ISSUES CONSIDERED
Clinical care
71. A review of the man’s medical care was undertaken by a doctor on behalf of
the prison’s local Primary Care Trust and a panel was convened to discuss the
review’s findings. The panel comprised a Chair, the medical director of the
prisons local hospice and consultant in palliative medicine, a member of the
Independent Monitoring Board.
72. Before the panel convened it was presented with a chronology of the man’s
care and ten clinical reports. At the review meeting the panel considered in
turn each of the clinical reports and also asked questions of those present. The
panel then retired, accompanied by my investigator, to consider its
recommendations. Draft verbal recommendations were fed back to the
attendees who were able to remain to the end of the meeting. The panel
concluded that the man’s care was not equivalent to the standard he would
have received had he been in the community. As a result of the discussion
some of the clinical reports were also updated to include further information.
73. The man’s family had a number of concerns relating to his treatment while in
custody. I set them out in the paragraphs that follow, along with the review
panel’s conclusions on each of the matters raised.
74. First, the family felt very strongly that an earlier diagnosis of the man’s
condition could have led to immediate treatment and a better prognosis. They
felt that he had not received appropriate treatment for his condition.
75. The family said that in February 2007 the man collapsed in the visits hall at
HMP Lewes. He told staff that he did not have any chest pain and, after being
given oxygen, he walked to the healthcare centre. He saw one of the prison
doctors who told him to take things easy and appointment was made to see
another doctor. After he had seen the prison doctor, he returned to the visits
hall. It was never explained to either the man or his family what was wrong
with him on this occasion. The family talked about how frightening this incident
had been and how he had become hot, and told them that his skin felt “itchy”.
He then glazed over and began to have a fit. The family said this was
especially frightening for his grand-daughters who were both present at the
visit.
76. The review panel concluded that the reason for the man’s collapse was not
certain. The panel said that when he saw the prison doctor after his collapse it
was thought that he might have fainted. He did not appear to have any further
medical problems whilst he was in Lewes. The panel judged that the man
received prompt nursing and medical attention at Lewes after collapsing during
a visit.
77. The family said that it was after this that the man said he was in pain and the
medical tests began. The family said that his white cell count was below what it
should have been, and his cancer count was “through the roof”. He told his
20
family that he did not get the care he needed from Camp Hill healthcare centre
because he was under the care of the hospital. The family said that he would
be told to go away by healthcare staff as he had a hospital appointment. They
said that he asked for pain relief but was not given it because he was having
tests under the care of the hospital.
78. The panel said that it was clear that, prior to 23 October 2007, healthcare staff
at Camp Hill had not been informed of the findings of the man’s medical tests
or discussions by the multi-disciplinary team (MDT). He was still being treated
as suffering from diverticulitis. Opiate (pain relief) medication was not
prescribed as it can make diverticulitis worse. It was also not prescribed due to
the problems associated with management of pain relief medication in prison
and the need to avoid trade in illicit use of drugs. The panel also did not think
that there was recognition by the hospital’s multi-disciplinary team of the fact
that the man was a serving prisoner and the associated restrictions.
The hospital cancer multi-disciplinary team meetings should be
requested to take special account of the needs of prisoners.
79. The family drew attention to the fact that, having initially been told the man had
cancer, they were then told that it was not cancer but diverticulitis. The hospital
wanted to do either a colonoscopy or endoscopy and he was told, by the
hospital, that he needed to take certain medication in advance of this. The
whole procedure was explained to him by the hospital. According to his family,
he told the prison that he needed the medication in advance of the test.
However, the prison healthcare centre told the man that he needed a medical
enema, which his family said he was given to administer himself in his cell.
When he then went to hospital he was told that he could not have the
investigative procedure because he had not been given the necessary
medication beforehand. This meant that the procedure was delayed by a
month, at which point he had a repeat colonoscopy instead of the planned
endoscopy.
80. The panel considered the evidence concerning the delays in the man’s
treatment. Although gastrointestinal cancer was suspected in July 2007,
prompt action was not taken to confirm the diagnosis. The panel
recommended that this process should be much more closely managed. They
concluded that the problems administering the bowel preparation were due to
administrative and communication problems within Camp Hill. It was noted that
these problems have now been overcome.
The progress of the case of a prisoner for whom a fast track referral has
been made or who is actively being investigated or treated for cancer
should be tracked by prison healthcare.
81. The family explained that, on one occasion when the man went to hospital, he
was given another colonoscopy - even though he told the staff that he did not
need one and required a endoscopy instead. The family said that another
appointment was made for him but he could not go because there were
21
insufficient prison officers to escort him to hospital and the appointment was
missed.
82. The family said that a growth was found after five months of treatment for
diverticulitis. The family feel that the man could have had five more months
of cancer treatment, had it been diagnosed earlier.
83. The panel said that it was not clear what the man was told following his
colonoscopy on 16 August. It was thought that both he and Camp Hill’s
healthcare team might have interpreted “no cancer in the large bowel” as “no
cancer in his body”. There was confusion about the procedures to check his
bowel. The lack of proper preparation of the man’s bowel also meant that
when the tests were carried out the results were not as clear as they could
have been. The panel recommended that a policy should be produced by
Camp Hill, in consultation with the local Primary Care Trust, with regard to
bowel preparation for colonoscopy.
The prison healthcare team should produce a policy on bowel preparation
for colonoscopy.
84. The panel considered that the delay obtaining a liver biopsy and therefore
confirmation of the man’s cancer was unacceptable. It was the consensus of
the panel that, if his diagnosis of cancer had been made earlier, he would have
received better care for his symptoms. It was also felt that he might have
received earlier consideration for release from custody. However, the panel
believed that, when the diagnosis was first considered in July 2007, a cure
would not have been possible even then.
85. In October, the man was about to learn his cancer diagnosis and prognosis.
The panel felt that in the community there would have been the opportunity for
a patient’s family to be involved in this process. Although the panel suggest
that this option should be considered for prisoners, I recognise that there are
security implications and so make no formal recommendation.
86. The review panel noted that, after the man’s diagnosis of possible cancer an
out-patient appointment was cancelled. The appointment was cancelled by
security and not healthcare staff. The panel agreed that this was not
acceptable. The panel judged that prisoners having attendance at a fast track
referral should have priority for hospital appointments.
Prisoners for whom a fast track referral has been made or who are
actively being investigated or treated should have priority for escort to
out-patient appointments.
87. The panel concluded that the prisons local Primary Care Trust, in partnership
with the three prisons on the island, should set up a joint working group. The
group should aim to establish a clear pathway for the management of the care
for patients with terminal illnesses. This should link with a project being
undertaken by healthcare on the island and the Kings Fund concerning
accommodation for terminally ill prisoners. It should include a robust system to
22
ensure the appropriate and timely access to advice and medication for control
of the symptoms of terminally ill prisoners.
The Primary Care Trust and the three prisons on the Isle of Wight should
set up a joint working group to establish a clear management pathway for
patients with a confirmed or potential cancer diagnosis or terminal illness
including appropriate pain management.
88. The family also drew attention to an occasion whilst in hospital, after the man’s
bedwatch staff had been withdrawn, when he slipped on water that was on the
floor and hurt his head.
89. Although this is outside my terms of reference, the review panel noted that after
the incident where the man had a fall at the prisons local hospital some actions
were not noted on the clinical record. Although an incident form was completed
by staff at the hospital, there was nothing documented in the man’s medical
record about his fall. The incident form recorded that, at around 5:45pm on 5
January 2008, he had fallen and had a cut to his forehead. Neurological
observations were started and a hospital doctor was contacted although there
are no medical records to say whether he came to see the man. The
observations continued at approximately hourly intervals until midnight. The
review panel suggested that the hospital review its documentation for incidents
when a patient falls.
90. The family said the man had a locked cupboard in his cell which contained his
controlled drugs. They said they understood the security concerns surrounding
prescribed drugs in prison, and the risk of medication being stolen, but they
have argued that he was in pain because the healthcare unit ran out of
medication. They have alleged that he would put in another repeat prescription
for his drugs but it would take three to four days to be filled. In addition, he had
a morphine syringe driver inserted when he was in the hospital but could not
retain it in prison. Whilst the prison had to put security first, the man’s family
felt that this was inequitable. Had he been going home rather than to prison,
he would have been able to keep the morphine line in and his pain would have
been controlled. The family felt that he would have done anything, even “gone
into solitary,” if that would have enabled him to keep his morphine line in and
have some pain relief.
91. The review panel acknowledged that administration of controlled drugs is a
complex issue in prison. Healthcare staff assess each prisoner particularly in
relation to in possession medication and the time and mode of administration of
medication. If a syringe driver is the most appropriate mode of administration
then the patient has to be admitted to the hospital or a local hospice. There is
also limited access to prisoners during the night (8:00pm until 7:30am) when
the prison is in patrol state. (Patrol state is when prisoners are locked up and
staff numbers are reduced to the minimum needed to patrol and maintain the
security of the prison.)
92. The family pointed out that the man had been on prescribed anti-depressants
for about six or seven years. They said he normally would have had to come
23
off them gradually but, because of his treatment and the effects, staff at the
hospital had to stop all non-vital medications. The family felt that this could not
have helped his mental state.
93. The panel said that it was normal practice to send a summary of the prisoner’s
medical record to the local hospital when a patient is admitted. It was not clear
whether this did or did not happen on 2 November 2007. It was suggested that
the anti-depressant medication might have been stopped because he was
vomiting.
94. The family felt that some of the man’s suffering was unnecessary. For
example, he did not get his antibiotics for a urinary tract infection (UTI). After
he went back to prison he asked daily, for three weeks, for his antibiotics for the
UTI, but never received them. On another occasion, he told them he had been
vomiting blood, which had been really worrying for him.
95. The panel noted that, at 4:58pm on 7 September 2007, the man was seen at
Camp Hill by the senior nurse. It was noted that he had a slightly raised
temperature. The nurse told the panel that, if she had had any cause for
concern or if the man’s temperature had been very high, he would have been
seen by the on-call doctor. He was seen in the clinic on 10 September and a
doctor prescribed antibiotics. The Head of Offender Management confirmed
when interviewed by the panel that there was no delay in the man receiving the
antibiotics.
96. When interviewed as part of this investigation, the Head of Offender
Management said that the prisons on the Isle of Wight had a clustered
healthcare arrangement and the pharmacy is housed in HMP Parkhurst. The
pharmacy has to distribute the medication for all three island jails (Albany,
Camp Hill and Parkhurst), which is up to 1,500 prisoners. She admitted that
Camp Hill had previously received medication quite late in the afternoon. This
could impact on the issuing of medication as it had to be checked and
sometimes they received three large boxes. This would mean the medication
for 200 - 300 people had to be checked, certified and then sorted into some
sort of chronological order ready for administering to prisoners. She said that
Camp Hill had experienced problems which had been raised with the Primary
Care Trust managers. The Head of Offender Management confirmed that the
arrangements for issuing medication have now been changed. There is now a
pharmacy runner and Camp Hill receives medication much earlier during the
day. I welcome this.
97. In a supplementary note dated 22 June 2008, the Head of Offender
Management told the panel:
“I have made checks as requested on the night of 2nd of November
2007 to see if [the man] raised with staff the fact that he was vomiting
blood and distressed. There is no written record at all on this date or
the previous night or the night after. I can only conclude that this was
not reported to the night staff at the time, but instead to the day staff
24
the following morning, he was sent to Healthcare the next (3rd)
morning and re-admitted to the local hospital that day.”
98. The panel noted the concerns raised by the family about possible delays to the
issue of the man’s medication. Medication for the three prisons on the island is
issued by staff at Parkhurst which can mean that there are delays in its receipt
elsewhere. Although there was no clear evidence of the delays being more
than a few hours, the panel felt that this should be remedied as soon as
practicable.
Prison healthcare should introduce as soon as possible Patient Group
Directives (PGDs)/nurse prescribing to increase prisoners’ access to
medication, including antibiotics.
99. The family also said that they were told that Camp Hill told staff in the hospital
that they could not cope with the man’s condition and that he should not return
to prison.
100. The panel thought that this referred to concerns raised by healthcare staff with
regard to the regime at Camp Hill. As already mentioned, Camp Hill does not
have 24 hour healthcare facilities. The man would have been locked up
overnight along with the other prisoners. Healthcare staff felt that this was
unsuitable for him as he was unwell. When my investigator spoke to prisoners
and staff at Camp Hill it was apparent that the man’s regime was relaxed.
Officers would let him out of his cell during patrol state.
101. The family were also concerned about Camp Hill not officially informing them
on several occasions when the man was admitted to hospital. This was
especially frustrating on the occasion when his daughter visited the prison and
was told that he was in hospital. His daughter said that she could have gone
straight to the hospital and not sat in the prison car park for over two hours.
The family said that the Head of Offender Management was aware of this
problem. She had told prison staff to keep the family informed whenever he left
the prison, but they had failed to do this.
102. In her written response to my investigator dated 22 May 2008, the Head of
Offender Management said:
“It is generally accepted by Governor grades that it is good practice to
inform the next of kin when a prisoner goes to outside hospital due to a
serious injury or an accident or if they make an attempt on their own
life. I did raise this verbally at a Governors’ morning meeting (which is
attended by Governor grades, Principal Officers, Head of Chaplaincy,
Head of Probation, Head of Learning and Skills, and Head of
Programmes) that it would be decent to inform his family when [the
man] did go to outside hospital and then get subsequently admitted. It
appears that on this occasion … this did not happen. I think one of the
problems here was the frequency he went out, which sometimes was
during the night. There was also written instructions regarding this. I
did not give anybody the responsibility to action this and the Duty
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Governor of the day would not necessarily have known when [the man]
would have had a visit booked. I believe the above may have led to
the family not being informed on this occasion. It is clear for this
incident that I need to formally raise this process and make individuals
responsible for informing families of such incidents.”
Bedwatch and the use of restraints
103. Whilst the man was a hospital in-patient, a bedwatch was carried out by prison
staff. The initial security risk assessment identified that an escort chain should
be used and two officers needed to be in attendance. The assessment was
subsequently revised: handcuffs were no longer to be used and only one officer
was to escort him. This was entirely appropriate and enabled the nursing staff
to have easy access when they carried out their duties.
104. My investigator found no evidence that Camp Hill did not adhere to the
instructions in Prison Service Order (PSO) 6300 (Release on Temporary
Licence). The prison allowed the man to be released on temporary licence in
December 2007 and he was given a mobile telephone. This enabled him to
keep in contact with both his family and Camp Hill.
105. From the bedwatch log, my investigator believes that the staff involved with the
man’s care behaved with compassion and sensitivity. The security
arrangements at the hospital seem to have been suitable, and to have struck a
good balance between public protection and respect for the man himself.
Risk assessment of the hospice
106. The family were distressed by the action taken when the man moved to the
prisons local hospice. An officer accompanied him to risk assess him and the
hospice. The officer took photographs as he was taken out of the ambulance
when being rushed to the hospice. Whilst the family said they understood the
security issues, they felt that this was insensitive and “over the top” when he
could barely walk. I appreciate that this was difficult for the family but, due to
the nature of the man’s offence, it was necessary for the prison to carry out the
risk assessment. Camp Hill would usually have carried out the assessment in
good time but, due to the nature of his illness, they hurried the procedure. This
ensured that the man was accommodated in a timely manner at the hospice. I
am sure, with the benefit of hindsight, Camp Hill would have approached the
assessment in a different manner which was more sensitive to his situation.
There may also be learning points in terms of the instructions given to staff over
the taking of photographs.
Actions by the area probation
107. The family were unhappy with the treatment they and the man received from
staff at the relevant probation area, after he was granted release on
compassionate grounds. The family had concerns generally about the
approach taken by the Deputy Team Manager and the probation officer.
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108. The family said that the issue of the man’s release from custody was not
handled well and that his return to the family home was delayed. This meant
that he only spent five days at home with his family before his death. The
family felt that the probation officer delayed the man’s return to the family home
and they were not happy with her conduct. The family also did not fully accept
the limitations of the exclusion zone. The family made it clear that they did not
hold Camp Hill or the Head of Offender Management responsible for what
happened to the man after he was granted release from custody on
compassionate grounds.
109. From my investigation it is clear that the man and his family may not have had
a clear understanding of what release on compassionate grounds entailed. I
think that this was a major stumbling block and led to a very poor relationship
between the family and staff of the relevant probation area. It was also
unfortunate that there was a breakdown of communication between Camp Hill
and the probation area. This meant that they were not working together
towards a common aim to ensure that the family received a consistent
message. I think that action should have been taken at early juncture when it
became known that the man was going to be released on temporary licence. I
also think that it would have been helpful if the probation officer, in her role as
Offender Manager, had visited him whilst he was still at Camp Hill to carry out a
risk assessment before he was released. This would have given her a better
idea of the potential risk he posed to his victim.
110. Staff at the probation area reacted immediately they were informed about the
man’s imminent release and tried to ensure a balance between public safety
and his needs. Once the probation officer and deputy team manager were
made aware of his intention to return to the family home, they tried to
accommodate this in a timely manner. They contacted the Victim Liaison
Officer to make arrangements for the exclusion zone to be revised and they
carried out necessary checks. When interviewed, the Deputy Team Manager
made it very clear that this was not the only case that the probation officer was
working on (she had a caseload of over 70) and every effort had been made to
speed up the process of returning the man to the family home. This action was
necessary to ensure public protection issues were clearly addressed and
adequate support was put in place for him to be able to come home.
111. I realise that this was a difficult situation for the family and I sympathise with
their frustration with what they perceived as a poor service. The issue of the
licence conditions was very emotive and it appears that this led to some
breakdown of the relationship between staff at Camp Hill and the probation
area. Both parties maintained what they saw as the moral high ground. The
fact is that the man had committed a violent offence and, due to the concerns
for the safety of his victim, an exclusion zone was created. I think that staff of
the probation did everything possible to accommodate the man’s needs after
his release. My investigator did not uncover any evidence to suggest that
either the Deputy Team Manager or the probation officer delayed the process.
Indeed, I recognise the hard work they carried out to ensure that he could
spend his last days at home with his family. However, I think that the failure of
staff at Camp Hill and the probation area to work together meant that a difficult
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situation was made worse. Better communication between them could have
avoided a lot of the animosity that occurred after the man’s release on
compassionate grounds was granted.
112. I recommend that a meeting is arranged between the Governor of Camp Hill
and the Chief Officer of the Probation Area. The aim of the meeting should be
to try to find out why communication failed on this occasion and to look at ways
to improve links in the future.
I recommend that a meeting is arranged between the Governor of Camp
Hill and the Chief Officer of the Probation Area. The aim of the meeting
should be to look at communication failures and ways to improve links in
the future.
113. The family were very complimentary about the support they received, towards
the end of the man’s life and after he died, from staff at the prison’s local
hospital, the last hospice, St Michael’s Hospice and Camp Hill, especially the
Head of Offender Management and a particular officer. They also appreciated
the contributions of the Chaplain, the Sister, and two prisoners.
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CONCLUSION
114. The man moved to Camp Hill in May 2007 and died, at his family home, of
natural causes in February 2008 after being released from custody.
115. I would like to commend the efforts taken by Camp Hill with regard to the
support he was given after he was admitted to hospital and when the security
restrictions were lifted.
116. As already mentioned, I think that there was a failure by both staff at Camp Hill
and the probation area to work together. Poor communication between them
made a difficult situation worse. I have recommended that the Governor and
Chief Officer consider my report and reflect on how to improve communication
in the future.
117. The clinical review panel has concluded that the care the man received was not
satisfactory and not equivalent to that he would have received in the wider
community. The panel also concluded that, had the diagnosis of his terminal
condition been made earlier, it could have meant him spending more time with
his family. After his diagnosis of terminal cancer I am satisfied that adequate
support was given to him. The findings of my own investigation, and the clinical
review, highlight that improvements to medical practices at Camp Hill need to
be made. I endorse the recommendations from the clinical review. These will
need to be addressed by the Isle of Wight Primary Care Trust in partnership
with the Governor of Camp Hill.
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RECOMMENDATIONS
HMP Camp Hill and the Probation Area
1. I recommend that a meeting is arranged between the Governor of Camp Hill and
the Chief Officer of the Probation Area. The aim of the meeting should be to look
at communication failures and ways to improve links in the future.
Accepted - The Area Office will facilitate a meeting to discuss the communication
failure between the establishment and Probation and ways to improve this in the
future.
Clinical
2. The progress of the case of a prisoner for whom a fast track referral has been
made or who is actively being investigated or treated for cancer should be
tracked by prison healthcare.
Accepted - Systems are in place to ensure the fast tracking of referrals. This is
monitored by Prison Healthcare Commissioners’ GP Partnership working with
area referred to identified leads in all three Primary Care areas to oversee all two
week referrals in the Healthcare Cluster.
3. Hospital cancer multi-disciplinary team meetings should be requested to take
special account of the needs of prisoners.
Accepted - The role of the healthcare lead is to ensure appropriate and timely
communication with the multi-disciplinary team (MDT) and ensure attendance of
the appropriate clinician at any meetings/discussions re the prisoner’s treatment
plan.
4. Prisoners for whom a fast track referral has been made or who are actively being
investigated or treated should have priority for escort to out-patient appointments.
Accepted - In the event of more than two prisoners requiring escort, Healthcare
staff clinically prioritise the fast track referral. Should there be requirement for
more than two fast track referrals on one day negotiations with the duty Governor
will take place with an expectation that all fast track referrals will attend their
appointment.
5. The prison healthcare team should produce a policy on bowel preparation for
colonoscopy.
Accepted - Healthcare staff respond to clinical requests received regarding
preparation for any procedures.
6. The Primary Care Trust and the three prisons on the Isle of Wight should set up a
joint working group to establish a clear management pathway for patients with a
confirmed or potential cancer diagnosis or terminal illness including appropriate
pain management.
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Accepted - Part 2 applies with the addition of ongoing work with departments at
the hospital to progress a clear cancer care pathway for prisoners. This is a
regular agenda item on partnership board, operational and modernisation and
prison healthcare operational group meetings.
7. Prison healthcare should introduce as soon as possible Patient Group Directives
(PGDs)/nurse prescribing to increase prisoners’ access to medication, including
antibiotics.
Partially accepted - Patient Group Directives are in place. At this moment in time
no staff are able to access the non-medical prescribing course. However, access
to prescription of medication out of hours will improve on 1st April when the new
GP contract commences.
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