Individual at Maidstone

Investigation into the circumstances surrounding the
death of a man in hospital, in October 2006 whilst in the
custody of HMP Maidstone
Report by the Prisons and Probation Ombudsman for
England and Wales
November 2008
This report considers the circumstances surrounding the death of a man in October
2006 at the local hospital. The man was in the custody of HMP Maidstone at the
time of his death. The post mortem concluded that he died as a result of hepatic
failure, caused by a history of alcoholism and hepatitis C which led to cirrhosis (liver
disease). The man was 49 years of age.
I extend my personal condolences to the man’s family and to all those touched by his
death.
One of my colleagues undertook the investigation with the assistance of the clinical
reviewer appointed by West Kent Primary Care Trust. I would like to thank the
clinical reviewer for providing a thorough clinical review of the care the man received
whilst in custody.
I would also like to thank the Governor of Maidstone and her staff for their
cooperation during this investigation. In addition, I am grateful to the clinical staff at
HMP Elmley, HMP Swaleside and at the hospital who have assisted the clinical
reviewer and my investigator in their enquiries.
Although he was a category C prisoner and nearly half way through a three year
sentence, the man died while still subject to restraint. My report considers why this
was so.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2008
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CONTENTS
Summary 4
The Investigation process 5
HMP Maidstone 7
Key findings 8
Issues
Clinical review 21
Findings related to prison policy and procedure 24
Recommendations with Prison Service response 30
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SUMMARY
The man had a longstanding history of drug and alcohol abuse before coming into
custody. He tested positive for three types of hepatitis – A, B and C. Although there
is no record of his taking illegal substances whilst in prison, concerns were raised
about a potential dependence on dihydrocodeine (DF118, an opioid analgesic). He
was repeatedly prescribed this medication for an injury sustained in 1992 and
declined to try other analgesics suggested by doctors.
The man had two hospital stays in 2006. In August 2006, he was diagnosed with a
pulmonary embolism (a blood clot on the lung), and in October 2006 he developed
cirrhosis of the liver and was diagnosed terminally ill.
Whilst in hospital, the man was accompanied at all times by two prison officers on a
bedwatch escort. He was also required to wear an escort chain. Both of these
measures are in accordance with security requirements, based on a risk
assessment. As the man’s condition deteriorated, his family and doctors at the
hospital asked for the restraints to be removed. The risk assessment for use of
restraints was reviewed on a weekly basis but each time concluded that the escort
chain should remain. The situation was revised on 22 October 2006, when a Duty
Governor visited the hospital and felt that another assessment might be justified
given the man’s continuing deterioration. A further assessment should have taken
place after this management check, but this did not occur and the man died three
days later, still wearing restraints.
His family continue to be unhappy with the security measures in place during the last
few weeks of his life. I consider the use of the escort chain in these circumstances
to have been both unnecessary and distressing for the man and his family. I would
like to have seen a more sensitive approach adopted, given his terminal and
deteriorating condition. Although the man was still mobile, he was weak and not
deemed an escape risk. It should have been possible to remove the restraints but
keep escort staff in place.
The clinical review concludes that, on the whole, the man received a good standard
of care based on sound clinical judgement. There are a number of concerns that are
highlighted relating to a more coordinated multidisciplinary approach to care planning
in prison healthcare.
Based on the clinical review, I make five recommendations and note two areas of
good practice. In addition, I make two recommendations of my own relating to
security measures.
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THE INVESTIGATION PROCESS
1. One of my colleagues opened the investigation on 31 October 2006. She
discussed the circumstances surrounding the man’s death with Maidstone’s
Governor. They agreed that all documents relating to the man would be sent to
the investigator for her to consider before she visited the prison.
2. My investigator asked a medical practitioner, West Kent Primary Care Trust
(PCT), to conduct a clinical review of the healthcare the man received in
custody. The investigator and the clinical reviewer agreed to hold joint
interviews with the healthcare staff at Maidstone who had provided medical
care for the man, as well as a number of discipline officers who had acted as
bedwatch escorts. These interviews were held on 10 and 31 January 2007,
and 15 February 2007. The clinical reviewer held further interviews with clinical
staff from HMP Elmley, HMP Swaleside and at the local hospital.
3. One of my family liaison officers contacted the man’s family to explain the
purpose of the investigation and arrange a visit. Both the FLO and the
investigator visited the man’s family on 11 January 2007. During this meeting,
the family raised a number of issues regarding security:
 Despite the man’s considerable ill health, he was not at any stage
released from restraints while in hospital. The family had requested for
over a week that they be removed, including a direct request to the Deputy
Governor. The family felt let down that the prison did not respond more
quickly in reassessing the security risk, considering the man’s terminal
illness and obvious deterioration in health and capabilities.
 The family understood that the man had a possible early parole date of 11
December 2006. They questioned whether this could have been taken
into consideration in assessing both the need for restraints and early
release on compassionate grounds.
 Staff had used a double length escort chain so that they could sit outside
the man’s hospital room. However, the family felt the reason for this had
not been properly explained to them by the prison.
4. The family also had specific issues regarding the man’s medical care:
 They questioned why it had taken a week to identify a blood clot during his
first inpatient stay at the hospital in August 2006.
 The family would like clarification whether the man was fit to be discharged
from hospital in August 2006. In addition, they asked whether the
diagnosis of liver failure could have been made earlier, as his health
deteriorated rapidly over the following two months.
 They would also like clarification why the man was discharged back to
Maidstone prison, rather than directly to inpatient facilities at HMP
Swaleside.
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 They were not happy with the level of support and counselling the man
received from nursing staff at the hospital on being told that he was
terminally ill. Indeed, the family was also distressed by the lack of support
they received in coming to terms with the man’s illness and the information
given to them. The man’s father was asked if his son was “for
resuscitation” before he had been told that he was terminally ill.
5. All but one of these issues are addressed in the main body of the report and the
clinical review. The clinical reviewer has not specifically commented on the
length of time it took to identify the blood clot in August 2006. However, she
clearly states that she believes the man received a high standard of appropriate
clinical care at the hospital.
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HMP MAIDSTONE
6. Maidstone is a Victorian prison that lies close to the town centre. The prison
holds up to 589 category C prisoners serving three years or more. There are
four main residential wings.
7. Healthcare at Maidstone is provided by West Kent Primary Care Trust (PCT).
The prison does not have a 24 hour healthcare facility and has limited scope to
care for someone with complex medical issues. Prisoners requiring inpatient
(but not hospital care) are usually transferred to HMP Swaleside where 24 hour
healthcare facilities and inpatient beds are available.
8. The healthcare unit is open from 7:45am until 8:15pm, Monday to Friday.
During the weekend it is open from 8:00am to 5:15pm. There is one person on
duty during this time. The same staffing level applies to weekday evenings.
9. Maidstone has a full-time nursing team. In addition, there is a team of GPs
shared by the three prisons within the PCT. (The other two prisons are
Swaleside and Elmley.) The GPs work on a part-time basis. At Maidstone, GP
surgery hours are 9:00am-12:00noon, Monday to Friday. The same GPs do
not always attend the same prisons, so it is sometimes difficult to guarantee
continuity of care. As part of the service level agreement with the PCT, there is
an on-call GP who can attend the prison if there is a medical emergency.
10. An unannounced inspection undertaken by Her Majesty’s Chief Inspector of
Prisons in 2004 reported that, “there are good links with the primary care trust
and other healthcare providers, and a very good system of clinical governance
had been established.”
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KEY FINDINGS
11. The man was arrested and taken into police custody on 10 June 2005. He was
transferred to HMP Elmley the following day under the direction of the
Magistrates’ Court.
12. Every prisoner coming into custody is subject to an initial health check. On
arriving at Elmley, The man was seen in reception by a nurse. He told her that
he had been in Hospital the previous week, but could not remember why. He
could not name all the medications he had been instructed to take, but did say
that he was currently taking diazepam and dihydrocodeine. (Dihrydocodeine is
an opioid analgesic (painkiller), normally used to treat severe pain or a severe
cough.) The man referred to his history of alcohol abuse. He also mentioned
that he had once been treated at a psychiatric hospital. The man could not
explain why he had been a patient there. The nurse noted no physical signs of
alcohol withdrawal. The man also said that he was an epileptic, but could not
say what medications he took, how often or what dose. He never referred to
the epilepsy again whilst in custody.
13. After this initial screening, the man was referred to the medical officer for a
second and more in-depth health screen (a requirement for every new
reception at prison). During this assessment he was prescribed inhalers and
chlordiazepoxide (commonly known as Librium), along with vitamin
supplements to manage alcohol withdrawal.
14. He was also referred to the substance misuse team and mental health in-reach.
15. The prison doctor of the substance misuse team saw the man on 14 June. The
man saw a nurse from the mental health in-reach team the following day. He
showed no signs of mood disorder or psychotic symptoms. Neither did he
declare any history or intention of self-harm or suicidal thoughts. He did say
that he had not been prescribed any diazepam or dihydrocodeine. It was
concluded that he would not need any further input from the mental health
team, but he was recommended to see the doctor regarding his prescriptions.
16. The man next saw a nurse on 21 June, complaining of swollen ankles. He told
the nurse that this occasionally happened. The nurse noted that his right leg
was notably “bigger than the left one” by 2cm in diameter. There were a
number of varicose veins on this leg and he experienced pain in his ankle on
flexing his foot. The nurse recommended that he see the medical officer the
following day. The man did not follow this up.
17. He next saw a member of healthcare on 27 June. Blood tests were ordered
and he asked about being prescribed sleeping tablets. It is not clear what was
done about his request. He was again referred to the substance misuse team.
18. On 15 July, the man had a doctor’s appointment. He complained that his
dihydrocodeine dosage was not high enough. He also said that he felt
depressed, was not eating properly and was still having difficulty sleeping.
However, it was noted in his medical record that he “looked well”. The doctor
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19. Aside from a chest infection in August, the man had no further health
complaints until September. During a triage clinic on 2 September, he asked
for one of his inhalers to be changed as he had been experiencing panic
attacks on taking a dose. The man also asked for his dihydrocodeine to be
given in-possession, rather than having it dispensed daily. This request was
granted during an afternoon appointment with the doctor and he was given 28
40mg tablets. A repeat prescription was issued 21 days later.
20. On 7 October, the man told a nurse that he had not been receiving his
prescribed medications (namely the dihydrocodeine) since they had gone
missing in reception when he went out to court. The nurse who was on
reception during the day that the man went to court said that she had issued
him with 28 tablets of dihydrocodeine on 30 September and that the man had
signed for them on return from court. It was noted in his medical record that he
should now receive them on a daily basis. Despite this, on 21 October a further
repeat prescription was issued for a month’s supply. The doctor’s entry in the
medical record, accompanying the issue of the prescription said that the man
should stop taking this particular medicine, as it was not recommended for
asthmatics. This is the first reference to such a caution in his records.
21. On 23 December, a triage nurse referred the man to a medical officer as both
of his legs had swollen. He was experiencing “pins and needles” and had a
high temperature. The doctor noted that his right leg was bigger than the left,
but “not swollen”. He was prescribed betnovate cream for a patch of eczema
on his lower leg.
22. The man returned to the healthcare unit on 10 January 2006. He said that “his
stomach ulcer had burst”. A nurse advised him to stay in healthcare and be
seen by the doctor. He declined, saying that he felt unwell and just wanted to
go back to his cell. The nurse stressed that this was not a good idea and
encouraged him to wait. The man ignored the advice and returned to his
houseblock. He was next seen on 13 January, when he went back to
healthcare complaining of pains in his legs. The doctor prescribed
dihydrocodeine and lansoprazole. (The latter is a medicine used to treat
stomach ulcers.)
23. On 20 and 31 January, blood tests were taken to assess the condition of the
man’s liver. It was noted that there was no evidence of liver disease at this
time. However, his platelet count was low and he would need another blood
test in two months time.
24. On 24 February, the man was sentenced to three years imprisonment and
taken back to HMP Elmley. He continued to be prescribed dihydrocodeine (but
not in-possession) and his antidepressants. There is no record of him ever
being reviewed for depression, or of any further investigation into his occasional
leg pains.
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25. On 7 April, a doctor from the local hospital wrote to the man, care of his father’s
home address. The letter said that the man had not been seen for “some time”
at the gastroenterology outpatients’ department. The doctor was concerned
that further investigations had not been undertaken and that he would need to
be assessed. The man was not able to attend any scheduled outpatient
appointments as the letters had not reached him in prison.
26. On 21 April, a prison doctor examined him. The man said that he was “in dire
pain” with his left shoulder. His prescription was altered to reduce the
dihdyrocodeine to 30mg and introduce paracetamol to better manage the pain.
The man was also referred to a physiotherapist.
27. The man returned to healthcare on 28 April, complaining that his pain had
increased due to the reduction in dihydrocodeine. The prison doctor contacted
the man’s GP in the community to discuss his ongoing pain and see how it had
been previously managed. The GP said that the man had only received
dihydrocodeine in the past for backache, and he was not aware of a
shoulder/upper arm injury. Given this information, it was decided that the man
should have an x-ray to better understand his complaint. The GP agreed with
the prison doctor that the lowered dose of painkiller should continue at 30mg.
The results of the x-ray were made available on 19 June. This confirmed an
old injury to his shoulder and upper arm.
28. On 27 June, the man had chest pain and asked to see a medical officer. He
asserted it was an infection, but he did not have a cough and asked for
dihydrocodeine. A doctor’s entry notes that the man did not appear
uncomfortable or in pain. Despite this, he insisted he had pains in his legs,
shoulder, chest and various other places. The doctor referred back to his
colleague’s entry on 21 April and wrote:
“I very much doubt that he needs dihydrocodeine and do not understand why
it continues to be prescribed despite several doctors’ wish that it be
discontinued.
[The man] did not wait very long after he saw me reading the notes and left
saying he would approach another doctor for this.
If it is prescribed please explain the clinical indication.
He probably has more need to address his addiction
N.B. Says GP prescribed it outside but this is untrue. GP says only codeine.
We really need to present a concerted approach to his demands.”
29. There was a further explicit entry in the man’s medical record, written by
another prison doctor on 29 June:
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“Please will all doctors read entry by my colleague 27 June 2006 because
there has not been strong evidence for prescribing dihydrocodeine. Heroin
background.”
30. The following day, the man was declared fit for transfer and he was taken to
HMP Maidstone. A first screen health check was completed by the duty nurse.
The man was later seen on 4 July by a locum doctor for a further check up.
The doctor correctly noted the previous entry alerting medical staff to the man’s
demands for dihydrocodeine and he refused to prescribe. He noted that there
was no clinical indication for prescribing that particular analgesic and he offered
him a different painkiller. The man declined.
31. At Maidstone, the man was initially placed in a double cell. He was not happy
sharing and was quickly moved to a single cell. On 30 July, the man
complained to healthcare staff of nausea, which he associated with the new
painkiller (zydol). The duty nurse noted that he appeared slightly jaundiced.
Nothing further was noted on this day. The clinical reviewer and my
investigator were told by the head of healthcare that an appointment was made
for him to see the doctor the following morning. This is not clear from the
notes.
32. By the time the man saw a doctor (it is not clear from the signature which GP
attended), he was experiencing right side abdominal pain; this area was tender
to touch. He was noted to be passing dark coloured urine. Blood tests were
requested and he was admitted to the local hospital, escorted by prison officers
and in restraints. This was appropriate and in compliance with prison security
requirements, given his assessed risk to the public.
33. The man remained in hospital whilst tests were conducted. He had an
ultrasound scan of his kidneys on 2 August, followed by a further scan on 4
August. The head of healthcare telephoned the hospital for daily updates. On
10 August, she was told that the man had been diagnosed with a pulmonary
embolism (a blood clot on the lung) and a secondary diagnosis of cirrhosis of
the liver. He was treated with the anti-coagulant warfarin, which prevents
clotting, and his analgesic was changed. A further update was given on 14
August. The man was now receiving a low protein diet and fluid restrictions
were in place. Tests were taken to see if there was any worsening in liver
function. The man was discharged back to prison later that day with the
following medications:
 combivalent and seritide inhalers (for his asthma/emphysema)
 lansoprazole (for his stomach ulcer)
 warfarin (to prevent further blood clots)
 lactulose (laxative)
 spironolactone (diuretic)
 mirtazapine (antidepressant)
 zomorph (opioid based analgesic)
38. The discharge instructions from the hospital were for him to continue taking
these medications and have an international normalised ratio (INR) test taken
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39. On 15 August, the man was called to healthcare to see the GP. He declined
to attend. Likewise, he did not attend when called to collect his zomorph and
mirtazapine. The man did not feel able to walk the distance to the healthcare
unit, and staff therefore offered him the use of a motorised chair to move
about the prison. He declined and did not want to get out of his bed. That
evening, his medications were brought to his cell. The duty senior officer said
he would speak to him the following morning about a transfer to HMP
Swaleside, where inpatient bed facilities were available.
40. The Head of Healthcare contacted the local hospital on 16 August to clarify
the man’s condition, mobility and physical needs prior to discharge. It was
confirmed that on discharge he was able to move around and to look after
himself. When considering the discharge, they did not expect him to require a
great deal of assistance. Given this information, she went to see the man.
She noted in his medical records that he walked to the wing unaided, but was
unsteady. The man maintained that he was still unwell and refused to walk to
healthcare for supervised medication but again declined the offer of a
motorised buggy. The head of healthcare explained the importance of
keeping mobile especially in light of his recent embolism. She reassured him
that his blood test (INR) had been booked in for the following week. It was
recorded that he was not happy with any of their discussion and returned to
his cell. The head of healthcare asked discipline staff on the man’s wing to
encourage him to walk to collect his meals and move about for short periods
in the day.
41. The man collected his medication on 17 August. He walked unaided and
appeared steady on his feet. However, he maintained that he would only
make one trip to healthcare each day so would pick up his medications the
next day when he went to see one of the prison’s part-time GPs.
42. The GP noted in the man’s medical record that he appeared pale, weak and
lethargic. It was his opinion that the man had been discharged from hospital
too soon and required bed rest. He noted that Swaleside had already been
contacted about the possibility of taking him as an inpatient; however they
were unable to take him at that time. The man again requested
dihydrocodeine to manage his pain. Despite former warnings in his medical
record, this was prescribed to him - 40mg twice a day. No clinical explanation
was given in his medical notes. During interview, the clinical reviewer asked
the GP why he had prescribed dihydrocodeine. He said that the man, “had an
addiction to dihydrocodeine, but this was irrelevant compared to the severe
pain that he was suffering and this was my clinical decision for him to continue
dihydrocodeine.” The man saw the GP again on 25 August and told him he
was still in pain. The dihydrocodeine was increased to three times a day.
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43. Entries in the man’s wing history sheet by discipline officers record that the
man appeared to be coping, but was not one hundred per cent well. He was
spending a lot of time alone in his cell, mainly due to his illness. Officers
encouraged him to walk about as per healthcare’s advice. A letter arrived on
30 August from the outpatients’ department at the local hospital, postponing
his appointment from 26 October to 15 November. No reason was given.
44. The prison GP next saw the man on 6 September. He noted that the man
was breathless, unable to sleep and mildly jaundiced. The man complained
that the dihydrocodeine was not working. The GP increased his prescription
to four times a day and wrote, “he needs to be an inpatient for sometime until
he is on his feet. Unable to walk from wing to the healthcare.” The man was
transferred to HMP Swaleside as an inpatient later that day. An escort risk
assessment was completed. The man’s risk of escape and to the public was
rated as medium. The assessment also noted that he was only able to walk
short distances.
45. On 7 September, Swaleside healthcare telephoned the head of healthcare at
HMP Maidstone to ask for the man’s last INR reading (to measure blood
clotting). It was 3.1, slightly higher than on leaving hospital. An entry in the
man’s medical notes on 11 September stated that he seemed to be managing
well, but was having some trouble sleeping. He was prescribed zopiclone
(sleeping tablets) and an iron supplement.
46. An INR reading was taken on 14 September. This showed that the man’s
level had dropped to 1.1 and his warfarin was increased from 3mg to 5mg. By
21 September, it had increased to 1.9. There were no further entries in his
medical record until 2 October. On this date, an entry noted that the man had
been asked to collect his medication from the healthcare office. He had
refused, saying he felt unwell and his chest was sore. A peak flow meter
reading was taken, but his breathing technique was very poor and only gave a
very low reading of 250. (A peak flow meter measures the rate at which a
person can expel air from their lungs.) It was noted that his ankles appeared
swollen. Further examination showed water retention (pitting oedema) which
can be linked to renal failure, liver failure and heart disease amongst other
illnesses. The examining nurse’s concerns were discussed with one of the
prison’s GPs who said that he would attend to the man.
47. An ECG was performed and the GP saw the man at 10:50am. No time had
been written against the earlier entry, so it is not possible to say how much
time had passed between the examinations. The GP requested an updated
INR test, but the last blood test was under-filled so it was not possible to give
a reading. The test had to be repeated.
48. On 5 October, the man attended an outpatient appointment at the
gastroenterology unit at another local hospital. After this, there were no more
entries in his medical record until 10 October when the man’s condition was
reviewed. The GP referred him to the medical registrar at the local hospital
“for advice/review” and he was taken to the medical assessment unit in the
accident and emergency department. The GP’s referral letter gave the man’s
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49. The man was admitted to a ward for further assessment. A hospital risk
assessment form was completed by the duty doctor on 11 October. (This is a
standard form which must be completed in all cases when a prisoner is
escorted to outside hospital. Its purpose is to ascertain the appropriate level
of escort and type of restraint to be used.) In the section to be completed by
prison medical staff, it was noted that there were no medical objections to the
use of restraints in the man’s case. The duty officer assessed him as being a
low risk to the public in terms of hostage taking and potential for escape.
However, given the nature of his offence and his mobility, he was required to
wear an escort chain (a length of chain attached to a single handcuff at each
end) at all times and be accompanied by two discipline officers. The escort
chain would only be removed in a medical emergency or for medical
treatment. (It is worth noting at this stage that the security risk for any
prisoner on bedwatch is regularly reviewed. Depending on the person’s
mobility or level of sickness, it can be reduced or heightened following
governor level authorisation based on a risk assessment.)
50. On 12 October, the man was moved to a side room. He was subject to barrier
nursing to control any possible spread of infectious disease such as hepatitis.
(Barrier nursing means that a patient is isolated in a separate room and
nurses wear protective clothing, such as gowns, masks and sometimes
rubber gloves to minimise the risk of passing on infection. All equipment,
utensils and bedding that have come into contact with the patient are
immediately sterilised.)
51. The man received oxygen therapy via a mask to aid his breathing,
intravenous fluids and fluid balance monitoring. A computer topography (CT)
scan was requested. (This produces a cross section image of the head and
body, which is then analysed by computer.) The next day the man refused
the paracetamol offered for pain relief. The escort staff telephoned the head
of healthcare to advise her that the man’s condition had been diagnosed as
terminal. The duty governor was informed and the man’s next of kin details
obtained. Although the man’s sister was already aware of his illness – she
had been in regular contact with Swaleside’s chaplaincy and had seen him in
hospital during his previous inpatient stay – it was necessary to officially
inform the family. The man’s consultant asked the prison to consider
releasing him from custody on compassionate grounds.
52. The man remained in the side room with two escorting officers. As he was
still able to get out of bed and walk unaided, the risk assessment for security
measures remained the same. He continued to wear an escort chain. The
other end of the chain was handcuffed to one of the prison officers. The
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53. The man continued to refuse paracetamol and only accepted minimal nursing
contact on 14 October. It was noted in the bedwatch log that he was refusing
all attempts to get him mobile and improve his hygiene. He preferred to
remain in bed. He developed left sided chest pain which was treated with
glycerine trinitrate spray (GTN).
54. The man’s sister visited him in hospital. She expressed concern about his
resuscitation status which had been inappropriately raised earlier. On arrival,
the man’s father had been asked whether the man “was for resuscitation”.
This question was posed to his father before formally explaining to him that
the man was now terminally ill. Senior medical staff were not available for
further discussion with the family and arrangements were made for a future
meeting with doctors to discuss the issue.
55. The man removed his intravenous drip and neither nursing nor medical staff
were able to successfully reinsert the needle. The hospital notes indicated
that the man should not be given either opiates, sedatives or dihyrdocodeine.
He was prescribed paracetamol for pain management, but he told staff he
would not take it. He continued to refuse paracetamol on 15 October, along
with all oral medication. He also refused to attend to his personal hygiene.
56. On 16 October, medical staff spoke to him, his father and sister. They
discussed the results of diagnostic tests, his poor prognosis, the importance
of taking his medications and the implications of his refusal. The man wanted
a stronger analgesic than paracetamol, but this was refused due to the
condition of his liver. He started to become uncooperative and verbally
aggressive towards nursing staff.
57. The hospital records indicate lengthy continuing discussions with the family
throughout the day regarding the man’s condition and prognosis. At this point
his resuscitation status was declared as ‘not for resuscitation’. The man was
also seen by the Macmillan Palliative Care Team, with a view to commencing
the Liverpool Care Pathway. (This is an integrated care pathway developed
in the late 1990s by palliative care specialists at Royal Liverpool and
Broadgreen University Hospitals with the Marie Curie Hospice in Liverpool. It
was created to improve care for dying patients and their families outside of a
hospice and is considered to be the gold standard in care for the terminally ill.)
58. Hospital records also show long conversations with the bedwatch officers on
duty that day. Further diagnostic tests had revealed severe oesophageal
varices. (This is a complication of cirrhosis - the varices are abnormally
enlarged veins in the lower part of the oesophagus. They develop when
normal blood flow to the liver is blocked. The blood backs up into the smaller,
more fragile blood vessels in the oesophagus, causing them to swell. The
varices do not present any symptoms unless they rupture and bleed.) As a
result of the oesophageal varices, the man could potentially have posed an
infection risk to the escorting staff.
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59. Given the risk of infection, it was agreed that the officers should be relocated
outside the man’s room and extended escort chains would be applied. The
man’s family complained to medical staff about the use of handcuffs. A doctor
asked the escorting officer on duty to remove the restraints. The officer
explained the prison’s security policy. As long as the man was still able to get
out of bed and the risk assessment considered him to remain a potential risk
to the public, the restraints would remain.
60. A review of the risk assessment took place that day. It took account of his
poor prognosis, but noted that he was still capable of moving himself about
unaided. The conclusion was that he should remain in restraints for the time
being and the decision would be regularly reviewed.
61. Escort officers notes showed that, despite the doctors and family’s concerns
regarding the restraints, the nursing staff on the ward were content for him to
remain restrained due to his infectious state. They felt it was safer for the rest
of the ward if the potential for risk of infection could be minimised by
restricting his ability to move about the hospital. The clinical reviewer asked
nursing staff about this. She was told that all decisions taken regarding how
and where to nurse the man were based on clinical need rather than his
status as a prisoner. She was also told that consideration had been given to
issues of dignity, as well as the potential disruption and distress to both the
man and other patients.
62. The ward sister telephoned Maidstone prison healthcare to tell them that the
man would need palliative care. Maidstone told her that this could not be
provided due to the absence of inpatient facilities, but they would contact
Swaleside to see if he could be temporarily transferred into their care.
63. The man’s family remained with him during the evening. His sister again
asked for the restraints to be removed and this was noted in the bedwatch
log. The escort officer again explained why they could not be removed and
that he did not have the authority to make the decision.
64. During the early hours of 17 October, it was noted in the bedwatch log that
one of the ward nurses told the officers that she would not feel safe around
the man if he was not restrained due his “rude and threatening” attitude at
times. The officer added that the man had been civil at all times during the
evening.
65. Later that day, the man’s consultant again raised concerns about the use of
restraints. He was told by an escort officer that the prison had instructed that
they remain. There was also further reference to nursing staff wanting the
man to remain restrained to minimise the risk of infection. The wing senior
officer told the escort officer that the consultant had now made two requests
to remove the escort chain and “this is not to happen”. The escort officer was
told that all requests for their removal were to be logged and the prison
informed.
16
66. The consultant spoke to the GP at HMP Maidstone about the possibility of
the man’s early release from custody on compassionate grounds. An officer
emailed the relevant forms, extracted from chapter 12 of Prison Service Order
6000 (early release on compassionate grounds), to the Governor, healthcare
and probation. She requested completion and return to her in the custody
office for collation.
67. The man did not fully comply with his medications, refusing all oral medicines
after teatime on 18 October. He had told a nurse earlier that day that he did
not have long left to live, and did not want to prolong it, but made it clear that
he had no intention of taking his own life. A Macmillan nurse visited him and it
was noted in the bedwatch log that he did not require her assistance.
68. The consultant again telephoned the prison GP. He reported that the man
was lucid but refusing treatment. He confirmed that the man was terminally ill,
but commented that it was difficult to predict how long he had to live. There
was a high possibility that severe internal bleeding could happen at any time.
At this time, the man was still able to walk around and fully aware of his
environment.
69. The prison GP wrote to the consultant and to another doctor (at the local
hospital) enclosing the early compassionate release forms. He asked them to
complete their section and return it to him. The prison’s GP stressed that both
the man and his family were pressing for early compassionate release so that
he could be made more comfortable without the restraints. He highlighted
that, before agreeing to the early release, the medical team at the hospital
had to feel sure that death was imminent.
70. Meanwhile, a prison probation officer completed his section of the report.
This was done purely as a paper exercise based on previous probation
reports as he had never met the man. The probation officer concluded that the
risk of re-offending and harm on release on licence remained high. He noted
that during his sentence the man had done little to address his offending
behaviour or substance misuse issues. Neither had he proved to be
cooperative or positive in attitude in discussions with his probation officer. He
felt that the man could still potentially be violent to others.
71. The man’s family visited him every day and continued to request that his
restraints be removed. On 19 October, the escort officer again explained at
length that he was unable to remove the restraints and that only the duty
governor had the authority to order their removal.
72. The man became increasingly restless and rude towards nursing staff,
particularly at night. His behaviour was to be reported to the prison and the
man was cautioned by escort staff. However, staff acknowledged that his
behaviour was linked to his increasing discomfort and frustration caused by
his illness. His pain was becoming unmanageable on his current dose of
morphine and so it was increased. On 21 October, the restraints were
removed briefly to place a bandage underneath to stop it rubbing against his
wrist.
17
73. The deputy governor visited the man on Sunday 22 October to undertake a
bedwatch management check and assess the security situation. She spoke
with a staff nurse who told her that the man was deteriorating and that it could
be two to three weeks before he died if the decline in his health continued.
She said there was a risk of infection to staff if he left the room and collapsed,
as staff might not be aware of his hepatic status. In light of this, the nursing
staff were happy for the man to remain in restraints. The deputy governor
noted that the man’s escape risk at this time was very low. Based on her
assessment, she recommended that the restraints remain, but that the escort
chain be doubled in length to be more comfortable. On return to the prison,
she wrote to Governor outlining the situation and recommending a risk
assessment review. The deputy governor wrote:
“The man is in a side ward on the second floor. The windows can be
fully open and a fit man could attempt to climb out of the window,
however to do this he would have to climb onto the window sill and also
successfully drop from the window without injury from quite a height.
He states that he has a history of back problems and received disability
allowance before entering prison.
He is conscious, but the nurse stated that he falls in and out of being
alert and is sometimes confused. Whilst I was present he got out of
bed and sat in the chair, however this was a struggle for him and he
had to be propped up with three pillows. He is obviously very
uncomfortable as he got back into bed after a short time, and then
whilst I was talking to the staff, got himself out of the bed and back onto
the chair again, which is next to his bed. He continuously moans and
groans because of his pain…
… I talked through the possibility of uncuffing him but staff remaining
outside the door. The staff nurse stated that she felt it was unlikely that
his health would allow him to move far, although she couldn’t totally
commit herself to his condition.
He had been able to walk to the toilet, which is just opposite his room,
however the hospital have stopped him using it for fear of infection and
therefore he remains in his room. Whilst I was there he complained
that his feet and legs hurt. They are very swollen and completely
white.
His escort risk assessment shows that he is enhanced with no
concerns regarding his behaviour.
The sister has asked staff if he can come off his chain and they
suggested that she speak to the Governor.
I believe that there is a very low risk of this offender trying to escape. I
suggest that there is also a low risk of the family attempting to take him
18
away from the hospital should he be uncuffed. He has made no effort
to try to move or do anything that the hospital say he can’t do.
Should we direct that he be uncuffed, there is a window leading into the
room where staff can have full view of the offender. Hospital staff have
stated that he will remain in that room for the rest of his time at the
hospital. Whilst I appreciate that security is paramount, I believe that
there would be a low risk of escape should we leave him uncuffed with
staff remaining outside his room. I am happy to speak to the sister to
assess the risk of him attempting to leave, prior to us making the
decision should you wish.
His PED [parole eligibility date] is December 2006 and his condition
and decline is very undignified for the family members that do visit
him.”
74. This document was left for Governing Governor to consider on the morning of 23
October. It is not clear what was done with the information. My investigator
interviewed the Governor and the deputy governor. They both remembered
discussing the issue during the morning operational meeting, but could not recall
what action had taken place as a consequence. The Governor told my
investigator that she would normally instruct an urgent risk assessment review to
consider the deputy governor’s recommendations. Unfortunately, she could not
remember asking for this to be done. My investigator checked with the prison’s
security department to see if a review was requested at the time. They had no
record of the request.
75. Later that day, the head of healthcare contacted the ward nurse for an update on
the man’s condition. She was told that his condition was very poor. The head of
healthcare noted in his prison medical record that “efforts continue to facilitate
compassionate release”.
76. The man’s family visited him again that evening. His sister asked to whom she
needed to speak to get the restraints removed. She was advised by an escort
officer to contact the prison. Her request was again noted in the bedwatch log
book. During the night, the man became increasingly restless and was noted to
be talking to himself continuously throughout the night. At 6.00am on 24
October, he tried to leave his side room. He told officers “you won’t stop me
going to the toilet”, but was told to go back in his room and that the nurse would
attend with the commode. The commode was brought in and removed, as and
when required.
77. The man’s father visited him during the afternoon. On leaving at 4.30pm, the
father told the escort officers that he believed that the man was not fully aware of
his surroundings. At midnight, the man pressed his alarm bell and a nurse
attended. It was noted that he was incoherent. Nursing staff tried to make him
more comfortable and commented that they believed his condition had
deteriorated. Hospital staff informed his sister of the situation.
19
78. The man passed away at approximately 1.10am on 25 October. The man’s
sister arrived at the hospital at 1.35am and was informed of his death by the staff
nurse. A site practitioner pronounced the man’s death at 2.50am. The duty
governor was notified and the bedwatch escort returned to the prison.
79. The next morning, the principal officer (PO) who is also the family liaison officer
at Maidstone prison, notified the Coroner’s office of the man’s death. The
Coroner’s officers had not been aware of the death until this time. The PO then
telephoned the man’s listed next of kin, his father, who had already been
informed of the man’s passing by his sister. The PO next rang the man’s sister
on the instruction of Governing Governor. His sister was very angry due to the
unresolved issue of the man remaining in restraints at the point of his death. Her
contact with the prison and the issue of restraints had been, from the family’s
point of view, deeply unsatisfactory. The man’s sister told the PO that she had
telephoned the prison three times and had been unable to speak to anyone,
aside from a chaplain who advised her to write to the Governor about the matter.
The PO took note of her concerns and offered to visit the family. This was
declined. The PO then agreed that she would telephone the man’s sister in a
few days.
80. Unfortunately, the PO had to telephone the man’s sister 10 minutes later to
inform her that the Coroner needed a member of the family to identify the body,
before a post mortem could take place. The PO explained why a post mortem
was required. She also offered to attend the hospital with the man’s sister for
support, but this too was declined.
81. A couple of days later, the PO again contacted the man’s sister to arrange the
return of his belongings. She also offered assistance in arranging the funeral,
including a financial contribution towards the cost. A visit to the prison took
place on 30 October.
20
ISSUES
Clinical review
82. A medical practictioner conducted the clinical review on behalf of West Kent
Primary Care Trust. This section summarises her findings and
recommendations.
Medical History
83. The man had a long-standing history of drug and alcohol abuse. Assessments
throughout the early days of his time at HMP Elmley established that he was
being prescribed chlordiazepoxide for alcohol withdrawal, had no history of self-
harm, and had previously tested positive for hepatitis A, B and C. The man
complained of inability to sleep due to constant pain for which he requested
dihydrocodeine (DF118) and sleeping tablets. He was also prescribed a
combivent inhaler to manage episodes of breathlessness. Some years
previously, the man had suffered a bone injury to his left upper arm and
shoulder.
84. Prison healthcare records show that the man was referred appropriately to the
substance misuse team, and the in-reach team at the psychiatric hospital, as
part of his initial assessment at Elmley.
85. Between June 2005 and June 2006, the man attended prison healthcare on
many occasions. In the majority of instances he complained of pain either in his
shoulder or in his lower limbs. The man was heavily reliant on DF118 for pain
control, and had been prior to his last conviction.
Findings
86. The man’s family asked the investigator to find out whether his liver disease
could have been identified at an earlier stage. Owing to his longstanding drug
and alcohol abuse, the man was susceptible to liver disease. Although the
clinical review did not consider his earlier medical history, the clinical
interventions during his time in custody would have covered the risks of liver
disease as a result of his substance abuse (through the referral to the substance
misuse team) and his hepatic status.
87. The man was diagnosed as having hepatitis A, B and C – all of which are liver
diseases. Patients with these conditions can be symptom free and therefore not
diagnosed until the disease is well established and further complications have
occurred. They can also present with inflammation of the liver, and jaundice
which could have masked any symptoms indicating onset of any further liver
disease. The scans and medical care that the man received were appropriate,
given that his use of alcohol and drugs had been curtailed in prison and his liver
would therefore have had time to recover. The liver is one of the few organs
which is capable of natural regeneration of lost or damaged cells. However, for
patients who have been relatively symptom free, the long term complications,
including cirrhosis, could be well established before symptoms occur.
21
88. On several occasions, the date of the man’s next hospital outpatient
appointment was checked by prison healthcare staff to ensure that it was
appropriate for his presenting physical condition. When his condition was
deemed to require an earlier appointment, this had been arranged. The degree
of his jaundice and any sign of it getting worse were taken into account and
informed this decision.
89. The man was appropriately referred to medical staff each time he specifically
complained about his swollen and painful legs. However, it appears that during
most of the subsequent examinations the man indicated that the pain had moved
to another part of his body, such as his shoulder or arm, with his leg no longer
being of concern. Ideally, nursing staff should have undertaken a Doppler test
prior to the doctor seeing him at both Elmley and Maidstone prisons. The
Doppler test is an ultrasound scan. A probe that emits ultra sonic waves is held
over the lower part of the leg where you would expect veins and arteries. The
speed at which the waves bounce back gives an indication of blood flow in the
area. Elmley do not have the equipment to do this test, but could have asked a
district nurse to come in and conduct it for them.
90. During the man’s time as an inpatient at the local hospital, decisions taken about
how and where to nurse him were based on clinical need rather than his status
as a prisoner. The man’s dignity, and the potential disruption and distress to
both the man and other patients were factors considered in the decisions made
by both ward sisters to nurse the man in a side room.
91. Issues of concern about the discharge planning process are noted below.
However, the reviewer is satisfied that the decision to discharge him from
hospital to HMP Maidstone was made using the same clinical and social care
criteria as would be used for any patient. From that perspective, there was
equity of service provision. However, a disparity arises as the home
circumstances of a patient in the general community differ greatly from those of
the prison population. The most pertinent difference is that a patient in the
general population has easy access to their medication. By comparison,
medication of any kind is valuable currency within prison, to the extent that some
medications are deemed not suitable to be held in possession. Due to the size
and layout of some establishments, the prisoner may have a considerable walk
and potentially a number of staircases to negotiate. The reviewer says these
kinds of issues should be considered when making decisions about the
discharge destination for patients coming back into the prison community.
92. The man’s family asked whether the length of time taken (approximately one
week) to identify the blood clot on his first admission to the local hospital on 31
July 2006 was acceptable. The clinical reviewer raised this with a sister (Local
Hospital) during interview. The sister said that a blood clot was already
suspected by the time he had reached the ward. Having been taken to hospital
on 31 July, the man arrived on the ward on 2 August from the medical
assessment unit where initial assessments had been carried out which led to the
diagnosis of a blood clot. The clinical reviewer concluded that this was not an
unreasonable length of time.
22
93. The reviewer judges that all infection control, equality, diversity, and clinical
governance policies were adhered to by both the local hospital and prison
healthcare staff.
Issues of concern
94. The clinical reviewer says that, although the man received a high standard of
clinical care based on sound clinical judgement, some areas of concern required
improvement:
 Some entries in the continuous medical record were illegible.
 Lack of compliance, mainly by medical staff, with record keeping policy
requirements. At each entry the prison establishment, date and time and
name of person making the entry should be stated clearly at the beginning of
the entry.
Standards of record keeping and documentation should be included as a
specific item in the performance monitoring and appraisal system for
medical staff employed by PCTs to work in prison healthcare.
 Lack of multi disciplinary care planning in prison healthcare. This led to:
o Lack of a co-ordinated approach to management of the man’s well
documented and long standing drug dependency, particularly in
relation to his use of dihydrocodeine.
o Poor discharge planning after first admission to the local hospital,
compounded by a lack of appreciation and understanding of the
security issues facing prison healthcare when patients are being
transferred back to their care. As a result, prison healthcare staff were
unable to make an informed assessment of the man’s mobility and
healthcare needs prior to his return to HMP Maidstone. This gave them
nothing to compare his behaviour and ability to once he was back on
the wing.
o General lack of awareness and understanding amongst hospital and
community based medical and nursing staff of the security issues
relating to the care of offenders.
The clinical reviewer makes the following recommendations in regard of these
specific issues:
Introduction of a requirement to hold a multidisciplinary case conference to
take place as soon after reception into a prison of any offender with a
known long-standing medical problem or condition. This case conference
would agree the management plan to be followed by all medical and nursing
staff.
23
A review of documentation with a view to developing a format for the
recording and transmitting of the agreed management plan to all staff,
especially in the event that the offender is transferred from one
establishment to another.
Development of a specific discharge protocol related to the safe discharge
of a patient back to a prison establishment.
The National Health Service in conjunction with the Prison Service should
consider awareness raising training for staff working in traditionally non-
secure environments caring for offenders. Alternatively, depending on the
likely frequency of offenders requiring care outside the prison healthcare
settings, the development of shared guidelines for best practice that can be
issued to all staff wherever the situation arises.
Good practice
95. Throughout the clinical review, a number of areas of good professional practice
are identified. There are two in particular worthy of repeating here.
Tracking of appointments
Throughout all transfers between prison establishments, details of outpatient
appointments for the man were checked to ensure none was missed or that
alternative dates were reasonable in terms of length of waiting time, depending
on the urgency of need.
Quality and detail of bedwatch record.
In all cases the bedwatch officer’s notes in the bedwatch records were extremely
detailed, correctly timed and signed. The only additional improvement that
would make following them easier would be the inclusion of a date at every first
entry after 23.59hrs.
Findings related to prison policy and procedure
Transfer from hospital
96. I would like to comment further on the last two observations made in the clinical
review. The head of healthcare at Maidstone prison maintained during interview
with my investigator that it is part of her duty to facilitate an appropriate transfer
from hospital back into custody. She said that the healthcare department
actively try to get involved as soon as the hospital begins developing a discharge
plan. The aim is to get a prisoner who needs a recovery period (that does not
require a bed in hospital) transferred directly to Swaleside’s inpatient facilities.
Despite these good intentions, this did not happen in the man’s case. Although
he was admitted to hospital on 31 July, it was noted in his prison medical record
that by 14 August there was still no discharge plan. Yet, later on in the day, a
further entry was made indicating that he was to be discharged and returned to
24
97. On his return to Maidstone, it was soon acknowledged that, contrary to the
hospital’s recommendations, the man would be better cared for at Swaleside as
an inpatient. Although healthcare staff at Maidstone made every effort to
accommodate his needs, at times he still struggled to walk to healthcare to pick
up his medications and he was visibly pale and weak. The man was said to be
very unhappy with his situation and felt that being on a normal wing he was not
receiving the level of care that he needed. The Head of Healthcare telephoned
the hospital to discuss the discharge plan. The hospital maintained that the man
was able to walk and care for himself.
98. Measures were put in place to make the man’s recovery at Maidstone easier.
Some medications were given to him in-possession. However, he was still
required to make his way to healthcare to collect his painkillers as they were
opiate based. The head of healthcare noted that some days the man would
collect his medications and others not. She told my investigator that, when a
prisoner does not collect analgesic medication, there is no follow-up. That would
only happen if it was a supervised medication. It is simply assumed that the
prisoner did not need a painkiller. If it transpired that the prisoner could not
physically attend, the medications would be taken to them on the wing. In his
case, a motorised buggy was offered to help him to move about the prison but
he refused it.
99. At this stage, discussions were restarted about transferring the man to
Swaleside for a period of recovery. The decision to request a transfer was
correct, however I wonder whether this could have been resolved before his
discharge had more detailed communication taken place in managing his care
plan. Greater prison healthcare input in the discharge plan would have provided
the opportunity to explain that HMP Maidstone does not have the facilities to
manage a prisoner requiring bed rest.
The use of the escort chain
100. The Prison Service National Security Framework gives guidance on the
procedures for escorting prisoners outside prison and the use of restraints.
There is particular advice on hospital escorts, bedwatches and when restraints
should be applied or removed during medical treatment. Maidstone’s local
operating policy for bedwatch duties and escorting a prisoner reflects those
outlined in the Security Framework.
101. The section relating to hospital escorts says that the prison must first undertake
a risk assessment to decide the level of escort and restraint required for the
safe custody of each prisoner. This should be done before movement to
hospital except in an emergency situation (when it should be completed within
24 hours). Factors to be taken into account include:
 the prisoner’s medical condition
 the prisoner’s security category
25
 the nature of their offence
 their risk to the public and hospital staff
 their motivation to escape.
101. The Security Framework stipulates that the normal arrangements for prisoners
being escorted from closed establishments are that they will be accompanied
by two officers and “restraints must be used unless there are medical
objections”. Restraints can be removed at the point of medical consultation or
treatment unless the risk of escape is too high. Although this is the normal
arrangement, the section on ‘escorting options’ states that other options are
available to prison managers. Two of these are:
 “an escort with two officers or more with no restraints”
 “an escort with one officer and no restraints (appropriate where the
prisoner’s medical condition of lack of mobility is such that he or she
cannot escape unaided and there is no evidence that an escape attempt is
likely).”
102. In instances where restraints are not applied and escort staff remain, officers
should be positioned between the prisoner and any exit and as close to the
prisoner as is practical.
103. The section on reviewing escort arrangements says that, “the level of security
necessary in all cases must be kept under review to take into account the
prisoner’s developing medical condition, the physical surroundings in which the
prisoner is located and any emerging intelligence.”
104. The section on restraints lists the circumstances in which handcuffs are usually
not necessary. The one specifically related to medical treatment states:
“On prisoners attending for medical treatment outside the prison, if the
prisoner’s medical condition renders restraints inappropriate or a risk
assessment demonstrates they are unnecessary in all the circumstances.
Restraints will not normally be necessary when the prisoner’s mobility is
severely limited, e.g. when he or she is on crutches ….”
105. With regard to the removal of restraints, the Security Framework says that they
can only be removed in certain circumstances during hospital treatment. It
does not list the circumstances but refers to the section on hospital escorts. It
says that restraints may be removed “when a medical professional requests
their removal on health grounds”. If necessary, escorting officers should first
obtain the permission of the duty governor before agreeing to such requests.
106. I remain concerned about the lack of a risk assessment review after the
submission of the deputy governor’s memorandum to the Governing Governor
on 23 October. My investigator asked the Governing Governor what action had
been taken in response to the memorandum. The Governing Governor
recalled reading the memo but could not say for sure what action was
suggested or taken. She also recalled the matter being raised during the
operational meeting held on the morning of 23 October. These meetings are
26
107. The Governing Governor told my investigator that the normal course of action
in response to a request to reconsider security measures would be to conduct a
review of the risk assessment. Normally, she would ask for this to be done as
soon as possible. She could not recall if she had made this request. There is
no indication in the risk assessment or bedwatch log that the review took place.
An auditable record must be made of key actions or decisions relating to
security.
108. Despite the concerns raised by doctors and the family regarding the restraints,
escorting officers noted that the nursing staff were content for the man to
remain restrained due to his infectious state. They felt it was safer for others in
the ward if the risk of infection could be minimised by restricting his movement
around the hospital. The clinical reviewer asked nursing staff about this. Both
the clinical reviewer and my investigator pointed out that restraints are not used
for medical reasons on non-prisoner patients so why was this a proper
justification for keeping him handcuffed. The clinical reviewer was told that all
decisions taken regarding how and where to nurse the man were based on
clinical need rather than his status as a prisoner. She was also told that the
issues of his dignity, and the impact on other patients, were also considered. I
regret to say I find this rather difficult to believe.
109. I understand the critical importance of security on bedwatches and that the
Prison Service is properly risk averse. The Service has an admirable recent
record in preventing escapes, and hospital bedwatches are an evident security
weak spot. However, the man was a terminally ill man, with a short life
expectancy (albeit undetermined). He was also a category C prisoner
approaching his Parole Eligibility Date. His health was deteriorating. He was
uncomfortable, in pain and, although mobile, it was a struggle for him to move
around. I question the need for this man to have remained in escort chains up
to the point of his death. The assessment undertaken by the deputy governor
on 21 October concluded that he was an unlikely escape risk and that
consideration should be given to on revisiting the need for restraints. It was an
undignified situation for him and distressing for his family (and, I imagine, for
the bedwatch staff), particularly as the process of seeking early release on
compassionate grounds was already underway.
110. In recent investigations into deaths of prisoners in custody at HMP Birmingham
and HMP Gartree, I have been critical of the lack of flexibility in local policy on
bedwatches. I have also commented that the problem is more deep rooted
than local policy. The Security Framework does not give explicit advice on
procedures for dealing with gravely ill or dying prisoners in outside hospitals or
hospices. There is no provision for prison staff to make a decision to remove
restraints on compassionate grounds when the risk of escape is clearly much
reduced. Yet I know of cases where Governors have given permission for
restraints to be removed on compassionate grounds and have always
commended them for doing so. I think that consideration should be given to
27
The Prison Service should ensure that a review of the escorts, restraints
and bedwatch sections of the National Security Framework takes place
with a view to providing advice to staff on the removal of restraints from
gravely ill or dying prisoners on compassionate grounds when their risk
of escape is much reduced.
Early release on compassionate licence
111. Early release on compassionate grounds can be granted in medical cases and
where a Governor supports the application. A form is submitted, with medical
and probation reports, to the Early Release and Recall Section of the Ministry
of Justice. Early release is granted only in the most exceptional circumstances.
112. An application may be considered where a prisoner is suffering from a terminal
illness and death is likely to occur soon. There are no set time limits, but three
months might be considered to be an appropriate period. It is essential to try
and obtain a clear medical opinion on the likely life expectancy. The Secretary
of State also needs to be satisfied that the risk of re-offending is past and that
there are adequate arrangements for the prisoner’s care and treatment outside
prison.
113. I am pleased to see that an application for early compassionate release was
begun as soon as the man was diagnosed terminally ill. However, in the man’s
case the consultants at the hospital were reluctant to put a time frame on his
life expectancy which could have been anything from three weeks to three
months. Nevertheless, in the PSO three months is considered to be an
“appropriate period”. It would therefore have been possible for the consultants
to submit a medical report supporting the application.
Post mortem
114. In the ‘history’ section of the port mortem report, it is recorded that the man was
buying and selling subutex in prison. It is not clear where this information was
obtained. My investigator has seen no evidence to suggest this happened.
Family liaison
115. HMP Maidstone has good family liaison processes in place. The family liaison
officer (FLO) is linked with other FLOs from three other prisons in the Kent
area. Regular meetings are held to provide support and to discuss
developments in their respective establishments. I think that this coordinated
and supportive approach to family liaison work is commendable.
116. The family liaison officer at Maidstone provided a high level of support to the
man’s family. It was unfortunate that the prison’s links with the family were not
as effective during the man’s illness. However, the efforts of the family liaison
28
Support and counselling
117. After being diagnosed terminally ill, hospital staff spent a day discussing the
implications of his illness with both the man himself and his family. The man’s
family expressed concern to my family liaison officer that neither they nor the
man felt adequately supported by the hospital or prison in coming to terms with
the news. My investigator noted the bedwatch log records that a Macmillan
nurse did try to offer services to the man, but he declined assistance.
Interviews with hospital staff also indicate that the discussions held with the
man and his family covered the implications of his resuscitation status.
29
RECOMMENDATIONS
Clinical
 Standards of record keeping and documentation should be included as a
specific item in the performance monitoring and appraisal system for
medical staff employed by Primary Care Trusts to work in prison
healthcare.
The Prison Service has accepted this recommendation, however request that it
“must be noted that the majority of healthcare staff at HMP Maidstone are still
directly employed by the Prison Service and not the Primary Care Trust.”
 Introduction of a requirement to hold a multidisciplinary case conference,
to take place as soon after reception into a prison of any offender with a
known long-standing medical problem or condition. This case conference
would agree the management plan to be followed by all medical and
nursing staff.
 A review of documentation, with a view to developing a format for the
recording and transmitting of the agreed management plan to all staff,
especially in the event that the offender is transferred from one
establishment to another.
 Development of a specific discharge protocol related to the safe discharge
of a patient back to a prison establishment.
 The National Health Service in conjunction with the Prison Service should
consider awareness raising training for staff working in traditionally non-
secure environments caring for offenders. Alternatively, depending on the
likely frequency of offenders requiring care outside the prison healthcare
settings, the development of shared guidelines for best practice that can be
issued to all staff whenever and wherever the situation arises.
General
 An auditable documented record must be made of key actions or decisions
to take place relating to security.
 The Prison Service should ensure that a review of the escorts, restraints
and bedwatch sections of the National Security Framework takes place with
a view to providing advice to staff on the removal of restraints from gravely
ill or dying prisoners on compassionate grounds when their risk of escape
is much reduced.
The Prison Service has accepted all of the recommendations made in this report. No action
plan has been submitted to date to outline how the recommendations will be addressed.
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