Individual at Full Sutton

Investigation into the death of a man whilst in the custody
of HMP Full Sutton, in February 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2009
This is the report of an investigation into the death of the man who died in February
2009 at hospital, whilst in the custody of HMP Full Sutton. He had been taken to
hospital in February. The man had been diagnosed with cancer.
A post mortem was held at the request of Her Majesty’s Coroner for East Riding and
Kingston upon Hull. It found that the man died of natural causes resulting from his
cancer.
The man had asked that his family should not be informed of his illness or death.
Nevertheless, staff at HMP Full Sutton made enquiries to identify any next of kin. Up
to the time of my circulating this report, no one has been traced. I extend my
condolences to anyone touched by the man’s passing.
This investigation was undertaken by one of my investigators. In addition, a review
of the man’s healthcare was commissioned from the East Riding of Yorkshire
Primary Care Trust. The Head of Quality Standards and Governance for East Riding
of Yorkshire NHS, carried out that review, and I am grateful to her. I would also like
to thank the Governor of Full Sutton, and his staff for their help and assistance. I am
particularly indebted to the liaison officer.
I endorse the four recommendations taken from the clinical review. These address
improved links to palliative care, training for healthcare staff in end of life care,
assessments for care planning, and the signing of entries in medical notes.
In this final report, I have made three amendments taken from the response by the
Prison Service in relation to chaplaincy care, the McMillan team, and aids to make
the man more comfortable. In response to the recommendations, the Head of
Healthcare has accepted the first recommendation and it has been suggested that
recommendations two and three be the joint responsibility of the Head of Healthcare
and the Primary Care Trust (PCT). I have amended those recommendations to
reflect that comment. Recommendation four is still pending a response from the
PCT.
The version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2009
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CONTENTS
Summary
The Investigation Process
HMP Full Sutton
Key Findings
Issues
Recommendations
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SUMMARY
The man was sentenced to life imprisonment in April 1973 by the Glasgow High and
Jury Court. He was released on a life licence and moved to North East England.
The man was twice recalled to custody; the second time was following a conviction
for indecent assault. The man was held in several high security prisons until his last
transfer into Full Sutton in 2001. The man was category A prisoner.
On reception into Full Sutton it was recorded in his medical notes that the man had
high blood pressure, asthma, chronic obstructive pulmonary disease and arthritis.
He was a heavy smoker. He was seen on a regular basis in the healthcare unit to
review his health and go to specialist medical clinics.
In July 2008, the man was admitted to the healthcare unit with a possible chest
infection. An electrocardiograph (ECG) to measure his heart rate was carried out,
and antibiotics were prescribed. He returned to his wing the following day at his own
request. He was regularly monitored on the wing by healthcare staff and had
consultations with the doctor.
The man saw the doctor in September after complaining of chest pain. After being
examined, he was prescribed pain relief and it was noted that it was possibly the
effects of his chronic obstructive pulmonary disease. The doctor referred the man
for an x-ray on 14 October, and he was admitted to the healthcare unit to treat dry
skin. The following day, he again returned to the wing at his own request. In
October, he went to an out patient appointment with an orthopaedic consultant about
his chest pain. An x-ray showed nothing of note in November.
The doctor spoke to a consultant physician in November regarding the man’s
continued chest pain. A referral was made a computerised tomography (CT) scan
(which shows images of the whole body). In December, the CT scan showed the
man had bone metastasis (cancer). He was admitted to the healthcare unit in
December and prescribed pain relief medication.
In January 2009, the man declined further medical investigations. He was now being
prescribed Oromorph, an opiate medication, and was being nursed for a terminal
illness.
Two weeks later, the man was admitted to hospital as his condition had deteriorated
and he needed constant oxygen. He was escorted by two officers and restraints
were put in place. Two days later, the restraints were removed as he was nearing
the end of his life. He died in February.
The man was nursed in the healthcare unit until three days before his death. The
clinical review has highlighted some issues regarding palliative and end of life care,
in addition to the need to improve entries in medical notes. I judge that the man
received good personal and emotional support from prison healthcare staff.
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THE INVESTIGATION PROCESS
1. In February 2009, my investigator visited Full Sutton to open the investigation
into the man’s death. My investigator was met by the Liaison Officer and
reviewed the man’s prison files and medical records. My investigator
requested copies of those documents to be sent to her.
2. The Ombudsman’s notice of investigation and terms of reference had been
sent in advance of my investigator’s visit. Members of the Independent
Monitoring Board and the Prison Officers’ Association did not ask to see my
investigator. Staff and prisoners did not respond to the notices of
investigation.
3. On my investigator’s visit, she visited the healthcare unit and saw the cell the
man lived in prior to his admission to hospital. Evidence for the report has
been taken from documents and records held in the man’s prison files. It was
determined that no staff needed to be interviewed.
4. A clinical review of the man’s medical care was commissioned with East
Riding of Yorkshire PCT, and it was carried out by the clinical reviewer. The
review looked at his medical history, his diagnosis of cancer, treatments, and
palliative care. The reviewer interviewed some members of healthcare staff.
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HMP FULL SUTTON
5. Full Sutton is a high security prison holding some of the most difficult and
dangerous offenders in the country. It was opened in 1987 and is a modern,
purpose built maximum-security jail for male category A and B prisoners.
6. The four original residential units are of a square design: A wing holds main
wing prisoners; B, C and D Wings hold vulnerable prisoners. E and F wings,
which were added later, are of improved design and both hold main wing
prisoners. Half of F wing houses the segregation unit. G wing is used for
induction and holds some vulnerable prisoners.
7. Healthcare services are commissioned through East Riding of Yorkshire
Primary Care Trust (PCT). Full Sutton has an inpatient healthcare unit that is
staffed by qualified nurses, healthcare assistants and discipline officers. The
nursing staff have a range of skills including mental health and there is a
nurse prescriber. Medical cover is provided by two doctors on a daily
sessional basis. An electronic records system has been introduced for
patients’ notes.
8. Nurse led clinics for ongoing conditions and vaccinations are held regularly,
and a dentist, physiotherapist and optician hold sessions in the unit. A walk in
centre for prisoners is available daily along with a practice nurse clinic for
appointments.
9. Her Majesty’s Chief Inspector of Prisons’ most recent inspection of Full Sutton
was in 2007. An extract from that report, commenting on healthcare services
says:
“There was evidence of individual patient care on the wings, with a
multidisciplinary approach involving the prisoner, discipline staff and
nurses and a joint care plan. This allowed a sick man to remain on the
wing at his request with at least twice daily support from health services
staff.”
10. The Independent Monitoring Board noted in their Annual Report of 2007:
“The healthcare centre manager has worked hard to introduce a
community care healthcare care system into Full Sutton which aims to
reflect the healthcare that individuals receive in the community.
Clearly, the restrictions that are inevitably imposed by operating in a
high security prison dictate that the new system needed some
adaptation through a process of medical risk assessments. The
system aims to push the initial healthcare treatment down to wing level
as well as introducing two nursing teams; one being responsible for the
vulnerable prisoners whilst the other cares for the main wing prisoners.
An important consequence of adopting the new healthcare system is
that an individual has the opportunity to take more responsibility for his
own health and he knows that the first point of contact is a nurse from
his wing team.”
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11. There have been three previous deaths at Full Sutton since my office started
investigating all deaths in prison custody in 2004. Two of the deaths were self-
inflicted and the other, which was due to natural causes, did not have any
similarities to that of the man’s.
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KEY FINDINGS
12. The man was born in Scotland. He was divorced with two children. In April
he was sentenced to life imprisonment at Glasgow High and Jury Court for
murder and robbery. In October 1993, he was released from prison on a life
licence and moved to the North East of England.
13. In January 1986, the man was charged with three offences and remanded to
a bail hostel in Durham. In February, he was recalled to custody by the
Scottish Home and Health Department and detained in HMP Durham. In
March, the man was sentenced to six months imprisonment for indecent
assault. He was transferred from Durham to Barlinnie prison in Scotland.
14. In October, in Perth prison, the man was the subject of a severe assault
during a riot. He later gave evidence at trial, and for fear of reprisals asked for
a move to England so that he could be released in England rather than
Scotland. He was transferred from Perth to HMP Leyhill in December 1989.
15. The man was released to a hostel, located in the grounds of HMP Wakefield,
in August 1990. The hostel provided accommodation for life sentenced
prisoners who were progressing towards their release on licence into the
community. He was employed whilst living at the hostel. During this time he
spent some weekend leave in Middlesbrough.
16. In March 1993, the man confessed to a senior officer at the hostel that he had
sexually assaulted a child. He was immediately taken back into HMP
Wakefield and placed in the segregation unit for his own protection. In
September, he appeared at Leeds Crown Court. He was sentenced to 15
months imprisonment, and his licence was revoked. He remained at
Wakefield until later transferring to HMP Durham.
17. The man was received into Full Sutton in 2001, and a first reception health
screen document was completed. It was noted that he had high blood
pressure, heart disease, chronic obstructive pulmonary disease, asthma and
some arthritis to his right knee. A prescription chart was opened and the man
was prescribed medication for his medical conditions, including an inhaler for
his asthma.
18. From 2001 until early 2008, the man was seen regularly by healthcare staff for
repeat prescriptions, and attended specialist clinics for his heart disease and
asthma. He also saw the optician and the dentist.
19. On 2008, the man was seen in the healthcare unit after complaining of
diarrhoea. He was advised to take plenty of fluid and rest. Two months later,
he experienced sore skin and pain in his back. He was seen in July by a
nurse who referred him to see the doctor. Four days later, the doctor
prescribed ointment for his skin and a bath oil to help the irritation. Pain relief
(Co-codamol) was also prescribed for his back pain.
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20. The man had an appointment with a nurse in July as he was short of breath
and still experiencing back pain. The nurse wrote that the man was taking
pain relief medication and noted she would check on him later. Two days
later, he was seen in his cell by a nurse. He had chest pain, with the pain
radiating down his left arm, and was short of breath. His blood pressure was
145/85 (normal range of blood pressure is 130/80) and his pulse rate was 77
beats per minute (normal rate is between 60-100). The man was transferred
to the healthcare unit for observation. His blood pressure had risen to 149/91
and his pulse rate was down to 66. An ECG was carried out. He remained
on the healthcare unit so he could be reviewed by the doctor. Blood tests
were taken.
21. A doctor examined the man four hours later. He was feeling better, and was
no longer short of breath or in pain. A chest infection was diagnosed and anti-
biotic medication prescribed. He was discharged from the healthcare unit and
returned to his cell. The next day, the man saw the doctor and the blood tests
were repeated. The doctor suggested that he stayed in the healthcare unit for
observations, but the man preferred to return to his cell and assured the
doctor that he would tell wing staff if he felt unwell.
22. In July, a nurse visited the man in his cell. She wrote that, although she had
been told he was unwell, on her arrival he was smoking and laughing. He told
the nurse that he felt better than earlier in the day. He was advised to
continue with the anti-biotics and pain relief. In August, his medical notes
showed that an x-ray result had been received. Nothing of note was seen in
the results.
23. The following day, wing staff asked healthcare staff to visit the man in his cell.
On arrival, a nurse noted that he was carrying out his wing cleaning duties.
She asked him to sit down and tell her what was wrong with him. The man
said that he had pain in his kidney area. The nurse advised him to have some
time off his duties and to rest in his cell. Although he was not happy about
this, he accepted her advice. The man was also advised to contact
healthcare if he had any further health problems.
24. The man next saw a nurse in August as he had unexplained bruising to his
right leg. The nurse noted that he had good circulation to his leg and there
were no signs of a deep vein thrombosis.
25. In September, the doctor examined the man who said that he had chest pain
three days previously. On examination, the doctor wrote that there was poor
airflow to the lungs and tenderness over the rib area. The man could not
recall any physical reason for the tenderness. The doctor also noted his
concern about the man’s chest pain and that he was not well. He had not lost
weight and he told the doctor the pain was not too bad. The doctor changed
his medication and requested a review of the man in a few weeks.
26. A week later, the man was seen by a nurse and he told her that he had pain in
the left side of his chest. The nurse made an appointment for him to see the
doctor the following morning. The doctor examined him in October; he was
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27. Three days later, the man was admitted to the healthcare unit as he was in
some discomfort with chest pain. An x-ray was ordered and the doctor also
asked for his blood pressure, pulse and temperature to be checked frequently.
In October, he was examined by the doctor who noted that he seemed to be
in less pain, but was tender in his rib area. There was no shortness of breath
and he was comfortable, however the doctor requested an x-ray to check
whether he had fractured a rib. He further wrote that the man’s dry skin
condition was still present and advised him to stay in healthcare for some
intensive treatment.
28. The following day, the man asked if he could return to his wing cell as he was
feeling much better. The nurse and the man discussed his smoking habit,
although he said he was not keen to give up. It was agreed that he would go
to healthcare everyday for skin care and a daily bath in special oils.
29. In October, a nurse was asked to see the man in his cell. The nurse saw that
he was sitting in a chair and appeared to be in some discomfort with pain in
the right side of his chest. His observations were noted as high blood
pressure of 206/96, and a regular pulse rate of 70 beats per minute. He had
not taken any pain relief since the previous day. He was transferred to the
healthcare unit and a chest x-ray was booked for the following day. Four
hours later, he told the nurse that he had hurt himself the previous day whilst
getting out of the bath and he was given Co-codamol. Later that evening, he
was advised to get into bed; he managed this without assistance from the
nurses.
30. The next day, He was examined by the doctor who again noted the chest pain
and tenderness in the rib cage area. He was not short of breath and a recent
x-ray did not show any changes. The doctor thought this was not a simple
case of low back pain, although there was no history of a physical injury. If
there were no immediate improvements then further levels of investigations
would be needed. The doctor repeated prescriptions for pain relief, and
asked for him to have his weight checked and a blood test taken. He
concluded that the man should be admitted to healthcare for a few days.
31. In October, the man went to an outpatient’s appointment with an orthopaedic
consultant. He remained an inpatient and the next day felt better and his skin
condition was improving. His notes showed that he had received two flu
vaccinations in error. The doctor and charge nurse were informed of this
mistake. The nurse told him about the mistake, which he laughed about. The
man was told he would be monitored very carefully over the next few days. In
November, he was discharged from healthcare and returned to his wing. The
doctor asked that nurses keep him under regular review whilst on the wing.
10
32. The next day, a nurse visited the man in his cell and found him holding his
chest and complaining of pain. He had not taken his pain relief that morning.
The nurse advised him to take his medication and contact healthcare staff if
the pain increased. The nurse visited him again later that day and noted that
he was looking well, although he still had some discomfort.
33. In November, the man was seen by a nurse and told her that the pain had
returned since he stopped taking the Co-codamol. The nurse noted that the
man looked untidy and was finding mobility difficult. She wrote that she would
speak to the doctor about him.
34. Two days later, healthcare staff saw the man in his cell following a call from
wing staff. He was lying on his bed, his blood pressure was high at 168/95
and his pulse rate was 82 beats per minute. He told the nurse he had again
not taken his pain relief. The nurse encouraged him to have his medication
and take it regularly. Later, the nurse checked with wing staff on his condition
and was told that he was now sitting up and feeling better. The wing staff
agreed to continue to monitor him.
35. In November, the doctor spoke to a consultant physician at hospital about the
man’s current medical condition and the pain at the base of his lung. X-rays
and blood results did not support the diagnosis of a cancerous tumour. The
consultant suggested that the man be treated symptomatically, and to repeat
medical investigations in a few weeks time. The doctor wrote in the man’s
medical notes that he would discuss his treatment with healthcare staff. The
doctor made a referral for him to have CT scan.
36. Later, a nurse saw the man in his cell. He was lying on his bed complaining
of abdominal discomfort and his pain relief was not helping. The nurse noted
that his cell was unclean and he looked dishevelled. He was taken to the
healthcare unit for a bath and healthcare staff asked wing staff if his cell could
be thoroughly cleaned. The man was admitted to the healthcare unit for
observation.
37. The following day, the man asked to go back to his wing cell. He said that he
felt better and his pain was under control. On 24 November, a multi-
disciplinary case meeting was held to discuss his risks, plans for his support,
and maintenance of his independent activities. It was agreed that both wing
and healthcare staff would work together to assist him to remain independent.
He would continue to go healthcare for a bath twice a week and his cell would
be cleaned by a prisoner trained in specialist cleaning routines.
38. Two days later, the man was visited by a nurse who assessed his general
physical condition and personal hygiene. On 4 December, he attended an
outpatient appointment for a CT scan.
39. The following day, a consultant physician from hospital telephoned the prison
doctor. The man’s CT scan showed spinal metastasis (spread of cancer cells
in his spine). The primary source of the cancer was unknown. The doctor
discussed any further tests with the consultant, prior to him being referred to
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40. In December, the man was now located the healthcare unit. His mobility was
poor and he used a wheelchair. The doctor and nurse told him about the
results of the CT scan and the diagnosis of cancer cells in his spine. He
became very distressed at the news and was supported by healthcare staff.
The doctor told him that the priority was to get his pain under control and that
he would speak to an oncologist. The man told the healthcare staff that he
did not want his family told of his diagnosis.
41. Later, the doctor examined him and noted that he had a slight headache and
pain in his chest. The doctor asked staff to monitor his emotional well being
following the news of his diagnosis earlier in the day. The doctor also spoke
to a consultant urologist (a specialist in kidney and urine illness) and a
consultant in haematology (specialist in blood disorders) at the hospital. As
the primary source of the cancer had not been identified, the doctor had a
discussion with the specialists to see what investigations would best be
followed.
42. The next day, the man saw a member of the mental health in reach team.
They discussed his diagnosis and his feelings about the news. He said he
would accept help when any problems arose and would be happy to see his
friends from the wing. He settled into the healthcare unit and was seen by the
doctor in December. The doctor noted that he would be more comfortable
sitting in a chair than in bed. His pain relief was reviewed and Tramadol (an
opiate based medication was prescribed). The following day, a recliner chair
was given to him to aid his comfort.
43. The man remained in the healthcare unit during December. He was
monitored daily and prescribed pain relief that worked to good effect. In
January 2009, a nurse recorded in the man’s medical notes that he was in
severe pain, weeping, distressed, and that his pain relief medication was
having little effect. The nurse telephoned the doctor who prescribed
Oromorph (a morphine based medication). Later, he was noted to be settled
in his chair and far more comfortable. He was not keen to have too much
Oromorph as he felt it was a sign of his deteriorating condition. He became
weepy when the nurse reassured him about the control of his symptoms and
the emotional support that was available to him.
44. The man saw the doctor the following day. The doctor noted that he was
settled, although the Oromorph had caused some disorientation. An
oncologist had spoken to the doctor and agreed to see him in his clinic on 5
January. Later, the doctor gave him his Oromorph and the man said he would
rather feel disorientated than be in pain. The doctor recorded that the nurses
would look in on him later.
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45. In January, the man was seen by an oncologist at hospital. On his return to
Full Sutton it was recorded that he had fractured his shoulder, which was
possibly due to the metastasis in his bones. His arm was in a sling and he
had received a session of radiotherapy (a treatment for cancer). The
consultant oncologist suggested further radiotherapy plus x-rays. He was
tearful. The following day, the doctor visited him and recorded that he was
comfortable with good pain control.
46. The man was seen by an occupational therapist in January to assess him for
aids that might help his mobility and daily living. The therapist recommended
a self-propelling wheelchair so the man could be mobile, and contact with
MacMillan Nurses (who specialise in the care of terminally ill people) for a
recliner chair. The doctor visited him and saw that he was coping and content
with the care being provided for him.
47. Later, a nurse spent some time with the man, and explained the likely
progression of his illness and the poor prognosis. He told the nurse that he
was not interested in applying for compassionate release. Although he
became distressed, he told the nurse that he wanted to die in prison as it had
been his home for the last 18 years. He again told the nurse he did not want
his family informed and felt that they would not welcome contact. The nurse
assured him and told him he could talk to staff at any time to discuss any
fears or concerns.
48. In January, the man had an x-ray of his pelvis and shoulder. His pain relief
was working well and he only asked for Oromorph when he felt he needed it.
Two days later, the doctor noted that an oncologist had telephoned the
healthcare unit and said they were waiting for the results of the latest x-rays
before making any further plans for his medical care.
49. The doctor saw him in January. He told the doctor that the extra pain relief
was working well. He was happy with the care and attention he was receiving
from healthcare staff and enjoying visits from friends and wing staff. He again
told the doctor that he did not wish any family involvement. Following
discussion with outside consultants, it was agreed that he would be admitted
to hospital for an examination of his bowel and stomach (colonoscopy and
endoscopy).
50. In January, a nurse spoke to him about his forthcoming hospital appointment
for the colonoscopy. He was concerned about the procedure and unsure
whether he wanted to go through with it. The nurse explained what the
procedure would entail. He said he would think about it and said he did not
want to have Oromorph at bedtime as it made him sleepy the next morning.
51. The following day, he told the nurse that he did not want to have the
colonoscopy and signed a disclaimer to that effect. The nurse notified the
hospital and the security department. The doctor also recorded that the man
did not want any further investigations and that he understood the poor
prognosis. He did say he would have a biopsy of his shoulder. The doctor
noted he would discuss this with hospital colleagues.
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52. The man continued to receive nursing care and pain relief medication. His
mobility was reducing but he remained in good spirits. In January, he
attended a mobile scanning unit for a magnetic resonance imaging scan
(MRI). (This scan uses magnetic and radio waves to take pictures of the body
tissues.) In January, it was recorded that Mr Peat fell over whilst going to the
toilet during the night. He did not sustain any physical injury but was shaken
by the experience.
53. The man was given an anti-sickness injection in February as his appetite was
poor. He was encouraged to take more fluids and a chart was started to
record and regulate his fluid intake. Both his legs were sore and dressings
were applied.
54. The following day, he was examined by the doctor who recorded that he
looked unwell. The primary site of his cancer was still unknown and the
hospital consultants were waiting for the results of the MRI scan to see if a
bone biopsy would be appropriate. In February, it was recorded that he fell off
his chair and bumped his head. He told the nurse he was alright, but he was
seen by the doctor who noted that he looked unwell and frail.
55. In February, the man appeared to be short of breath. He was given oxygen
and the nurse contacted the doctor. Later, a doctor examined him and found
he was experiencing breathing difficulties. He was given steroids, continued
with the oxygen, and arrangements were made for him to be admitted to
hospital. He was becoming distressed and by this time the healthcare unit
was running low on oxygen. He was escorted by two officers to hospital. He
arrived at hospital at 3.20pm, the double cuffs were removed and escort chain
applied. (An escort chain is a 1.8 metre length of chain with one cuff attached
to the prisoner and the other to an officer.)
56. The following day a nurse at the hospital contacted the healthcare staff. The
nurse told the staff member that the man was now on a ‘pathway to die plan’.
(This plan of care provides pain relief for symptoms and other treatments are
stopped. The patient’s emotional and physical needs are fully supported in
the days leading up to death.) His medical notes showed that a case
conference was held at the prison’s healthcare unit and at which it was
agreed that, in accordance with his wishes, his next of kin would not be
informed of his terminal illness or imminent death. The prison chaplain visited
him hospital later in the day.
57. In February, the escort chain was removed. The man was now unable to get
out of bed and was receiving pain relief via a syringe driver. At 5.30pm, he
had another visit from the chaplain. He died at 4.20am the following day.
58. Following his death the prison’s family liaison officer, made several enquiries
to trace any relatives. Although the man had specifically instructed that his
next of kin should not be informed of his illness or death, the prison made the
decision to make some enquiries to find any relatives. A letter was sent to an
address in the North East of England, thought to be that of the man’s sister,
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59. The man’s friends were informed of his death by wing staff. The chaplain at
Full Sutton arranged a funeral service which was attended by the family
liaison officer and the Governor. A memorial service for him was held in the
prison chapel in February 2009.
60. The chaplaincy at Full Sutton have asked that the report be amended to
reflect the fact that they saw the man on a daily basis and shared in his
spiritual and emotional preparation for dying. They also visited the hospital at
7.00am on the day he died to administer Last Rites.
15
ISSUES
Clinical Care
Clinical findings
61. The clinical reviewer, spoke to healthcare staff at Full Sutton and read the
man’s medical records. In her review she comments on four aspects of the
man’s care. She says there was some difficulty in identifying members of
staff who had made entries in his medical records, and interventions and care
plans were not always clearly documented. There were no measurements in
place to risk assess his pain control and accidental falls, and no
documentation to indicate a review of his long term medications. Lastly, the
clinical reviewer comments on the lack of liaison with the community palliative
care team for support and advice to healthcare staff.
62. A response to the draft report notes that several messages were left with the
McMillan team in respect of the palliative care needs of the man.
Unfortunately, by the time they arrived some three weeks later he had already
been transferred to hospital.
63. A lack of training and education for the care and management of terminally
patients was a factor in the man’s care whilst in Full Sutton. An end of life
care plan was not always used, with no evidence of special pressure relieving
resources being made available. An assessment of his deterioration and
effective pain control was not evident, but he did not always offer a good
description of his symptoms. He preferred to stay on the wing rather than be
in the healthcare unit and was anxious about the effects of some of his
medication.
64. It was noted in a response to the draft report that he slept on an airflow
mattress and was also provided with a soft recliner chair, which he found
more comfortable.
65. Healthcare staff told the clinical reviewer that the absence of a diagnosis, and
the man’s reluctance to take some medication, would have had some effect
on the levels of his pain relief during the later stages of his illness. He had
told healthcare staff that he was comfortable. In the future, pain control
templates will be used in the healthcare unit.
66. The clinical reviewer writes that there was evidence of good communication
between healthcare staff and the man at throughout his illness. The
availability of dedicated healthcare staff allowed him to stay on the wing whilst
benefiting from regular health reviews.
67. The clinical reviewer comments:
“It was not evident in the records that the palliative care team was
contacted for advice or that pain management assessment tools were
utilised as a basis for a developing pain management plan. This could
16
have aided the healthcare team in the management of the man’s
symptoms. Although this would not have affected the outcome it may
have resulted in a more effective approach to care during the terminal
stages of his life. It is however acknowledged that documentation shows
that he was … reluctant to comply with advice which could have had an
impact on the recognition of his symptoms.”
68. I endorse the following recommendations made by the clinical reviewer:
The Head of Healthcare should improve liaison with the palliative
care team with the aim to obtain advice regarding adoption of Gold
Standards Framework within the prison healthcare setting.
The PCT should adopt validated risk assessment tools which include
assessment, care planning and outcomes with regard to tissue
viability, nutrition and falls.
69. The clinical reviewer further comments:
“It is recognised that to nurse terminally ill patients within a prison
environment as a preferred place of death is at present unusual and, due
to restrictions of security and access to services, can be challenging.
However, as HMP Full Sutton could be identified as a preferred place of
death in the future it is suggested that consideration be given to the
systems which would need to be in place for this to be achieved.”
She therefore makes the following recommendation which again I
endorse:
The Head of Healthcare should ensure healthcare staff are provided
with training regarding end of life care with specific reference to
symptom management and oncological emergencies through the
palliative care team.
70. The clinical reviewer concludes:
“I found the documentation to be fragmented and on some occasions it
was very difficult to establish what nursing interventions had taken place
and by whom. Although names were evident on all entries often the
designation of the staff member who had undertaken the care was not”
There should be a review of documentation to ensure that evidence
of care planning and the designation of staff are clearly evident.
.
Support for the man
71. It was clear to my investigator that the man received support and assistance
from discipline and healthcare staff throughout his illness. His friends helped
him to remain on the wing by assisting with his day to day living. When he
transferred to healthcare, he was visited by his friends. This support was
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72. I acknowledge the prison’s decision in not making contact with the man’s
family during his illness, as was his wish. I believe their attempts to make
contact following his death were carried out with sensitivity. The opening of
the man’s inquest was delayed as the Coroner suggested that the prison try to
find his next of kin. Despite enquiries by the Liaison Officer, no family
members have yet been traced.
Conclusion
73. The clinical reviewer has made recommendations in relation to the care of
prisoners with terminal illnesses and access to community palliative care
services. That aside, I judge that the man was well cared for by prison and
healthcare staff. In the absence of family support, He received emotional and
practical help which reflected by his wish to die in prison surrounded by
people who had, in effect, become his surrogate family.
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RECOMMENDATIONS
For the Head of Healthcare
1. There should be a review of documentation to ensure that evidence of care
planning and the designation of staff are clearly evident.
Accepted – “This is a systems error on the Systm One Clinical record
system, which has been reported. Until the fault is resolved staff with enter
information manually.”
For the Head of Healthcare and the Chief Executive of East Riding of Yorkshire
PCT
2. The Head of Healthcare should improve liaison with the palliative care team
with the aim to obtain advice regarding adoption of Gold Standards
Framework within the prison healthcare setting.
Pending
3. The Head of Healthcare should ensure healthcare staff are provided with
training regarding end of life care with specific reference to symptom
management and oncological emergencies through the palliative care team.
Pending
For the Quality Assurance Manager East Riding of Yorkshire PCT
4. The PCT should adopt validated risk assessment tools which include
assessment, care planning and outcomes with regard to tissue viability,
nutrition and falls.
This is to be responded to by the PCsT - Pending
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