Individual at Norwich

Investigation into the circumstances surrounding the
death of a man at HMP & YOI Norwich
in August 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2009
This is the report into the death of a man. The man died at HMP Norwich in August
2008, having been transferred from HMP Exeter the previous day. The Coroner for
Norfolk did not request a post mortem as the man had been diagnosed with cancer
of the lung two months earlier.
Although he was terminally ill when he transferred to Norwich, his death was not
expected to occur so suddenly. I extend my sincere condolences to the man’s family
and friends.
The investigation into the circumstances of the man’s was conducted on my behalf
by two of my investigators. My thanks go to the Governor of Norwich, the Governor
of HMP Exeter, and the Governor of HMP Dartmoor, and their respective groups of
staff, for their help and assistance.
Although the man’s death occurred within the area covered by Norfolk Primary Care
Trust, in light of the fact that he had been so recently transferred from Exeter it was
agreed that Devon Primary Care Trust (PCT) should commission the review of his
healthcare. The PCT appointed somebody to conduct a clinical review of the care
afforded to the man whilst he was in Dartmoor and Exeter. I am most grateful for her
review.
In this final report the Ministry of Justice and Department of Health have accepted
one of the recommendations. The second recommendation to the Head of
Healthcare Services is noted pending a response. The man’s family were contacted
and did not wish to make any further comment.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2009
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CONTENTS
Summary
The Investigation Process
HMP & YOI Norwich, HMP Exeter and HMP Dartmoor
Key Findings
Issues
Recommendations
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SUMMARY
In September 2007 the man was remanded to HMP Dorchester. He was seen by a
reception nurse who noted that he was not receiving any regular medication. The
man was generally well but told the nurse that he had lost weight, which he attributed
to anxiety about his court appearance. The man was sentenced to six years
imprisonment on 10 October, and returned to Dorchester. He was transferred to
HMP Dartmoor on 2 November.
In June 2008 he was examined by a doctor following a referral from a nurse. The
man had told the nurse he had a cough, was short of breath, and still losing weight.
The doctor noted the man’s symptoms and suspected a cancer related illness. He
immediately referred the man for urgent further investigations, and an x-ray hospital.
Four days later, the doctor told him that it was highly probable he had a tumour on
his lung. Arrangements were made to support the man and for him to be assessed
regularly by healthcare staff. He was moved to a ground floor cell.
On 31 June the man was admitted to hospital as his condition had deteriorated.
Three days later, he started a course of radiotherapy (a treatment for cancer
symptoms). Consideration was given to his prison allocation given his medical
condition, and discussion took place between healthcare staff at Dartmoor and HMP
Exeter. Other enquiries were made with the Nelson Unit in HMP Norwich. (This unit
is resourced to provide nursing care for older prisoners with age related and terminal
illnesses.) On 23 August the man was diagnosed with a chest infection and his
prognosis was poor. Six days later, on discharge from hospital, he was transferred
to Exeter as the healthcare facilities there were more appropriate for his immediate
needs.
However the man’s condition deteriorated further, and on 20 August it was decided
that he should be transferred to Norwich. He was assessed by the palliative care
team and the prison doctor who agreed that he was well enough to withstand the
long drive from the West Country to East Anglia. An ambulance was arranged and
paramedics accompanied him on the journey.
The man arrived at Norwich in the afternoon of 21 August, and he was seen by a
nurse from the palliative care team. He was tired after the journey but seemed to
settle and relax in his new surroundings. During the night he was observed regularly
by healthcare staff on the Nelson Unit and appeared to be sleeping peacefully. He
was checked on 22 August at 5.20am, and was sleeping. However, at 5.35am the
healthcare assistant noticed that he was not breathing. The paramedics were called
but it was found that the man had died.
The man was transferred to the Nelson Unit as it was judged that this was in his best
interests. However, my investigation draws attention to an apparent lack of
communication between Dartmoor and Exeter and I make a related
recommendation. My second recommendation relates to the lack of suitable
facilities for long-term sick and terminally ill prisoners across the country.
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THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened on 28 August 2008 when
my colleagues visited HMP Norwich. (Notices and the Ombudsman’s terms of
reference had been sent to the prison in advance.) My investigators met with
the Head of Safer Custody, reviewed the man’s prison file and medical notes,
and took copies of all relevant documents. No members of the local
Independent Monitoring Board nor the Norwich branch of the Prison Officers’
Association wished to meet with my investigators, as they are well aware of the
procedures for a death in custody investigation.
2. Later my two investigators visited the Nelson Unit. My investigators met the
Head of Healthcare and the Deputy Governor.
3. One of my Family Liaison Officers spoke to the man’s daughter by telephone on
2 September 2008. The man’s daughter raised several matters for the
investigation to consider. They included her father’s transfer to Norwich, and
his application for a compassionate discharge.
4. On the morning of 9 October my two investigators visited Exeter and spoke to
the Head of Healthcare and a doctor. Later that day, they visited Dartmoor and
spoke to the Head of Healthcare.
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HMP & YOI NORWICH
5. Norwich is a city centre prison, predominantly serving the courts of East Anglia.
It has an operational capacity (maximum crowded capacity) of 557, holding
remand and sentenced adult men and young offenders. The prison is divided
into two sections. One area accommodates young offenders and the
healthcare centre, and the other is for all other prisoners.
6. The healthcare centre provides 24-hour healthcare cover and has space for a
maximum of 23 in-patients. On the ground floor of the centre is the Nelson
Unit. This unit has been designed and equipped to enable older and less able
prisoners to be supported and cared for within the confines of the prison
environment.
7. HM Chief Inspector of Prisons last inspected HMP Norwich in November 2006.
An extract from that inspection noted:
“Health services had improved under management by Norfolk PCT. There
had been considerable investment in an electronic clinical management
system, and clinical governance arrangements were linked with the PCT’s
clinical governance strategy.”
8. Two extracts from the Independent Monitoring Board (IMB) Annual Report for
2007 noted as follows:
“Over the last year there has been no difficulty recruiting nurses
with the right experiences.  Lessons have been learnt from death in custody
reviews, which have been included in protocols, risk assessments and
action plans. Risk assessments have been completed on a range of issues
from infection control, the misuse of medication and bullying
to ‘flu outbreaks and staff shortages. There is a good working relationship
with the PCT with the sharing of emergency on-call.”
“The Nelson Unit for elderly prisoners has introduced an innovative ‘open
door’ policy to deal with deaths, of which there have been four this year. It
has also used the voluntary sector to develop various social activities which
are being developed. A handrail has now been fixed and the prisoners will
at last be able to use a specially made garden.”
9. There have been 17 deaths at Norwich due to natural causes since my office
took responsibility for investigating all deaths in prison custody in 2004. (Given
its function, it is inevitable that the Nelson Unit experiences a high number of
deaths.) Since 2007, seven prisoners have been transferred to the Nelson Unit
from outside the Norfolk PCT area for terminal care. Four of those prisoners
travelled over 100 miles to receive this specialist support as none was available
locally. In all four cases the prisoners were only in the Nelson Unit for a relatively
short period of time before they died.
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10. In previous reports into deaths at Norwich I have highlighted many areas of
good practice. The staff of the Nelson Unit are highly experienced in providing
care for the elderly and for those who are terminally ill.
HMP & YOI EXETER
11. Exeter prison is located within the city of Exeter and was built around 1850. It
currently has four accommodation units with a healthcare facility in support.
The certified normal accommodation is 314 and the operational capacity 533.
The prison holds both adult male remand and convicted prisoners committed to
custody from Cornwall, Devon, and south west Somerset.
12. The HM Inspectorate of Prisons conducted an unannounced inspection of
Exeter in October 2007. The report said of healthcare services:
“Health services had maintained much of the progress previously
reported. There was only a short waiting list for the dentist. Pharmacy
arrangements were basically satisfactory, although there were still
problems with arrangements for in-possession medications. Mental
health work was good and developing. The inpatient regime remained
poor, and secondary health screening for new arrivals was voluntary,
which was inappropriate.”
13. The Independent Monitoring Board’s Annual Report for 2007 said of the prison:
“There are some very dedicated, professional staff working in Exeter
Prison. Relationships between staff and prisoners are very good.
Prisoners generally feel safe in custody. However, we would like to see
a more purposeful and constructive use of prisoners’ time through the
extension of education, skills and leisure opportunities. The challenges
of operating within predominantly Victorian buildings designed for
another age are immense. The pressure of very high prisoner numbers
adds to the difficulties and requires continuous attention to the
maintenance of clean and safe living and working environments. As
monitors, we expect to see creative management solutions to these
problems in the coming year.”
14. One of my investigators recently investigated a death at Exeter. My
subsequent investigation report included concerns regarding the nursing of
prisoners with palliative care needs. All my recommendations were accepted
by the Primary Care Trust and the Prison Service, and I am pleased to report
here that the investigation into the man’s death found that some of those
recommendations had already been addressed.
HMP DARTMOOR
15. Dartmoor is a category C training prison located in the village of Princetown,
Devon, with an operating capacity of 625. The prison was last subject to a full
inspection by HM Chief Inspector of Prisons in February 2003. An
unannounced follow up in February 2006 revealed a prison that had improved
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16. Dartmoor works collaboratively with HMP Channings Wood and HMP Exeter as
part of the Devon Prisons Health Partnership (DPHP). Healthcare at the prison
is commissioned by Devon PCT. The prison’s healthcare department has a
doctor available every weekday. Overnight and weekend cover is provided by
Devon Docs, an out of hours service commissioned by the PCT. There is no in-
patient facility within the healthcare unit. A dedicated nurse is based in the
Vulnerable Prisoners Unit on F wing.
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KEY FINDINGS
17. In September 2007 the man was received into HMP Dorchester following a
court appearance. It was noted in the first reception screening that he had lost
a stone in weight which he attributed to anxiety about his court case. His
weight was recorded as 57.5kg. No further information was recorded in his
medical notes other than a history of a hernia and a skin graft to his nose. The
man was not receiving any regular medication.
18. The following month the man was sentenced to six years imprisonment by a
Crown Court. On 2 November he was transferred to Dartmoor and was seen
by a nurse on arrival. He told the nurse that he had lost two stone in weight,
which again he attributed to stress. The nurse advised him to make an
appointment with the doctor if his weight loss continued. There is no record of
his weight on this occasion. The man declined the offer of an appointment to
see the doctor.
19. The man had no further contact with any healthcare staff until 16 May 2008
when he complained of abdominal cramps and diarrhoea. His temperature had
risen to 38 degrees and he was mildly dehydrated. (A normal temperature
reading is 36.5 degrees.) He was advised to dissolve a teaspoon of sugar and
a pinch of salt into boiled water to sip. He was also given paracetamol for his
raised temperature and Gaviscon for stomach cramps. The symptoms settled
the following day.
20. On the evening of 23 June 2008, a nurse was called to visit the man in his cell
as he was complaining of shortness of breath. He said that he had had a cough
for three weeks and continued to lose weight, now weighing 55kg. The man
was examined by a doctor the following morning who suspected cancer of the
lung. He was referred for an urgent x-ray and a request was made for a priority
appointment at hospital under the two week referral. (When there is suspicion
of a cancer related illness, a doctor can request further urgent investigations to
take place within two weeks of their referral.)
21. On 27 June, the doctor advised the man that he might well have a malignancy
(moreover, a cancerous tumour). He seemed to take the news well and was
moved to a more appropriate cell on the ground floor to reduce the need for
climbing stairs. Food supplements were prescribed and a computerised
tomography (CT) scan was booked for the following week. (A CT scan is an x-
ray procedure that takes images of the whole body.) On the same day thee
man signed a waiver declining to attend the Court of Appeal for a hearing the
following week as he did not feel fit to travel.
22. The man was seen in his cell on 30 June by a nurse who noted that he was
breathless and who gave oxygen. His breathing settled down and the nurse
advised him to rest. Later, he was seen again by a nurse. His medical notes
show that he was now located on the ground floor and his meals were being
brought to him. The nurse encouraged him to ask for help whenever he needed
it.
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23. The following day the man was seen by a nurse in his cell at the request of wing
staff. He was extremely breathless, which settled when he rested. He was
given some oxygen. The nurse noted that he would need a wheelchair when
his daughter visited the prison in a few days time. (The prison’s disability
liaison officer would arrange a wheelchair to aid the man’s mobility.) Lastly, the
nurse recorded she would make contact with the Red Cross for the loan of a
more suitable and comfortable chair for him.
24. Later that day, the doctor visited him in his cell. He noted that the man was
unwell and it was not safe for him to stay in his cell due to his deteriorating
health. The man was transferred to hospital by ambulance with two officers.
He was restrained by an escort chain. (An escort chain is a 1.8 metres length
of chain with a cuff attached to the prisoner and the other to an officer.)
25. On 2 July, healthcare staff made contact with the hospital for an update on the
man’s condition. He was having a CT scan and feeling much better. The
following day, the man’s medical notes record that a diagnosis of lung cancer
had been made. Further tests were underway and he was to remain in hospital
for the time being.
26. The man started a course of radiotherapy, and a course of chemotherapy (a
treatment for cancer using intravenous medication) was being considered. On
8 July, his appeal against conviction was turned down.
27. During this time healthcare staff at Dartmoor maintained contact with the
hospital. It was agreed to transfer the man to HMP Exeter when he was ready
for discharge because Exeter has 24-hour healthcare facilities. Healthcare staff
at Dartmoor staff contacted the MacMillan nurse to discuss his ongoing cancer
nursing support, and liaison systems were put in place.
28. It was further recorded that a transfer to another health authority would not be
appropriate as the man was continuing receiving treatment for his cancer from
hospital. A compassionate discharge would not be possible at this time as he
was at an early stage into his sentence.
29. Meanwhile, in response to a request from a doctor, a senior officer from the
security department at Dartmoor began to look into the possibility of the man
being transferred to a prison nearer to his daughter in South East London. The
officer was unable to identify anywhere more suitable. However, in this process
the senior officer became aware of the specialist facilities for older prisoners in
the Nelson Unit at Norwich. The officer emailed the Head of Healthcare at
Norwich to explore the possibility of transferring him to their care in the near
future. She replied, sending a copy of the admission criteria and asking for
further medical information.
30. The information sent from Norwich said:
“In order to provide an appropriate service it is necessary to outline those
for whom the service would be inappropriate to provide admission for:
- those who require admission to the Acute NHS Trust services
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- those who require continuous services of a specialist NHS team
- those who require continuous observation due to an acute psychiatric
illness or disturbed behaviour
- those who require specialist treatments or investigations that cannot be
met within this care setting
- those who are applying for early release on compassionate grounds.”
31. The doctor at Exeter concluded that the man did not meet these criteria, and on
18 July wrote in the medical notes that he was still in hospital and would not be
suitable for transfer to Norwich.
32. On 23 July, the man developed a chest infection and it was decided that he was
too ill for the course of chemotherapy. The hospital nurse said that the man
would need palliative care (specialist nursing care for terminal illness). The
doctor recorded in his medical notes that he would need nursing care on his
discharge from hospital, with oxygen available when required. The hospital
said he did not need hospice care at that time. (Hospices provide nursing care
for terminally ill patients.) The doctor noted that the man would be discharged
to Exeter for 24-hour nursing care, and his transfer from hospital to Exeter had
to be by ambulance and not by a prison vehicle.
33. Six days later the man was discharged from hospital to Exeter. He was
admitted to the healthcare centre and seen by the doctor. It was noted that he
was frail with obvious weight loss. Oramorph (a morphine based medication)
was prescribed for pain relief along with further medication to control his
symptoms. The doctor started the process to apply for early release for medical
reasons. He discussed this with the man’s daughter with a view to getting him
registered with her family doctor.
34. A probation officer based in the prison assessed that there was a low risk of the
man re-offending and a medium risk of harm to children. There were some
concerns about him being released to his daughter’s address, but the probation
officer thought that they could be managed with the help of Social Services.
She said that she would have no concerns about risk if the man’s condition
deteriorated and he was cared for in a hospice.
35. However, the Governor noted on the application form that the man should not
be released. The main reason was that it would result in him residing in the
family home, and this would breach his court order. In addition, he was in
denial of his offences and was at an early stage of his sentence.
36. On 30 July, in tandem with the application for early release, a multidisciplinary
meeting took place at Exeter to discuss the man’s care. Amongst those present
was a nurse from a local service for care and support of people with terminal
illness. It was agreed to seek permission to leave his cell door unlocked 24
hours a day to allow easier access by the staff providing care and support. The
hospice nurse agreed to arrange for a hospice bed to be provided when the
man needed it, and weekly visits by palliative care nurses were planned.
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37. Over the next few days the man’s pain control appeared to be well managed
and a community matron visited him. Following this visit, a profile bed with a
pressure-relieving mattress was ordered to help reduce the risk of him
developing pressure sores. The man was seen daily by the doctor and a
nursing care plan was put in place.
38. The man’s daughter visited him on 2 August. An entry in his personal file the
next day noted that staff had a follow-up telephone conversation with her. The
entry said, “she was extremely pleased with everything – it had all gone better
than she expected and she thought he looked very well considering and found
staff to be very kind and helpful.”
39. The profile bed and pressure-relieving mattress were delivered on 5 August,
and the man appeared to be more comfortable as a consequence.
40. The hospice nurse and community matrons visited the man again on 6 August.
On 9 August, the doctor increased the dose of slow-release morphine
prescribed for pain control.
41. The man’s family visited him again on 11 August. Although he was now in the
care of the healthcare team at Exeter, it would seem that staff at Dartmoor had
maintained contact with Norwich and it had been agreed to transfer him. They
emailed Exeter to inform them of this, and an entry was made in the man’s
clinical record to this effect. By this time all active treatment and clinical
investigations had been stopped and he was just being treated with
symptomatic palliative care.
42. On 19 August, a nurse noted that steroid treatment was now less effective and
that “the transfer to Norwich was very timely”. The man remained comfortable
and, following a discussion with the doctor it was noted that he was “not for
resuscitation”. (Not for resuscitation indicates that, should the patient go into
heart failure, resuscitation would not be deemed appropriate.)
43. The man was examined by the doctor on the morning of 20 August and was
assessed as well enough to travel. He was frail and unable to walk, but he was
able to feed himself and take fluids. The following day at 8.00am he was
transferred by ambulance from Exeter to Norwich, accompanied by two officers
and a nurse. The man was not restrained. He arrived at Norwich at 2.00pm.
44. On the same day, a letter written on behalf of the Secretary of State for Justice
was faxed to the Governor of Exeter advising that the Secretary of State had
refused to grant early release.
45. The man was admitted to the healthcare unit for older prisoners and assessed
by the palliative care team. A comprehensive clinical assessment was carried
out, and he was assessed by a Consultant in Palliative Care. The man was
breathless on exertion and had a persistent cough. He complained of a dull
ache across his lower chest which was associated with eating food. It was
noted that he had significant weight loss and reduced mobility although he
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46. The man was described as low in mood, tearful and exhausted after his journey
from Exeter. The palliative care nurse discussed his resuscitation status with
him. The related paperwork was completed and he made it clear that he did not
wish to discuss this any further. It was agreed to continue with the medication
that he had been receiving.
47. A member of nursing staff telephoned the man’s daughter to inform her that her
father had arrived safely at Norwich and was resting. The man settled into his
new surroundings and was noted to be sleeping comfortably that night.
48. On 22 August, the night staff observed the man at 5.20 am when he was said to
be peaceful. However, when he was checked by the healthcare assistant at
5.35am he was not moving and not responding, although was still warm to
touch. An emergency ambulance team was contacted in accordance with the
prison’s procedure. At 5.58am, the man’s death was confirmed by the
paramedics.
49. The man’s next of kin (his daughter) lives some distance from Norwich. The
Duty Governor at HMP Reading was contacted and he agreed to visit her to
inform her of her father’s passing. Following the visit, his daughter telephoned
Norwich and spoke to the Head of Healthcare.
50. As a post mortem examination was not undertaken. It is not possible to say
anything in more detail about the cause of death other than that it was a result
of cancer.
51. The man’s daughter was offered support and assistance from the Head of
Healthcare at Norwich. The Governor of Dartmoor made a financial
contribution towards the man’s funeral expenses.
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ISSUES
Clinical care
52. A review of the man’s health care was commissioned by Devon NHS Primary
Care Trust. A panel of clinicians met to consider the report and its findings.
53. The review has found many examples of good clinical practice whilst the man
was in the healthcare unit at Exeter and recognises the contribution of the
multidisciplinary team towards his care. I note the clinical review panel’s
commendation of healthcare staff for the care they gave the man. No
recommendations were made in relation to healthcare procedures and services.
The review did not include his short time at Norwich.
Care of terminally ill prisoners
54. As soon as the man was diagnosed with cancer and admitted to hospital,
healthcare staff at Dartmoor and Exeter discussed the options for his nursing
care when he was discharged.
55. The man’s daughter was able to speak directly to a doctor about her thoughts
and wishes to support her father at the end of his life. Hospice care was
considered, as well as compassionate discharge that would have allowed him
to stay with his daughter. The compassionate discharge was unsuccessful and
hospice care was inappropriate at that stage of his illness. Options for his
palliative care lay firmly with Exeter.
56. The man’s daughter lived a considerable distance from Exeter and visiting her
father during these difficult times was stressful. The Nelson Unit at Norwich,
whilst still a long distance from her home, did offer suitable palliative care.
57. The palliative care of prisoners who cannot be released from prison is
problematic, and family involvement is subject to the policies and procedures of
each prison.
58. The Nelson Unit is one of the few prison health centres in the country that has a
dedicated service for terminally ill prisoners. Until funding becomes available to
provide more appropriate facilities elsewhere, the Nelson Unit will continue to
be under pressure to offer places to prisoners who have to travel considerable
distances to get there. As the number of elderly prisoner’s increases, the need
for additional units like Nelson Unit becomes more and more obvious.
59. I have raised this issue in a number of my reports. It is my firm view that there
needs to be a better geographical spread of specialist units for elderly, long-
term sick, and terminally ill prisoners. I therefore make the following
recommendation:
The Department of Health and Ministry of Justice should jointly review the
provision of healthcare facilities for elderly, long-term sick and terminally
ill prisoners to ensure a better geographical spread.
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Compassionate Release
60. Approximately five weeks before the man died, his daughter had a conversation
with the doctor at Exeter and discussed the possibility of the man being granted
compassionate release and moved to her home. She said that the doctor
advised her that this would not be possible because her father was too ill to
make the two a half hour journey home at that stage of his treatment. In
addition, the transfer of treatment from hospital to hospital would be
inappropriate at that time.
61. Later, the doctor approached the man’s daughter’s family doctor to see if her
father could be transferred to the practice. The man would be nursed by his
daughter in her home if an application for compassionate release was
successful. The man was now receiving palliative care nursing, and medical
treatments had ceased. The family doctor agreed and so the doctor who the
daughter had spoken with started the process of applying for compassionate
release.
62. Exeter’s probation officer thought that there was a medium risk of harm to the
man’s daughter’s family, and it would be better if he was cared for in a hospice.
However, the Governor felt that, in any event, release would be inappropriate
as it was early in the man’s sentence; he denied that he had committed the
offence, and release would breach a court order. The application for a
compassionate release was submitted to the Ministry of Justice for
consideration. The Secretary of State subsequently turned down the
application on 21 August 2008.
Communication between Dartmoor and Exeter
63. Health services for prisoners in Dartmoor and Exeter are commissioned by
Devon NHS Primary Care Trust and provided by Devon Prisons Health
Partnership. While the man was in hospital, Dartmoor continued to take
responsibility for his care by daily contact with the hospital.
64. When he moved to Exeter from hospital, the lead responsibility for his care was
transferred to healthcare staff at HMP Exeter. In spite of this it would appear
that staff at Dartmoor continued to liaise with Norwich over the possibility of
transferring the man to the Nelson Unit. Exeter was not informed of this.
65. It is likely that the doctor would not have pursued the possibility of
compassionate release had he been aware that a transfer to Norwich was still
being sought by Dartmoor. This would have avoided raising false hopes in the
man’s daughter that her father might have been released to her care.
The Head of Healthcare Services should remind staff of the importance of
good communications between all services covered by Devon Prisons
Health Partnership when prisoners are transferred from one to the other.
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The man’s transfer to Norwich
66. The man’s daughter was concerned that her father was too ill to be moved from
Exeter to Norwich. He had spoken to his daughter about a week before the
transfer and told her that he had been advised to go to Norwich where there
were better facilities. His daughter was keen for him to have the best available
care.
67. A member of staff at Dartmoor had told the man about the facilities at Norwich
following his diagnosis of lung cancer. As he expressed an interest, the staff
made enquiries with the Nelson Unit to see if he would be accepted.
68. The Head of Healthcare at Norwich provided Dartmoor with information about
the Nelson Unit, including the admission criteria and the situations when
admission is inappropriate. The doctor at Dartmoor, once he became aware of
this information, concluded that the man was not eligible for transfer as he did
not meet the unit’s criteria at that stage of his illness.
69. Whilst the enquiries were made with the best interests of the man in mind, they
did cause some confusion for both healthcare staff at Exeter and the man’s
family.
70. In the meantime, the man was admitted to hospital for lengthy treatment and it
was agreed that he would need to be discharged to Exeter because of the 24-
hour healthcare facilities that are unavailable at Dartmoor.
71. As I have noted on many occasions, the facilities at the Nelson Unit in Norwich
provide excellent palliative care for terminally ill prisoners. Whilst Exeter and
Norwich could scarcely be further apart, the facilities that the Nelson Unit could
offer to the man were far better than those at Exeter. He had been told about
the Nelson Unit and opted to go there.
72. Hospice care is available to prisoners in Exeter through good links with the local
palliative care services. At the stage of his illness when he elected to go to
Norwich, hospice care was not appropriate to meet his nursing and therapeutic
needs. The palliative care team considered it right that the man should be
transferred to Norwich. At the time of his transfer, whilst he was very ill, it was
not thought that his death was imminent.
73. Immediately prior to his transfer, a doctor examined the man. It was agreed
that he was fit to undertake the journey. On the journey a qualified nurse and
two officers accompanied him in a private ambulance, fitted for medical
emergencies. Whilst a journey lasting six hours was clearly not ideal, the
practical arrangements for his transfer were good practice.
74. The fact that the man died so soon after his transfer was unexpected.
However, his death was dignified and in much better surroundings in the Nelson
Unit than would have been the case at Exeter.
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75. Given that this report covers three prisons (Norwich, Exeter and Dartmoor), I
suggest that copies are shared with the Governors and Heads of Healthcare in
all three establishments.
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RECOMMENDATIONS
The Department of Health and Ministry of Justice should jointly review the
provision of healthcare facilities for elderly, long-term sick and terminally
ill prisoners to ensure a better geographical spread.
Accepted – “Work is already underway to review the level of need, and
develop a strategy for the delivery of healthcare to chronic and terminally ill
prisoners. This work is being done in partnership between Offender Health and
NOMs.”
The Head of Healthcare Services should remind staff of the importance of
good communications between all services covered by Devon Prisons
Health Partnership when prisoners are transferred from one to the other.
Pending – A response from the Head of Healthcare Services has not been
received at the time of circulation of this final report
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