Individual at Birmingham

Investigation into the circumstances surrounding the death
of a prisoner, while in the custody of HMP Birmingham,
at Sandwell General Hospital in 20 February 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2008
This is a report of the investigation into the circumstances surrounding the death of a
60 year old man at Sandwell General Hospital on 20 February 2008, whilst in the
custody of HMP Birmingham.
The man had been diagnosed with prostate cancer and chronic lymphatic leukaemia
in 2005 and received regular treatment at City Hospital, Birmingham. On 19
February 2007, he complained of severe stomach pain. He was taken by ambulance
to Sandwell General Hospital where he was admitted to intensive care. He
underwent an emergency operation during which it was discovered that he had
further cancer of his bowel. Following the operation, his condition deteriorated
further, resulting in major organ failure. Consultants at the hospital informed the
family that, in their opinion, life support should be withdrawn. The sudden
deterioration in the man’s condition surprised staff that had been caring for him at the
prison. Despite the best efforts of the medical team, he died on 20 February, with his
family at his bedside. I would like to offer my sincere condolences to the man’s
family for their loss.
An investigator carried out the investigation on behalf of the Ombudsman. I would
like to thank the Governor of Birmingham, and in particular the Safer Custody
Governor, for their assistance and the prompt provision of the man’s documents. I
am also grateful to the Joint Director of Healthcare, HMP Birmingham who, on behalf
of Heart of Birmingham Primary Care Trust, oversaw the clinical review process. In
conducting this investigation, the investigator was heavily reliant upon the medical
notes as well as the clinical review. I have, however, raised some concerns about
the impartiality of the clinical review process carried by the Primary Care Trust and
urge them to consider how best to ensure independence in future investigations of
this nature.
The investigation has found that there was initially some delay in arranging the man’s
medical appointments with the hospital, but this had not impacted on the diagnosis or
prognosis. However, a recommendation in respect of this, as well as
recommendations regarding urgent referrals and access to medication has been
made.
Jane Webb
Deputy Prisons and Probation Ombudsman October 2008
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Contents
SUMMARY...............................................................................................................................4
THE INVESTIGATION PROCESS...........................................................................................6
HMP BIRMINGHAM.................................................................................................................7
KEY FINDINGS........................................................................................................................8
ISSUES..................................................................................................................................18
RECOMMENDATIONS..........................................................................................................23
Annexes
1. Clinical review with supporting letter
2. Extracts from medical record
3. Wing history file from March 2007
4. Compassionate release documentation
5. Staff statements
6. Bedwatch paperwork 19 – 20 February 2008
3
SUMMARY
The man was a prisoner at HMP Birmingham. He had been in custody since
November 2002, and was sentenced to 22 years imprisonment in October 2004. He
had a history of heart problems that had been identified on his reception into custody.
During his remand, he had received treatment for these conditions but they were not
considered to be life threatening and were managed with medication.
In September 2004, he reported having trouble in passing water. One of the doctors
at the prison made an urgent referral to the Urology Department at City Hospital,
Birmingham. However, due to administrative errors, the prison failed to make an
appointment and this caused a significant delay. He was finally seen in May 2005.
At this appointment, the consultant indicated that the man would require a biopsy.
There were delays carrying out the biopsy as his existing medication was
incompatible with the procedure and because he was unable to tolerate the biopsy
under local anaesthetic. The biopsy was finally carried out in December, together
with a biopsy of his lymph gland that had been identified as enlarged at an earlier
appointment. The results of the biopsies indicated that he was suffering from
prostate cancer and chronic lymphocytic leukaemia (CLL).
Treatment for the man’s prostate cancer was arranged immediately as it was thought
to be the more serious of the two conditions. The treatment was in the form of
hormone injections every three months. In addition, he attended regular
appointments at both the Urology Clinic and Haematology Department of City
Hospital. He responded well to the treatment on his prostate gland and, as a result,
the Haematology Department was able to begin treatment for CLL in May 2006.
In August 2006, the man initiated a clinical negligence claim against a doctor who, at
the time, was a lead doctor at HMP Birmingham. The man listed a number of issues
in his claim, which was handled by his solicitors. However, the prison and the doctor
responded to all the points raised and the claim was subsequently dropped.
The man had applied for release from custody on compassionate grounds soon after
being diagnosed. One of the criteria for such release is that the prognosis for the
patient’s life expectancy is less than three months. As he did not meet the criteria,
his application was refused. The man continued to pursue the application and the
requirements initially influenced him to refuse further treatment after his first course
of chemotherapy. He was of the impression that he would be able to continue his
treatment after he was released, but specialists at City Hospital informed him that he
urgently needed further treatment and any delay could be detrimental. He was
informed in March 2007 that his second application for compassionate release had
also failed. After this and, on the advice of his specialist, the man agreed to undergo
a second course of chemotherapy.
He responded well and in October 2007, during a routine appointment, the possibility
of stem cell collection was discussed with him. If the man continued to make good
progress, it was planned to begin this process in January 2008 with a possible
transplant in March or April.
On 19 February, the man was suffering from stomach pain and was examined in his
cell by a doctor. Although she was not immediately concerned, given the man’s
4
ongoing problems, the doctor contacted a consultant at City Hospital for his opinion.
Following this conversation, the decision was taken to admit the man to Sandwell
General Hospital for further checks.
On his arrival at the hospital, a number of doctors assessed him and initially his
stomach pain seemed to be subsiding. However, later that afternoon, the escort staff
became aware that the man was experiencing increased pain and they immediately
alerted the doctor. The man was moved to the Intensive Care Unit (ICU) and
prepared for possible surgery and the escort staff removed the restraints to allow
medical treatment to be unhindered.
On the advice of the hospital, the prison informed his family of his condition. In the
meantime, the man had gone into cardiac arrest and, after being stabilised, was
taken into theatre for an operation on his stomach. His condition continued to
deteriorate during the operation and he had a further cardiac arrest. During the
operation, it was discovered that he had suffered a perforated colon and that cancer
had spread to his bowel.
Following surgery, he was returned to the ICU and placed on life support. His family
arrived at the hospital during the evening of 19 February to spend time with him.
When they returned the following morning, the doctor advised them of the prognosis
for his condition. The doctor informed the family that he had taken the decision to
withdraw life support and explained that to do otherwise would just prolong the
inevitable. The man’s family were at his bedside when, at 11.45am on 20 February,
the doctor pronounced him dead.
After the man’s death, the duty governor visited the hospital and spoke to his family.
She also ensured that staff who had been involved in his care and security had
access to support.
I have made three recommendations relating to hospital referrals and appointments,
as well as access to medication. I have also registered my concern about the
independence of clinical reviews commissioned by the Heart of Birmingham Primary
Care Trust (PCT).
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THE INVESTIGATION PROCESS
1. An investigator conducted the investigation on behalf of the Ombudsman. On
21 February, he contacted the Safer Custody Manager at HMP Birmingham.
The Governor produced prison records of the man who died, including his
medical record, for examination. Notices were issued to staff and prisoners to
inform them of the investigation process and to give them the opportunity to
speak with the investigator. No responses were received. During the
investigation, the investigator was in regular contact with the healthcare centre
at HMP Birmingham. His requests for further information from the doctors at
the prison, was supplied without delay.
2. At the start of the investigation, the investigator wrote to Heart of Birmingham
Teaching PCT to request a clinical review into the man’s medical care. The
Director of Healthcare at HMP Birmingham contacted the investigator to inform
him that she would be overseeing the process. The investigator questioned the
independence of this arrangement. However, despite the prison’s best efforts
to obtain further assistance from the PCT and much correspondence from the
investigator, a doctor at Birmingham Prison, carried out the review. I consider
this a conflict of interest and my investigator informed both the Director of
Healthcare at Birmingham and the reviewer that the independence of the report
had been called into question. The prison therefore arranged for the papers
and the clinical reviewers report to be reviewed by a General Practitioner (GP)
at HMP Swinfen Hall. The doctor at Swinfen Hall confirmed that he was content
with the documentation and that, in his opinion, the report was un-biased. I
have therefore attached the review as an annex to this report.
3. One of the Ombudsman’s Family Liaison Officers (FLO), contacted the man’s
mother. She was happy to talk with the FLO and spoke about her son’s life and
sadness at his death. She informed the FLO that she would prefer her other
son to deal with any details concerning the death and gave the FLO his contact
details. The FLO attempted to make contact but unbeknown to her the mobile
number she had been given had changed. She sent the family information
about the Ombudsman’s office and its role as well as her contact details. The
man’s brother discussed the family’s concerns and the FLO indicated that the
draft report was ready for issuing and that many of these concerns had been
considered.
4. The investigator wrote to HM Coroner to inform him of the nature and scope of
the investigation. The investigator was also provided with copies of statements
taken by West Bromwich Police. These proved very useful and I am grateful to
them for making these available. A copy of the report will be sent to the coroner
to assist with his enquiries.
5. A copy of the draft report was sent to the Prison Service and the man’s family.
The Prison Service accepted the recommendations and their response can be
found on page 24. The man’s family provided my FLO with a number of
concerns following sight of the draft report. A majority of these related to the
healthcare afforded to him. I have included their concerns in the appropriate
sections of my final report.
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HMP BIRMINGHAM
6. HMP Birmingham is a local prison for adult male offenders, holding up to 1450
prisoners. It has recently undergone a programme of refurbishment that has
provided new workshops, educational facilities, a new healthcare centre and
gymnasium. Improvements to existing facilities have also been made.
7. Heart of Birmingham Primary Care Trust is responsible for the delivery of
healthcare. General Practioners (GPs) deliver primary care clinics. Registered
nurses, mental health nurses and discipline officers staff the in patient facility
during the day. At night, there is a nurse and discipline officer on duty.
8. There have been seven previous deaths from natural causes at Birmingham
since the Ombudsman took over responsibility for investigating deaths in
custody in April 2004. I am not aware of any similarities between
recommendations made following these deaths and those made following this
investigation.
9. An announced inspection by HM Chief Inspector of Prisons, Ms Anne Owers,
was carried out in February 2007. The inspection concluded that:
“Birmingham was suffering from many of the pressures of an
overcrowded prison system. Those pressures made it much more
difficult to deliver safe, decent and purposeful outcomes for prisoners. It
was a credit to staff and managers that the prison remained a much
better place than it had been in 2000, and the scale of the task should
not be underestimated. But this inspection found that the prison was
not responding sufficiently proactively and robustly to the challenges it
now faced, and indeed that some of the old culture was now
reasserting itself. We do not underestimate the difficulty of sustaining
progress, with increased pressures and increased expectations of
delivery. The fact that Birmingham was not performing sufficiently well
against three of our four key tests is a measure of the challenge facing
its managers.”
10. The Independent Monitoring Board (IMB) published their last annual report in
2007. The Board commented on healthcare provision:
“The EMIS system – a computerised management information system
working across the NHS – promised for December came into operation
in May. It is working extremely well having started in reception and
then throughout healthcare.
“Primary care nursing vacancies have now been filled but they are not
yet in post. There should be little need to use agency nurses except in
emergencies.
“The complement of doctors is complete and some of them do extra
duties in reception rather than using Locum Doctors, although there is
still a need to use Locum Doctors to fulfil the medical demand.”
7
KEY FINDINGS
Initial custody and medical treatment
11. In November 2002, the man was remanded into custody at HMP Blakenhurst.
On arrival, a member of the healthcare staff recorded his medical problems. He
told medical staff that he had been under the care of a doctor at the Glenfield
Hospital in Leicester. He was being treated for cardiomyopathy (abnormality of
the heart muscle), hypertension (high blood pressure) and atrial fibrillation
(irregular heart beat). He was receiving medication to treat all these symptoms
when he arrived into custody.
12. The man was at Blakenhurst for a short period. He transferred to HMP
Winchester on 28 November after being sentenced to two years imprisonment.
When he arrived at Winchester, a healthcare officer (HCO) saw him. A follow
up appointment with the doctor was scheduled for the following day. The man
settled into the prison regime quickly. This was not his first period in custody.
13. He was due to appear at Wolverhampton Magistrates’ Court on 2 December, on
further charges. While in reception, he complained of chest pain and the escort
was postponed until the prison doctor could see him. Following tests, including
an electrocardiogram (ECG), it was concluded that the symptoms were most
likely to be anxiety related. The HCO contacted the Observation, Classification
and Allocation (OCA) department at Winchester prison. He explained that it
would be preferable for the man to return to Blakenhurst in order to attend his
court appearances, as it was closer to the court.
14. Two days later, on 4 December, he collapsed on the wing and had to be taken
to the Royal Hampshire County Hospital (RHCH). After examination by a
doctor, he was admitted for observations. The man returned to the prison on 11
December following treatment. There were no other problems relating to this
and no further healthcare involvement at Winchester.
15. Due to his outstanding further charges, the man was confirmed as a category A
prisoner on 16 December 2002. This meant that he could no longer be held at
Winchester, a local category B prison. He was transferred to HMP Woodhill on
17 December, one of eight prisons designated as high security.
16. On arrival at Woodhill, the man was seen by a HCO in reception. His
medication including warfarin (a tablet used to thin a patient’s blood and prevent
clotting) was recorded. He was also placed on the sick list. The HCO arranged
for him to have an International Normalised Ratio (INR) test. The purpose of
this test is to monitor the thinning of the blood. The blood needs to be thin
enough to prevent clots but not too thin to increase the risk of bleeding. He
attended regular INR tests while at Woodhill and throughout his time in custody.
17. On 19 May 2003, the man was temporarily transferred to HMP Blakenhurst to
attend his ongoing court case. He returned to Woodhill on 16 June but
continued to be transferred back and forth during his court case. His medical
treatment continued in both prisons. He was considered not to pose such a
8
Transfer to HMP Birmingham
18. The man was transferred to HMP Birmingham in January 2004, as his trial had
been moved to Dudley Crown Court. He was subsequently sentenced on 25
October 2004 to 22 years imprisonment. Before sentencing, the judge in his
case had requested a report from his cardiologist, which was administered by
the healthcare team at Birmingham. His cardiac problems remained stable
throughout his time in prison.
19. On 13 September 2004, he reported sick. He discussed problems he had
encountered in obtaining a repeat prescription and, as a result, changes to his
medication were made. During the consultation, the man also mentioned that
he had been having difficulty urinating. Further tests were arranged and an
appointment made for him to be seen again in one week.
20. When the doctor saw him on 20 September, she recorded a more detailed
history. She noted that he was getting up at least five times a night to go to the
toilet. The man also said that he sometimes had symptoms during the day.
There was no sign of weight loss or back pain which may have indicated
infection. However, upon examination the doctor found that the man had a soft
enlarged prostate. In view of this, a blood test for prostate specific antigen
(PSA) was arranged. The PSA test is done as a prostate cancer-screening test.
A normal PSA level is less than 3.5 with a raised level being an indication of
possible cancer and the need for referral. His PSA level was 7.9.
21. The doctor referred him for an urgent urology appointment on 27 September.
The hospital confirmed that the waiting time for a urology appointment was 13
weeks. The healthcare department at Birmingham received a letter in
December 2004, which invited them to arrange an appointment for the man with
the Urology Department at City Hospital. However, for reasons that remain
unclear, this was not done and he was removed from the waiting list. The
prison healthcare team referred him again. This meant another 13 week wait
for an appointment. On 14 February 2005, a letter from the Urology
Department invited healthcare at Birmingham to arrange an appointment again.
This was finally booked for 17 May 2005.
In response to the draft report, the man’s family said they felt that the missed
appointment demonstrated the lack of ‘duty of care’ provided to him by the
doctor. They also said that the comments ‘reasons that remain unclear’ in
relation to the failure to book an appointment were unacceptable to them.
22. As is the usual procedure for escorts out of prison, the prison conducted a risk
assessment before the appointment took place. This assessment indicated
that, due to his perceived level of risk, two members of staff would have to
escort the man and he would be handcuffed. As my report highlights below, he
went to hospital on a number of occasions and this level of risk remained the
same. He was seen in a consultant’s clinic on 17 May. Tests showed that he
might have diabetes, which might account for his symptoms. Due to his raised
9
23. The man attended for the appointment on 10 August, but it had to be postponed
as he was still taking warfarin. warfarin increases the risk of bleeding, therefore
patients have to stop taking it before any operation. The hospital wrote to the
prison to reiterate the instructions advising that the man would need to stop
taking the drug at least five days prior to the appointment, and requesting that
the prison inform them of a satisfactory time for the procedure. The prison
doctor contacted the consultant’s secretary on 23 August to rearrange the
biopsy.
In response to the draft report, the man’s family said that as the doctor who
contacted the hospital was the doctor responsible for INR testing she should
have been aware of the need for his warfarin to be stopped prior to the biopsy.
The family said this again highlighted where the doctor failed in her ‘duty of
care’ towards the man.
24. Between September and December, the man attended the hospital on four
separate occasions. On 28 September 2005, he attended City Hospital for the
biopsy on his prostate. Unfortunately, this time he was unable to tolerate the
procedure under local anaesthetic and it was rebooked to be carried out under
a general anaesthetic. He was admitted on 6 December. During his pre-
assessment, doctors found an enlarged lymph gland in his neck so the biopsy
was cancelled. He returned to the prison on 9 December. The hospital gave
instructions for the man to remain off warfarin until after the biopsy had been
completed.
25. He underwent both the prostate biopsy as well as a biopsy of his lymph gland
under general anaesthetic on 12 December. City Hospital notified the prison
healthcare team on 20 December that the biopsies found him to have both
prostate cancer and chronic lymphocytic leukaemia (CLL). He remained in
hospital until 22 December. He had a catheter inserted following his biopsy as
he had developed urinary retention. Arrangements were made by the hospital
for the man to attend the Haematology Department to discuss treatment for the
CLL and to return to the Urology Clinic in three months to check his progress.
26. Through his solicitors, the man applied for compassionate release after he was
initially diagnosed with prostate cancer and leukaemia. The criteria for a
prisoner to be released on compassionate grounds include a prognosis that the
prisoner’s life expectancy is less than three months.
27. The man was prescribed hormone injections to treat the prostate cancer, but
these could not be given at the prison. As a result, the prison doctor contacted
City Hospital on 30 December, to arrange for a nurse from the prison to
accompany the man and be shown how to administer them. In spite of some
confusion between the security department and healthcare, he attended with a
nurse on 3 January 2006. The man continued to receive the hormone injections
every four weeks, which later reduced to every three months.
10
28. A consultant saw the man in his clinic at City Hospital in February. He
assessed him for possible radiotherapy as additional treatment for his prostate
cancer. During the assessment, the man told the doctor that he had been
diagnosed with testicular cancer in 1971 for which he had received radiotherapy
at Leicester Royal Infirmary. The doctor arranged for information to be obtained
on the level of radiotherapy that the man had previously received in order to
plan future doses.
29. He was admitted to City Hospital on 4 April. His catheter, inserted in
December, was removed from his bladder for a trial period to determine
whether he was able to pass urine spontaneously. The trial was successful.
While admitted for this procedure, the Haematology Team at City Hospital also
took a bone marrow sample from him.
30. Another consultant at City Hospital, Haematology Department had seen the
man in January 2006. At that time, the doctor considered his most pressing
need was for the treatment of his prostate cancer. In view of this, no other
immediate treatment was considered for leukaemia. However, the doctor
recorded in a letter on 25 January to the medical officer at Birmingham prison,
that anti-CLL treatment might be necessary in the next six months.
31. The man responded well to treatment for prostate cancer and tests showed his
PSA to be 0.3 in April 2006. This indicated a good response to the hormone
injections. The urology team at City Hospital continued to see him regularly and
his PSA dropped further to 0.1. A doctor saw the man again in clinic in May
2006. The doctor said that the man remained asymptomatic (no noticeable
symptoms) in relation to his prostate cancer. In view of this, and the man’s
good response to the hormone treatment, the doctor felt that there was no need
to offer radical radiotherapy. As a result, he was happy for his colleagues to
proceed with treating the man’s CLL.
32. In May, the prison doctor contacted the hospital on the man’s behalf in order to
get information on his prognosis, as he continued to pursue his application for
compassionate release. However, his prognosis did not meet the criteria and
he was informed that his application had been unsuccessful in July 2006.
33. In August 2006, he instigated a clinical negligence claim against the doctor at
Birmingham prison through his solicitors. He considered aspects of his
treatment had been unsatisfactory. In an exchange of correspondence over the
following months, the healthcare department responded to the man’s solicitor
addressing the points raised. It is my understanding that following this
correspondence the claim was not pursued any further.
In response to the draft report, the man’s family said that his claim against the
doctor for clinical negligence was not subsequently dropped. They confirmed
that in the event of his legal aid being withdrawn the family would have provided
financial support for him to continue the case. The family also said that the man
had asked them to pursue the case on his behalf, in the event of his death, as a
matter of principle.
11
34. The man began treatment for CLL in May. Following the first cycle of treatment,
he was seen again at City Hospital where he complained of feeling fatigued.
The consultant considered it was too early to say whether the treatment was
having any effect, but the dosage was nevertheless increased from 4mg to
6mg. This was increased again at the next two reviews over the following eight
weeks. When he was seen in the clinic on 21 September, he complained of
backache but said that he had no other symptoms. It was also noted that the
man had missed one of his cycles of treatment. The doctor prescribed his fifth
cycle and booked a CT scan after his sixth cycle of treatment in November.
35. The man attended the clinic in November. Tests showed that he had not
responded to the first line of treatment and a second line of chemotherapy
treatment was recommended. A doctor saw the man again on 16 November, at
the clinic. He explained the course of treatment and what it would mean if that
treatment was delayed. However, despite all the risks and benefits being
explained, the man said that he wanted to wait until January 2007 before
deciding on treatment. His reasons were that he was continuing to pursue his
release from prison on medical grounds. The man believed that his application
would be successful and he would be in a position to continue his treatment
after his release.
During the investigation, it was apparent from hospital correspondence that the
man’s application for compassionate release featured heavily in his decision-
making. In response to the draft report, his family comment that he had
discussed his concerns regarding the dangers of the second course of
chemotherapy. In their view, he did not refuse this on the basis of his
application for compassionate release, or the grounds associated with the
criteria.
36. When a doctor saw the man in the clinic in January 2007, he explained that he
was still awaiting a decision regarding his release on compassionate or medical
grounds. The doctor said that treatment would not be initiated until it was clear
whether he would remain in Birmingham or return to Leicester. He also said
that they would only be able to postpone it for a few weeks but it might have to
be started sooner if the disease progressed. Arrangements were made for the
man to be seen again in five weeks.
37. The man’s consultant had received a letter from him regarding his treatment
and ongoing application for release. On 8 February, the consultant addressed
the issues raised by the man in a letter to his solicitors. In the letter to the
consultant, the man had expressed concern about a number of issues regarding
his prison custody, including unsatisfactory conditions within the prison’s
medical wing. The consultant replied that he considered the decision to offer
the man intravenous chemotherapy was correct. It was also apparent from the
consultant’s response that both he and his team had concerns about the man’s
decision to delay this treatment. In responding to his concerns about the prison
environment, the consultant said that while some of his points could possibly be
upheld, there was no justifiable reason for the man to delay his treatment. The
consultant referred to another prisoner from Birmingham prison that he had
treated without complication. He also commented on the good liaison between
12
38. On 14 March 2007, the man was informed that his second application for
compassionate release had been refused. It was explained that despite his
medical problems the Secretary of State felt that his case did not meet the
criteria for compassionate release. However, the Governor was advised to
monitor his condition and refer his case again if there was a significant
deterioration.
39. When the consultant saw the man on 22 March, he recorded that in his opinion
he had lost a considerable amount of weight since his previous attendance at
the clinic. However, the man said that his appetite was good and any weight
loss was attributable to a healthier diet. The consultant made it clear to him that
the CLL was progressing and that he was in urgent need of chemotherapy. He
told the man that with good communication between his team and the medical
staff at the prison, he saw no reason for the treatment to be delayed while he
was still in custody. However, the man again raised concerns regarding the
level of medical support that he would receive at the prison. Based on his
previous experience of administering the same treatment to another prisoner,
the consultant disagreed with his concerns.
40. A palliative care plan was put in place by the prison healthcare team to ensure
that the man was cared for in line with NHS standards. When he was seen in
April, the consultant informed him that earlier tests had shown that the
prognosis for his leukaemia had become poorer. Because of this, he
considered the chemotherapy should be started without further delay. The man
again discussed his medical care at the prison and told the consultant that he
had now been made ‘Priority 1’. This meant that if he became unwell he would
be given immediate access to healthcare. He finally agreed to begin
chemotherapy and his consultant arranged for him to return for his first cycle.
41. In total, the man underwent four cycles of R-CHOP chemotherapy (R-CHOP
refers to the drugs used during the treatment), which required regular
attendance at the hospital. When he attended the consultant’s clinic in July
2007, he asked again about his life expectancy. He was still focused on
obtaining compassionate release. The consultant told him his concerns that
despite improvements in his circulating disease, his lymph nodes had shown
little response to the first line of chemotherapy. Faced with the prospect of the
man having to undergo a second line of treatment in the form of FC
chemotherapy (FC refers to the drugs used during the treatment), the
consultant assessed that the man’s estimated survival could be less than 12
months. This prognosis, although relatively short, still did not meet the criteria
for release from custody. All the risk factors and benefits of further treatment
were explained to him, and the consultant arranged for this further treatment to
start within two weeks.
42. Following the first cycle of the FC chemotherapy, tests showed a regression in
the disease in the man’s lymph nodes. It was also recorded that he was gaining
weight. His second cycle of treatment was scheduled to be given orally over
three days. Between this and his final course of treatment, he attended an
appointment in October at the Haematology Clinic. A doctor who discussed
13
43. When the consultant saw him at the end of October, he too discussed the
possibility of the man undergoing a stem cell transplant. The consultant had
received a positive report on the man’s prostate cancer indicating that it was in
remission. This meant that, in spite of the prostate cancer, there were no
reasons for the transplant not to proceed. During the appointment, the man
said that he was feeling very well and was maintaining a good appetite despite
losing some weight. Further appointments were scheduled, including scans of
his abdomen to check on the progress of the leukaemia.
44. The progress of his request for compassionate release was again mentioned
when he was seen at the consultant’s clinic. He told the consultant that he
believed his latest application would be successful before Christmas. He also
said that, when released, he would like to continue his treatment at City Hospital
rather than returning to Leicester as he had previously mentioned. During the
appointment, a scan was carried out to enable the decision on his stem cell
transplant to be made. The results were very positive and communicated to
him in late November 2007. The consultant told him that tests would be carried
out again once he had completed his chemotherapy and if results remained the
same, a stem cell transplant would be arranged for early 2008.
45. The man had a routine appointment at the haematology clinic on 13 December.
Doctors explained to him that the test results had indicated that stem cell
collection could be started prior to him undergoing any further chemotherapy.
During the appointment, he said that he was feeling well apart from having
suffered from a bout of food poisoning the previous week. The man was told
that, once sufficient stem cells had been collected, he could proceed to a
transplant in either March or April 2008.
46. Throughout his illnesses and between attending for treatment, the man was
employed in the kit store on his wing, looking after and issuing clothing to other
prisoners. Staff commented that he continued to work well and remained in
good spirits, despite his ongoing treatment. Entries in his wing history file
indicate that he continued to work until February 2008.
Events leading to the man’s death
47. The prison nursing staff saw the man on three occasions during the first week of
January 2008. He complained of further abdominal pain and some of his
medications were stopped as a result. He told the doctor on 17 January that
the pain was colicky but he had not vomited. He felt that his symptoms were
the result of food poisoning that he attributed to butter that he had been given.
Following an examination, the doctor said that she did not consider that his
symptoms were due to food poisoning and, in her opinion, antibiotics were not
appropriate.
14
48. His complaints of abdominal pain and intermittent diarrhoea continued. A stool
culture was tested, which indicated no infection. Nursing staff at the prison
continued to review him on his wing every few days during January and
February. On these occasions, he said that he was happy and had no real
concerns or other problems.
49. However, on 19 February one of his wing officers asked a nurse to see him as
they were concerned about his condition. The man told a nurse that he had
been suffering from diarrhoea and vomiting and had been unable to get out of
bed due to abdominal pains. The nurse contacted the prison health centre and
asked for the man to be seen in cell by a doctor.
50. At around 9.30am, the doctor saw him in his cell. The man told her that he had
been to Russells Hall Hospital the previous afternoon for further stem cell
collection. He said that he had vomited on his return, but not since. He had
continued to suffer from diarrhoea and was finding it difficult to get to the toilet
due to the cramps. The doctor examined him and considered he looked unwell.
She recorded that he had ‘cold peripheries’ and looked in pain. His pulse rate
was not raised, but was irregular due to atrial fibrillation (AF). She also
recorded that the lower part of his abdomen was particularly tender. However,
there was nothing to indicate peritonitis (inflammation of the peritoneum).
51. Following her assessment, the doctor considered that the man did not require
immediate hospital treatment. However, given her knowledge of his history and
her previous consultations with the man’s consultant, she contacted him for his
advice. The doctor’s impression was that he might have picked up an infection
the previous day while attending for treatment. After talking to the consultant, it
was decided to admit the man to Sandwell General Hospital, Birmingham.
52. An ambulance was called and it arrived at 10.43am. After discussions with the
healthcare team and ensuring the man was comfortable, the ambulance left the
prison for Sandwell General Hospital at 11.23am. He was escorted,
handcuffed, by prison staff. On arrival at the hospital, the man was admitted to
a ward. His handcuffs were removed and the escort chain applied. This gave
him more freedom of movement and allowed the medical staff better access to
carry out their observations.
53. Despite continuing pain, the man appeared settled for the remainder of the
morning and was checked regularly by nursing staff and doctors. However,
during the afternoon, he became increasingly short of breath and appeared to
the escort staff to be in more pain. A nurse saw him at an officer’s request, but
the man continued to deteriorate. An officer went to the nurse’s station about
ten minutes later and asked a doctor to see the man. The first doctor to
examine him immediately asked other doctors to assess him and he was then
moved to the Intensive Care Unit (ICU) at 3.00pm.
54. A doctor explained to the escort staff that they considered that something had
burst in the man’s stomach for which he would require immediate surgery and
requested that the restraints be removed. After consultation between the escort
staff and Duty Governor at the prison, the restraints were removed at 3.25pm.
15
55. At 3.30pm, two other prison staff arrived at the hospital to take over the escort.
They were informed by the doctor that the man was in a serious condition which
might be life threatening. It was decided that his next of kin should be notified.
They informed the Orderly Officer and the chaplaincy team at the prison and the
process of contacting his relatives was begun. It was clear to the investigator
that events on the afternoon of 20 February moved very quickly and the prison
acted as soon as the hospital indicated that the man’s condition had
deteriorated at 3.30pm.
In response to the draft report, the man’s family said that they felt that the
Governor should have informed them of the man’s condition when he was
moved to intensive care at 3.00pm. They considered that not informing them
until he was in a critical condition was ‘most disgraceful’.
56. The man continued to deteriorate and, at 4.00pm, he went into cardiac arrest.
Nursing staff and doctors began resuscitation and he was stabilised. He
remained in a serious condition and was moved to theatre to undergo an
operation on his stomach. While in theatre, the man had a further cardiac
arrest. It was discovered that the pain had been caused by a perforated colon
but also that the cancer had spread to his bowel. The prognosis for recovery
was not very good and medical staff informed the escort at 6.00pm that the man
could die within the next few hours. Following the operation, he returned to the
ICU, on life support, where he remained unconscious.
57. The prison chaplain arrived at the hospital and was informed of the man’s
condition. He told the escorting staff that he had managed to contact the family
and they would be attending the hospital but had to travel a long distance.
58. The man’s family arrived at the hospital at around 9.30pm and were
understandably upset. They spent about an hour at his bedside and spoke to
the escort staff. His brother told the escort staff that they did not expect him to
survive the night. Throughout the night, nursing staff attended to him but there
was no improvement in his condition.
59. At 7.45am the following morning, the prison staff changed shifts. They
remained in view of the man’s bed but were positioned across the ward to give
him a degree of dignity. His family returned to the hospital at 10.50am and the
doctor explained the man’s condition. That he was being maintained on the
machine and was unlikely to survive without it. His family accepted the doctor’s
decision that treatment should be withdrawn. Without the support of the
machines, he passed away peacefully with his family by his side at 11.45am on
20 February.
Events following the man’s death
60. A governor visited the hospital at 12.30pm, along with a member of the prison’s
care team. The governor met the man’s elderly mother, brother, sister and
partner. His brother spoke highly of the care that the man had received at the
hospital and confirmed that they had given permission for treatment to be
withdrawn.
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61. The man’s brother was upset that his brother’s requests for compassionate
release had not been successful. The man’s partner informed the governor that
he had belonged to the Holy Trinity Church in Leicester. The family spoke of
concerns regarding his medical treatment while in custody, including missed
hospital appointments, which the governor was unable to comment on at that
time. I hope that these concerns have been addressed in my report.
62. The governor remained at the hospital until 3.50pm. During this time, she
spoke to the hospital about the man’s medical records and confirmed that all
personal effects had been accounted for. On her return to the prison, she
liaised with the prison care team to ensure that all staff involved were contacted
and offered support as required.
17
ISSUES
Access to healthcare
63. After seeing the man in September 2004, the doctor made an urgent referral to
the Urology Department at City Hospital. On receipt of the referral, the hospital
indicated a waiting time of 13 weeks, which was normal for this particular clinic.
However, the man did not attend until 17 May 2005, some seven months later.
This delay was caused by the failure of the healthcare department to respond to
requests from the hospital for an appointment to be booked. Consequently, he
had to be re-referred, incurring a further 13 week wait. There is no evidence to
suggest that these delays made any difference to the man’s prognosis, but to
wait seven months for an appointment originally listed as an urgent referral is
unacceptable. It is unclear whether the original referral was made under NHS
policy guidelines in which patients with suspected cancer should be seen by a
specialist within two weeks and, if not, why this was not the case.
In order for external healthcare providers to make timely clinical
interventions and provide continuity of care, the Head of Healthcare
should introduce procedures to check that appointments have been
booked.
The PCT should ensure that if the ‘two week rule’ for patients suspected
of having cancer is being used for referrals in the wider community, it is
also implemented for those being held in custody and requiring the same
treatment.
64. The treatment that the man received at hospital impaired his immune system
and meant that he was more likely to contract illnesses. In view of this, the
healthcare team recommended that he spent time on the healthcare wing
during his treatment so that he could be monitored more closely. However, it
was his wish to remain in his cell on the wing and the healthcare team
respected this. As his illness progressed, the man’s care was based upon the
NHS Gold Standard Framework for End of Life Care.
65. Between December 2007 and January 2008, the man developed a stomach
upset which was a new symptom. During this time, he was seen on a number
of occasions by the healthcare team and by staff at the hospital’s Haematology
Department. Investigations were undertaken that included blood tests to
identify an underlying cause for his stomach upset but the results of the tests
were normal. In her review, the clinical reviewer considered that the man’s final
illness was not predictable.
Provision of medication
66. It is necessary for a person who is taking warfarin and requires an operation to
be reviewed and, if necessary, the medication should be suspended to prevent
the risk of bleeding. When the man attended for the biopsy on 10 August, it had
to be postponed as he was taking warfarin. Given that they were aware of the
impending biopsy, I am surprised that the prison healthcare had to be told to
withdraw this medication. The postponement of the biopsy led to an
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67. The man was taking a variety of medications and he was concerned about
access to them. He had returned from hospital with medication which was
taken from him and this led to a delay in him obtaining it. The warfarin required
regular monitoring and it is evident that this was done. The clinical review
acknowledges that some doses of warfarin had been missed and says that this
is clearly not acceptable in any situation. In her review, the clinical reviewer
also says in relation to prisoners’ access to medication:
“Warfarin poses particular problems within the prison due to the need
for close monitoring and frequently changing doses. We have
attempted on several occasions to put robust management protocols in
place to facilitate the safe and effective management of Warfarin. The
situation has improved but we are constantly looking at the problem
and seeking to improve the quality of our care. In-possession,
medication is now being recorded on EMIS (Electronic Medical
Information System) on the day it is delivered to the patient. This will
allow for tighter control of in-possession medication and make
monitoring easier and more reliable.”
I welcome the steps being taken by the healthcare team at Birmingham and
make no further recommendations in relation to this.
68. Given the potential for the misuse of prescription medication within the prison
environment, it is essential that the prison has in place facilities that allow in-
possession medication to be stored safely. In the clinical review, the reviewer
confirms that there are currently no such facilities available at Birmingham and
goes on to say:
“Steps are now being taken to provide every prisoner with a lockable
cabinet. This will improve safety and security of medication and reduce
the risks of medication being stolen. It will also hopefully allow more
prisoners to have a wider range of daily medication in-possession.”
Again, I welcome the steps being taken by the healthcare team and endorse
this with the following recommendation.
I recommend that the Governor and Director of Healthcare at HMP
Birmingham ensure that the initiative to provide lockable cabinets is
progressed promptly, to ensure that delays in prisoners getting access to
their medication are avoided.
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The man’s complaints regarding his medical care
69. The man had made numerous complaints about the medical treatment he was
given at Birmingham, which culminated in a claim in respect of medical
negligence against a doctor. The points raised by him, via his solicitors, related
to missed appointments and access to medication. It was acknowledged that,
due to unforeseen circumstances, the man had indeed missed one appointment
but this had not been detrimental to his treatment. In relation to medication,
there had been instances when he became concerned about not taking
warfarin. The reasons it had been withdrawn were normally due to the ongoing
cancer treatment but it was also acknowledged that some doses should not
have been missed. The doctor responded in full to the man’s solicitors,
addressing all the points raised. I understand that following this the matter was
not pursued further.
70. The clinical reviewer also acknowledges the breakdown of the relationship
between the man and the doctor. The reviewer says that following the man’s
complaints she took over the management of his care and was able to maintain
a good working relationship with him. She further adds:
“Problems such as this cannot be planned for but the healthcare
department must be clear that it is our responsibility to find a workable
compromise, where possible, to ensure that patients medical needs
take priority and that the patient care does not suffer when problems
such as this arise.”
I endorse the clinical reviewer’s views.
71. The healthcare team at Birmingham and staff at City Hospital liaised well in the
delivery of the man’s treatment. The good working relationship between the
consultants and the doctor ensured that, once the man started to attend his
appointments, treatment was delivered in a timely manner and his imprisonment
did not present a barrier to this.
Application for compassionate release
72. When the man was diagnosed with both prostate cancer and leukaemia, he
immediately applied for compassionate release. Given that he was in the early
stages of his sentence and a definitive prognosis could not be given, he was
unlikely to be successful. However, both prison staff and those involved in the
man’s medical care continued to support his application. Again, this highlighted
the good working relationship between the team at City Hospital and the
healthcare team at Winson Green.
73. This was an area of concern for the man’s family who felt that his illness might
progress too quickly for there to be time to re-apply for compassionate release.
The man’s family told my Family Liaison Officer that they had even written to
the Queen just before Christmas 2007 to ask her to become involved.
However, the family did not receive a response. This demonstrates the family’s
efforts in trying to make it possible for the man to spend his remaining time with
them.
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Escort staff and restraints
74. When hospital staff notified the escort officers of the deterioration in the man’s
condition on 19 February, they quickly removed the restraints to allow treatment
to be delivered. After it became clear that the man’s condition was critical, the
escort staff positioned themselves in such a way that provided his family some
degree of privacy and dignity. That said, his family felt that it was unnecessary
for three officers to be present, and I agree. I would like to remind the Governor
of Birmingham of the revised guidance issued in February 2008, in relation to
restraining prisoners who are seriously or terminally ill. The guidance requires
prisons to balance the sensitive nature of a prisoner’s changing physical
condition against the need to provide the public with adequate protection when
deciding on the level of restraint or escort.
Family Contact
75. The man’s family felt that there had been a delay in them being informed that he
had been taken to hospital, and that it was 5.00pm before they were contacted.
Due to this they felt that they had lost time to spend with their son and brother.
However, I have found nothing during the investigation to suggest that there
was an unnecessary delay. The man arrived at hospital around midday and at
that time was said to be comfortable. The prison would have treated this at that
point as any other discharge to hospital as there was no indication that it was
life threatening. It is not the procedure to contact the families of prisoners on
each occasion that a prisoner attends hospital. When it became apparent that
the man’s condition had deteriorated and could be life threatening, the escort
staff immediately contacted the prison and a member of the chaplaincy made
contact with the family. It is regrettable that the man’s family were unable to
spend any longer with him I believe that every effort was made by the prison to
make contact as soon as it was apparent that his life might be at risk.
76. Following the man’s death, the Safer Custody Manager maintained regular
contact and made a number of visits to the man’s mother ensuring that all of her
son’s property was returned. The family have appreciated this assistance and
thoughtfulness.
Independence of the clinical review
77. Since this office took over responsibility for investigating deaths in custody in
2004, there have been 16 deaths at HMP Birmingham. All but two of these
required a clinical review to be conducted. The clinical reviews for the first nine
deaths were carried out independently, by medical practitioners unrelated to the
prison. However, the last five reviews commissioned by my office have been
undertaken by senior healthcare staff employed at Birmingham. While I have
found the quality of the reviews to be of a high standard, I am concerned that
the Heart of Birmingham Teaching PCT appears to have moved away from the
use of independent medical practitioners for such reviews.
78. A doctor conducted the man’s clinical review in spite of being the clinical lead
GP at Birmingham. While her review was thorough and addressed a number of
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22
RECOMMENDATIONS
1. In order for external healthcare providers to make timely clinical interventions and
provide continuity of care, the Head of Healthcare should introduce procedures to
check that appointments have been booked.
The Prison Service accepted this recommendation in full and said:
There is now a detailed Protocol in place for making and following up any internal
/ external appointments to be made for any prisoner requiring one.
All client data and all referrals are registered and followed through and tasked via
the computer system EMIS. The system used by all clinical and administration
staff, to ensure continuity of care is maintained.
To ensure the waiting times are not excessive, there is also a tracker system in
place used alongside a Calendar to chase up if necessary. The target date was
immediate.
2. The PCT should ensure that if the ‘two week rule’ for patients suspected of having
cancer is being used for referrals in the wider community, it is also implemented
for those being held in custody and requiring the same treatment.
The Prison Service accepted this recommendation in full and said:
This is part of our referral system, and all patients are seen within the hospital
waiting time protocols. The target date was immediate.
3. I recommend that the Governor and Director of Healthcare at HMP Birmingham
ensure that the initiative to provide lockable cabinets is progressed promptly, to
ensure that delays in prisoners getting access to their medication are avoided.
The Prison Service accepted this recommendation in full and said:
The feasibility and practicalities of adopting this system are being piloted in HMP
Featherstone. We will be arranging a visit to the prison discuss/review the
scheme in conjunction with the SMT. The plan would then be to pilot a similar
scheme on one of our wings at Birmingham. The target date is March 2009.
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