Individual at Frankland

Investigation into the circumstances surrounding the
death of a man
at HMP Frankland in August 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2009
Final Report: April 2009
This is the report of an investigation into the circumstances of the expected death of
a prisoner at HMP Frankland, on 23 August 2008. The man was 47 years old at the
time of his death from lung cancer. I would like to offer my sincere condolences to
the man’s family, his friends and to all those who knew him and were touched by his
passing.
My colleague conducted the investigation on my behalf. An independent review into
the man’s care was undertaken on behalf of the County Durham Primary Care Trust.
I am grateful to the clinical reviewer for his valuable contribution. I would also like to
thank the Governor and Deputy Governor of HMP Frankland for their cooperation
with the investigation. I am particularly grateful for the high standard of liaison.
One of my Family Liaison Officers contacted the man’s father who said that he was
happy with the way in which the prison managed his son’s terminal illness.
I conclude that the care the man received at Frankland was very good and his
wishes were respected. Healthcare and prison staff provided a high level of care to
him. I make one recommendation and three commendations. The recommendation
relates to the need for timely applications for release on compassionate grounds
when a terminal illness is diagnosed. Of the three commendations, the first relates
to prison staff who, despite being in the restricted environment of a category A
prison, were flexible about the man’s care. The second acknowledges the support
and care give to the man by his carer and fellow prisoner. The final commendation
goes to healthcare staff who, through multi-disciplinary working, managed the man’s
care effectively and in accordance with his wishes for as long as was practical. It is
pleasing to note that this report mirrors a previous investigation exemplifying the
excellent partnership between healthcare at Frankland and external healthcare
providers.
The prison service have accepted my recommendation and commendations and
their detailed response is on the final page of this report.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2009
Final Report: April 2009 2
CONTENTS
Summary 4
The investigation process 6
HMP Frankland 8
Key findings 9
Issues 15
Recommendation, commendations and prison service response 18
Final Report: April 2009 3
SUMMARY
In 1999, the man was convicted and given a life sentence. He was not familiar with
prison life and, during the early part of his imprisonment, found it difficult to cope with
his transfer from one prison to another.
The man arrived at Frankland in early January 1999 as a category A prisoner.
(Prisoners are risk assessed and given a category based on their offence and the
risk that they pose to the public should they escape. There are four levels of
category: A, B, C and D, with category A prisoners being the most dangerous.) He
worked hard during his sentence to address issues specific to his offence and,
before he died, had made sufficient progress to achieve category B status.
(Prisoners for whom the highest security conditions are not necessary but for whom
escape must be made very difficult.)
Records show that the man attended the healthcare unit at Frankland for minor
matters until 2006. In 2002, he had managed to stop smoking with specialist help
from healthcare. This was a huge achievement as he had been described as
“heavily addicted” and a “chain smoker”.
When the man attended healthcare in October 2006, he complained of coughing
blood. After investigation, he was advised to tell staff if the condition worsened. By
November 2007, the man’s condition had deteriorated. Healthcare staff suspected
he had tuberculosis and referred him for further tests. While awaiting the test
results, prison staff reacted appropriately by carrying out infection control
procedures. The man was confined to his cell and isolated from staff and other
prisoners.
Test results proved that the man did not have tuberculosis, but an x-ray showed that
he ”had a clear mass on his lower right lung”. In late December, the man suspected
he had cancer but was reluctant to undergo any tests to confirm the diagnosis before
Christmas 2007 and the New Year of 2008.
A number of full discussions between healthcare professionals and the man
regarding the consequences of him not having treatment are documented in the
clinical record. The man made an informed decision to have neither chemotherapy
(chemical treatment to kill cancer cells) nor the recommended bronchoscopy (a
procedure where a thin flexible tube is passed down the throat to examine the
airways) or a computerised tomography (CT) scan (cross sectional x-ray of internal
organs) in January 2008. His personal officer told my investigator that the man did
not want his fear that he had cancer to be confirmed.
In May 2008, the Community Macmillan Team for Palliative Care were consulted and
asked to assist with the management of the man’s care. I believe that at this point,
when it was recognised that the man was terminally ill, an application should have
been made for release on compassionate grounds. However, no application was
made until 7 August, following a letter from the Palliative Care Consultant to the
Governor of Frankland. I have made a recommendation in this regard.
Final Report: April 2009 4
The prison made every effort to ensure that the man’s wish to be allowed to die in
the cell he considered his home was respected. In the final hours of his life, the
Palliative Care Pathway for the dying was followed but the medication he needed
could not be given appropriately in his cell. At this point, he was moved to the
healthcare unit. I consider this appropriate. Healthcare staff ensured that his door
was left open as he requested.
It was regrettable that the man’s father, who lives in the South of England, was told
of his son’s death by telephone. My investigation found that, in this instance, it was
understandable and reasonable due to the time and distance involved and the
likelihood of the man’s father being contacted by a prisoner before the prison could
break the news appropriately. Every effort appears to have been made by
Frankland’s Family Liaison Officer to find a Family Liaison Officer within a local
prison who could undertake the task on her behalf. There was no one available so
the Family Liaison Officer telephoned the man and spoke with him at length.
Final Report: April 2009 5
THE INVESTIGATION PROCESS
1. I was notified of the man’s death on 23 August 2008. Terms of Reference and
Notices were issued to staff and prisoners at Frankland telling them that an
investigation would be taking place, and inviting those who wished to see the
investigator to make themselves known. My investigator requested copies of the
man’s core record, clinical record (CR), and other records relevant to his time in
custody and to his death.
2. My investigator also contacted the Coroner to inform him of the nature and scope
of my investigation and to request a copy of the post mortem report. The report
concludes that The man died of :
1a. Pneumonia, due to
1b. Squamous cell carcinoma of the right lung.
The Coroner has requested a copy of my report upon completion and I am happy
to comply.
3. My investigator visited Frankland on 13 October 2008. She met the deputy
governor, acting head of healthcare, and members of healthcare staff. My
investigator visited C1 wing, where the man had been located, and informally
met the man’s personal officer other wing officers and Mr Ken Jones, the
prisoner who assisted the man during his illness.
4. My investigator telephoned the seconded probation officer at Frankland
regarding the man’s application for compassionate release.
5. A clinical review of the man’s medical care was commissioned from County
Durham Primary Care Trust. The clinical reviewer focussed on the medical care
the man received at Frankland. His review appears as an annex to this report.
6. My family liaison officer telephoned the man’s father. The man’s father told her
that he was satisfied with the manner in which his son had been cared for and
raised no issues for my investigator to consider.
Final Report: April 2009 6
HMP FRANKLAND
7. HMP Frankland is part of the Prison Service High Security Estate. It holds
prisoners convicted of serious offences including category A and B prisoners and
those serving sentences of over four years. The maximum prison capacity is 732
men and the prison has been assessed as one of the Prison Service’s high
performing prisons.
8. In conversation with my investigator, the acting Healthcare manager described
good links with the Primary Care Trust, with visiting consultants for orthopaedic
clinics, a dental suite, digital x-ray facilities and two full time doctors. The
manager acknowledged that at the time of the man’s illness there was a 70 per
cent nursing complement with five vacant nursing staff posts. My investigator
noted that on the day she visited, new nursing staff were on an induction tour of
the Healthcare centre apparently bringing the staffing levels to near full
complement.
9. The prison’s inpatient healthcare centre has 18 beds. The healthcare
department has adopted ‘telehealth’ technology. This is a diagnostic service with
a direct camera link between the prison and Airedale Hospital Accident and
Emergency Department where a doctor within the prison can have a second
opinion on a medical problem from a consultant at the hospital.
10. Prisoners who need end of life care are placed on the Durham & Chester Le
Street Community Integrated Care Pathway. The man benefited from a
multidisciplinary care package led by a Marie Curie consultant in palliative care.
Healthcare staff meet regularly to discuss cases with an external palliative care
team and have a named nurse who leads on this area.
11. In her inspection report dated June 2008, Ms Anne Owers, HM Chief Inspector of
Prisons acknowledged the difficulties Frankland faced with the challenging, albeit
relatively static population. Ms Owers assessed that healthcare provision was
good, with well-maintained accommodation. There were no concerns raised that
are relevant to the man’s care.
12. In their last available report in 2006, the Independent Monitoring Board identified
specific problems still prevalent today around overcrowding and difficulties in
transferring prisoners to prisons where they are able to progress through their
sentence.
13. Within my earlier report of the investigation into the death of another prisoner
who died from natural causes on 29 November 2004, I made a recommendation
that “All prisoners who are diagnosed with a terminal illness should be regularly
reviewed by the multi-disciplinary team and considered for early Compassionate
Release or Release on Temporary Licence in a timely manner”. While I am
pleased to see that effective working relationships are now established between
the Macmillan team and the prison palliative care team, I am disappointed that
the recommendation I made in the other prisoner’s report has not been
implemented. I repeat the recommendation.
Final Report: April 2009 7
KEY FINDINGS
14. The man was received into HMP Woodhill from HMP Belmarsh on 26 October
1998. He remained at Woodhill until he transferred to HMP Highdown on 3
November 1998. At Highdown, he expressed his anger at this transfer to the
healthcare officer in interview on 12 November and records show an F2052SH
document was opened. There is no evidence to show why this document was
opened as his clinical record said that he did not have suicidal thoughts.
Therefore, the investigator was unable to ascertain specific staff concerns about
the man’s behaviour and continuing upset at being transferred from Woodhill.
15. Further entries in the man’s clinical record, in the early part of his sentence, chart
his frustration at being unable to return to Woodhill. His preferred method of
coping appeared to be to withdraw from mixing with others and refuse prison
food and survive on snacks purchased from the prison shop. Referrals were
made to the prison psychiatrist and, in an appointment on 8 December 1998, the
man refused to talk, writing down his answers to the psychiatrist’s questions as
he asked them. The psychiatrist concluded that the man had no mental disorder.
16. An entry in the clinical record by a medical officer at Highdown, on 26 December
1998, indicates that the problems the man continued. After assessment, it was
concluded that the man was not suffering from “depression or with any suicidal
ideation”. The man transferred to another prison on 1 January 1999 but it is not
clear from the records which one it was.
17. On 20 May 1999, the man received a life sentence and he gradually became
accustomed to prison life at Frankland. Having been described as a very heavy
smoker, he attended healthcare for help to stop smoking in November 2002 and
was successful in achieving this. Other than this, it appears from medical
records that he did not attend the healthcare department for any significant
health problems until 9 October 2006.
18. A mental health nurse (RMN) who made the entry on 9 October 2006 said that
the man attended healthcare complaining of “spitting up blood… seen by the
prison doctor advised nothing serious to inform staff if condition worsens”. There
is no evidence of a referral for further investigation at this stage. My investigator
was unable to ask the prison doctor why he did not refer the man for further
investigations as the doctor now lives abroad.
19. The man attended an appointment with a second prison doctor on 27 November.
He told her that he had been suffering from “flu-like symptoms for the past five
weeks, was finding it difficult to walk and described himself as ‘feeling like an old
man’”. The second prison doctor suspected tuberculosis and prescribed
paracetamol for his symptoms. Clinical records and the man’s wing history sheet
show that appropriate procedures were followed for infection control. Healthcare
maintained medical confidentiality appropriately. Wing staff were informed that
the man was suspected of “having a contagious disease” without disclosing the
likely nature of illness. They responded correctly by isolating the man from staff
and prisoners and confining him to his cell until test results were known. Test
Final Report: April 2009 8
results received on 3 December said there was no indication that the man had
tuberculosis.
20. The man’s x-ray results prompted an urgent referral to a chest physician
because of a “clear mass on his right lower lung”. A letter dated 3 December
2007 from a third doctor at Frankland was sent to the chest physician at
University Hospital of North Durham requesting an urgent appointment for the
man under the “two week rule”. (This is a procedure where patients who are
suspected of having cancer are seen by a hospital specialist within 14 days of
referral by a doctor.)
21. A note in the man’s wing history sheet on 9 December reveals that he was aware
that he would be seen by a consultant either in healthcare or in a hospital in the
community. He disclosed his fears to staff that he might have cancer. He
wished to spend Christmas and the New Year peacefully and said he did not
wish to pursue any further investigations at the time. In the meantime, at a
medical clinic held at the prison on 12 December, it was noted his symptoms
continued and his refusal to be admitted to hospital was acknowledged.
22. In response to the third prison doctor’s referral letter, the man attended an
appointment on 18 December with the consultant in Thoracic and General
Medicine. The consultant wrote to the third prison doctor at Frankland the same
day saying ”I strongly suspect this man has small cell lung cancer”. The hospital
arranged a bronchoscopy and a computerised tomography scan (CT) for the
following day but the man refused to attend either and signed a disclaimer to that
effect.
23. The man refused all further treatment from this point. The prison’s attempts to
persuade him to accept treatment and their explanations of the consequences
are well documented within his clinical records. The man also made it clear that
he did not wish to be treated outside the prison healthcare department.
24. On 24 December, the prison telephoned the Macmillan palliative care team in the
community. The clinical record says that the Macmillan team had asked that the
team be contacted again once a definitive diagnosis had been made and the
man had been informed. They would then go to the prison to meet the man.
25. The second prison doctor told the man on 8 January 2008 that it was likely he
had small cell cancer of the lung. She explained that the only available treatment
was chemotherapy. The clinical records show that the man wanted information
about his likely life expectancy and quality of life if he accepted chemotherapy
and, similarly, if he did not. My investigator believes that the man was given
sufficient and appropriate information regarding his prognosis to empower him to
make informed decisions regarding his treatment.
26. My investigator spoke at length with the man’s personal officer. The personal
officer explained that she been the man’s personal officer for 18 months and
knew him well. She told my investigator that the man was terrified of cancer and,
in her view, refused treatment as he did not want to have his diagnosis
Final Report: April 2009 9
confirmed. She explained that, in addition, he was a private man and did not
want to go out to hospital in handcuffs which he would have found undignified.
27. According to his personal officer, the man “panicked” when his medication was
not always available. The personal officer explained that this was in part due to
a ”huge turnover” and shortages of staff in Healthcare. To overcome the
difficulty, the man’s personal officer arranged for a member of healthcare to visit
him every Monday in his cell to dispense his medication. She told my
investigator that wing staff approved this as it allowed healthcare staff to make a
general observation of the man while dispensing his medication.
28. The man’s personal officer impressed my investigator with her commitment to
the man’s care and this is an example of excellence in personal officer work.
She ensured that he received his medication on time and liaised effectively with
the healthcare department when his medication was not always available. She
told my investigator that she made sure she knew about the palliative care plan.
My investigator gained the impression that the plan was difficult to follow at times
because the man’s personal officer found that he did not always ask for what he
needed. She said she thought he felt that if he asked for more equipment or help
he would “end up at a hospice”.
29. In these circumstances, the man’s personal officer said that she made every
effort to ensure that his wishes were respected. The man remained in his cell on
the wing although it would have been easier for both him and the wing staff if he
was moved to healthcare. She managed to obtain an air mattress to reduce the
risk of bed sores and increase his comfort. Her motivation was that the man
regarded his cell as his home and he wished to die there rather than in
healthcare or in a hospice. The personal officer said that she arranged for the
man’s friend and fellow prisoner to collect the man’s medication when he was no
longer able to do so. The other prisoner stayed with the man when he took his
medication so that he was nearby in case the man experienced any difficulties.
The other prisoner told my investigator that he assisted the man telephone his
father when he could be moved to a telephone. He did not undertake any
personal care tasks as the man was able to do these for himself throughout his
illness.
30. My investigator was told that the other prisoner was not trained in the role of
carer and neither was he paid for it. The man’s personal officer said that the
other prisoner asked staff if he could assist his friend and was given the flexibility
to do so. The safeguards in this instance were that staff were aware of the other
prisoner’ role and were flexible around the regime. The man’s personal officer
said she spoke with the other prisoner often and was vigilant in ensuring that the
task the other prisoner had undertaken was not too onerous and emotionally
demanding.
31. In her thematic review on older prisoners in 2004, HM Chief Inspector of Prisons
Anne Owers makes a recommendation regarding local policy for prisons in using
prisoners as special assistance for other less abled prisoners. Her
recommendation says that “Prior to a national scheme all prisons should
encourage, train support and reward nominated prisoner helpers to assist less
Final Report: April 2009 10
able prisoners.” Although the other prisoner had asked to assist the man, his
help was not acknowledged by the prison.
32. On 31 March, the medical director wrote to the consultant. In his letter, the
medical director writes that he had spoken at length with the man who believed
that he has lung cancer and was clear that he did not want any further
investigation. The medical director referred to “bony secondaries” and noted that
he had referred the man to the Macmillan consultant in Palliative Medicine.
33. The man’s care was managed by what I judge to be the effective teamwork of a
number of people. They included the wing staff, his personal officer, healthcare
staff, his friend and carer, the other prisoner and the Macmillan palliative care
team under the leadership of the Macmillan consultant. Clinical records show
that following a referral to the Macmillan consultant, the lead nurse of the
Macmillan team visited the man on 23 May for an initial assessment. She
reviewed his medication and an end of life care plan was discussed. The lead
nurse visited the man every week to discuss pain management. She ensured
that his medication was effective and adjusted it accordingly when it was not.
The man’s personal officer recalled that although the man was reluctant to
engage with the lead nurse at first, he found her help and advice invaluable and
confided in her rather than healthcare staff. She gave him her telephone number
and he was able to call her when he needed to. Healthcare staff frequently
reminded the man that he could contact them through the wing staff at any time.
34. A multidisciplinary meeting was arranged on 10 June at St Cuthbert’s Hospice to
discuss the man’s future management. Healthcare staff were invited together
with the Macmillan consultant. No notes or minutes of the meeting are available.
35. In a letter dated 7 August 2008, the Macmillan consultant wrote to the Governor
requesting that the man be considered for early release on compassionate
grounds so that he could be cared for at his father’s home or in a nearby
hospice. The seconded probation officer, informed my investigator that he was
not asked to provide a compassionate release medical condition report until
around 13 August when he saw the man on the wing. I agree with the seconded
probation officer that it would have been helpful if the process had started around
the time the man was thought to have terminal cancer. Unfortunately, the
process was started too late.
36. Following a visit to the man, the Macmillan consultant wrote to the fourth doctor
at Frankland on 11 August. The man’s preference to remain on the wing was
made clear and his deterioration, as well as his wish not to be resuscitated, was
noted.
Events of 22 August
37. Clinical records show that the man was seen by a fifth doctor at 3.40pm at the
request of nursing staff. He was noted to be “extremely ill”. The man was able
to tell nursing staff that he wanted to die in his cell.
Final Report: April 2009 11
38. Later in the afternoon, a Sister telephoned healthcare from the wing to say that
she was arranging the man’s transfer from the wing to the healthcare
department. She contacted the on call doctor, the medical director, at 5.10pm to
inform him that the man had deteriorated. The Sister explained to my
investigator that this decision was made because it was clear that the man’s
medication required more intensive management than could safely be given on
the wing.
39. The man was moved to the healthcare inpatient unit. Following the medical
director’s assessment, he was cared for according to the Integrated Care
Pathway for the dying. Arrangements were put in place for twilight nursing staff
to take over when Macmillan nurses finished. Medication was arranged through
a prescription completed by the medical director.
40. The clinical record entry made by the medical director says that the main
concern was to keep the man free of pain. This was achieved through a syringe
driver which administered Diamorphine with Midazolam, and Hyoscine if
required. (Diamorphine is for pain relief, Midazolam is a sedative and Hyoscine
helps prevent muscle spasm.)
41. In his statement to the Governor, the principal officer (PO) said he came on duty
at 7.00pm and undertook the role of Oscar 1 from another principal officer.
(Oscar 1 is the officer with operational control of the prison.) He was told that the
man was “extremely poorly” and that healthcare staff had been briefed as to how
they should manage him. The principal officer said that the deputy governor had
instructed that the man’s door was to be left unlocked. My investigator
understood this to be the man’s wish. The principal officer said the medical
director had confirmed to the healthcare staff that the man did not wish to be
resuscitated. The principal officer then accompanied the Healthcare Officer
(HCO) as he administered treatments to prisoners throughout the establishment.
42. In his statement, the second healthcare officer says, that he arrived for duty at
6.15pm. The Sister told him that the man was now on the Integrated Pathway for
the dying and that he was to administer Diamorphine as prescribed by the
medical director, with further Diamorphine to be given through the syringe driver
if necessary. My investigator noted that as the man complained of further pain,
the second Healthcare officer discussed this with the first Healthcare officer and
further Diamorphine was given as required to ensure that the man was as pain
free as possible. The second Healthcare officer said that, over the next two
hours, while he went about other duties in healthcare, the man deteriorated. He
told my investigator that although he was aware that staff were in and out of the
man’s room all evening, he had intended to return to his room to keep him
company. Sadly, the man died before he could do so.
43. On or around 12.30am, the second Healthcare officer noticed that the man
stopped breathing. The second Healthcare officer tried to find a pulse. When he
could not find one, he returned to the office and informed senior prison staff. The
second Healthcare officer then contacted the doctor at the out of hours centre. A
Doctor from the out of hours centre attended the prison and verified the man’s
death at 1.05am.
Final Report: April 2009 12
44. The man’s father, who lived in the South of England, was informed by telephone.
The prison’s Family Liaison Officer told my investigator that she spoke with
prisons local to where the man’s father lived and asked for a Family Liaison
Officer to go to his home to tell him the news in person. Regrettably, Frankland’s
Family Liaison Officer was unable to find a Family Liaison Officer available to
undertake this task. She told my investigator that she made a “judgement call” in
telephoning the man’s father because of the distance involved and the “threat of
prisoners telling him” before the prison had the opportunity. The Family Liaison
Officer spoke at length with the man’s father who was aware of the situation. It is
unfortunate that the man was told by telephone but I believe this was
understandable and appropriate in the circumstances.
45. My investigator spoke with staff who confirmed that they had received the
appropriate support from the prison and that they were aware of support
networks if they feel they need it. The other prisoner confirmed to my
investigator that he had felt supported during the man’s illness and following his
death.
Final Report: April 2009 13
ISSUES
Clinical care
46. The clinical review was undertaken on behalf of County Durham Primary Care
Trust. The clinical reviewer reviewed all necessary records and spoke with my
investigator. He concluded that the management of the man from his initial
diagnosis until the end of his life was compassionate and caring. The clinical
reviewer is of the view that the man had clearly decided for himself that he had a
malignant disease and that he did not want any further investigations or
interventions.
47. The clinical reviewer is of the opinion that the consultant and the medical director
“went the extra mile” in ensuring that the decisions the man made were informed
and that he was aware of the consequences of his actions. I agree.
48. The multidisciplinary working between the healthcare staff and the Macmillan
team led by the Macmillan consultant is a very good example of how good care
can be given and symptoms effectively managed according to a prisoner’s
wishes. My investigator found the Sister to be empathic and compassionate in
her role as palliative care nurse for Frankland and in the man’s case in particular.
The Governor should write to Healthcare staff to commend them for their
excellent care and management of the man’s illness throughout.
49. Particular attention is drawn to the man’s personal officer whom the clinical
reviewer and my investigator feel exemplifies excellence as a personal officer
and whom the man thanked for her care in his letter to the Governor. I
understand from the deputy governor that the man’s personal officer was
recognised for her work and was named “Employee of the Month”. My
investigator spoke with the man’s personal officer and she was unaware of this.
In the circumstances I would recommend that the man’s personal officer be
commended for her excellence as a personal officer.
The Governor should write to the man’s personal officer commending her
for her excellent work as a personal officer in respect of the man.
Compassionate release
50. My investigator noted that preparations for release from prison on
compassionate grounds were not started by the prison until the Macmillan
consultant wrote to the Governing Governor on 7 August 2008. It is accepted
that the man’s decline was rapid and that compassionate release is not
appropriate in every case. However, where possible, the process should be
started as soon as it is known that a prisoner is terminally ill and has indicated an
interest so that procedures are in place for a speedy release. I repeat the
recommendation mentioned earlier in this report at paragraph 19 regarding an
earlier recommendation in this regard.
Final Report: April 2009 14
The Governor should ensure that where prisoners have indicated they wish
to apply for early release on compassionate grounds, the process is
started as soon as it is known that a prisoner is terminally ill so that
arrangements are in place for a speedy release.
Record keeping
51. My investigator and the clinical reviewer found the standard of record keeping to
be poor in the prisons in which the man was held prior to Frankland. The
handwritten clinical records were difficult to follow because signatures were often
illegible and names are not written in block capitals underneath the signature.
Neither was it always clear which prison the man was in at the time the
assessment was made.
52. By contrast, record keeping at Frankland was good with clear and detailed
entries through the EMIS computerised system. Staff who made entries on the
system charted concerns, noted why decisions were made and the medication
given.
The man’s location
53. Every effort appears to have been made by healthcare staff to ensure that the
man’s wish to remain on the wing was respected for as long as possible.
Healthcare staff demonstrated a caring and compassionate approach and liaison
with the community Macmillan team was effective and appropriate resulting in
good management of the man’s symptoms throughout.
54. I commend the Governor, security and wing staff for their flexibility in
accommodating the man’s wish to remain on the wing as long as possible while
mindful of the security considerations and regime of a category A prison. The
man was allowed to leave his cell door open during the day and that permission
was extended to the other prisoner who was located opposite to the man and
assisted him with his medication. Those who wished to were permitted to keep
the man company during the day. It is acknowledged that it would have been
easier for staff to have insisted that the man be cared for as an in-patient in
healthcare, particularly in the light of risks around the large amount of medication
he was prescribed. However, these difficulties were addressed and managed
and the man’s wish to remain on the wing for as long as was possible was
granted.
The Area Manager should write to the Governor and staff on A wing, A3
landing as appropriate to commend them for their flexibility in
accommodating the man’s wish to die with dignity, in the manner he chose,
as far as was possible in the circumstances.
Using prisoners as carers
Final Report: April 2009 15
55. My investigator and clinical reviewer note the valuable contribution the other
prisoner made in assisting the man as his health deteriorated. Wing staff
ensured that the other prisoner was able to care for the man as necessary by
allowing his cell to be opened in the mornings for him to assist the man with his
medication. My investigator has seen a letter from the other prisoner addressed
to a Senior Officer thanking him and all staff who “helped and shared
compassion” to the man during his illness and for giving him the opportunity to be
seen as trustworthy to sit with the man during his illness. He thanks staff for
“letting me know that he [the man] passed away peacefully in his sleep”. The
man’s personal officer assured my investigator that the other prisoner was cared
for during and after the man’s death and the other prisoner confirmed this. The
man’s personal officer informed my investigator that the other prisoner was not
paid for his care of the man. She said that he asked staff if he could care for him
out of friendship and staff finally agreed. The man’s personal officer said that
she is aware that the other prisoner finds it difficult to adjust to life without the
man and that she keeps a careful watch on him. She told my investigator that the
other prisoner was greatly heartened by a recent letter of support from the man’s
father. My investigator felt that the other prisoner’s valuable contribution to the
man’s care has not been given sufficient acknowledgement by the prison.
56. My investigator has seen a letter from the other prisoner, addressed to the
Senior Officer in gratitude for the care and compassion of the staff to the man
and to himself, in his role as carer. It is clear that staff were flexible about his
regime as they were able to unlock the other prisoner separately from others
specifically so he could care for the man. The other prisoner has thanked staff
for “letting me know that he passed away peacefully in his sleep”.
The Governor should write to the other prisoner acknowledging his
support of the man by providing practical care and emotional support.
CONCLUSION
59. The man’s was terminally ill and his death was expected. It was well managed in
all the circumstances, particularly considering the constraints within a high
security prison. Staff made every effort to ensure that his wish to die in the cell
on C wing that he considered his home was respected. His move to healthcare
in the final hours of his life so that his medication could be more safely managed
was entirely appropriate.
60. Although I make one recommendation relating to earlier consideration being
given to compassionate release, the investigation found that the management of
the man’s care during his illness and at the end of his life demonstrated what is
achievable when healthcare, the prison staff and, in this case, a prisoner work
together towards a single aim. The result is that the quality of care given to the
man equalled and, quite possibly exceeded, that which he would have received in
the community.
Final Report: April 2009 16
RECOMMENDATION AND COMMENDATIONS
Recommendation
The Governor should ensure that where prisoners have indicated they wish to
apply for early release on compassionate grounds, the process is started as
soon as it is known that a prisoner is terminally ill so that arrangements are in
place for a speedy release. This recommendation is repeated from an earlier
recommendation.
Partnership working is underway with the Prison and PCT to implement a full
palliative care policy within the prison. When a prisoner enters the end of life
pathway as part of this from a palliative care point of view, the Head of Healthcare
will formally write to the Governor. The Governor will then contact other relevant
departments to begin work on whether early release on compassionate grounds is
possible and if so begin the process. Target date for completion is 30th June 2009.
Commendations
The Area Manager should write to the Governor and staff on A wing, A3
landing as appropriate to commend them for their flexibility in accommodating
The man’s wish to die with dignity, in the manner he chose, as far as was
possible in the circumstances.
Accepted. A letter will be written by the Director in recognition.
The Governor should write to the other prisoner acknowledging his support of
the man by providing practical care and emotional support.
Accepted. A letter will be written from the Governor in recognition.
The Governor should write to Healthcare staff to commend them for their
excellent care and management of the man’s illness throughout.
Accepted. A letter will be written from the Governor in recognition.
The Governor should write to the man’s personal officer commending her for
her excellent work as a personal officer in respect of the man.
Accepted. A letter will be written from the Governor in recognition.
Final Report: April 2009 17