Individual at Isle of Wight

Investigation into the circumstances surrounding the
death of a man at HMP Albany,
in hospital in January 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2008
This is the report of an investigation into the death of a man who died in January
2008 at hospital whilst a prisoner at HMP Albany. The man had transferred from
Albany to the healthcare centre at Parkhurst for 24 hour medical care in December
2007. Later, he was admitted to hospital, his health deteriorated and he died six
days later. The man was 74 years old.
A post mortem was held at the request of HM Coroner for the Isle of Wight. It found
that the man died as a result of natural causes resulting from chronic obstructive
pulmonary disease and congestive cardiac failure. I extend my sincere condolences
to the man’s partner, family and friends.
This investigation was undertaken by one of my investigators. In addition, a review
of the man’s healthcare was commissioned from Isle of Wight Primary Care Trust. I
am grateful to Primary Care Trust who carried out the review. I would also like to
thank the Governor of Albany and his staff for their help and assistance. I am
particularly grateful to a Governor and a Principal Officer (PO).
The man was an elderly prisoner who had a number of ailments. It is clear from the
investigation that staff of various disciplines, as well as fellow prisoners, made every
effort to treat and care for the man in a sensitive and compassionate manner. This
was in spite of his own reluctance to take responsibility for his health and to comply
with the interventions offered.
I make no recommendations in this report. However, I am pleased to commend both
nursing staff and officers on F and G wing for the support they showed to the man.
The standard of family liaison demonstrated by Albany was also very high.
In this final report, the Governor of Albany was pleased to note that both nursing and
wing staff were commended for the support they showed to the man and that the
report noted the high standard of family liaison.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2008
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CONTENTS
Summary
The investigation process
HMP Albany
Key findings
Issues
Good practice
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SUMMARY
The man was sentenced to seven and a half years imprisonment in May 2005 at
Crown Court. He was received into HMP Elmley that day. His first reception health
screen document noted that he was receiving medication for ischaemic heart
disease. The man transferred to HMP Lewes in September. It was recorded that he
was a frail man, unwell and had a nasty cough.
Three weeks later the man was transferred to HMP Albany. Following his reception
into Albany, he was given an electrocardiogram (ECG) to monitor his heart rate. The
man told the doctor that he had refused medical investigations in the past, but
agreed to a blood test.
In January 2006, the man complained of nausea. He was prescribed a medication to
reduce acid in his stomach and an appointment was made for him to attend hospital
for an endoscopy (a procedure to look at the gullet and stomach). The man said he
would not have the procedure, but nevertheless the doctor still made the referral. A
second ECG indicated no changes since the previous one, other than one atrial
ectopic (a problem to with the electrical system of the heart).
Over the next 14 months, the man was seen on a regular basis by healthcare staff
and the doctor. His medication was reviewed and new drugs were prescribed to
treat his ongoing medical conditions. In March 2007, the man was taken to the
accident and emergency department at hospital as he was experiencing chest pain
and pain radiating down his arms. The man was referred to another hospital for an
angiogram, a test that identifies how well the heart is working. He refused to go to
the hospital, discharged himself and returned to Albany.
In April 2007, the man moved to F and G wing which was considered more
appropriate to his medical needs. It provided better accessibility for his wheelchair
and the cell had a shower and toilet with disability access. A buddy carer (a
prisoner, who helps and supports older and disabled prisoners) was assigned to
assist the man with his day to day living. However, he was unhappy about the move
to this wing. A few weeks later, the man was allocated a nurse for basic medical
care, three times a week, to help with bathing, dressing and medication. In July, he
was assessed in his cell by an occupational therapist who suggested adaptations to
make him more comfortable.
Over the next few months, the man’s condition continued to deteriorate. His legs
became painful and swollen, he was breathless and his blood circulation was poor.
The man was seen by the doctor regularly. As well as the personal care nurse, he
was supported by wing and healthcare staff on a daily basis.
In December, the man’s condition deteriorated seriously. He was admitted to
hospital for an assessment and discharged back to Albany that day. The following
day, he was moved to HMP Parkhurst’s healthcare centre for 24 hour medical care.
Nevertheless, a week later he was admitted to hospital.
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Six days after his admission to hospital, the man died. The cause of death was later
given as chronic obstructive pulmonary disease and congestive cardiac failure. The
man was 74 years of age..
Before and after the man’s death, staff at Albany went to great lengths to sustain
contact with his relatives. I have commended staff for their exemplary handling of
their brother’s throughout his illness, and for the family contact thereafter.
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THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened in January 2008 when my
investigator visited HMP Albany. She met the Governor and a member of the
senior management team. Representatives of the Independent Monitoring
Board (IMB) of the Prison Officers’ Association (POA) did not ask to meet my
investigator. Notices about the investigation and the Ombudsman’s terms of
reference had been sent to the prison in advance of her visit.
2. Later my investigator visited F and G wing and spoke to an officer who knew
the man well. She also spoke to three friends of the man on the wing. In
February, my investigator attended an Incident Review Meeting to appraise
the man’s healthcare while he was in prison custody.
3. One of my family liaison officers, telephoned the man’s brother. The family
did not have any concerns about the care offered to their brother by the
prison. They also expressed their gratitude for the help and support offered
since his death. Information about the investigation was also relayed to the
man’s solicitor who agreed to continue to support the man’s partner if she
wished to contribute to the investigation.
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HMP ALBANY
4. HMP Albany was designed and built as a category C training prison on the
site of a former military barracks on the outskirts of Newport, Isle of Wight.
Soon after it opened in the 1967, it was decided to upgrade the security and in
1970 Albany became part of the dispersal (high security) system.
5. In 1992, the prison was redesignated as a category B closed training prison.
Prior to 1998, half the prisoner population at Albany was accommodated in
the Vulnerable Prisoners Unit, and the other half in normal residential wings.
Albany now only holds sex offenders and other vulnerable prisoners and
operates one regime. In 2002, a category C Unit was added and the prison
currently holds up to 526 prisoners. The average age of the population is
significantly higher than in most prisons.
6. The healthcare arrangements are managed in a cluster that includes HMP
Parkhurst and HMP Camp Hill. Parkhurst is the only one of the three with in-
patient facilities. Albany has a healthcare unit designated for the delivery of
primary care services.
7. HM Chief Inspector of Prisons conducted a full inspection of Albany in
November 2007 and noted the following in relation to healthcare:
“Health services were very basic, although there were good
relationships between health services staff and prisoners. Nurse-led
clinics could not be established because of staff shortages. There was
good access to general practitioner services, but high numbers of
prisoners were prescribed opiate-based medication. Dental services
were good but a high number of prisoners failed to attend for
appointments. Mental health in-reach services were good, but there
was no primary mental health support. A high number of outpatient
appointments had to be cancelled because of a shortage of escort
staff.”
8. The Albany Independent Monitoring Board Annual Report 2007 was positive
in praise of the prison’s staff. An extract from the report said:
“The Board would like to give praise to the officers at Albany who go
about their duties with extreme professionalism with the ever
increasing demands of the Prison Service.”
9. The death of the man was the second death from natural causes investigated
by my investigator at Albany. She was encouraged by the improved liaison
she found between healthcare and wing staff. One of the changes since my
investigator’s previous investigation was the inclusion of the disability officer in
the assessment of disabled and sick prisoners. These developments
reflected recommendations made in her earlier investigation.
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KEY FINDINGS
10. The man was sentenced to seven and half years imprisonment in May 2005
by a Crown Court. He was received into HMP Elmley where his first
reception health screen document noted that he was receiving prescribed
medication for heart disease. His doctor confirmed that he was suffering from
ischaemic heart disease for which he had been prescribed atenolol and
clopidogrel. On 25 May, the man was examined by the prison doctor as he
was feeling dizzy and sick. On examination, the doctor diagnosed an ear
infection and prescribed antibiotic medication.
11. On 17 July 2005, the man told an officer he had felt a pain in his right forearm
that had made him feel dizzy. He went to grab a chair to steady himself, and
knocked his arm on the chair causing a wound. The man was taken to
healthcare where a nurse cleaned and dressed the wound with steri-strips.
His observations were taken and were within the normal range. The man was
later seen by a doctor who requested twice weekly dressings and asked him
to return if there were any problems. The man refused a tetanus injection.
Six weeks later, the man saw the triage nurse and complained of cramp in his
hands as well as was coughing up lots of phlegm. He was referred to the
doctor who diagnosed bronchitis and prescribed antibiotic medication.
12. The man transferred to HMP Lewes on 8 September. It was noted he was a
frail man with a nasty cough. Three weeks later, he transferred to HMP
Albany. His medical notes showed that he was feeling unwell, had a history
of feeling faint, and there was a trace of blood in his urine. He was not fit for
work.
13. On 6 December 2005, the man was seen in healthcare. He had nausea. He
told the doctor that he had refused medical investigations in the past, but
agreed to blood tests.
14. The man was seen again seen in healthcare five weeks later, feeling unwell
with chest pain. His observations were noted to be within normal range and
an electrocardiogram (ECG) to monitor his heart rate was carried out. The
following day a nurse checked the man to appraise his general health. He
said he was feeling better; there was no chest pain, although he did feel light
headed at times. An appointment was made for the man to see the doctor
and the nurse noted that he seemed frail.
15. On 17 January 2006, the man saw the doctor and a second ECG was
performed. This showed no change from the previous test with one atrial
ectopic (an atrial ectopic beat is a problem in the electrical system of the
heart, specifically an extra heartbeat caused by a signal to the upper
chambers of the heart). The man still complained of nausea and some
anterior chest pain when he ate. He was prescribed omeprazole to reduce
acid in his stomach.
16. Three weeks later, the man saw the doctor who suggested that he refer him
for an endoscopy for his digestive problems. The man told the doctor he
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would not have an endoscopy. Despite this refusal, the doctor still referred
him to the hospital for the procedure. The man was also complaining of
feeling tired and loss of appetite.
17. The man had a further consultation with the doctor on 9 March. He
complained of headaches and the doctor prescribed predniscolone, an anti-
inflammatory medication for temporal arteritis (inflammation of the blood
vessels around the head and neck). On 13 March 2006, the man attended
the healthcare centre for blood tests. Insufficient blood was taken for the
sample, so it was repeated on 15 March when it was also noted that the man
was having headaches.
18. On 3 May, the man saw a nurse who noted poor compliance in taking his
medication. Two days later, he saw the doctor. His head pain persisted and
his medication was continued with paracetamol for pain relief. Four days
later, an appointment for him to attend St Mary’s Hospital for an endoscopy
was cancelled by the hospital.
19. When the man saw the doctor on 9 June, he was feeling better and the
predniscolone was to be reduced. One month later, he sent a letter to the
mental health in reach team. In the letter, he said that he had been feeling
low, depressed and wished to see someone from the team. A member of the
mental health team suggested to the man that he spoke to a nurse as they
were unable to take self referrals.
20. Two weeks later, the man was seen in healthcare. Despite encouragement
from the nurse, he refused to attend an appointment at the hospital for an
endoscopy and signed a disclaimer to this effect. On 31 July, a nurse spoke
to the man about his medication. He seemed to be confused about his
dosage and it was agreed that he would collect his medication from the
dispensary. On 6 August, the man attended healthcare complaining of back
pain. He was prescribed pain relief and returned to his cell in a wheelchair.
21. The man’s medical notes recorded that on 17 October 2006 he was not
complying with his medication. A week later, he was examined in healthcare
and noted to have a cold, shortness of breath and a cough. When the doctor
asked about the use of his inhaler, the man said he did not use it as he was
allergic to it. An antibiotic medication was prescribed. Three weeks after this
consultation, it was noted that he was feeling better and had been advised
about his smoking habit.
22. On 5 January 2007, the man asked for pain relief from the doctor for
headaches, neck pain and pain in both arms. He said he was not sleeping
and found mobility difficult. The doctor noted that the man seemed vague,
and a painkiller was prescribed. Twelve days later, the man went to
healthcare for blood tests. He complained to the nurse that he had received
poor healthcare at Albany and the doctors could not find what was wrong with
him. He was reminded that he had refused to attend the hospital for an
endoscopy. The nurse offered to see if he could be transferred to F and G
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wing (which is located on the ground floor and was more suitable for his
needs). An appointment was made for the man to have a chest x-ray.
23. The x-ray result, examined on 1 February, showed an abnormality with an
indication of a previous history of tuberculosis. The next day the man was
seen in healthcare. He complained to the nurse that his friends in the wing
had told him he was not receiving the right medication. It was explained to
him that all medical staff were trained and competent. The man became
aggressive and was asked to leave the healthcare centre. On 5 February, he
saw the doctor who told him he had to take some responsibility for his health
and reminded him that he had refused a medical investigation. The man
continued to smoke heavily and took no exercise. Four days later, he told a
nurse in healthcare he had cut down on his smoking and was taking some
exercise. He also told the nurse he had some rectal bleeding and a sample
was requested for testing.
24. On 20 February, the man was seen by the nurse and doctor. The man had
felt dizzy and had pain in his left shoulder going into his stomach. An ECG
was carried out. It recorded no changes from his previous ECGs.
25. The man was seen in his cell by a nurse on 3 March. He had taken some
exercise and had become unwell with chest pain and pain radiating down his
arm. The man was taken to a hospital’s accident and emergency department
by ambulance and remained as an inpatient. Tests indicated that he had
increasing heart problems as well as anaemia. He was referred to another
hospital for an angiogram (this test gives information about the blood inside
the heart, and how well the pumping chambers and valves are working). The
man refused to go to this hospital and discharged himself back to Albany on 8
March.
26. The man’s medical notes for 17 March recorded poor compliance with his
medication. On 5 April, the doctor noted that he had become increasingly
immobile, was feeling dizzy and had been unable to collect his medication.
The doctor questioned whether the prison was able to offer the resources the
man needed given his medical condition. He was still smoking, which was
against medical advice.
27. A week later, escorted by a fellow prisoner, the man was taken to see a nurse
in healthcare in his wheelchair. It was noted by the nurse that he would
benefit from a transfer to F and G wing as it was more appropriately
resourced to cope with his physical condition. The nurse spoke to a governor
who supported this transfer. On the instruction of the healthcare manager the
nurse also wrote to a hospital’s occupational therapy unit, requesting an
assessment.
28. On 24 April, the nurse noted that the man’s transfer to F and G wing was
being processed and he was waiting for a space. The prison’s disability
officer also supported this move. Three days later, the man moved to F and
G wing. The man was assisted by a buddy carer who was also a friend of his.
10
The buddy carer helped the man with his day to day living, which included
sorting his laundry, cleaning his cell and fetching his meals when appropriate.
29. In early August, the man was seen by a nurse. He was unwell and his
breathing was laboured. The nurse referred him to the doctor who prescribed
medicines were appropriate for his needs.
30. It was recorded on 31 May 2007 that the man had refused to attend hospital
for a chest x-ray as he did not want to wear prison clothing on escort. His
medical notes indicated that there was no medical reason why he should not
wear prison clothing. The man refused to attend a second x-ray appointment
at the hospital on 6 June.
31. A week later, the man was assessed by the healthcare manager and a doctor.
The healthcare manager noted that the man was able to get from his
wheelchair to his bed but would benefit from a high back chair. It was also
recorded that a shower with a seat would enable the man to bathe more
easily. An appropriate cell on F and G wing was identified to which the man
would move. The healthcare manager arranged for the man to be checked in
his cell by a nurse twice a day to assess his needs.
32. On 13 June, an agency nurse, and later a healthcare nurse, was assigned to
visit the man to assist with his personal care three times a week. This routine
carried on throughout his time on the wing. The nurse would help him bathe
and carry out medical directives in respect of the man’s basic care plan. At
the end of June, the nurse assisted him to complete a self referral form for
occupational therapy services.
33. An occupational therapist completed a full assessment of the man’s needs in
his cell on 5 July 2007. The agency nurse was present throughout. The
assessment noted that aids to help the man in his cell would be appropriate
and the occupational therapist then liaised with the disability officer. The
following day, the man refused to attend an outpatient appointment for an x-
ray as he did not want to be escorted by officers using restraints.
34. In early August, the man was seen by a nurse. He was unwell and his
breathing was laboured. The nurse referred him to the doctor who prescribed
antibiotics. A few days later, the man was still unwell and was prescribed a
stronger antibiotic. He told the doctor he was allergic to inhalers and
nebulisers. The doctor noted that, if there was no improvement in the man’s
health, he would need to be admitted to hospital. The doctor saw him again
on 7 August. There had been no change in his condition and he agreed to try
a nebuliser as his medical notes did not record any allergic reaction to this
treatment.
35. On 13 August, the man had a discussion with the doctor regarding his refusal
to attend an x-ray. He told the doctor he had not refused to go to the hospital,
but had refused to be accompanied by an officer who had no respect for him
(there is no evidence to support the man’s assertion about the officer). The
man also told the doctor he had never been unwell on A wing and all his
11
medical problems were related to his transfer to F and G wing. The doctor
made another referral to the hospital for an x-ray.
36. Two weeks later, a member of the mental health team, saw the man following
a referral from wing staff. The member of the mental health team noted no
open display of mental health symptoms. Nevertheless, he made a referral
for the man to see a consultant psychiatrist. There is no record in the man’s
medical notes as to whether this referral to the psychiatrist took place.
37. On 3 September, the man reported to healthcare with painful, swollen feet
and he was referred to the doctor. The following day, he was prescribed
antibiotics for a possible infection. It was noted that there was poor circulation
in his legs and feet. Two weeks later, the doctor referred the man to a
chiropodist for a vascular assessment. The doctor noted that the man had an
ischaemic foot (reduced flow of blood to the foot) and thought there might be
a need for a vascular operation. The man was still complaining about being
located on F and G wing. The doctor recorded that the man was on F and G
wing for health and safety reasons and should not be transferred back to A
wing.
38. The man was seen by the chiropodist on 14 September. A Doppler
assessment was undertaken (the assessment tests the blood flow into legs
and feet). It was noted that his blood flow index into either limb was poor due
to absent pulses. The chiropodist asked the doctor to make an urgent referral
for The man to attend the vascular clinic at the hospital. Three days later, the
doctor wrote to the vascular surgery unit at a hospital for an appointment.
39. On 20 September, the doctor increased the man’s analgesia by prescribing
codeine for pain in his legs, back and chest. Again, it was noted that he was
still smoking. Eight days later, the doctor recorded that the man had a small
lump under his left armpit. A referral was made to the surgery unit at a
hospital for further investigation.
40. Throughout October, the man was seen and treated for pain in his legs, and
he was using his nebulisers regularly. On 29 October, the doctor noted that
the man had advanced chronic obstructive pulmonary disease (lung disease),
and peripheral vascular impairment (restricted blood flow). Five days later,
the man refused an influenza vaccination. On 7 November, he refused an
appointment at the hospital for a minor operation for the removal of the lump
under his left armpit. An appointment was also received for the man to see
the vascular surgeon in January 2008.
41. Following a consultation with the man on 15 November, the doctor noted that
the man had been incontinent of urine on a few occasions. The doctor
suspected cerebrovascular disease (a brain disorder caused when the blood
supply to the brain is disrupted in some way). On 30 November, the personal
care nurse noted that a small red blister had appeared on the man’s left shin.
Four days later, it was noted that this blister was oozing fluid and a dry
dressing was applied. On 6 December, the doctor noted that the blister was a
leg ulcer and reviewed it the following day. It was noted that the man’s skin
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was frail, the pain was worse at night, and non-sticky dressings were to be
applied regularly.
42. The personal nurse noted on 9 December that the man had removed the leg
dressing himself. The following day, her told his personal nurse that he would
remove the leg dressing again if it irritated him.
43. On 17 December, the duty governor spoke to a nurse in healthcare about the
man’s deteriorating condition and his lack of co-operation with regard to his
medical condition. The nurse advised the duty governor that the man was
waiting for an outpatient appointment and might well have to have his left leg
amputated. The duty governor insisted that the doctor see the man. Four
days later, the doctor noted that the leg ulcer was not healing, and his foot
and toes were red and swollen. It was also recorded that the man had tried to
remove his leg dressing three days before, and the ability of staff to keep him
on normal location was becoming increasingly difficult. The wing officers and
the man’s friends made sure he was cared for, but it was becoming
impossible to keep him comfortable.
44. On 21 December, the man was taken to a hospital’s accident and emergency
department for an assessment. He was discharged later that day. The next
day, a nurse assessed the man in his cell. The nurse noted that he was
unable to walk unassisted, could not wash or dress himself and was unable to
go to the toilet without help. The healthcare centre held a multi-disciplinary
case conference to review his deteriorating condition. It was noted that he
had been discharged from hospital with morphine medication to manage his
pain relief. The man was unable to self medicate, nor reach his cell bell, and
therefore he could not be managed on normal location. Albany contacted the
24 hour healthcare unit at HMP Parkhurst and it was agreed to transfer the
man to the unit where he could receive appropriate medical and personal
care.
45. Over the next nine days, the man was nursed on the inpatient healthcare
centre at Parkhurst. He had experienced pain in his ulcerated leg, his
breathing was problematic, he had difficulty swallowing, and was said to be
un-cooperative and rude to staff. Staff could no longer offer him adequate
nursing care. On 31 December 2007, following a multi-disciplinary
conference, the man was admitted to hospital. He was escorted by one
officer and was not restrained.
46. On 4 January 2008, a Principal Officer (PO), a family liaison officer at Albany,
was made aware of a serious deterioration in the man’s health. The PO
contacted the man’s solicitor to inform her of the man’s condition. The
solicitor told the PO that the man had a partner, but she was not well and
might be confused if contacted by strangers. The solicitor agreed to visit the
man’s partner to tell her about his deteriorating health. The solicitor also gave
the PO contact details of the man’s brother.
47. The PO tried to telephone the man’s brother but there was no answer. Later
that day, the solicitor rang a governor and informed him that the man’s partner
13
had been visited but was unable to leave her house or even allow family into
the house. The solicitor agreed to inform the man’s partner herself when the
man died.
48. At 4.25pm on 4 January, The PO spoke to hospital staff and asked for advice
on whether it would be better for the man to be moved to a hospice. Hospital
staff indicated that, due to the man’s condition, hospital care was the most
suitable for him. Several minutes later, the PO was able to make contact with
the man’s brother and told him of his brother’s serious medical condition. The
PO offered assistance with travel to the Isle of Wight to visit his brother, but
this was declined. The PO said he would update him daily on his brother’s
condition and I understand the man’s brother greatly appreciated this help.
49. Hospital staff monitored and reviewed the man and he had a line inserted into
his vein for a morphine pump for pain relief. His condition was described as
very poorly and near to death.
50. The next day (5 January), the PO the man’s solicitor to update her on his
condition. The solicitor told the PO that the man’s partner did not want visitors
to the house, but had accepted the news that her partner was very ill. The
solicitor suggested that further updates on the man’s health should be
directed to his brother. The PO then contacted the man’s brother again. The
PO spoke to the man’s nephew, as his father was out. The PO again offered
assistance with travel if the man’s brother wished to see his brother and
updated the family on their brother’s condition.
51. At 11.10am on 6 January, the man passed away and his death was confirmed
by hospital doctors. The escorting officer informed the prison. The PO rang
the man’s brother to tell him what had happened. During the conversation,
the man’s brother confirmed that he was not on his own and that his son was
with him. The man’s brother thanked the PO and said he would inform the
rest of the family. At 11.35am, the PO contacted the solicitor who agreed to
go and visit the man’s partner to tell her the news. Two hours later, she rang
the PO to confirm that she had done so.
52. Later that day, the PO again telephoned the man’s brother and spoke to his
son. The man’s nephew told the PO his father was out informing other
relatives. The man’s nephew thanked the PO for his support. On 7 January,
the PO telephoned the man’s brother and explained to him the procedures in
relation to his brother’s death and discussed funeral arrangements. The PO
confirmed the prison would cover the full costs of the funeral.
53. On 16 January, a memorial service for the man was held in the prison’s
chapel. Friends of the man held a collection and a donation was made to a
charitable organisation.
54. On 23 January 2008, the Governor of Albany and two family liaison officers
travelled to meet the man’s family and hand over his property. They attended
his funeral the following day.
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ISSUES
Clinical Review
55. A review of the man’s medical care at Albany was carried out by a consultant
in public health. As part of this review, an incident panel meeting was held at
Albany House on 28 February 2008. Members of healthcare staff from
Albany and Parkhurst were present at the meeting, together with the
consultant and my investigator. The consultant’s review noted:
“The man was in poor health when he was received into HMP Albany
on 27 September 2006 and unfortunately his health continued to
decline due to Chronic Obstructive Pulmonary Disease and Peripheral
Vascular Disease that both had a poor prognosis.
“At HMP Albany, the man had frequent medical supervision and was
given medication and nursing care. However, he refused further
investigation (a coronary angiogram) and was unable to act on advice
to stop smoking.
“As the man’s health declined, he was cared for firstly in F & G Wing at
HMP Albany (which has better facilities for disabled prisoners) and
then in the inpatient wing at HMP Parkhurst. Finally he was admitted
to hospital, where he died on 6 January 2008.
“In my view, the man received care of a standard he would have
received had he not been sentenced and remained in the community,
be it possibly in a residential or nursing home.”
56. I concur with the consultant’s view that the man received a standard of care
equivalent to that he would have received in the community.
The man’s location on F and G Wing
57. The man was unhappy about being transferred from A wing to F and G wing.
However, the accommodation in A wing had been unsuitable taking into
account his failing health and age. The move to F and G wing offered the
man ground floor accommodation with an en suite shower and toilet. His cell
was wheelchair accessible.
58. The man was assisted by a ‘buddy carer’ and was also fortunate that this was
a friend he had known before his reception into prison. The buddy carer told
my investigator that the man was a likeable man, but one who could be
“cantankerous” and who knew his own mind. The buddy carer helped the
man, and offered him friendship and support in his day to day needs. I note
and welcome the provision of a buddy carer scheme and the buddy carer’s
support to his friend.
59. Whilst on F and G wing, I believe the man was also very well supported by
both wing and healthcare staff. I recognise the good practice in allocating a
15
personal nurse to attend to the man’s basic medical care, and give assistance
with bathing, dressing and medication.
I commend the nursing staff and F and G wing officers for the support
and care they offered to the man.
Family Liaison
60. The man kept in regular telephone contact with his family following his
reception into Albany. His next of kin were recorded as neighbours living
close to his partner and his solicitor was noted on his record as being a point
of contact. When the man was admitted to hospital the family liaison officer
contacted his solicitor who gave information on his partner. As his partner
was unwell and would not open her door to visitors, the solicitor offered to visit
the man’s partner on behalf of the prison and this was agreed as the best way
forward. When it became obvious that the man’s partner would not be able to
deal with the situation, the solicitor gave the prison details of the man’s
brother.
61. Contact was made with the man’s brother and one of the family liaison officers
kept in touch regularly up to his death. This support continued until the
funeral. Although a face to face visit should normally be undertaken to inform
relatives of a death in custody, in the particular circumstances the prison used
a sensitive approach which was appreciated by the solicitor and the man’s
brother. The Governor wrote a letter of condolence to the family following the
man’s death, met the family a day before the funeral accompanied by the
family liaison officers, and covered all the funeral expenses.
62. The Death in Custody Protocol and Procedures Log recorded all interventions
when the man was admitted to hospital, then up to and after his death. The
log noted conversations with the solicitor and family.
I commend the exceptional good practice demonstrated by the family
liaison officers in respect of the man’s family.
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GOOD PRACTICE
I commend the nursing staff and F and G wing officers for the support and
care they offered to the man.
I commend the exceptional good practice demonstrated by the family liaison
officers in respect of the man’s family.
Accepted - It is pleasing to note that both nursing and wing staff at HMP Albany were
commended for the support they showed to the man and that the report noted that the
standard of family liaison demonstrated was very high.
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