Individual at Birmingham

Investigation into the circumstances surrounding the
death of a man at hospital in November 2008, whilst in the
custody of HMP Birmingham
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2009
This is the report of the investigation into the death of a man in November 2008. He
died of natural causes at hospital, whilst a prisoner at HMP Birmingham.
I offer my sincere condolences to the man’s family. I am pleased that they felt well
supported by the prison following his death.
The investigation was conducted by one of my investigators, on my behalf. I would
like to thank the Governing Governor of HMP Birmingham and another Governor
colleague for assisting the investigation.
The local Primary Care Trust commissioned a doctor to undertake a review of the
clinical care the man received whilst at Birmingham. I am grateful for his timely
review.
The man arrived at Birmingham in April 2008 with a few current health problems. He
told staff in reception that he was waiting for a hip replacement. For the first five
months of his sentence, he enjoyed reasonable health and had little contact with
healthcare staff. However, in September he began to complain of chest pains.
When he was assessed, he told healthcare staff that he was not eating and had
difficulty walking. It seems he had become reliant on his cellmate who collected his
food and generally helped to look after him.
The man was admitted to hospital in November. He was told that he might have
cancer, but tests proved inconclusive. In fact, up to the point of his death, medical
staff had not been able to confirm the diagnosis. Unfortunately, this meant that the
prison was not able to apply for him to be released from prison on compassionate
medical grounds.
The clinical reviewer and I conclude that, in respect of his terminal condition, the
man received a good standard of medical care whilst at Birmingham. However, the
investigation has identified omissions in other aspects of the healthcare he received
at the prison.
In addition, I am concerned to learn that wing staff do not routinely record important
information about prisoners. I make two recommendations which concern the
interactions between wing staff and prisoners, and two about communication with
prisoners’ families and local hospitals.
This was the third natural causes death to have occurred at Birmingham in 2008. I
have not found any similarities between the circumstances of the deaths.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2009
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CONTENTS
Summary
The Investigation Process
HMP Birmingham
Key Events
Issues
Conclusion
Recommendations
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SUMMARY
The man appeared at the Crown Court In April 2008, charged with racially
aggravated common assault. He was sentenced to 12 months imprisonment with a
12 months extended licence period to follow. He arrived at HMP Birmingham later
that day. He told healthcare staff in reception that he needed a hip replacement,
was asthmatic and had been consuming about 200 units of alcohol per week prior to
being sentenced. He was placed on an alcohol detoxification programme and
prescribed the appropriate medications. He was also prescribed medication to help
with his hip pain and asthma.
Shortly after his arrival at the prison, the man was briefly monitored under suicide
and self harm support procedures because he told staff that he had thought of
harming himself. Within a few days, staff were satisfied that he had settled into life
at the prison and that he no longer posed a risk to himself.
In June 2008, the man was transferred to HMP Stocken for two weeks and was then
returned to Birmingham. During the first five months of his sentence, he had few
health concerns and little contact with healthcare staff. However, in mid-September
he began to complain of chest pains and was referred to the cardiologist at the local
hospital.
On 26 October, the man once more complained of chest pains. During assessments
by medical staff, he said he had not been eating and relied on his cellmate to collect
his meals. He said he had not been able to get out of bed for several days. A wing
officer told a member of healthcare staff that the man had not been able to get out of
bed to use the toilet, and that his cellmate had had to help clean him up. (No entries
to reflect his difficulty walking or inability to look after himself were made by wing
staff in either the wing observation book or his prison file.)
The following day (27 October 2008), the man was admitted to healthcare. He
complained of abdominal pain and related symptoms and so a blood test was carried
out. The results revealed a number of abnormalities and he was referred to the local
hospital. The man was admitted to hospital on 5 November, and remained there for
a week. Hospital staff carried out a number of tests that indicated that he might have
cancer. His family was contacted and told that he was unwell.
The man discharged himself from hospital on 13 November. At this stage he was
not considered to be seriously unwell, but staff monitored his condition. As terminal
cancer was a possibility, staff began the process of applying for him to be released
from prison on compassionate grounds. However, without a confirmed diagnosis of
a terminal condition, this was not an option. Sadly, the diagnosis was not confirmed
until the post mortem was performed.
On 20 November, prison healthcare staff decided that the man needed to return to
hospital for further treatment. Over the next ten days his condition deteriorated. His
family was again contacted and told that he was seriously ill. He died at about
8.00pm on 30 November.
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The investigation has focussed on the clinical care the man received whilst at
Birmingham, and this was generally found to be of a good standard. I have also
considered whether wing staff knew about and recorded that he was not eating, nor
was properly able to look after himself, before his admission to healthcare.
I have made four recommendations. Two concern interaction between wing staff
and prisoners, and two concern communication (with families when prisoners are
admitted to hospital, and with local hospitals).
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THE INVESTIGATION PROCESS
1. My office was notified of the death of the man on 30 November 2008. The
investigation was allocated to one of my investigators on 3 December. My
investigator issued notices to staff and prisoners at HMP Birmingham inviting
them to contact her with any information they felt might be relevant to the
investigation. No one responded to these notices. My investigator and her
colleague conducted interviews with staff at the prison in January 2009.
2. Two prisoners who had shared cells with the man at Birmingham were identified.
One had since been released and my investigator wrote to him at his home
address inviting him to take part in the investigation. He did not respond. The
second prisoner had been transferred to HMP Parc. Another investigator from
my office visited Parc and requested an interview with him. This prisoner did not
wish to contribute to the investigation.
3. The local PCT appointed a doctor to undertake a clinical review of the care the
man received whilst at Birmingham. Both the clinical reviewer and my
investigator were provided with copies of the man’s medical records. My
investigator also received a copy of his prison records.
4. HM Coroner was notified of the investigation and provided my investigator with
the results of the post mortem. The Coroner will receive a copy of my report into
the man’s death to assist with his inquiries.
5. One of my family liaison officers contacted the man’s sister to invite members of
his family to be involved in the investigation process. The family had no specific
questions or concerns about the care the man received whilst at Birmingham.
However, I hope this report provides them with a picture of his time in prison and
the care he received.
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HMP BIRMINGHAM
6. HMP Birmingham is a large local prison serving the courts of Birmingham and
much of the West Midlands. It holds up to 1,450 adult male prisoners, both on
remand and sentenced. The prison has undergone significant improvement over
the last few years, including the building of a new healthcare centre.
7. The HM Chief Inspector of Prisons last conducted a full announced inspection of
the prison in February 2007. She noted that the prison was, once more, under
“acute population pressure” which affected both staff and prisoners.
Relationships between staff and prisoners were found to be problematic, with
residential staff having little input to prisoners’ progress or resettlement. Entries
in prisoners’ personal prison files were “mostly poor”. The personal officer
scheme, which had been criticised during the previous inspection, remained
“ineffective”.
8. Healthcare provision at the prison was found to be “mostly satisfactory”. It was
largely delivered from a “modern, purpose-built unit” by three distinct groups of
staff working in primary care, in-patient care and in-reach. Relationships
between healthcare staff and prisoners were identified as good, particularly on
the in-patient wards. All in-patients had a care plan and a named nurse and
officer.
9. All prisons are also monitored by an Independent Monitoring Board (IMB),
members of which are drawn from the local community. They have full access to
each prisoner and every part of the establishment. The last available annual
report by the Birmingham IMB covers the period July 2007 to June 2008. The
Board noted that overcrowding within the entire prison system, and at
Birmingham specifically, remained a concern. Healthcare provision was
recognised as having gone through significant changes over the year. The Board
highlighted that healthcare facilities at Birmingham were viewed as both a local
and national resource and that, as a result, “more robust partnerships” were
necessary. Overall, however, the Board was “impressed … with the dedication
and professionalism of the staff”.
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KEY EVENTS
10. The man appeared at the Crown Court in April 2008 charged with racially
aggravated common assault. He was given a 12 month custodial sentence, with
a 12 month extended licence period to follow his release. He arrived at HMP
Birmingham at 4.10pm the same day.
11. At about 7.00pm, the man underwent the first reception healthscreen with a
nurse. (The purpose of the healthscreen is to identify any immediate physical or
mental health concerns and make necessary referrals to the doctor or other
specialist services.) The man told the nurse who carried out the first reception
healthscreen that, although he was registered with a doctor in the community, he
had not had an appointment in the last few months. He said that he needed a hip
replacement. The nurse recorded that the man was a smoker, and that he had
asthma and used two inhalers but did not know their names. He told the nurse
that he had experienced fits in the past (the cause of the fits was not recorded).
12. During the healthscreen interview, the man said that he had consumed about 200
units of alcohol in the week before he was sentenced. As a result, the nurse
referred him to the doctor to be prescribed medication to combat any symptoms
of alcohol withdrawal. The man said he had not used any drugs in the last
month. He told the nurse that he had attempted to harm himself in the past,
outside prison. However, he said that he currently had no thought of harming
himself. He also said that he had never received any medical treatment for
mental health problems. At the end of the interview, the nurse recorded that she
had referred the man to the drug and alcohol service in the prison and to the
mental health team (because of his history of self-harm). She concluded that he
was fit for normal location, and for work, and could be located in any cell. He was
located in a shared cell on D wing, the first night centre.
13. At 8.35pm, the man saw another nurse for a mental health reception screen. She
recorded that he “appeared in distress” and said he was thinking of harming
himself. He told the nurse that he did not have a plan to harm himself and that he
was likely to feel better once he had taken medication to relieve the symptoms of
alcohol withdrawal. As a result of the mental health screen, the nurse completed
a Concern and Keep Safe form, the first stage of the Assessment, Care in
Custody and Teamwork process (ACCT). (Prisoners considered to be at risk of
harming themselves are monitored and supported under the ACCT process.)
14. Another nurse made an entry on the man’s medical record later the same day.
She recorded that he was a “very heavy drinker”, who was experiencing
withdrawal symptoms including moderate tremors, sweats and moderate anxiety.
Following this assessment and the earlier first reception healthscreen, the prison
doctor prescribed a number of medicines, namely chlordiazepoxide hydrochloride
tablets (used to treat alcohol withdrawal), thiamine hydrochloride (frequently
prescribed to patients who abuse alcohol), vitamin B tablets and ibuprofen (a pain
relief medication). The doctor also prescribed an inhaler to treat the man’s
asthma.
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15. The following day (26 April 2008), an officer carried out the ACCT assessment
interview with the man on D wing. The man said he felt low and depressed but
had no thoughts or plans to harm himself. The officer concluded that the ACCT
book should remain open, to be reviewed a week later. On 29 April, an SO, the
officer who carried out the assessment and the man agreed the ACCT book
should be closed.
16. Between 28 April and 19 June, the man had several contacts with healthcare
staff for minor complaints, including hip pain and a cold. He continued to be
prescribed ibuprofen tablets, thiamine and vitamin B tablets, and inhalers for his
asthma.
17. On 19 June, the man was transferred to HMP Stocken for almost two weeks. It
has not been possible to find out why this happened. Entries on his prison file
indicate that it was an uneventful couple of weeks. My investigator asked
Birmingham for copies of his medical records from Stocken but, to date, they
have not been located.
18. The man was transferred back to Birmingham on 7 July and was located on K
wing, which holds 180 prisoners. He was placed in a shared cell. Staff at
Birmingham made no entries in his personal file after that date. His medical
records indicate that, on his return to Birmingham, he underwent a further first
reception healthscreen. Again, his asthma and hip pain were identified. The
nurse that carried out the second first reception healthscreen referred the man to
the doctor and to the mental health team. He was seen that day by another
nurse for the mental health reception screen. She recorded his history of
depression and previous attempts to harm himself in the community. She
referred him to the doctor for a possible prescription of anti-depressants. The
man did not attend his doctor’s appointment on 14 July, but no reason for this is
noted.
19. The man’s next significant contact with healthcare staff occurred on 16
September when a nurse responded to an emergency radio call at 9.15am. She
recorded on the man’s medical records that he had complained of chest pain
during a morning activities session. When she arrived to assess him, the man
told her that he had suffered a heart attack in January 2008 and had been
admitted to hospital for two weeks. The nurse recorded that the pain was “sharp
and radiating to left shoulder”. She gave the man aspirin and a spray used to
ease heart pain, particularly angina. She decided to refer him to the doctor and
recorded that she had made an appointment for him. The nurse checked the
man a few hours later and recorded that he was “feeling better now” but that the
pain was still there.
20. On 23 September, a second doctor assessed the man following the chest pain
the previous week. He prescribed aspirin and advised the man to use the spray
when necessary. The doctor recorded that the man was a Jehovah’s Witness
who had refused to undergo a blood test. He noted that he should be referred to
a heart specialist, and made the referral that day.
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21. A month later, on 25 October, the man complained of “feeling generally unwell”
and having more chest pains. A second emergency radio call was made for
healthcare staff to attend. A nurse assessed the man and recorded in his
medical records that he “looked unwell”. The man complained of a cough and
chest pain. He told the nurse that he had not been eating. She referred him to
the doctor, and a third doctor assessed him later that day. The doctor diagnosed
a chest infection and prescribed antibiotics.
22. The following day (26 October), another nurse was called to see the man on K
wing at about 7.00am. He was again complaining of chest pains, centred on his
sternum, and of chronic hip pain. He told the nurse that his cellmate had had to
lift him up from the floor. The nurse gave him a dose of paracetamol and aspirin.
He made the following entry in the man’s medical records:
“Later officer came to tell me that [the man] is not able to get out of bed to
reach toilet and so he was in a mess and the cellmate helped to clean (not
good due to infection) and cellmate collects food for him. It is said he has not
been out of bed for some days.”
23. My investigator interviewed an officer as part of the investigation. He had been
based on K wing since March 2008 and was identified as one of the man’s
personal officers while he was located on that wing. (Personal officer schemes
operate in most prisons. Each prisoner is allocated a named officer or officers
who act as their first port of call if they need help or advice. Usually, a prisoner’s
personal officer is expected to make entries in the prisoner’s file on at least a
fortnightly basis.) The officer said that the personal officer scheme at
Birmingham had been restructured during 2008 and was re-introduced in
October. He could not remember having met the man and had not made any
entries in his prison file.
24. The officer was asked whether staff would be aware of prisoners who did not
collect their food over a prolonged period. He explained that it could be difficult
for staff to notice when a prisoner was not collecting their meals. My investigator
asked if there was any system in place to monitor this, and he replied that there
was no formal system:
“Well the prisoners themselves actually, because we have a menu system on
[K] wing and the prisoners deal with that side of things. So we don’t actually
know until he lets us know or basically if we’re just on there we just notice that
he’s not taking it.”
25. The officer was also asked whether wing staff would generally be aware of a
prisoner who was physically unable to look after himself and get out of bed. He
said that staff would “definitely” be aware of this. My investigator asked what
wing staff would do if such a situation arose. The officer said that a prisoner who
was not able to look after himself would need to be admitted as an in-patient in
healthcare. He explained that wing staff would therefore inform healthcare staff.
He was asked whether this kind of information would be recorded anywhere. He
said that he suspected “it would be healthcare who’d be sort of writing down the
notes or whatever the doctor says”. He said staff would also normally record
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such information in the wing observation book. (Each prison wing has an
observation book which is used to record important information about individual
prisoners or occurrences on the wing. It is used to pass information between
staff working different shifts.)
26. The wing observation book for K wing contains one entry relating to the man. It
was made by another officer on 26 October. The entry reads, “Prisoner suffering
with chest pain. Seen by nurse at 07.30. Will return to check up on him.” There
are no entries relating to the man’s mobility or ability to look after himself. No
entries were made to record that he was not collecting food.
27. Following his assessment of the man, the nurse that saw him at 7.00am recorded
that he had talked to healthcare to see if the man could be admitted as an in-
patient. A bed was available and so the nurse wrote that he had informed K wing
staff and they would take the man to ward 2. At 11.54am that morning, a
different nurse recorded that an emergency radio call had been received for
healthcare staff to attend to the man. This nurse noted that the man had
apparently collapsed as he was being escorted to the healthcare ward. During
her examination of him, she found him to be “pale, looks ill, in pain”. She
recorded that he was “very weak and not eaten”.
28. Later that day, another nurse in the in-patient ward recorded that the man was
still complaining of pain and weakness due to his loss of appetite. However, he
was seen to eat his lunch and dinner. He appeared to settle and staff recorded
that there were no further problems that night.
29. The following day, 27 October at 1.06pm, a nurse recorded in the man’s medical
records that he was complaining of abdominal pain, with acid reflux symptoms
(where acid from the stomach leaks into the gullet), diarrhoea and vomiting. He
was examined and prescribed medication. The nurse wrote that the man was not
to take any more ibuprofen, and that his weight should be monitored, blood
samples taken, and he should be reviewed later that day. There was no further
mention made of the man being a Jehovah’s Witness or of refusing the blood
test, which was in fact carried out several days later. Another nurse recorded at
6.35pm that the man remained on his bed during association (the time of day
when prisoners are unlocked and may mix with each other). He told this nurse
that he had vomited sputum and that his left hip was painful. He said he did not
want his evening meal.
30. In the afternoon of 28 October, the man told the nurse he had talked to the
previous day that he had vomited sputum again. Over the following few days, he
appeared settled and no further health concerns were reported. The third doctor
recorded that the man missed an out-patient appointment with a cardiology
specialist at an outside hospital on 30 October, apparently because healthcare
staff were not aware of it.
31. On 4 November, the man’s blood was tested. The GP clinical lead at the prison
provided my investigator with her own written review of the care the man
received. She wrote that the results of his blood tests revealed that he had a
“significantly raised white cell count indicating ongoing infection, raised
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inflammatory markers and abnormal liver function tests”. However, the most
concerning result indicated that there might be problems with the man’s kidney
function. The third doctor reviewed the blood test results on 4 November. He
recorded in the medical records that the man was not “acutely unwell” but that he
presented with a “picture of Addison’s disease” (a stomach disorder which
causes fatigue, vomiting, diarrhoea and joint or muscle pains). The third doctor
made an urgent referral for an out-patient appointment at the hospital.
32. The following day, the man was assessed by the GP clinical lead as he
complained of feeling unwell. She recorded that he was “unsteady, looks and
feels unwell”. In her report, the GP recorded that, by this time, the man’s blood
pressure had “dropped significantly” and he had a very fast heart rate. She was
concerned that his condition was deteriorating. In the light of his recent blood
test results and her assessment that day, the GP decided that he should be taken
to an outside hospital by ambulance as an emergency. (The records concerning
the man’s transfer to the hospital, the level of restraints used, and the number of
officers assigned to supervise him whilst in hospital, were not provided to my
investigator in time for inclusion in this report.)
33. The man remained in hospital for assessment. Three days later, on 7 November,
the GP recorded in his medical record that hospital staff had identified that he
had an abnormal heart rhythm. He was diagnosed with a build up of fluid in his
abdomen, a sample of which was taken for analysis. The GP noted that the
cause was as yet unknown, but cancer was a possibility. She wrote that the man
would undergo a CT scan (computerised tomography – a type of x-ray which
produces a two dimensional picture of the body) and a surgical review. The
hospital would inform the prison healthcare centre when a diagnosis could be
made.
34. On 10 November, the man underwent an ultrasound scan at the hospital. (An
ultrasound scan uses sound waves to produce images of the internal organs and
structures inside the body.) The following day, the GP recorded that the hospital
had provisionally diagnosed the man with an advanced gastrointestinal
malignancy (cancer). He was to remain in hospital and undergo further tests over
the following days. A nurse made an entry on the man’s medical record on 12
November, seven days after he had been admitted to hospital. She recorded that
she had had a conversation with a governor grade and a probation officer from
the public protection team, about the man’s next of kin being informed of his
condition. Following the necessary checks, it was decided that his partner would
be contacted so she could visit him in hospital if she wished.
35. My investigator spoke to another governor grade, who acted as the prison’s
family liaison officer, by telephone. She said that when the man became ill she
had contacted his partner. She had also made contact with his sister, whom he
had not seen for a number of years. His sister was able to visit him in hospital.
36. Because there were indications that the man’s condition might be serious, the
prison began to explore whether he might be released on temporary licence
(ROTL) or compassionately released in due course. This is in line with guidance
contained in Prison Service Order (PSO) 6000, Parole Release and Recall, and
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PSO 6300, Release on Temporary Licence. The first Governor grade received
information about the nature of the man’s offence and the risk he would pose to
others if released. On 14 November, he advised the GP to request that the man
be considered for release on compassionate grounds.
37. The GP was interviewed as part of the investigation. She said that the
application was complicated because the hospital had not been able to provide a
definite diagnosis at this point. Although his symptoms indicated that he might
have cancer, they were also consistent with abdominal tuberculosis which is a
treatable condition. Unless the man was diagnosed with a terminal condition, the
GP was unable to go ahead with the application for compassionate release, and
she had explained this to the hospital consultant. The consultant had said that
staff would continue to take fluid samples from the man’s abdomen and would
perform a tissue biopsy if his condition stabilised. Without a tissue biopsy,
medical staff agreed that a diagnosis would remain difficult.
38. On 13 November, the man decided to discharge himself from hospital. My
investigators asked the GP about the circumstances of his decision. She
explained that there were two common reasons why prisoners might decide to
discharge themselves from hospital. Prisoners often wanted to return to prison,
where they are allowed to smoke in their cells, rather than stay in hospital wards
where smoking is not allowed. She also said that prisoners complained it was
embarrassing to be on a hospital ward escorted by prison staff and held in
handcuffs.
39. During interview, the GP explained that healthcare staff would discuss patients’
decisions to discharge themselves, to ensure the prisoner had the capacity to
make the decision. If staff had any doubts, they would arrange for the patient to
be seen by a psychiatrist who would make an assessment of their mental
capacity. She said that there had been occasions when staff had been able to
persuade a patient not to discharge himself from hospital. The man told the GP
that he was tired of undergoing medical tests and wanted to be able to smoke.
She told my investigators that “part of him seemed to know that it was a terminal
illness and the other part was very optimistic.”
40. My investigators asked the GP whether the man’s decision to discharge himself
caused the prison’s healthcare staff any difficulties or concerns. She replied that
on 13 November he was “not too unwell” and was able to move around. The GP
said that she discussed his condition with healthcare staff, who were aware that
he would probably need to return to hospital to have fluid drained from his
abdomen. She also explained that healthcare staff agreed he should be
readmitted to hospital should his condition worsen.
41. The discharge letter sent from the outside hospital to the prison healthcare centre
noted that the man had discharged himself against medical advice. It was
recorded that he had been told he might have cancer. He was discharged with
prescriptions to combat his irregular heart rhythm and constipation and an
antibiotic, all to be taken under medical supervision. On his return to HMP
Birmingham, he was given a bed in the in-patients ward in healthcare.
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42. The third doctor made an entry in the man’s medical records on 14 November.
He recorded that he and the man had discussed his condition. The man had told
the doctor that he had wanted to return to the prison for “a rest” but that he would
be willing to go back to the hospital for further treatment. The doctor prescribed
morphine to control the man’s pain.
43. On 17 November, the man complained to healthcare staff that he had been
vomiting during the night and that morning. The GP assessed him later that day
and discussed the possible diagnosis of cancer. She noted in his medical
records that he understood that “cancer is very likely”. She then discussed
whether he would like staff to resuscitate him if he became suddenly unwell or his
heart was to stop. She recorded that “the man would like active treatment for
symptoms control” but that he did not wish to be resuscitated. Also present
during this conversation were a nurse and an officer. My investigators asked the
GP about the conversation. She said that, as she thought that his condition was
terminal, she had talked to him about the treatment he would like. She said that
she did not ask him to sign a written statement to confirm that he did not wish to
be resuscitated and so it did not constitute a legally binding advance directive.
(This is a written document, often drawn up by a solicitor, which indicates a
person’s wish to refuse all or some forms of medical treatment.) This meant that
healthcare staff would be able to call an ambulance or seek external medical
attention for the man if necessary.
44. Shortly after their conversation, the man was visited by a mental health nurse and
offered the support of the primary care mental health team. He told the nurse
that he was tired and would speak to them another day.
45. When the man experienced pain, healthcare staff administered morphine to him.
Over the next few days, he remained “poorly” and with a “grossly distended”
abdomen. On 19 November at 10.08pm, he fell in his cell but did not want to be
examined by healthcare staff, telling them that he was “okay”. He was noted to
be awake throughout the night, rubbing his swollen abdomen. The following
morning, the GP assessed his condition and decided that he needed to return to
the hospital to have the fluid drained from his abdomen.
46. An urgent medical escort risk assessment was carried out before the man was
taken to hospital. The nurse who had discussed contacting the man’s family
recorded that the man was “too ill” to escape unaided from custody, that he was
possibly suffering with cancer and a heart condition. She concluded, however,
that there were no medical objections to the use of restraints. Wing staff and the
prison’s security department had no information to suggest that he might be an
escape risk. It was decided that he should be accompanied by two officers and
should be held in a single handcuff with an escort chain attached. (This is a long
chain which runs between the prisoner and a member of prison staff.) On arrival
at the hospital, he was admitted to a ward. Healthcare staff recorded in his
medical records that they made contact with hospital staff twice a day to receive
reports on his condition.
47. The next day, 21 November, a third governor grade and the Governing Governor,
agreed that the man’s restraints should be removed because he was quite
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unwell. He was still to be escorted by two members of Prison Service staff
(known as a bedwatch) and was not to be left alone, particularly if he had visitors.
If his medical condition improved, the escort chain was to be reapplied. Officers
undertaking bedwatch duties completed a log. They recorded that the man was
becoming increasingly confused and restless. On 23 November, members of his
family visited him in hospital.
48. On 26 November, healthcare staff contacted the hospital again and were told that
the results of further tests were awaited. The man was too poorly to undergo a
tissue biopsy which would confirm the cancer diagnosis. The hospital had
arranged for Macmillan nurses to visit him. (Macmillan nurses are specially
trained to provide palliative care for cancer patients. Palliative care is provided
when patients will not recover from their illness, and are receiving treatment to
reduce the severity of their symptoms.)
49. The man’s medical records indicate that over the next few days his condition
remained the same. On 28 November, the Safer Custody governor visited him
in hospital. He asked her to contact his family and let them know he was
seriously unwell. The Safer Custody governor telephoned both the man’s partner
and sister and left messages asking them to contact her.
50. On 30 November at 6.55pm, nursing staff advised one of the bedwatch officers,
that the man’s family should be contacted as his condition was worsening. His
sister was contacted by telephone by a member of prison staff. At 7.35pm, two
more officers arrived at the hospital to take over bedwatch duties. About half an
hour later, one of the relief bedwatch officers recorded in the log that he had
called for nursing staff to attend the man because of his condition. At 8.20pm,
the ward sister told him that the man had died. This was confirmed by a hospital
doctor an hour later.
51. The post mortem confirmed that the man died of natural causes, namely bilateral
broncho-pneumonia and carcinomatosis (widespread cancer).
52. The prison family liaison officer told my investigators that the governor on duty on
30 November had telephoned the man’s sister to let her know he had died. She
made further telephone contact with her on 3 December. The prison arranged
and made a financial contribution towards the man’s funeral. His sister told my
family liaison officer that staff at the prison, and in particular the prison family
liaison officer, had been “wonderful”. She said she had written to staff to thank
them for their support and help.
Support for staff
53. My investigator asked the Safer Custody governor what support would normally
be offered to staff who undertook bedwatch duties. She explained that staff who
undertook bedwatch duties were not generally offered specific support. However,
staff who were present when a prisoner died would normally be contacted by the
staff care and welfare team. It has not been possible to confirm whether the relief
bedwatch officers were offered support following the man’s death.
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Support for prisoners
54. The Safer Custody governor told my investigator that, following a death in
custody, the Governor produces a notice to prisoners which is displayed around
the prison. She confirmed that such a notice was issued following the man’s
death.
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ISSUES
Wing staff’s interaction with the man
55. In late October 2008, whilst located on K wing, the man complained to medical
staff that he was not eating and that his mobility had reduced to such an extent
that he was reliant on his cellmate. An entry in his medical records on 26
October noted that his cellmate had helped to clean him when he had been
unable to use the toilet. No entries had been made in his prison file since 30
June, over three months before he was admitted to healthcare. Furthermore,
there were no entries in the K wing observation book to indicate that wing staff
were aware of, or concerned about, the man’s health and ability to look after
himself.
56. Quality entries in prisoners’ files and wing observation books are an important
means of assessing the level of interaction between wing staff and those in their
care. The personal officer said in interview that wing staff would “definitely” be
aware of the man’s inability to properly care for himself. There is, sadly, no
evidence to suggest this was the case.
The Governor should remind all staff of the importance of making quality
entries in prisoners’ files and in wing observation books.
57. The personal officer told my investigators that there was no formal system for
staff to identify prisoners who did not collect their meals. The GP said in
interview that healthcare staff relied on wing staff to bring such prisoners to their
attention.
The Governor should introduce a formal system whereby wing staff can
identify and record those prisoners who do not collect their meals.
The personal officer scheme
58. My investigator was told that the personal officer scheme was not fully functional
on K wing in October 2008 when the man became unwell. I understand that it
was reintroduced on the wings, after some restructuring, around that time. I
believe that the man’s health problems might have been identified more quickly
had the personal officer scheme been effective. While I appreciate the difficulties
of operating a personal officer scheme in a local prison with high levels of
turnover, I hope that following the restructuring a robust system is now in place.
Clinical care
59. As noted above, the local PCT commissioned a doctor to undertake a review of
the clinical care the man received whilst at Birmingham. The clinical reviewer
has reviewed the man’s medical record and concludes:
“I have not been able to identify any particular shortcomings in [the man’s]
care, necessitating any significant change in practice.”
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60. The clinical reviewer says that the management of the man’s alcohol
detoxification was worthy of note. When he arrived at Birmingham, he told staff
he had been drinking approximately 200 units of alcohol per week. The clinical
reviewer considers that the reduction from this level to nil was managed without
any apparent problems.
61. When the man arrived at Birmingham, he told healthcare staff in reception that he
was awaiting a hip replacement. During his time at the prison, he complained
that his hip caused him pain. There is no indication in his medical record that
staff contacted his doctor in the community to check whether he had any
outstanding hospital appointments.
The man’s chest pains
62. On 16 September, the man complained of chest pains and was seen as an
emergency by the nurse. He told the nurse that he had suffered a heart attack
earlier in the year. The nurse referred him to the doctor but he was not assessed
by one until 23 September – five working days later. During the course of the
investigation, the GP was asked whether, given his medical history, the man
should have been assessed as a priority. She explained that the prison’s nursing
staff are trained to differentiate between “cardiac chest pain” and other types of
chest pain which do not require urgent assessment by a doctor. The GP told my
investigator that the nurse checked the man’s condition later the same day and
decided that, as his discomfort had settled, he did not need an urgent
appointment. A routine appointment was requested as a consequence.
63. The GP was also asked why the man had missed his out-patient appointment
with the cardiologist at the hospital. She provided further information about this
by email. I understand that the man was sent confirmation of his hospital
appointment directly. Healthcare did not receive a copy of the letter and so were
not aware of it. Once they became aware that he had missed the appointment,
they faxed the hospital to arrange a new appointment. Given that the referral to
the hospital cardiologist was made by a prison doctor, I am concerned that
healthcare staff had not been informed of his out-patient appointment.
The Director of Healthcare and the PCT should review the procedures in
place to ensure that healthcare staff are aware of external medical
appointments.
64. My investigator found that, once he had been admitted to healthcare, staff looked
after the man with care and consideration and responded quickly to his
healthcare needs. Healthcare staff remained in regular contact with the hospital
whilst he was a patient there. However, because staff at the hospital were not
able to confirm the diagnosis of cancer, the prison could not arrange for him, to
be compassionately released.
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Use of restraints
65. My investigator has not yet been provided with the records relating to the man’s
first admittance to hospital on 5 November. They should detail the risk
assessment carried out and the level of restraints used during his stay. When he
was re-admitted to hospital on 20 November, it was decided that he should be
escorted by two members of staff and should be restrained by a single handcuff
and an escort chain. It was entirely appropriate that, the following day, the
decision was made to remove the restraints.
Release on compassionate grounds
66. Very soon after it became clear that the man was seriously unwell, the prison
considered whether he was suitable for release on compassionate medical
grounds. Unfortunately, the lack of a confirmed diagnosis of a terminal condition
meant that he could not be released prior to his death. I am pleased to note the
speed with which consideration was given to his possible release.
Contact with the man’s family
67. The man’s sister told my family liaison officer that she and his family had received
very good support from the prison. However, I am disappointed that it took seven
days for the man’s next of kin to be contacted when he was first admitted to
hospital on 5 November.
The Governor and the Director of Healthcare should ensure that they inform
the next of kin at the earliest appropriate opportunity when a prisoner is
admitted to hospital.
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CONCLUSION
68. The man arrived at HMP Birmingham in April 2008. He had some physical health
conditions on his arrival but they caused him few problems during the first five
months of his sentence. He began to complain of feeling unwell in September,
and by mid-October he had been admitted as an in-patient in the healthcare
centre. In November, he was told that he probably had cancer, but up to his
death a confirmed diagnosis had not been possible. This limited the steps the
prison could take to release him from prison before his death.
69. The clinical reviewer and my investigator identified that the man received a
generally good standard of care from medical staff at the prison. This was
particularly the case once it was clear that he was seriously unwell. This
investigation has revealed several omissions in the healthcare he received prior
to that, although I do not believe they had an impact on his death. I have made
recommendations to improve communication with prisoners’ families and with
local hospitals. Additionally, my investigator found that improvements could be
made to wing staff records of their interactions with prisoners. Wing staff self-
evidently have an important role in highlighting concerns about prisoners’ health
to medical staff, and there are steps that should be taken to make this more
robust.
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RECOMMENDATIONS
1. The Governor should remind all staff of the importance of making quality entries in
prisoners’ files and in wing observation books.
The Prison Service has accepted this recommendation. An Operational Order will
be written reminding staff of the requirement to make quality entries in prisoner
history sheets and observation books, either as part of the Personal Officer
Scheme, or following interactions where necessary.
2. The Governor should introduce a formal system whereby wing staff can identify
and record those prisoners who do not collect their meals.
The Prison Service has accepted this recommendation. A system for monitoring
the collection of meals has been devised with a target completion date of June
2009.
3. The Director of Healthcare and the PCT should review the procedures in place to
ensure that healthcare staff are aware of external medical appointments.
The Prison Service has accepted this recommendation. A tracker system is in
place and regular statistics are recorded and audited.
4. The Governor and the Director of Healthcare should ensure that they inform the
next of kin at the earliest appropriate opportunity if a prisoner is admitted to
hospital.
The Prison Service has accepted this recommendation. Next of kin can be
informed when a prisoner’s condition has been diagnosed as critical, with the
approval of the Governor or Duty Governor as per the Local Security Strategy.
This information will be included in the bedwatch packs that accompany the
prisoner to hospital.
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