Individual at Dartmoor

Investigation into the circumstances of the death of
a man in hospital in September 2006, whilst a prisoner at
HMP Dartmoor
Report by the Prisons and Probation Ombudsman for
England and Wales
February 2007
This is a report into the death of a man who died on the morning of
2 September 2006 hospital, whilst a prisoner at HMP Dartmoor. He had been found
unconscious on the floor of his cell a few hours earlier. The man was 59 years old
and had been suffering from cancer
The man was serving a sentence of life imprisonment imposed in1982 for serious
sexual offences. He had served two previous custodial sentences for similar
offences.
I extend my sincere condolences to the man’s family and friends for their loss.
This investigation was undertaken by a colleague. I would like to thank the Governor
of Dartmoor, and her staff for their help and assistance in this investigation. I am
also grateful to South Hams and west Devon Primary Care Trust who was
commissioned to undertake a clinical review into the man’s medical care.
Including the recommendations in the clinical review, I make eight recommendations
relating to healthcare issues and commend five areas of good practice. The final
report notes that the Devon Primary Care Trust providers of healthcare services in
Dartmoor have accepted the recommendations.
This version of my report, published on my website, has been amended to remove
the name of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prison and Probation Ombudsman February 2007
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CONTENTS
Summary
The Investigation Process
HMP Dartmoor
Key Events
Issues
Recommendations
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SUMMARY
The man died at 8.55 am on 2 September 2006 in hospital. He had been found
unconscious in his cell at HMP Dartmoor some four hours earlier.
He was serving a sentence of life imprisonment imposed in 1982 at Crown Court. In
1999, he transferred to HMP Dartmoor from HMP Maidstone and was resident on
the Vulnerable Prisoners Unit (VPU).
In 2004, the man was diagnosed with bowel cancer. He was treated in hospital for
his illness. Treatment included surgery and chemotherapy. In April 2006, while
being treated for another condition, it emerged that the cancer had returned. His
condition then rapidly deteriorated. In June 2006, it was confirmed that the man was
suffering from metatasic malignant disease (cancer) and his prognosis was
described as poor.
When he was not receiving hospital treatment, the man was cared for, physically and
emotionally, on the wing at Dartmoor until the day he died. (Dartmoor does not have
a 24 hour healthcare unit.) He remained in his cell and was assisted in his daily and
palliative care by prison staff, the wing nurse and fellow prisoners. The man had
asked not be transferred to HMP Exeter where there is 24 hour healthcare. It was
his wish to remain at Dartmoor with his friends and in a community with which he
was familiar.
An application for a compassionate discharge was under consideration when it
became obvious that the man’s condition was deteriorating very quickly. The
collection of reports and evidence to support the application was underway when he
died. Given the man’s offences, prison security information and psychiatrist’s
reports, his release on compassionate grounds may not have been appropriate in
any event.
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THE INVESTIGATION PROCESS
The investigation into the man’s death was opened by a colleague on 18 September
2006 when she visited Dartmoor. She met with the Governor a Senior Manager and
a Senior Officer (the latter representing the local branch of the Prison Officers’
Association). Notices and terms of reference had already been received at the
prison by post.
On 15 September, my colleague had spoken to the chair of the prison’s Independent
Monitoring Board (IMB).
My investigator reviewed the man’s prison file and obtained a copy. A copy of his
medical records was also made available.
A review of the healthcare the man received was carried out at the direction of South
Hams and West Devon Primary Care Trust (PCT).
On 19 September, my investigator visited the VPU wing where the man had spent
his last few years in Dartmoor. She later spoke to healthcare nurse manager, a
member of the chaplaincy team and an Officer from the VPU.
One of my Family Liaison Officers, wrote to the man’s family informing them of the
investigation. The family has not raised any specific issues they wish to be
considered.
No matters were raised by any of the man’s friends on the VPU at Dartmoor.
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HMP DARTMOOR
Dartmoor is a category C training prison with an operating capacity of 625. The prison was
last inspected by HM Chief Inspector of Prisons in February 2003.
Dartmoor works collaboratively with HMP Channings Wood and HMP Exeter as part
of the Devon Prisons Health Partnership. There is no in­patient facility within the
healthcare unit. A dedicated nurse is based in the VPU on F wing.
South Hams and West Devon PCT have had the commissioning responsibility for
Dartmoor’s healthcare since April 2003. The prison’s healthcare department has a
doctor available every weekday. Overnight and weekend cover is provided by
Devon Doc, an out of hours service commissioned by the PCT.
Two other prisoners have died at Dartmoor since I became responsible for
investigations into all deaths in prison custody in April 2004. One death was self
inflicted and the other was due to natural causes.
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KEY EVENTS
Events leading to the death of the man
The man first became unwell in 2003 with pain in his leg and diarrhoea like
symptoms. He was seen regularly by the medical officer and prescribed appropriate
medication. The man was referred to hospital for an out­patient appointment in the
gastroenterology department.
In January 2004, the man saw a consultant enterologist. Further tests and
investigations were undertaken. On 23 August that year, a letter to the medical
officer at Dartmoor from the consultant indicated that the man had been diagnosed
with colorectal cancer in his ascending colon (bowel cancer). A computerised
tomography (CT) scan was requested. On 16 September, his (CT) scan confirmed
bowel cancer.
On 21 October, the man was admitted to hospital and underwent surgery to remove
a small section of his large intestine. He was escorted by two officers and remained
under escort during his stay in hospital. He was discharged to Dartmoor on 29
October.
The surgery was followed by chemotherapy which the man received at the hospital
on prison escort. On 31 December, he was visited on the VPU wing by a Macmillan
nurse who offered advice and support.
The man attended the hospital on 19 February 2005 as an emergency admission
with a painful left leg. A deep vein thrombosis (DVT) was diagnosed and he was
discharged to Dartmoor on 20 February with appropriate medication.
On 2 April, an entry in the man’s medical notes recorded that he had discovered a
lump in his thyroid. This was diagnosed as a cyst (a small swelling). A
transcutaneous electronic nerve stimulation (TENS) machine was ordered by
healthcare to aid his pain relief. (This device relieves pain by providing a distracting
electronic stimulation to the surface nerves in the affected region.) On 20 April, a
Macmillan nurse reviewed the man’s care and offered support.
A bone scan undertaken at the hospital on 26 May indicated no evidence of cancer
cells, although it did show features suggestive of degenerative disease in the man’s
back. On 4 July, a letter from the Macmillan nurse specialist recorded that he did not
have any identified palliative care needs at that time.
The man underwent an x­ray on his abdomen on 11 October. The results of this x­
ray showed ‘no abnormality noted’. In December, he was seen at the hospital in the
dermatology department for a swollen and painful finger. This was treated with
appropriate medication and the man was referred to a plastic surgeon.
The man attended the hospital on 25 January 2006 with a suspected DVT in his left
leg. The condition was diagnosed and he was discharged with medication and a
request for healthcare to take regular blood tests from the man to keep a check on
his blood clotting.
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On 26 April, the man saw the consultant oncologist at the hospital and it was
diagnosed that his cancer had returned. He was still receiving treatment for his DVT.
The suitability of chemotherapy was discussed by consultants at the hospital. On 9
June, the medical officer started the man on a morphine based medication to help
with pain control. When he attended an out patient appointment at the hospital on
26 July, the results of a CT scan showed thatthe cancer had progressed. The
possibility of chemotherapy was again discussed. The man’s medical notes record
that on 28 July he was advised that chemotherapy might not be appropriate as it
would make him ill and might even shorten his life.
On 31 July, the man was appearing very jaundiced (yellow colouring on the skin). A
referral for himto attend an Acute Jaundice Clinic was sent to the hospital. On 3
August, healthcare staff contacted Macmillan nurses for support and advice. The
following day, the man expressed his wish to remain at Dartmoor although his
condition was deteriorating. He felt comfortable with familiar prison staff and friends
on the wing. He did not wish to be transferred to HMP Exeter where there was 24­
hour healthcare.
On 8 August, the man attended the Acute Jaundice Clinic and his illness was
reviewed. Observations and tests were carried out. By 15 August, he was very
unwell. He was not eating but taking fluids. The medical officer noted that the man
was too unwell to be adequately looked after at Dartmoor and should be transferred
to Exeter. The medical officer also recorded in the man’s notes that he was refusing
to be transferred. Two days later, the medical officer noted that wing staff felt they
could manage The man on the wing. The Macmillan nurses would be contacted for
further advice and palliative support and care.
On 24 August, the man had a massive oedema (fluid swelling) on his legs.
His pain relief of morphine was increased. The man was still refusing to go
to Exeter and the medical officer noted that his wishes would be respected.
he was visited by a Macmillan nurse later that day.
Over the next seven days, the man was visited regularly by the medical officer and
the Macmillan nurse. The wing nurse, assisted in basic care and the man was
supported by prison staff and prisoners.
On 2 September at 4.45am, the man was discovered lying on the floor of his
cell by night staff. At 4.50am, the night orderly officer entered the cell and
immediately called for an ambulance as the man was obviously very unwell. He
appeared to be bleeding and was unrousable although he was still breathing.
At 6.00am, the man was taken to hospital by ambulance. The ambulance had
arrived at the prison at 5.10am. The delay in transporting the man to hospital was
due to the need to find two members of staff to escort him in the ambulance.
He died at 8.55am. A member of the chaplaincy team started a death in custody log.
The man’s brother was contacted at 9.10am and his sister at 11.30am. Both had
had little contact with their brother. The man’s brother asked that the prison make
the funeral arrangements. He would send a letter to the prison giving his consent.
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The two officers on bed watch and the night orderly officer were contacted by the
member of chaplaincy for support in his role as a Care Team member. A critical
incident debrief for those involved with the man was held on 21 September.
After quotes were obtained for the man’s funeral, a funeral director was
commissioned. His funeral took place on 28 September at the prison. His relatives
were unable to attend due to ill health and distance to travel. The service was open
to staff and prisoners.
A post mortem confirmed that the man died of natural causes with contributing
factors of metastatic colorectal carcinoma and bilateral basal pneumonia.
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ISSUES
Clinical Review – the man’s medical care
A review of the man’s medical care, from the onset of his illness to his death, was
carried out by a review panel. The panel was led by the Commissioning and
Development Manager for South Hams and West Devon Primary Care Trust (PCT).
The panel took into account:
· The appropriateness of the care and treatment provided for the man.
· The identification of any specific strengths or weaknesses in his care.
· Whether the NHS and Prison Service policies were followed.
· The examination of factors that may have contributed to the man’s untimely
death.
· Any recommendations and learning for the improvement of care for other
prisoners.
The panel noted that the man died as a consequence of metastatic bowel cancer.
This condition had been jointly monitored and appropriately treated pallatively, by his
oncologist, pain management specialist and doctor, during the time leading to his
death. He was also supported by Macmillan Nurses who visited the prison.
The Clincial Reviewer offers the following observation from his clinical review:
“During the early stages of his illness, there may have been some delay in the
patient presenting his condition being fully investigated and diagnosed. This
was not due to his clinical management within the prison, but likely due to
unremarkable earlier results to investigations at out­patients and the delayed
colonoscopy investigation. It would be speculative to determine whether this
would have had a material effect on his prognosis. However, the two week
wait standard for referrals of suspected cancers was in place within the prison
and would expedite referral and full investigation today.”
The Clinical Reviewer comments that:
“Communication between those involved in the man’s care was assessed as
excellent. The man was unable to be considered for compassionate release
given the rapid progression of his illness. He refused to be transferred to
Exeter where he could have received 24 hour nursing care. However, the
healthcare staff attended the man daily, monitored his condition and took
appropriate action during his last stages of life.”
The clinical review identified eight recommendations for service improvement and
three areas of good practice, all of which I accept in full.
· The chronologies of the medical notes were poorly maintained and would have
benefited from a summary sheet. Notes, investigations and letters should be kept
in specific sections allowing easier reference.
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· Medical record entries should be legible, with a legible signature and designation
recorded.
· Evidence of multi­disciplinary review and care planning of patients with terminal
illness should be maintained in the patient record, especially determining a
planned and prepared response when the patient is dying.
· Equipment for supporting a dying patient within the community should be
immediately available to prisoners from the joint loan store and not be subject of
delay through local purchasing.
· Where appropriate, consideration should be given (and documented as early as
possible) to a compassionate release as part of a considered multi­disciplinary
plan to manage a prisoner with terminal illness.
· For completeness, visiting practitioners should either make an entry or have their
visit recorded in the prison patient record.
· A review should be undertaken of the protocol/policy for the administration and
monitoring of anti­coagulant therapy.
Good Practice:
· Excellent and timely telephone communication was maintained between the
prison medical officer, the oncologist and pain management specialist supporting
the management of the man’s care in the latter stages.
· The involvement of Macmillan Nurses should be regarded as a positive support
for both the patient and healthcare staff, providing equity with what may be
experienced in the community.
· The man’s wishes to remain in prison were totally respected, and appropriate
care was provided under difficult circumstances and constraints.
The man’s care at Dartmoor
I judge that the man was well looked after by staff at Dartmoor, especially by
healthcare and prison staff on the wing. The support, care and assistance they
offered allowed him to remain at Dartmoor, in accordance with his wishes.
When she spoke to my investigator by telephone, the chair of the IMB commended
the officers on the wing for the way in which they cared for the man. My investigator
came to a similar view.
The way in which prison staff and healthcare staff on F wing cared for and
supported the man was a model of good practice.
An application for compassionate discharge was in the process of being put together
when the man died. The application was ready on 23 August but not submitted as
the prison was still waiting for Probation Service contact. The application noted that
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his offences and medical and psychiatric reports indicated that a discharge might not
have been appropriate even though he was so ill. Information received by the
security department at Dartmoor in August 2006 underpinned the need for an in
depth review of the man’s eligibility for compassionate discharge. In addition, a
Parole Board Review held on 6 June 2006 recorded that the man was not suitable
for release or for a transfer to open conditions. The panel was aware of his illness at
the time of the Review.
A member of the chaplaincy teamvisited the man during the last few months of his
illness. He offered him spiritual support and comfort. The Chaplaincy member
produced an excellent log of events following the man’s death. It chronologically
recorded contact details and events up to the final arrangements for his funeral. The
chaplaincy member officiated with the chaplain at the man’s funeral.
The support the member of chaplaincy gave to the man during his illness and
his actions following his death demonstrate good practice.
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RECOMMENDATIONS
1. The chronologies of the medical notes were poorly maintained and would
benefit from a summary sheet. Notes, investigations and letters should be
kept in specific sections allowing easier reference.
Accepted ­ Some prisoners have been in the system for a long while and are still
using old style medical records. These records to be identified and updated to new
versions.
2. Medical record entries should be legible, with a legible signature and
designation recorded.
Accepted – Re­enforce the need for clear signed entries. Internal memo to be sent
to all nursing staff. Regular reminder via staff briefings, minutes to be noted.
Review commissioned to look at writing and legibility of records for cluster care.
3. Evidence of multi­disciplinary review and care planning of patients with
terminal illness should be maintained in the patient record, especially
determining a planned and prepared response when the patient is dying.
Accepted – Prisoners identified with a serious or terminal illness will be monitored
and their care pathways identified via the creation of a new proforma held and kept
within the prisoner IMR. This form will be up­dated by Healthcare and other medical
professionals in light of new treatment or information. This proforma will remain in
place until it is replaced by NHS IT software.
4. Equipment for supporting a dying patient within the community should be
immediately available to prisoners from the joint loan store and not be
subject of delay through local purchasing.
Accepted – Single point reference document listing agencies/departments that carry
equipment (to form part of the Action Care Pathway form)
5. Where appropriate, consideration should be given (and documented as
early as possible) to a compassionate release as part of a considered multi­
disciplinary plan to manage a prisoner with terminal illness.
Accepted – This recommendation was actually being used, but it was no evident in
the IMR. Outcome of Risk Assessment from Security file to action care pathway
form.
6. For completeness, visiting practitioners should either make an entry or
have their visit recorded in the prison patient record.
Accepted – All agencies visiting any prisoner will document IMR. Internal memo to
all nursing staff.
7. A review should be undertaken of the protocol/policy for the administration
and monitoring of anti­coagulant therapy.
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Accepted – Clinical Review to be carried out and policy/protocol renewed.
Good Practice
1. Excellent and timely telephone communication was maintained between the
prison medical officer, the oncologist and pain management specialist
supporting the management of the man’s care in the latter stages
2. The involvement of Macmillan Nurses should be regarded as a positive
support for both the patient and healthcare staff, providing equity with what
may be experienced in the community.
3. The man’s wishes to remain in prison were totally respected, and
appropriate care was provided under difficult circumstances and
constraints.
4. The way in which staff and healthcare staff on the wing cared for and
supported the man was a model of good practice.
5. The support the member of chaplaincy gave to the man during his illness
and his actions following his death demonstrate good practice.
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