Individual at Bullingdon

Investigation into the death of a man in October 2007
following his release on temporary licence
from HMP Bullingdon
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2008
This is the report of an investigation into the death of a man who was a
prisoner at HMP Bullingdon. The man died in October 2007 at a hospice in
Oxfordshire, with his mother at his side. I offer my sincere sympathy and
condolences to the man’s mother, and to all of those affected by the loss of
her son.
The man had been diagnosed with cancer around five months before his
death. He died shortly after being released on temporary licence. A post
mortem examination was not carried out, as the Coroner’s office was not
informed of the man’s death.
This investigation was carried out on my behalf by one of my colleagues. An
independent review of the man’s medical care in prison was carried out by the
Oxfordshire Primary Care Trust. I am most grateful to the clinical reviewer for
his assistance.
I would also like to thank the Governor and staff at Bullingdon for their full and
ready co-operation during the course of the investigation. I am especially
obliged to the Deputy Governor for the liaison that he provided.
The man died shortly after an application for his compassionate release was
turned down by the Ministry of Justice. I make four recommendations and
highlight three examples of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2008
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CONTENTS
Summary 4
The investigation process 5
HMP Bullingdon 6
Key findings 7
Issues 13
Recommendations 16
3
SUMMARY
The man who is the subject of this report was received into HMP Bullingdon
on 16 May 2007, having been arrested by his local police force on the same
day. He had been released on licence from HMP Usk the previous year, and
the licence was revoked following his arrest. On the same day as his arrest,
the man had been discharged from a local hospital, where he had been
diagnosed with suspected penile cancer.
The man attended an outpatients appointment at a different hospital on 22
May, at which the diagnosis was confirmed. He was admitted to this hospital
on 10 June, and a penectomy (surgical removal of the penis) was performed
the following day. The man developed an infection in his wound following the
operation, and this was treated by antibiotics. Other than this he was as well
as could be expected, and he did not complain of any pain. However, on 6
August 2007, he was urgently admitted to the hospital with suspected
methicillin-resistant staphylococcus aureus (commonly known as MRSA).
This was confirmed on 13 August, and the man remained in hospital until the
end of the month for treatment.
In the days following his return to Bullingdon, the man reported that his left leg
was swollen and slightly painful. He was still mobile, however, and able to
walk around the healthcare centre (where he was now living permanently as
an inpatient). On 20 September, he was reviewed by a prison doctor, who
noted that the man’s left thigh was red, hot to the touch and painful. The
prison doctor arranged for the man to be admitted to hospital that day.
The man did not return to Bullingdon following this admission. A
computerised tomography (CT) scan on 3 October showed that the cancer
was now so widespread that chemotherapy was inappropriate.
On 15 October, the man moved to a hospice in Oxfordshire. An application
for early release on compassionate grounds, which had been signed by the
Deputy Governor on 11 October, was refused by the Ministry of Justice on 17
October. The reasons for the refusal were that the prognosis was uncertain
and there was a risk that the man would re-offend were he to be released.
Following this refusal, an application for release on temporary licence was
approved by the Governor on the morning of 23 October. Sadly, the man died
just a few hours later, at 2.15pm, with his mother at his side.
The man suffered from a rare and unpleasant form of cancer. The clinical
reviewer concludes he received sensitive and appropriate care from
healthcare staff at Bullingdon. He does raise concerns about a three week
period in July 2007 in which it appears the man was not reviewed by a prison
doctor or nurse. However, he goes on to say that “there is no evidence that
any harm resulted”.
I make four recommendations, and highlight three areas of good practice.
4
THE INVESTIGATION PROCESS
1. The investigation was opened on 25 October 2007, when my investigator
issued notices announcing the investigation to staff and to prisoners. The
notices included an invitation to those who wished to submit information
relating to the man’s death to make themselves known to my investigator.
No prisoners came forward as a result.
2. My investigator was given access to the man’s prison files, including the
medical record. He visited Bullingdon on 12 February 2008, and
interviewed one member of staff during the course of the investigation. An
independent clinical review of the man’s health needs whilst he was in
custody was carried out by the Clinical Governance Lead at Oxfordshire
Primary Care Trust.
3. My senior family liaison officer contacted the man’s mother on 15
November 2007. She said that she had found the prison to be very helpful
and had no issues that she wished the investigation to address. She
spoke particularly of a prison nurse who visited the man in hospital with
the prison’s family liaison officer, and of whom he was fond. She asked
that the nurse be recognised in the report. The man’s mother also asked
that the prison’s family liaison officer be recognised for the help that she
provided.
The kind and respectful way in which healthcare staff and the family
liaison officer liaised with the man and his mother during the last
weeks of his life should be formally recognised.
5
HMP BULLINGDON
4. HMP Bullingdon is located near the town of Bicester, Oxfordshire. It is a
modern prison, accommodating up to 963 prisoners. There are five wings,
made up of both single and shared cell accommodation. The majority of
prisoners are category C, although some category B prisoners are
received from the local courts.
5. Bullingdon has a 22-bed inpatients facility, with clinical care available at all
times. The outpatients facility delivers a daily triage (assessment) system,
referring prisoners to a doctor as necessary. Medication is also dispensed
from the facility. A doctor is available for prisoners every weekday, and
there is an on-call system at weekends and out of hours.
6. Her Majesty’s Chief Inspector of Prisons, Ms Anne Owers, carried out an
unannounced inspection of Bullingdon in 2004. She found a prison that
had “visibly improved” since an inspection that had taken place two years
earlier.
7. Many of the recommendations that Ms Owers had made regarding
healthcare in the earlier inspection had been achieved or partially
achieved. Notably, Ms Owers said that the regime in healthcare had
improved. However, Ms Owers expressed concern about the length of the
waiting list to see a doctor (this was two weeks at the time). She
recommended an urgent review to address the situation.
8. This is the eleventh death to have occurred at Bullingdon since April 2004,
when I began investigating all deaths in prison custody, and the seventh to
have been due to natural causes. Although some also involved patients
suffering from terminal cancer, there are few similarities in the issues
raised in those cases to that of the man.
6
KEY FINDINGS
9. On 14 May 2007, the man was admitted to his local hospital with a
fungating penile lesion (a growth on the penis). He was given a likely
diagnosis of penile cancer.
10. The man was discharged from on 16 May. On the same day, he was
arrested by the local police for a similar offence to those for which he
had previously been imprisoned. His licence was revoked and the man
was received into HMP Bullingdon that day.
11. The man was seen by a Healthcare Officer (HCO) on 16 May 2007,
following his arrival at Bullingdon. The HCO completed a first reception
health screen (a routine health screen for all new arrivals into prison) at
which the man spoke of no health concerns other than his recent
diagnosis. The man said that he was anxious about his medical
condition, but was otherwise okay. The HCO admitted him to the
healthcare centre overnight, for observation.
12. On the following morning, the man was seen by a Staff Nurse. He spoke
of a family history of heart disease, and they discussed the probable
diagnosis that he had been given. The nurse referred the man to a
prison doctor and he was subsequently seen that afternoon.
13. The man told the prison doctor that he had first noticed the penile lesion
around six months previously. He was taking antibiotics and the doctor
renewed his prescription. She also passed the man as being fit for
ordinary location. He subsequently moved from healthcare to a cell on E
wing.
14. On 22 May, the man attended an outpatients appointment at a local
hospital. A diagnosis of penile cancer and suspected lymph nodes
(small organs that can trap cancer cells travelling through the body) was
confirmed. The man was told that he would have to undergo a
penectomy (surgical removal of the penis) on a date yet to be confirmed.
15. The man was scheduled for a review with a prison doctor on 24 May, but
did not attend. On 29 May, he was admitted as an inpatient to the local
hospital for a penile biopsy. The man was discharged on 31 May and
admitted to the healthcare centre on his return on account of a wound to
his penis that had resulted from the biopsy. He was seen by a prison
doctor on his return and the wound was assessed.
16. The prison doctor saw the man again the following day, and passed him
fit to return to E wing. The man said that he was able to dress his own
wounds, and that his pain control (he was taking paracetamol and
ibuprofen) was adequate.
17. On 10 June, the man was again admitted to the local hospital as an
inpatient. A penectomy was performed on 11 June, and the man was
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discharged to Bullingdon on 14 June. He was admitted to the healthcare
centre on his return, for observation.
18. The man saw the prison doctor on the following day, and said that he
was feeling well. The prison doctor assessed him as being fit to return to
E wing, but the man remained as an inpatient until 18 June as there was
no room on the wing.
19. The man returned to the local hospital on 21 June in preparation for a
bilateral inguinal node dissection (an operation to examine the lymph
nodes in the groin) scheduled for the following day. However, the
operation was cancelled due to an infection in the man’s wound, and he
therefore returned to Bullingdon’s healthcare on 26 June. He was
prescribed a course of antibiotics to fight the infection.
20. The man’s wound was assessed by a Staff Nurse on 28 June. She
noted that it still looked to be infected. The nurse advised the man to
make sure that he kept the wound dry most of the time. On 3 July, the
man was assessed by a prison doctor and passed as fit to return to E
wing. Again, however, there was no room on the wing, and the man
therefore stayed in healthcare until 8 July.
21. On 23 July, the man was admitted as an inpatient to the local hospital.
The procedure that had previously been postponed went ahead on 24
July, and the man was discharged on 3 August. On his return to
Bullingdon he was again admitted to the healthcare centre as an
inpatient, and was reviewed by a prison doctor.
22. The man was seen again by the prison doctor on 4 August, and said that
he was feeling well and was not in pain. The doctor saw him again on
the following day and noted that the man’s wound was infected,
reddened and painful. He prescribed a course of antibiotics.
23. The infection did not improve, however, and the wound on the man’s
groin was noted on 6 August to be very inflamed and firm to the touch.
The prison doctor suspected methicillin-resistant staphylococcus aureus
(commonly known as MRSA). He arranged an urgent admission to the
local hospital for tests and the man was admitted on the same day. He
was accompanied by two officers and cuffed to one by means of an
escort chain (a long chain with a handcuff at both ends).
24. A Staff Nurse from Bullingdon visited the man at the local hospital on 9
August. He said that he was feeling well, apart from some discomfort to
his wound. The nurse noted that the man was receiving intravenous
antibiotics and daily dressings. She spoke to the Senior House Officer,
who confirmed that they had been able to drain a lot of fluid from the
man’s wound and were hopeful that the antibiotics would prevent the
need for further surgery. The Senior House Officer added that they
were, at that stage, unsure of the man’s prognosis.
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25. On 13 August, it was confirmed that the man was MRSA positive. He
therefore remained at the hospital until the end of the month for
treatment. The man’s cuffs were removed on 16 August, following a risk
assessment.
26. On his return to Bullingdon on 30 August, the man was again admitted to
the healthcare centre as an inpatient. He was reviewed by a prison
doctor on 31 August, and told him that he was feeling better and had no
pain. The doctor noted that the man’s left leg was swollen. At his next
review, on 2 September, the doctor noted that the leg was still swollen
but not painful. However, on 3 September, the man said that his leg was
now slightly painful. He was given paracetamol.
27. The man’s wound was cleaned and dressed by nursing staff every day.
He developed a cough and sore throat for a few days from 8 September,
but otherwise his condition was stable. The man was still mobile, and
able to walk around healthcare and carry out tasks such as collecting his
own meals.
28. On 20 September, the man was seen in the morning by a Staff Nurse.
The man told her that he had been getting hot flushes at night, and the
nurse noted that his left thigh was red and hot to touch. She referred
him to the prison doctor who saw the man later that morning. The doctor
noted that the man’s left thigh was painful, and arranged for him to be
admitted to the local hospital.
29. The man arrived at hospital on the same day and was admitted as an
inpatient. He was accompanied by two prison officers and cuffed to one
by means of an escort chain. The escort was reduced to one officer on
21 September, and the chain was removed on 23 September at the
request of an unidentified residential governor.
30. Healthcare staff at Bullingdon were in telephone contact with the man’s
ward every few days for updates on his progress. On 3 October he had
a CT scan, the results of which indicated that the lymph nodes were
enlarged and that cancer was widespread within the nodes. A
Bullingdon nurse, who telephoned the ward on 4 October, was told that
the man had been given a prognosis of around one month. This was
disputed, however, on the following day when the man was visited by the
Head of Healthcare. The Head of Healthcare was told by the senior
registrar that the man’s life expectancy was indeterminate and that he
was unaware that anyone had given a prognosis of one month. It was
also revealed that the man had a deep vein thrombosis (DVT, a clot that
forms when the flow of blood is restricted in a vein). Despite this news,
the man was in good spirits, and looking forward to a visit from his
mother that afternoon.
31. On 10 October, it was noted that the man was refusing all pain relief. He
also had a cough which was getting worse. On the same day, the
oncologist (cancer specialist) reviewed the man’s CT scan and decided
9
against chemotherapy due to the widespread disease. A cancer care
nurse discussed with a Staff Nurse from Bullingdon the possibility of the
man moving to a hospice. She spoke about this to the Head of
Healthcare, who felt that it was an appropriate move and agreed to
speak to the Deputy Governor about the possibility. On the following
day, it was agreed that the man would move to a hospice in Oxfordshire
on 15 October.
32. An application for early release on compassionate grounds was
completed at Bullingdon on 11 October 2007. It was faxed to the Pre
Release Section (PRS) of the Ministry of Justice on the same day. The
application form includes a section to be completed by the prison’s
Medical Officer. The prison doctor who completed the section wrote
that:
“The man has been suffering from penile cancer. The cancer was
diagnosed a few months ago. He had an operation in a local hospital.
At present the cancer is widespread, therefore he is terminally ill. The
oncologist has reviewed his CT scan and does not give him
chemotherapy or radiotherapy. He is symptomatic with shortness of
breath and cough. The palliative care team are now involved in his
treatment. In my opinion the man should be transferred to a hospice.”
33. The form also contained a section asking for the Medical Officer’s
prognosis. The prison doctor wrote that the prognosis was “bad”.
34. The application for early release on compassionate grounds also
includes a section to be completed by the prison’s probation officer. It
was completed by the Public Protection Probation Officer, on 10
October. On the grounds of the man’s offending behaviour, she
concluded that:
“In the event of a release, suitable resettlement arrangements would
have to include an element of frequent, if not constant, supervision … I
cannot support early release on compassionate grounds.”
35. The final section of the application was completed by the Deputy
Governor on 11 October. He noted that he considered the man’s risk to
be “minimal”, and concluded:
“Considering the medical condition with death likely within 14 days and
the location within a hospice balanced against nature of offending, I
would recommend early release.”
36. An HCO spoke to staff on the man’s ward on 12 October, and was told
that he was still mobile and not complaining of pain. As arranged, the
man moved to the hospice on 15 October. He was still accompanied by
one officer, but not cuffed.
10
37. The man was visited by a Staff Nurse from Bullingdon and the prison’s
family liaison officer on 16 October. The nurse noted that the man
appeared to be relaxed and comfortable. His mobility was impaired by
his shortness of breath, but the man was still able to walk to his en suite
toilet. The nurse added that the man seemed to be in denial about his
prognosis.
38. On 17 October, the application for early release on compassionate
grounds was refused by PRS for two reasons. First, advice from the
Department of Health was that the prognosis given was “uncertain” and
“not expressed authoritatively”. Secondly, given the advice in the
probation officer’s report and the man’s offending history, PRS
considered that there remained a significant risk of re-offending.
39. Following the refusal of the man’s application for early release, the
possibility of release on temporary licence was discussed on 19 October.
The man was also offered the opportunity of having his property brought
to the hospice so that he could give it to his mother. He accepted this
offer.
The man was given the opportunity personally to hand over his
property to his mother in the last few days of his life.
40. On 21 October, the man’s condition deteriorated. He was more
frequently out of breath and his cough got worse. He tried to remain
independent by walking to the bathroom by himself, but was able to do
so less often. On 22 October, the man’s deterioration was described as
“rapid”. His mobility was now poor and he was only able to sit on his
chair.
41. On the morning of 23 October, a second application for early release on
compassionate grounds was initiated. A prognosis obtained from the the
hospice, which said that the man was unlikely to live for more than two to
three days, was faxed to PRS. They then prepared a submission to
Ministers advocating the man’s release.
42. In the meantime, the man was released on temporary licence by the
Governor. His escort remained at one officer, but the officer was asked
to sit outside the room. The man was visited that morning by the
prison’s family liaison officer and a Staff Nurse. He was now restricted
to bed and was very short of breath. The man died at 2.15pm, with his
mother at his side. Sadly, this was before his release on compassionate
grounds could be approved.
Following his release on temporary licence, the officer
accompanying the man was asked to sit outside his room at the
hospice. This allowed the man and his mother to spend time alone
together before his death.
11
43. A post mortem examination was not carried out, as the Coroner was not
informed of the man’s death by prison staff. His funeral was held on 31
October. In arranging the funeral, the prison acted appropriately in
accordance with Prison Service Order 2710, the Prison Service
guidelines for dealing with a death in custody.
12
ISSUES
Issues raised by the clinical review
44. The clinical review was conducted by the Clinical Governance Lead at
Oxfordshire Primary Care Trust. He comments that the man suffered
from a “rare and particularly unpleasant form of cancer”. He goes on to
say that the man’s care at Bullingdon “appears to have been sensitive,
appropriate, caring and professional”, and that the man was “speedily
readmitted” when he needed more intensive hospital treatment. I agree.
45. The clinical reviewer also notes that:
“More detailed medical records would have been helpful in carrying out
this review, but there is no evidence this would have improved the level
of care the man received and nothing to suggest it was substandard.”
46. There is no evidence in the man’s medical record of him receiving a
doctor’s or nursing review from 3 July 2007 until he was admitted to
hospital three weeks later on 23 July. The man was an inpatient in the
healthcare centre for a short time during this period until a bed was
found for him on E wing. My investigator spoke to a prison doctor at
Bullingdon who had reviewed the man regularly. The doctor recalled
that the man was taking antibiotics at the time because of his infection,
but that he was physically fine.
47. The clinical reviewer writes as follows:
“There is nothing to suggest this was a period when he needed any
specific care, but in the light of the attention paid to him at other times it
seems strange that no reviews of his condition took place between
these dates. If there was no contact there is no evidence that any
harm resulted, although the man would undoubtedly have benefited
from the support.”
The Head of Healthcare should ensure that procedures are in place to
guarantee that all patients suffering from a potentially terminal
illness are reviewed regularly by a nurse or doctor.
Compassionate release
48. Chapter 12 of Prison Service Order 6000 sets out the following criteria
for compassionate release on medical grounds:
(cid:127) the prisoner is suffering from a terminal illness and death is likely to
occur soon; or the prisoner is bedridden or similarly incapacitated; and
(cid:127) the risk of re-offending is past; and
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(cid:127) there are adequate arrangements for the prisoner’s care and treatment
outside prison; and
(cid:127) early release will bring some significant benefit to the prisoner or
his/her family.
49. As I have discussed in paragraphs 35-38 and 41, the Governor
submitted an application for early release on compassionate grounds on
11 October 2007. The application was refused by the Ministry of Justice
on 17 October because of an uncertain prognosis and a significant risk
that the man would re-offend were he to be released. Given the content
of the probation officer’s report of 10 October, I consider that this was
not an unreasonable decision. However, it was manifestly a risk-averse
decision that paid relatively little heed to the operation the man had
undergone, the terminal nature of his illness, and the fact that (by the
time the decision was made) he had already been transferred to a
hospice. A decision to have agreed the application would not have been
unreasonable either.
50. I am, however, pleased to note that the Pre Release Section were
advocating the man’s release following the second referral on 23
October 2007. Sadly, he died before the application could be approved
by Ministers.
A copy of this report should be sent to the head of the Pre Release
Section for his consideration.
51. The prison doctor who my investigator interviewed completed the section
required of the Medical Officer in the application. He told my investigator
that this was the first time he had completed such an application, and he
was not given any guidance how to complete the form. In the form, the
doctor noted that the man’s prognosis was “bad” but did not provide a
timeframe.
52. PSO 6000, section 12.4.1 says that “it is essential to try to obtain a clear
medical opinion on the likely life expectancy”. It goes on to say, in
section 12.5.1, that “it is essential that an indication of likely life
expectancy is included in the report”.
53. Advice from the Department of Health was that the prognosis given was
“uncertain” and “not expressed authoritatively”. This was one of the
factors for the refusal of the man’s application, although the risk of re-
offending was more significant. Nevertheless, it would be unfortunate if
the success of a future application were to be delayed because further
details of the prognosis had to be sought by the Ministry of Justice.
The Governor should ensure that guidance and advice is available to
the Medical Officer when completing the relevant section of an
application for early release on compassionate grounds.
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Informing the Coroner of the man’s death
54. Following the man’s death on 23 October, the Coroner was not informed
of his death by staff at Bullingdon. This is an important process following
a death in custody, as it is the Coroner who presides over the inquest
into the death and who orders the post mortem. As the Coroner was not
informed of the man’s death, a post mortem examination to determine
the cause of death did not take place.
55. PSO 2710, regarding actions to be taken following a death in custody,
provides a list of those who must be “promptly” notified by telephone.
Second on this list is the Coroner.
56. The Deputy Governor told my investigator that he understood it was the
role of the hospice or the police to inform the Coroner in this case. I note
that the man had been released on temporary licence for around three
hours before his death, and was not therefore technically in custody
when he died. Strictly speaking, it might be considered that PSO 2710
did not apply.
57. However, three hours was a very short time between the man’s release
on temporary licence and his death. I also note that the man was
escorted by a prison officer when he died, as required by his licence
conditions. The Duty Governor was therefore informed of the man’s
death immediately after it occurred.
58. Given these circumstances, I think it would be reasonable to have
expected Bullingdon to have informed the Coroner of the man’s death.
The Coroner would then have been able to make a prompt decision
regarding whether to request a post mortem examination.
The Governor should ensure that all future deaths of prisoners who
have been released on temporary licence are reported promptly to
the Coroner.
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RECOMMENDATIONS
The Head of Healthcare should ensure that procedures are in place to
guarantee that all patients suffering from a potentially terminal illness
are reviewed regularly by a nurse or doctor.
Partially accepted – Procedures to be formalised regarding this area. Some
patients, however, may not wish to participate with such requirements.
A copy of this report should be sent to the head of the Pre Release
Section for his consideration.
Accepted - this should have been referred to the Head of Pre Release Section
as Release and Recall section hasn’t existed since April 2007.
Paragraph 49 - Pre Release Section have said that the criteria for early
release on compassionate grounds clearly state that the risk of re-offending
must be past. Given the high level of concern expressed by the Probation
Service they were not convinced that it had decreased to such a level. In
addition Offender Health did not support the application for early release
either, a key factor being the evident risk of harm/re-offending, despite the
man’s surgery.
The covering page to Pre-Release Section’s refusal notification expressly
invited the Governor to refer the case again if there was any significant
deterioration in the man’s condition. The Governor did so by faxing a
prognosis from the Sue Ryder Hospice Care on 23 October. This stated that
the man would be unlikely to live for amore than another 2-3 days. A
submission to Ministers advocating release was started but very shortly
afterwards the man died.
The Governor should ensure that guidance and advice is available to the
Medical Officer when completing the relevant section of an application
for early release on compassionate grounds.
Accepted – In all cases the Deputy Governor will continue to personally liaise
with the relevant medical practitioners to try to ensure that reports completed
are, where possible, able to provide timescales for life expectancy for
individual patients.
The Governor should ensure that all future deaths of prisoners who
have been released on temporary licence are reported promptly to the
Coroner.
Accepted – Guidance issued within contingency plans to Operational
Managers.
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GOOD PRACTICE
The kind and respectful way in which healthcare staff and the family
liaison officer liaised with the man and his mother during the last weeks
of his life should be formally recognised.
The man was given the opportunity personally to hand over his property
to his mother in the last few days of his life.
Following his release on temporary licence, the officer accompanying
the man was asked to sit outside his room at the hospice. This allowed
the man and his mother to spend time alone together before his death.
17