Wolten, Alan

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Alan Wolten,
a prisoner at HMP Liverpool,
on 10 November 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2024
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Summary
1. The Prisons and Probation Ombudsman aims to make a significant contribution to
safer, fairer custody and community supervision. One of the most important ways in
which we work towards that aim is by carrying out independent investigations into
deaths, due to any cause, of prisoners, young people in detention, residents of
approved premises and detainees in immigration centres.
2. If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate,
our recommendations should be focused, evidenced and viable. This is especially
the case if there is evidence of systemic failure.
3. Mr Alan Wolten died in hospital of oesophageal cancer on 10 November 2023,
while a prisoner at HMP Liverpool. He was 86 years old. We offer our condolences
to Mr Wolten’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Wolten received at HMP
Liverpool was of a reasonable standard and was partially equivalent to that which
he could have expected to receive in the community. They concluded that his
mental health and psychiatry care exceeded that which could have been expected
in a community setting.
5. However, the care in relation to falls management was not in line with national
guidelines and there was no evidence that an advance care plan was discussed
with Mr Wolten.
6. The clinical reviewer made one recommendation about Mr Wolten’s end-of-life care.
She made a further five recommendations about matters not directly related to Mr
Wolten’s death but which the Head of Healthcare at HMP Liverpool will want to
address.
7. We found that the family liaison officer did not have any contact with Mr Wolten’s
family before he died. Despite Mr Wolten’s health deteriorating on 9 October 2023,
the prison did not inform his family of his condition. They were not notified until the
hospital told them on 24 October.
Recommendations
• The Head of Healthcare should ensure that end-of-life care planning is held with
terminally ill prisoners, including discussing DNACPR, and involving family
members, where relevant.
• The Governor should review the family liaison process and assure themselves that
when a prisoner becomes seriously or terminally ill, timely arrangements are made
for a family liaison officer to be appointed, who will initiate contact with their next of
kin.
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The Investigation Process
8. HMPPS notified us of Mr Wolten’s death on 10 November 2023.
9. NHS England commissioned an independent clinical reviewer to review Mr Wolten’s
clinical care at HMP Liverpool.
10. The PPO investigator investigated the non-clinical issues relating to Mr Wolten’s
care.
11. The PPO family liaison officer wrote to Mr Wolten’s next of kin, his daughter, to
explain the investigation and to ask if she had any matters she wanted us to
consider. She asked for a copy of the report.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
13. Mr Wolten’s family received a copy of the draft report. They did not make any
comments.
Previous deaths at HMP Liverpool
14. Mr Wolten was the nineteenth prisoner to die at HMP Liverpool since 10 November
2020. Of the previous deaths, twelve were from natural causes, four were self-
inflicted, one was drug-related, and one was unascertained. We have made
previous recommendations about the need for the next of kin to be informed
promptly when a prisoner becomes seriously or terminally ill and that the family
liaison officer supports families before and after a prisoner’s death. We have also
previously recommended that Liverpool should have more effective oversight of the
work of family liaison officers so that the role can be reallocated promptly when
needed.
15. Liverpool agreed to implement these recommendations. They told us that next of
kin information is tracked through weekly performance meetings, and all prisoners
who become seriously or terminally ill are assigned a family liaison officer who will
inform family members at the earliest opportunity. Liverpool acknowledged that they
had a low number of trained family liaison officers, and told us that as of June 2022,
they had two more in post. In addition, Liverpool told us that family liaison officers
were assigned by the Safer Custody team who track progress.
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Key Events
16. On 25 April 2018, Mr Alan Wolten was sentenced to fourteen years in prison for
sexual offences and sent to HMP Liverpool. His diagnosis of dementia was noted
during his initial reception health screen.
17. On 18 April 2019, Mr Wolten was diagnosed with lung cancer while in hospital.
18. On 14 May, Mr Wolten told his offender supervisor that he had declined
chemotherapy as he felt it would negatively impact on his quality of life considering
his age.
19. On 21 August, Mr Wolten attended a hospital appointment to discuss his diagnosis.
A hospital doctor told him that he would have an appointment in around four weeks
to discuss surgery for his lung tumour. They also told Mr Wolten that the cancer
was not aggressive.
20. On 5 November, Mr Wolten attended a hospital appointment. He decided not to
have an operation for his lung tumour and opted for radiotherapy instead.
21. On 7 November, a nurse put Mr Wolten’s radiotherapy care plan in place. He was
scheduled to attend hospital daily (Monday to Friday) for four weeks. She offered to
move him to the healthcare unit, but he declined.
22. On 1 November 2020, Mr Wolten received a clear computerised tomography (CT)
scan. It was agreed that he would have a scan for lung cancer every six months.
23. Mr Wolten attended hospital throughout 2021 and 2022 for appointments with the
urology department (which treat disorders of the kidneys, ureter, bladder, prostate
and male reproductive organs).
24. On 9 December 2022, a GP operating at Liverpool made an entry in Mr Wolten’s
medical record noting that Mr Wolten’s health remained remarkably stable, and his
previous diagnosis of lung cancer had not shown progression on his CT scan
results. She identified that Mr Wolten was at risk of falls, his cancer reoccurring, his
physical health deteriorating and his dementia progressing.
25. On 17 January 2023, healthcare staff told a prison GP that they had noticed a
general deterioration in Mr Wolten and he was appearing more confused.
26. On 5 October, a nurse asked for a doctor to see Mr Wolten due to symptoms of
dysphagia (problems swallowing), vomiting, constipation, a distended abdomen and
poor communication.
27. On 6 October, a GP operating at Liverpool reviewed Mr Wolten and carried out a
full physical examination. He noted Mr Wolten’s frailty, hearing impairment and
dementia diagnosis. He noted that he would not be surprised if Mr Wolten passed
away in the next 12 months but he was not actively dying at present. (There is no
evidence that the cancer had returned at this stage.)
28. On 9 October, when nursing staff saw Mr Wolten to give him his medication, he
appeared more confused, and he declined his medication. They arranged for an
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urgent GP review. A GP saw Mr Wolten and noted that he was more alert and
rousable. He subsequently took his medication. A nurse discussed arranging a
palliative assessment with a colleague due to Mr Wolten’s recent deterioration.
29. On 10 October, healthcare staff agreed that Mr Wolten should be sent to A&E
because of his general deterioration, vomiting and risk of dehydration. An
ambulance was called at 10.15am and paramedics took over his care at 11.00am.
Mr Wolten was not restrained during this escort because he was frail and could not
walk well.
30. On 16 October, hospital staff informed a prison nurse that Mr Wolten had an
oesophageal stricture (a narrowing of the food pipe which can restrict the passage
of food through to the stomach) and was being fed through a nasogastric tube.
31. On 23 October, a hospital nurse told a prison nurse that Mr Wolten had a soft
thickening of the oesophagus and was on an intravenous line for aspiration
pneumonia (which occurs when food or liquid is breathed into the airways or lungs,
instead of being swallowed). They said that Mr Wolten was very unwell and may not
survive. A palliative care plan was put in place for him.
32. On 24 October, an officer was allocated as Mr Wolten’s family liaison officer.
33. On 25 October, the hospital told healthcare staff that Mr Wolten was nearing the
end of his life and was likely to pass away within seven days. They said that his
daughter had been informed of his hospital admission and a do not attempt
cardiopulmonary resuscitation (DNACPR) instruction had been put in place.
34. On 27 October, Mr Wolten’s Prison Offender Manager started Mr Wolten’s
application for early release on compassionate grounds. She tried to secure
accommodation for Mr Wolten, but he passed away before the application could be
finalised.
35. On 31 October, hospital staff told a prison nurse that as Mr Wolten’s condition had
stabilised and he did not need palliative medication or a syringe driver (a device
which administers a continuous supply of medication), they wanted to discharge
him to Liverpool’s care and refer him to the community palliative team. The nurse
told the hospital that they did not currently have any inpatient beds available.
36. On 7 November, hospital staff told a prison nurse that a syringe driver had been put
in place and Mr Wolten was being managed by the palliative care team. The
hospital said that in light of this, Mr Wolten would not be returning to Liverpool but
may be eligible for a hospice bed.
37. At approximately 1.30am on 10 November, Mr Wolten died in hospital.
Post-mortem report
38. The post-mortem report concluded that Mr Wolten died of oesophageal cancer.
39. At an inquest held on 14 November 2023, the Coroner concluded that Mr Wolten
died of natural causes.
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Findings
Clinical Findings
40. The clinical reviewer concluded that the clinical care Mr Wolten received at HMP
Liverpool was partially equivalent to that which he could have expected to receive in
the community. The clinical reviewer stated that the healthcare he received from the
mental health and psychiatry team exceeded that which he could have expected to
receive in a community setting. There was good practice in the high standard of
care for Mr Wolten’s dementia, the high level of input from healthcare staff in
discussions about his care and the high level of social care input which was
appropriately tailored to Mr Wolten’s needs and deteriorating health.
41. However, she noted that the care in relation to falls management and prevention
was not in line with national guidelines.
42. The clinical reviewer also found that despite Mr Wolten’s age, frailty and cancer
diagnosis, there was no evidence that a discussion had taken place in relation to his
advance care planning or whether he wanted to be resuscitated if his heart or
breathing stopped. She stated that people approaching the end of their lives should
be offered comprehensive, holistic assessments so that a personalised care plan is
developed to meet their changing needs and preferences.
43. The General Medical Council’s definition of end-of-life care is that people are
‘approaching the end of life’ when they are likely to die within the next 12 months.
We recognise that a GP at the prison noted on 6 October – just over a month before
Mr Wolten died - that “he wouldn't be surprised if Mr Wolten passed away in the
next 12 months, but that he was not actively dying at present”. We also note that
nursing staff were prompt in requesting a palliative assessment due to Mr Wolten’s
recent deterioration. However, given his age, poor health and deteriorating
condition, the advance care planning process should have been discussed with him
and started sooner. This may have resulted in healthcare staff identifying earlier
that he was reaching the end of his life and allowed them to put in place palliative
care. We make the following recommendation:
The Head of Healthcare should ensure that end-of-life care planning is held
with terminally ill prisoners, including discussing DNACPR, and involving
family members where relevant.
44. The clinical reviewer also made five recommendations about matters not directly
affecting Mr Wolten’s death, which the Head of Healthcare at HMP Liverpool will
want to address.
Liaison with Mr Wolten’s family
45. Prison Service Instruction (PSI) 64/2011 on safer custody states that prisons must
have arrangements in place for an appropriate member of staff to engage with the
next of kin of prisoners who are either terminally or seriously ill.
46. Mr Wolten should have been assigned a family liaison officer on 9 October 2023,
when his health deteriorated, and nurses discussed a palliative assessment. Mr
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Wolten was then admitted to hospital on 10 October. Liverpool should have initiated
contact with Mr Wolten’s family to notify them of his condition and his hospital
admission.
47. Although an officer was appointed as Mr Wolten’s family liaison on 24 October,
there is no record that she contacted Mr Wolten’s family before he died on 10
November.
48. The officer told us that when she was appointed, she was completing a family
liaison training course so was not available to carry out her family liaison role. She
said that she was then on annual leave until 6 November. On return from leave, she
tried to get an update from the bed watch officers, who told her that Mr Wolten had
received a visit from his family on 27 October and 1 November. However, she did
not contact Mr Wolten’s family.
49. Having been notified of Mr Wolten’s death on 10 November, the officer asked for a
family liaison officer from another prison to visit and break the news in person to Mr
Wolten’s next of kin.
50. The officer’s first contacted Mr Wolten’s next of kin by email on 12 November to
introduce herself as their family liaison officer.
51. Given that we have raised issues about family liaison previously, and Liverpool
assured us that improvements had been made, we make the following
recommendation:
The Governor should review the family liaison process and assure
themselves that when a prisoner becomes seriously or terminally ill, timely
arrangements are made for a family liaison officer to be appointed, who will
initiate contact with their next of kin.
Adrian Usher
Prisons and Probation Ombudsman May 2024
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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