Individual at Littlehey

Investigation into the circumstances surrounding the
death of a man at HMP Littlehey
in September 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2010
This is the report of an investigation into the death of a man, a prisoner at HMP
Littlehey. He died in September 2009 in hospital. He was 65 years old. He died
nearly three weeks after being released from prison on temporary licence. His early
release was arranged because of his ill health. I offer my sincere sympathy and
condolences to his family and all those affected by his loss.
The man suffered from exacerbated Chronic Obstructive Pulmonary Disease
(COPD), a condition where the airways to the lungs are narrowed, and metastatic
malignant melanoma (skin cancer which has spread throughout the body). A post
mortem examination was not carried out as the Coroner was satisfied that there
were no suspicious circumstances surrounding the death. The inquest concluded he
died due to natural causes.
The investigation was carried out by my colleague and assisted by a fellow
investigator. An independent review of the man’s medical care in custody was
carried out by clinical reviewers on behalf of the local Primary Care Trust. I am most
grateful to them for their assistance.
I would also like to thank the Governor and staff of Littlehey for their full and ready
co-operation during the course of the investigation. I am especially obliged to the
Deputy Governor and the Performance Manager for their help in liaising with my
investigators.
The man had been sentenced to seven and a half years imprisonment at Crown
Court in January 2005. Having initially been in custody at HMP Elmley, HMP
Maidstone and HMP Bullingdon, he was transferred to Littlehey in July 2008. He
had been diagnosed with COPD prior to being sentenced and the condition was
managed throughout his time in custody. In June 2009 he had a malignant
melanoma removed from his back but unfortunately the cancer had spread and his
health subsequently deteriorated.
I make six recommendations. They centre on the initial reception healthscreen and
provision of a wheelchair, the scheduling of hospital appointments by Littlehey and
the potential provision of oxygen at the prison. I also consider the man’s initial
referral to hospital and the subsequent palliative care he received.
Notwithstanding my recommendations, this is a report of which NOMS can be proud.
It is clear that staff showed a great deal of compassion when looking after the man,
and I commend their use of care plans along with the consideration they gave to his
location within the prison. I am also particularly pleased that he was released on
temporary licence at the earliest opportunity, without any restraints but with an officer
escort to provide him with some company in his final days.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2010
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CONTENTS
Summary
The investigation process
HMP Littlehey
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
The man first entered custody on remand at HMP Elmley in September 2004. He
was later convicted of a serious sexual offence and sentenced to seven and a half
years imprisonment. He had therefore been in prison for nearly five years when he
died at hospital in September 2009 at the age of 65.
The man had been diagnosed with Chronic Obstructive Pulmonary Disease (COPD)
around five years before he was remanded into custody and this condition was
managed throughout his time in prison. He had periods during his sentence when
his symptoms deteriorated and he would receive additional medication. He
transferred to HMP Maidstone in 2006, and approximately a year later was provided
with a motorised trolley to assist his movement around the prison. He was also
registered disabled around this time. In November 2007, he transferred to HMP
Bullingdon and eight months later he was moved to Littlehey. On one occasion, he
went to HMP Bedford overnight so that his extreme shortness of breath could be
monitored on a 24 hour basis. He saw a doctor and was discharged back to
Littlehey the following day.
Throughout the man’s time at Littlehey, and following careful consideration from
staff, he remained located on the induction wing, in a shared cell with another
prisoner. Although there was a delay of nearly three months before he was allocated
his own wheelchair, he was allowed to borrow one in the meantime from the
induction wing.
In April 2009, one of the prison doctors examined the man following the discovery of
a large mole on his back which had apparently changed in appearance. He was
immediately referred to hospital where it was confirmed that he had skin cancer.
The malignant melanoma was removed in July.
The man’s condition deteriorated following this operation and he lost weight. For
medical and security reasons, Littlehey staff were unable to prescribe him oxygen to
assist with pain relief, but he was given other medication along with a patch that
slowly released painkillers into his system. He refused to attend two hospital
appointments in the month following his operation, one of which was attended by a
nurse from the prison in his place. In August, he was informed that the cancer had
spread to his lymph glands and the hospital would need to make further
investigations to determine if it had spread any further.
A week later, the man attended a hospital appointment where he was assessed as
having difficulty swallowing, along with severe back pain. The doctor recommended
further investigations to determine the cause but he declined any more appointments
and was therefore discharged from hospital. Back at the prison, in August, his
condition rapidly deteriorated such that an ambulance was called and he was
released on temporary licence to hospital. His condition continued to deteriorate and
he died in the hospital in September. His funeral was held with two Governors in
attendance.
In the course of this investigation I have given consideration to the prison reception
process, including the delay in providing a wheelchair for the man, and I make two
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recommendations in this regard. I have also considered whether the referral process
to the local hospitals is robust and the scheduling of his appointments. I have made
two recommendations in relation to the palliative care he received.
I am also pleased to commend the actions of staff at Littlehey in reviewing
appropriate care plans for the man, demonstrating a sensitivity of judgement in
relation to his location within the prison, and releasing him on temporary licence
without restraints when his condition deteriorated.
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THE INVESTIGATION PROCESS
1. The investigation was opened in September 2009, when the investigator issued
notices announcing the investigation to staff and to prisoners. The notices
included an invitation to those who wished to submit information related to the
man’s death to make themselves known to the investigator. Four members of
staff were subsequently interviewed. No prisoners came forward.
2. The investigator was given access to the man’s prison files, including the medical
record. She later returned to Littlehey with another investigator in October and
interviewed the four members of staff. The Independent Monitoring Board (IMB)
and the Prison Officers’ Association (POA) did not meet with the investigator.
Littlehey has previous experiences of death in custody investigations and is
familiar with all the procedures.
3. An independent clinical review of the man’s health needs whilst he was in
custody was carried out by two clinical reviewers on behalf of the local Primary
Care Trust. One reviewer joined both investigators for the interviews at Littlehey
in October.
4. My Senior Family Liaison Officer wrote to the man’s former partner in October
2009 to advise her of the investigation and invite her to raise any matters she
wished to be addressed. At the time of issuing this report, she had not raised any
issues. I hope that this report helps his family to better understand what
happened in the time leading to his death.
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HMP LITTLEHEY
5. HMP Littlehey is a category C prison for convicted and sentenced adult males.
(On arrival into prison, prisoners are risk assessed and given a category based
on their offence and the risk that they pose to the public should they escape.
Category C prisoners are defined as those who cannot be trusted in open prison
conditions but who would not have the ability or resources to make a determined
escape.)
6. The prison has an operational capacity of 726 adult male offenders, but typically
holds around 690. Littlehey first opened in 1988 with eight residential wings.
Two additional units were added in 1997 and 2003, and in 2010 it will expand to
provide capacity for up to 480 young offenders. Littlehey integrates sex
offenders, who make up 80 per cent of the current population, into the normal
regime of the prison. The prison offers a Sex Offender Treatment Programme as
well as work and education opportunities.
7. Provision of healthcare within the prison is the responsibility of the local Primary
Care Trust (PCT). A general practitioner (GP) service is provided by a local
National Health Service practice six mornings a week. A nursing team works on
site during the day on weekdays and Saturday mornings. At other times, advice
is available through an out of hours service. There are no inpatient beds at
Littlehey.
8. The prison was most recently inspected by HM Chief Inspector of Prisons on an
announced visit in July 2007. In her report, she said:
“This full announced inspection confirmed that Littlehey remained an
impressively safe prison, with mutually respectful staff-prisoner relationships,
a reasonable amount of purposeful activity and an appropriate focus on
resettlement. Littlehey remains an impressive and improving prison, able to
work effectively with some very high risk prisoners. It provides a
fundamentally safe and respectful environment, in which prisoners are
generally occupied purposefully.”
9. Health services were described as adequate, although some waiting lists were
long. The report indicated that, “Despite some good individual care, better
support was also required for Littlehey’s increasing ageing and infirm population.”
10. HM Chief Inspector also thought that the resettlement strategy needed to be
more comprehensive and improved assessments of risks and needs undertaken,
particularly for sex offenders. However, her report noted some impressive
interventions for sex offenders, with public protection being well managed.
11. In a thematic report on older prisoners in England and Wales in June 2008, HM
Chief Inspector commented that Littlehey held over 182 prisoners over the age of
50, but had no long-term strategic plan for dealing with its elderly population.
However, Littlehey was upheld as a good example in terms of the physical
activity and bowling league provided for the over 60s. The prison had also, at the
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time of the inspection, just begun to operate a specific clinic for over 65s,
although its location on an upper floor meant access was difficult for the infirm.
12. An Independent Monitoring Board (IMB) is appointed to each prison by the
Secretary of State for Justice. Its members are wholly independent of the
National Offender Management Service (NOMS) and the prison’s management
team. Each IMB is required to produce an annual report to the Secretary of
State, highlighting good practice and areas of concern.
13. Littlehey’s latest IMB report covers the period February 2008 to January 2009.
The Board considered that Littlehey “continued to be a well run prison providing a
safe and respectful environment for prisoners”. However, they were concerned
that funding for the OAP Unit in the healthcare centre had been refused despite
Littlehey’s relatively high number of older prisoners, and that the post of
disability/elderly officer was not full time. The IMB noted that half of those over
60 are in employment whilst the other half are unassigned and left on the wing.
The gym hosts activities for this group three times a week. The IMB were
disappointed that, whilst a strategy for the elderly has been discussed, it had still
not been formalised: “more could be done, without spending a fortune, to meet
the needs of this growing group”.
14. The Board reported that “healthcare continues to operate well, despite an
increase in the prison population during the period of review, and received a
positive report following an audit conducted by the area team”.
15. The National Offender Management Service is responsible for the management
of prisons in England and Wales. Every three months it publishes an
assessment of each prison’s performance against 34 measures. Prisons can
gain a rating of between one (serious concerns) and four (exceptional
performance). Littlehey has scored a three (good performance) for the last three
quarters, and before this scored a four.
16. The man’s death was the 14th to have occurred at Littlehey since April 2004,
when I began investigating all deaths in prison custody in England and Wales.
All but two of the previous deaths were due to natural causes. My reports into
these previous deaths have generally reflected well on Littlehey. Only one
previous recommendation, in relation to health screening at reception, is relevant
to this report.
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KEY FINDINGS
17. Following his arrest and charge for a sexual offence, the man was remanded into
HMP Elmley in September 2004. He was subsequently convicted at Crown Court
in December. In January 2005, he was sentenced to seven and a half years
imprisonment. Throughout this time he remained at HMP Elmley.
18. The man had suffered ill health and shortness of breath for around five years
before his reception into custody. This was due to Chronic Obstructive
Pulmonary Disease (COPD), whereby the airways to and from the lungs become
narrowed. In January 2005, he had a review with the prison doctor who
prescribed amoxicillin (used to treat bacterial infections) and Becloforte (an
inhaler) in relation to his COPD. In August, the doctor also added salbutamol
(which aids the opening of airways to the lungs) to his prescription.
19. Throughout his time in prison the man was described as being no problem to
staff, attaining enhanced status in March 2005 under the Incentives and Earned
Privileges (IEP) Scheme. (IEP rewards and encourages prisoners’ good
behaviour and has three levels – basic, standard and enhanced. Enhanced is
the highest of the three.)
20. The man completed the Sex Offender Treatment Programme in June 2006 and
transferred to HMP Maidstone two months later. The reception health screen (a
routine health screen for new arrivals into prison) noted his diagnosis of COPD.
In September, he was assessed in healthcare. He was given advice about
stopping smoking and applied for the smoking cessation course.
21. Nearly a year later, in August 2007, the man had a healthcare review in which
staff assessed his shortness of breath. This resulted in a motorised trolley being
obtained for him to assist his mobility round the prison. He was also
subsequently registered disabled.
22. In November 2007, the man moved to HMP Bullingdon. Following assessment,
he continued to be prescribed the same medication and a recommendation for
spirometry (used to measure the severity of lung conditions) was made. It is not
clear from his medical records whether this took place.
23. The man then transferred to Littlehey in July 2008, along with another prisoner
with whom he had become friends at Bullingdon. A Healthcare Officer (HCO)
conducted a reception health screen. Littlehey’s reception health screening form
for prisoners transferring in from another establishment is different to that used in
other prisons. The prisoner is asked various questions about their mental and
physical health. There is no space for the interviewer to ask for, or add, any
additional information, or to record any of the prisoner’s concerns.
24. The man needed a nebuliser (a mist inhaled into the lungs) and staff asked for
him to be assessed by the general practitioner. The doctor explained in interview
that GPs are never present at a reception health screen, and will only see new
prisoners when asked to do so by the reception nurse or healthcare officer.
Alternatively, prisoners can make an application to see a GP themselves once
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they are located in their cell on the first night. The doctor said in such instances
they will usually be given an appointment for the following day.
25. During the reception health screen, the man also made enquiries about obtaining
a wheelchair due to his shortness of breath but was informed this was not
possible at Littlehey. During interview, the HCO explained that he believed this
was Littlehey’s policy since he was not aware of any other prisoners having
access to a wheelchair at the establishment. The deputy governor told my
investigators that this was not the case and prisoners should be assessed on an
individual needs basis. However, she went on to explain that the structure of
Littlehey does require prisoners to have a degree of mobility since the prison is
set out over a substantial area and there are no lifts.
26. Although there was a delay in the man being allocated his own wheelchair, the
deputy governor explained he would have had access to one kept for general use
on the induction wing. However, this was not recorded in the medical notes.
Subsequently, in September, a nurse ordered him his own wheelchair which he
received in October. It was recorded in the wing history sheet that he said this
wheelchair helped him greatly. There were also discussions about obtaining him
a motorised trolley. The deputy governor confirmed that there would have been
no objection to this in principle, but a full assessment would have had to take
place as to how he would move around the prison using the trolley.
27. The man remained in a shared cell with his cellmate on the induction wing (E
wing) for the duration of his time at Littlehey. Prisoners normally only stay on this
wing during an initial period in the prison of up to two weeks while procedures
and the regime are explained to them. They would then be moved to another
residential wing. E wing therefore has a relatively transient population.
28. However, E wing was assessed to be the best place for the man given his limited
mobility. It is the only wing at Littlehey where everything, such as the servery and
showers, is located on the same level. The cells are also slightly bigger on this
wing and staff would have been able to see him more easily should he have had
any difficulties. The Clinical Nurse Manager explained in interview that the
decision to retain the man and his cellmate on E wing would only have been
taken after a discussion between healthcare, wing staff and the man himself to
make sure everyone was in agreement. She said that staff try to make sure a
balance is struck between the prisoner’s wishes and the most appropriate
location for them. However, I have seen no evidence that staff documented this
discussion.
29. The cellmate effectively acted as the man’s carer and they chose to remain in a
shared cell together throughout the man’s time at Littlehey. Whilst Littlehey does
not have an official policy in this respect, the arrangement was agreed informally
in line with both prisoners’ wishes. The cellmate collected the man’s meals and
assisted in other ways as necessary. The deputy governor said that Littlehey has
a policy of trying to place those with health difficulties in a shared cell so that one
prisoner can raise the alarm if their cellmate’s condition deteriorates. Both the
man and his cellmate were offered the chance to change wings but chose to stay
on E wing in a cell together.
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30. The deputy governor acknowledged the difficulties facing Littlehey when locating
older or disabled prisoners. She said that they had submitted numerous
applications for a chair lift but had never been successful in receiving the funding
they required. She had recently learnt of another source of funding for elderly
prisoners that was currently working with HMP Norwich. She said Littlehey had
been assessed as having the third largest elderly prisoner population in the
country and had been encouraged to apply for funding on that basis. If
successful, this would provide links with Help the Aged, and help ensure that
prisoners on release have access to the services to which they are entitled.
31. The deputy governor also told my investigators that the prison had identified a
member of staff to work with disabled and older prisoners full-time. She has
since confirmed that this post was filled as of December 2009.
32. Although the man was unable to work because of his ill health, the deputy
governor said that he would have been offered alternative activities, some of
which could have been done in his cell such as assisting with organising
reception paperwork. However, again I have seen no documentary evidence that
he was offered such activities - nor that he would have wanted them or been able
to take part.
33. In August 2008, the man went to healthcare with severe symptoms of COPD.
Prednisolone (a steroid used to treat allergic reactions), amoxicillin and
salbutamol were prescribed, and he was nebulised to help his breathing.
Because of his extreme shortness of breath, he transferred to HMP Bedford,
where there is 24 hour healthcare, overnight in September. The doctor at
Bedford assessed him and deemed him fit to be transferred back to Littlehey the
following day.
34. One month later, the man was described as being breathless which was
diagnosed as possibly being due to the overuse of his inhaler. The doctor
continued with the same medication and also started him on Seretide (used to
decrease inflammation in the lungs), with a view to reviewing this in four weeks.
35. In January 2009, the man told staff he did not want to be considered for release
on parole licence. The reasons were not recorded.
36. The man had an appointment in April during which he showed the doctor a large
mole on his back that had become sore and was bleeding. In order to rule out
malignancy (cancer), the doctor immediately referred him to the dermatology
department at the local hospital. This referral took place under the National
Health Service (NHS) two-week rule for suspected cancer. (The two-week rule
was introduced by the NHS to ensure that patients with suspected cancer would
be seen within 14 days of being referred by their general practitioner.) It is
unclear whether the man was seen as a result of this referral as it was not
recorded in his medical records.
37. During interview, the doctor indicated that he would have dictated the referral
letter for the secretary to then type up and post or fax. He said he was not aware
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of a formal follow up process for hospital referrals at Littlehey; it would be up to a
prisoner or nurse to check the progress of the referral. The doctor commented
he was aware of other referrals that had gone missing.
38. The man had an appointment with another doctor in May who made another
urgent referral to the hospital which was faxed to them on the same day. This
referral notes that the man had a mole on his back which was growing rapidly. A
care plan was started at this point which was appropriately reviewed. Ten days
later, a hospital doctor assessed him in the dermatology department at the
hospital and referred him on to a plastic surgeon for removal of the lesion which
had been diagnosed as a malignant melanoma (a skin cancer). Records indicate
that this letter was typed, and presumably sent, in May.
39. In June, the man had his chest and upper abdomen x-rayed at the hospital to
check his lung function in relation to his COPD. Ten days later he was seen by
the plastic surgeon who apologised for the delay in him being referred to him
from dermatology. (The reason for this delay remains unclear.) Four days later
he was admitted for the removal of the malignant melanoma at another hospital.
He underwent surgery the following day and remained an inpatient at the hospital
until July when he returned to Littlehey. A referral to follow up oncology (the
branch of medicine dealing with cancer) was made.
40. A nurse observed the man in July and noted he was having considerable
difficulties breathing. She consulted the doctor regarding an assessment for
oxygen therapy, which had been prescribed for him while at hospital. The doctor
made an onward referral for this oxygen assessment for “symptomatic, wound
healing and prognostic benefits” and the man was seen by another nurse who
concurred oxygen would be beneficial. This nurse noted in the medical record
that, for security reasons, she did not think this would be possible.
41. During their interviews with staff my investigators asked about these security
implications. Whilst the deputy governor had been unaware that the man had
been refused oxygen, she explained that a full risk assessment would have been
required before it was prescribed. This would be to ensure that he was the only
prisoner able to have access to the oxygen, and also to assess its potential to be
used to assist a prisoner’s escape. The flammable nature of oxygen would also
have been an issue, more so since both he and his cellmate smoked. Oxygen
was never prescribed for him at Littlehey.
42. A prison doctor assessed the man in July and recommended that he start on
Fortisip (a nutritional drink for those who cannot maintain a balanced diet)
because of his visible weight loss. Four days later, the man refused to go to his
hospital appointment as he said he had been given insufficient warning to get up.
The clinical nurse manager explained that details of hospital appointments are
given to the staff on the wings the night before an appointment and would reach
the prisoner by about 8.00pm. She said that if prisoners refuse to go to an
appointment staff try to encourage them to do so. But if they continue to refuse,
medical staff will rebook the appointment or re-refer the prisoner.
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43. This particular appointment was rearranged at a later time. Again on this date,
the man said he was unable to go to the hospital since he felt unwell. A nurse
went in his place. It was planned that a doctor would visit him on the wing to
discuss his results and move him to a healthcare facility closer to his home, ready
for his approaching release date.
44. Later that day, the doctor saw the man and explained that the cancer had spread
to his lymph glands (the lymph glands act as the ‘cleaner cells’ of the body and
are part of the immune system), and he would need to be assessed by an
oncologist at the hospital to determine if it had spread anywhere else. The doctor
gave him a leaflet on melanoma to provide more information. He also formulated
a care plan for him. This was to increase the meal supplements, ensure he
attended oncology appointments at the hospital, and to review regularly his
decision that he did not want to move nearer his former partner and did not want
her to be told about his diagnosis.
45. The clinical nurse manager confirmed during interview that the man was also
offered the services of Macmillan Nurses who offer information, support and
advice to people diagnosed with cancer. However, she said that he was a private
man, who did not like to discuss his difficulties, and he declined the offer, feeling
he had all the support he needed from prison staff. (This discussion is not
recorded in the medical record.) She was of the opinion that he was fully aware
of his condition and was co-operative with treatment. But he also knew his own
mind and made his own choices regarding his clinical care. She went on to say
that Littlehey had not had much contact with Macmillan Nurses as they had not
had the need to.
46. The next day, a nurse telephoned the hospital as she was concerned regarding
the rapid deterioration in the man’s health. She was advised to start giving him
Forticreme (a nutritional supplement) to increase his strength in the hope that he
could attend all his future hospital appointments. In August, the clinical nurse
manager telephoned his probation officer as she was concerned that his
discharge board to plan his release had taken place in July when his prognosis
was more positive. She advised his probation officer that she was concerned for
his welfare on release.
47. When the man was seen in August by a nurse in his cell, he was struggling to
speak due to the pain. He was given pain relief, including the use of a Butrans
Patch which slowly releases a painkiller into the system over a number of days.
He remained adamant that he did not want his former partner to be told of his
condition. He intended to live with a friend in Maidstone on his release which
was scheduled to be in September 2009.
48. Healthcare staff reviewed the man’s care plan to include adequate pain relief and
the management of his weight loss through Fortisip, Calogen (a meal
supplement), soups, and other foods that appealed to him. The plan also
included management of his COPD, observation and care of his pressure sores,
and to ensure his privacy and dignity at all times.
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49. In August, the man had an oncology appointment at hospital. The doctor noted
that he was suffering from dysphagia (difficulty swallowing) and back pain for
which he was receiving morphine. The doctor recommended a Computerised
Tomography (CT) scan (an x-ray procedure that takes images of the whole body
and is able to give good pictures of the soft tissues which do not show on
ordinary x-rays) and an endoscopy (a procedure whereby a camera is passed
down the patient’s throat) to investigate further. The man declined this further
investigation saying he was feeling better since starting on meal supplements.
No further review was planned but the hospital indicated he could be seen again
as required. He was discharged.
50. The following day, the clinical nurse manager telephoned the doctor to obtain a
more specific diagnosis and prognosis so that she could consider the possibility
of compassionate release. The doctor was unable to be more specific since the
man had refused to have any further investigations the previous day. She also
spoke to the man about the possibility of moving to a prison closer to his release
area. This would have facilitated social visits, as well as reducing the distance he
would need to travel home once released. It would also make it easier to put
together a community care package. He declined this offer, indicating he wanted
to stay at Littlehey for as long as he could. He had made friends there,
particularly his cellmate who provided him with much support. It was agreed that
he would stay as long as possible at Littlehey and that no decisions regarding his
transfer would be made without involving him.
51. The next day, when the clinical nurse manager went to visit the man on the wing,
his condition had significantly deteriorated. He was having difficulty breathing
and his pain was widespread. She took his blood pressure and called an
ambulance to transfer him to hospital. She told my investigators that he still did
not want to go to hospital but she felt there was no alternative as his condition
had deteriorated so significantly. The man’s cellmate was very upset. Again staff
offered to contact his next of kin (his former partner), but he refused saying that
they should receive their first call from the prison after he died.
52. The man was transferred to hospital as an inpatient. He was released on
temporary licence (ROTL) on condition that he was escorted by one member of
staff with no restraints. The deputy governor explained that a risk assessment
was completed as part of this ROTL and it was felt that, in light of his mobility
problems as well as his deteriorating condition, no restraints were necessary.
She also explained that an officer escort as a licence condition was included on
the basis of decency and support rather than for security. Prison staff were
aware that the man had no visitors during his time at Littlehey, and the escorting
officer was therefore mainly to provide some company for him at the hospital.
53. My investigators discussed the possibility of compassionate release with both the
clinical nurse manager and the deputy governor. They both said that it was not
considered for two reasons. First, his release date was imminent. Second, as he
had not had any visitors during his time at Littlehey, they felt that if he was
released to a hospital he would be very much on his own, with no family or
support.
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54. Having kept in regular touch with the hospital, the prison staff were informed that
the man’s condition was terminal with spinal metastases, meaning that the
cancer had spread. Oxygen was administered and he was bed bound. The
clinical nurse manager asked the hospital’s palliative care consultant about the
possible next steps given the man’s imminent release. The consultant felt the
man would be likely to stay on the ward until his release when he could be moved
to a nursing home or hospice.
55. The clinical nurse manager visited the man the next day in order to consult him
on decisions about his care. She again offered to contact his former partner or
write her a letter, which he once more declined. She reflected that she felt the
officer accompanying him was providing him with some company, and she asked
him where he would like to spend his final weeks. He replied that he would like to
be in Whitstable, Kent. During interview, she told my investigators that she felt
that the prison had good links with palliative care specialists in the hospital, and
that any recommendations they made were adhered to by prison staff.
56. During an evening in September, the man’s condition deteriorated. The deputy
governor visited and read some birthday cards to him which had been sent by
members of his family. He then agreed that his next of kin could be contacted,
but asked that they did not visit. The deputy governor called his former partner
that evening to tell her of his condition.
57. The following morning, at 3.50am, an officer noticed that the man had stopped
moving and informed the ward nurse. Twenty minutes later the doctor confirmed
that he had died.
58. The deputy governor telephoned the man’s former partner to break the news.
She then travelled to the former partner’s home, along with the prison’s family
liaison officer to offer their condolences and further support, including offering to
pay for the cost of the funeral. His former partner said she would inform his older
son.
59. The following day, the prison’s family liaison officer rang the man’s son as he had
received a message to contact him. He explained the procedures, what would
happen next, and the support available to him from the prison. The prison family
liaison officer formally identified the man’s body. His funeral was held and was
attended by the deputy governor and governor.
60. All the staff to whom my investigators spoke said that they felt well supported by
Littlehey’s care team when they were told about the man’s death.
61. An officer, who works on E wing, told the cellmate about the man’s death. The
officer said the cellmate was understandably upset. He remained with him for a
substantial period of time and offered the support of all E wing staff. The
cellmate made a request to attend the funeral, but since he was not a close
family member, this was denied on security grounds.
62. The chaplain at Littlehey said he would have held a memorial service for the man
at the request of prisoners or staff, but no one had asked him to do so.
15
ISSUES
Reception health screen
63. The man transferred from Bullingdon to Littlehey in July 2008. A reception health
screen was carried out following his arrival at the prison. Unlike the ‘first
reception health screen form’ which is universal throughout the Prison Service for
new entrants to prison, the reception health screen form for prisoners transferred
from other establishments is not standardised. PSO 3050 allows for each prison
to “develop a local protocol and procedure … to meet its local needs”.
64. The reception health screen at Littlehey was conducted by the HCO, who
completed the form in full. Whilst the form contains questions relating to some
specific chronic diseases, including asthma, there is no space for the patient to
give any additional information about their medical history or concerns they have.
Although they were unable to say for certain, the clinical nurse manager and the
clinical reviewer were both of the opinion that the man might have been aware
that his mole was an issue when he transferred to Littlehey. It would therefore be
helpful if space were available on the form to record any additional information or
concerns.
65. Following a death due to cancer at Littlehey in January 2009, I recommended
that
“the Head of healthcare at Littlehey should consider amending the reception
health screen to allow space for additional information about significant
diseases or operations not covered elsewhere on the form”.
66. This recommendation was accepted and Littlehey indicated the action had been
completed as of January 2010. I now further recommend that:
The Head of Healthcare at Littlehey should consider amending the
reception health screen to allow space on the form for additional
information about prisoners’ concerns.
67. The other clinical reviewer comments that he was unable to confirm whether a full
medical assessment of the man took place at reception. PSO 500 (Reception
Procedures) states that the purpose of a medical assessment in reception is “to
determine whether they [prisoners] have any immediate healthcare needs and
whether they present a risk of harm to themselves or to others”.
68. PSO 500 indicates that a full search must take place to prevent prisoners
bringing unauthorised articles into custody. Full medical examinations would not
take place unless deemed necessary due to concerns a patient has about their
health. The man did not tell medical staff about the lesion on his back until nearly
a year later. I am unable to comment on how long he had known that this might
be a problem; although he did tell staff and prisoners that he knew he had been ill
for some time. The clinical nurse manager confirmed that he would have had
plenty of opportunity to discuss this with medical staff. As would be the case in
the community, it is the responsibility of the prisoner to alert medical
16
professionals to their concerns.
Provision of a wheelchair
69. The man was incorrectly informed during the reception health screen that he
would not be able to have a wheelchair at Littlehey. This was despite the fact
that he had already been registered disabled and had use of a motorised trolley
at his previous establishment. Although staff told my investigators he would have
been able to borrow one from the wing, this was not recorded in the medical
record. There was a delay of around three months before he was given his own
wheelchair. It is apparent that having his own wheelchair made it easier for him
to cope in Littlehey. I make the following recommendation:
The Head of Healthcare should ensure all staff are aware of equipment
available to prisoners, including wheelchairs, and the process for obtaining
such equipment.
70. The clinical reviewer comments that a prisoner’s mobility requirements must be
assessed before their arrival at a prison to ensure the establishment to which
they are being transferred is suitable. Since Littlehey is a category C prison,
transferred prisoners come from other establishments rather than directly from
court. In the man’s case, Bullingdon provided Littlehey with his ongoing medical
record. As Littlehey does not have type three healthcare facilities, meaning there
is no inpatient unit or 24 hour healthcare, the clinical nurse manager said an
assessment was made before the man’s transfer that he could cope at Littlehey.
However, this is not documented in his paperwork. HMP Bedford is the nearest
prison with type three healthcare, and the deputy governor told my investigators
that prisoners will normally be transferred there if they need a higher level of care
than can be provided at Littlehey.
Location of the man on the induction wing
71. The man lived in the induction wing (E wing) throughout his time at Littlehey.
This allowed him to have access to everything on one floor and also to remain in
a shared cell with a cellmate, who had become his friend and unofficial carer.
Both the man and his cellmate seem to have benefited from this arrangement,
and it seems to have provided him with some comfort as he became increasingly
ill. Both prisoners were offered the chance to move wings, or in the man’s case
to move prisons to somewhere with type three healthcare, but they preferred to
remain where they were. The man’s inclusion in the decision making as to where
he was located is very much apparent from his records. I make the following
observation:
Allowing prisoners with limited mobility to remain on the induction wing for
longer periods so that they can access facilities and share a cell is good
practice.
17
Older and disabled prisoners
72. The deputy governor was realistic regarding the difficulties facing Littlehey with
regard to their older and disabled population. I welcome the efforts she is making
to secure funding to improve access around the prison, along with the recent
appointment of a full-time officer to work with this group of prisoners.
Referral to dermatology
73. The man initially disclosed the lesion on his back to prison staff in April. He was
subsequently referred to dermatology but this referral seems to have been
misplaced. A second, urgent referral was faxed to the hospital in May when the
man again presented himself to the prison doctor. Subsequently, he attended a
dermatology appointment ten days later. Five days after this he was referred to a
plastic surgeon in relation to having the mole removed. He had an appointment
with the plastic surgeon in June, and underwent the operation to remove the
melanoma. This was nearly two months after his first disclosure of the melanoma
to the prison doctor.
74. During interview, the prison doctor indicated that a two week wait would be
expected for an urgent initial referral. This is in line with the guidelines introduced
by the NHS regarding referrals for suspected cancer. Since the man was initially
referred in April and was not seen until May his appointment fell outside these
guidelines. The doctor also said that, after this initial appointment, the referral to
plastic surgery should only take around five days. The clinical reviewer indicates
that there should be:
“… a maximum of one month from an urgent referral for suspected cancer to
the beginning of treatment. If a patient waits longer it should be because of
delays in the diagnostic process and not the system of care.”
The man’s treatment therefore seems to fall outside the national guideline with
regard to timeliness.
75. The clinical reviewer also says:
“Hospital appointments need to be chased where appropriate to ensure the
prisoner is seen in a timely manner in line with national guidelines for the
condition for which they are being referred ... There needs to be a mechanism
in place to ensure that when appointments are not provided to time that the
hospital where they have been referred are contacted and the appointment
chased and this is recorded in the IMR.”
76. I make the following recommendation:
The Head of Healthcare should ensure there is a robust procedure with
regard to referrals to outside hospitals and, where no appointment is
obtained within national guidelines, this should be followed up and noted
on the IMR. This is particularly pertinent for patients suspected of having a
18
malignant disease who are entitled to be seen under the NHS “Two week
rule”.
The PCT may wish to take steps to ensure that local hospitals are adhering to
this rule, although the matter is outside my formal remit.
Care Plans
77. Following the discovery of the malignant melanoma on the man’s back in May
2009, healthcare staff consistently used and reviewed care plans. This included
a plan to increase meal supplements and to ensure he attended oncology
appointments at the hospital. It also involved the regular review of his location
and whether he wanted his former partner to be informed of his condition.
78. The clinical reviewer comments, “Care plans were set up at an appropriate time
for the man and discussed with him. They were regularly reviewed by healthcare
staff as different issues arose.”
79. During the investigation, the genuine level of care and concern demonstrated by
staff was evident. It is clear from the medical notes that staff from all areas, as
well as the prisoner were involved in making the man’s illness more manageable
and making him comfortable. I am pleased to note the compassion shown by all
those who dealt with him and consider they should be commended.
The Governor should commend staff for their care and compassion in
managing the man, clearly involving him in formulating his care plans,
which were appropriate and reviewed regularly.
Prescription of oxygen
80. In July 2009, the prison doctor referred the man for an assessment for the
prescription of oxygen which had assisted him when he was an inpatient at
hospital. This assessment indicated oxygen would be beneficial to assist with his
breathing and for pain relief. However, it was subsequently decided that this
prescription would not be possible due to the security risks presented and the fact
that he and his cellmate smoked (oxygen is highly flammable). The clinical
reviewer comments that the referral and assessment therefore seemed pointless
unless the man agreed to stop smoking. He recommends that, “Healthcare
should discuss with the prisoner prior to referral to ensure there will be
concordance with the proposed treatment”.
81. I make the following recommendation:
The Head of Healthcare, in consultation with the security department,
should consider whether prescription of oxygen would be possible at
Littlehey. Any risk analysis should be completed prior to referral of a
prisoner to hospital for assessment for oxygen therapy and in full
discussion with the prisoner.
19
Attendance at appointments
82. In July and August 2009, the man refused to attend hospital appointments as he
said he had not been given enough notice or could not get out of bed. The
clinical nurse manager was very clear during interviews that all prisoners were
informed of their appointments at 8.00pm the day before they were due to attend.
This is in line with security procedures. However, it is not recorded that the man
signed disclaimers, as would be expected, for the appointments he missed.
83. The clinical reviewer comments that:
“It can be difficult when a prisoner has a chronic illness that affects their ability
to mobilise and they need time to get ready for an appointment. It is essential
that where hospital and transport timings allow a later appointment, that this
should be considered.”
84. It should be noted that the first appointment the man missed was in the morning.
This was rearranged to an afternoon appointment in August, thereby trying to
accommodate his needs. However, he still felt too weak to attend and a nurse
was sent in his place. The appointment was again rearranged and he attended
on another date in August. After the initial appointment, staff therefore made
considerable efforts to enable him to attend his hospital appointments, explaining
the importance of them and on one occasion sending a nurse in his place to
obtain more information regarding his condition. Ensuring he could attend his
hospital appointments was also subsequently included as part of his care plan.
Nonetheless, I make the following recommendation:
The Head of Healthcare should ensure that, where possible, hospital
appointments for prisoners with chronic illnesses are arranged at a
convenient time of day, and they are given sufficient notice.
Release on temporary licence and early release on compassionate grounds
85. The man was released on temporary licence in August 2009 for compassionate
reasons because of his very poor health. I am very pleased to note that no
restraints were applied to him given his poor health and limited mobility. When
released, he had one officer escorting him to provide company rather than for
security reasons. I commend these actions:
The man was released on temporary licence around three weeks before his
death with an officer escort, thereby providing him with the comfort of
some company in his final days. This is a demonstration of good practice.
86. As I have noted above, early release on compassionate grounds was not
considered for two reasons. The man was due for release anyway in September
and, if released earlier, it was feared he would have been isolated because he
had no visitors. On these grounds, it was felt that release on temporary licence
was preferable. I judge that this decision was both kind and proper in the specific
circumstances.
20
Palliative care
87. The clinical nurse manager told the investigators that the man was offered a
Macmillan Nurse but that he declined the offer, although there was no evidence
of this in the medical record. She also gave consideration to moving him to a
prison with appropriate healthcare nearer his home, and contacted his probation
officer for their thoughts on the matter.
88. After the man was admitted to hospital the palliative care consultant discussed
his options with him, including going to a nursing home on his release. The
consultant also advised the clinical nurse manager that the next step would
possibly be a nursing home or hospice as he believed the man only had a few
weeks left to live, and that he would be in hospital until his release date.
89. The next day, the clinical nurse manager visited the man in the hospital and
asked where he would like to spend his final weeks. He replied he would like to
go to Whitstable and she agreed to discuss this with the consultant.
90. The clinical reviewer comments that:
“Palliative care pathways in HMP Littlehey are not developed, although care
planning and coordination of care needs across organisational boundaries
does occur. To date Macmillan Nurses have not been utilised. When
prisoners require the higher levels of care they are referred on to other
centres but with an ageing prison population the earlier stages of the pathway
need to be considered … The Gold Standard framework for prisons is due to
be developed next year but in the interim healthcare should consider
recommendations made in the Gold Standard framework as well as input from
community palliative services.”
91. The Gold Standard framework is concerned with helping people to live well until
the end of their life once diagnosed with a terminal illness. It aims to ensure that
patients receive the right care and treatment at the right time. I make the
following recommendation:
The Head of Healthcare should consider developing protocols and links
with local Macmillan Nurses and strengthening palliative care pathways.
They should also consider recommendations made in the Gold Standard
Framework.
21
CONCLUSION
92. Staff at Littlehey made considerable efforts to make the man as comfortable as
possible. Whilst not an ideal prison for a wheelchair user, staff ensured he
remained located in a cell with a friend, who also acted as an unofficial carer,
until he was transferred to outside hospital shortly before his death. The
importance of the man’s own opinions in decisions regarding his own care is
clearly apparent from records and interviews with staff. It is well documented that
he wanted to stay at Littlehey for as long as his condition allowed.
93. Furthermore, the man’s release on temporary licence with an officer escort,
around two weeks before his death, afforded him dignity and some company
during his final days. Although I have made recommendations regarding
particular points of his care, including palliative pathways, appointments and
hospital referrals, I assess that overall staff acted with compassion and in the
best interests of him in accordance with his own wishes.
94. In sum, this is a report that reflects well upon Littlehey and NOMS as a whole.
22
RECOMMENDATIONS
1. The Head of Healthcare should consider amending the reception health
screen to allow space on the form for additional information about prisoners’
concerns.
This recommendation was accepted. A review of the local reception
screening tool will be undertaken by the Clinical Services Manager.
2. The Head of Healthcare should ensure all staff are aware of equipment
available to prisoners, including wheelchairs, and the process for obtaining
such equipment.
This recommendation was accepted. A review will be undertaken of current
procedures and a NTS produced to ensure clarity.
3. The Head of Healthcare should ensure there is a robust procedure with
regard to referrals to outside hospitals and, where no appointment is obtained
within national guidelines, this should be followed up and noted on the IMR.
This is particularly pertinent for patients suspected of having a malignant
disease who are entitled to be seen under the NHS “Two week rule”.
This recommendation was accepted. A review will be undertaken with the AO
appointments to understand current practice and ensure national targets are
achieved.
4. The Head of Healthcare, in consultation with the security department, should
consider whether prescription of oxygen would be possible at Littlehey. Any
risk analysis should be completed prior to referral of a prisoner to hospital for
assessment for oxygen therapy and in full discussion with the prisoner.
This recommendation was accepted. The Head of Healthcare will meet with
the Head of Security to examine the feasibility of prisoners using oxygen in
their cells.
5. The Head of Healthcare should ensure that, where possible, hospital
appointments for prisoners with chronic illnesses are arranged at a convenient
time of day, and they are given sufficient notice.
This recommendation was accepted. The AO appointments will review the
current systems in place with the Security Department.
6. The Head of Healthcare should consider developing protocols and links with
local Macmillan nurses and strengthening palliative care pathways. They
should also consider recommendations made in the Gold Standard
Framework.
This recommendation was accepted. The Head of Healthcare will explore
developing greater links with local palliative care specialists.
23
GOOD PRACTICE
1. Allowing prisoners with limited mobility to remain on the induction wing for
longer periods so that they can access facilities and share a cell is good
practice.
2. The Governor should commend staff for their care and compassion in
managing the man, clearly involving him in formulating his care plans, which
were appropriate and reviewed regularly.
3. The man was released on temporary licence around three weeks before his
death with an officer escort, thereby providing him with the comfort of some
company in his final days. This is a demonstration of good practice.
24