Individual at Birmingham City Hospital

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Investigation into the circumstances surrounding the
death of a man
at Birmingham City Hospital
in December 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2009

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This is the report of an investigation into the death of a man at Birmingham City
Hospital on 25 December 2007. The man was 43 years of age and was a
Vietnamese national.
The man was a prisoner in HMP Birmingham until 13 November 2007 and was sent
to Birmingham City Hospital that day for investigations. He was diagnosed with
metastatic gastric carcinoma (stomach cancer) on 24 November and given a very
poor prognosis. The man was granted an executive release from prison custody on
14 December and he died just 11 days later while still in hospital.
The terms of reference for the Ombudsman’s investigations excludes investigations
into deaths of persons who have been released from custody. However, the terms
of reference do permit the discretion to investigate to the extent appropriate, cases
that raise issues about the care provided by the prison. The Ombudsman decided to
exercise this discretion in this man’s case.
I extend my sincere condolences to the man’s family and friends and all those
affected by his loss.
This investigation was undertaken by one of my investigators. A clinical review of
the man’s care and treatment has been carried out by a Consultant in Public Health
at the Heart of Birmingham Primary Care Trust. A Clinical Lead doctor at HMP
Birmingham, carried out her own review of the man’s treatment and I have received
a copy of her report in addition to that written by the Consultant in Public Health. I
am grateful to them both.
In the case of a death through natural causes the findings of the clinical review are
central to the report. The clinical review in this case indicates that the man received
a standard of care that was at least equal to, or possibly better, than he could have
expected to receive in the community. The Clinical Lead doctor at HMP Birmingham
however, raises an interesting point about the greater prevalence of gastro-intestinal
cancer in the Vietnamese population. I commend her intention to provide ongoing
education to the medical team at Birmingham about disease profiles amongst
different population groups.
I have found evidence of good practice in the use of translation services and in
arranging for the man to make telephone calls to his family in Vietnam. This report
makes no recommendations.
Jane Webb
Deputy Prisons and Probation Ombudsman February 2009
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CONTENTS
Summary 4
The Investigation Process 5
HMP Birmingham 6
Key Findings 7
Issues 11
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SUMMARY
The man was a Vietnamese national who was received into HMP Birmingham on 24
July 2007 as a remand prisoner. In his First Reception Health Screening interview
the man reported having no concerns about his health.
A little over a month after arriving in Birmingham, the man saw a nurse to whom he
reported having experienced abdominal pains two days earlier. From that time
onwards the man had repeated consultations with healthcare staff where he spoke of
similar symptoms.
Although one clinician recorded that the man’s English was clear enough for him to
explain his symptoms, others clearly found him harder to understand and so they
used a telephone interpretation service for their consultations. There were also
occasions when the man was unable or unwilling to go to the treatment room where
a call could be made to the interpretation service so his cell-mate acted as the
interpreter.
As the man continued to complain of abdominal pain Birmingham arranged a
number of blood tests at the end of August. These came back as normal. On 14
October, the man’s symptoms included an episode of vomiting. His condition
deteriorated during the day and he was sent out to Birmingham City Hospital for
investigations. The man was returned to prison later that day with a diagnosis of
constipation.
The man continued to complain about abdominal pain. Initially his treatment at
prison was based upon the hospital diagnosis and laxatives were prescribed. The
man continued to complain of similar symptoms. During examination on 12
November, the man was found to have an enlarged and tender liver and to be
clinically anaemic. More blood samples were taken and the results later that day
were highly abnormal. The man was referred back to Birmingham City Hospital.
Just over a week later the man was diagnosed with widespread abdominal cancer
that had spread to his liver. He remained in hospital.
All of the man’s relatives live in Vietnam and towards the end of November HMP
Birmingham made arrangements for him to have daily use of a prison mobile
telephone so he could speak to his family.
The man was granted an executive release from prison custody on 14 December
and on that day the prison bed-watch officers withdrew from the hospital. His
condition began to deteriorate quite rapidly from around the middle of December and
he died in the early morning of 25 December.
The clinical reviewer from Heart of Birmingham Teaching Primary Care Trust has
reviewed the man’s clinical care in prison. He has found that the quality of care
provided to the man was equal to or possibly better than that he would have received
in the outside community.
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THE INVESTIGATION PROCESS
1. Several weeks after the man’s death, the Ombudsman’s office received a letter
asking that I consider issues surrounding the man’s clinical care and treatment
in Birmingham. The sender of the letter was a Buddhist chaplain at HMP
Birmingham. In a telephone conversation with the investigator, the Buddhist
chaplain said that the man had repeated consultations with healthcare staff
reporting abdominal pain. However, the man’s ability to explain his symptoms
would have been severely compromised because of his poor command of
English. The Buddhist chaplain did not think that translation services were
used to assist the consultations. The Ombudsman therefore decided to
investigate the circumstances around the man’s death as a discretionary case.
2. The investigator obtained the man’s clinical records from Birmingham and
approached Heart of Birmingham PCT to ask them to undertake a clinical
review. The review was carried out the Consultant in Public Health.
3. Notices were issued to Birmingham informing staff and prisoners about the
investigation and inviting them to contact my investigator with any concerns.
No staff or prisoners have come forward in response to the notices.
4. The investigator spoke to the vice chair of Birmingham’s Independent Review
Board (IMB). The IMB member said that the IMB had no direct knowledge or
dealings with the man while he was in Birmingham. He also said that
Birmingham did provide interpretation services to assist prisoners at clinical
consultations. He was not aware of any prisoner complaints about the absence
of such support.
5. One of the Ombudsman’s Family Liaison Officers wrote to the man’s family in
Vietnam. The letter had been translated into Vietnamese and it explained the
investigation process and it invited the family to raise any concerns or questions
they would like explored or addressed. To date, no response has been
received to the letter.
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HMP BIRMINGHAM
6. HMP Birmingham is a local prison built in 1849 for adult male prisoners. The
prison can hold up to around 1,450 prisoners.
7. In February 2007, Birmingham received an announced inspection from Her
Majesty’s Chief Inspector of Prisons, Ms Anne Owers. In the section of her
report about Health Services Ms Owers wrote:
“Prisoner wanting to see a member of the [primary care] team completed an
application form … The waiting time to see a [General Practitioner] was 2.5
days …”
8. At the time of her inspection 35 per cent of prisoners at Birmingham were from
black and minority ethnic groups. This investigation has shown that healthcare
staff make use of a telephone interpretation service to assist in clinical
consultations for prisoners with a poor command of English.
9. The Independent Monitoring Board’s last published report (for the 2006/2007
operational year) contained nothing that was directly relevant to the
circumstances surrounding the man’s care and treatment.
10. Since I took on responsibility for the investigation of deaths in prison custody in
April 2004, there have been nine deaths through natural causes of prisoners at
Birmingham. There were no issues arising in any of those cases that were
directly relevant to the circumstances of the man’s case.
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KEY FINDINGS
11. The man was born on 5 August 1964 and was a Vietnamese national. He was
arrested on 18 July 2007 and, having spent several days in police custody, was
remanded into HMP Birmingham on 24 July.
12. Documents completed during the man’s reception referred to him speaking little
or no English. A nurse who saw the man for the health screening aspect of his
prison reception, noted that she used ‘Language Line’ to assist the consultation.
(Language Line is a telephone interpretation service.) Information recorded by
the reception nurse included that the man had not consulted a doctor in recent
months and had no concerns about his physical health.
13. The man was seen by another nurse on 27 August having complained two days
earlier about abdominal pain. The man said that another prisoner had given
him some anti-acid tablets and he was now feeling okay, although he did have
some mild back pain. The nurse noted that the man looked well and was
playing cards with his cell-mate. Later on that day the man went to the
medicine hatch to collect some painkillers (Ibuprofen).
14. On 31 August, the man was assessed by one of Birmingham’s doctors. The
man reported that he had had epigastric (upper abdominal) pain for the last six
months. He also reported sometimes passing dark stools. The prison doctor
prescribed medication (Lansoprazole) for the man’s abdominal pain and
requested that a blood sample should be sent for testing. The results were
received several days later and all were noted to be normal. Several weeks
later a further blood sample was taken for repeat testing of a particular bacterial
infection that is especially prevalent among people in poorer countries and
which causes abdominal inflammation. The result of the test was negative.
15. The man saw another of Birmingham’s doctors on 1 October. The man
reported that he was still suffering intermittent epigastric pain. He also reported
feelings of nausea and he said that the medication he had been prescribed had
not helped. The doctor prescribed some different medication (Ranitidine). He
also noted that he used Language Line during the consultation.
16. In the late morning of 14 October, the man told wing staff that he had severe
abdominal pain. Staff contacted healthcare and a nurse came to the wing to
examine the man. She noted that the man asked to remain in bed so she was
unable to use Language Line from the treatment room. However, the man’s
cell-mate was able to translate for him. The cell-mate reported that the man
had vomited that morning although he was no longer feeling nauseous.
Through his cell-mate the man also reported that he had no difficulty in passing
urine and opening his bowels and that there had been no blood in his faeces.
The healthcare nurse examined the man’s abdomen which she found to be
normal. She finished by noting that she would review the man in an hour’s
time.
17. When the healthcare nurse returned to see the man at 1.45pm she noted that
he had vomited twice since she had last seen him and that his abdomen was in
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spasm. The man was sent to the accident and emergency department at
Birmingham City Hospital where he was diagnosed with constipation. He was
sent back to the prison that afternoon with a treatment plan to include a
prescription of laxatives and a more digestible diet.
18. The man was reviewed the following day by the second prison doctor using
Language Line. The doctor noted that the man was improved from the day
before although his abdomen was slightly tender. The doctor explained the
treatment plan of laxatives for his constipation.
19. On 18 October, the man reported to the nurse that he had abdominal pain and
was not opening his bowels regularly. The nurse checked the man’s clinical
records and saw that he was being prescribed laxatives. He advised the man
to drink a lot and he gave him some pain killers.
20. Three days later the man saw a fourth nurse. The man reported that he was in
constant pain and was also feeling nauseous. The nurse gave the man some
painkillers and arranged for him to be reviewed by a doctor.
21. A third prison doctor saw the man for a review on 24 October. She used
Language Line to assist in the consultation. The man said that he was
improving, although he also reported that he had not opened his bowels for four
days. The doctor changed the man’s laxative.
22. On the evening of 29 October, wing staff asked healthcare to see the man who
was complaining about abdominal pain. The fourth nurse visited and she noted
the cell-mate reporting that the man had vomited earlier that day. The cell-
mate’s description indicated that the vomit might have contained blood. The
man said that he felt sick whenever he ate. The nurse noted that she would
arrange another appointment with a doctor.
23. The man was seen by nurses on the following two days. His epigastric pain
had settled but he now had a headache. The man was told that he should drink
more water. The nurse who saw the man on the second day, 31 October,
noted that his English was clear enough to give information about his symptoms
and she had not needed to use Language Line.
24. Just two days later, on 2 November, the man was seen in his cell by a fifth
nurse who noted that he was complaining of great epigastic pain. She noted
that the man was in too much pain to go to the treatment room to use Language
Line so his cell-mate acted as translator. The nurse examined the man and she
recorded that his abdomen was normal and that he had not been vomiting. The
nurse noted that the man should be referred back to a doctor for re-
assessment.
25. A week went by before the man next saw a clinician. A sixth nurse saw the
man on 9 November as he was complaining of continued epigastric pain. The
nurse noted that the man would be reviewed by a doctor.
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26. On 12 November, the man was seen by the clinical lead doctor together with
another nurse. The man’s English was noted to be clear enough for him to give
his clinical history. Examinations showed that the man’s liver was enlarged and
tender. Blood samples were taken and sent for urgent testing. The results later
that day indicated that the man’s haemoglobin (oxygen carrying red blood cell)
levels were low and other measures were also highly abnormal. On 13
November, he was sent back to Birmingham City Hospital for further
investigation.
27. The man remained in Birmingham City Hospital from that time onwards. A note
was made in his prison healthcare records on 20 November that his likely
diagnosis was colonic carcinoma (cancer of the colon) which had spread to his
liver. The hospital also said that further tests were to be carried out the
following day. A subsequent note in the man’s prison healthcare records made
on 24 November confirmed a diagnosis of advanced gastric carcinoma. An e-
mail from the hospital several days later indicated that the man had a very poor
prognosis and was only expected to survive for two or three months.
28. When a prisoner is sent to outside hospitals he will normally be accompanied
by a minimum of two bed-watch officers and that happened in this case. The
prisoner will also usually be handcuffed and that was again the case with the
man. Handcuffing arrangements are, however, subject to review depending on
individual circumstances. The man’s handcuffing arrangements were reviewed
on 2 December when it was decided that they should be removed due to the
nature of his illness.
29. All of the man’s family live in Vietnam and the records made by the bed-watch
officers make reference to that fact. The man was noted to have declined an
opportunity to speak to his family on a hospital telephone due to the high call
charges. It was decided therefore that the man should be allowed daily use of
a prison mobile telephone to allow him to speak to his family at the prison’s
expense. The records show that the man was able to speak to his family
almost every day from 29 November until the middle of December. He was
initially permitted to speak for five minutes per day but that was soon increased
to 15 minutes per day.
30. On 14 December, the man was granted an executive release from prison
custody and on that day the bed-watch officers withdrew from the hospital. The
withdrawal of the bed-watch officers resulted in the man losing use of the prison
mobile telephone. It would seem that any prospect that the man might be able
to return to his homeland was no longer an option as by now he was too ill to
travel.
31. The Buddhist chaplain told my investigator that he first met the man in the
previous August and shortly after arriving in HMP Birmingham. The Buddhist
chaplain said that he visited the man in hospital almost every day after he was
diagnosed as terminally ill.
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32. Despite treatment at Birmingham City Hospital, the man’s condition began to
deteriorate as December progressed and he died in the early morning of 25
December.
33. After the man’s death, the Buddhist chaplain made contact with the local
Vietnamese community who arranged a funeral which was financed by social
services. Five staff from Birmingham, including the Buddhist chaplain,
Birmingham’s Head of Safer Custody and the IMB vice-chair, attended the
funeral. In keeping with Buddhist tradition, the man’s body was cremated and
his ashes returned to his family in Vietnam.
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ISSUES
The man’s clinical care in Birmingham
34. The man was received into HMP Birmingham on 24 July 2007 and a little more
than a month later made his first complaint of abdominal pain. The review of
the man’s clinical care and treatment was carried out by the Consultant in
Public Health. The clinical reviewer indicates in his review that the records
suggest that the man’s complaints were managed appropriately. This included
undertaking appropriate blood tests to investigate the possibility of serious
abdominal diseases.
35. The clinical reviewer has mentioned the man’s referral to Birmingham City
Hospital on 14 October where he was diagnosed with constipation. The clinical
reviewer notes that that diagnosis was accepted by the healthcare staff at
Birmingham prison and initially used by them as the basis for the man’s clinical
management. The clinical reviewer accepts that it could be argued that prison
healthcare gave undue regard to the diagnosis of constipation made at the City
Hospital, but he goes on to point out that within three weeks prison healthcare
staff realised that the diagnosis was inappropriate and ordered further tests.
36. The clinical reviewer refers to an issue contained in a report about the man’s
care written by the Clinical Lead General Practitioner in Birmingham prison1.
The matter raised by the clinical lead is the differences in the disease profile for
populations from different areas of the world. She reports that a man of 43 with
normal blood results and no weight loss would not meet the British criteria for
urgent referral for gastro-intestinal investigations. However, gastric cancer is
much more common in South East Asia and screening programmes are in
place in some countries for early detection. The Clinical Lead goes on to say
that if the healthcare team had been more aware of the higher risk profile posed
by this population group it is likely that the man would have been referred for
further investigation sooner. She also felt that the continuing symptoms of
gastric pain during September should have led to a routine referral for
endoscopy. The Clinical Lead concludes that the man’s case raises the
importance of continuing education regarding different disease profiles and
disease presentation in different population groups. The Clinical Lead writes
that she intends to deal with this issue at the monthly healthcare department
learning session.
37. In responding to the Clinical Lead’s observation, the clinical reviewer wrote that
he carried out research showing that in England, only about 12 people aged 45
and under are diagnosed with gastric cancer. He went on to say that while the
rate for the Vietnamese is probably three times that of the English race, that still
represents a small number in clinical terms. He concludes on this point by
suggesting that even in Vietnam, the man would not have been considered at
high risk for gastric cancer.
1 The clinical lead’s report appears in full at annex B.
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38. As a non clinician I am in no position to enter into a debate on the merits of the
respective arguments put forward by the Clinical Lead and the clinical reviewer.
However, given the diverse nationalities found within a prison such as
Birmingham I am certainly in favour of the Clinical Lead’s intention to promote
learning about the differing disease profiles within differing populations.
Whether or not possession of such knowledge would have made very much
difference in the man’s case is of course a separate consideration. On this
point the Clinical Lead indicates that given the advanced stage of the man’s
disease on diagnosis, it is highly unlikely that the cancer would have been
treatable even if diagnosed in October.
39. Returning to the clinical reviewer’s review, his overall conclusions on the man’s
care in Birmingham prison were that his access to care was at least as good as
that available to a member of the general community. The quality of his care
was equal to or possibly better than would generally have been offered in a
typical general practice.
Use of interpretation services
40. One of the issues raised by the Buddhist chaplain was whether the man’s care
at Birmingham might have been compromised because of his poor command of
English. The man’s clinical records contain a number of entries that are
relevant to this matter. For a number of the consultations it was noted that
Language Line was used. On other occasions the man’s cell-mate was noted
to have acted as an interpreter to help explain his symptoms. However one
nurse noted that she found the man’s English clear enough for her not to have
to make use of any interpretation support. And I note that that nurse’s entries
are among the most detailed of those found in the man’s records.
41. I have already commented on the clinical reviewer’s findings about the standard
of care provided to the man. I find no evidence that the man’s standard or
command of English resulted in his care being compromised in any way.
Decision to remove the handcuffs
42. On 2 December, an assessment was made about whether to remove the man’s
handcuffs. By then it was known that the man was terminally ill, although it was
thought that he might live another two or three months. As part of the
assessment, consideration was given to whether the man might try to escape
and the risk he would pose to the public if he were to escape. The man was not
deemed to pose a high risk so it was decided the handcuffs should be removed.
Two bed-watch officers remained at the hospital with the man until he was later
released from custody.
43. In my opinion, the decision to remove the handcuffs following the risk
assessment was the correct decision in the circumstances. The presence of
two bed-watch officer was entirely sufficient to ensure appropriate public
protection.
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Provision of a mobile telephone
44. The man’s second and final transfer to hospital was made on 13 November.
Shortly after that date it was realised that he was terminally ill and at most only
had a few months to live. All of the man’s family live in Vietnam and bed-watch
officers recorded one occasion when he declined to contact them on a hospital
telephone due to the prohibitive charges. To overcome the problem of contact
the man was allowed the use of a prison mobile telephone. He was initially
allowed a daily five minute call but within days was being allowed a 15 minute
call each day. When the man was released from prison custody on 14
December the bed-watch officers came away so the man no longer had access
to a prison mobile telephone.
45. The Buddhist chaplain said that he continued to visit on an almost daily basis,
but it was not a good outcome for the man to have lost the support of the bed-
watch officers and the use of the prison mobile telephone.
46. Prison Service Order (PSO) 4400 deals with the provision of telephone services
for prisoners. Ordinarily, prisoners will make their telephone calls from ‘public’
PIN-phones located on the prison wing and they will usually bear the full cost of
all calls that they make. PSO 4400 refers, however, to circumstances where
prisons should consider providing assistance. For instance:
“Where there are urgent legal or compassionate circumstances, such as …
a domestic crisis, Operational Managers have discretion to allow [use of an
official telephone]. Before agreeing to such an application, Operational
Managers must satisfy themselves that the need could not adequately be
met by means of a visit or letter. The costs of these calls must be at public
expense.
“Foreign national prisoners or those with close family abroad must be
permitted a free five minute call once a month where the prisoner has had
no domestic visits during the preceding month.”
47. I consider it to have been good practice on HMP Birmingham’s part to have
provided the man with an official (mobile) telephone to make daily telephone
calls to his family. This is especially so given that the permitted duration for the
calls was quickly increased from five minutes to 15 minutes per day. It must
then have been quite a blow to the man for him to lose this provision when he
received his executive release. At that point the man ceased to be a prisoner
and so HMP Birmingham ceased to have any responsibility towards him. This
was a comparatively rare instance of an individual being disadvantaged as a
direct result of his release from prison custody. I do not believe that HMP
Birmingham warrant criticism for this somewhat anomalous outcome.
48. I can find no evidence, however, that the prison sought to put in place
alternative support arrangements for the man. Birmingham City Hospital has a
social service team as well as a patient advice and liaison team. I consider that
best practice would have been for those teams to have been approached by the
prison and asked to help support the man after his release from custody.
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