Individual at Hewell

Investigation into the circumstances surrounding the
death of a man at hospital, whilst in the custody of
HMP Hewell, in October 2008,
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2009
This is the report of an investigation into the death of a man who died in October
2008 at hospital, whilst in the custody of HMP Hewell. He had been transferred from
Hewell to the hospital on 2 October. He had been diagnosed with cancer of the
small intestine. He also suffered from celiac disease. (Celiac disease is an immune
reaction triggered by gluten, a collective name for a type of protein found in wheat,
rye and barley.)
A post mortem was held at the request of HM Coroner for Worcester. Whilst no post
mortem report has been received, the examination found that the man died from
natural causes. I extend my sincere condolences to his former partner, children,
family and friends.
This investigation was undertaken by one of my investigators. She was
accompanied for interviews by a second investigator. In addition, a review of the
man’s healthcare was commissioned by the Primary Care Trust (PCT). I am grateful
to the appointed clinical reviewer’s.
I would like to thank the Governor of Hewell and the Governor of HMP Birmingham,
and their staff for their help and assistance. I am particularly grateful to Hewell’s
Liaison Officer. I also acknowledge the help given by the Judge and the staff at the
Crown Court.
I make 12 recommendations to reflect the key issues investigated, in relation to
healthcare, bed watches, diet and the role of family liaison. One recommendation is
to the Chief Executive of the PCT for improved communication between prison
healthcare and the wider National Health Service. Five of the recommendations are
to the Head of Healthcare at Hewell in relation to record keeping, management of
celiac disease, care plans and communication. The remaining recommendations are
to the Governor to improve communication between the prison and the bereaved
family, the provision of medical diets, and the managing of bedwatches. Lastly, one
recommendation is to the Governors at Hewell and Birmingham regarding the need
for sensitivity on the part of bedwatch staff.
I also endorse the recommendations made in the clinical review.
This final report acknowledges some minor factual inaccuracies as identified by the
clinical reviewer. The prison service and PCT have accepted ten recommendations
and partially accepted two recommendations.
The response from the man’s family to the draft report raised issues, some of which
were inaccuracies as identified from their re-call of certain events. Those
inaccuracies have been amended into this report. The man’s family felt that he was
malnourished and the prison service had failed to provide the correct diet. At the
time of his admittance to hospital for his cancer treatment, they felt his ability to
withstand the rigours of the treatment was effected by his poor physical condition.
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The man’s family have been advised of the inquest procedures and their right to
raise such issues at the hearing.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2009
3
CONTENTS
Summary
The Investigation Process
HMP Hewell Grange
Key Findings
Issues
Conclusions
Recommendations
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SUMMARY
The man was convicted of drug related offences at the Crown Court in April 2008.
The Judge agreed to the man’s defence counsel’s request to adjourn sentencing
whilst a medical report was prepared. He was remanded to Hewell to wait for
sentencing.
On reception into Hewell, healthcare staff noted that the man had celiac disease and
that it was important for him to receive a gluten free diet. It was also recorded that
he was underweight and frail. His community doctor was contacted for his medical
history and prescription medication.
In mid April, the man was admitted to an outside hospital, as he was unwell with pain
in his rib area. The following day he was discharged back to Hewell and prescribed
an anti-depressant to raise his spirits. Two weeks later, he was examined by a
qualified nurse prescriber after complaining of chest pain, fever and a bad cough.
She prescribed an antibiotic and noted that he had lost weight. The nurse
encouraged him to eat more calories and prescribed a food supplement drink. Later,
the nurse asked the kitchen staff to provide gluten free cakes and biscuits.
The Assistant Disability Officer saw the man in his cell on 12 May. The Assistant
Disability Officer noted that he seemed quite ill, and that he was not always receiving
the correct diet from the kitchen. Later that day, he was admitted to hospital as he
had become unwell with diarrhoea and vomiting. Two days later, he returned to
Hewell and was monitored on the healthcare unit, returning to his houseblock three
days later. The Assistant Disability Officer saw the man again and noted that he was
still not receiving the correct diet. He reminded kitchen staff of his dietary needs.
The man returned to the healthcare unit on 27 May for a week as he was unwell. It
was recorded in his medical notes that the kitchen was not providing enough food for
him and it was not always gluten free. On 19 June, at the Crown Court, the Judge
reviewed a medical report by the Chief Medical Officer at Hewell, outlining the man’s
celiac disease and his general ill health. He was then sentenced to four years
imprisonment.
Following gastroenterology tests in another outside hospital in July and August 2008,
the man was diagnosed with cancer of the small intestine. In late August, a wing
officer noted that he was still receiving the incorrect diet. The officer reported this to
healthcare staff who in turn made contact with the kitchen.
On 2 October, the man was admitted to the outside hospital following a surgical
procedure. Two officers acted as bedwatch escort and he was restrained by an
escort chain. Six days later, he started treatment for cancer. The man’s treatment
was stopped and he moved into the Intensive Care Unit on 22 October. At 7.40pm
on 25 October, his life support machine was turned off on the advice of hospital staff.
The family were at his bedside.
The man seems to have been well cared for by wing staff in Hewell. However, I am
concerned by difficulties he faced in respect of receiving the correct diet. My report
also considers security measures for prisoners taken to outside hospital, risk
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assessments on the use of restraints, communication, family liaison and the
recording of information in medical records.
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THE INVESTIGATION PROCESS
1. My investigator visited Hewell on 3 November 2008 to open the investigation
into the man’s death. The Ombudsman’s terms of reference and notices of
investigation had been sent to the prison in advance of her visit. The
Independent Monitoring Board and the Prison Officers’ Association did not ask
to meet her.
2. My investigator did meet the Liaison Officer and reviewed the man’s prison
file. My investigator asked that copies of documents from the file and the
man’s medical notes be sent to her. There was no response to the notice of
investigation from staff or prisoners.
3. A review of the man’s medical care was commissioned by the PCT and two
clinical reviewer’s were appointed.
4. On 10 December, my investigator and one of my family liaison officers visited
the man’s former partner, his next of kin, at her home. His former partner
raised concerns over his medical care whilst in Hewell. Those concerns
included the management of his diet and celiac disease, communication with
the prison, and the sensitivity of bedwatch staff. I will deal with those points in
the issues section of this report.
5. My investigator and her colleague carried out interviews with prison staff at
Hewell on 6 and 7 January 2009. My investigator returned to Hewell on 18
February to interview the catering manager, with the clinical reviewers.
6. On 3 March, my investigator and her colleague interviewed an officer at
Hewell, then travelled to HMP Birmingham to interview two officers who had
acted as bedwatch escorts whilst the man was in hospital.
On 12 March, my investigator visited the Crown Court to review documents from the
man’s trial in April 2008. My investigator searched his court file to find any
information relating to reports requested by the trial judge into the man’s medical
condition.
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HMP HEWELL
7. HMP Hewell was created on 24 June 2008 by the merger of three former
prisons located on the same site: Blakenhurst, Brockhill and Hewell Grange.
The new prison caters for category B, C, and D prisoners. There are a total of
eight houseblocks on the site. One has dormitory accommodation with the
remainder having single or double cell occupancy.
8. Hewell primarily serves the Worcestershire, West Midlands, and Warwickshire
areas.
9. Healthcare is provided by the Primary Care Trust. There is 24 hour nursing
care with an inpatient unit. The unit is staffed by qualified general and mental
health nurses.
10. The last inspection by HM Chief Inspector of Prisons, of HMP Blakenhurst (the
site which is now the category B prison and where the man was located) was
in 2006. The Chief Inspector found:
“Health services were good quality and safe, with adequate cover out of
hours. The prison and the primary care trust were working well together to
develop clinical governance and a whole-prison approach to health.”
11. There has not been an Annual Report by the Independent Monitoring Board
since the clustering of the three prisons in June 2008.
12. This is the second death that has occurred since the merger of the three
former establishments. The previous death did not have any similarities to
the circumstances of the man who is the subject of this report.
8
KEY FINDINGS
13. In April 2008, the man was remanded to Hewell following a court appearance
at the Crown Court. His defence counsel asked for an adjournment for a
detailed medical report owing to his poor state of health. The Judge agreed to
the adjournment and arranged for the man to be examined by a doctor who
would provide the court with a history of his medical condition.
14. On his reception into prison, the man was seen by a member of the healthcare
staff. A first reception health screen document was completed and noted that
he suffered from celiac disease. He was taking vitamin and mineral
supplements and required a gluten free diet. The document further noted that
he walked with a stick due to lower back pain, appeared to be underweight,
and was having problems sleeping.
15. A general health assessment was completed and the man’s weight was
recorded at 52 kgs for his height of 1.75 metres. (This meant that he was
clinically underweight.) The doctor deemed that he was unfit for work. A fax
was sent to his community doctor for further information about his medical
condition, and blood tests were ordered.
16. On 14 April, the man’s medical notes recorded that information received from
his community doctor confirmed that he suffered from celiac disease. Recent
blood tests indicated liver disease. An appointment was made for him to see
the doctor the following day. The doctor prescribed vitamin and mineral
supplements along with paracetamol and Fortisips (a food supplement drink).
The doctor asked that the man’s community doctor be contacted again so that
a full list of his medications could be reviewed.
17. The man was seen by a nurse on houseblock six on 20 April. The nurse
noted he looked pale and was complaining of pain in his right rib area. An
appointment was made for him to see the doctor. The next day he was
examined by the doctor. His observations were noted as temperature 36.7
degrees (within normal range 36.5), blood pressure 104/76, (lower than
normal range of 120/80) and pulse rate of 75 beats per minute (within normal
range of 60-100). He was pale and short of breath and the doctor arranged
for him to be admitted to an outside hospital.
18. The man stayed in the hospital overnight until he was discharged back to
Hewell. His medical notes recorded his gluten free diet and he was
prescribed Fluoxetine (an anti-depressant) as he was feeling low. On 1 May,
he did not attend a doctor’s appointment, but no reason was given.
19. On 8 May, the man was seen in his cell by a nurse as he had not gone to the
treatment hatch for his medication. The nurse noted he was pale, and he told
her that he had not eaten for a few days and had a bad cough. The nurse
referred him to see the triage nurse. At 11.00am, he was seen in his cell by a
nurse. The nurse, a qualified nurse prescriber, noted that he was unwell with
chest pain, a cough and fever, and prescribed an antibiotic, Amoxicillin. The
nurse discussed the man’s diet with him as his weight had dropped to 48kgs.
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She encouraged him to increase his calorie intake and take his Fortisips twice
a day. Later, the nurse spoke to kitchen staff to ask them to provide gluten
free cakes and biscuits as well as increasing his food intake.
20. Four days later, a member of wing staff and an Assistant Disability Officer
made an entry in the man’s personal file:
“I have spoken to [the man] in my role as the ADLO which is the Assistant
Disability Liaison Officer, and he does appear to be quite ill. He is
currently on medication for a chest infection and pain killers for a lower
back problem. He states that his diet is gluten free but he is not eating all
the food and he does have a gaunt look on his face and quite pale.
Medical staff have been notified and I have also requested that they check
his weight. Can all staff monitor this prisoner during the day and it would
be advisable to keep his door open when occupied so he can increase his
mobility and aid his circulation.”
21. Later, the man was seen by a nurse who noted that he was suffering with
diarrhoea and vomiting. He had a poor appetite and his observations were
recorded as low blood pressure (88/59) and a high pulse rate (110 beats per
minute). The nurse referred him to the doctor. The doctor examined him and
started to make arrangements for him to be transferred to hospital. The
assistant disability officer spoke to him and re-assured him that he could
return to houseblock six when his health improved. The officer told the man
that he would find a specially designed disabled cell for him with more space.
In the meantime, he was admitted to the healthcare unit so that staff could
monitor his condition. At 4.30pm, he was transferred to an outside hospital.
22. On 14 May, the man returned to Hewell and stayed in the healthcare unit for
observation. He was monitored on the unit and a care plan was opened. The
next day, his medical notes record that he was extremely thin and that his
dietary needs should be observed and checked regularly. He was
encouraged to take supplementary food drinks.
23. Two days later, the man asked to return to houseblock six to be with his
friends as he felt unsettled in the healthcare unit. Following discussion with
wing staff, he returned to the houseblock. He was told that if he felt unable to
cope on normal location he should tell healthcare staff, and arrangements
would be made for him to transfer back to the healthcare unit. A care plan
was formulated and sent to houseblock six for the attention of nursing staff.
24. The following day, the man was seen in his cell by nursing staff. Although he
was feeling better and eating more, it was noted that he was still being sent
inappropriate meals from the kitchen. The assistant disability officer emailed
the kitchen staff, reminding them to send a gluten free diet. On 25 May, it was
recorded that a prescription was also requested for Build Up, a supplementary
food drink.
25. On 27 May, the man became unwell again with diarrhoea and was transferred
to the healthcare unit. His blood pressure was low at 104/78 and pulse rate
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normal at 88 beats per minute. His weight had risen to 53kgs and his medical
notes record that the kitchen was providing salad for him. Whilst appropriate
for his diet it did not provide enough calories to address his weight loss. An
appointment was ‘put back’ for him to attend the Gastroenterology
Department at an outside hospital, due to a security problem.
26. The following day, a nurse noted that the man was due a vitamin B injection
and his care plan was updated. He had the injection on 30 May, and his notes
record he was eating and taking fluids, although his blood pressure remained
lower than the normal range. Three days later, his weight had increased by
several kilos although his medical notes record that he was not eating enough
and was fussy about his food. He was seen by a doctor who noted that he
should take 2,000 calories daily, have a monthly weight chart, record his daily
intake of food, and receive a dietician’s advice leaflet.
27. The man transferred back to houseblock six on 2 June. A revised care plan
was formulated and regular monitoring was arranged by healthcare staff. On
7 June, a wing officer asked healthcare staff to visit the man in his cell as he
was complaining of diarrhoea. The nurse visited him and, following his
medication, he felt better. Two days later, his medical notes record that he
had again been given an inappropriate diet from the kitchens. This was
followed up by healthcare staff who contacted kitchen staff to remind them
that the man must receive the correct diet for his medical needs. An
outpatient appointment was cancelled for security reasons on 12 June.
28. On 14 June, it was recorded in his medical notes that the kitchen had sent a
pie for the man. This is inappropriate for celiac disease, and healthcare staff
again spoke to kitchen staff about his dietary requirements and that salads did
not provide enough calories.
29. Five days later, the man went to the Crown Court for sentencing. A medical
report from the Medical Director of Hewell outlined the medical interventions
that the man had received in Hewell, including inpatient admissions and
described his current medical condition. Later that day, he was sentenced to
four years imprisonment and returned to Hewell. On 4 July, he weighed
53kgs, his blood pressure remained low and he complained of swollen feet.
30. In response to the draft report the man’s former partner felt that the prison
misrepresented their ability to provide for his special dietary needs and this
was overlooked in the report from the Medical Director.
31. The man went to the outside hospital on 10 July for gastroenterology tests
which had previously been cancelled. The following day he was seen by a
nurse. His weight had dropped to 52kgs. The nurse asked the kitchen staff to
increase the amount of food allocated to him within the confines of his special
diet.
32. The man was examined by the doctor on 30 July and his weight had
increased by a kilo. The doctor noted that the man had problems sleeping
and complained of leg and joint pain. Pain relief medication, Tramadol, was
11
prescribed and he was advised to try to eat more. It was noted that he was
waiting for a computerised tomography (CT) scan. (A CT scan takes x-ray
images of the whole body.) However, the appointment for the scan was
cancelled on 5 August for security reasons.
33. On 12 August, the man attended an outpatient appointment for his CT scan
and his care plan was updated the next day. He was still receiving daily visits
by nursing staff and his clinical observations monitored. A letter from a
Consultant Physician and Gastroenterologist at the outside hospital to the
Chief Medical Officer at Hewell, written on 14 August, confirmed suspicions
that the man had an intestinal lymphoma (cancer of the lymph glands in the
small intestine).
34. The man’s medical notes recorded on 18 August that his weight had fallen to
51kgs and the nurse intended to discuss re-commencing high calorie drinks
with the doctor. On 23 August, an officer noted in the man’s personal file that
he had been sent inappropriate food. At interview the officer said:
“He had to be on a special diet and the main diet that the kitchen used to
send him up more or less every day was pasta which was the one thing
that he couldn’t eat. On the odd occasion when we (the kitchen) did sort
of get it right, they would send him a salad.”
35. The officer said he spoke to a nurse as the problem with the man’s diet had
not been resolved. He hoped that, as a nurse, she could speak to the kitchen
staff to rectify the problem. The officer went on to tell my investigators that the
servery staff (prisoners who serve up meals on the houseblock) would help
the man if he had not received an appropriate meal. They would plate up food
for him to boost his diet and provide a suitable meal. The officer also spoke to
the nurse about the man’s continued frailty and deteriorating health. He told
the nurse that he might benefit from more supplementary food drinks, as he
had told the officer he found them beneficial. The nurse told the officer she
would see that the man was prescribed further liquid food drinks.
36. On 29 August, the man’s medical notes record that the officer told healthcare
staff that the man had been informed, at an outpatient appointment two days
earlier, that he would require surgery, to confirm his diagnosis of cancer.
Healthcare staff were unaware and asked the healthcare administration to
confirm with the hospital. His medical notes further noted that gluten free
products were to be ordered from a pharmaceutical shop, that he should be
seen daily, and that his weight would be checked weekly.
37. It was recorded on 11 September that the man was still losing weight and
more food supplement drinks were prescribed. Three days later, he was seen
by a member of healthcare staff who noted that the kitchen were still not
consistently providing an appropriate diet, although he did have gluten free
foods in his cell. An appointment was made for him to attend hospital for a
pre-operative assessment.
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38. On 2 October, the man went to an outpatient appointment at the outside
hospital. A risk assessment was completed and he was placed on an escort
chain (an escort chain is a 1.8 metre length of chain with a cuff attached to the
prisoner and the second cuff attached to a prison officer). Following the
surgical procedure, he was admitted to the hospital and two officers
commenced a bedwatch. On 6 October, he was fitted with a feeding tube.
39. The man was told by hospital staff that chemotherapy (a treatment for cancer
related disease) would commence on 8 October. On 9 October, the bedwatch
notes record that he would remain in hospital for up to three weeks. Officers
from HMP Birmingham and HMP Long Lartin provided bedwatch staff to
support Hewell.
40. On 10 October, a hospital doctor spoke to the bedwatch officers about
restraints being removed as the man was immobile and his medical condition
was deteriorating. A principal officer (PO) was at the hospital completing a
management check. The PO told my investigators he spoke to the doctor who
said that, if the man’s condition continued to deteriorate, restraints would
seem inappropriate. The PO passed this information onto the security
department on his return to Hewell.
41. Five days later, the bedwatch notes record that the man was in pain and very
unwell. Hospital staff asked for details of his next of kin as they were worried
about his health. His former partner arrived no later than a half hour after
being told of the deterioration. At 4.15pm the bedwatch officers spoke to the
duty governor and permission was given to remove the restraints. Family
members were allowed to visit and spend time with him.
42. Two officers were carrying out bedwatch duties on 16 October and were
sitting away from the man’s bedside. His children visited him around 2.00pm
with their mother, his former partner and one of the bedwatch officers was in
the room on their arrival. The second bedwatch officer told my investigators
that the family were unhappy about the officers being present in the room.
The officer reminded the family that the man still needed officers to be present
and, if his condition improved, there was a possibility that restraints could be
re-applied. The second bedwatch officer told my investigators that this upset
the family and caused some distress. Later, the bedwatch notes record that
the man was receiving a number of visitors and they had to be reminded that
only two people were allowed in his room at a time, as per the hospital rules.
43. It was noted the following day that the man was still receiving more than two
visitors and there was some tension between them. The doctors reiterated
the hospital rules of two visitors to the prison staff. On 18 October, a new risk
assessment was completed and the bed escort was reduced to one officer.
The bedwatch officer made contact with the duty governor and it was agreed,
with hospital permission, that the man could have three visitors by his
bedside. Later that day, one of the visitors refused to give his name to the
bedwatch officer and swore at him. The next day another visitor also refused
to give his name. (For security reasons all visitors to a prisoner on a
bedwatch escort must give the escorting officers their names.)
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44. In response to the draft report, the man’s former partner is clear that the
hospital never specified to the family the number of visitors allowed. She can
only assume that this was only ever communicated to the bedwatch staff. Her
view is that the hospital staff were happy throughout.
45. On 20 October, following a risk assessment, it was noted that the bedwatch
officer would now be located outside of the man’s hospital room. At 5.00pm,
the officer raised concerns about the number of visitors coming and going out
of the man’s room. The following day, the bedwatch was increased to two
officers who were to remain outside his room. A risk assessment noted that
hospital staff hoped to improve his mobility. At 1.00am on 22 October, he
moved to the high dependency unit (HDU). Five hours later he was
transferred to the intensive care unit (ITU).
46. At about 5.40pm, one of the visitors asked the bedwatch officers why they
were still providing an escort for the man. The officers explained the rules to
the visitor who then said that another person would be visiting and he would
not give his name. The officer explained that the man was still in custody and
that all visitors must give details to the bedwatch officers, as they do when
visiting at a prison. The officers remained on duty outside the ITU.
47. According to the bedwatch notes at 9.20am on 24 October, the bedwatch
officers refused entry to a visitor who would not give his name. By now, the
man was on a life support machine. In response to the draft report his family
cannot re-call that any visitor being refused entry.
48. The man’s former partner spoke to the bedwatch officers at 4.00pm on 25
October. She telephoned a governor and the officers left the ITU area as his
life support machine was going to be switched off. The officers moved to the
foyer area of the hospital thereby allowing the family privacy with the man. At
7.40pm, his life support machine was switched off and he died with his family
at his bedside. At the time of writing, a post mortem report has not been
received.
49. The chaplain at Hewell held a short prayer service for the man in the prison’s
chapel. Patrick’s family were offered financial assistance towards his funeral
expenses as required by Prison Service Order 2100.
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ISSUES
Clinical Care
50. A clinical review of the man’s medical care was commissioned by the PCT.
The reviewers, a retired Director of Public Health, and a retired NHS Director
of Corporate Affairs, conducted a wide ranging and comprehensive review for
which I am grateful.
51. The reviewers interviewed clinical staff from the NHS Trusts, a doctor from the
man’s community practice, the Head of Catering Services at Hewell, and a
prison liaison officer. The reviewers comment on five specific areas of his
care:
(cid:127) The reception process.
(cid:127) The management of the man’s illness, including day to day healthcare and
care planning.
(cid:127) The identification of dietary needs and the provision of food.
(cid:127) Record keeping.
(cid:127) Security arrangements for sick prisoners in external NHS settings and
communication between prison healthcare and the NHS outside the prison.
Reception process
52. The clinical reviewer’s note that the man’s previous medical history and celiac
disease was correctly identified and his medication recorded. Healthcare staff
noted that he was underweight, with lower back pain. A senior staff nurse
undertook a general health assessment and confirmed his dietary needs of a
gluten free diet. A doctor ordered blood tests and requested his previous
medical notes from his community doctor. The clinical reviewer’s comment
that:
“The first reception health screen and the subsequent general health
assessment appear to have been through and well documented. They
followed national guidelines.”
Communication between healthcare and external National Health Services
53. The clinical reviewer’s reviewed the man’s outpatient appointments and the
cancellation of some of those appointments.
54. Before the man had been received into Hewell, his community doctor had
referred him for a gastroenterology outpatient appointment. The date of that
appointment had to be changed on three occasions and a final date of 10 July
was agreed. The reason for the cancelled appointments was because
hospital booking clerks and medical staff informed him of the dates. The NHS
staff involved were not aware that prisoners should not know the date of their
appointments. For security reasons appointments for prisoners should be
only made with prison healthcare staff. Similarly, a CT scan appointment had
to be altered from 5 to 12 August.
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55. The Acute Hospitals Trust and Hewell have a joint policy on prisoner visits to
hospital, although that policy did not cover Hewell with the outside hospital.
(the outside hospital was not one of Hewell’s normal places of referral for
prisoners requiring hospital treatment.) Medical staff at the hospital did not
always know who to make contact with at Hewell and found it difficult to
telephone. Likewise, healthcare staff found it hard to contact hospital staff as
the telephones were not always answered. Ward staff seemed reluctant to
offer information to prison staff with whom they were unfamiliar. Therefore, it
would seem the policy was not always adhered to. The clinical reviewers
comment that:
“There was a lack of clarity about the aspects of communication between
healthcare staff in the prison and those in an NHS Trust that did not have
established links with the prison. This led to delays in the timing of the out
patient appointments.”
They make the following recommendation which I endorse:
The PCT should develop protocols covering healthcare provision in
prison, security, booking of appointments and communication for use
when prisoners visit a NHS Trust. A copy should be taken by the prison
escort officers to hand over to hospital staff at the first attendance.
Management of the man’s illness and day to day healthcare and care planning
56. Healthcare staff were aware of the man’s celiac disease. He was encouraged
to eat more and prescribed vitamin and food supplements. However, some
weight changes were not always noted and a doctor asked that his weight
should be monitored using the same scales. There were problems with his
malabsorption of food, which a better diet might have helped to resolve.
57. The man’s repeated bouts of diarrhoea were noted, however there was no
clear plan for treating his symptoms. His symptoms were monitored and it
was thought that some diarrhoea was due to his inappropriate diet and, on
one occasion, related to taking an antibiotic.
58. It was noted that the intestinal lymphoma could have been present in his
system for some time. The lymphoma might also have been the cause of
some of the symptoms that the man suffered, and not just his celiac disease
and inappropriate diet. The clinical reviewer’s comment on the diagnosis of
his lymphoma by saying:
“Even after July, whilst the diagnosis was being progressively firmed up,
there were no new insights into how to manage [the man’s] treatment,
largely because there was little more that could be done in the prison
setting.”
In response to the draft report, the man’s family believes that the sentencing
judge was misled about the ability of the prison to meet his medical needs.
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59. A CT scan appointment on 12 August confirmed that the man had an intestinal
lymphoma. He was then referred to a consultant at the outside hospital.
During August, the man lost more weight and was prescribed further food
supplement drinks. The man was seen by a consultant haematologist on 27
August who hoped that a tissue biopsy would follow in two weeks time. This
biopsy did not take place for five weeks but there is no indication as to the
reason for the delay.
60. The clinical reviewer’s comment:
“Without these delays, [the man] would have had a diagnosis earlier, and
chemotherapy treatment may have started earlier. However, he would not
have been any stronger than he was when he was finally admitted to the
outside hospital, and the consultants told us that the outcome would not
necessary have been any different. There was only a 25 per cent chance
of survival at three years, and an overall ten to fifteen per cent likelihood of
being cured.”
61. The man continued to be monitored by healthcare staff until he was admitted
to hospital for the biopsy on 2 October. He remained in hospital afterwards
and chemotherapy was started as the only hope to control the lymphoma. It is
noted in the clinical review that the bowel collapses for about one third of
patients receiving chemotherapy for this type of lymphoma.
62. The clinical reviewer’s conclude that:
“The delay in securing a biopsy caused [the man] more pain and an earlier
diagnosis would have meant earlier treatment. Unfortunately, the outcome
would have been the same even with an early diagnosis. [His]
deterioration was unexpected with low white cell blood count and he was
suffering from fever and shivers all associated with the side effects of
chemotherapy. He then developed acute respiratory failure that could
have been a reaction to the chemotherapy or acute respiratory distress
syndrome.”
63. In response to the draft report, the mans’ former partner’s main point is that
the man did not survive because he was malnourished and was not strong
enough to handle chemotherapy. She insists that the oncologist at the hospital
told her that he would not survive because he had malnutrition not because he
had cancer. The oncologist is attributed as saying that the cancer was
normally survivable.
I endorse the recommendations made by the clinical reviewers:
Prison healthcare staff should improve their awareness of the
management of celiac disease. In particular, consideration should be
given to the clear and consistent recording of significant indicators such
as weight and the results of blood and other tests; the use of referral to a
17
dietician and to nurse specialists; and the use of gastrointestinal review
when the disease is not under control.
Scales use to weigh prisoners should be calibrated regularly to ensure
consistent and accurate readings.
Diet and the provision of appropriate meals
64. The man’s former partner told my colleagues that his condition was well
known to both medical and prison staff in Hewell. Indeed, the judge who had
remanded him into custody on 11 April 2008 ordered that the Prison Service
should provide a medical report to the court outlining how the prison could
provide and monitor an appropriate diet during any sentence of imprisonment.
Hewell had stated that they could provide such a service. When he was
sentenced, the judge said in open court that the man’s dietary needs “must be
catered for”.
65. My investigator visited the Crown Court offices where the Judge had given
permission for her to review the man’s court files. Although she could not take
away copies of the files, she reviewed a medical report provided by the chief
medical officer at Hewell outlining the man’s medical condition and inpatient
admissions to hospital. From the court records available to my investigator
there was only one reference to the judge’s comments about his dietary
needs. This was at the court hearing in April when the Judge said, “His [the
man’s] physical condition would be taken care of.”
66. The man saw the doctor four days after he arrived in prison and the doctor
noted his celiac disease and his prescribed medication, which included
vitamins and food supplement drinks. This suggested that the catering
services had already been contacted to ask for an appropriate diet.
67. A nurse made contact with the kitchen staff on 8 May, and recorded:
“… they will provide gluten free cakes and biscuits and increase the
amount of food he [the man] receives.”
68. Nevertheless, the man complained to his former partner and his brother that
he was not getting the right food. He also said that no one would listen to him
when he complained. He told his former partner that he would often be
unable to have any breakfast or midday meal because he was offered things
he did not like, and he frequently only ate one meal a day.
69. The man was sent the wrong type of food for his medical condition on many
occasions. Often he would get pasta dishes, and on one occasion, he was
sent a pie. Neither is gluten free. The servery staff looked after him and,
once it became apparent that he was experiencing difficulty receiving
appropriate food, they would ensure that he was given something that he
could eat.
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70. My investigators spoke to a senior officer (SO) from houseblock six where the
man had lived. The SO remembered a long period trying to arrange a gluten
free, high protein diet. The man lived on the houseblock for six months and
staff knew of his dietary requirements as soon as he was located there. From
then until he left the prison, continued efforts were made to communicate with
the kitchen about his medical condition. The SO said he understood the
difficulties of providing so many meals, but felt that mistakes were made too
many times.
71. In interview, the catering manager told my investigator that prisoners with
specific dietary needs are notified to the kitchen by healthcare. (All meals are
prepared on site including those prisoners needing a special diet.) The
kitchen has a display board which indicates the prisoners with special dietary
needs. Special dietary foods are prepared in individual containers and sent to
the wing servery. The catering manager said that all diets can be catered for
and he had previous experience of catering for a celiac diet. However, baked
goods that are gluten free are not available through the normal procurement
process (contractual ordering of food). Instead, the catering manager went
outside the prison to purchase gluten free bread, cakes and biscuits in a local
supermarket when it became apparent that the man required a high
carbohydrate diet.
72. My investigator saw packets of gluten free biscuits and cakes in the man’s
property during her visit to Hewell on 3 November 2008. She also noted that
there were packets of ginger biscuits which are not gluten free. The catering
manager told my investigator the biscuits could have been ordered by the man
through the canteen. (The canteen is a service for prisoners who can order
goods and foodstuffs using their private money.)
73. Not only did the man need gluten free food, he also required a high
carbohydrate diet. This could have been facilitated by using other foods that
would give him a high calorie intake. Salad type meals did not have sufficient
calories to boost his calorie intake. It is of great concern that the catering
service at Hewell seem to have consistently failed to ensure that he was
offered the correct diet for his medical condition.
74. The clinical review notes that eating non-gluten free food is unadvisable for
people with celiac disease, as it can cause inflammation of the digestive
system. Over a long period of time it can also increase the risk of lymphoma.
However, the reviewers were told by hospital doctors that, in the few months
of the man’s imprisonment, eating these foods would not have caused his
lymphoma, and it would not have been aggravated by his prison diet. His
lymphoma would have been developed over a much longer period.
75. In response to the draft report, the man’s family have commented that he did
not refuse food because he did not like what was offered, it was the fact that
he was unable to eat the food as it was not commensurate to his gluten free
diet. The prison had told the Judge at the man’s trial that his dietary needs
would be catered for however this was obviously not the case. The bouts of
diarrhoea may well have been caused by the inadequate diet he was offered.
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76. The clinical reviewer’s comment:
“It has not been possible to establish how many times [the man] actually
ate inappropriate food. Sometimes the initial lack of appropriate provision
by the kitchen was corrected following the intervention of other staff.
Sometimes he was given extra supplies of food to build him up, by servery
and other staff. [The man] did not like all the food that was provided for
him, such as fish, which was a gluten free part of the prison diet. He
refused to eat this. He did not always find specifically gluten free products
to be palatable. He was recorded as being picky at times. On other
occasions he did not eat or drink because he was feeling unwell, not
because the food provided was inappropriate.”
77. In conclusion the clinical reviewer’s say:
“Prison Service Order (PSO) 5000 (Prison Catering Services) sets out a
responsibility on the Prison Service to ensure that appropriate diets are
provided to prisoner with celiac disease. There was a lack of clarity as to
who was responsible for [the man’s] diet, and no co-ordinated approach
between healthcare staff and the catering department, despite the efforts
of individual members of staff. There was no consistent system in place to
ensure that [he], as a person authorised to receive special diets, actually
received them from the kitchen.”
78. PSO 5000 annexe 25 says:
“Beware of adults who have celiac disease, also known as gluten
intolerance, who need to avoid all cereals containing gluten (wheat, oats,
barley or rye). Alternative foods made from maize (i.e. polenta), rice, rice
flour, potatoes, buckwheat, sago, tapioca, soya, soya flour are available.
Seek expert advice from a dietician where necessary. Some gluten foods
are available on prescription.”
79. The provision of appropriate diets for prisoners with a medical condition is
essential for their health and well being. It would seem that the man did not
receive a suitable diet and, despite the interventions of healthcare and wing
staff, mistakes were made repeatedly.
80. I note the two recommendations made by the clinical reviewer’s in relation to
the dietary needs of prisoners and specifically the adherence to PSO 5000.
The Governor should ensure that all prisoners who require a special diet
for medical conditions should receive appropriate meals. Steps should
be taken to make sure that all special and medical diets are provided to
the required standard as set out in PSO 5000.
A record should be made in the medical record if a special diet has been
requested by a healthcare professional. Any modifications to such a
request should also be recorded. There should be an ongoing
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accessible and up to date record in the kitchen of any such request for
as long as the prisoner remains in the prison and requires the special
diet.
Record keeping
81. The clinical reviewer’s comment on the standard of record keeping in the
man’s medical notes. They note that most entries were in sequence, legible,
dated and signed. However, identification of the staff making the entries was
not always easy to follow and some entries were not signed.
82. There were some gaps in the medical records and documents, which
included:
(cid:127) The medical report provided by the Chief Medical Officer to the Crown Court
Judge.
(cid:127) No formal medical request to the kitchen for the provision of the man’s gluten
free diet.
(cid:127) Results of blood test and other tests undertaken by healthcare staff.
(cid:127) Copies of signed care plans. Only two signed plans were found (which were
dated 14 and 27 May) and an unsigned plan dated 24 September.
(cid:127) A gap in the continuous medical record between 29 September and 5
October, when the man attended hospital for an overnight stay and did not
return.
83. Discharge care plans were formulated when the man left the healthcare unit
and returned to the houseblock. The plans were kept on the wing and not
copied into the medical records. Those plans should provide information for
all healthcare staff and not just those carrying out wing duties.
The clinical reviewer’s make the following recommendations which I endorse:
The Healthcare Unit should remind all staff, of the importance of signing
entries in the medical record, and writing or stamping their names legibly
so that they can be identified.
Discharge care plans should be documented in the medical records
when prisoners move from the healthcare unit to houseblocks.
Security Arrangements
84. The family has raised questions as to why the number of escorts was
increased from one to two and why two officers remained when the man was
unconscious towards the end of his life.
85. The deputy governor told my investigators that it is standard security policy to
assign two officers to carry out a bedwatch in hospital. One of the officers is
normally cuffed to the prisoner. The deputy governor was involved in the
decision to reduce the bedwatch to a single officer on 18 October. She was
21
satisfied that the room where the man was located was suitable. Also there
was less risk of infection if only one officer was present.
86. Although it would have been difficult for the man to escape, the intention was
always to increase the number of officers to two officers if he regained his
strength.
87. On 21 October, the deputy governor was told that the man was eating and
drinking again. She said that she understood that he was likely to be mobile
as his condition was improving and hospital staff were working to increase his
mobility. In addition, he received many visitors. At times the officers felt that
security could have become compromised by the number of visitors when one
officer was on duty.
88. The man’s family have commented on receipt of the draft report, that the man
was not eating and drinking at this stage and his condition was not improving.
From bed watch notes it was indicated that hospital staff had informed bed
watch staff that his condition was improving. This information was given to the
deputy governor.
89. I understand the family’s frustration about the number of officers on bedwatch
when it was obvious the man was too ill to be an escape threat. Nevertheless,
security must always be fully considered and I accept the reasons for
increasing the bedwatch to two officers.
Restraints
90. An escort risk assessment was completed on 8 October to determine the level
of bedwatch staff and the use of restraints. Two days afterwards, a hospital
doctor spoke to bedwatch staff about the man’s deteriorating condition and the
use of restraints. By then, he was immobile and very weak.
91. Later that day, the PO and the doctor spoke about the man’s condition and
agreed that restraints would be inappropriate should his condition continue to
decline. The doctor did not ask the restraints to be removed immediately.
92. A risk assessment was not completed by senior managers when the
information was passed to the security department by the PO. Five days
elapsed between the conversation between the PO and the doctor and the
removal of restraints. By this time, the man’s wrists were so thin that a
bandage had been placed under the cuff to protect any injury.
93. A risk assessment should have been completed once the security department
became aware of the doctor’s comments on the use of restraints. Whilst it
may not have been appropriate to have removed the restraints immediately,
an assessment would have given clearer instructions as to why they were to
remain in place. Using a bandage to prevent injury indicated the poor physical
state the man was in, and I believe the use of restraints was an extreme
reaction when he was so frail and immobile.
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94. The man’s family found it very upsetting to learn that the restraints could be
re- applied if he got better. The man’s former partner, meanwhile, had been
telling both her children that their father was deteriorating and this remark
raised unnecessary hope.
95. The bedwatch officer concerned told my investigators that he merely reminded
the family that restraints could be re-applied at any time, should the man’s
condition improve. The application of restraints would be risk assessed before
they were used.
96. It is customary for a risk assessment to include a contingency in the event of
the prisoner’s medical condition improving and that restraints may be re-
applied. It would not be normal or good practice to discuss risk assessments
with a family. However, if a family liaison officer had been appointed the
matter might have been explained more sensitively.
97. The clinical reviewer’s review the use of restraints within their report. From
their investigation at the outside hospital and interviews with hospital staff, it is
noted that there were mixed feelings about the use of restraints. Some
hospital staff found them undignified and an intrusion into patient
confidentially. However, the presence of the escorts was not generally
regarded as intrusive by hospital staff. The clinical reviewer’s comment:
“Bedwatch and escort requirements for seriously ill prisoners sometimes
appear to be inappropriate. There is a balance to be found between
necessary security arrangements and the dignity and care of very ill
people.”
I agree with the following recommendation made by the clinical reviewers.
The Governor should ensure risk assessments are completed when
hospital staff raise the use of restraints. Escorting seriously ill prisoners
can be within acceptable boundaries and the use of physical restraints
can take into account the risk of physical injury to a frail person.
Good Practice
98. I find that the general standard of care offered to the man during his time in
Hewell was good. There was evidence of detailed history taking and
appropriate prescribing. Regular weighing to monitor his health should be
commended, though this would have been more useful if the weighing scales
had been regularly calibrated and the results consistently charted rather than
simply recorded at irregular intervals in the medical record.
99. Healthcare staff and prison officers on houseblock six appear to have been
genuinely concerned about the man’s welfare, and many people went out of
their way to help him. The assistant disability officer was especially
supportive. For example, he asked all staff to monitor the man during the day
and said that his cell door should be kept open to assist his mobility.
Healthcare and prison staff dealing with him were aware of the importance of
23
a proper diet, and numerous attempts were made to resolve the problems
although not always successfully. There were attempts to improve liaison
between the hospital and the prison as time went by, and especially towards
the end of his life.
Further family issues
Prison healthcare unit
100. The man told his former partner that he was afraid about returning to the
prison healthcare unit because it was ‘filthy’. My investigator visited the
healthcare unit and found it to be of a good standard of cleanliness. It was
difficult to understand what he meant by ‘filthy’. He did not like being located
in the healthcare unit and preferred to be on the wing with supportive friends
and wing staff. In interview, the assistant disability officer told my
investigators that the man said he did not like being in the healthcare unit as
many of the other patients had mental health problems. The noise and
general atmosphere of the unit caused him some anguish.
101. In 2005, during an inspection of the healthcare unit at HMP Blakenhurst, HM
Chief Inspector of Prisons referred to the décor, cleanliness and general
physical state of the healthcare unit and noted that: “The physical environment
was good.”
Information from the prison
102. The man had suffered from regular bouts of chest infections and was in and
out of hospital. His former partner was not told about these admissions and
would have liked to have been informed.
103. If an admission to hospital is made for a potentially serious condition, next of
kin should be informed and visiting information passed to the family. This is
particularly important as the cost of telephone calls from hospital beds is very
high.
When a prisoner is admitted to hospital as an in-patient, next of kin
should be informed of the admission.
Bedwatch staff
104. The man’s former partner made a number of criticisms of the behaviour of
bedwatch staff. She alleged that individual officers seemed to have different
rules to follow. For example, there was inconsistency about whether they
asked for visitors’ names. She found some officers to be very helpful and kind
but this contrasted with poor behaviour by others. She said that some of the
officers from Hewell were fantastic whereas some of the ones from
Birmingham were unpleasant. She also said that bedwatch officers slept
whilst on duty some nights.
24
105. She particularly mentioned a male officer from the man’s wing who had shown
special sensitivity and care. Unfortunately, she could not remember his full
name but thought his first name was [name removed]. This officer was able to
tell her how well liked the man had been on the wing and how much he would
be missed. Another officer from Hewell she marked out for positive comment
was a bearded officer, who has since been identified.
106. Interviews were carried out with wing officers and bedwatch staff. Officers
from Birmingham told my investigators that they had not seen colleagues
sleeping and they had not slept themselves whilst carrying out bedwatch
duties. This was also confirmed by another officer who had carried bedwatch
duties at night.
107. It is difficult to say more about the allegations made by the man’s former
partner in light of the denial by the officers. I acknowledge the positive
comments by her in relation to officers from Hewell, and can only say that I
find the comments made about officers from Birmingham to be disappointing.
Bedwatch staff should be reminded of their duties and the sensitive
nature of carrying out those duties with terminally ill prisoners.
Family Liaison
108. Throughout his time in hospital, the man’s former partner found it hard to talk
with the wide range of individual officers on bedwatch duties. She commented
that no members of the prison management team spoke to her, despite
making regular checks of bedwatch staff. She would have appreciated a
single point of contact, and a named member of staff whom she could have
spoken to about her concerns.
109. Daily management checks of bedwatches are made by senior managers. The
checks are an essential part of ensuring the prisoner’s security and the safety
of staff. The management checks should have identified the difficulties of both
staff and family, particularly concerning the number of visitors and the
negative comments from the man’s family.
The Governor should ensure that management checks for bedwatches
address the need to support the staff and the family.
110. On the day that the man died, his former partner rang the duty governor at the
prison to tell him that the life support machine would be switched off. She felt
that it should not have been for her to take the initiative of telling him. If she
had been allocated a named link person with the authority to monitor and
explain bedwatch policies, she might have been saved some of the
discourtesy she says she experienced from some officers.
111. When a prisoner is taken into hospital for serious and terminal medical care,
the support of a family liaison officer is helpful to address issues and concerns
as they arise from the family and staff. This is even more essential when the
prisoner is entering the final phase of a terminal illness. Good communication
25
with the family at this very emotional time can provide support and comfort. It
also ensures that the practicalities following a death can be carried out
sensitively.
A family liaison officer should be appointed when a prisoner is seriously
or terminally ill in hospital.
Support for the man on the wing
112. The man was offered support and assistance by staff and prisoners on the
wing. It was noted that he was a compliant and pleasant prisoner. Although
very unwell, he asked if he could do any small task and was given the job of
cleaning the cell cards. This small piece of work gave him an opportunity to
spend some of his time in a constructive manner.
113. The man’s friends on the wing and those who worked in the servery assisted
him to carry and share food so he could have a meal when the kitchen failed
to provide a suitable diet. The officers on the wing also supported him in their
regular communication with the kitchen staff and healthcare staff, challenging
the inadequate meals sent for him. In particular, the assistant disability officer
tried to address the issue of his poor diet. I am pleased to recognise the
support and assistance given to the man by the assistant disability officer, and
by other staff and prisoners on houseblock six.
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CONCLUSIONS
114. The care and treatment received by the man during his time in Hewell was
generally well organised and documented by healthcare staff in both
houseblock six and the healthcare unit. Significant care and support was also
provided by the assistant disability officer, who had a key role to play, and by
other prison officers.
115. A more proactive approach to managing the man’s illness might have
occurred if healthcare staff had had a greater understanding of the
management of celiac disease, especially in more challenging circumstances
when the condition was not under control and there were indications of
previous neglect.
116. Many attempts were made to ensure that the man received an appropriate
gluten free and nutritious diet, and he often did. However, there were
systemic failings that prevented this happening as a matter of course for every
meal. This is very disappointing indeed.
117. Nevertheless, the clinical reviewers conclude that:
“It is likely that [the man] already had a lymphoma before he arrived in
prison, and that this was in part a cause of the symptoms that he
displayed during the following months.”
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RECOMMENDATIONS
The Chief Executive of the Primary Care Trust
1. The PCT should develop protocols covering healthcare provision in prison,
security, booking of appointments and communication for use when prisoners
visit a NHS Trust. A copy should be taken by the prison escort officers to hand
over to hospital staff at the first attendance.
Accepted – “The PCT has already made significant steps to improve its record
keeping and information systems. It has recently, successfully rolled out the
Systm 1 national record system. All transfers to hospital should go with a letter
outlining the patient’s current situation and any relevant treatment and other
details. However, we will look into introducing a pro-forma that ensures some
basic information is included along with the communication which is usually from
the GP.”
Head of Healthcare at Hewell
1. Prison healthcare staff should improve their awareness of the management of
celiac disease. In particular, consideration should be given to the clear and
consistent recording of significant indicators such as weight and the results of
blood and other tests; the use of referral to a dietician and to nurse specialists;
and the use of gastrointestinal review when the disease is not under control.
Accepted – “Training, either directly of through an on-line source to be provided
on recognising and treating a patient with celiac disease. The training will reflect
the recommendation that particular attention should be made of the patient’s
weight and other observations. Links will be made with the dietetic team in
county, to see if support can be provided in the prison setting.”
2. Scales used to weigh prisoners should be calibrated regularly to ensure
consistent and accurate readings.
Accepted – “Current scales will be reviewed and alternative scales sources if
necessary. The calibration will be tested in line with manufacturer’s
recommendations.”
3. A record should be made in medical notes if a special diet has been requested by
a healthcare professional. Any modifications to such a request should also be
recorded. There should be an ongoing accessible and up to date record in the
kitchen of any such request for as long as the prisoner remains in the prison and
requires the special diet.
Accepted – “Since [the man] was at HMP Hewell, Systm 1 – a new computerised
system for healthcare, has been implemented and this record allows for special
dietary arrangements to be recorded. Systems are already in place to identify
any special medical dietary needs. These are updated as information is
received.”
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4. The healthcare unit should remind all staff of the importance of signing entries in
the medical record, and writing or stamping their names legibly so that they can
be identified.
Accepted – “Systm 1 automatically records the date of entry and who made that
entry. Because the entry is typed it is legible and can be tracked back to the
person making that particular entry.”
5. Discharge care plans should be documented in the medical records when
prisoners move from the healthcare unit to house blocks.
Accepted – “Discharge plans will be developed through Systm 1.”
The Governor of Hewell
1. The Governor should ensure that all prisoners who require a special diet for
medical conditions receive appropriate meals. Steps should be taken to make
sure that special and medical diets are provided to the required standard as set
out in PSO 5000.
Accepted – “Systems are already in place to identify any special medical dietary
needs, however exceptionally food items may not be available through the
normal contract. In this instance they need to be procured through PCT. At
present there is not a written protocol in place for this. However, this will be
addressed.”
2. The Governor should ensure risk assessments are completed when hospital staff
raise the use of restraints. Escorting seriously ill prisoners can be within
acceptable boundaries and the use of physical restraints can take into account
the risk of physical injury to a frail person.
Accepted – “Risk assessment documents will be reviewed to ensuring medical
staff give clear views regarding the application of restraints to seriously ill
prisoners, as is current practice.”
3. The Governor should ensure that management checks for bedwatches address
the need to support the staff and the family.
Partially accepted – “Management visits will ensure support is given to prisoner
and staff as is current practice. Advise to be given to bedwatch staff that family
liaison officer (FLO). Family will be supported by FLO.”
4. A family liaison officer should be appointed when a prisoner is seriously or
terminally ill in hospital.
Accepted – “FLO will contact family when initially transferred to hospital.”
5. When a prisoner is admitted to hospital as an in-patient, next of kin should be
informed of the admission.
29
Partially accepted – “Where a prisoner has been diagnosed as seriously ill, then
consideration will be given to notifying NOK based on risk assessment.”
The Governors of Hewell and Birmingham
1. Bedwatch staff should be reminded of their duties and the sensitive nature of
carrying out those duties with terminally ill prisoners.
Accepted – “Brief to be raised for staff who are conducting supervision of
seriously or terminally ill patients.”
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