Individual at Frankland

Investigation into the circumstances surrounding the
death of a man, a prisoner at HMP Frankland,
in February 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2010
This is the report of an investigation into the circumstances of the death of a man in
February 2009. He was 68 years old and a prisoner at HMP Frankland. He died at
hospital from post operative complications following planned surgery to repair an
aortic aneurysm.
Although the man had been unwell with suspected heart problems for some time, the
aortic aneurysm was only diagnosed shortly before his death. He was a Jehovah’s
Witness. His refusal to have a blood transfusion because of his religious beliefs was
a complicating factor, and his death was sudden and unexpected. I offer my sincere
condolences to all who knew him and were affected by his death.
My colleague conducted the investigation on my behalf. An independent review of
the man’s medical care was undertaken by a clinical reviewer on behalf of the local
Primary Care Trust. I am grateful to him for his very valuable contribution. I would
also like to thank the Governor and staff at Frankland for their cooperation and
assistance with the investigation. I am particularly indebted to the liaison officer who
provided a high standard of liaison to my investigator. I must apologise for the delay
in issuing this report.
A Root Cause Analysis of the man’s clinical care while in hospital was also
undertaken by the NHS Foundation Trust. I am very grateful to the Trust for
disclosing their report to my office. The Patient Safety Manager gave consent on
behalf of the Trust for the Root Cause Analysis to be annexed to this report.
The man gave his former wife as his next of kin. The prison tried to notify her of his
passing but discovered, sadly, that she had herself died some time before him. He
had also nominated a Jehovah’s Witness minister who was unaware that he had
done so. There were no other named next of kin who could be involved in the
investigation.
I make four recommendations in my report. The first relates to the cancellation and
re-arrangement of medical appointments: the reasons for any cancellation should be
clearly marked in the prisoner’s medical record with an audit trail to the clinician who
agreed the decision. The second asks the Head of Healthcare to ensure that, if
handwritten entries are made on a medical record, the corresponding information is
also entered on the EMIS computer system. A third recommendation asks the Head
of Healthcare to ensure the regular review of prisoners with long term medical
conditions within nationally accepted guidelines. The fourth and final
recommendation relates to the recording of all significant medical conditions in a
prisoner’s medical records so that they are easily accessible to the healthcare
professionals providing care.
2
The National Offender Management Service has accepted my recommendations and
their response is documented on page 21 of my report.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2010
3
CONTENTS
Summary
The investigation process
HMP Frankland
Key findings
Issues
Recommendation and commendations
4
SUMMARY
The man was sentenced to life imprisonment on 14 December 2001 at Crown Court.
He served his sentence at Frankland until his death in February at hospital from a
haemorrhage following planned surgery. He was 68 years old.
Throughout his sentence, the man attended prison healthcare for various medical
complaints. He complained of a pounding heartbeat in November 2004 and
underwent an electrocardiogram (ECG) the following year. (An ECG is a test to
measure the electrical activity of the heart.) The prison doctor was concerned that
the ECG showed he had a slow heart beat. The doctor referred him to a consultant
cardiologist and in July 2006 he was diagnosed with a leaking heart valve and high
blood pressure. A yearly review of the condition was advised.
In December 2006, the man complained of chest pain and was sent to hospital as an
emergency but discharged the following day with a diagnosis of non-specific cardiac
pain. A few months later, the hospital wrote to prison healthcare staff to give the
result of a 48 hour ECG. In that letter, the hospital raised concerns regarding the
cancellation of cardiac clinic appointments by the prison.
In July 2007, the man changed his religion from Roman Catholic to Jehovah’s
Witness. He signed an Advance Medical Directive form consenting to all necessary
medical treatment but not blood transfusions or blood products. Records show that
medical staff at the prison and the hospital discussed the implications of this with
him. This is relevant to the circumstances surrounding his death as his religious
beliefs affected his medical treatment when he needed a blood transfusion following
surgery shortly before he died.
The man continued to attend healthcare and hospital appointments throughout 2007
and 2008. He was diagnosed with triple vessel disease in February 2008 and
surgery was recommended. In May 2008, the cardiologist referred him to a
cardiothoracic surgeon at hospital. The surgeon decided to take a joint approach
with a vascular surgeon. This was because a scan had revealed that he had an
aortic aneurysm as well as a leaking heart valve. The hospital consultants had to
decide in which order to treat the leaking valve and the aneurysm as both were life
threatening conditions. They decided that he would undergo heart surgery first
followed by a repair to the aortic aneurysm.
Further concerns around the cancellation by the prison of an appointment for a
medical procedure to deal with the man’s heart problem were raised by the
consultant cardiologist in September 2008. The medical procedure was successfully
carried out in December.
In February 2009, the man underwent surgery to repair the aneurysm. While in the
intensive care unit, complications arose and he was returned to the operating
theatre. He deteriorated further and prison officers escorting him throughout have
described a “magnificent effort” by hospital staff to save his life. Their efforts were
sadly unsuccessful and he died shortly after.
5
The man did not have next of kin and had nominated the prison’s Jehovah’s Witness
minister, who was unaware he had been so appointed.
The clinical reviewer has made a number of recommendations relating to record
keeping and the management of patients with long term medical conditions that I
endorse. He has also raised the issue of the cancellation of important hospital
appointments. I have been unable to determine conclusively whether the prison or
the hospital cancelled those appointments, although the available evidence suggests
strongly that the prison was responsible on a number of occasions.
As the man was a prisoner at the time of his death, the hospital undertook a Root
Cause Analysis to review his care. They concluded that he died from bleeding
following surgery and raised concerns that prison escort staff witnessed the
traumatic details of surgery.
My investigation found that the man received healthcare comparable to that which he
would have received in the community.
6
THE INVESTIGATION PROCESS
1. I was notified of the man’s death in February 2009. Terms of Reference and
notices were issued to staff and prisoners at Frankland telling them that an
investigation would be taking place, and inviting those who wished to see the
investigator to make themselves known. My investigator requested copies of his
core and clinical records, as well as other documents relevant to his time in
custody and to his death.
2. My investigator also contacted the Coroner to inform him of the nature and scope
of my investigation and to request a copy of the post mortem report. The report
concludes that the man died of:
1a: Haemorrhage, due to
1b: Repair of atherosclerotic abdominal aortic aneurysm.
3. A clinical review of the man’s medical care was commissioned from the local
Primary Care Trust (PCT) and undertaken by a clinical reviewer. He focussed on
the medical care he received at Frankland and while at hospital. He reviewed all
necessary records and conducted interviews jointly with my investigator. His
review appears as an annex to this report.
4. My investigator visited Frankland in May 2009 with the clinical reviewer. She
toured A wing where he had been located and spoke with staff and prisoners
who knew him. She also spoke with a member of the prison’s Independent
Monitoring Board (IMB).
5. The man did not have any next of kin who wished to be involved in the
investigation. He had nominated the prison’s Jehovah’s Witness minister but he
did not know about this.
7
HMP FRANKLAND
6. HMP Frankland is part of the Prison Service’s High Security Estate. It holds
prisoners convicted of serious offences including category A prisoners, as well as
those serving life sentences and sentences of over four years. The maximum
prison capacity is 732 men. Frankland has been assessed as one of the
National Offender Management Service’s high performing prisons.
7. The prison’s inpatient healthcare centre has 18 beds. The healthcare
department has adopted ‘teleheal’ technology. This is a diagnostic service with a
direct camera link between the prison and a hospital Accident and Emergency
Department. It means a doctor within the prison can have a second opinion on a
medical problem from a consultant at the hospital. There are good links with the
Primary Care Trust, with visiting consultants for orthopaedic clinics, a dental
suite, digital x-ray facilities, and two full time doctors.
8. In her inspection report published in June 2008 HM Chief Inspector of Prisons
acknowledged the difficulties Frankland faced with a challenging, albeit relatively
static, population. She assessed that healthcare provision was good, with well-
maintained accommodation
9. In their last available report dated 2006, the prison’s Independent Monitoring
Board (IMB) identified problems relating to difficulties in transferring prisoners to
other prisons where they could access courses in order to progress through their
sentence. A member of the IMB told my investigator that the IMB viewed the
prison as professionally run by both governors and staff. He described prisoners
as receiving “fair treatment” and considered that “processes were adhered to”
despite frustrations in dealing with a cumbersome and bureaucratic culture.
10. I have raised concerns in previous death in custody investigation reports that
important medical appointments in the community have been cancelled by
Frankland because of a lack of escort staff. My investigator raised this issue with
the prison during this investigation as both she and the clinical reviewer noted
that it was a relevant factor in the care the man received.
8
KEY FINDINGS
11. The man was remanded into custody at HMP Forest Bank on 13 February 2001.
He was convicted of serious sexual offences and sentenced to life imprisonment
with a tariff of seven years and one month on 14 December 2001 at Crown
Court. (A ‘tariff’ is the minimum time that must be served in prison before release
can be considered by the Parole Board.) His tariff was due to expire in January
2009.
12. The man had served lengthy sentences for similar sexual offences in the past,
and asked to be protected from other prisoners under prison rule 43 (now rule
45) and the prison agreed. (Rule 45 is a provision under which prisoners can be
segregated from others for the good order of the prison or for their own
protection.)
13. An entry in the man’s records dated 27 December 2001 says that, while in the
segregation unit, he was coping well with the news that he had been sentenced
to life imprisonment.
14. In early 2002, the man regularly attended the healthcare centre in Forest Bank to
have an abscess on his left knee dressed. He moved to HMP Frankland in
March 2002 where he remained until his death. A reception interview identified
that he should attend for an asthma assessment. His knee condition
deteriorated and he was sent to hospital for treatment.
15. The clinical record reflects that the man did not attend the asthma clinic on a
number of occasions, but no explanation is noted. On 28 January 2003, an entry
in the clinical record shows that he received reassurance from the healthcare
department about experiencing a heightened awareness of his heartbeat. He
also attended healthcare throughout 2003 and 2004 with a foot wound requiring
frequent treatment and dressing. Action plans were drawn up, implemented by
healthcare staff, and reviewed by a prison doctor. An entry in the clinical record
dated 18 June, with an illegible signature, said that a recurrence of tinea pedis1
was suspected as the reason why his foot condition would not heal.
16. The man continued to attend healthcare during 2004 for asthma reviews and to
have his foot dressed. In November 2004, he attended an asthma review in
which he told the healthcare worker he was using the inhaler as directed and that
he was experiencing a pounding heart rate. He was advised that this was
normal but it was noted he was reluctant to accept this assessment. He was
also advised to mention his pounding heartbeat to the doctor when he next saw
him.
17. The following year, an entry in the clinical record dated 7 December 2005 says
that the man had an Electrocardiogram (ECG). Healthcare staff were not
concerned about the result and gave no supporting reason for further
investigation as he was said to look and feel well at the time. However, a prison
doctor wrote to a consultant cardiologist at hospital on 9 December 2005 asking
1Tinea Pedis is more commonly known as Athlete’s Foot, a fungal infection.
9
him to comment on the ECG. Although the prison doctor acknowledged that the
man did not have a family history of heart problems, he noted that his pulse was
slow and wondered if the changes on the ECG were significant.
18. On 23 March, the hospital Cardiology and Respiratory Investigations Unit sent an
appointment to the man for a further ECG on 31 March 2006. He attended the
appointment and was diagnosed as suffering from moderate left ventricular
hypertrophy2 (LVH).
19. A few days later on 3 April 2006, the prison doctor wrote a further letter to the
consultant cardiologist saying he was uncertain whether the man’s problem was
due to his blood pressure which had risen from 140/65 to 193/73 at the last
reading. The cardiologist’s response confirmed the previous diagnosis of LVH
and suggested that the man had high blood pressure. He advised that the
hospital should conduct a clinical assessment of the man’s aortic valve disease
and that he would arrange a routine clinic appointment on the prison’s behalf.
The appointment was made for 6 July.
20. The prison doctor wrote to the man on 8 May 2006. He explained that the
consultant cardiologist was concerned that he might have mildly raised blood
pressure and that his heart valve was slightly leaking. He advised him that he
would need to begin taking medication to reduce his blood pressure. This
included penicillin to cover the possibility of any future operations to the heart
valve.
21. The man went to the hospital on 6 July. He was diagnosed with mild aortic
stenosis3, moderate aortic valve regurgitation4 and high blood pressure. His
prescription for ramipril5 was increased to control his blood pressure and help
with his LVH, while that of his inhalers for asthma remained unchanged. There
was no indication that surgery was required at this stage, but it was
acknowledged that he might need this at some point. A yearly review was
advised.
22. The prison doctor told the man of the outcome of his hospital appointment. He
placed responsibility upon him to keep in touch with healthcare regarding his
heart condition.
23. On 17 December 2006, the man went to healthcare saying he had central chest
pain that radiated down both arms and into his neck. He was sent to hospital as
emergency. He was discharged the following day with a diagnosis of non-
2Left ventricular hypertrophy is enlargement (hypertrophy) of the muscle tissue that makes up the wall
of the heart's main pumping chamber (left ventricle).
3Aortic stenosis is a narrowing which restricts red blood from moving from the left ventricle into the
aorta.
4Aortic regurgitation (AR) is the leaking of the aortic valve of the heart.
5Rampiril is an ACE inhibitor (trade name Altace) used to treat high blood pressure or in some
patients who have had a heart attack.
10
specific cardiac pain, an ECG having showed some ischaemic changes.6 His
medication on discharge was aspirin, ramipril7, amlodipine8, cetirizine9,
citalopram10 and inhalers for asthma. The clinical reviewer has questioned the
prescription of citalopram as there is no mention in the clinical notes of him
suffering from depression.
24. An appointment was made for the man to have a computerised tomography (CT)
scan on 29 January 2007. (A CT scan creates detailed images of the inside of
the body, giving good pictures of the soft tissues of the body which do not show
on ordinary x-rays.) The appointment was changed by a handwritten note on the
letter to 7 February 2007. No reason is given in the clinical record.
25. On 8 January 2007, the man attended the clinic of a consultant ear, nose and
throat surgeon. The man had longstanding nasal difficulties following an injury in
earlier life. An urgent scan was advised and an appointment given by the
hospital for 26 March 2007 at 4.00pm. He did not attend. The appointment letter
is crossed through and a note “cancelled – staff and time” is written on the lower
right hand side. The hospital wrote to the prison on 26 March to advise that he
had not attended his appointment. This suggests that the prison might not have
told the hospital to cancel the appointment. A note at the bottom of the letter
says that the appointment was cancelled by the prison due to the time it was
scheduled and the prison was awaiting a further appointment. An entry in the
clinical record dated 27 March confirms that he should have attended the ENT
clinic the day before but this was cancelled by the prison. This was not the first
occasion that his appointments with the hospital were cancelled and I address
the matter later in this report.
26. The clinical record shows that, on 14 May 2007, the man went to the healthcare
centre complaining of chest pain. The prison doctor referred him to a cardiac
consultant at hospital, giving a brief history and asking for her advice on the
nature of the chest pain. The consultant responded by letter on 21 May that the
chest pain could be due to a number of causes, and she would assess the man
shortly on his annual review. However, at that review clinic, he denied having
chest pain or tightness on exertion in the previous December.
27. On 4 June, the cardiac consultant invited the man to have a 48 hour ECG at the
hospital. (A portable tape recorder would be fitted to record the rhythm of his
heart.) The result of the investigation was detailed in a letter from the consultant
to the prison doctor on 23 July. In that letter, she said that the man’s original
review was due in July but the prison had changed it to 16 October 2007 and had
also cancelled the September appointment. She was concerned about this and
said that she would contact the prison again after his review in October.
6Ischaemia means a reduction in the blood supply, usually as a result of a blocked artery, causing
less oxygen to be transported to tissue.
7Ramipril is a drug used to treat high blood pressure.
8Amlodipine is a long-acting calcium channel blocker used for treating high blood pressure and in the
treatment of angina.
9Cetirizine is a non-sedating antihistamine used in the treatment of allergic rhinitis.
10 Citalopram is an anti-depressant drug used to treat major depression associated with mood
disorders.
11
28. Meanwhile, healthcare staff continued to monitor and treat the man for
hypertension (high blood pressure). The handwritten clinical record shows that
he had an ECG at the prison around 18 July and the results were sent to the
cardiac consultant.
29. The man’s core record contains a signed Notification of Change to Religious
Registration indicating that he changed his religion from Roman Catholic to
Jehovah’s Witness in July 2007. This is significant as he was unable to have a
blood transfusion when his condition deteriorated after surgery shortly before he
died.
30. My investigator and the clinical reviewer spoke with a prisoner who knew the
man well. Regarding his conversion to Jehovah’s Witness, the prisoner thought
that he “believed in it deeply” and was aware he might need blood during any
future surgery but would refuse. The prisoner was not confident that the man
fully understood the consequences of refusing a transfusion. However, he had
also told him that he was not bothered about it as he was not going to be
released from prison as he had “nothing to go back to”.
31. Healthcare staff were called to the wing on 21 August 2007 when the man
experienced palpitations and shortness of breath after lifting boxes. He was
advised to go to healthcare if he felt any further episodes, but declined to attend
the doctor that evening.
32. Neither the electronic nor the handwritten clinical records show that the man
attended the cardiac consultant’s clinic on 16 October 2007. However, she wrote
to the prison doctor following the man’s attendance thereby evidencing that he
did go to the clinic. She found him “somewhat vague and variable” when he
gave her his medical history, but she was pleased to hear that he had given up
smoking in January 2007. She confirmed he had been placed on the waiting list
for a coronary angiography to explore whether he had coronary artery disease,
and she hoped to perform this within the next two months.
33. On 13 February 2008, the man attended the healthcare cardiovascular disease
(CVD) clinic. He said he had stopped smoking a year before and felt better for it.
He had managed his high blood pressure by using his religious beliefs to reduce
the stress in his life. He was given the opportunity to ask questions about his
health but declined saying that he was fine at the time.
34. The man saw the cardiac consultant at hospital on 20 February 2008. He
underwent a cardiac catheterisation11 procedure and was diagnosed with triple
vessel disease. An entry in the clinical record notes his religion as a Jehovah’s
Witness and that surgery was recommended. It was also implied that there were
issues to be discussed about further surgery and his religious beliefs.
11 A coronary catheterisation is a minimally invasive procedure to access the coronary circulation and
blood filled chambers of the heart using a catheter. It is performed for both diagnostic and treatment
purposes.
12
35. On 21 April, the man signed an Advance Medical Directive form, witnessed by
the Jehovah’s Witness minister. The form confirmed that he consented to all
necessary medical treatment excluding the transfusion of blood or blood
products.
36. The cardiac consultant referred the man to a consultant cardiothoracic surgeon
at another hospital. In her referral letter of 27 May, she gave a detailed
background of his medical history including information regarding the cardiac
catheterisation performed in February. A computerised tomography (CT) scan
revealed that he also had an aortic aneurysm12 measuring 7.5cm in diameter.
She said that he wished to be considered for cardiac surgery, and that she had
referred him to a vascular surgeon for an opinion on management of the
aneurysm. She suggested to the cardiothoracic surgeon that he might wish to
consider a joint approach with the vascular surgeon. She copied her letter to the
prison doctor at the prison and asked him to discuss the situation with the man.
37. In addition to the man’s heart complaint and aortic aneurysm, he also had a long
term chest complaint and arthritic pains. On a routine appointment in June a
healthcare worker thought he appeared a little anxious about his forthcoming
operation. He recorded that he would review the man again shortly.
38. The consultant vascular surgeon wrote to the cardiac consultant in early June to
advise that he had arranged for an urgent CT scan to see if the man was suitable
for surgery for the aneurysm. On 8 July, he wrote to the prison doctor saying
that he and the vascular surgeon had concluded that the best course would be
for the man’s heart to be treated first and then the vascular surgeon would
arrange to repair the aortic aneurysm. The vascular surgeon commented that
the cardiothoracic surgeon had planned to see the man on 7 July but the prison
had cancelled the appointment “due to lack of prison warders”. He said that the
cardiothoracic surgeon would be able to see him in two weeks with surgery
planned for August. The vascular surgeon asked the prison doctor if there was
any added weight that the hospital could give to the man’s case regarding “the
prison officer staffing side of things”. Again, I refer to the matter of the
cancellation of appointments later.
39. The man told healthcare staff on 15 July that he was using the GTN13 (glyceryl
trinitrate spray) much more often, even for the smallest physical exertion. He
was advised not to exert himself too much as it appeared that he was making
himself do some form of exercise regardless of whether he felt like it. He was
asked to tell discipline staff if he was finding it too hard to keep his cell clean and
make his bed. If so, healthcare staff would be able to help him manage his daily
living.
40. The cardiothoracic surgeon wrote to the cardiac consultant confirming he had
spoken to the vascular surgeon about the man’s conditions. The cardiothoracic
12 Dangeous ballooning of the aorta (the main artery leaving the heart) caused by disease to the
artery's wall.
13 Glyceryl trinitrate (GTN) is an alternative name for the chemical nitroglycerine, which has been
used to treat angina and heart failure.
13
surgeon said that the vascular surgeon was quite worried about the possibility of
the aneurysm rupturing. From the content of the letter it is clear that the
cardiothoracic surgeon knew that the man was a Jehovah’s Witness. An
angioplasty was considered to be a suitable method of dealing with the heart
problem, with the added benefit that he would quickly be able to have “life saving
aneurysm surgery” if this route was adopted.
41. In her letter dated 2 September, the cardiac consultant says she saw the man at
the hospital on that day. She said that the percutaneous coronary intervention
(PCI)14 (otherwise known as an angioplasty) planned in August to deal with his
heart problem had been cancelled by the prison due to shortage of staff. There
is no entry in his medical record referring to either the appointment or the
cancellation. She discussed his planned surgery with him. She told him that he
did not need aortic valve surgery at present and that, following his PCI, the
vascular surgeon would carry out surgery to repair the aortic aneurysm. She
would review him in six months when she expected both operations to have been
carried out.
42. The external appointments clerk at Frankland made an entry in the man’s clinical
record on 11 November 2008. She said that the appointment for the angioplasty
operation had been cancelled by the hospital as the doctor was unavailable. In
contrast, the doctor recalls that the prison cancelled the appointment due to the
unavailability of prison staff. Meanwhile, the prison continued to monitor the
man’s other health conditions such as his eye care, chronic rhinitis, bladder
problems and asthma.
43. The doctor carried out the PCI on 17 December. He wrote to the prison doctor at
the prison on 13 January, commenting that he hoped the surgery would relieve
the man’s angina. He suggested medication should be continued (aspirin and
clopidogrel15) for four weeks, and at that point a repair to the aortic aneurysm
could be considered if necessary. The man returned to his cell at his own
request (rather than staying in healthcare), and staff saw that he looked well with
no further problems.
44. On 3 February 2009, a Risk Assessment for Hospital Escort/Bed watch form was
completed. Restraints were to be applied on leaving the prison and removed
once the man was under anaesthetic. They were to be reapplied in the recovery
room before he regained consciousness. He was said to be an enhanced
status16 prisoner with no adjudications against him and was not at risk of self-
harm.
45. On 8 February, the man was admitted to ward 13 at hospital for the operation to
repair the aortic aneurysm. At 11.00pm that day, the escorting officers recorded
14 Percutaneous coronary intervention is a procedure used to open blocked blood vessels that cause
heart attacks.
15 Clopidogrel is an oral antiplatelet agent used to inhibit blood clots in coronary artery disease.
16 There are three levels under the Incentives and Earned Privileges scheme: basic, standard and
enhanced. Enhanced status is the highest level for those prisoners who comply with the prison rules
and address their offending behaviour. It confers privileges such as additional visits.
14
in the bed watch log17 that he had been polite and cooperative while travelling to
the hospital.18 It was also recorded in the log that he did not have next of kin but,
in the event of a difficulty, he wished his former wife and the prison chaplain to
be told. The hospital had the contact details. It was noted in the log that he had
signed “forms from the surgeon” to confirm that he did not wish to have a blood
transfusion.
Events in February
50. Events on the day of the operation were recorded in the bedwatch log. The man
was prepared for his operation early in the morning. Medical staff explained to
him in depth what would happen during the operation and the risks involved. The
log indicated that he was happy and underwent the operation at around 9.30am.
The officers were able to watch the operation through a window with loosely
slatted blinds.
52. The operation ended at 2.30 pm, and the man was placed in the intensive care
unit where he was assessed constantly by staff. The Root Cause Analysis (RCA)
document19 completed after his death said he had lost 900ml of blood during
surgery and received four litres of Hartmans20 plus 450 mls of saved blood. The
operation was described as “uneventful” and a plan of how to manage him post-
operatively was put in place.
53. Around 15 minutes later, the man began to deteriorate and medical staff were
concerned. The RCA said that he was noted to be pale and clammy with a
distended stomach. The consultant was not overly concerned at this point and
went to operate on another patient. The size of his stomach gradually increased
and medical staff told the consultant surgeon.
54. By 3.30pm, there was little sign of improvement in the man’s condition. An hour
later, medical staff began cardio pulmonary resuscitation (CPR) because he did
not have any blood pressure.
55. Two officers21 were the escort officers on duty at the hospital and were present
during the medical team’s efforts to save the man when he returned from the
operating theatre on the first occasion. Officer A said that once the man began to
deteriorate, the medical team made a “magnificent effort” to save him.
56. The on-call surgeon reviewed the man while the consultant surgeon was
performing another operation. He was taken back to the theatre at around
4.30pm. Both officers watched the operation in the preparation room outside the
17 A Bedwatch Log is the written history of time and events taking place while the prisoner is out of the
prison in hospital. Escort officers are responsible for recording the details.
18 A Bedwatch officer is a prison officer who escorts the prisoner to the hospital and remains with
him/her at all times. This is to maintain the safety and security of the public and to ensure that the
prisoner does not escape.
19 A Root Cause Analysis is a formal review of clinical care of a patient that is undertaken by the
hospital when a patient dies.
20 Hartmans is a substitute solution for blood products that is acceptable to Jehovah’s Witnesses
during operations.
21 Officer B was not interviewed for this investigation as he was on sick leave.
15
operating theatre. The escorting officers were told by hospital staff that the first
operation had to be repeated. However, their efforts to save the man were
unsuccessful as they could not stop the bleeding.
57. While the man was in the operating theatre, a surgeon asked one of the officers
to try and contact the Jehovah’s Witness minister as the man had nominated him
as his next of kin. The minister arrived at 6.27pm. He spoke with medical staff
and spent a few minutes at the man’s bedside. A few minutes later the prison
officers were told that he had died.
Events after the man’s death
57. Officer A recorded that another officer on duty, Officer C, had contacted the
prison at 7.10pm to give prison staff essential information regarding the time of
the man’s death. Officer C also gave the name of the member of the medical
staff (consultant anaesthetist) who pronounced the man death. In respect of the
man’s next of kin, Officer C explained to the Duty Governor that the Jehovah’s
Witness minister was unaware he had been nominated as next of kin and did not
wish to be involved.
58. The police were called in accordance with procedures following a death. A police
constable and Officer C identified the man at 8.10pm. The prison officers left the
hospital to return to the prison at 8.45pm.
59. Officer A told the investigator that, upon their return, the Duty Governor, orderly
officer and care team met with them. A hot debrief was carried out and they were
given very good support, with members of the care team enquiring after their
wellbeing some weeks after the man’s death.
16
ISSUES
Cancellation of appointments and record keeping
62. This investigation has revealed that several of the man’s hospital outpatient
appointments were cancelled. The clinical reviewer was greatly concerned that
they had been cancelled because of a shortage of prison escort staff. He
explained that the man had two potentially life threatening conditions. In his
opinion, the prison healthcare department did not appreciate the seriousness of
the conditions and had left it to administrative staff to alter and cancel
appointments.
63. My investigator and the clinical reviewer interviewed the external appointments
clerk during the investigation. She told the clinical reviewer and my investigator
that the reasons for the cancellations had not been recorded. She said that she
was permitted two escorts to hospital per day, one in the morning and the
afternoon, and had to prioritise prisoners. Around two hospital appointments per
month were cancelled because of a lack of escort staff and, at the time my
investigator visited in May 2009, she said seven had been cancelled since
January. While someone unclear regarding what happens if an escort is not
available for an appointment, she said that she would ask the Head of Healthcare
or another medically qualified member of staff for advice before she cancelled it.
64. The clinical reviewer sought further clarification on the matter and wrote to the
cardiac consultant, consultant cardiologist and cardiothoracic surgeon. All were
clear that the cancellation of appointments was at the behest of the prison, and I
annex copies of each of their letters to this report. However, the medical record
entry made by the external appointments clerk on 3 November 2008 says that
the appointment for the man’s angioplasty was cancelled by the hospital as the
consultant cardiologist was on leave. She made a similar entry around a week
later saying that the provisional appointment made for that day had been
cancelled as the surgeon was unavailable. In his letter to the clinical reviewer,
the cardiothoracic surgeon’s recollection appears to contradict this. He recalls
that the consultant cardiologist had a “number of frustrations in getting the patient
transferred over” and the PCI was not carried out until December.
65. I am critical of some of the record keeping at Frankland. The prison uses a dual
system of handwritten notes alongside a computerised system. The
computerised system was in place in August 2006, but healthcare staff used
handwritten notes in parallel without updating the IT system with the potential for
important clinical information to be lost. For example, the reference in the
handwritten record to a healthcare discussion regarding the man’s forthcoming
operation and his religious faith dated 21 February 2008 does not appear in the
computerised medical record. Neither record mentions the hospital appointment
scheduled for 7 July or its cancellation.
66. Due to this poor record keeping, it is difficult for Frankland to evidence that the
cancellations were initiated by the hospital. Moreover, the written recollection of
the consultants places responsibility on the prison. Moreover, there is
contemporary evidence to consider. In his letter of 8 July 2008 to the prison
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doctor, the vascular surgeon is very clear that the prison had cancelled the man’s
appointment with the cardiothoracic surgeon on 7 July. The clinical reviewer
says:
“The consultant cardiologist had planned to carry out percutaneous coronary
intervention in the third week of August 2008. However when this date was
given to the Prison Service, the hospital was notified that this date was not
suitable because of a shortage of staff available to escort the man to hospital.
He had an appointment to see the cardiac consultant in July 2007 and this
appointment was changed on several occasions by the prison authorities.
The cardiac consultant states that no appointments were cancelled by the
hospital.”
66. The issue of whether the prison or the hospital cancelled appointments for the
man remains unresolved, albeit the available evidence points strongly in the
direction that on a number of occasions the prison was responsible. Whatever
the case, it was evidently very unfortunate that hospital appointments to
investigate and manage his serious medical conditions were not met. The
clinical reviewer has noted that the man had two potentially life threatening
conditions. In his opinion, the prison’s healthcare department did not appreciate
the seriousness of the conditions and left it to administration staff to alter and
cancel appointments. I endorse the clinical reviewer’s recommendations in
respect of this issue.
The Governor and the Head of Healthcare should review the policy relating
to cancelling and re-arranging appointments. The reasons for
cancellations should be clearly marked in the medical records with an audit
trail to the clinician who agrees the decision.
The Head of Healthcare should ensure that if handwritten entries are made
on a medical record, the corresponding information is also entered on the
EMIS computer system.
Prisoners with long term conditions
67. The clinical reviewer has noted that the man was diagnosed with hypertension in
July 2006, but could not find evidence of regular monitoring of his blood pressure,
cardiac condition or a review of his aneurysm by healthcare.
The Head of Healthcare should ensure that prisoners with long term
conditions such as hypertension and ischaemic heart disease should be
regularly reviewed in accordance with nationally accepted guidelines.
The computer record
68. The clinical reviewer has noted that the Active Problems section of the EMIS
computerised record system does not give an easily accessible summary of his
significant medical conditions. I endorse his recommendation in that regard.
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The Head of Healthcare should ensure that healthcare staff review and
record all significant medical conditions in the medical records so that they
can be easily accessible to the healthcare professional providing care.
Significant medical conditions should be highlighted in the Active
Problems section of the computer records.
Root Cause Analysis
69. As the man was a prisoner at the time he died, a Root Cause Analysis (RCA)
was undertaken by the NHS Foundation Trust. This focussed on his clinical care
while in hospital. The root cause of his death was stated as “bleeding following
surgery for abdominal aneurysm repair”. A notable finding was the hospital’s
concerns that prison staff remained with the prisoner throughout the surgery and
following recovery and saw “all the traumatic details of a massive bleed with
chest and abdomen open”.
70. The investigator raised this issue with Officer A and with the Security Policy
Section at National Offender Management Service. Officer A said that he and
Officer B attended the man while in the preparation room outside the operating
theatre. This was because he was still handcuffed by an escort chain to Officer
A. (This is a long chain with a handcuff at both ends. An officer is handcuffed to
the prisoner via the chain. It is used when a prisoner is on bedwatch or being
examined if there is deemed to be a risk of escape.) Both officers had to wait for
the man to be sedated for his operation before the handcuffs could be safely
removed. This was in accordance with policy and best practice. Before entering
the preparation room, both officers had to remove their clothing and wear the
same sterile gowns and masks as the surgical staff.
71. The actions of the hospital are not within my remit as Ombudsman. However,
the Governor may wish to raise the issue with the hospital trust and ask that,
where possible and appropriate, surgical staff close the blinds on windows in
operating theatres to protect prison staff from unreasonable exposure to surgical
procedures on prisoners.
The man’s religious beliefs
72. The man made formal declarations that for religious reasons he would not be
prepared to have a blood transfusion. Both the prison and the hospital explained
to him the potential consequences. He also discussed it with a fellow prisoner
who considered that, as well as being constrained by the doctrines of his faith he
was unconcerned about the possible impact as he thought he would never leave
prison. The post mortem report says that, although the outcome might have
been the same, his “chances of survival would have been greater if transfusions
had been available”.
Conclusion
73. The man was already in late middle age, with a number of pre-existing medical
conditions, when he entered prison in 2001. Two life threatening conditions were
diagnosed during his sentence, namely a leaking aortic valve and an aortic
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aneurysm. This investigation has found that important appointments to treat
these two conditions were cancelled. It is not entirely clear whether these were
cancelled by the prison or the hospital as each party cites the other as
responsible. The available evidence suggests strongly that the prison was
responsible on at least some occasions.
74. In July 2007, the man changed his religious belief to that of a Jehovah’s Witness.
As a result, he was unable to benefit from a necessary blood transfusion
following complications after surgery. This had a considerable impact on his
chances of survival.
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RECOMMENDATIONS
1. The Governor and the Head of Healthcare should review the policy relating
to cancelling and re-arranging appointments. The reasons for
cancellations should be clearly marked in the medical records with an audit
trail to the clinician who agrees the decision.
Accepted. This new process has been implemented since beginning of February
2010.
2. The Head of Healthcare should ensure that if handwritten entries are made
on a medical record, the corresponding information is also entered on the
EMIS computer system.
Partially accepted. Full electronic records have been used since mid 2007. Old
IMR are no longer used as current working documents. Go Live date for transfer
to TPP is July 2010.
3. The Head of Healthcare should ensure that prisoners with long term
conditions such as hypertension and ischaemic heart disease should be
regularly reviewed in accordance with nationally accepted guidelines.
Accepted. Within the man’s records his Blood Pressure recordings were
identified as such and not coded as “Hypertension”. He had a number of blood
pressure checks in the year prior to his death – in excess of the nationally
accepted guidelines. Coding issues will be addressed in line with the Go live
date for transfer to TPP.
4. The Head of Healthcare should ensure that healthcare staff review and
record all significant medical conditions in the medical records so that they
can be easily accessible to the healthcare professional providing care.
Significant medical conditions should be highlighted in the Active
Problems section of the computer records.
Accepted. This coding issue has been identified due to the poor training
schedule for the original rollout of EMIS. This action will also be addressed in the
Go-Live in July for TPP. Significant work is being undertaken regarding coding
and clinic templates prior to July and a standardised approach across the cluster
is to be implemented.
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