Individual at Norwich

Investigation into the death of a man
whilst in the custody of HMP Norwich in November 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2010
This is the report of an investigation into the death of a man, a prisoner at HMP
Norwich. He died on 25 November 2009, in the healthcare centre. He was 64 years
old. I offer my condolences to his family and friends for their loss.
He had a significant medical history of chronic disease, including hypertensive
disease, gastric problems, heart disease and angina. In 2007, he was diagnosed
with a malignant tumour of his rectum and prostate, which later spread to his bones,
liver and lungs. He failed to respond to chemotherapy and the disease eventually
led to his death.
This investigation was carried out by one of my investigators. I would like to thank
the governor of HMP Norwich and the family liaison officer for their participation and
invaluable assistance in the investigation. The clinical reviewer who undertook a
review of the man's clinical care, on behalf of Norfolk Primary Care Trust, and I
appreciate her assistance.
I am satisfied that the level of care delivered by the healthcare team was adequate
and I am pleased to note the level of decency and dignity that terminally ill prisoners
receive at Norwich. The clinical review makes eight recommendations regarding
clinical matters, which I endorse. I make two recommendations regarding the
provision of escorts for hospital appointments and the need to consult offender
managers and complete risk assessments when prisoners transfer to a hospice.
The version of my report, published on my website, has been amended to remove
the names of the woman/man who died and those of staff and prisoners involved in
my investigation.
Jane Webb
Acting Prisons and Probation Ombudsman September 2010
2
CONTENTS PAGE
Summary
The investigation process
HMP Norwich
Key findings
Issues
Recommendations
3
SUMMARY
The man was born in March 1945 and died in November 2009, at HMP Norwich. He
was 64 years old and had been diagnosed with rectal and prostate cancer, which
had spread to his bones, liver and lungs.
He was sentenced to life imprisonment in 1988 with a tariff of seven years. He spent
the majority of his sentence at HMP Wakefield, where he suffered significant ill
health. However, he completed a number of offending behaviour programmes and
eventually was re-categorised to category C.
When the man’s cancer was first diagnosed, he had a six month course of
chemotherapy in 2008. After a short period of remission, the cancer recurred and he
had a further course of chemotherapy in the first few months of 2009. In May of that
year, he decided to stop his treatment. His consultant later agreed to the man’s
decision as the treatment had not been effective and his condition had deteriorated.
In August 2009, he transferred to HMP Norwich to be nearer to his family and
receive palliative care at their elderly persons unit.
A number of requests for compassionate release were made on his behalf. Initially,
he did not meet the criteria regarding life expectancy. Unfortunately, when a later
application was made, appropriate accommodation could not be obtained to ensure
that a robust release plan could be implemented. The man settled in at Norwich,
where his symptoms were treated. Towards the end of October, the community
specialist palliative care doctor, who also works at the prison, arranged for him to be
admitted to a local hospice to adjust his pain control medication. After a few days,
the man asked to return to Norwich so that he could smoke.
After another six weeks at Norwich, the man died peacefully in the healthcare centre.
His family had been told of his deterioration and had the opportunity to visit him
before he died.
The clinical reviewer makes eight recommendations regarding clinical matters. She
also identified some good practice in respect of the man’s healthcare at both
Wakefield and Norwich. I make a further two recommendations suggesting a review
of the arrangements for escorting prisoners to hospital and ensuring that offender
managers are part of the decision-making process when prisoners are transferred to
a hospice.
4
THE INVESTIGATION PROCESS
1. The man died in November 2009, aged 64. My investigator opened the
investigation when she visited HMP Norwich on 8 December. She received
copies of the man’s personal and medical records.
2. HMP Norwich issued notices to staff and prisoners informing them of the
investigation and inviting anyone who had relevant information to contact the
investigator. No one responded.
3. As the man had only been at Norwich for approximately four months before
he died, my investigator contacted staff at HMP Wakefield and West
Yorkshire Probation area. She also spoke to his offender manager, at
Greater Manchester Probation area.
4. Norfolk Primary Care Trust commissioned a clinical review of the healthcare
provided to the man. I am grateful to the clinical reviewer for her review which
is attached as an annex to this report. The clinical reviewer comments on
good practice at both Wakefield and Norwich and highlights issues for
consideration in healthcare and palliative care services at Norwich.
5. One of my Ombudsman’s family liaison officers spoke to the man’s sister to
ask if there were any matters that she wanted to be addressed in the report.
Her only concerns were that the man had told her there had been a short gap
in his medication during his stay at HMP Norwich and that he had asked to be
released to a hospital. She felt that her brother had been well cared for and
had settled in well. She also wanted it to be known that she had been treated
excellently by the family liaison officer at Norwich.
5
HMP NORWICH
6. HMP Norwich is a city centre prison, predominantly serving the courts of East
Anglia. It has an operational capacity (maximum crowded capacity) of 700, having
opened a new wing in September 2009. It holds both remand and sentenced male
adults and young offenders. The prison is divided into two sections, one
accommodating young offenders and the healthcare centre and the other for the
remainder of prisoners.
7. The healthcare centre provides 24 hour healthcare cover and has space for a
maximum of 23 inpatients. On the ground floor of the centre is a specialist elderly
persons unit, the Nelson Unit. It has been designed and equipped to enable older
and less able prisoners to be supported and cared for.
8. Previous reports by the Ombudsman highlight areas of good practice. Both clinical
and disciplinary staff are experienced at providing care for the elderly and for
those, like the man, who are terminally ill. When a prisoner is coming to the end of
his life at the prison, there is an ‘open door policy’. (Cell doors are left open to
facilitate quick support or assistance and the prisoner is free to move around as he
feels able.)
9. There are established links with community palliative care services, including
Priscilla Bacon Lodge, the local hospice, where the man spent some time towards
the end of his life. The relationship between the prison and such community
services provide good continuity of treatment and a multi-disciplinary approach to
the treatment of terminally ill prisoners.
10. HM Chief Inspector of prisons last inspected HMP Norwich in November 2006.
The inspection found there were good links with palliative services and good use of
the Liverpool Care Pathway.
Liverpool Care Pathway
11. The Liverpool Care Pathway (LCP) is a key recommendation in the National
Institute for Health and Clinical Excellence (NICE) guidelines for support and
palliative care. It is a continuous quality improvement programme for the care of
terminally ill patients. It has been developed to transfer the hospice model of care
into other settings, such as prisons.
12. The LCP is a multi-disciplinary process which provides an evidence based
framework for end of life care. It provides guidance on different aspects of care
required, including comfort measures, anticipatory prescribing of medicines and
discontinuation of inappropriate interventions. Additionally, psychological and
spiritual care and family support can be included.
6
HMP WAKEFIELD
13. HMP Wakefield is a high security prison for those serving four years or over,
including life sentenced prisoners. The prison provides workshops and an
education department offering both full and part-time education. The programmes
department offers a range of offending behaviour courses including the Sex
Offender Treatment Programme and a range of extended sex offender
programmes.
14. The prison’s healthcare centre is separate from the main residential areas. All the
cells have integral sanitation and the prison has recently been refurbished. The
most recent inspection report on Wakefield by HM Chief Inspector of Prisons was
issued in April 2008
15. In relation to the healthcare at Wakefield HM Chief Inspector of Prisons reported:
“Good attention was paid to palliative care, which was appropriate to
the population profile at Wakefield.”
“There had been some recent investment of resources by the primary
care trust, a physical health needs assessment had been completed
and joint working was apparent. Some improvements were being
made, but some of the accommodation was not fit for purpose.
Prisoners had to wait too long to see a GP. There were a number of
problems with pharmacy and medicines management. Dentist services
were good. Mental health services were inadequate. Too many outside
hospital appointments were cancelled with little monitoring of
the reasons.”
16. The Independent Monitoring Board (IMB) at Wakefield published their most recent
annual report in April 2008. They said of healthcare provision, which had
undergone a number of changes:
“The commissioning process of services by the PCT is now providing an
increase in resources and investment, this along with the appointment of a
new Head of Function and a new healthcare manager, both of whom have
embarked upon a proactive management style, has resulted in the provision
of better services and an increase in morale among staff.”
7
KEY FINDINGS
17. The man was convicted of a violent offence on 22 September 1988 and
sentenced to life imprisonment with a tariff (minimum time to serve) of seven
years. He spent most of his sentence at HMP Wakefield, in West Yorkshire
but transferred to HMP Norwich in August 2009, as he had terminal cancer
and wanted to be nearer to his family.
18. Throughout his sentence, the man had significant health related problems.
He had heart and circulatory disease during the early 1990s leading to a
coronary artery bypass, whilst he was at HMP Wakefield. During this time, he
also had stomach and back problems resulting in a laminectomy. (A
laminectomy is an operation to remove the bony coverings of the spine to
widen the spinal canal, in order to relieve pressure on nerves and reduce
pain.)
19. The man’s most recent health problems started in 2007. In March, he was
diagnosed with a malignant tumour of his rectum. It had spread to his bones
in August and a further diagnosis of prostate cancer was made at this time.
The man was taken to St James’s Hospital, Leeds, for surgery to remove the
tumours, which subsequently led to a short remission of his rectal cancer.
20. During the first half of 2008, he had chemotherapy. He remained in pain
throughout the year, but refused to be admitted to the healthcare centre.
Unfortunately, his prostate and bone cancer continued to spread and, in
January 2009, he was again diagnosed with rectal cancer. In March, he was
told the cancer had spread to his liver and lungs.
21. Doctors gave him a life expectancy of six months at this time, although his
consultant said that if he had chemotherapy, it might be extended to more
than a year. The man’s consultant arranged palliative care for the man and
he was introduced to a Macmillan nurse. (Palliative care is the active holistic
care of patients with a terminal illness, taking account of their spiritual, family
and medical needs. It is sometimes provided by Macmillan nurses.) The
hospital started chemotherapy, with a view to extending the man’s life.
22. The man continued to take part in his sentence plan and completed the Better
Lives Booster course in which he was reported to have done well. (The aim
of a sentence plan is to enable a prisoner to use their time constructively,
reduce the risks posed and avoid further offending.) During this time he
occasionally felt very emotional and asked to move to a prison nearer to his
family. It is clear from the records that he was able to discuss his concerns
with prison and nursing staff at HMP Wakefield and felt well supported.
23. On 11 May, the man asked to be considered for compassionate release.
However, at this stage he was still considered to be a high risk and his
consultant had commented “is receiving chemotherapy and remains
independent“. His prognosis at this time was six to 12 months. There was no
evidence to suggest that it would be detrimental to his life expectancy or
general health to remain in prison at that time. On the same day, the man
8
decided to stop his chemotherapy and he pulled out his Hickman Line. This is
an intravenous line from his chest to a vein, to enable chemotherapy drugs to
be pumped into his system.
24. The man’s offender manager considered the request for compassionate
release but did not support it as he thought that the man still posed risks,
particularly to female nursing staff. Furthermore, the prison considered that
the man did not meet the criteria for compassionate release. Prison Service
Order 4700, advises that the prisoner should have a prognosis of three
months or less, to be considered for release.
25. At a hospital review on 26 May, the man discussed his decision to stop
chemotherapy with his consultant who agreed, as he had deteriorated. The
man’s health then started to deteriorate further. It is recorded in medical
reports that he lost weight, had a loss of energy and was starting to feel
increasingly ill. His life expectancy was reduced to two months.
26. At this stage, the man decided to stop taking his other medication. Staff
suggested that he move to the healthcare centre but he refused and so a
carer was arranged to help him around the wing. His carer, prison and
medical staff supported and counselled him and he subsequently resumed his
medication. Towards the end of May, he agreed to move to the healthcare
centre, where he could be better cared for. According to medical records and
wing history sheets, he received many visitors from other prisoners.
Healthcare staff said they “would do everything in their power to make him
comfortable”. The prison appointed a family liaison officer as a link between
staff and the man’s family.
27. A further request for compassionate release was made on 27 June by the first
prison doctor at Wakefield, who said that the man had “much less than 6
months to live”.
28. The man’s offender manager responded to this request immediately.
However, in his report of 12 June, he says that he had problems finding
appropriate accommodation. The man wanted to be released into the care of
his sister but this was not possible. His sister said she did not feel able to
care for him adequately and that the local authority would not allow her
brother to live with her. The man’s offender manager made enquiries of
Southend on Sea Adult Social Services Department, regarding release to a
nursing home and was told that they needed a nursing needs assessment by
the prison healthcare.
29. The man’s offender manager was also told that the man would need to be
registered with a general practitioner (GP) in the community, before the
medical report could be submitted to the panel, for consideration of release.
Attempts were made to register him with his sister’s GP, but this was
declined. It is not clear why, although the man’s offender manager states in
his report that GPs are not obliged to take patients. The local Primary Care
Trust was then contacted with a view to ensuring that the man was provided
with a GP. The relevant professionals from both the prison and probation
9
service continued in their efforts to ensure that all of the available options for
release on compassionate grounds, were fully explored. However, because a
specific release address could not been approved, it was not possible to
construct a complete and robust risk management plan, and so the request
could not be supported. This decision was upheld by the Parole Board and
the Secretary of State in October 2009.
30. At the same time as the man’s offender manager enquiries, staff at Wakefield
explored the possibility of the man transferring to a prison nearer to his
sister’s home. HMP Norwich is known for its elderly prisoners unit and its
links with community care for those who are coming to the end of their lives.
It was also closer to his sister’s home.
31. In preparation for this, the man was re-categorised to category C in August,
based on the fact that he had completed his Better Lives Booster programme.
(On arrival into prison, prisoners are risk assessed and given a category
based on their offence and the risk that they pose to the public should they
escape. There are four levels of category: A, B, C and D, with Category A
prisoners being the most dangerous.) The man had started as a category A
prisoner. His risk was further reduced by the physical restrictions caused by
his ill health. He was happy to transfer to Norwich but concerned about
continuity of treatment and, having spent many years at Wakefield, felt he
would miss his friends and staff.
32. His Macmillan Nurse, supported and counselled him through this period and,
on 5 August, the man agreed to the transfer. The prison staff organised it
swiftly and on 11 August, he was assisted to go to the wing to say goodbye to
his friends. Healthcare staff at Wakefield passed medical information to
Norwich, so that they were prepared for the man’s arrival.
33. The man travelled to Norwich on 12 August where he was given a single cell,
with integral sanitation. No medical notes were completed on his arrival at
Norwich, although notes were made retrospectively at 1.44pm on 13 August.
These notes showed that he arrived “tired but alert and oriented. He enjoyed
a meal in the dining area”. The record gave further information about the
man’s existing physical abilities and noted that he would be assessed by the
palliative care team later that day.
34. The man’s pain relief medication consisted of a long term acting morphine
preparation (MST), which was topped up every four hours with Oramorph,
(short term relief for break through pain). There is no record of a full, holistic
assessment on arrival at Norwich, but the locum doctor reviewed him at
12.24pm on 13 August. He prescribed 28 days of the general medications but
only two days of MST. The doctor said that this would be reviewed by the
specialist palliative care staff later that afternoon.
35. At 6.03pm, the specialist palliative care nurse, assessed the man. According
to the records, he had not been given Oramorph all day and was suffering
from pain in his lower abdomen. The specialist palliative care nurse
contacted the Macmillan nurse at Wakefield and was told that no matter what
10
the MST dose, the man still required Oramorph every four hours. The locum
doctor prescribed it on 14 August. The man also expressed his wish not to be
resuscitated in the event of his collapse and signed the appropriate
documents after discussing it with staff.
36. There is another entry in the medical history on 19 August, where the man
said he had not had Oramorph as regularly as he did in Wakefield. He
complained of increased pain over the next few days and staff recorded that
this was disturbing his sleep. On 2 September, the man said his pain was no
longer under control. Staff contacted the specialist palliative care nurse who
instructed that his MST should be increased and said that she would review
him.
37. On 5 September, the man ran out of cyclizine tablets (sickness relief) which
he had brought with him from Wakefield. Although the locum doctor had
prescribed a further supply on 12 August, they had not been dispensed. As
there were no cyclizine tablets in the pharmacy, the doctor gave another form
of anti sickness tablet, metoclopramide, as a substitute.
38. Over the next few weeks, the man complained of increasing pain, swollen
testicles and a mucous like discharge and bleeding from his rectum. A
second prison doctor, arranged an emergency computed tomography (CT)
scan (a detailed x-ray which can show three dimensional images inside the
body) on 13 October, with a view to having radiotherapy to help with his pain
relief. However, the prison was unable to provide an escort to accompany
him to hospital.
39. The investigator asked the head of healthcare about the procedure for taking
prisoners to hospital appointments. Only four appointments per day were
allowed, two in the morning and two in the afternoon because of the staff
resources required to escort prisoners. She was told that healthcare staff
were not consulted about which prisoners attend their appointment. Staff
were not informed that the man could not attend until after the appointment
time. The second prison doctor arranged a further scan for 23 October, which
the man attended.
40. Meanwhile, according to medical records, the man’s pain increased and he
became confused and emotional. The governor agreed that there should be
an open door policy, so that staff could attend to the man immediately, if
necessary. As a result of the man's increased pain, the second prison doctor
made arrangements for him to be transferred to Priscilla Bacon Lodge, a local
hospice, with a view to improving pain control. The governor agreed and, on
26 October, the man moved into the hospice. (The man’s offender manager
told the investigator that he was unaware of this move at the time.)
41. The investigator was told that whilst the man was resident in the hospice, he
only had one prison escort officer. No restraints were used and he had a
single room. At his own request, the man returned to the healthcare centre at
the prison on 2 November. He asked to return so that he could smoke freely.
11
Medical records showed that he was more settled and his pain was more
controlled on his return.
42. On 5 November, the man refused to take his medication and told staff that he
wanted to “give up and die”. The second prison doctor and a nurse spoke to
the man and he started to take his medication again the following day, 6
November.
43. The man’s friend, who was his nominated next of kin visited him on 13
November. She contacted his sister and alerted her to her brother’s
deterioration. After a telephone call from the man’s friend, the head of
healthcare arranged for the man’s sister to be permitted to visit whenever she
could, so she was not tied to prison visiting times. His sister subsequently
visited him.
44. Over the next ten days, the man deteriorated further and was unable to
swallow his medication without vomiting. The second prison doctor said that
at this stage it would be best practice to administer medication via a syringe
driver. (A syringe driver is small portable battery operated pump, which
administers medication over a 24 hour period.) However, when the
investigator asked about this she was told that none of the nursing staff felt
adequately trained to use this method. Many of the staff were agency nurses.
Instead the man’s medication was injected subcutaneously (under the skin) at
regular intervals. Although it was agreed this was not the best method, it was
adequate to ensure that he was pain and symptom free.
45. In interview the head of healthcare and the second prison doctor said that a
recent recruitment drive for permanent staff had taken place. Now that the
prison had more stable staffing they were able to roll out training for syringe
driver use. Furthermore, continuity of assessment and care would be much
better.
46. On 25 November, at 7.25, a first prison nurse, one of the full-time, permanent
nurses at the prison went in to check the man. She told my investigator that
she knew he was ”very poorly” and she wanted to see him before she finished
her shift because she knew he was near to the end of his life. She noted that
his breathing was very shallow. She held his hand and “he took one more
breath and then stopped breathing”. She said that she stayed with the man
for another five minutes and then left to tell relevant staff. He had
continuously stressed that in the event of his death, he was not to be
resuscitated. The most recent review took place when he arrived at Norwich.
47. The prison doctor pronounced the man dead at 9.25am. The prison’s family
liaison officer and the head of healthcare visited the man’s nominated next of
kin, to inform her of his death. She asked them to contact his sister to tell
them, which they did by telephone. The prison family liaison officer
telephoned one of his sisters’ and she said that she would then telephone her
other sister. From that time the prison liaison officer treated both the man’s
friend and the man’s sisters, as next of kin and arranged the funeral with them
both. The prison liaison officer said that the prison would meet funeral costs.
12
When the Ombudsman’s family liaison officer spoke to the man’s sister, she
had nothing but praise for the way the prison staff had informed her of the
news of the man’s death. She asked that we commend the prison family
liaison officer in this report and was satisfied that her brother had been treated
with dignity.
ISSUES
Clinical care
48. The clinical reviewer conducted a review of the clinical care given to the man,
on behalf of Norfolk PCT, and her report is attached at annex 1. The review
looks broadly at the provision and management of healthcare services
generally within the prison and more specifically at the particular standard of
care the man received.
49. The clinical reviewer focussed on the following areas – assessment, medical
support, staffing, coordination and consistency of care and medication. Her
conclusions are summarised below:
(cid:127) There were inconsistencies in assessments due to staffing difficulties
and entries in the electronic medical records system were not always
appropriate.
(cid:127) In terms of medical support, more input was provided by the specialist
palliative care team than in the community, partly because locum GPs
had insufficient knowledge of the man.
(cid:127) Owing to high levels of nursing staff absences and the consequent use
of agency staff, there was a lack of coordination of care as well as a
breakdown in communication and forward planning in obtaining
medication. Staff were also inexperienced in the use of syringe drivers
for pain control. However, an alternative method was used which was
adequate for the man’s needs.
In the light of her findings, the clinical reviewer makes eight recommendations
relating to clinical matters, which I endorse.
50. The clinical reviewer also identified a number of areas of good practice. At
Wakefield, there was good palliative care with support networks both inside
and outside of prison. There was also good coordination and communication,
particularly the consistency of having assessments made by the same GP
which provided good follow-up and reassessment. Norwich worked
collaboratively with the specialist palliative care service and gave attention to
the man’s dignity. Steps have been taken to provide a dedicated person in
the healthcare centre to handle the process for releasing prisoners, in
consultation with the specialist services.
13
Escort arrangements for hospital appointments
51. On 13 October 2009, an emergency CT scan was arranged for the man. He
was unable to attend as no prison staff were available to escort him. Staff
explained to the investigator that only two people per day could attend
hospital appointments because of the staff needed to escort them. The
decisions about who could attend such appointments were not routinely
discussed with healthcare staff and they were not told that the man could not
go until after the appointment time had elapsed.
The Governor and head of healthcare should review the system for
arranging escorts for hospital appointments to ensure that healthcare
staff are consulted and appointments for terminally ill prisoners are
given appropriate priority.
Applications for compassionate release
52. The man made three requests for compassionate release. The first one was
refused because it was not within the criteria stated in PSO 4700. The
second was not supported because adequate risk assessed accommodation
could not be secured for the man. The third was still in the administrative
processes when he died. I am satisfied that staff at Wakefield dealt
appropriately with the requests.
Transfer to hospice
53. In order to provide better management for the man’s increasing pain, he
transferred to Priscilla Bacon Lodge, a local hospice. While resident there, he
was in a single room, escorted by one officer in plain clothes and was not
placed in restraints. I am pleased to note the sensitivity of these
arrangements. However the offender manager was not aware that the man
had moved to the hospice until after the event and there was no record of a
risk assessment having taken place. Whilst the decision was made by the
governor and the palliative care specialist and was in the man’s best interests,
a comprehensive risk assessment, taking account of the offender manager’s
views, should have been completed.
The Governor should ensure that the decision to transfer a prisoner to a
hospice is taken in consultation with the offender manager and a full
risk assessment is completed.
Conclusion
54. The man went into prison with a number of chronic illnesses. He was then
diagnosed with cancer, but failed to respond to treatment. He transferred to
the elderly prisoners unit at Norwich where he was given palliative care for his
symptoms. Although he spent a short time in a local hospice for pain control,
he chose to return to the prison. He did not meet the criteria for
compassionate release and a final application made towards the end of his
life was still being considered when he died. The investigation has found that
14
the man was given appropriate care and treatment and his family and peers
were able to visit him throughout his illness. His family were told of his
deterioration, so were able to see him before he died.
15
RECOMMENDATIONS
1. The Governor and head of healthcare should review the system for arranging
escorts for hospital appointments to ensure that healthcare staff are consulted
and appointments for terminally ill prisoners are given appropriate priority.
Accepted – In future prison escorts will liaise with healthcare when they are
unable to fulfil agreed escort duties. Healthcare staff will prioritise escorts
based on clinical need. The Governor will inform staff of this procedure by
means of a GNTS. This has now been completed.
2. The Governor should ensure that the decision to transfer a prisoner to a
hospice is taken in consultation with the offender manager and a full risk
assessment is completed.
Partially accepted – the man was admitted to the Priscilla Bacon Lodge for
symptom control rather than ‘end of life care’. The offender manager would
have been consulted as part of the decision making process as to where the
man’s ‘end of life care’ was to take place, if this was to be outside the
establishment.
16