Individual at Swansea

Investigation into the circumstances surrounding the
death of a prisoner at HMP Swansea, who died in
hospital, in June 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2008
This is the report of an investigation into the circumstances of the death of a
man at hospital in Swansea on 13 June 2007. He was 42 years old. The
man had been admitted to the hospital 15 days earlier after collapsing in his
cell at HMP Swansea. He had suffered from cirrhosis of the liver and was
seriously ill when first received at Swansea in May 2007.
The man died as a result of multi-organ failure. I would like to extend my
condolences to his parents, the other members of his family and all those
touched by his death.
The investigation was led by one of my investigators. I must thank the
management and staff at HMP Swansea for their assistance and co-operation
during the course of his enquiries. I am also grateful to the Investigation
Manager of Healthcare Inspectorate Wales, who conducted an independent
review of the man’s medical care in prison.
It is evident that, during his relatively short time at Swansea, the man medical
care was efficient and, with one exception, well documented. Once he
transferred to hospital, staff maintained regular contact and continued to
respond positively and sympathetically to his needs.
Contrary to his wishes, the man’s family was unwittingly informed of his
whereabouts. Fortunately, this did not cause any acrimony and the family
was amicably reunited and able to spend the last few days of the man’s life
with him.
I am disappointed that the prison did not offer a contribution towards the
man’s funeral expenses and one of my two recommendations addresses this
point. I also identify an instance of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2008
CONTENTS
Summary 4
The investigation process 5
HMP Swansea 6
Events leading up to June 2007 7
Actions after the man’s death 13
Issues considered during the investigation 14
Conclusion 18
Recommendations and good practice 20
SUMMARY
1. The man died in June 2007 in hospital. He had been admitted to the
hospital 15 days earlier after collapsing in his cell at Swansea prison.
2. Prior to his imprisonment, the man was already seriously ill with chronic
liver disease. During his first health screen, it was recorded that he
had cirrhosis of the liver, hepatitis C and B, asthma, chest pains and
was very jaundiced. Nursing staff confirmed his medication with his
GP practice and the surgery confirmed that he had chronic cirrhosis.
The receiving nurse referred the man to see a doctor the following day
and gave him diazepam to assist with his alcohol withdrawal. The man
had no history of self-harm and was allocated to a shared cell in the
Rehabilitation Unit of the induction wing. At his second reception
health screen on 26 May he was found to be dependent on morphine
sulphate (MST) pain reliever, and was also prescribed medication for
withdrawal from alcohol and liver failure.
3. Just after 9.00am on Tuesday 29 May, the man collapsed on the floor
of his cell. The attending nurse found him jaundiced, incoherent and in
pain. She telephoned the duty doctor who arrived within three or four
minutes and diagnosed acute liver failure. The man was then taken to
hospital for urgent treatment.
4. Shortly after the man’s admission to hospital, his family was
inadvertently told of his whereabouts against his wishes. At that point,
the man was in a coma so his escort was reduced and no restraints
were used. Release on Temporary Licence was considered, but not
approved. An accompanied release was therefore authorised and the
escorting officers’ presence was solely for support purposes.
5. The man remained in the High Dependency Unit until 5 June when he
transferred to a ward where he received intravenous medication and
continuous oxygen therapy. His general condition remained poor, and
on 12 June the prison requested a written prognosis to support an
application for his early release from prison. The man died of multi-
organ failure at 8.40pm the following day, surrounded by his family. At
the request of the man’s family and with the agreement of the Coroner,
no post mortem was performed.
6. I make two recommendations concerning the loss of a controlled drug
prescription and the failure of the establishment to offer a contribution
towards the man’s funeral expenses. I am pleased that both
recommendations have been accepted. In the case of the offer of
assistance with funeral expenses belatedly acted upon after a further
error was discovered following a letter to my office from the Swansea
Coroner. I also identify as good practice the prompt actions of the
nurse and Pharmacist who went to great lengths to obtain essential
medication for the man. Both staff members have been commended
by the Governor at Swansea.
THE INVESTIGATION PROCESS
7. My investigator visited HMP Swansea on 22 June 2007. He was given
a full briefing about the circumstances surrounding the man’s death.
The liaison governor who was also Head of Security, was subsequently
briefed by my investigator on later visits. My investigator also met
representatives of the Prison Officers’ Association and the Independent
Monitoring Board.
8. Invitations were extended to staff and prisoners inviting anyone who
might have information relating to the man to make themselves known
to the investigator. No prisoners took up the invitation. The
investigator met relevant prison staff, including members of the medical
department. There was no police involvement in the man’s death.
One of my Family Liaison Officers wrote to the man’s mother and
spoke to the man’s brother on 20 September.
9. Swansea prison provided copies of the man’s prison and medical
records. The Investigation Manager at the Healthcare Inspectorate
Wales (HIW), conducted a clinical review.
HMP SWANSEA
10. HMP Swansea is a small category B local prison built in the Victorian
era. It has an operational capacity of 425, holding adult males, both
remanded and sentenced, in cellular accommodation.
11. Healthcare at Swansea is provided by the Swansea NHS Trust.
Medical services are provided by a Primary Care Physician who visits
daily and sees prisoners who have applied for an appointment. The
clinical staff provide a day time service, and are all appropriately
qualified. Sudden illnesses and treatments are managed by nursing
staff.
EVENTS LEADING UP TO JUNE 2007
12. As noted above, the man was first received into prison at HMP
Swansea in May 2007 after he was convicted and sentenced to four
months imprisonment by the Magistrates’ Court. A pre-sentence report
dated May was written by a probation officer. The report said that the
man was well known to the Probation Service and that he was
frequently in hospital because of his alcohol misuse, although he was
alcohol free when the report was written. The report also confirmed
that in the recent past the man had suffered from liver failure for which
he had received in-patient treatment. His prognosis was poor and a
relapse into alcohol use held a real risk of him dying from liver failure.
The report proposed that a suspended sentence order with a curfew
requirement would be the best way to deal with the offences for which
he was before the court.
13. The senior officer (SO) on duty on Friday 25 May, in the reception area
at Swansea, was interviewed. He said that the man had arrived at
around 4.00pm. He had known the man over several years and had
spoken to him. He felt that the man seemed his normal self, but noted
that his skin colouring was very yellow. He also noticed that he was
more unkempt and thinner than he remembered him. The man told
him that he had been living rough prior to his arrest and mentioned that
he had a drink problem. The SO’s memory was that the man had
problems with alcohol in the past.
14. The man went through the normal reception procedures. At his initial
reception interview he gave his mother as his next of kin. He also
asked that his family not be informed that he was in prison.
15. The duty nurse at reception interviewed the man at about 4.30pm for
his first health screen. During the interview the duty staff nurse
recorded that the man told him that he was suffering from hepatitis C,
which had been diagnosed in 1996, and that he had been a carrier of
hepatitis B since 1983. He also recorded that the man had cirrhosis of
the liver, asthma, chest pains and was allergic to penicillin. The duty
staff nurse noted on the man’s Continuous Clinical Record that he had
raised concerns about his hepatitis C, that he was very jaundiced and
that he had not taken any medication for the previous 24 hours. He
also noted that the man was waiting to go into rehabilitation for his
drink problems and that he had given the man 10mg of diazepam. The
duty staff nurse listed the prescription drugs the man told him he was
taking.
16. At 5.40pm, the duty staff nurse telephoned a registered nurse at the
Swansea Healthcare Centre (HCC). He asked her to confirm with the
man’s doctor that the medication listed was correct and that nothing
had been omitted. The HCC nurse did so and noted that the
receptionist at the GP’s surgery emphasised that the man was
extremely poorly with cirrhosis of the liver due to his alcohol abuse.
There was no mention of asthma medication.
17. The duty staff nurse continued the health screen to determine whether
any other medical condition existed. The man told him that he drank
half a bottle of vodka daily and that in the last week he had drunk two
bottles. He had not used drugs in the previous month. The man also
told the duty staff nurse that he had no mental health problems or
history of self-harm. However, his Prisoner Escort Record (PER) said
that he had suffered from depression and “s/harm years ago”. A urine
test was conducted which showed a positive indication for
benzodiazepine, a drug prescribed by his GP. As the man used
alcohol to excess, the duty staff nurse put him on an immediate alcohol
withdrawal regime of 10mg diazepam, the maximum he was allowed to
give. He also referred the man to see a doctor the following day for an
assessment of his physical health.
18. A cell sharing risk assessment was completed by the duty SO. This
included the information given by the man that he had no history of
self-harm. He was then allocated to the Induction Unit (F wing) where
he was located in cell R3-02 in the Rehabilitation Unit with another
prisoner.
19. The following day (26 May), the man attended a Reception Board
which concluded that he should have no problems at Swansea, other
than his medical conditions. Later that day, he attended his second
reception health screen. He was noted to have a pulse of 112 (the
clinical reviewer noted that this is higher than normal) and blood
pressure of 133 over 89 (again higher than normal range, but not
excessively so). On examination, the man was jaundiced, with a
painful abdomen, and he said that he had cirrhosis. The man’s mental
condition was noted as being fully orientated and normal in
appearance, mood and speech. His dependency on morphine
sulphate (MST) pain reliever was recorded and the duty medical
officer, prescribed the following medication:
Thiamine 100mg daily - a vitamin B replacement for withdrawal
from alcohol
Vitamin B Compound strong twice a day
Omeprazole 20mg daily - to treat stomach ulceration
Spironolactone 100mg four times a day - to treat liver failure
Frusemide 40mg daily - used to treat fluid retention
diazepam 15mg twice a day
MXL 90mg - a slow release morphine sulphate drug for pain relief
20. The medication prescribed was in line with that confirmed with the
man’s GP surgery by the HCC nurse on the previous evening. All
except the MXL 90mg were prescribed for a period of 28 days. At
about 10.30 -10.45am, the HCC nurse asked the off duty prison
pharmacist, to attend the prison to dispense the drugs for a seriously ill
patient – the man who is the subject of this report. When she arrived at
about 11.10am the prison pharmacist went to A wing Treatment Room.
The duty medical officer gave her a prescription for the man and told
her that all the items must be dispensed. The Prison Pharmacist then
went to the prison pharmacy to check her stocks of drugs against the
prescription and noted that the spironolactone, vitamin B compound
and MXL 90mg were not in stock. She telephoned a local pharmacist
with whom she has a support arrangement, but on this occasion he
was unable to supply the shortfall. The prison pharmacist then
telephoned a local pharmacy supply company, AAH Hospital Service,
who delivered the medicines at about 12.15pm.
21. On delivery of the medicines, the prison pharmacist recorded the MXL
90mg, a morphine based “controlled” drug, in the Controlled Drugs
Register. She then entered four MXL 90mg capsules onto the
Controlled Drug log for use by the man. The other non-controlled
drugs were entered by her on the man’s Prescription and
Administration Record Chart. She dispensed the drugs in accordance
with the prescription. The spironolactone and vitamin B Compound
were part dispensed on 26 May, the balance being dispensed on 29
May. Four MXL 90mg capsules were dispensed on 26 May to be given
at a rate of one daily. At about 1.00pm, the duty staff nurse collected
the four MXL 90mg capsules (for which he signed in the pharmacist’s
Controlled Drugs book) and took them away with him for storage in the
D wing treatment room controlled drug cabinet. One MXL 90mg
capsule was given to the man at 2.10pm on 26 May by the dispensing
nurse, witnessed by the duty staff nurse.
22. The investigator requested and copied documents relating to the
acquisition and issue of medication and the destruction of unused
controlled drugs relating to the man. However, healthcare staff at
Swansea were unable to produce the controlled drug prescription
written by the duty medical officer on 26 May covering the man’s use of
MXL 90mg.
23. On 27 May, the man was given Imodium after reporting sick with a
stomach upset. The HCC staff nurse also completed a nursing care
plan, with the aim of assisting him to detoxify from alcohol safely and
comfortably. At 11.30am, the man was given his prescribed
medication which included the administration of MXL 90mg by the
dispensing nurse, witnessed by the HCC nurse.
24. On 28 May, The HCC nurse’s entry in the Daily Record of Nursing
Care shows that the man’s prescription medication was in place and
that he was compliant with his regime. He was eating a little and was
encouraged to drink plenty of water and tea. His medication regime
appeared to be going well. At 11.45am, the dispensing nurse, again
witnessed by the HCC nurse, gave him his prescribed medication
which included the MXL 90mg.
25. Soon after 9.00am on the morning of Tuesday 29 May, a Registered
mental nurse, was on F wing. The SO who was in charge of the wing,
told her that he thought that the man was sitting on the floor of his cell
and was unwell. The Registered mental nurse went immediately to cell
R3.02. She found the man sitting on the floor and asked his cellmate
to step outside. In interview, she said that his face was swollen. He
was also jaundiced, mumbling, incoherent and in pain. He looked
much worse than when she had seen him a few days before. She
realised he was ill, so went to nearest telephone in D wing office and
called the HCC. She told the healthcare officer (HCO), who was with
the medical officer, that the doctor was needed in the Rehabilitation
Unit immediately.
26. The Registered mental nurse went back to cell R3-02 and within three
or four minutes the Medical Officer had joined her. She briefed the
Doctor, re-iterating that the man looked considerably more jaundiced
than when she had seen him two days earlier. The Doctor then took
charge. The Medical Officer found the man lying awkwardly on the cell
floor between the side of the lower bunk and a cabinet, complaining of
pain whenever he was touched. She explained to the man who she
was and he agreed to be examined by her in the cell. The registered
mental nurse went to the treatment room on D wing to collect a
sphygmomanometer (a device to measure blood pressure), a
stethoscope and the emergency response bag. There was no
stethoscope so she telephoned a staff Nurse and asked him to bring
one from the Healthcare Centre. She then went back to the man’s cell.
27. When she returned to the cell, the registered mental nurse helped the
Medical Officer to lift the man onto the bed to make the examination
easier and more thorough, but this caused him much distress. Before
the staff nurse who was bringing the stethoscope arrived, the medical
officer listened to the man’s chest by putting her ear to it. She noted
that he was breathless, markedly jaundiced and had bruises to his
back and arms. The clinical reviewer comments that this might have
indicated that his liver was not working because his blood was not
clotting.
28. A short time later, the staff nurse joined the doctor and registered
mental nurse in R3-02, bringing the stethoscope and a blood pressure
machine. The medical officer found that the man’s pulse was weak
and his blood pressure could not be measured because of the difficulty
in applying the blood pressure cuff. In view of the pain he was
suffering, all further examination ceased. It was the medical officer’s
opinion that the man was suffering from acute liver failure and that
required urgent hospital treatment. An emergency ambulance was
called at 9.50am.
29. Given the location of the man’s cell, the Registered mental nurse was
uncertain whether the ambulance crew would be able to get the man
on their trolley. She therefore went to the A wing treatment room to
collect a trolley on which to lay him. On returning to the cell, the
Registered mental nurse comforted the man. He was barely lucid, but
indicated that he was in pain. The charge nurse brought the man’s
medical record from the Healthcare Centre and the Registered mental
nurse made some notes for the ambulance crew. These included that
the man was alcohol dependent and hepatitis C positive.
30. The emergency ambulance arrived at 10.01am. According to the
Registered mental nurse, very soon after the ambulance arrived the
man seemed to pick up and become a little brighter. She allowed the
ambulance crew to take the man’s medication chart with them. The
ambulance left Swansea prison for the local hospital Accident and
Emergency Department (A&E) at 10.21am. After examination, the man
was admitted to the hospital at 1.30pm.
31. All the necessary internal departments at Swansea were notified. The
Prison Service Area Office and the police were also informed. An
incident form was completed by the principal officer (PO). Later, the
registered mental nurse went back to see the man’s cellmate, who had
been moved to another cell, to make sure he was alright. He appeared
surprised but grateful that she had done so, and told her that the man
had been collecting his food but had not eaten any of it.
32. A senior officer (SO) was the designated Family Liaison Officer (FLO).
Soon after the man’s departure from Swansea to hospital, he tried to
contact the man’s family, but was unable to find a telephone number.
The Swansea security department then telephoned the police at
12.50pm asking them to notify the man’s next of kin, his mother. They
eventually contacted her at around 2.00pm. The escorting officer
noted on the Hospital Watch Occurrence Log that at 2.00pm he had
telephoned Swansea to inform the prison not to contact the man’s next
of kin.
33. At 2.30pm, the prison officer escort was reduced to one officer. Ten
minutes later, at 2.40pm, the charge nurse in Swansea’s Healthcare
Centre gave the local hospital staff the telephone number for the man’s
next of kin. At 4.15pm, the man was moved to a ward (Coronary Care
Unit) and at 9.20pm he was moved to the High Dependency Unit
(HDU). At 1.00am on 30 May, the man’s parents, brother and sister
visited him, staying until 2.00am.
34. The man’s daily progress report for 30 May shows that he was
receiving large amounts of oxygen. His hospital risk assessment
indicated that he was “currently in a coma” and was very seriously ill. It
concludes that, because of his condition, the hospital escort was now
an ‘escorted absence’ and no restraints were necessary. Release on
Temporary Licence (ROTL) was considered but not approved. Instead,
an accompanied release was authorised and the escorting officers’
presence was for support purposes rather than supervision. The risk
assessment was authorised by the Head of Security. An unsigned
note indicates that a telephone call was made to the man’s mother at
11.40am on 30 May to update her on his condition.
35. On 31 May, it was noted in the man’s clinical record that he remained
in the HDU and was receiving 100 per cent oxygen. His condition was
stable but still critical and he now had a chest infection. A note in the
record dated 1 June at 8.35am indicates that he was suffering from
pneumonia. At 1.30pm that day, the man’s parents, aunt and uncle
visited him at the local hospital. At 3.40pm, the man’s father received
his property from a PO who was at the hospital and the visit finished at
4.00pm.
36. The single remaining MXL 90mg capsule issued for use by the man
was returned for destruction to the prison pharmacist, on 31 May by the
HCC Nurse . It was destroyed on that day by the prison pharmacist,
witnessed by the HCC nurse.
37. The HCC nurse and an accompanying SO visited the man on 3 June.
The HCC nurse reported that he was still in the HDU, his level of
consciousness had improved and there was a slight improvement in his
condition. The man asked for squash or lemonade. The HCC nurse
was unable to provide this at the time, but promised to discuss the
request with the duty governor on her return to Swansea. She did so
and the requested items were supplied from the prison canteen. At the
man’s request, she also contacted his parents to inform them of his
condition.
38. On 5 June, it was noted in the man’s daily progress report that he had
been transferred to Ward 10, where he was receiving intravenous
medication and continuous oxygen therapy. He was visited by the
charge nurse and the liaison governor, who gave him £4.35 in cash to
buy items while in hospital. The charge nurse recorded that the man
was rousable, but very weak and his general condition remained poor.
39. At 12.30pm on 6 June, the man’s mother, sister and brother-in-law
visited until 1.45pm. The man’s hospital risk assessment, authorised
by Swansea’s deputy governor, indicated that he was “very weak and
in a critical condition” and was unable to get out of bed. It was
reiterated that the escorting officers’ presence was for support only.
On 9 June, there was no change in the man’s condition. His aunt and
cousin visited. His aunt telephoned on 11 June to tell the man that she
would visit again during the following weekend.
40. On 12 June, the Head of Healthcare spoke to the Consultant’s
secretary at the hospital, requesting written confirmation of the man’s
prognosis with a view to Swansea applying for his early release from
prison.
41. On 13 June, the man’s family visited at 2.05pm. During this time, an
additional SO paid a management visit. He wrote on the management
visit form that the man was in a pitiful condition and that he was being
comforted by his mother and aunt. At 8.40pm on the evening of 13
June, the man died with his family around him. A doctor based at the
hospital certified his death from multi-organ failure at 8.50pm.
ACTIONS AFTER THE MAN’S DEATH
42. The accompanying officer informed the orderly officer of the man’s
death. He also extended condolences to the man’s family and ensured
that they had the appropriate contact details for the prison, including
those of the chaplain. The family then left the hospital and returned to
Northampton. The accompanying officer thanked the hospital staff for
their help and left at 9.45pm. The orderly officer initiated the prison’s
contingency plan for responding to a death in custody. All necessary
Prison Service staff were informed and the man’s prison and medical
records were secured.
43. At 2.20pm on 14 June, the Family Liaison Officer, telephoned the
man’s mother. He spoke to her son and gave his condolences. He
also inquired about disposal of the man’s remaining property at
Swansea and was asked to return it by post, which he did. The Family
Liaison Officer gave the son of the man’s mother his details but the
family chose to make no further contact. At the request of his family
and with the agreement of the Coroner, no post mortem examination
was carried out on the man.
44. The Acting Governor sent a letter of condolence to the man’s parents
on 18 June, in which he invited contact with the Family Liaison Officer
should they wish to do so. No offer of assistance with funeral
expenses was made either in that letter or at any other time.
ISSUES CONSIDERED DURING THE INVESTIGATION
Medical care
45. The man was seriously ill with chronic liver disease when he arrived at
HMP Swansea in May 2007. The probation officer who prepared his
pre-sentence report for the court was aware of this and had included it
in what he wrote.
46. The clinical review carried out by a doctor from the Healthcare
Inspectorate was based on the man’s prison medical record, hospital
bed watch logs and statements from prison staff. It included an
assessment of the care provided for the man by staff at Swansea after
his reception, as well as their subsequent contacts with him and the
local hospital until his death on 13 June.
47. The clinical reviewer reported that the Swansea healthcare nursing
staff correctly contacted the man’s GP surgery on 25 May to find out
what medication he had been prescribed so that they could administer
the correct dosages.
48. The man was seen by the duty medical officer on 26 May. The medical
officer prescribed appropriate medication for the conditions with which
the man presented and in line with medication given by his GP prior to
his detention at Swansea. The nurse on duty was so concerned about
the seriousness of the man’s condition, coupled with the fact that it was
a Bank Holiday weekend, that she called in the Swansea pharmacist
from home to dispense the prescriptions. These included a Controlled
Drug Prescription for MXL 90mg, a morphine based drug. The
pharmacist made strenuous efforts to acquire sufficient drugs to enable
the man’s medication to proceed without hindrance until after the
extended weekend. All the documentation supporting the acquisition
and administration of the drugs is correct as is the recording of the
destruction of prescribed but unused drugs. However, the Controlled
Drug Prescription written by the doctor on 26 May could not be found at
Swansea.
The Governor and Swansea Local Health Board should review the
arrangements at Swansea for the safe retention of healthcare
documents.
49. A nursing care plan was completed on 27 May to assist the man to
detoxify from alcohol. This regime appeared to be going well until his
collapse on 29 May. He was seen immediately by the prison doctor
who made a working diagnosis of acute liver failure and sent him to
hospital. In her report the clinical reviewer said that medical staff had
acted promptly in sending the man to hospital following the collapse.
Prison nursing staff then maintained contact with the hospital to
monitor his progress. She described this as good practice.
50. The clinical reviewer judged that the quality of the entries in the
medical and nursing notes was very high. They had been timed, dated
and signed legibly, as recommended in the professional standards for
record keeping. Prescriptions had been clearly written. Hospital
bedwatch logs were completed correctly by the accompanying officers
and, from the information within those logs, the clinical reviewer
identified no problems with secondary healthcare.
Escort and early release arrangements
51. On 29 May, the man had been assessed and confirmed as a category
D prisoner (the lowest security category). He had been provisionally
allocated to HMP Prescoed, an open prison.
52. When the man was transferred to hospital, his condition was serious
and his prognosis poor. He was escorted at the local hospital by the
normal complement of two prison officers who took with them the
standard security equipment, including handcuffs. In light of the man’s
poor prognosis and his security category, the escort was subsequently
reduced to one officer.
53. The man remained very seriously ill. The prison therefore reduced the
hospital escort to an escorted absence without restraints. Release on
Temporary Licence (ROTL) was considered, but not approved.
Instead, an accompanied release was authorised by the Head of
Security. The accompanying officers’ presence was for support
purposes only. This position was reiterated on 6 June by the deputy
governor.
I commend the Head of Security for authorising the accompanied
release which afforded the man a greater degree of dignity at the
end of his life.
54. On 12 June the Head of Healthcare, asked the secretary of the man’s
Consultant for written confirmation of the man’s prognosis, with a view
to submitting an application for his early release from prison under the
provisions of section 10(1) of the Crime (Sentences) Act 1997:
“10(1) The Secretary of State may at any time release a prisoner
if he is satisfied that exceptional circumstances exist which
justify the prisoner’s release on compassionate grounds.”
55. It is evident that Swansea took into account all the circumstances
surrounding the man’s situation. They took appropriate steps to ensure
that he was properly escorted, as well as initiating the procedure for
early release. Unfortunately, the man died before the application could
be made.
Next of kin issues
56. The man had asked, on reception, that his whereabouts be kept from
his family. This request was noted. The Family Liaison Officer at
Swansea, knew of the man’s poor prognosis but had been unaware
that he had asked for his next of kin not to be told of his whereabouts.
He made attempts to contact the man’s mother without success, before
passing the matter to the prison security department. An SO
telephoned the Police and sent a fax asking them to contact the family.
The man’s mother was informed by police at 2.00pm. Coincidentally,
at the same time a message was passed from the man’s escorting
officer to the prison telling them not to contact his next of kin. Very
early on the morning of 30 May, the man’s mother, father, brother and
sister visited him in hospital.
57. Under most circumstances, the wishes of the prisoner in respect of his
family must take precedence and be respected. However, in this case,
an unwitting mistake by the FLO set in motion the process that led to
the man’s family being informed and attending the hospital. Following
that first visit, it is evident that the man and his family were in regular
contact until his death two weeks later, something that appeared to
benefit them all.
58. Given that this information was divulged as a result of a genuine
mistake rather than a deliberate contravention of policy, and that the
contact clearly benefited both the man and his family, I have made no
recommendation on this point. The staff at Swansea appear to be
aware that it is mandatory to respect the wishes of prisoners with
regard to their next of kin.
59. Paragraph 4.2 of PSO 2710 advises that, following a death in custody,
prisons must send a letter of condolence to the family containing an
invitation to them to visit the establishment. It also requires that an
offer to help with reasonable funeral expenses be made. Although a
letter of condolence was sent, some elements required by PSO 2710
were not included. The investigator found no evidence that an offer to
assist with funeral expenses was made.
The Governor should ensure that the requirements of PSO 2710
are fully met and that assistance with funeral expenses is offered.
A retrospective offer should also be made to the man’s family.
Family issues
60. On 20 September 2007, my Family Liaison Officer had a telephone
conversation with the man’s brother in which he expressed some
concerns about a conversation between his mother and a doctor at the
local hospital.
61. The doctor had told his mother that the man already had morphine in
his system and that they could not give him any more. The family was
confused because they thought that morphine could not have been
prescribed in prison. The man’s brother said that the family was aware
that toxicological tests could reveal whether this was the case or not.
However, no post mortem examination took place and as a result no
toxicological samples were taken from the man. The clinical reviewer
has confirmed that morphine and other 'controlled' drugs can be
prescribed if a prisoner needs them. The investigation found that
morphine was prescribed to the man on 26 May by the duty medical
officer. The prescription itself has since been lost but supporting
documentation indicates that it had been properly administered.
62. The mans’ brother also said that the hospital had wanted to establish
the trigger for the man’s rapid deterioration. The clinical reviewer
commented:
“The hospital staff would try to establish a trigger for the man’s
relapse, by performing various tests - on his blood, for example.
Reasons for a relapse are many and could be an infection,
sedation or a bleed from the stomach. For this reason, since the
man had had morphine in HMP Swansea, the hospital would be
unable to give the man morphine-based pain relief, until they
were aware of the cause of his relapse.”
63. No cause for the man’s deterioration has been established.
CONCLUSION
64. Since 1990, the man had served a number of short prison sentences,
several of which had been at Swansea. All his offences were related
directly to his misuse of alcohol. Eventually, this led to serious health
problems of which the court was aware when he was sentenced to
imprisonment on 25 May.
65. On the man’s arrival at Swansea, his medical conditions were noted
and confirmation of his medication was obtained from his GP. He was
assessed by a prison doctor on the following day. Appropriate
medication was prescribed and an off duty prison pharmacist was
brought in to dispense the medicines.
I commend the HCC Nurse and the prison pharmacist who acted
promptly to obtain sufficient medication for the man.
66. The man’s medical regime progressed smoothly. The clinical reviewer
pointed out a number of instances of good practice at Swansea. These
include confirming medication with the patient’s GP, the prison
maintaining regular contact with the hospital and supplying the hospital
with the telephone contact details for the man’s next of kin (albeit that
in this instance next of kin contact had been invoked in error). The
clinical reviewer also noted that the quality of the entries in the medical
and nursing notes was very high. Entries were timed, dated and
signed legibly, and prescriptions were clearly written, as recommended
in guidelines. I agree with her assessment. However, the Controlled
Drug Prescription written by the prison’s medical officer is not now
available having been mislaid. All other relevant healthcare
documentation supports the actions taken by healthcare staff in the
administration of the man’s medication.
67. For the brief period that the man was at HMP Swansea, his treatment
for his pre existing condition was appropriate and timely. When he
became so ill as to require transfer to hospital, this was undertaken
quickly. After he was sent to hospital, the contact between the local
hospital and healthcare staff at Swansea was such that the man’s
condition and needs were monitored by Swansea and acted upon,
sympathetically and promptly.
68. The arrangements for escorting the man were appropriate and
proportionate when he was first admitted to hospital. Thereafter, the
escort was reviewed and reduced in line with the prevailing situation. It
was commendable that the accompanying officer was eventually
present solely for support purposes. It is clear that the officers who
accompanied the man at the hospital acted in a discreet and humane
manner with him and his family.
69. The man’s request that his family was not to be informed of his
whereabouts were not adhered to. As he was unaware of the man’s
wish, the FLO began a process that led to his family being informed
and attending the hospital. Following that first visit, the man’s family
visited several times and they were in regular contact with him
throughout his time in hospital. They were also with him at his death.
Although a mistake had been made in informing the man’s next of kin
of his illness, the outcome was a positive one for him and his family.
70. Some oversights were made in the letter of condolence sent on 18
June as it seems that the prison made no offer of a contribution
towards funeral expenses. This should be remedied retrospectively.
RECOMMENDATIONS
The Governor and Local Health Board should review the arrangements
for the safe retention of healthcare documents.
This recommendation has been accepted by HMP Swansea who responded
in an Action Plan dated 13 June 2008 that:
“All medical documents to be retained in a safe environment – these
documents must be available for future access.”
The Action Plan target date identifies that this action has been completed.
.
The Governor should ensure that the requirements of PSO 2710 are fully
met and that assistance with funeral expenses is offered. A
retrospective offer should also be made to the man’s family.
This recommendation has been accepted by HMP Swansea who responded
in an Action Plan dated 13 June 2008 that:
“Death in custody contingency plan to be followed in any future event.”
The Action Plan target date identifies that this action is an ongoing item
“Head of finance to ensure retrospective offer is made to the family of
the man”
The Action Plan target date identifies that this action has been completed.
Following the receipt of a letter from HM Coroner in Swansea dated 18
August my investigator made enquiries at Swansea prison revealing that no
retrospective offer had been made. The Deputy Governor at Swansea
investigated and established that an error had been made. On 27 August an
offer of assistance with funeral expenses was made to the man’s family by the
Swansea Family Liaison Senior Officer.
GOOD PRACTICE
I commend the Head of Security for authorising the accompanied
release which afforded the man a greater degree of dignity at the end of
his life.
I commend the HCC Nurse and the prison pharmacist who acted
promptly to obtain sufficient medication for the man.
The Governor at Swansea also commended these members of his staff.