Individual at Stafford

Investigation into the circumstances surrounding the
death of a man at a hospital in July 2006,
while in the custody of HMP Stafford
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 who died on an evening in July 2006 in hospital. He had been released
on temporary licence from HMP Stafford earlier that day after the seriousness
of his condition became apparent. His mother and brother were at his
bedside. He was 34 years old.
The Ombudsman investigates the deaths of all prisoners in custody, including
those due to apparent natural causes. In this case, the investigation was
carried out by one of his investigators. She also commissioned an
independent clinical review from South Staffordshire Primary Care Trust
(PCT). I am grateful to the clinical reviewer for carrying out the clinical review
of the man's care. I am also grateful to the Governor and his staff for their
assistance during the investigation.
The man who is the subject of this report died of small bowel ischaemia, a
rare disease and very uncommon in someone of his age. It was caused by a
tumour on the blood supply to the bowel. He had been receiving treatment for
bowel problems before he arrived in prison. In prison, after a sustained period
of ill health that led to many tests and hospital appointments, the ischaemia
was discovered to be at too advanced a stage to be treatable.
When the man attended hospital appointments he was escorted by prison
officers to whom he was handcuffed. He found this distressing and, on a
number of occasions, refused to go to hospital as he did not wish to be seen
this way. Matters escalated when a consultant refused to examine the man
while he was wearing restraints and prison staff refused to remove them for
security reasons. The man made a complaint to this office which was partially
upheld and the impasse was eventually resolved when the consultant
examined the man in the prison. The Ombudsman made a recommendation
about the use of restraints during medical consultations. Although the
recommendation was accepted, it had not been complied with and so I repeat
it here.
I apologise for the length of time it has taken to issue this report and for any
additional distress which has been caused. I offer my sincere sympathy and
condolences to the man’s family for their loss.
I make one recommendation regarding the use of restraints during medical
consultations.
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.
Jane Webb
Deputy Prisons and Probation Ombudsman March
2010
CONTENTS
Summary
The investigation process
HMP Stafford
Key findings
Issues
Conclusion
Recommendations
SUMMARY
This man was born on 10 June 1972 and died of cancer in July 2006 at the
age of 34.
In 2003, the man was sentenced to eight years imprisonment. After a few
months at HMP Blakenhurst, he transferred to HMP Stafford, where he
remained until his death. During the reception process he told staff that
before his imprisonment, he had consulted his doctor about Crohn’s disease
and had been waiting for an appointment with a consultant gastroenterologist.
The prison doctor/the prison medical officer contacted the consultant and
asked him to examine the man.
For the following year, the man suffered from bowel problems, for which he
had many tests and consultations with medical staff. He was examined by
consultants in different areas of medicine as they struggled to identify the
cause of his illness. The man lost weight until he weighed just over seven
stones.
When the man went to hospital appointments he was escorted by officers to
whom he was handcuffed. He did not like to appear in public in this way and
on several occasions, he refused to attend consultations.
In August 2005, the man kept an appointment with a consultant
endocrinologist (the medical speciality that cares for thyroid disease and
diabetes) and again was in handcuffs. The consultant endocrinologist refused
to examine him while he was in restraints and the officers, following their
manager’s instructions, refused to remove them. The consultant
endocrinologist ordered some tests for the man but refused to examine him
and the man returned to prison without having had an examination.
The man made an official complaint about the handcuffs remaining in place
and, after what he saw as an unsatisfactory response, appealed. As he was
unhappy with the reply to the appeal, he complained to the Ombudsman. His
complaint was partially upheld. In June 2006, the consultant endocrinologist
went to the prison and examined the man in the healthcare centre who, by
this time, was very frail. The consultant endocrinologist made a provisional
diagnosis of chronic pancreatitis and arranged for an urgent scan and other
tests.
The man was admitted to hospital for four days in early July, with severe
abdominal pain for which he received pain killers. He returned to the hospital
on 13 July where he was examined and prescribed medication for irritable
bowel syndrome. Two days later, he returned to the hospital, still in severe
pain. An x-ray showed an obstruction in the small bowel and staff therefore
kept the man under observation to begin with. The man did not improve and,
on 19 July, doctors carried out an exploratory operation that revealed
ischaemia (restriction in blood supply) to the bowel. No treatment was
possible other than pain relief.
Prison staff applied for the man to be released on temporary licence, which
was granted. Sadly, the man died that evening, with his mother and brother
at his bedside.
THE INVESTIGATION PROCESS
1. The investigation was opened by telephone on July 23 2006. The
following day, the notices to staff and prisoners were posted. The prison
sent all the man's prison records, including his medical records to the
investigator. She added to her documents the papers concerning the
man’s complaint to the Prison and Probation Ombudsman (PPO).
2. One of the PPO Family Liaison Officers (FLOs) made initial contact with
the man’s mother, then a further FLO took over FLO responsibilities. The
man’s mother expressed anger at the National Health Service and the
Prison Service. She said that while at her son’s bedside a doctor had said
that he might not have died had he received more appropriate and timely
treatment. I have tried to address this issue in this report and hope I have
provided some answers. I regret that this report is delayed which has
meant that the man’s mother has had to wait for three years before
reading of my findings.
3. The Deputy Director of Primary Care, South Staffordshire PCT,
commissioned a review of the clinical care the man received. The review
began with a meeting of a panel of clinical staff from the PCT who
discussed the man’s treatment and the issues it raised. One of the
members was a consultant surgeon. The review was then carried out by a
clinical reviewer.
4. No formal interviews with staff were conducted. The main issue was
whether the man was appropriately referred for tests and to consultants.
This report is therefore based on a review of all the relevant paperwork,
especially the man’s medical records, prison records and the clinical
review.
HMP STAFFORD
1. HMP Stafford was built in 1794 and, apart from the period 1916 - 1940,
has been in continuous use as a prison ever since. It holds 627
category C prisoners. Vulnerable prisoners are accommodated on E, F
and G wings. Prisoners on G wing are all on the enhanced level of the
Incentives and Earned Privileges Scheme (IEP). E and F wings
housed a mixture of prisoners on enhanced, standard and basic levels.
(IEP is used as an incentive to reward good behaviour in prisons.
There are three levels - basic, standard and enhanced. Incentives
include access to in-cell television, more private cash to spend, wearing
own clothes, more time out of cell and community visits. Every prison
sets its own criteria to obtain each level.) All prisoners work unless
there are medical reasons why they cannot do so, or they are past the
retirement age.
2. There is a medical hatch on the ground level landing between E and F
wings. E and F wings also share a full-time nurse who oversees
prisoners reporting sick, treatments and sees prisoners on the wing
throughout the day as necessary. There is no in-patient facility at
Stafford.
3. The Independent Monitoring Board report for 2005 - 2006 highlights a
number of concerns. Issues such as the provision of canteen services,
the refurbishment of cells and the type of work available in the
workshops would have affected the man, but no more so than any
other prisoner.
4. HM Chief Inspector of Prisons carried out a full, announced inspection
on 3 - 7 July 2006. Several of her findings and recommendations are
relevant to the man’s time in the prison.
“Relationships between healthcare staff and prisoners appeared
to be good, and mutually respectful. We were disappointed to
find that there was no signed service level agreement (SLA)
between the prison and the PCT. … Chronic disease
management was patchy, with some examples of good practice,
such as the work undertaken with diabetic prisoners. We were
also pleased to note that prisoners were risk-assessed for
medication.
“The accredited offending behaviour programmes provided were
appropriate and sufficient to meet the needs identified in the
2005 area analysis. Prisoners in both parts of the prison had a
realistic chance of completing a programme during their time at
Stafford.
“Prisoners were generally satisfied with the applications system,
but outcomes were not routinely recorded and staff were not
proactive in dealing with applications. Complaint forms and
confidential envelopes were not always freely available. The
promptness of replies to complaints had improved, and they
were courteous and helpful.”
Escorting prisoners to hospital appointments
5. Prison officers escort prisoners to their hospital appointments, often
using handcuffs. An escort chain is usually used as an alternative to
allow for situations such as a prisoner needing to go to the toilet or for
particular treatments to be given. The escort chain has a longer length
of chain, with handcuffs at either end. One end is attached to a prison
officer’s wrist and the other to the prisoner’s wrist.
6. A prisoner who needs to remain in hospital, who has not been released
from custody on temporary licence, is escorted and monitored by
prison officers under the “bedwatch” procedures. This usually means
that two officers remain at the bedside and record any significant
changes or events.
7. Subject to a risk assessment, the Governor decides whether the
prisoner should be handcuffed and the number of officers required to
accompany the prisoner. Risk assessments are made when a
prisoner attends hospital for in-patient and out-patient appointments.
These are dynamic assessments which can be further considered at
any stage during the escort or bedwatch required. The location of the
consulting room/ward and possible escape routes and the prisoner’s
offence are considered before reaching a conclusion. The National
Security Framework advises governors on matters of security.
KEY FINDINGS
8. The man was arrested on 6 February 2003 and charged with serious
offences. The following day, he appeared at a crown court where he
was remanded in custody to HMP Blakenhurst.
9. Upon arrival at Blakenhurst, the man underwent a reception health
screen which showed that he was not receiving any medication. Staff
noted that the man had seen his community doctor recently about
Crohn’s disease, an inflammation of the bowel. He said that he had
suffered from testicular cancer at the age of five. He also said that he
had tried to commit suicide after he had committed the offence by
taking an overdose of paracetamol.
10. Staff recorded in the man’s medical record that he was awaiting an
appointment with a consultant gastroenterologist at an outside hospital
on 24 February. The man had first seen the consultant
gastroenterologist in 1999 regarding his bowel problems when the
possibility of Crohn’s disease was discussed. However, repeat
examinations in May 2001 showed no abnormality.
11. Due to the nature of his offence, the man was placed in the
segregation unit. (The purpose of segregation is to maintain safety,
order and discipline. A segregation unit provides temporary
accommodation for prisoners who have become violent or disruptive,
committed offences against prison rules or require protection if they are
under threat from other prisoners.) Staff told him that he would remain
in the segregation unit under Rule 45 (for his own protection) until a
space became available in the vulnerable prisoners unit. On 17
February, the man was convicted of the offences at a crown court and
remanded for sentencing.
12. On 15 April 2003, the man was sentenced to eight years imprisonment
and the following month he transferred to HMP Stafford. In Reception,
staff recorded his weight as 10 stones. On 13 May, the man had his
induction and all his paperwork was completed. The following week,
the man started working in workshop 1 and was described as a very
good worker. Throughout July and August, the man continued to do
well at work and on 9 August, he gained the enhanced level of the
Incentives and Earned Privileges Scheme.
13. The prison medical officer wrote to the consultant gastroenterologist on
8 October, asking him to re-examine the man regarding his bowel
problems. The prison medical officer said that the man was still
complaining about diarrhoea and fat in his stools. He had arranged for
blood tests to be carried out and would enclose the results for the
consultant gastroenterologist.
14. The consultant gastroenterologist responded to the prison medical
officer on 31 October. He said that, before the man was imprisoned,
he had thoroughly investigated the man’s problem of diarrhoea. He
had found evidence of primary bile salt malabsorption for which he had
prescribed cholestyramine (a drug which reduces the levels of
cholesterol in the blood and improves the itching associated with liver
disease). He was not sure if the man had taken this medication
appropriately. The consultant gastroenterologist said that he had
planned on repeating this but the man had failed to keep his
appointments, (although this might have been due to his
imprisonment). He also explained that he had suggested that the man
was admitted to hospital so that further tests could be done. He added
that the prison medical officer agreed to ask for a visit from the man as
a matter of routine. He would also discuss the situation with his clinical
biochemist and update the prison medical officer on the situation.
15. Four days later, the consultant gastroenterologist again wrote to the
prison medical officer to say that he had discussed the man’s situation
with a consultant clinical biochemist. He had decided to reassess the
man’s neurotensin levels (a 13-amino acid peptide found in the brain
and spinal cord that affects pituitary hormone release and
gastrointestinal functions). The consultant gastroenterologist said he
would discuss this further with the consultant clinical biochemist but
would still see the man as a matter of routine in due course.
16. The prison medical officer wrote to the consultant clinical biochemist on
7 November, asking him to arrange a date for the tests. He asked for a
week’s notice of the appointment so that an appropriate escort could
be arranged. The consultant clinical biochemist arranged an
appointment for the man on 4 December. However on 3 December,
the day before he was due to be seen, the man refused to attend the
appointment as he did not want to be seen in handcuffs in the hospital.
17. In April 2004, the man was given a warning as staff found that he had
too many possessions during a routine check of his cell. The following
month, staff described him as a good worker and he moved to G wing,
which housed enhanced prisoners. However, on G wing the man took
time to settle in and was warned about his attitude towards staff on G
wing.
18. From May to July, the man’s bowel problems worsened and he
suffered diarrhoea and abdominal pains. He had lost 11lbs since
February and was alarmed at his weight loss. The prison medical
officer therefore wrote to the consultant clinical biochemist requesting
another appointment, saying that the man had promised to attend this
time.
19. The man received further warnings in July regarding his attitude
towards staff on G wing. He was told that his attitude and behaviour
were not acceptable for an enhanced prisoner on G wing and warned
that he would be moved to E wing.
20. On 14 July, staff reviewed the man’s completion of the Sex Offender
Treatment Programme (SOTP). They recommended that he should
complete the Enhanced Thinking Skills and the SOTP Booster
programmes. They also suggested that he complete drug and alcohol
awareness courses.
21. The following day, the man returned to E wing after continuing poor
behaviour on G wing. Entries made in the man’s record state that he
started feeling sorry for himself at this point and was making claims
that he had been victimised. He was considered to have given poor
excuses for his behaviour to try to gain sympathy. It was suggested to
the man that he should improve his demeanour and attitude. By
August, the man had settled down in E wing. An IEP review revealed
that the man was no cause for concern and he remained on the
enhanced IEP status.
22. During September and October, the man complained of back pains.
On 24 September, he went to a lumbar spine (lower back) examination.
The resulting report showed that the man’s spine was not abnormal
and suggested an orthopaedic referral for further investigations. The
consultant clinical biochemist wrote to the man on 5 October asking
him to attend hospital on 24 October for a blood test.
23. On 2 December, the consultant clinical biochemist presented the test
results of a Gut Hormone profile on the man. They provided no
evidence of gastroentero-pancreatic nueroendocrine tumours to
account for his chronic watery diarrhoea. On 17 December, the
records showed that the blood received by the hospital on 20 October
was “within normal limits”.
24. Shortly before Christmas, the man started work in the greenhouse and
gardens. He also requested a single cell because of his medical
problems, which he felt produced unpleasant conditions for his cell
mate. However, his request was denied due to his behaviour when
previously on G wing. A note in his records confirmed that he accepted
the decision quite well.
25. A consultant orthopaedic surgeon wrote to the prison medical officer on
1 February 2005, to say that he had listed the man for MRI and DEXA
scans. (MRI scanning is used to detect structural abnormalities of the
body and a DEXA scan is used to measure the density of bones.) He
also said that the man would need to be reviewed by an
endocrinologist.
26. The man refused to attend his appointments with the prison medical
officer three times in March. He also made another request for a single
cell. The same month, staff noted in the man’s prison record that he
was “having no problems” and was “a polite and respectful man”.
However, on 10 April, officers expressed concerns over the man’s
deteriorating health.
27. The consultant gastroenterologist diagnosed primary bile salt
malabsorption. He noted that this condition would certainly account for
the man’s diarrhoea and prescribed cholestyramine, a medication that
lowers the cholesterol levels in the blood. However in April, the man
refused to take his medication as he said it made him feel worse. A
note was made in the man’s records that he now also had a pain in his
elbow. In July, the man declined to see the doctor and said that he
was fit and well.
28. For operational reasons, staff were unable to take the man to an
appointment with the consultant endocrinologist on 14 July to an
outside hospital. Prison managers had to temporarily halt the
movement of people within the prison and all staff had to be on alert.
On 1 August, the consultant endocrinologist wrote a letter of complaint
to the Governor, saying that he had only received a message from
Stafford at 1.45pm on the day to say that the man would not arrive at
the hospital until 2.30pm. He said that he could not see the man then
as he had other patients but had now arranged another appointment
for him. The consultant endocrinologist said that the prison should
inform the hospital as soon as possible if they were unable to keep an
appointment. He said that Stafford had wasted his time and had
inconvenienced the man. In response, the prison medical officer wrote
to the consultant endocrinologist and apologised for not keeping the
appointment. He explained that situations would sometimes arise
within the prison that require a shutdown and all staff had to be on
alert. Therefore there were no spare staff to take anyone to
appointments. The prison medical officer told the consultant
endocrinologist that he appreciated the man being given another
appointment.
29. The man was escorted to his appointment with the consultant
endocrinologist at an outside hospital on 25 August. He was
handcuffed to an officer. The consultant endocrinologist asked for the
handcuffs to be removed but the escorting officers refused. This was
because the risk assessment did not allow them to do so. The
consultant endocrinologist therefore refused to examine the man,
although he did arrange for some blood tests to be done.
30. On the man’s return to Stafford, he made a formal complaint regarding
the refusal by the officers to remove his handcuffs. He wrote on the
complaint form that the handcuffs had been removed on previous
occasions and asked what would happen when he went for his MRI
scan.
31. The following day a senior officer (SO) answered the man’s complaint
and said:
“When a prisoner goes out of prison on escort he must not be
removed off the handcuffs, this can only happen on the authority
of the duty governor and not the doctor you have an
appointment with. I cannot give a reason as to why the doctor
did not examine you. Prior to your MRI scan the room will be
risk assessed by the escorting staff and permission sought from
the duty governor of the day in order to take you off the cuffs.”
32. The man was unhappy with the response from the senior officer and
completed an appeal form. He asked why, if this was the policy, that
the escorting officer had not telephoned the duty governor. He added
that both his and the consultant endocrinologist’s time had been
wasted. A man from the security department answered the man’s
complaint and reiterated the senior officer’s response, saying:
“When your MRI scan appointment is confirmed a risk
assessment of you and the area are going to be completed.
The information on these risk assessments will dictate the
handcuffing policy.”
33. The man remained unhappy with this response as he felt that it had not
answered his question about why the escorting officer had not
contacted the duty governor. He said that he had been in a lot of pain
and had not given any cause for concern on previous hospital visits.
34. The consultant endocrinologist wrote to the prison medical officer on 31
August to explain that, “as a matter of principle” he would not “interview
or examine a man in chains”. He said that he regarded this as
malpractice and had apologised to the man for not being able to
assess his condition properly. He said that he had, however, arranged
for some blood tests to be done and would write to the prison medical
officer once the results had arrived. He also informed the prison
medical officer that the man’s restraints would have to be removed for
the forthcoming MRI scan.
35. The following day, the man made a formal complaint that he had
recently wrongly lost his job because of security issues. He said that
he had a good relationship with the officer in charge of the gardening
party. He also said that he had spoken to his personal officer who told
him that his voluntary drug tests (VDT) and mandatory drug tests
(MDT) had all been negative. The man asked for the decision to be
reversed. In response, the man was told that he had been seen at the
rear of G wing, which was an unauthorised place, without being
supervised. The man was told that this was the reason why he had
been removed from the work party. The fact that he had a good
relationship with the officer in charge of the gardening party and had
negative VDTs and MDTs was of no significance.
36. The man appealed on 7 September and said that the garden work
would not require him to go round the back of G wing without
supervision. He said the officer in charge of the gardening party had
always given them authorisation to work unsupervised around the
back. The man said if this was the reason then others should be taken
off the work party too. He asked for the exact date that was being
referred to and asked if the officer in charge of the gardening party
could be spoken to in order to confirm the position. Staff reiterated that
information had been received from the security department that the
man was unsupervised at the back of G wing and therefore he was
removed from the garden party. The man explained in his reply that
they had not been told that the back of G wing was an unauthorised
area. He said that it was impossible to work unsupervised and the
officer in charge of the gardening party had said that he was happy as
long as they were in the G wing complex. The man again asked for the
officer in charge of the gardening party to be spoken to. The man was
told that the decision was justified as members of the garden party had
previously been told that the area behind G wing required supervision.
It was also explained that there was no reason as to why he should not
be considered for future employment on the party should the
opportunity arise.
37. On 12 September, the prison medical officer forwarded the consultant
endocrinologist’s letter to the Governor (which set out his refusal to
assess a patient in handcuffs) and told him that there was no other
doctor to whom the man could be referred. The following day, he wrote
to the consultant endocrinologist enclosing the Area Manager’s details.
The doctor also wrote to the Area Manager, enclosing the consultant
endocrinologist’s letter.
38. A week later, on 19 September, the man’s appeal regarding the
removal of his handcuffs was answered by the Head of Operations and
Security. He said that there was no record of a request to the duty
governor for the handcuffs to be removed.
39. Two days later, the consultant endocrinologist sent the man’s test
results to the prison medical officer. The consultant endocrinologist’s
opinion was that there was no “definable abnormality here” and that he
did not propose to arrange a follow up. On 22 September, the then
Governor replied to the prison medical officer, enclosing a letter that
she had written to the Director of Clinical Standards on 27 June. In this
letter the Governor set out the prison’s policy on hospital escorts. On
29 September, the consultant endocrinologist wrote to the Area
Manager, suggesting that a compromise be sought.
40. The then Governor replied to the consultant endocrinologist on 6
October, explaining the policy on restraints. She offered two
alternatives - increasing the number of clinics held in the prison or
providing a secure consulting room in the hospital. She told the
consultant endocrinologist that she would hold a meeting on 18
October with the head of healthcare, head of operations and security
and the Director of Clinical Standards. She offered to update him after
the meeting. On 10 October, the consultant endocrinologist wrote to
the Area Manager and suggested that consultations in prison should be
possible.
41. The consultant endocrinologist wrote to the prison medical officer on 11
October, regarding the outcome of the man’s tests. He said that the
problem appeared to be primary bile malabsorption and suggested that
the man start on cholestyramine. He told the prison medical officer that
he had written to the Prison Service regional manager, seeking
guidance on whether the man’s handcuffs could be removed and, if
they were, then he would gladly see the man in the clinic. On 17
October, the Area Manager wrote to the Governor enclosing the
consultant endocrinologist’s letter. She asked the Governor to keep
the consultant endocrinologist informed of the discussions on
restraints. On the same day, the Governor wrote to the consultant
endocrinologist informing him that the Director of Clinical Standards
had cancelled the meeting, but that a further meeting was to be
arranged.
42. In November, the man consulted healthcare staff about back pain
which got worse throughout the month. On 19 November, the man
was admitted to a local hospital with abdominal pain. A consultant
surgeon examined the man and said that the abdominal palpitation test
revealed some upper abdominal tenderness but no other significant
signs. The man remained on the ward for observation and, as his
symptoms started to settle, he was discharged with arrangements for
an outpatient ultrasound scan. He returned to Stafford two days later
on 21 November.
43. Five days later, the man had another IEP review which confirmed that
he maintained good behaviour and was usually no problem for staff.
He remained on the enhanced IEP level. However, on 23 December, it
was noted that the man had abused an officer during the morning roll
check. (At various times of the day a full roll check takes place to
account for all prisoners, these usually take place at shift handovers.)
It was noted in his records that his behaviour needed to be more
consistent when dealing with staff.
44. The man’s bad back pains continued. In the middle of February, he
had a thoracolumbar spine MRI scan. A consultant radiologist
concluded that possible malabsorption and a metabolic abnormality
was the most likely cause. He said:
“Rather difficult to put these together but the gibbus (the hump
of a deformed spine) and vertebral body wedging would be
compatible with Scheuermann’s disease (known as a
hunchback). However, the more diffuse increase in fat content
of the lumbar spine and lower thoracic vertebral bodies is more
difficult to explain. A metabolic abnormality might account for
this although I do not know why the thoracic vertebral bodies are
not affected.”
45. The consultant radiologist also referred to “Previous irradiation of the
lower half of the body” as the possible cause of the man’s abnormal
spine. This was presumably a reference to the fact that the man was
diagnosed with testicular cancer when he was five years old and
received radiation therapy.
46. The man wrote to the Ombudsman’s office on 23 February 2006, to
complain about the use of restraints during his hospital appointment.
He explained that his ill health had prevented him writing within the
three month deadline after the response to his appeal. The
Ombudsman agreed to investigate the man’s complaint and one of his
investigators carried out the investigation. She wrote to the consultant
endocrinologist on 22 March and telephoned the man two days later.
47. During March, the man’s health continued to be poor and he had some
time off work. However, a nurse recorded in the man’s medical file that
he appeared pain free and was happy on the wing.
48. On 4 April, the man made a formal complaint about the food served at
Stafford. He said that he now had a problem with the sandwiches
served at lunch because he had lost weight. He said that he weighed
only eight stones (8 stones, compared to 10 stones when he arrived at
Stafford). The prison doctor told him that he was unable to do anything
and that it was up to the Governor to decide whether to provide cooked
meals. The man said he did not eat sandwiches and he would
continue to lose weight if nothing was done. In response he was told
that the kitchen had no control over the policy regarding sandwiches at
lunchtime and was told to seek medical advice from the doctor as soon
as possible regarding his weight loss.
49. Nine days later, the man appealed and suggested that if the menu
could not be changed the Governor should consider adding items such
as sausage rolls, pizza slices or cheese on toast to the menu. In
response, he was told that prison surveys are done annually and that
this issue would be raised at the next meeting. The man replied that
annual surveys were never taken into account and a better result could
be achieved by staff listening to prisoners as they walked around the
prison. He added that, if the budget was inadequate, there must be
cheaper yet more palatable meal options. In response, the man was
told that comments made in the food book and at the prisoner food
representatives’ council were taken into consideration. Also that the
sandwich meal reflected what most of the working public ate for lunch
and was in line with the majority of Category C prisons. The response
made it clear that there were no plans to change the lunchtime menu at
present.
50. On 10 April, the consultant orthopaedic surgeon treating the man
reviewed him and assessed the results of the MRI and bone density
scans. The consultant orthopaedic surgeon treating the man wrote to
the prison medical officer to explain that the man ideally should be
treated with cholestyramine. He said that if this was beneficial in
helping the man to gain weight, then he would need to be treated for
osteoporosis. The consultant orthopaedic surgeon treating the man
undertook two further investigations. These included plasma proteins
and electrophoresis of urine for myeloma protein to make sure that the
fatty changes in the lumbar spine were due to the osteoporosis. He
informed the prison medical officer that he would arrange for the man
to be reviewed by a gastroenterologist. The consultant orthopaedic
surgeon treating the man then wrote to a further consultant
gastroenterologist on 24 April to ask if he would be able to see the man
as he thought that he needed to be treated by a gastroenterologist
rather than an orthopaedic surgeon. The consultant orthopaedic
surgeon treating the man also explained that the man appeared to
have a primary bile salt defect and needed treatment with
cholestyramine.
51. Records show that on 8 May the man was seen by the consultant
orthopaedic surgeon who suggested treatment for osteoporosis. Two
days later, the man was taken to an outside hospital for an ultrasound
scan and it was noted that the man was well behaved and caused no
problems. His restraints were removed for the duration of the scan.
The ultrasound was of the abdomen but bowel gases caused difficulty
detecting anything and nothing of concern was noted. The man’s
weight was noted to be 7 stones (a loss of 2.5 stones in the three years
since he came to Stafford). On 16 May, the prison medical officer
recorded that the man should be referred to the consultant
endocrinologist. However a referral could only be made once the
Governor had responded to the consultant endocrinologist’s letter of 31
August 2005, (when he wrote that he would not interview or examine a
man in restraints). Two days later, on 18 May, the man applied to work
in the garden again but his application was refused due to his medical
condition.
52. At 9.30am on 21 May, a nurse was called to the wing to examine the
man as he was complaining of severe stomach pains above the belly
button and to the right side of the abdomen. His temperature, blood
pressure and pulse checks were taken. On 29 May, prison managers
suggested that the consultant endocrinologist examine the man in
prison.
53. The then Deputy Ombudsman responsible for complaints
investigations issued a draft report on 5 June, partially upholding the
man’s complaint. The She stated that, although the man did not
appear to pose a high risk, the escorting officers had behaved
appropriately. As I have explained, the National Security Framework
(NSF) indicates that there is a presumption that, unless the risk
assessment states otherwise, prisoners should not be restrained during
treatment or medical examination whilst they attend outside hospital.
54. A risk assessment had been carried out on the man and the assessor
indicated that the man was a risk to the public and to hospital staff.
However, the then Deputy Ombudsman responsible for complaints
investigations was concerned about the accuracy of the information in
the risk assessment. The assessment stated that the man did not have
a conviction for common assault, which was not the case, although he
had received a police caution. The assessment also referred to a
“history of drugs”, which staff in the security department had been
unable to explain to the complaints investigator. Also, it was unclear in
what respect the man posed a risk to hospital staff as his custodial
behaviour had not given any cause for concern and he had never been
involved in an escape attempt.
55. The then Deputy Ombudsman responsible for complaints
investigations noted that the man was upset that the escorting officers
had not contacted the duty governor for permission to remove the
handcuffs when asked to do so by the consultant endocrinologist. The
man said that the officers had told him that they did not need to contact
the duty governor. The then Deputy Ombudsman responsible for
complaints investigations said that the officers were correct in saying
this, as the risk assessment made the situation quite clear to the escort
staff that the man was to remain restrained throughout his visit, unless
his life was in danger.
56. Finally, the then Deputy Ombudsman responsible for complaints
investigations recommended that the Governor and Head of Security
review the way in which risk assessments are conducted to ensure that
the prison complied with the NSF. Also the Governor should contact
Mid Staffordshire General Hospitals NHS Trust to discuss
arrangements for the treatment and examination of prisoners who
cannot safely be removed from their restraints. The recommendations
were accepted.
57. The man’s weight was noted to have fallen further to 7 stones by 6
June. The following week, he was re-categorised as category D and,
on 23 June, the consultant endocrinologist examined him in the prison
healthcare centre. He made a provisional diagnosis of chronic
pancreatitis (inflammation of the pancreas) and arranged an urgent
computerised tomography (CT) scan and other tests. He noted that
the man had been referred to the further consultant gastroenterologist
but said that he would deal with the matter as it was urgent. The
consultant endocrinologist added that if the man’s condition
deteriorated, it would be necessary to admit him into hospital. On the
same day, the consultant endocrinologist wrote to the prison medical
officer to inform him that the man’s condition had deteriorated, that he
had lost more weight and had a good deal of pain.
58. From 4 to 8 July, the man was admitted to outside hospital with severe
abdominal pain. On his return to Stafford, a note in the medical record
showed that he “looked better, the pain was reduced and was returned
with tramadol and paracetamol”. (Both drugs are pain relievers.) Two
days later, the man had an appointment with the doctor, who recorded
that the CT scan had found nothing abnormal, except for a small
pancreas and that he was still in pain. A few days later, the man’s
weight was recorded as 6.5 stones.
59. On 13 July, the man told healthcare staff that he had central abdominal
pain which had lasted for 12 hours. When he was examined he was
distressed and tender over most of his abdomen, bowel sounds were
present and tramadol was not helping with the pain. The prison
medical officer arranged for the man to be sent to outside hospital,
where he was examined in the A&E department by a consultant in A&E
medicine.
60. The consultant in A&E medicine said in a letter to hospital managers
that the man had arrived at the A&E department at 10.27am and he
had attended him at 10.49am. He recorded that the man had a history
of mid-gut abdominal pain and had sustained a loss of four and a half
stones in the past year. He recorded that reports showed that previous
investigations of blood, recorded the man did not have any nausea or
vomiting. He had no bowel upset and no urinary symptoms. On
examination, the consultant in A&E medicine recorded that there was
no evidence of anaemia or jaundice and examination of the chest and
cardio vascular system revealed no abnormalities. In his notes, the
consultant in A&E medicine recorded that
“There was abdominal tenderness on the lightest of abdominal
palpitation and recorded that the pressure of his stethoscope
when listening to the bowel sounds did not produce any signs of
abdominal tenderness. He recorded that the bowel sounds
were hyperactive and that the hernial orifices were intact.”
61. The consultant in A&E medicine said that his initial diagnosis
suggested the possibility of irritable bowel syndrome and perhaps a
supratentorial (an area of the brain) problem. The consultant in A&E
medicine prescribed Colpermin (capsules containing peppermint oil) for
irritable bowel syndrome for seven days and discharged the man.
62. The man returned to the prison on the same day. The escorting officer
made a formal complaint to the prison doctor regarding the brevity of
the examination carried out by the consultant in A&E medicine. The
following evening, wing staff asked the duty nurse to examine the man.
She arrived at 7.05pm, and the man told her that he had abdominal
pains but did not want to see the out of hours doctor.
63. On 15 July, staff contacted the out of hours doctor as the man was
experiencing severe pain. The doctor recorded that the man was very
unwell, that his abdomen was very tender, and he asked for an urgent
referral to the Emergency Assessment Unit at an outside hospital. At
2.30pm, an ambulance took the man to the hospital. Again he was
wearing handcuffs. He had severe pain and distress on examination
and an x-ray showed features of an obstruction in the small bowel.
Staff initially managed the man conservatively and made a preliminary
diagnosis of pancreatitis associated with an ileus. (An ileus is a partial
or complete non-mechanical blockage of the small and/or large
intestine. It is most often associated with an infection of the membrane
lining the abdomen.)
64. The following day, the man was catheterised and he was treated with
intravenous fluids and analgesics (drugs used to relieve pain). A note
was made following the ward round by a consultant surgeon which
stated that the man’s abdominal pain had improved that morning. A
subsequent ward round on 17 July recorded that the man had been
pain free throughout the night. The prison Head of Healthcare
contacted the hospital the same day for an update on the man.
65. No findings were recorded after the ward round on 18 July. The
catheter was removed, instructions were given to remove the
intravenous fluids and it was recorded that the man could eat and
drink. Another note recorded on 18 July said that the man appeared to
have small bowel disease. A discussion was undertaken with the
consultant surgeon. The advice was that a repeat abdominal x-ray
would be undertaken. If the small bowel dilation had not reduced
consideration would be given to undertaking a laparotomy (a surgical
procedure involving an incision through the abdominal wall to gain
access into the abdominal cavity).
66. At 7.00pm on the same day, a junior doctor visited the man. He was
complaining of pain and it was noted that he had not passed any urine
since the catheter had been removed. A bladder scan revealed
270mls of urine in his bladder. Further x-rays revealed a worsening of
the small bowel obstruction and as a result an exploratory laparotomy
was undertaken on 19 July.
67. The exploratory operation revealed that the man had ischaemia (a
restriction in blood supply, generally due to factors in the blood vessels,
with resultant damage or dysfunction of tissue) in the bowel. A section
of the bowel had died and the man’s condition was beyond treatment.
The escort informed healthcare staff that the man had only a “few
hours to live”. The head of healthcare went immediately to the hospital
and at 5.10pm the Head of Operations and Security gave permission
for the escort chain to be removed. The escorting officers then moved
outside the ward.
68. The man was released on temporary licence and the escorting staff
returned to the prison. The man’s mother and brother arrived to be
with him and, at 7.00pm, he passed away.
ISSUES
The man’s health
69. The clinical reviewer compiled her report after a review panel had met
to consider the man’s clinical care. She noted that:
“[The man] had been seen by both nursing staff and the medical
officer. On each occasion his symptoms were taken seriously
and a number of referrals had been made to different
consultants at different hospitals.”
She also noted that he had had various tests and his medication was
regularly reviewed.
70. My investigator’s notes of the meeting record that the consultant
surgeon on the panel told the other members that this form of cancer is
quite rare. It is normally only seen in older people and he had never
seen it in someone as young as this man. The clinical reviewer notes
the consultant surgeon on the panel as saying:
“[The man’s] previous medical history was biased against a
laparotomy operation as all the diagnostic tests that had been
performed had not revealed anything. [The consultant surgeon]
advised the panel that it was impossible to say whether
performing the laparotomy any earlier would have made any
difference to the outcome in this case as the patient had died of
something very rare.”
In his opinion, the ischaemia was:
“most likely to have developed between 15 and 19 July. The
blood supply to the small bowel was being invaded and
obstructed and therefore it is impossible to tell when the critical
instant was.”
71. The consensus of the panel was that the clinical care that the man
received was “timely, sensitive and appropriate”. It was equal to the
care that he would have received had he been in the community.
72. The clinical review also discusses and makes recommendations
concerning actions by members of the PCT, including a complaint
raised by a prison officer with the Parliamentary and Health Service
Ombudsman about the way in which a hospital doctor behaved
towards the man. These matters are outside my remit and I make no
comment on them.
Use of restraints
73. As a prisoner, when the man attended his hospital appointments he
was handcuffed to a prison officer. This is standard procedure and,
given the man’s offences, I am satisfied that it was a necessary
security precaution. However, the consultant endocrinologist refused
to examine him whilst restraints were in place – whether handcuffs or
an escort chain. He explained in letters to prison managers that he
considered it against human dignity and was “a matter of principle”.
74. The Prison Service’s National Security Framework (NSF) sets out the
security policy and procedures for prison managers. One section deals
with prisoners wearing restraints (either handcuffs or escort chain) to
attend hospital appointments. The policy is “unless the risk
assessment states otherwise prisoners should not be restrained during
treatment or medical examination whilst attending outside hospital”.
75. The officers escorting the man were instructed not to remove the
restraints and so they did not, not even when the consultant
endocrinologist proposed to begin his examination. The man’s
complaint was that the officers did not contact the prison managers at
the time and ask for further instructions.
76. The then Deputy Ombudsman in charge of the Complaints Team did
not uphold that part of the complaint. However, she did uphold the
man’s complaint regarding two incorrect items of information on which
the security risk assessment was based. She also recommended that
prison managers reconsider their local policy requiring restraints to
remain on during medical consultations, to bring it into line with NSF
policy.
77. The recommendation was accepted. However, in subsequent
correspondence with the prison security manager, the complaints
investigator learned that the prison’s policy had not changed to reflect
the NSF. I therefore repeat the recommendation here.
The Governor should ensure that the local policy on the wearing
of restraints during medical consultations is consistent with and
conforms to the National Security Framework.
78. I note that the matter was eventually resolved (after the involvement of
the Ombudsman’s office) by the consultant endocrinologist examining
the man in prison. It would have been better had that arrangement
been made several months earlier. I trust that if similar circumstances
pertain in the future that this compromise will be implemented as a
matter of course.
CONCLUSION
79. The man suffered a long period of ill health, during which he had many
tests and saw a number of different consultants. However, it was only
in the last few days of his life that the doctors discovered the rare
cancer that caused his death. By that time, no treatment was possible.
80. The issue that stands out in this report is how firmly and unfairly the
man was caught in the impasse between the doctor’s principles and
the prison’s very strict implementation of security measures. I am
pleased that the matter was eventually resolved but less happy with
how long it took.
RECOMMENDATION
The Governor should ensure that the local policy on the wearing of
restraints during medical consultations is consistent with and conforms to
the National Security Framework.
The Prison Service accepted the recommendation. Their response was:
“A local protocol is being drawn up in line with the National Security
Framework. The Governor is to raise this at the next PCT (Primary Care
Trust) Partnership meeting to ensure their protocols are compliant.”
This was achieved by 20 September 2009.