Individual at Manchester

Investigation into the circumstances surrounding the
death of a prisoner at HMP Manchester,
at North Manchester General Hospital in July 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2009
This is the report of an investigation into the death from natural causes of a man at
North Manchester General Hospital on 28 July 2008. The man was 70 years of age
and was a Pakistani national. At the time of his death, the man was a prisoner in the
custody of HMP Manchester.
I extend my sincere condolences to the man’s family and friends and all those
affected by his loss.
This investigation was undertaken by one of my colleagues. A clinical review of the
man’s care and treatment has been carried out by Manchester Primary Care Trust.
In the case of a death through natural causes the findings of the clinical review are
central to the report, so I am very grateful for their review.
The man’s physical health had been gradually deteriorating over the final two years
of his life, and in July 2007 he was moved to the prison’s in-patient unit. Following a
collapse in late June 2008, he was discharged to outside hospital where he
remained for the final month of his life. The man’s primary cause of death was
disseminated (widespread) cancer, but that diagnosis was only made at post
mortem.
The clinical reviewer found that the man did not present with any symptoms to
indicate to staff at the prison that he was suffering from cancer.
The clinical reviewer has made two recommendations relating to improvements in
continuity of care, both of which I endorse.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2009
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CONTENTS
Summary 4
The Investigation Process 5
HMP Manchester 6
Key Findings 7
Issues 11
Recommendations 13
Annexes
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SUMMARY
The man was a Pakistani national who was received into HMP Manchester on 18
December 2004 as a remand prisoner. In his First Reception Health Screening
interview the man reported a number of clinical conditions, including abdominal and
chest pains as well as several age related conditions (he was 66 years old at this
time). He also reported being treated for depression in the past. He was prescribed
several medications and his health was subject to regular monitoring.
The man’s clinical records indicate a slow and gradual deterioration in his health
from January 2006 onwards. This included increasing mobility problems, and he
was eventually offered a move into healthcare. The man refused the offer saying
that he would die if he became an in-patient.
By the middle of 2007 it was noticed that the man had lost a lot of weight: losing 17
kilograms (kg) in two months. He said that his weight loss was because he had no
appetite and so was not eating. There is regular comment in the man’s records
indicating that he mainly ate snack foods such as crisps.
Having refused a second offer to move into healthcare, the man eventually agreed to
do so at the end of July 2007. By then his main problems were noted to include
frailty, lethargy, lack of appetite, weight loss and poor mobility. Blood tests were
found to be within normal limits. The man continued to lose weight through the
remainder of 2007 and into 2008. By this time the man was spending most of his
time lying in bed. He was also noted to be smoking heavily. A psychiatrist recorded
his impression in June 2008 that the man was suffering from dementia and a
depressive episode.
The man had still not been diagnosed with any major life-threatening illness when,
on 27 June 2008, he lost consciousness while being taken to the bathroom. After
measuring his pulse, blood pressure and rate of respirations, staff called for an
emergency ambulance. The man was transferred to North Manchester General
Hospital for assessment. He was accompanied by two prison officers in accordance
with standard procedures. Investigations were undertaken at the hospital and, in the
meantime, the man was noted to remain poorly. Several weeks later the hospital
informed the prison that the man was nearing the end of his life. He died at 8.50am
on 28 July. At the time his condition remained undiagnosed, but at post mortem he
was found to have had widespread cancer which was recorded as his primary cause
of death.
The medical care that the man received in prison was reviewed on behalf of
Manchester Primary Care Trust. She has found that the man did not present with
any symptoms indicating that he was suffering from cancer of the lung. She has,
however, made two recommendations to improve provision of care in the future.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 5 August 2008 when two of my colleagues
visited HMP Manchester. My colleagues met healthcare staff who gave them an
overview of the progress of the man’s final illness. They also spoke to two of
HMP Manchester’s Muslim chaplains who had contact with the man’s family, and
one of his close friends. Notices were issued to staff and prisoners notifying
them of the investigation. No staff or prisoners have come forward in response
to the notices.
2. The clinical reviewer, a trained nurse, was appointed by Manchester PCT to
carry out a review of the man’s clinical care and treatment. The clinical
reviewer’s investigation included interviews with staff. Her report is attached as
an annex. I rely heavily on the clinical reviewer’s findings in arriving at my own
findings and conclusions.
3. My Senior Family Liaison Officer wrote to the man’s family who now live in the
United States of America. She also wrote to a close friend of the man’s whom
he had nominated as his next of kin. My family liaison officer explained the
investigation process to both parties and invited them to raise any concerns or
questions they would like explored or addressed. To date, no response has
been received to the letters.
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HMP MANCHESTER
4. HMP Manchester is a Victorian local prison within the Prison Service’s high
security estate, and is situated not far from the city centre.
5. At the time of the investigation, the prison served Magistrates’ and Crown Courts
in the Greater Manchester area holding up to 1,269 male adult prisoners. Its
accommodation comprises two Victorian radial buildings containing nine wings
with a mix of single and double cells, a segregation unit and a healthcare centre.
6. Healthcare at HMP Manchester is provided by the Manchester Primary Care
Trust. The healthcare centre provides 24 hour nursing care and medical cover,
and has beds for up to 38 prisoners.
7. The last inspection of HMP Manchester by Her Majesty’s Chief Inspector of
Prisons was an unannounced short follow-up inspection in May 2007 that was
published in the following October. One of the Chief Inspector’s
recommendations was about the need for the prison to review its policy on the
provision of in-possession medication (that is, medication held by the prisoner).
The reason for the recommendation was in part because the existing policy was
past its 12 month review date. It had also been found that the existing policy did
not include a documented risk assessment to determine the prisoner’s suitability
to hold in-possession medication.
8. In their report on HMP Manchester for the period 1 March 2007 to 29 February
2008, the prison’s Independent Monitoring Board (IMB) expressed their concern
that elderly prisoners with complex mental health and physical needs were being
held in the healthcare centre which had neither the appropriate facilities nor
equipment to respond to their needs. The IMB referred in their report to an
inquest into the death of a 75-year old prisoner when the Coroner commented
that the healthcare centre of a category A prison was not a suitable environment
for the care of the elderly and infirm.
9. None of the circumstances surrounding my previous investigations at HMP
Manchester is directly relevant to the circumstances of the man’s death.
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KEY FINDINGS
10. The man was a Pakistani national who was arrested at Manchester airport on 17
December 2004. At court the following day, the man was remanded into HMP
Manchester. He was 66 years of age at that time. During his initial health
screening the man reported that he had a number of clinical conditions including
high blood pressure, high cholesterol, arthritis, and abdominal and chest pains.
A prison doctor prescribed medication for these conditions. The man also said
he had been treated in the past for depression.
11. The man reported his marital status as ‘separated’. He said that he had four
children, and he named as his next of kin a woman living in Karachi, Pakistan,
whom he said was his daughter. (After the man’s death it was discovered that
this person was a close friend rather than a blood relation.) He also said that he
was a Muslim.
12. The man was subsequently sentenced to ten years imprisonment for importation
of drugs and he remained in HMP Manchester to begin his sentence. He was a
category C prisoner.
13. Between July 2004 and December 2005, the clinical review indicates that the
man’s health was stable. During this period he received regular monitoring and
treatment for his chronic conditions and for other minor ailments.
14. All of the man’s activities centred on education. He reported having had no
formal education as a child, but at the prison he took classes in mathematics and
a range of information technology (IT) courses. He gained qualifications in both
subjects and was reported to be an enthusiastic and hard working student. The
man’s wing files show that he was always quiet and polite to staff and compliant
with the rules. He spent most of his time in his cell, rarely associating with other
prisoners. The man received occasional visits from a friend who lived in
Manchester.
15. Meanwhile, the man’s clinical records show that he began to experience health
problems from January 2006. These included problems with his balance and co-
ordination. He was provided appropriate treatment for those conditions. In July
2006, the man was transferred to HMP Garth but a week later was transferred
back to HMP Manchester. The man needed a walking stick by this time and it
would seem that Garth was not a suitable environment for someone with his
degree of mobility problems.
16. After his return to HMP Manchester, it was found that the man had not been
collecting his medication. When questioned, he said that he had stopped taking
his medication as he was feeling better. Nevertheless, his medication was
restarted. Shortly after this it was noted that the man’s balance had deteriorated
further. Due to her concerns about his ability to care for himself, the
physiotherapist recommended that the man be admitted to healthcare. He
refused admission however, saying that he would die once he became an in-
patient. A blood test result from around this time showed that everything was
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within normal limits. A few weeks later, the man was diagnosed with ‘Type 2’
(non-insulin dependent) diabetes. His blood pressure was also fairly unstable.
17. Throughout 2007, the man continued to have unstable blood pressure and he
was monitored for this. He was also monitored for his diabetes, which did
remain stable. The man was noted to be generally deteriorating, and his poor
mobility made it difficult to collect his meals and to get to the toilet. It was again
suggested that he should move into healthcare but he again refused.
18. On 1 July 2007, the man was weighed and, at 59kg, found to have lost 17kg in
the previous two months. He was seen by one of the prison doctors that day.
The man told the doctor that he thought he had lost about 4.5kg in the last 20
days. He said that he was not eating as he had no appetite. He denied vomiting
or feeling depressed. The doctor requested further blood tests. That same day,
one of the nurses noted that the man had not collected his in-possession
medication for about ten weeks. His records also contain reference to the fact
that he was only eating snack type foods such as crisps and Bombay mix.
19. Two weeks later the man was seen by another of the prison doctors. He found
that the man’s blood pressure was raised and he also detected a heart murmur.
He referred the man to the cardiology department at North Manchester General
Hospital where investigations resulted in a decision that no treatment was
necessary at the time.
20. Due to a further deterioration in his general physical condition, the man was
eventually admitted to healthcare as an in-patient at the end of July. The main
concerns were his frailty, lethargy, lack of appetite, weight loss and poor
mobility. He was prescribed various medications including vitamin tablets and
food supplements. The man remained in healthcare from this time onwards. His
weight and clinical observations were monitored on a regular basis. His blood
was also tested regularly, with no irregularities detected.
21. Little seems to have changed through early 2008, apart it seems from a
continued slow deterioration in the man’s general condition. At interview with the
clinical reviewer, both doctors and nurses described the man as a very private
person who was reluctant to cause problems for the staff and reluctant to
discuss his clinical needs.
22. In March 2008, it was noted that the man was becoming less able and needing
more assistance with his personal care. He usually spent most of each day lying
in bed. Reference was also made to the extent of the man’s smoking (it seems
he was a heavy smoker). He remained reluctant to eat and his weight went
down to 53kg. Further blood tests were undertaken but the results were again
within normal limits.
23. HMP Manchester’s In-patient Manager is a Registered Mental Health Nurse. He
told the clinical reviewer that he recommended on two occasions that the man
should be referred to a consultant physician for older people, but the doctors
made no such referral. The In-patient Manager also made an application for the
man to be transferred to the older persons unit at HMP Norwich. That
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application was approved, although the man died before the transfer could be
made.
24. By June 2008, the man’s weight had dropped further to 48kg. All other signs
and symptoms were the same as before. During the latter part of the month, he
was assessed by a psychiatrist who noted his impression that the man was
suffering from dementia and a depressive episode. He decided that he should
be referred to a psycho-geriatric unit for further assessment. A blood test
towards the end of the month revealed the man to be anaemic.
25. On the morning of 27 June, the man was being taken to the bathroom in a
bathchair when he went into a state of collapse. Staff took him back to his cell
where they took clinical observations and began giving oxygen. An emergency
ambulance was requested. By the time the ambulance arrived the man was
noted to have recovered consciousness but said he had no recollection of what
had happened. He was taken to North Manchester General Hospital for
assessment. He was accompanied by two prison officers and, as is customary,
he was handcuffed. Within several days, however, it was decided that the man’s
handcuffs should be removed.
26. Healthcare staff at the prison kept in regular contact with the hospital. The
prison’s nurse manager noted on 2 July that the man had suffered a stroke. She
went on to note that she found him in reasonable spirits when she and one of the
prison Imams visited him that afternoon. The man remained in the North
General Hospital for the next month where various tests and examinations were
undertaken. He received treatment and physiotherapy and was noted to be
mobilising on the ward. He received further visits from the prison Imams, and
his friend was told that he was in hospital so she also visited.
27. On 9 July, the Imam telephoned the woman in Karachi who was understood to
be the man’s daughter to let her know that he was in hospital and that he was
not very well. During the following weeks the Imam, and another of the Imams,
made further visits to the man and telephoned the man’s ‘daughter’ to update
her. The Imams also made arrangements for the man to speak directly to her
himself.
28. The entries in the man’s records indicate that he remained fairly stable for a
while, but on 23 July an entry was made to say that he was very poorly. An
entry made in the early afternoon of 27 July said that the hospital was stopping
all medication apart from pain relief, and that the man was not expected to live
much longer. He died the following morning but at that time his condition
remained undiagnosed.
29. At post mortem, the man was found to have had widespread cancer, including
cancer of the lung. This diagnosis appears to have surprised the clinicians at
HMP Manchester.
30. After the man’s death the Imam telephoned the man’s ‘daughter’ to inform her of
the news. Some weeks later, HMP Manchester discovered that she was not in
fact a blood relation. The man’s biological family, two sons and two daughters,
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all live in the United States of America, as does their mother, the man’s ex-wife.
It seems that the man’s family heard of his death via a cousin. HMP Manchester
subsequently established contact with the man’s biological family and his two
sons came to the UK to take charge of the funeral arrangements. In accordance
with procedures, the prison offered assistance with the funeral expenses.
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ISSUES
The diagnosis of the man’s condition
31. The man arrived in HMP Manchester in December 2004. At the time he had a
number of age related chronic clinical conditions including high blood pressure
and abdominal and chest pain. He remained reasonably stable for the first 12
months before the onset of a gradual deterioration from January 2006.
32. The man made few if any complaints that he was suffering any pain. The
evidence of staff was that the man was someone who did not want to cause any
bother, so it may well be that he was suffering more than he was prepared to tell
others.
33. Of course, the man’s weight loss was startling. But it is well documented that he
was eating very little and it seems that it was a lack of appetite that he usually
cited as his reason for not eating. The man’s weight and general condition were
monitored and he had a number of blood tests. All the results were within
normal limits until late June 2008 when the man was noted to be anaemic. This
result was recorded on the day before his transfer to North Manchester General
Hospital.
34. The evidence of the In-patient Manager was that he had suggested to doctors on
two separate occasions that the man should be referred to a consultant
physician for older people. No such referral was made, and the clinical reviewer
has said that it would have been prudent to have done so especially given his
history of weight loss and heavy smoking. The clinical reviewer goes on to say
that a referral for further investigations might have identified the underlying
pathology.
35. It was towards the end of June 2007 when the man was transferred to outside
hospital where he remained for a complete month without a diagnosis. The
primary diagnoses of disseminated carcinomatosis and carcinoma of the
bronchus (widespread cancer including cancer of the lungs and airway), together
with other, secondary, diagnoses, were only made at post mortem. If a major
NHS hospital was unable to diagnose the man’s condition, it would seem
unreasonable to criticise a prison healthcare team for failing to do so. I say this
with the caveat that a referral to a consultant physician for older people might
have resulted in an earlier diagnosis. (It does not follow, of course, that an
earlier diagnosis would necessarily have affected the outcome.)
In-possession medication
36. Where possible, prison healthcare units aim to allow prisoners to hold their own
medication, which of course reflects what happens in the community. However,
a prisoner should only be issued with their own medication if it is safe to do so
and provided the prisoner understands the prescription. The man had been
issued with his medication but, in July 2007, staff realised that he had not been
collecting it for around ten weeks. The clinical reviewer has made a
recommendation about the issue of medication being held in the prisoner’s
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possession (a matter also subject to recommendation following the most recent
inspection of HMP Manchester by Her Majesty’s Chief Inspector of Prisons).
Continuity of care
37. The clinical reviewer has pointed out that while the man was an in-patient in the
healthcare unit, the majority of doctors there were locum staff. She goes on to
speculate that an earlier request for further investigations might have occurred if
there had been continuity amongst the medical practitioners. The clinical
reviewer also reports that the prison was in the process of employing a team of
permanent doctors, and so I make no recommendation.
38. Another of the clinical reviewer’s findings is that a weekly ward round by
multidisciplinary staff would provide a more comprehensive assessment of a
prisoner’s progress. She recommends that such a system be introduced and I
strongly endorse her recommendation. She also suggests that these reviews be
documented and all actions followed up. Had such a system been in place when
the man was there it seems to me more likely that a referral to a consultant
physician for older people would have been made.
Provision of care
39. In its most recent annual report, the IMB at HMP Manchester commented that
the prison’s healthcare unit lacked the facilities and equipment to care
adequately for older prisoners with complex mental and physical needs. HMP
Manchester had made appropriate and reasonable arrangements for the man’s
transfer to the older persons unit at HMP Norwich; unfortunately his transfer to
outside hospital and subsequent death then intervened.
Contact with the man’s family
40. The man’s biological family, who live in the USA, did not learn of his death until
some weeks afterwards. The reason for this was that HMP Manchester
understood his next-of-kin to be a woman living in Pakistan whom the man
described as a daughter. The Imams at HMP Manchester made early contact
with this woman both to let her know that the man was in hospital and to tell her
how he was progressing. I consider such early contact to be very good practice.
The Imams understood they were contacting the man’s biological family, and
neither they nor the prison warrant any criticism for the fact that the true
biological family did not learn the news until some time later.
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RECOMMENDATIONS
The following recommendations were made by the clinical reviewer, both of which I
endorse: The Prison Service’s response to the recommendations are included in
italics bellow each recommendation.
1. HMP Manchester’s in-possession medication policy should be adapted to cater
for older vulnerable prisoners who have health problems including those with limited
mobility. A prisoner’s in-possession status should be reviewed immediately if he is
found to be non-compliant or if his health status changes significantly.
Prison Service response: recommendation accepted. The in-possession medication
policy caters for all prisoners within HMP Manchester. To ensure that elderly and
vulnerable prisoners are catered for, a review will take place during the elderly
persons’ clinic to maintain compliance and to ascertain if there is a change in the
prisoner’s health. Target date for completion is 30 April 2009.
2. The head of healthcare should introduce a system of regular reviews by
medical staff and the multidisciplinary team for in-patients thus enabling all team
members’ views to be considered. The meetings should be documented and all
actions followed up.
Prison Service response: recommendation accepted. Regular reviews will be
undertaken with a multi-disciplinary approach. The reviews will be documented and
managers will ensure all actions are followed up. Target date for completion is 30
April 2009.
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