Individual at Hewell

Investigation into the circumstances surrounding the
death of a man, a prisoner at HMP Hewell,
in August 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2009
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This is the report of an investigation into the circumstances surrounding the death of
a prisoner at HMP Hewell. The man died at Alexandra Hospital, Redditch, on 12
August 2008. He was 58 years old. A post mortem showed the cause of death was
lung cancer.
The man’s next of kin are his wife and two sons. I offer them my sincere sympathy
and condolences, as I do to all of the man’s friends and acquaintances who have
been touched by his death.
The investigation was carried out on my behalf by my colleague. Both he and I
would like to thank the Governor of HMP Hewell, and all of her staff, in particular the
doctor, for their full and ready co-operation during the course of our inquiries. I must
also thank Worcestershire Primary Care Trust (PCT) for the appointment of the
clinical reviewers.
The man had been granted temporary release from prison on 7 August 2008
because of his illness. This report recognises and commends the actions taken by
the Governor and staff for the care and dignity given to the man in the period leading
up to his death. I also commend the thorough internal Clinical and Managerial
Review carried out by HMP Hewell. I endorse the areas of good practice identified in
the review and fully support the recommendation relating to the development of a
local End of Life Care policy and the planning of night cover for prisoners with
healthcare needs.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2009
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CONTENTS
Summary 4
The Investigation Process 5
HMP Hewell 6
Key Findings 7
Issues 9
Good Practice 13
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SUMMARY
The man was recalled to HMP Hewell on 9 June 2005 for breaching the conditions of
his licence. He had been sentenced to life imprisonment in 1972 but was released
on life licence in 1995.
The man suffered from epilepsy, which was controlled by medication. During his
time at Hewell, The man had several periods when he did not have an epileptic fit for
months at a time.
The man had been a life-long smoker until two years before his death and had
regularly suffered from bronchitis. He successfully stopped smoking following his
attending the prison’s stop smoking clinic in December 2006.
At the beginning of April 2008, the man developed a persistent cough that continued
for some four weeks. He was referred to hospital for chest x-rays on 21 May. The x-
rays showed that further examination was required.
He attended the outpatients department of the hospital on 17 June for further tests.
Two days later he was admitted to the healthcare centre at Hewell for a period of
assessment and treatment for tuberculosis. The man was seen by the tuberculosis
nursing specialist who advised on the treatment to be given.
On 22 June 2009, the man complained about severe pain in his chest. He had also
vomited twice after lunch. He was seen by the prison doctor and referred to
Alexandra Hospital, Redditch, for further tests. Following these tests on 23 June it
was found that he had terminal lung cancer.
The man’s illness was managed by the healthcare team at Hewell, with on-call
palliative care available, until his condition deteriorated on 7 August. At this point his
needs could no longer be met at Hewell and he was transferred to Alexandra
Hospital. Unfortunately, no hospice places were available at that time. The man
remained at the Alexandra Hospital whilst efforts were made by the palliative care
consultant and Macmillan Services to find him a hospice place but to no avail. He
died in hospital at 2.00pm on 12 August 2008. He was aged 58.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 14 August 2008 when my investigator issued
notices announcing the investigation to staff and prisoners. The notices included
an invitation to those who wished to submit information relating to the man’s
death to make themselves known. No prisoners came forward as a result.
2. My investigator visited HMP Hewell on 9 September. During his visit he was
given copies of all documentation relating to the man. He returned on 13
October when he interviewed two members of staff. In addition, he enjoyed
excellent liaison one of the appointed independent clinical reviewers.
3. One of my family liaison officers spoke to the man’s wife and sons to inform them
of the investigation. The family had no issues that they wished the investigator to
consider. They explained that the man had expressed his satisfaction with the
level of care he had received.
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HMP HEWELL
4. HMP Hewell was created on 25 June 2008 by the merger of three prisons
located on adjacent sites (HMP Blakenhurst, HMP Brockhill and HMP Hewell
Grange). The new prison caters for category B, C, and D prisoners. There are a
total of seven houseblocks. One has dormitory accommodation with the
remainder having single or double cell occupancy. The man was a category C
prisoner located in houseblock 2.
5. Hewell primarily serves the Worcestershire, West Midlands, and Warwickshire
areas. It offers a wide range of industrial training and educational courses,
including Open University. It also provides victim awareness and anger
management courses. Hewell has 24 hour healthcare cover with inpatient
facilities.
6. The death of the man was the first to have occurred since the merger of the three
former establishments.
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KEY FINDINGS
7. The man had been sentenced to life imprisonment in 1972. He was released on
life licence from HMP Leyhill in 1995. His licence was revoked and he was
recalled to HMP Blakenhurst (subsequently merged into HMP Hewell) on 9 June
2005.
8. On returning to prison the man was assessed by the doctor and prescribed the
anti-epileptic medications Sodium Valproate and Lamotrigine. (He was allowed
to have these medicines in his possession throughout his time in prison.) The
following day, he was reviewed and placed on a five day alcohol detoxification
programme.
9. The man had periods of several months when he was free of epileptic fits. His
blood pressure was monitored but did not require any treatment.
10. The man had been a smoker for most of his life. It was noted when he returned
to prison that he had an instance of haemoptysis (coughing blood) some three
weeks earlier. He had a chest x-ray on 20 June 2005, the results of which were
clear.
11. In May 2006, the man had a Parole Board hearing. The outcome was that he
was to remain in closed conditions.
12. During December 2006, the man successfully gave up smoking having attended
the prison’s stop smoking clinic. From examination of his medical records, it
would seem he suffered no major ill-health prior to his final illness.
13. The man had a cough and saw the doctor at Hewell on 7 April 2008. The doctor
found that he had no problems swallowing, his thyroid was not swollen, and his
respiratory examination was normal. The man was seen again on 25 April due to
a dry cough. The examination of his chest was normal. However, the cough
persisted and the man felt dizzy so he saw the doctor again on 6 May. He was
not breathless and did not have a fever. A referral was made for him to have a
chest x-ray.
14. On 21 May 2008, the man went to hospital for his x-ray. He had a review with
the prison doctor six days later when the results were received. At this review, it
was recorded that he looked unwell and was breathless. The results of the chest
x-ray indicated that there might be a growth on his lungs. An urgent referral was
made for scans and a bronchoscopy (visual examination of airways and lungs) to
be carried out.
15. The bronchoscopy and biopsy (removal of cell tissue for examination) took place
at an outpatient clinic at Alexandra Hospital, Redditch, on 17 June. The man
was seen by prison healthcare staff several times a day over the following four
days. By 22 June, his condition had become worse. He was complaining of
severe chest pain and was wheezing. He was admitted to the Alexandra
Hospital for further assessment.
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16. The next day the hospital completed further tests and diagnosed that the man
had terminal lung cancer. He was told this directly the hospital consultant.
17. The man returned to Hewell on 26 June and was placed in the healthcare centre.
Healthcare staff had organised a cell with a pressure relieving mattress and
obtained appropriate breathing equipment. The healthcare team was contacted
by the hospital consultant to explain his diagnosis and prognosis and a palliative
care plan was put in place. This included liaison with the hospital’s palliative
care team for support and guidance. The prison chaplaincy maintained liaison
with the man’s family once the diagnosis of terminal cancer had been made.
18. In light of the man’s condition, senior management at Hewell made
representations to the Ministry of Justice for a review of his status. This followed
a Parole Board recommendation on 10 June that the man was suitable for
transfer to open prison conditions. A letter was received from the National
Offender Management Service on 8 July confirming that the Secretary of State
agreed with the Parole Board’s recommendation and that he had been
recategorised as a category D prisoner.
19. The man’s condition deteriorated gradually over the following weeks. The
healthcare team remained in regular contact with the palliative care team for
advice on managing his condition. The man was also visited by someone from
the Primrose Hospice. The prison chaplaincy team also arranged for his family
to visit regularly.
20. By 7 August, the man was having difficulty swallowing and drinking. He also
suffered an epileptic fit that day. The healthcare team at Hewell agreed that his
needs could no longer be met at the prison. Following discussion with the
hospital consultant, the man was transferred to Alexandra Hospital as no hospice
place was available. He was granted Release on Temporary Licence on 7
August which meant he could go to hospital unescorted. He was visited by his
family, members of healthcare, and the chaplaincy.
21. From that date the man remained in Alexandra Hospital. Efforts were made to
secure him a place in a hospice but none was available. On 12 August at
2.00pm the man died.
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ISSUES
Internal Review
22. Following the man’s death Hewell conducted its own Clinical and Management
Review. This looked at all aspects of his care and offender management from
the time he was recalled to prison in June 2005.
23. The review highlighted three areas of good practice:
“The excellent communication with the Palliative Care Team ensured
appropriate management of a condition for which many staff would not
have experience.
“The effective communication and liaison between healthcare and
prison staff resulted in rapid re-categorisation … allowing him to be
transferred to hospital with dignity, without prison escort staff.”
“The maintenance of documentation in the clinical record was to a high
standard throughout.”
24. In addition the review made two recommendations:
“The development of a local policy for End of Life Care or reference to
Worcestershire PCT End of Life policies.
“The pro-active planning of night cover for patients who are very
unwell.”
25. I agree with the clinical reviewer that the healthcare team, led by a doctor,
provided the man with excellent standards of care. They also maintained a close
working relationship with the palliative care team at the Alexandra Hospital to
obtain the best advice and to ensure the most appropriate care was being given
at all times.
I commend the thorough internal Clinical and Managerial Review that was
undertaken. I endorse the areas of good practice.
Release on Temporary Licence
26. Senior management at Hewell acted swiftly and appropriately in making
representations to the Secretary of State regarding the man’s categorisation.
The outcome ensured that the man did not have to be escorted by prison staff, or
held in restraints, thereby ensuring his dignity during his last few days in hospital.
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Clinical care
27. The independent clinical review into the man’s death was conducted by two
acting clinical reviewers. Their review concludes as follows:
“The general picture that emerges is that the man’s health problems
were investigated and managed in a very professional way.
Appropriate referrals were made to other healthcare professionals both
within and outside the prison. Healthcare staff’s perseverance with
smoking cessation and their ultimate success in persuading him to quit
smoking is remarkable.”
Record keeping
28. The clinical review further states:
“The general standard of record keeping in the medical records and
drug charts was excellent. The vast majority of the records were
legible, dated and signed. For the most part they were filed in
sequence. We were especially pleased with the level of detail in the
individual entries.
“We visited the medical records store and were impressed with the
general sense of order.”
I frequently have cause to criticise standards of medical record keeping in my
reports. Healthcare staff at Hewell are to be congratulated on the findings of the
clinical review.
End of life policy
29. Concerning care offered to the man once the terminal nature of his illness had
been diagnosed, the clinical review says:
“We were told by a doctor that the prison had had little experience of
caring for and treating terminally ill prisoners. Consequently, in this
case there was an element of having to learn and work it out as they
went along. Although they did not have a prison palliative care policy
they did have a copy of Worcestershire PCT ‘Guidelines for symptom
management in the last days of life’. They also obtained a copy of HMP
Birmingham ‘End of life policy’. We understand that the healthcare unit
is now developing its own local policy. Communication, support and
patient involvement were clearly evident in the man’s case.
Partnership working with other healthcare professionals and with the
prison was quite remarkable. The prison chaplain also played an
important role.”
I also fully support the recommendations made relating to the development
of a local End of Life Care policy and planning of night cover for prisoners
with healthcare needs.
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Effective Liaison
30. The clinical review highlights the effective joint working between healthcare and
mainstream prison staff:
“The man was a Life prisoner. This meant that he would always need
to be escorted and restrained when outside prison. A doctor liaised
with prison staff to try to have him released on compassionate grounds
so that he could spend his last days in a hospice, if necessary. The
Governor thought that because of his previous offences he would be
unsuitable for compassionate release. It was then proposed that the
man should be re-categorised as a category D prisoner so that he
could be released on temporary licence. The proposal was quickly
agreed by the Ministry of Justice. This meant that on the last two
occasions that he went to hospital, the man was able to travel without a
prison escort. This is an excellent example of effective liaison between
healthcare and the Prison Service.”
31. The clinical reviewers have identified and recognised the following four areas of
good practice:
“The general standard of care offered to the man was high, both for his
day to day health care and throughout his last illness. There is good
evidence of detailed history taking, consideration of possible
diagnoses, and appropriate prescribing with detailed, regularly revised
and well-documented care plans. We were impressed by the depth
and frequency of the observations (weight, blood pressure, pulse,
mobility etc.); by the use of appropriate assessment tools such as
Waterlow score; by the allocation of a named nurse; and by the
frequency of requests for blood tests and X-rays.
“Healthcare staff’s perseverance with smoking cessation and their
ultimate success in persuading an inveterate smoker to quit is
remarkable.
The palliative care afforded to the man was excellent. This required
partnership working with the prison and the local palliative care team
and, possibly, the rapid learning of some unfamiliar skills by members
of the prison healthcare team.
“The general standard of record keeping in the IMR and drug charts
was excellent.”
32. The clinical review concludes:
“The care received by the man during his stay in HMP Hewell was well
organised and of a high standard. In the last two and a half months of his life
the man was skilfully and compassionately looked after by over 40 doctors,
nurses and other healthcare and related staff. There is strong evidence of
team working within the prison healthcare unit but also effective partnership
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working with the palliative care team and the other hospital teams. The man
was involved in his care and was treated with the utmost dignity.”
I commend the actions taken by the Governor and staff at HMP Hewell for the
care and dignity given to the man in the period leading up to his death.
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GOOD PRACTICE
1. I commend the thorough internal Clinical and Managerial Review that was
undertaken. I endorse the areas of good practice.
2. I also fully support the recommendations made relating to the development of a
local End of Life Care policy and planning of night cover for prisoners with
healthcare needs.
In response two these to issues a Local End of Life policy will be completed by
September 2009, and a joint protocol regarding access to prisoners with health
needs at night will be developed by July 2009.
3. I commend the actions taken by the Governor and staff at HMP Hewell for the
care and dignity given to the man in the period leading up to his death.
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