Individual at Durham

Investigation into the circumstances surrounding
the death of a man
at HMP Durham in December 2009
1
This is the report of an investigation into the circumstances surrounding the
death of a man who died from cancer on 15 December 2009, in HMP
Durham.
The investigation was led by an Investigator from my office. My Senior Family
Liaison Officer contacted the man’s daughter and asked her if she had any
questions or concerns about his death. I offer them, and all those affected by
his death, my sincere condolences.
I am grateful to the Clinical Reviewer from Custodial Care Innovative Solutions
(CCIS) who completed a clinical review of the healthcare received by the man
in prison on behalf of NHS County Durham.
Although I make five recommendations designed to improved nursing practice
at Acklington and Durham, there is much to commend in the level of care
received by the man at both prisons during his final illness. I am particularly
pleased that the man’s daughter had high praise for the way that she and her
father were treated at Durham.
Jane Webb
Acting Prisons and Probation Ombudsman October 2010
2
CONTENTS
Summary 4
The investigation process 5
HMP Acklington and HMP Durham 6
Key events 7
Issues 12
Conclusion 15
Recommendations 16
3
SUMMARY
The man was serving a sentence of eight years imposed in August 2005. He
was a category C prisoner, serving his sentence at HMP Acklington. In April
2009, he complained of problems urinating and lower back pain. He
continued to complain of lower back pain throughout July 2009.
On 30 July 2009, he was examined by the doctor and found to have cellulitis
(a severe infection of the skin and surrounding tissue) in his pelvic area and
swollen glands. He had a high temperature and high blood pressure. He was
treated with antibiotics.
Two days later on 1 August, he was admitted to Wansbeck General Hospital
in Ashington Northumberland, where he was diagnosed with terminal prostate
cancer that had spread to his lungs, liver and bones. He was treated as an
inpatient and returned to Acklington on 26 August.
Healthcare staff at Acklington made commendable efforts to look after him but
in October 2009, the man’s condition had deteriorated to the point that he
required 24 hour healthcare. This was not available at Acklington and so he
was transferred to HMP Durham on 16 October.
At the man’s request, staff at Durham contacted his daughter whom he had
not seen for some time. She visited her father twice and remained in contact
with him until his death.
The man’s condition continued to deteriorate and he died on 15 December
2009. I conclude that some care planning at Acklington is in need of
improvement but that this did not affect the outcome for the man. Healthcare
staff there made great efforts to care for him. I make three recommendations
designed to improve nursing practice at Acklington.
I also conclude that the healthcare the man received at Durham was of a high
standard. I make one recommendation to improve record keeping at both
prisons.
The man’s death was the 11th death by natural causes that the Ombudsman
has investigated at Durham since 2004. I found no similarities between these
and the circumstances surrounding the man’s death.
4
THE INVESTIGATION PROCESS
1. I was made aware of the man’s death on 18 January 2010 when my
office was contacted by HMP Durham. They had not been contacted
by my office as is customary after every death in custody. HMP
Durham had notified the National Offender Management Service’s
(NOMS) National Operations Unit (NOU) when the man died on 15
December 2009 but NOU did not pass this information to my office.
The case was allocated to the Investigator on 18 January. The
Investigator spoke to the Prison’s Liaison Officer. The relevant
paperwork was sent by post to my office.
2. The Investigator spoke subsequently to the Clinical Reviewer who had
been commissioned to write a clinical review of the healthcare received
by the man. The Clinical Reviewer works for Custodial Care Innovative
Solutions – a private company commissioned by NHS County Durham
to provide independent clinical reviews of the healthcare provided to
prisoners who die in Durham prison. The Investigator discussed the
man’s case with the Clinical Reviewer and they agreed that the review
should look at the care the man received in both Acklington and
Durham. The Clinical Reviewer sent her report to NHS County Durham
on 22 March. To date I have not received the final copy approved by
NHS County Durham.
3. My Senior Family Liaison Officer, talked to the man’s daughter by
telephone. The man’s daughter said the healthcare staff were very
supportive and helpful. She praised the way they had looked after her
father. She said that the Governor had made sure that her visits to her
father went as smoothly as possible. She was grateful for all that had
been done for the man and thought the care had been above and
beyond that which she had expected from a prison. The prison
returned her father’s property to her and contributed financially to the
cost of his funeral.
5
HMP ACKLINGTON
4. Opened in 1972, Acklington is a category C prison for convicted adult
men. Category C prisoners are those who cannot be trusted in open
conditions but who are unlikely to try to escape. Acklington is located
in Northumberland and is England’s most northerly prison. It has no
full time medical officer and no in-patient healthcare facility.
HMP DURHAM
5. HMP Durham is a category B local prison taking adult male sentenced
and remand prisoners from the courts of the North East and Cumbria.
Category B prisoners are those who do not require maximum security
but for whom escape needs to be made very difficult. There is 24 hour
healthcare provision which includes a clinical director and a general
practitioner supported by a primary care nursing team. There are 19
inpatient beds.
6. A report of a full unannounced follow-up inspection by Her Majesty’s
Chief Inspector of Prisons in October 2009, made the following
comments regarding the inpatient unit:
“There were 19 inpatient beds, of which 15 were occupied at the
time of the inspection. The majority had mental health
diagnoses, but there were also prisoners with physical illnesses,
such as cancer, bowel disease and tuberculosis. The inpatient
unit was managed by the mental health coordinator and staffed
mainly by HCSWs [Healthcare Support Workers] and discipline
officers. A registered nurse was allocated each day but, due to
staffing pressures, was not always on duty. Time out of cell was
good but often compromised due to operational requirements in
the prison. Inpatients complained of a lot of ‘bang up’ due to
shortages of discipline staff. They had access to the showers
and gym, and education classes were held on the unit every
weekday, but there was no communal dining out despite the
space to facilitate this. Inpatients associated well and there was
good interaction with discipline and nursing staff. The medical
director held a weekly multidisciplinary ward round, and both
GPs were available daily if needed.”
7. The latest Independent Monitoring Board report was not available at
the time of writing.
8. The Ombudsman has investigated 11 deaths from natural causes in
Durham since taking on responsibility for investigating deaths in
custody in April 2004. I have identified no common factors between
any of these deaths and that of the man.
6
KEY EVENTS
9. The man was sentenced to eight years imprisonment on 8 August
2005. While on trial he was located in HMP Durham but, after
sentence, he was categorised as a category C prisoner and transferred
to HMP Acklington in Northumberland. The man’s time in custody in
Acklington was unremarkable. He worked full time in the woodwork
workshop and had no disciplinary record.
10. The man used healthcare facilities at Acklington rarely until March
2009 when he complained of a painful rash on his groin. He was
treated with antibiotics and painkillers. Five weeks later on 22 April, he
complained of urinary problems. He reported hesitancy in emptying his
bladder, pain and frequent attempts at urination. On examination his
bladder was found to be full. The man’s medical record shows that he
was advised he needed to give a urine sample so that it could be
tested for a urinary tract infection. The record shows that the man was
told if this proved negative he would need to have his prostate gland
examined. The man is recorded as saying that he was unable to pass
urine for a sample. There is no evidence on the record that a sample
was taken at this time or any record of test results or a prostate
assessment.
11. On 6 May 2009, the man had a fall in his cell and complained of lower
back and hip pain. A Nurse spoke to him in his cell and he reported
that he had not been able to urinate that day. The Nurse examined the
man again in the healthcare centre the same evening. By this time he
had passed urine but the nurse advised him that, as it was not a new
problem, he should see the doctor. The next day the man reported that
he was constipated but was passing urine normally.
12. The man became eligible for release on parole in July 2009. An
application was completed at Acklington and the Parole Board met to
consider it on 7 July. The Board concluded that the man was not
suitable for early release on licence because the level of risk he
presented could not be safely managed in the community. The man’s
continued claims to be innocent precluded his attendance on offending
behaviour courses.
13. The man continued to complain of lower back pain throughout July
2009. On 30 July, healthcare staff were called to his cell. The man
was found to have a temperature and a painful rash and swollen
glands in his pelvic region. The doctor examined him the next day and
diagnosed cellulitis (a severe inflammation of the skin and surrounding
tissue) in the man’s groin. He was treated with antibiotics but
complained later the same day that they were making him feel worse.
His medication was reviewed by the doctor and he was given a
different type of antibiotic. The Practice Nurse wrote in the medical
record that the man appeared confused.
7
14. The next day, on 1 August, the Nurse that had previously spoken to
him in his cell visited the man in his cell. She recorded that he looked
unwell and had been vomiting during the night. He had a temperature
and there was blood in his vomit. The Nurse spoke to the doctor who
advised that the man should be taken to hospital. He was taken by
ambulance to Wansbeck General Hospital the same day and admitted.
15. After tests, the man was diagnosed with prostate cancer that had
spread to his lungs, liver and bones. His condition was assessed as
terminal and he began hormone injections as a palliative measure.
16. On 7 August, the Practice Nurse received a call from a doctor at
Wansbeck General Hospital. The Nurse wrote in the medical record
that she received little information from this call, apart from the fact that
the man would need palliative care when he was discharged from
hospital. The Nurse decided to attend a meeting at the hospital
scheduled for 13 August in order to find out more about the man’s
prognosis (the likely outcome of his illness). The Nurse asked other
staff to contact the hospital daily in the meantime to check on the
man’s condition.
17. The Nurse attended the meeting on 13 August but was then on leave
and did not update the man’s medical record until 17 August. On 16
August, the Nurse that had previously spoken to him in his cell phoned
the ward sister at the hospital. She would not supply information over
the telephone but indicated that the minutes of the meeting of 13
August would be available to prison healthcare staff. The ward sister
did reveal that the man had developed a deep vein thrombosis (DVT –
a blood clot in the vein) in one of his legs.
18. On 17 August, the Practice Nurse wrote in the medical record that the
man only had months left to live. He was able to care for himself but
needed pain relief medication during the night that could not be
facilitated at Acklington (because they do not have 24 hour healthcare).
The pain management team at the hospital were going to assess the
man to see if he could have a different pain relief regime that would
allow him to remain at Acklington.
19. The Practice Nurse also spoke to the ward sister the same day. She
was told that the man’s condition had worsened due to his DVT. The
next day she called the ward again and was told that the man had
become more ill and was no longer able to care for himself. The
Practice Nurse found out the name of the palliative care nurse at the
hospital, and spoke to her on the telephone. They had a long
discussion and the Practise Nurse arranged to meet her at the hospital
the next day.
8
20. On 19 August, the Practice Nurse met the man and the Palliative Care
Nurse from the hospital. The Practice Nurse reported that the man
was tearful but that his pain was manageable. He told the Practice
Nurse he would like to get in touch with his mother who he had not
seen for some ten years. When he last had contact with her she was
in poor health. The man told the Practice Nurse that he felt isolated
and depressed. The Practice Nurse told him that she would try to visit
him when her workload allowed and would see if it was possible for
one of his friends from the wing to visit him.
21. On 25 August, the Practice Nurse spoke to another palliative care
nurse at the hospital. The man’s condition had improved slightly. He
was able to care for himself and was walking using a zimmer frame.
The Nurse discussed the man’s pain relief medication with the prison
doctor and confirmed that it would be possible to manage him at the
prison. The man was taken back to Acklington on 26 August and
located in a disabled person’s cell. His door was left open whenever
possible to prevent him feeling isolated. [Normally, for security reasons,
all cells are locked at set times during the prison day.]
22. The Practice Nurse broke the news to the man on 30 August that his
mother had died some years previously. She reported that the man
was tearful but not shocked. She asked one of the man’s friends on
the wing to sit with him for a while. The same day, the Nurse arranged
for the man to have full cream milk and Ensure drinks (a brand of
nutritional supplement for people unable to take in the required number
of calories from food) as part of his diet.
23. On 4 September, healthcare staff at Acklington began weekly palliative
care reviews with the man to monitor his condition and needs. On 17
September, the man complained that he was in pain. On 21
September, the Nurse that previously spoke to the man in his cell
spoke to the Palliative Care Nurse in the hospital because the man’s
condition had deteriorated. He reported frequent vomiting and was
losing weight. Because of the obvious deterioration in the man’s
condition the Practice Nurse made arrangements for him to be
reviewed by Macmillan nurses or the community palliative care team.
24. A Community Palliative Nurse specialist, visited the man with the
Practice Nurse on 24 September. The man told them that he would
like to attend education to take his mind off his condition. The next day
he was referred to an art class. At a palliative care review the same
day the man reported that his vomiting was now under control after a
change to his medication. The Nurse that had previously been to see
him in his cell reported a deterioration in the man’s physical and mental
state. He became angry and frustrated with the palliative care nurses
when they tried to encourage him to talk about his death.
9
25. On 30 September, the man told a Nurse that he had felt like taking all
of his medication during the night. He was depressed that he was not
getting out of his cell or doing education. An ACCT booklet
(Assessment, Care in Custody and Teamwork - the National Offender
Management Service’s procedures for monitoring prisoners thought to
be at risk of self harm or suicide) were put in place. The next day the
Practice Nurse made arrangements for the man to attend education in
the following week.
26. On 3 October, the man was unable to stand unaided. He told a Nurse
that he thought he needed to be transferred somewhere where he
could have more help. Although the man improved during the next few
days, by 9 October his medical record showed that he was not coping
well and was finding it hard to care for himself. Wing staff also
expressed concern to healthcare staff about his ability to look after
himself.
27. Following a palliative care review on 10 October, it was decided to try
to transfer the man to HMP Durham where there is an inpatient ward
with 24 hour healthcare. Durham did not have a bed available at such
short notice so the man was taken to Wansbeck General Hospital
instead. The Practice Nurse liaised regularly with Durham healthcare
staff and Wansbeck Hospital. On 12 October, she spoke to the
Palliative Care Nurse at the hospital, who agreed that Durham was a
suitable destination for the man.
28. The man was transferred to an inpatient bed at Durham on 16 October.
He was unhappy with the transfer and, on 18 October, began to refuse
his medication apart from that prescribed for his DVT and paracetamol.
On 22 October, a Doctor examined him and found him to be in pain
and distressed. The man had vomited clots of blood. The Doctor
arranged for the man to be admitted to the University Hospital of North
Durham (UHND) the same day.
29. The man was discharged back to Durham after a single night in UHND.
While in UHND he refused treatment and medication. On his return the
man said he was pleased to be back in Durham but, on 26 October, he
asked to return to Acklington. On 27 October, the man had a palliative
care review with the Palliative Care Nurse at Durham and a Doctor and
a Nurse from St Cuthbert’s Hospice. The man expressed a desire to
be cared for at Acklington and to die in a hospice. An advance care
plan was outlined and steps were taken to complete a formal Do Not
Attempt Resuscitation directive (DNAR). (Advance care planning is a
process enabling a patient to express wishes about his or her future
health care in consultation with their health care providers, family
members and other important people in their lives. Based on the
ethical principle of patient autonomy and the legal doctrine of patient
consent, advance care planning helps to ensure that the concept of
consent is respected if the patient becomes incapable of participating
in treatment decisions.)
10
30. On 2 November, the man signed his advance care plan. He told staff
that he would like to contact his daughter and it was agreed that the
prison chaplain would facilitate this.
31. A week later, on 9 November, the Prison’s Seconded Probation Officer
told the man that he had managed to contact his daughter who was
willing to speak to him. The man spoke to his daughter the same day
and she agreed to visit him. On 11 November, his advance care plan
was reviewed and signed.
32. The man’s daughter and her partner visited him on 19 November. The
prison contributed to their travel expenses. The man’s medical record
indicates that the visit appeared to go well.
33. Although he attended education and association on the ward when his
health permitted, the man’s condition continued to deteriorate. His
mood was described as low but had improved once he had re-
established contact with his daughter. From 25 November, he was
recorded as needing increased medication to manage his pain. By 8
December, a Doctor recorded that the man’s pain was becoming
increasingly difficult to assess and it might be appropriate to transfer
him to a hospice for stabilisation.
34. The Palliative Care Nurse from St Cuthbert’s Hospice, visited the man
on Thursday 10 December. She decided to arrange a review during
the week beginning Monday 14 December to discuss a potential
admission to the hospice for symptom control. On 11 December, the
man was semi-conscious. Staff arranged for a syringe driver to assist
his pain control. The Doctor that had previously noted his pain level
was becoming difficult to asses spent some time talking to the man.
He recorded that the man was very near the end of his life but was not
in any pain. The Doctor also wrote that the man was not to be
resuscitated. He was not on duty over the weekend (12 and 13
December) and added that he did not think it was appropriate to
transfer the man but that staff should admit him to hospital if they felt
unable to look after him.
35. At 2.00pm the same day, a Nurse rang the man’s daughter to tell her
that her father was near the end of his life. She offered his daughter
the opportunity to visit and to call at any time. The man’s daughter and
her partner visited him the next day. The man remained asleep
throughout the visit. Staff rang his daughter on 13, 14 and 15
December to keep her informed of his condition. The man remained
sleeping. He was given diamorphine to ensure that he felt no pain.
The man died at 2.30pm on 15 December. Staff rang his daughter at
3.00pm to break the news to her.
11
ISSUES CONSIDERED
Clinical care at Acklington
36. The clinical review notes that the man suffered from hypertension (high
blood pressure) at Acklington. This was discovered during his first
reception health screen but there is no evidence that it was monitored
by the prison healthcare team. The man had his blood pressure
checked on 24 and 31 October and 4 November and was prescribed
medication to combat his hypertension. However, he did not ask for a
repeat prescription after this and the practice nurse did not follow this
up.
37. When the man first presented with urinary problems in April 2009 he
was told that he needed to provide a sample in order to rule out an
infection. If an infection was ruled out then he would need a prostate
assessment. There is no evidence that either a urine sample was
taken nor a prostate assessment made.
38. The review concludes that Acklington failed to develop care plans to
address the man’s needs in respect of his hypertension, pain
management, constipation, dyspepsia (indigestion) and vomiting. At
draft report stage Acklington pointed out that their healthcare
department resembles a community setting and does not have 24 hour
nursing care or an inpatient facility. Care plans are in place for patients
that require regular dressings, post operative care, detoxification and
who have mental health issues. Care plans are always activated for
patients requiring palliative care. I note that the review also concludes
that these failings in nursing practice at Acklington did not affect the
outcome for the man. The review makes three recommendations
designed to improve practice at Acklington that I endorse. All the
recommendations are listed in the final section of this report.
39. I should like to add however, that there is also much to be commended
in the attempts of healthcare staff at Acklington to look after the man.
He was allocated a cell designed for a disabled prisoner and his door
was left open when possible to allow prisoners to visit him and sit with
him. Nursing staff, made great efforts to ensure that he did not feel
isolated during his time both in Wansbeck hospital and in the prison.
The community palliative care team and Macmillan nurses were
involved appropriately. Efforts were made to structure the man’s pain
management so that he could remain at Acklington, which had been
his home for the best part of four years and where he felt most
comfortable and had friends, as long as possible.
Clinical care at Durham
40. The man was unhappy with his transfer to Durham and initially refused
a significant proportion of his medication. There is evidence that staff
did their best to explain to the man why he needed to take the
12
medication and to encourage him to do so. Staff at Durham contacted
the man’s daughter at his request and facilitated regular visits and
contact with her. This appeared to improve the man’s mood.
41. The clinical review concludes that the man received a high standard of
care at Durham. Healthcare staff were well supported by the
community palliative care team and Macmillan nurses. The man’s end
of life care was managed in accordance with the Liverpool Care
Pathway (an outline of care which a patient can expect in the final
hours and days of life) and his last days were peaceful and pain free.
42. I am pleased to read that the man’s daughter had nothing but praise for
the healthcare staff who looked after her father in Durham. I note too
that she received significant support from the Governor when she
visited the prison.
The man’s allocation to Durham
43. The man repeatedly said that he wanted to be located in Acklington
prison. This is readily understandable as he had lived there for some
four years and had made friends there. It had been his home. When
he became ill he appeared to strike up good relationships with
healthcare staff there. It was closer to his relatives and therefore
easier for them to visit (albeit at that stage he was not in touch with his
daughter). However, the severity of his illness and the amount of
nursing and pain relief he required simply could not be provided at
Acklington. I therefore consider that the most appropriate allocation
within the prison system was to Durham, which is geographically the
nearest prison with 24 hour healthcare.
Clinical record keeping
44. The clinical review highlights the fact that the electronic medical
records do not automatically record the time that entries are made.
Terminally ill prisoners have considerable amounts of medication which
is to be administered when necessary rather than at set intervals. In
such cases, especially when opiate based painkillers are being used, it
is vitally important to know exactly when such drugs have been
administered.
45. The review concludes that, “There is strict professional guidance about
the administration of medication and in particular controlled drugs and
the recording of this.” A recommendation is made to audit record
keeping at both Acklington and Durham. I have acknowledged in
previous reports that the use of electronic medical record systems in
prisons does pose difficulties for staff. Such systems are designed for
use in GP surgeries in the community when the doctor can make
entries during the consultation. In prison there are no computer
terminals on the wing and staff make entries retrospectively when they
have time to do so. I also acknowledge that in this case the man was
13
not on any controlled medication at Acklington and had medication in
possession apart from the 12 hours he was subject to ACCT
procedures at Durham. Nevertheless the clinical reviewer’s comments
about the need to record the time of entries relating to the
administration of drugs to terminally ill patients are valid.
I recommend that the heads of healthcare at Acklington and
Durham remind staff to pay particular attention to noting the time
that medication is given to terminally ill patients which is
especially important when administering controlled drugs.
14
CONCLUSION
46. The man received a high standard of care at both Acklington and
Durham. I was impressed by the many instances at both prisons when
staff made extra effort to make his situation more comfortable. Notably
the regular contact from staff at Acklington when the man was in
outside hospital and the decision to leave his cell door open to
encourage other prisoners to spend time with him. I was also
impressed with the excellent liaison by staff at Durham from the
Governor downward with the man’s daughter.
15
RECOMMENDATIONS
From the clinical review:
1. A review of clinical leadership within the healthcare setting at HMP
Acklington, including an audit/review of current healthcare roles,
responsibilities and working practices should be undertaken.
Response from NOMS at draft report stage:
Requesting a review of the clinical leadership doesn’t fit with the overall
positive outcomes of this report, however, it is accepted that a review
of systems to ensure continuity of care is justified.
Review of systems, role and responsibilities to ensure communication
between medical, nursing and administration staff are improved to
facilitate the continuity of patient care.
2. A structured case management approach at HMP Acklington, for those
prisoners with complex/long term conditions, including the introduction
of care plans, should be established.
Response from NOMS at draft report stage:
A structured clinical management approach will be implemented for
patients with complex/ long-term conditions.
3. Current protocol and policy for managing hypertension at HMP
Acklington should be reviewed to ensure safe and competent practice,
including compliance with current National Institute for Clinical
Excellence (NICE) guidance for hypertension.
Response from NOMS at draft report stage:
Patients with long term conditions are currently under review by the
medical director and practice nurse.
Systems will be implemented to ensure continuity of care where
patients are identified as having long term conditions from initial
screening. This will be facilitated by the introduction of system one.
4. A record keeping audit at both HMP Acklington and HMP Durham, to
establish compliance with the National Midwifery Council (NMC)
professional guidance around record keeping, should be undertaken.
Response from NOMS at draft report stage:
Current emis system to be modified to included designation of
healthcare professional and time of intervention. System one October
2010 implementation will automatically facilitate this.
The clinical team leader will audit the nursing documentation.
16
From the PPO
1. I recommend that the heads of healthcare at HMP Acklington and at
HMP Durham remind staff to pay particular attention to noting the time
that medication is given to terminally ill patients which is especially
important when administering controlled drugs.
Response from NOMS at draft report stage:
the man had his medication in possession apart from 12hours when he
was on an acct. The man was not on any controlled medication whilst
at Acklington.
Clinical documentation for the recording of administration of medicines
will be reviewed to facilitate an area for nurses to enter the time the
medication was given.
Good practice
1. The decision by staff at HMP Acklington to locate the man in a disabled
cell and to keep his door open when possible is good practice.
2. The daily contact maintained by nursing staff at Acklington with
Wansbeck General Hospital and the regular visits they made is good
practice.
3. The regular contact maintained with the man’s daughter at HMP
Durham is good practice.
17