Individual at Manchester

Investigation into the circumstances surrounding the
death of a man at HMP Manchester
in November 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2010
This is the report of an investigation into the death of a 55 year old prisoner at HMP
Manchester who died from natural causes in November 2008. He was serving a
sentence of nine months imprisonment imposed in August 2008, and had been
diagnosed with terminal lung cancer.
I would like to add my personal condolences to those already expressed to the
man’s family on behalf of this office by my Senior Family Liaison Officer.
The investigation was conducted by an investigator. In addition a clinical reviewer
was asked by the local Primary Care Trust to undertake a review of the man’s
clinical care. I am grateful for the assistance they both received from staff at HMP
Manchester and would like to thank the Governor and his staff for their co-operation.
I must apologise for the delay in issuing this report which was caused by the late
receipt of the clinical review.
The man’s family has expressed concerns about his care and treatment which I have
carefully considered. The clinical reviewer has concluded that his care was not
equivalent to that he would have received in the wider community. She has also
judged that his palliative care, while of an acceptable standard, was not in line with
the best practice advised by the Macmillan Cancer Support. Her review raises a
number of learning points that the prison health partnership will need to consider
seriously. She has made six recommendations which I endorse.
I have made no separate recommendations of my own.
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.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2010
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CONTENTS
Summary
The investigation process
HMP Manchester
Key events
Issues considered
Conclusion
Recommendations
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SUMMARY
The man was born in 1953. He was 55 years old when he died at HMP Manchester
in November 2008. His death was from natural causes as a consequence of lung
cancer (bronchial carcinoma).
The man had been sentenced to nine months imprisonment in August 2008 at
Crown Court. He was received into custody at HMP Manchester on the same day.
At his first health screening interview it was recorded that he had received burns on
his hands and face in an accident in 2007, and previously had suffered a collapsed
lung. He was a smoker but he chose not to accept assistance to help him to stop
smoking.
The man was admitted to local hospital in October 2008. Following tests, he was
diagnosed with lung cancer. The prognosis was that his condition was terminal. He
transferred to hospital in November.
Whilst the man was in hospital, a bedwatch was carried out by prison staff. The
initial security risk assessment concluded that handcuffs were to be used and two
officers needed to be at his bedside. The assessment was later revised by the duty
governor in October and handcuffs were no longer used. His family were allowed to
visit him whilst he was in hospital. He was discharged from hospital in November
and returned to HMP Manchester where he was admitted to the healthcare centre.
During November, the man returned to hospital for palliative chemotherapy. He
returned to Manchester at 9.55pm and was again admitted to the healthcare centre.
At around 6.40am, a nurse commenced her duty on the healthcare centre and
checked on him around five minutes later. As she was unable to rouse the man, the
nurse informed her colleagues of her concerns. They then all entered his cell. They
could not find any signs of life and an ambulance was called. On arrival at his cell,
the paramedics took over responsibility for his care. They carried out an electro-
cardiogram (a graphical recording of the electrical activity of the heart) which
confirmed that there were no signs of life. The paramedics pronounced that he was
dead at 7.24am.
After it was confirmed that the man had died, HMP Manchester activated its death in
custody contingency plan. The police were informed and visited the prison. They
found no suspicious circumstances. His body was released to the undertakers who
removed him to the mortuary for post mortem examination.
The review carried out by the clinical reviewer has identified a number of issues
relating to the care provided for the man. The review highlights areas of practice that
could be improved, and makes six recommendations.
I make no recommendations of my own.
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THE INVESTIGATION PROCESS
1. The investigation was opened in November 2008 by my investigator. He
issued notices announcing the investigation to staff and prisoners. These
notices included an invitation to anyone who wished to submit information
relating to the man’s death to make themselves known. In the event no one
came forward. My investigator also studied all relevant prison records, which
included the man’s main prison record and his medical records.
2. My investigator visited HMP Manchester in November 2008 and February 2009
and discussed aspects of the man’s treatment with staff. He met a
representative from the Independent Monitoring Board and interviewed the
Director of Healthcare.
3. The local Primary Care Trust commissioned a clinical reviewer, a trained nurse,
to carry out an independent review of the man’s clinical care. I am grateful to
her for undertaking such a thorough review.
4. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation and to request a copy of the post mortem report.
Upon completion, this report will be sent to the Coroner to assist in his
enquiries into the man’s death.
5. My Senior Family Liaison Officer contacted the man’s family. This gave them
the opportunity to discuss the purpose of the investigation and to raise any
concerns or questions that they wanted to be addressed. My Senior Family
Liaison Officer and investigator later met the family to discuss the following
matters:
(cid:127) The poor level of healthcare and medication the man received whilst he was
in the custody of HMP Manchester.
(cid:127) Why he had been located on the lifers (C) wing when he only had to serve a
short sentence.
(cid:127) His complaint against a prison officer who had acted unprofessionally.
(cid:127) Why early release had not been considered in view of his medical condition.
(cid:127) Why they had not been informed that he was dying and the delay in informing
them of his death.
(cid:127) The delay in making arrangements for the family to identify his body.
(cid:127) The family also said that some of his property was missing. This included
clothing, letters and a notebook.
6. The family praised the two prison officers who were with the man at the
hospital. The family also confirmed that Manchester had arranged and paid for
the funeral and service.
7. My investigator has attempted to address the issues raised by the family within
this report. I hope that it provides them with a better understanding of the
events leading up to the man’s death.
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HMP MANCHESTER
8. HMP Manchester is a large prison, Victorian in external appearance but greatly
refurbished internally. Cells have televisions, electric sockets and sanitary
facilities. Manchester holds both unconvicted and sentenced prisoners, as well
as a small number of high security (category A) prisoners. For this latter reason,
it is part of the high security estate and physical and other security within the
prison reflects this.
9. 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. The
prison is divided into two main blocks. The upper prison contains four wings (G-
K) which include the First Night Centre and the induction wing. The lower prison
has five wings (A-E).
10. After the evening roll call to confirm prisoners are all accounted for, the prison
enters what is called patrol state. This is defined as follows: ‘Prisoners are
locked up and staff numbers are reduced to the minimum needed to patrol. The
main role of staff at this time is to maintain the security of the prison and the
safety of all prisoners.’
11. When the night patrol officer arrives on the wing, a hand-over is given by the
officer on evening duty and a sealed packet containing keys is passed from one
to the other. The keys in the sealed packet are only to be opened in an
emergency. When the officer on duty the next day arrives, he or she receives a
hand-over from the night patrol officer and another roll check is carried out
before the night patrol officer leaves the wing. When staff were unable to rouse
the man on a morning in November 2008 and had to enter his cell, the prison
was in patrol state.
12. Healthcare at Manchester is commissioned by the local Primary Care Trust. The
healthcare centre provides 24 hour nursing care and medical cover, and has
beds for up to 38 prisoners.
13. During 2008, there were two other previous deaths from natural causes at
Manchester. The investigator has reviewed my reports into those deaths but
has found no common factor between them and the circumstances surrounding
this investigation.
Independent Monitoring Board
14. Each prison has an Independent Monitoring Board (IMB). IMB members are
independent and unpaid. They monitor day-to-day life in their prison and ensure
that proper standards of care and decency are maintained. Each IMB produces
an annual report. In their report on Manchester for the period 1 March 2007 to
29 February 2008, the 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 HM Coroner commented that the healthcare centre of a
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category A prison was not a suitable environment for the care of the elderly and
infirm. The report also said:
“Manchester is a well-run prison which is meeting most of its Key
Performance Targets … The Board has witnessed many occasions
when staff have demonstrated sensitivity to prisoners’ needs, e.g. in
Reception on arrival at prison, officers giving information on what was
happening and answering any questions … “
Her Majesty’s Chief Inspector of Prisons
15. The most recent inspection by Her Majesty’s Chief Inspector of Prisons was an
unannounced, short inspection in May 2007 as a follow-up to her 2004 full
inspection. Her report of this latter inspection, published in October 2007, said
in relation to safety at Manchester that “the application of category A
procedures to the small number of category A prisoners had implications for the
quality of life for all prisoners, 630 of whom were merely category C prisoners.
Better and more equitable risk management was required.” Her report spoke
about the improvement in staff-prisoner relationships, and in particular the
impact of the group officer scheme which meant that prisoners would be
allocated a named officer who would be responsible for engaging proactively
with them.
7
KEY EVENTS
16. In August 2008, the man was sentenced by Crown Court to nine months
imprisonment. He arrived at HMP Manchester the same day. This was not his
first experience of prison although he had not been in custody since August
2000.
17. During the man’s first reception health screening interview, it was recorded that
he had been diagnosed with asthma, had previously had a collapsed lung, and
had received burns on his hands and face. (In January 2007, he was injured in
a fire at an electrical substation and subsequently spent six weeks in the Burns
Unit at a local hospital.) He was allowed to keep his Salbutamol (asthma)
inhaler and Diprobase cream (for his burns) in his possession. He was a
smoker but he chose not to accept help to stop smoking. He was located on
the healthcare centre for his first two days at Manchester before he moved to G
wing.
18. In August, the man was assessed for Home Detention Curfew (HDC) by a
Probation Service Officer. (HDC is also known as “electronic tagging”. A small
electronic "tag" is fitted to the ankle. The tag sends a regular signal to a
monitoring centre that confirms the presence of the person in their place of
curfew. If they are absent or try to tamper with the equipment the monitoring
centre is alerted and the breach investigated.) She recorded that the man had
previously breached curfew orders and failed to surrender on many occasions.
HDC was therefore not authorised. On the following day he moved to K wing.
19. The man was seen in September by a locum doctor. He had been feeling light-
headed and experiencing palpitations whenever he stood up. An electro-
cardiogram (ECG, a graphical recording of the electrical activity of the heart)
was carried out. It indicated that there was no sign of a heart attack. A referral
was made to local hospital for a 24 hour ECG to be carried out. An
appointment was also made for him to attend the Blood Clinic two days later.
20. The man was seen by a prison doctor in September. In his letter to the
Cardiology Department at the local hospital following his consultation with him,
the prison doctor wrote:
“I would be grateful for your opinion of this man who has been
complaining of feelings of dizziness whenever he stands up, for
approximately 2 weeks. On occasions he has actually passed out. …
He is difficult to auscultate [listening to the sounds made by the internal
organs of the body for diagnostic purposes], but I think I heard a
systolic murmur. … I am sure he would benefit from an
Echocardiogram or 24 hour ECG.”
21. On the following day a second locum doctor carried out a routine review of all
the new blood test results that had been returned to the healthcare centre.
During her review, she noted that the man’s blood test results were not within
normal limits. The results suggested he had developed anaemia due to blood
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loss. She arranged for him to attend an emergency appointment with the
doctor for the following day.
22. A second prison doctor saw the man in September. After she examined him,
the doctor noted that he was not losing blood but he did have a chest infection.
She prescribed Flucloxacillin (an antibiotic capsule) and iron tablets. A further
appointment was arranged for the blood test to be repeated the next day but
this appointment was cancelled by the man.
23. In September, the Deputy Director of Reducing Re-offending reviewed the
man’s application for HDC. He noted that here was a pattern which indicated a
likelihood of re-offending during the HDC period. He also noted that there was
a likelihood of failure by the man to comply with the conditions of the HDC
curfew. He therefore considered that the man would find it difficult to comply
with the conditions of HDC and he could not grant it. He suggested that if the
man was not satisfied with his response he could take forward this matter with
the Governor and by appeal to my office as Prisons and Probation
Ombudsman. The man made a formal request for a hearing to appeal against
being refused permission for HDC in November. One of the Governor’s
secretaries acknowledged his request three days later and said that
arrangements would be made for him to meet with the Deputy Governor.
There is no record of the man pursuing this issue further with my office.
24. The man moved to C wing in September.
25. In September, the man was seen for a routine patient review by the second
locum doctor. After her review with him, she wrote to the Gastroenterology
Department at the local hospital. In her letter she asked if the hospital could:
“Organise an endoscopy for the man [An endoscopy is a test that looks
inside the body. The endoscope is a long flexible tube that can be
swallowed. It has a camera and light inside it.] … [he] has had a
persistent burning sensation in the epigastium and cough at night with
burning feeling in the gullet. He has had this for several months. He
has now been found to be anaemic. I now enclose copies of his recent
full blood count. He thinks he has lost a stone over the past few
months. His past medical history includes heavy drinking, and he tells
me he had an endoscopy done 15 years ago, but cannot remember the
results. I am concerned about a possible gastric malignancy. I would
be grateful for your input.”
26. In October, the man was taken to hospital for a chest x-ray and an endoscopy.
He returned to the prison on same day. The result of the x-ray was reviewed
by the prison doctor which indicted possible lung tumour. The prison doctor
faxed the x-ray results to the Rapid Access Clinic and the Day Case Clinic at
the local hospital. The x-ray results recorded:
“There is a soft tissue mass in the medial aspect of the right upper lobe
which might extend beyong the horizontal fissure with moderate
pneumonitis reaction around this mass is as well seen in the base of
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the right upper lobe on the lateral view and is highly suspicious of
malignant lung tumour. A CT [Computerised Tomography] scan to be
organised as soon as possible.”
27. In his letter to the prison doctor dated October, the man wrote that his
breathing:
“ … had deteriorated further I find I need to rest to catch my breath at
least there is time to make my bed the same thing with the simple task
of sweeping the cell floor. The dizzy spells are more oftern and a great
deal more intense. Palpitations feel like my heart is going to burst. …
The only time I leave the cell is to collect my meals and hot water for a
cup of tea, I feel vulnerable, useless, dirty, smelly and a complete
waste of space. No I’m not being bullied or threatened but I do realise
how weak and incapable I’ve become.”
28. At around 4.13pm three days later in October, the man was admitted to the
healthcare centre at Manchester as he was experencing problems with his
breathing. Two hours later he was taken by ambulance to hospital where he
was admitted to a ward. A CT scan was carried out after he was admitted.
Eight days later he moved to another ward.
29. A bedwatch was carried out whilst the man was in hospital. The initial security
risk assessment concluded that an escort chain should be used and two
officers should be in attendance at his bedside. A log of activities was
maintained by the officers on bedwatch duty which was checked on a regular
basis by a visiting duty governor. The man’s family was able to visit him whilst
he was in hospital.
30. In her letter received at Manchester in October a Senior House Officer at the
local hospital wrote:
“The CT scan showed a large mass in his right lung with superior vena
cava [the large vein which returns blood to the heart from the head,
neck and both upper limbs] obstruction consistent with carcinoma
[cancer] … He had a biopsy and will be liaising with another hospital
regarding management however the prognosis is poor with a life
expectation on three to twelve months.”
31. The risk assessment for the man was revised in October: restraints were no
longer to be used although two officers would continue to remain at his
bedside. On the same day, a nurse was informed that he was going to be
transferred to another hospital in November. He was being transferred for a
procedure to insert a stent. (A stent is a tube which is inserted into a vessel to
keep the channel open and prevent closure.)
10
32. In his letter dated 31 October, the Consultant Chest Physician at the local
hospital, wrote that the man had:
“incurable lung cancer, which is currently causing breathlessness and
obstruction of the main blood vessel draining from his head and upper
limbs. This is causing considerable swelling of his head and symptoms
of dizziness. On occasions to his admission [to hospital] he had
collapse secondary to this. He has been referred to another hospital
for further management of his problems, but unfortunately his life
expectancy is very poor. There has been deterioration in his physical
state since he has been admitted and I would estimate that he has no
more than four to six weeks to live. In view of this I would be grateful if
you would consider relaxing the security restrictions around the man.
In particular the need for him to be chained to a prison officer,
restrictions on telephone calls, and visiting. The telephone calls are a
particular concern to him as his sister is agoraphobic and he is unable
to see or contact her in any other way at this moment in time … The
treatments to be provided at the other hospital may well require regular
attendance every two weeks for burst of chemotherapy.”
33. During the morning in November, the man made a complaint that the snoring of
one of the bedwatch staff had kept him awake all night. A Senior Officer made
arrangements with Manchester for the duty governor to visit him. The duty
governor wrote the following entry in the bedwatch log:
“Enquiries made with the man regarding his allegation … He was very
complimentary regarding the way he had been treated by prison staff,
and was clearly upset about the previous 10-6 shift. He was
encouraged not to dwell on the incident but allow us to investigate the
matter. He was content to do this and appeared in much better spirits
by the time we left.”
34. In November, the man moved to another hospital. On the following day he was
granted release on temporary licence (ROTL). The licence was only applicable
for the periods he was in the local hospital and the other hospital. The
condition of the licence was that he was not allowed to leave the hospital
without prior permission from the prison. During the afternoon of 4 November,
he had a stent inserted. He was discharged from the hospital and returned to
Manchester two days later (on 6 November).
35. On his return to Manchester, the man was admitted to the healthcare centre.
The discharge information from the other hospital stated that he had a
prognosis of between three and nine months to live. The man told healthcare
staff that he thought that he had a prognosis of two weeks. He informed staff
that he wished to be kept pain free and was hoping that he would be released
early on compassionate grounds.
36. The prison doctor advised that for his pain relief the man should be given 20mg
of MST (Morphine Sulphate Tablets, an opioid painkiller which mimics the
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action of naturally occurring pain-reducing chemicals called endorphins) at 12
hourly intervals and 10mg/5ml of Oramorph (an oral form of morphine sulphate)
at four hourly intervals. A second nurse wrote in his medical record:
“On asking him how he feels about his prognosis he states okay as
long as he is pain free. He also informs me that he hopes to be
released on compassionate grounds as his family will look after him. I
have informed him that at present he will be looked after within
healthcare and his needs will be reviewed accordingly. He appears
content with this at present.”
37. The prison doctor saw the man in November and they discussed his prognosis.
They also discussed the issue of resuscitation and the man told him “to let me
go and not mess”.
38. A staff nurse came on duty at 8.00pm in November; she was informed half an
hour later that the man was to due to have his dose of MST. When she
checked the MST blister pack the expiry date was recorded as “20.11.05”. She
discussed this with a colleague and as the medication appeared to have
expired they decided not to administer it. In medical record, the staff nurse
wrote:
“Informed by nursing staff on the late shift that no MST tablets in
pharmacy. I contacted the hospital and spoke to the Night Sister
informed her of this and asked if there was any way a dose of MST
could be obtained from them tonight to prevent the man from missing
his dose and potentially being in pain due to this. I was informed by
her that this was not possible, against hospital policy and advised I
speak to their on call pharmacist. I spoke to on call pharmacist,
informed him of the situation. He again stated that this was not
possible even though I informed him that a member of nursing staff
from healthcare who had been on the late shift was prepared to go to
the hospital to obtain this as this way it could still be checked by two
nurses, one at the hospital and on arrival back at the prison.”
39. As the staff nurse was unable to resolve the situation she contacted the prison
doctor at home. He advised the staff nurse to increase the man’s dose of
Oramorph of 10mg/5ml from four hourly to two hourly intervals. He recorded in
the man’s medical record that this would make up for the missing dose of MST.
It was later discovered that the date on MST blister pack had been read
incorrectly and was in fact not out of date.
40. At around 9.57pm in November, the staff nurse entered the man’s cell as he
was short of breath and appeared quite panicked. In his medical record, the
staff nurse wrote:
“The man stated he had not been using his oxygen for the last two
hours as felt he hadn’t needed it. Has been up having a wash, trying to
arrange his pillows. He is now using his oxygen via mask. Deep
breathing exercises encouraged and reassurance given. No specific
12
concerns raised by him. Denies any pain at present. Advised to use
his oxygen as needed and inform staff if he feels breathless or has any
concerns. I made his bed for him and arranged his pillows in the way
he informed me would be comfortable for him and aid his breathing.
After a short while he appeared more settled.”
41. When my investigator met with the representative from the Independent
Monitoring Board (IMB) at Manchester, she said that healthcare staff have a
good relationship with prisoners and that the staff resources in this area
seemed to have increased. She confirmed that she had not known the man but
she produced an entry log completed by her colleague who saw him during the
morning of 10 November. Her colleague had visited the healthcare centre and
had been accompanied by a new member of the board. Her colleague wrote:
"... in H.C.C [healthcare centre] do not appear to be any problems. New
member of the board and I met the man, a terminally ill patient, at own
suggestion he sent in a Confid/Access App [confidential access
application] to Gov 1. Seeking early release on compassionate
grounds. We understand this may be considered favourably. We are
to remain in contact with the man."
42. After his visit from the IMB, the man was taken to hospital for palliative
chemotherapy. He returned to the prison at around 9.55pm and was again
located on the healthcare wing (cell MX-07). As he was struggling with his
breathing, he was advised to use the oxygen in his room and to press his cell
bell if he needed assistance.
43. At around 00.15am in November, the man rang his cell bell and asked for pain
relief. The night nurse checked with the hospital to confirm the dose of the
man’s pain relief medication. The nurse at the hospital confirmed that the man
had received 20mg of MST tablets whilst he was at the hospital. The night
nurse took the medication to him. However, as he was unable to get up from
his bed and as the prison was in patrol state permission was given for the cell
door to be unlocked. The man was given the MST at 01.00am. At around
01.48am, the night nurse recorded that he was “awake, lying in his bed, using
O2 [oxygen] intermittently says he is still feeling the pain but not as much as
before. Advised to be on his buzzer if he needs any more help. Continue to be
observed.”
44. The first nurse commenced her duty on the healthcare centre at around
6.40am, and she checked on the man around five minutes later. She noted
that he was propped up in his bed by the backrest and cushions. As she was
unable to rouse him, she immediately informed the Healthcare Senior Officer
(HCSO) and a third nurse of her concerns. The HCSO contacted the Principal
Officer (radio call sign Oscar One) and, as the prison was still in patrol state,
asked for permission to enter the man’s cell. The HCSO then entered the cell.
He was accompanied by three nurses. They laid the man flat and the checked
for signs of life. His pupils were fixed, no heart beat could be detected using a
stethoscope, and no breathing sounds or movements could be heard.
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45. At 7.02am, the HCSO informed the prison control room that the man did not
have a pulse and asked for an ambulance to be called. The ambulance arrived
at 7.15am and the paramedics were immediately escorted to the healthcare
centre. They then took over responsibility for his care and carried out an ECG.
The ECG confirmed that there were no signs of life, and the paramedics
pronounced that he was dead at 7.24am. Staff then brushed his hair, put a
sheet over his body and locked his cell. The ambulance left the prison at
7.46am.
46. The Director of Healthcare and a Principal Officer were appointed by
Manchester as the prison’s Family Liaison Officers. They contacted the man’s
family to inform them of his death and to offer their condolences. A chaplain
from the prison chaplaincy accompanied his family when they went to view his
body. The Director of Healthcare maintained contact with the family and
assisted with the funeral arrangements. Manchester also offered financial
assistance with the costs of the funeral. The man’s funeral took place on 27
November and the Director of Healthcare attended at the express wish of the
family.
47. The prisoners in the healthcare centre were told about the man’s death on the
day he died. Staff also asked prisoners whether they required anything or
wanted to speak to a Listener. (Listeners are trained by Samaritans to provide
confidential emotional support to fellow prisoners in distress.) The staff who
discovered that the man had passed away when they opened his cell were
offered support from the prison’s care team.
48. The post mortem report records the man’s death as due to natural causes, as a
consequence of disseminated bronchial carcinoma (lung cancer).
14
ISSUES CONSIDERED
49. When visited by my investigator and family liaison officer, the man’s family told
them that they had concerns about the care he had received whilst in custody.
I set these out in the paragraphs that follow.
Clinical care
50. The man’s family felt very strongly that the level of healthcare and medication
he received whilst in custody at Manchester was poor. They said that he had
written notes and letters detailing his level of care whilst at Manchester and in
outside hospital. The content of the letters has caused the family additional
distress. As already mentioned above, he wrote a letter to the prison doctor
asking for additional medication to relieve his pain and treat his condition. In
other letters to his family he wrote that he was only receiving iron tablets and
Salbutamol (asthma medication).
51. As noted above, a review of the man’s medical care was undertaken by the
clinical reviewer on behalf of the local Primary Care Trust. My investigator
informed the clinical reviewer of the concerns raised by the man’s family and
she reviewed his medical notes and the interventions of healthcare staff. She
also interviewed a number of staff. In order to evaluate the action of clinicians
involved in the man’s care, the clinical reviewer also consulted with members of
the local Primary Care Trust death in custody panel.
52. From the medical records, it was clear that the man was seen regularly by
healthcare staff and referred to secondary care when appropriate. However,
the clinical reviewer notes that there was no evidence that a secondary health
screening took place for him. (The secondary health screening is a general
health assessment and should be offered to every prisoner in the week
following arrival in custody. This assessment is equivalent to a primary care
assessment when registering with a General Practitioner in the community. It
provides an opportunity for gathering further health information, health
education and promotion, and importantly checking how a prisoner is settling
in.) An appointment was made for him to have a secondary health screening
but it was cancelled and no further appointment was made. The clinical
reviewer makes a recommendation that this process is reviewed by the Director
of Healthcare at Manchester.
The Director of Healthcare should review the Secondary Screening
Process. The process should occur wherever the prisoner is located and
whatever pathway he is following.
53. When interviewed by the clinical reviewer, the staff nurse recalled that the man
was annoyed when he had to wait for his pain relief medication. The clinical
reviewer notes that the normal practice in the healthcare centre was for
medication to be issued at timed intervals (for example two or four hourly). The
hospital and Macmillan Cancer Support advocate that the patient self manages
their pain relief. This means that the medication is taken when and how often
the patients feels it is necessary. The clinical reviewer also notes that
15
healthcare staff did not have contact with the Community Macmillan Nursing
Team. They could have advised healthcare staff on the current best practice in
the care of terminally ill patients.
54. The clinical reviewer makes a number of recommendations relating to the
terminal care for prisoners at Manchester. These include identifying a suitable
member of staff to take a lead role for palliative and end of life care and
providing additional training for staff.
The Director of Healthcare should identify a member of the nursing staff
to take a lead role for end of life and palliative care and to establish and
maintain a wider engagement with local palliative care networks.
The Director of Healthcare should ensure that members of the nursing
staff attend pain management workshops, as well as training to address
holistic assessment and communication skills in palliative care.
The Primary Care Trust should develop a 24 hour help line for palliative
care issues as described in the NICE Guidance: Improving Supportive
and Palliative Care for Adults with Cancer which includes the Prison
Service.
55. The clinical reviewer also recommends that the Director of Healthcare ensures
that nursing staff are aware of reflective practice. Reflective practice is part of
the requirement for nurses constantly to update professional skills. The nurse
can focus on their knowledge, skills and behaviour to ensure that they are able
to meet their responsibility for providing care to a patient to the best of their
ability.
The Director of Healthcare should ensure that the nursing staff are aware
of reflective practice.
56. The clinical reviewer further recommends that the Director of Healthcare should
ensure that Manchester’s palliative care policy takes into account the principles
outlined in the End of Life Strategy (issued by the Department of Health, July
2008). The aims are to provide high quality care for prisoners approaching the
end of their lives thereby ensuring that prisoners are treated as individuals and
that there is recognition of their changing needs and detention requirements.
The Director of Healthcare should review and ensure that HMP
Manchester’s palliative care policy takes into account the principles
outlined in the End of Life Strategy (DOH, July 2008).
57. The clinical reviewer concludes that the man was not a well man when he
arrived at Manchester. His medical problems were identified and acted upon in
a timely manner. He was treated in the local hospital and another hospital
where he had steroid medication and a stent inserted to relieve his symptoms.
The consultant at the other hospital decided that he would then receive
palliative chemotherapy treatment. However, the clinical reviewer has found no
16
evidence of any discussion at the other hospital or at the prison as to where the
man should receive palliative care.
58. Healthcare staff cared for the man once he was discharged from hospital.
They carried out a nursing assessment and developed a care plan on his return
to Manchester. However, this did not include pain management tools which
would be expected when managing a person in the terminal stages of life. The
clinical reviewer has also found no evidence of the management of the man’s
psychological and emotional needs. There does not appear to have been any
contact with Macmillan Cancer Support who could have offered advice in pain
management and palliative care. However, the clinical reviewer notes that the
man was only in the healthcare centre for a short period before his death. She
also acknowledges that the prison doctor did spend time speaking to him
regarding his prognosis and pain management. He also discussed whether the
man wanted to be resuscitated. This was good practice. Overall, the clinical
reviewer judges that the practices in healthcare were acceptable but not up to
date with pain management as advised by Macmillan Cancer Support and the
other hospital.
59. Unfortunately, the misunderstanding by the nursing staff as to whether the
man’s pain relief medication was out of date did lead to an initial delay in the
administration of this medication during his first night in the healthcare centre.
The clinical reviewer says that the paramount principle in terminal care is the
management of a person’s pain. Self management of breakthrough pain is
encouraged by the other hospital but was not the practice in HMP Manchester.
She suggests this probably had an adverse effect psychologically for the man.
He expressed frustration about the management of his pain relief, due to
moving from self management at the hospital to a timed managed
administration when he returned to prison.
60. The clinical reviewer believes that palliative care patients should receive
individualised care with ongoing assessments. She has found no evidence of
anticipatory end of life planning. She notes that the Director of Healthcare at
Manchester was involved in discussions to expedite the man’s early release,
although unfortunately he died before this could be agreed.
61. The clinical reviewer judges that, although staff at Manchester did their best to
give effective care in the circumstances, terminal care patients should be
transferred to a more appropriate setting to receive end of life care.
Location in prison
62. The man’s family wanted to know why he had been located on the lifer wing (C
wing) when he was only sentenced to nine months. According to the family,
prisoners sentenced to five years or more are located on the lifer wing.
63. The man was located in several different wings throughout his time at
Manchester. The Deputy Safer Prisons Co-ordinator has confirmed that
although C wing predominantly houses prisoners serving life and indeterminate
sentences for public protection (IPP), it was also home to other prisoners, like
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the man, who had shorter sentences. My investigator noted that he was only
located on C wing from late September until he taken to hospital in October.
When he returned to the prison in November, he was located on the healthcare
wing where he remained until his death.
64. In his written response to my investigator a Senior Officer wrote:
“Whilst the man was on C wing he never really came to staff's or my
attention. Even his cell mates never raised any issues. I have asked
staff if they can remember anything about him and all seem to have the
same opinion. He was a quiet man but didn’t have any problem in
approaching or talking to staff. He appeared to get on with numerous
other prisoners and never raised any concerns. I'm sure he attended
treatments daily and I remember on one occasion getting his inhaler
replaced. I can't remember any other issues, medical or anything
else during his stay on C wing.”
Behaviour of prison staff
65. The man’s family said that he had made a complaint against a prison officer. In
one of his letters to the family, he referred to the officer making noises in his
ear every time he tried to sleep and making him kneel down in his restraints
and pretending that the man’s son was driving a car at great speed. This has
caused his family additional distress. The family also expressed their concern
about a comment made by an officer on reception at Manchester. As the man
was being taken to hospital, they believed an officer had said to him ‘Dead man
on arrival’.
66. Before he met the man’s family, my investigator had noted that he had made a
complaint about the behaviour of a member of staff who was on bedwatch duty.
The man had complained that a Principal Officer’s (PO) snoring had kept him
awake all night and that he blocked his route to the en suite toilet. In his
bedwatch log entry for 1 November at 3.30am, the PO wrote: “Prisoner
complaining that the vibes from the staff were keeping him awake … checked
with nursing staff and this can be attributed to the medication.”
67. The man’s complaints were investigated by the Director of Operations at
Manchester. He found no evidence to substantiate the man’s claim of
inappropriate behaviour. An officer who was on the bedwatch duty with the PO
told the Director of Operations that the PO was quietly reading notes for most
of the night. The officer confirmed that the man had used the toilet just outside
his room on each occasion and had not asked to use the en suite toilet. The
officer also said that he believed that at no time did the PO act in an
unprofessional manner. When interviewed by staff at Manchester in
November, the man apologised for what had happened and said that the officer
had not done anything wrong. The man believed that his medication had made
him act in an irrational manner. The Director of Operations found no evidence
to substantiate the man’s complaint or evidence of inappropriate behaviour by
the PO. He did recommend that the PO should not carry out bedwatch duties
for the man to avoid any further misunderstandings.
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68. My investigator was unable to find any supporting evidence to substantiate the
complaint made by the man. No officers or prisoner approached my
investigator to raise any concerns about the care provided to him.
69. In her written response on this matter, the Deputy Safer Prisons Co-ordinator
wrote that she could not find any reference in the copies of the man’s letters to
“Dead man on arrival”. She wrote that the man was complimentary in his
documented comments that he made about staff, stating that officers had been:
“… absolutely magnificent with me, and I can feel proud in the fact that
such a fine body of your officers who showed exceptional kindness,
courtesy, understanding, respect and manners that were impeccable.”
70. My investigator was unable to find any evidence to substantiate the alleged
comments made by staff when the man left the prison.
Early Release
71. The family said that they were aware that release papers had been submitted
two weeks before the man’s death, and were concerned this had not been
considered earlier in view of his medical condition.
72. As mentioned previously, release on temporary licence was agreed for the man
in October 2008 whilst he was in hospital. The licence was only applicable for
the periods he was in hospital. The condition of the licence was that he was
not allowed to leave the hospital without prior permission from the prison. In
her family liaison log, the Director of Healthcare wrote:
“It had been highlighted to myself that the man was terminally ill.
ROTL [release on temporary licence] had been discussed the week
previous, so I brought it to the attention of the Governor first thing on
Monday morning and that I felt ROTL was necessary for him, to give
him dignity in life, prior to his death, as he had only been given what I
felt at that time was 3 – 6 months to live. On returning to the Health
Care Centre I was informed that we had had a further letter, and the
man had now been given a shorter life expectancy. I informed the
Governor, and myself, the Governor and a Nurse had a meeting to
discuss this.”
73. I believe that Manchester took action at the earliest juncture to investigate the
possibility of releasing the man from custody. Home Detention Curfew had
already been considered but not agreed due to his previous history of non-
compliance. Once it became clear that his prognosis was very poor a meeting
was arranged to investigate the options available to the prison. Unfortunately,
the meeting was arranged but did not convene as he had already passed away.
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Use of restraints
74. The initial security risk assessment when the man was taken to hospital
identified that an escort chain should be used and that two officers needed to
be in attendance. This was in line with normal practice and enabled the
nursing staff to have easy access when they carried out their duties. The use
of handcuffs for prisoners on escort to hospital has been the subject of recent
case law in relation to the issue of decent and humane treatment. (Judgment
by Mr Justice Mitting on 23 November 2007 in case of (1) Graham (2) Allen v
Secretary of State for Justice.) I know that the Prison Service is currently
drawing up new guidance in relation to this matter. Manchester’s decision that
the man should be handcuffed in the first instance was in line with its standard
procedures.
75. I am pleased to report that the risk assessment for the man was regularly
reviewed and revised during his time in hospital. As a result, the level of
restraints was reduced and the escort chain removed. In my judgement, this
was well managed. My investigator also found that the bedwatch notes were
concise with legible and appropriate entries.
Notification of the man’s death
76. The man’s family wanted to know why they had not been informed that he was
dying and why it took six hours for them to be informed of his death. They were
concerned that the notification of the death had not happened as soon as
possible. The family explained that the Director of Healthcare and a Police
Officer had informed the family of his death at 1.30 pm.
77. My investigator was able to confirm that staff were not aware that the man’s
death was imminent. He was ill and his prognosis was very poor but his
sudden death was not expected by staff at Manchester.
78. With regard to how the news of the death was delivered, the Deputy Safer
Prisons Co-ordinator wrote that:
“… a full risk assessment and collation of facts is essential when
delivering the news and making the first visit to the family. The Director
of Healthcare and the PO completed this and attended Stalybridge
Police Station (at police request) and then arrived at the address at
approximately 11.00am.”
79. In the Director of Healthcare’s note about the visit in November, she wrote:
“At approximately 06.55am in November 2008 I was informed that the
man had died of natural causes in his bed during the night. At
approximately 09.30am I was given the task of designated Family
Liaison Officer. Myself and a PO, who is also a Family Liaison Officer,
collated all the necessary information about the next of kin, and the
circumstances surrounding the man’s death. We had informed the
Police Liaison about the address of his daughter … we were instructed
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to attend Stalybridge Police Station before we attended the family. We
arrived at the man’s daughter’s address at approximately 11.00am.”
The Director of Healthcare subsequently accompanied the man’s daughter to
inform other members of the family of his death before she returned to
Manchester.
80. The man had been quite poorly but there was no indication that his death was
imminent. He appears to have passed away peacefully in his sleep and was
discovered by staff around 6.40am in November. His death was confirmed by
paramedics at 7.24am and the prison then implemented its death in custody
procedures. The prison’s family liaison officers ensured that the collated all
necessary information for their visit. They were then told by the police that as
there had been “incidents” at the family’s address they had to attend the local
police station before they informed the family.
81. I believe that staff at Manchester informed the man’s family of his death in as
timely a manner as was possible. The delay was unfortunate but necessary as
the family liaison officers had to act on the information they had been given by
the police. After the Director of Healthcare informed the family about the man’s
death they asked her to attend another address to tell other family members.
She was also later asked by his family to attend his funeral.
Delay in identification
82. The family were informed on the day of the man’s death they would need to
identify his body and someone would ring that afternoon to arrange. However,
there was no contact for another five days and this had caused additional
stress for the family.
83. In her family liaison officer log, the Director of Healthcare wrote:
“In November 2008 I received a telephone call from the man’s family. I
rang them back and they both stated that they had not had any contact
with the police. I attempted, on numerous occasions to contact the DI
on the number given, to no avail. I then contacted the Police Liaison
Officer within HMP Manchester, who also tried to contact Grey Mare
Lane Police Station, but was unsuccessful, so she e-mailed the DI …
At approximately 5.30pm in November 2008 I also contacted the man’s
family, to advise them that I was unable to contact the police, but the
Police Liaison had attempted on my behalf. Unfortunately one member
was unavailable to speak, but I did speak to another member. At 12
o’clock in November 2008 I had still had no contact with the DI, but I
have been in contact with the Coroner’s Liaison and arrangements
have been made for the family to attend hospital at 10 o’clock
tomorrow morning.”
84. In November 2008, the prison chaplain attended the mortuary with member of
the man’s family for the identification of his body. I appreciate that the man’s
family were upset by the delay. My investigator found no evidence that the
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prison did not attempt to assist with this process. The Director of Healthcare
followed up the concerns raised by his family and attempted to get the police to
contact them. When this did not work, she contacted the Coroner’s office and
arrangements were made for his family to identify his body with the prison
chaplain attending to give them support.
Return of the man’s property
85. The man’s family said that some of his property was missing. This included
clothing, letters and a notebook. The notebook detailed his wishes and
thoughts. His family had written their telephone numbers on the front cover of
the notebook. They had received a photocopy of the front cover of the
notebook from the Director of Healthcare but not the rest of notebook. They
had asked for the rest of the notebook but were told it has been misplaced.
The family were concerned that, if the prison could provide a photocopy of the
notebook cover, then they must have the rest of the notebook. They had also
requested the letters the family wrote to the man but were told that he must
have thrown them away. They did not believe this was the case as he kept
everything. The family were also concerned that they only received a small
amount of his clothing and would like to know what has happened to the rest.
86. My investigator discussed the concern about property in his interview with the
Director of Healthcare. She confirmed that she had spoken to the man’s son in
November about returning the property. This was taken to the man’s
daughter’s house the following day. During her visit to his family in November,
the Director Healthcare contacted both the local hospital and the other hospital.
This was to check that the hospitals had not retained any of the man’s property.
87. When the Director of Healthcare returned to the prison she spoke to two
officers who had been on bedwatch duty in November, about the man’s
notebook. The first officer recalled an A4 size book but did not recall a
notebook. The second officer confirmed that the man packed all of his own
belongings at the hospital. The Director of Healthcare confirmed that she
checked Healthcare, Security and Reception at Manchester but was unable to
locate any further property. This information was relayed to the family by her.
88. In November, the prison chaplain spoke to the man’s daughter about her
father’s property. The Director of Healthcare contacted the man’s daughter
after checking her father’s property card. On the following day, the Director of
Healthcare spoke to the nurse on Ward 4 at the other hospital who had
discharged him. The nurse confirmed that no property was left there. She
again checked all areas within the prison and spoke with the Dedicated Search
Team who had completed the clearance of his cell. She also contacted the
Detective Inspector to check if the police had retained any of his property.
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89. In her written response to the concerns raised by the family the Deputy Safer
Prisons Co-ordinator wrote that in March 2009:
“Safer Custody Team have contacted HM Coroners Office to establish
if they have a notebook or any property belonging to the man. They
have confirmed they have only what we copied and provided them.
They confirm they do not have a notebook.”
90. My investigator tried to find a resolution to these concerns. The property noted
in the man’s records has been returned but the family do not accept that this
was all of his belongings. Unfortunately, I do not know how to resolve this
situation with regard to his alleged missing property. I am frankly puzzled that
a front page of notebook was located and copied to the family but that the rest
of the notebook cannot be located. This is a regrettable situation as the
contents of the notebook allegedly contained his personal thoughts which are
now lost. I commend staff for allowing the man to pack his own bag when he
left hospital for the last time, but unfortunately we will never know if the rest of
the notebook was lost at this point or at an earlier or later juncture. I regret that
my investigator was unable to resolve this issue satisfactorily.
Aftercare
91. The family has praised the two prison officers who were on bedwatch duty with
the man at the hospital. They described them as ‘brilliant’. The family
confirmed that Manchester had arranged and paid for the funeral and service.
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CONCLUSION
92. The man arrived in HMP Manchester in August 2008 with a history of health
problems. He died of natural causes three months later.
93. From the bedwatch log, it was clear to my investigator that the staff involved
with the man’s care behaved with compassion and sensitivity. The security
arrangements at the hospital were in line with current policy and expectations.
94. In light of the clinical review, I judge that the man’s care was not equivalent to
what he would have received in the wider community. The findings of the
clinical review and my own investigation highlight that there is a need for some
improvements to healthcare practices at HMP Manchester.
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RECOMMENDATIONS
1. The Director of Healthcare should review the Secondary Screening Process.
The process should occur wherever the prisoner is located and whatever
pathway he is following.
Recommendation accepted: An audit calendar will be initiated to ensure that
the secondary screen process is adhered to.
2. The Director of Healthcare should identify a member of the nursing staff to
take a lead role for end of life and palliative care and to establish and maintain
a wider engagement with local palliative care networks.
Recommendation accepted: A lead nurse will be appointed to palliative care
and networks will be established
3. The Director of Healthcare should ensure that members of the nursing staff
attend pain management workshops, as well as training to address holistic
assessment and communication skills in palliative care.
Recommendation partially accepted: A lead nurse will be appointed to
undertake necessary qualifications in pain management and will be the lead
on this for the other staff.
4. The Primary Care Trust should develop a 24 hour help line for palliative care
issues as described in the NICE Guidance; Improving Supportive and
Palliative Care for Adults with Cancer which includes the Prison Service.
This is for the Primary Care Trust to comment on.
5. The Director of Healthcare should ensure that the nursing staff are aware of
reflective practice.
Recommendation accepted: Staff will be reminded of the benefits of reflective
practice.
6. The Director of Healthcare should review and ensure that HMP Manchester’s
palliative care policy takes into account the principles outlined in the End of
Life Strategy (DOH, July 2008).
Recommendation accepted: The Palliative Care policy will be reviewed to
ensure the principles are recognised.
25