Individual at Frankland

Investigation into the circumstances surrounding the
death of a man, a prisoner at HMP Frankland,
in March 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2009
This is the report of an investigation into the circumstances surrounding the death of
a man, a prisoner at HMP Frankland. The man died in March 2009. He was 66
years old. A post mortem showed that the cause of his death was cancer.
I offer my sincere sympathy and condolences to the man’s family, as I do to all of his
friends and acquaintances who are touched by his passing.
The investigation was carried out on behalf of the Ombudsman by my colleague.
Both he and I would like to thank the Governor of HMP Frankland and all his staff for
their full and ready co-operation during the course of our enquiries. I also thank the
clinical reviewer for the clinical review he led on behalf of the local Primary Care
Trust (PCT).
This report recognises that the clinical care and consideration given to the man by
the staff was equitable to that he would have received in the community. I make two
recommendations concerning improved communication between HMP Frankland
and external NHS services and families.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman October 2009
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CONTENTS
Summary
The Investigation Process
HMP Frankland
Key Findings
Issues
Recommendations
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SUMMARY
In May 1986, the man was convicted of murder and sentenced to life imprisonment.
He was first sent to HMP Wormwood Scrubs and, over the following 18 years,
transferred to different prisons until he arrived at HMP Frankland in January 2004.
Due to experiencing chest problems the man had a computerised tomography (CT)
scan of his chest at the University Hospital of North Durham (UHND) in August 2006.
It indicated a small shadow on his lung area. He had further x-rays in November and
the results showed an abnormality.
The man was told in December that lung cancer had been diagnosed. In February
2007, he had a pneumonectomy (an operation to remove part of the lung). A course
of chemotherapy began but the man decided to stop the treatment in July 2007. It
was also noted that he continued to smoke.
The man saw the prison doctor in November 2008 as he was coughing more than
normal and felt as if his oesophagus (gullet) was squashed. The doctor recorded
that air entry could be heard in the upper regions of the left lung and that he had an
irregular heart beat. The doctor conducted an electrocardiograph (ECG) (a
recording of the electrical acitivity of the heart) which confirmed that he had atrial
fibrillation (abnormal heart rhythm that involves the two upper chambers of the
heart).
In January, the consultant thoracic surgeon visited Frankland and saw the man. He
recorded that there had been a four month history of weight loss with a dry cough
and decided to arrange for a CT scan as it had been two years since his operation.
The results showed that the man had wide spread cancer. In March, the prognosis
was made that his life expectancy would be quite short and that he should be treated
with a palliative care.
Healthcare staff tried to speak to the man in March about his prognosis and his
wishes for his end of life care but he was too poorly to discuss resuscitation or
decide on his preference for his end of life care.
The man’s sister was visiting at the prison in March when, at 3.35pm, a nurse
recorded that there was no sign of breathing and that her brother had died.
The clinical review highlights that the care the man received at Frankland was
equitable with what he would have expected in the community. I make
recommendations concerning the co-ordination of referrals to NHS specialists and
developing a communication strategy between the prison and the hospital trust and
families.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 9 March 2009 when the investigator issued
notices 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. One prisoner came forward as a result and was interviewed.
2. The investigator visited HMP Frankland on 31 March. During his visit he was
given copies of all the documentation relating to the man. They included his main
prison record and medical records. He also met a member of the Independent
Monitoring Board (IMB). During this visit the investigator interviewed one
prisoner. He also visited healthcare to see the man’s cell. He returned on 27
May when he interviewed three members of staff.
3. The local Primary Care Trust appointed a clinical reviewer to carry out a review of
the man’s clinical care. The investigator and the clinical reviewer discussed
aspects of the man’s treatment and healthcare whilst he was at Frankland. I am
grateful to the clinical reviewer for providing such a thorough and timely review,
and for addressing the family’s concerns.
4. The investigator contacted HM 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. The senior family liaison officer contacted the man’s family to inform them of the
investigation. The senior family liaison officer and the investigator later met the
family who raised the following concerns:
(cid:127) Why were there delays and cancellations of the man’s medical appointments?
(cid:127) Why had the man not been granted a transfer to a prison closer to the family?
(cid:127) Why was the man not considered for compassionate release given his
medical condition?
(cid:127) Why was the man not moved to a hospice?
(cid:127) Why they had not been informed that the man’s condition had deteriorated at
an earlier stage?
(cid:127) Why was it difficult for the family to contact healthcare by phone to enquire
about the man?
(cid:127) Why was the man not on oxygen, as there were damped bed sheets being
used?
(cid:127) Why the man’s sister had not been prepared for the shock of his physical
condition and to find him not clothed on the lower part of his body, with no
duvet cover?
The investigator has attempted to address the issues raised by the family within
the report. I hope that the report provides the family with a better understanding
of the treatment given to the man prior to his death. The family expressed their
gratitude to the prison’s family liaison officer and the Governing Governor, for
their sympathetic dealings with them.
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HMP FRANKLAND
6. HMP Frankland is one of eight maximum security establishments in England and
Wales. The prison holds convicted category A and B adult male prisoners, and
some high risk remand prisoners. The operational capacity of the prison is 734.
7. Healthcare services are provided by the local Primary Care Trust, which is
independent of the Prison Service. The healthcare centre provides 24 hour
inpatient care in two six-bedroom wards and eight furnished rooms.
8. The most recent full inspection report by HM Chief Inspector of Prisons, dated
March 2003, describes Frankland as offering a safe environment based upon
good relationships between staff and prisoners. The inspection found good staff
understanding of individual prisoners and their needs.
9. Following a short unannounced follow up inspection on 25 October 2005, the
Chief Inspector recorded that healthcare services had improved since the full
inspection. However, primary care still needed development and staffing
shortages had hindered progress.
10. The latest Independent Monitoring Board (IMB) report (for the year 2006-07)
found that healthcare had improved during the course of the year. The IMB
reported that morale amongst healthcare staff, which had previously been low,
had stabilised and improved. They also reported that all sections of healthcare
appeared to be working well.
11. This is the 21st death from natural causes to have occurred at Frankland since
April 2004, when I began investigating all deaths in prison custody in England
and Wales. One of the reasons for such a high figure is due to the fact that
Frankland has in-patient facilities. An earlier investigation concerned another
man who suffered from cancer. That report recognised the excellent palliative
care co-ordination and management and I am pleased that this which was
evident in the man’s case as well.
6
KEY FINDINGS
12. The man was born in November 1942. He predominately lived in the Sussex
area. He was not married and had no children. Although he had told the prison
and medical authorities that he was a South African citizen, the Ombudsman’s
investigator contacted the South African consulate but was unable to confirm his
status.
13. The man was convicted of murder in May 1986 and sentenced to life
imprisonment. His sentence began at HMP Wormwood Scrubs and, over the
following 18 years, he transferred to different prisons until he arrived at HMP
Frankland in January 2004. Heworked in the food canteen at the prison.
14. Due to chest problems, the man had a computerised tomography (CT) scan of
his chest at the University Hospital of North Durham in August 2006. The scan
indicated a small shadow on his lung. He was informed by a prison doctor of the
result and that further investigations would be made. The man had more chest x-
rays in November and the results were abnormal.
15. The man was informed in December that the hospital had diagnosed lung cancer.
In February 2007, he had a pneumonectomy (an operation to remove part of the
lung) performed by the Consultant Thoracic Surgeon at The Freeman Hospital,
Newcastle upon Tyne. After the operation the man began a course of
chemotherapy and, in addition, the prison doctor prescribed Ensure drink
supplements three times a day.
16. In May, the prison doctor saw the man as he said that he was having difficulty in
sleeping due to the chemotherapy. The doctor prescribed Temazepam (a short
term treatment for sleeplessness) to be taken for three nights. Four days later
the man saw another prison doctor, as he had a chesty cough. The second
prison doctor recorded that this was also due to the chemotherapy.
17. The Consultant Thoracic Surgeon reviewed the man in July at Frankland. The
consultant recorded that the man was much better following his operation.
However he had stopped the chemotherapy treatment at his own request and felt
better as a result. The Consultant Thoracic Surgeon also noted that the man was
still smoking following surgery. On examining him, the Consultant Thoracic
Surgeon noticed a small seroma (swelling caused by a pocket of clear fluid that
sometimes develops in the body after surgery) in the wound, which could be
removed under sterile conditions at the prison. The procedure was carried out in
September by a Consultant Colorectal Surgeon, from University Hospital of North
Durham (UHND). The Consultant Colorectal Surgeon saw the man in the
healthcare centre at Frankland and removed 35ml of fluid from the seroma which
removed the swelling.
18. The man was reviewed by the Consultant Thoracic Surgeon in December who
areviewed the cause of the build up of fluid. The consultant thought that it was
likely to be pneumonectomy space fluid (that is space in the chest cavity which is
created after the removal of the lung) which was a direct result of a small hernia
(protrusion of tissue) in the muscles between the ribs. The Consultant Thoracic
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Surgeon had not seen the condition in a patient before. He considered that
surgery was an option to rectify the problem. However there was a potential
complication of infection which would have disastrous consequences. This was
explained to the man, who accepted the potential risk, and the Consultant
Thoracic Surgeon proposed to peform the operation in February 2008.
19. In January 2008, the man saw the Consultant Colorectal Surgeon in the
colorectal clinic at the healthcare centre at Frankland. The Consultant Colorectal
Surgeon removed 60ml of fluid from the swelling, which made the man feel more
comfortable.
20. The man had another review with the Consultant Thoracic Surgeon in March.
The Consultant Thoracic Surgeon recorded that the Consultant Colorectal
Surgeon had removed fluid on two occasions. He commented that, alarmingly,
the man carried out the procedure himself with non-sterile utensils, but the
situation had remained stable. The Consultant Thoracic Surgeon noted that an
operation was planned in April, but was concerned that further operations had
two risks. The first risk was that pneumonectomy space fluid infections are
difficult to eradicate and can be fatal. The second risk was the possible effect on
the chest cavity containing the heart and the vessels of the heart which also
could be fatal. The Consultant Thoracic Surgeon recorded that no further
removal of fluid was to be performed. In May, the Consultant Thoracic Surgeon
reviewed the man and decided that no further treatment would be undertaken on
the seroma.
21. In September, the man was seen by a Nurse when she took his Ensure
supplement drinks to the wing. The nurse recorded that the man said that he had
not felt very well at the beginning of the week, but now felt much better. He said
that he received a lot of support from staff and fellow prisoners and had no
concerns at that time. He would alert staff straight away if he had any problems.
22. The man saw a third prison doctor in November as he was coughing more than
normal and felt as if his oesophagus (gullet) was squashed. The doctor
examined him and recorded that he heard air entry in the upper regions of the left
lung and he had an irregular heart beat. The third prison doctor conducted an
electrocardiograph (ECG) which records the electrical acitivity of the heart. The
ECG confirmed that the man had atrial fibrillation (abnormal heart rhythm that
involves the two upper chambers of the heart). The third prison doctor referred
the man to the UHND for further examination.
23. The man had further tests at the hospital which confirmed the diagnosis of atrial
fibrillation. Bisoprolol Fumerate (a beta blocker to control heart rhythm) was
prescribed, together with Simvastatin (to treat high cholesterol) and Warfarin (a
treatment for atrial fibrillation). The man was sent back to prison and an
outpatient appointment arranged with a hospital doctor at the hospital’s rapid
access clinic the next day. He was kept in healthcare overnight for observation.
24. The following morning the man refused to go to the hospital appointment with the
hospital doctor. It was explained that the appointment was important and the
consequences of refusing to attend were serious. The man signed a disclaimer
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form which stated that he was aware that he would be taken off any waiting list.
He also discharged himself from healthcare against medical advice, and signed a
separate disclaimer stating that he wished to return to the wing.
25. In December, a second Nurse was called to F wing to see the man who had
fallen. The nurse found him lying on his bed. He was fully coherent and not
confused. He told the nurse that he had pulled muscles in his left shoulder and
arm about three days previously and been resting in bed ever since. He said that
he had not been eating very much but had been drinking normally. He told the
nurse that he had got out of bed at about 4.00am to go to the toilet. He thought
that he passed out for a short while and then got back into bed afterwards. He
said he felt much better but did not feel well enough to go to work. The second
Nurse recorded that there were no apparent injuries from the fall. She advised
him to eat regular healthy meals and try not to smoke. The nurse referred the
man for a follow up appointment with the prison doctor later the same day.
26. Later that morning, at 11.55am, two Nurses responded to a call from F wing to
see the man, whose condtion had deteriorated. He was experiencing
considerable pain to his left ribs and was unable to move. Due to his medical
history, an ambulance was called to take him to the emergency department at the
local hospital.
27. The man was discharged later from the emergency department and returned to
prison. A quantity (100ml of fluid had been drawn from his chest cavity which
immediately reduced the pain. He was seen in healthcare by a third Nurse who
recorded that his blood pressure was 111/73 and that he was happy to take
paracetamol to relieve the pain. The man remained in healthcare overnight for
observation.
28. The next day, the third prison doctor reviewed the man who said that he felt much
better and wanted to return to the wing. The doctor recorded that his pulse was
still irregular but deemed him fit to return to the wing.
29. In December, the man had blood samples taken. The reason was to test for his
international normalised ratio (INR) which determines the clotting tendency of the
blood. The result was that he had a raised INR of five. (A high INR level, such
as five, indicates that there is a high chance of bleeding. An INR of 0.5 shows
that there is a high chance of a blood clot. The normal range for a healthy person
is 0.9 –1.3 and 2.0 – 3.0 for people who are prescribed Warfarin.).
30. A fourth prison doctor saw the man the next day and explained the INR test
results. The doctor advised that he should stop taking Warfarin for two days and
then resume taking it if the INR result was within the required range. The third
prison doctor conducted an INR test on 24 December and the result was 3.5
31. The man saw the fourth prison doctor in January 2009 for a review of his
medication. He told the fourth prison doctor that he had stopped taking Warfarin
as he felt dizzy and unwell. The doctor explained that it could take up to six to
eight weeks to reach the right level and dosage of warfarin. The man agreed to
restart taking Warfarin.
9
32. Healthcare staff received a call in January from F wing staff asking them to go
urgently to see the man who was breathless and feeling unwell. A fourth Nurse
saw him in his cell. She recorded that the man was not actually breathless, but
had difficulty breathing in the night and had been vomiting up to 14 times a day
for the previous four days. He was taken to healthcare by wheelchair for
continued assessment in quiet surroundings. An ECG was undertaken which
produced abnormal results showing that he still had an irregular heart rhythm.
He returned to his cell later that day.
33. Three days later the fourth prison doctor saw the man to review his condition.
The doctor recorded that his weight was 61.5kg and that a few “scattered
crackles” could be heard in his chest. He was advised to continue taking the
Warfarin and to contact healthcare straight away if he felt unwell.
34. In January, the Consultant Thoracic Surgeon visited Frankland and saw the man.
He recorded that he was “shocked to see the change in him” who had a dry
cough and an irregular heart rhythm despite being given treatment. The
Consultant Thoracic Surgeon decided to arrange for another CT scan as it had
been two years since the man’s surgery.
35. Five days later the man saw the third prison doctor who, following examination,
advised that he needed to be an inpatient in healthcare. The doctor recorded
that the man had pain in his left flank which worsened when he coughed and his
blood pressure was 114/78. He also told the third prison doctor that he felt sick
after eating. The third prison doctor noted that he was pale and thin and he was
taking Ensure drinks.
36. The fourth prison doctor saw the man the following day and recorded that his
weight had fallen to 59kg. The doctor also noted that he was coughing a lot and
had episodes of shortness of breath. A referral was made, with the man’s
consent, to the MacMillan Nursing Service for a palliative care nurse to provide
advice on pain management and emotional support to him.
37. In February, the man saw the fourth prison doctor as he was experiencing pain in
the left side of his chest, was coughing frequently and feeling hot and cold. The
doctor prescribed Amoxicillin (an antibiotic used in treatment of bacterial
infections) and a Salbutamol inhaler (which is used to treat broncial spasms).
Two days later the fourth prison doctor reviewed the man who said that he felt
much better, his breathing was better, he was not coughing as much and his
appetite had improved. Four days later a MacMillan nurse visited Frankland and
provided advice on the man’s pain management regime.
38. The third prison doctor saw the man in February as he had refused to take some
of his medication. He told the doctor that he had stopped taking Warfarin as it
made him vomit and feel unwell. The third prison doctor recorded that he was
coughing and producing a light yellow phlegm. The man told the doctor that he
felt very despondent about his deteriorating health. The third prison doctor
explained the reasons and benefits of his medication. He said that he was taking
his Ensure supplement drinks, even though nursing staff told the doctor that he
10
regularly refused to have them. The third prison doctor removed Warfarin from
the man’s medication and prescribed Ciprofloxacin (treatment of severe or life
threatening bacterial infections) and senna tablets (laxative).
39. Later the same day a full nursing assessment was carried out by a fifth Nurse.
The man accepted that, due to his deteriorating condition, he needed more
nursing care to assist with all aspects of his daily life. He asked to move into the
ward area of the healthcare centre as he would enjoy the company. Following
discussions with senior staff, he was moved onto the ward.
40. Over the next 11 days the man was seen every day by nursing staff. He regularly
refused food despite the best efforts of staff to encourage him to eat. He also
declined blood tests and to have a bath or bed bath.
41. In February, the man went by ambulance to the outpatients department at UHND
to have the CT scan arranged by the Consultant Thoracic Surgeon. The third
prison doctor reviewed him the following day. The doctor recorded that he was
still not eating or taking the senna tablets. The man also continued to refuse to
take Warfarin due to the side effects. The third prison doctor prescribed
Lactulose solution (laxative), Glycerol Rectal Suppositories (another laxative),
and Phenindione (an anticoagulant).
42. The nurse from the MacMillan team, saw the man three days later. The nurse
recorded that his condition was clearly deteriorating, but he was comfortable and
was being treated sympathetically, including being allowed to dress as he
wished. The man told the MacMillan nurse that he was tired but pain free and
was happy with his nursing care. The Consultant Thoracic Surgeon had not yet
seen the results of the CT scan and the MacMillan nurse said that she would
discuss this with him.
43. The Consultant Thoracic Surgeon faxed a letter to the fourth prison doctor in
March to confirm the results of the CT scan. The consultant stated that the man
had widespread cancer and expressed the opinion that his life expectancy would
be quite short. The Consultant Thoracic Surgeon also stated that there was no
further treatment that could be offered to the man and that he should be put on a
palliative care pathway. (This is an individual care plan used for patients who are
reaching the end of their lives.)
44. The Consultant Thoracic Surgeon’s letter was shown to a fifth prison doctor. This
doctor thought it more appropriate for the fourth prison doctor to tell the man of
the results as he had had most dealings with him. However the fourth prison
doctor was not available for the next two days (4 March). A palliative care plan
was put in place by the fifth Nurse. The man remained on the ward in healthcare
at his own request but this would be reviewed if his condition deteriorated further.
45. The MacMillan nurse visited Frankland the next day and discussed the man’s
care with healthcare staff. They decided that he should be informed of his
prognosis. The MacMillan nurse and a sixth Nurse spoke to the man about the
tests and the prognosis. He said that he understood that his death was likely to
occur in the very near future but was too tired to discuss anything else.
11
46. In March, a multidisciplinary meeting involving the MacMillan Nurse, healthcare
staff and a senior prison manager was held at the prison. The purpose of the
meeting was to discuss the man’s deteriorating condition and his end of life care.
Due to his incurable condition, it was agreed that resuscitation would not be
appropriate. The fourth prison doctor and the MacMillan Nurse tried to speak to
the man about his wishes but he was too unwell to discuss resuscitation or tell
them his preference for his end of life care.
47. Later that same day the man was moved into a single cell in healthcare. The fifth
Nurse had commenced the end of life care pathway and recorded that his
breathing had deteriorated. A member of healthcare staff sat with him all the
time. The Governor had given permission for his cell door to remain open to
allow staff to give appropriate care and to maintain his dignity.
48. Healthcare staff attempted to contact the man’s sister, who lived in West Sussex,
by telephone to inform her of her brother’s deteriorating condition. They had no
success at first but she was contacted a few hours later at another address in
County Durham. The prison arranged for his sister to visit and stay with him in
healthcare until 10.00pm that night.
49. The man’s sister returned to the prison the following morning at 8.30am and
remained for the rest of the day. The prison family liaison officer stayed with her
throughout the day, and healthcare staff made sure that she had food and drink.
50. At 3.35pm a seventh Nurse was called to the man’s cell by an Officer. The nurse
observed that there was no sign of breathing and that the man had died. (His
sister was outside the cell at the time talking to the prison family liaison officer
and a Governor.) The Nurse informed the man’s sister that her brother had died.
The prison liaison officer stayed with her at his bedside for some time and a
member of the chaplaincy team came to speak to her.
51. The prison made arrangements to allow the man’s sister to use the telephone to
contact relatives and provided a taxi to return her to the address in County
Durham. An on call doctor certified the man’s death at 4.50pm.
52. The prison offered financial assistance towards the funeral expenses which
included transporting the man’s body to West Sussex where the family wished
the funeral to take place.
12
ISSUES
Clinical care
53. The clinical review examined in depth the care the man received from both the
healthcare staff at Frankland and external medical professionals. The review
concludes that, overall, he received equitable care from the healthcare team at
Frankland as he would in the community. The clinical reviewer specifically said:
“It is my opinion that the care he received leading up to his death, by the
nursing and medical team, was common and acceptable medical practice.”
54. The review did highlight one aspect of the man’s care that gave rise to concern.
“On 4th February 2005 he was referred for investigation of a possible stroke.
Somehow this referral letter was never sent and it was not until 16th February
2006 that the referral was sent. On this aspect his standard of medical care
had fallen below common and acceptable medical practice.”
The clinical reviewer made the comment that this situation can occur in any busy
general practice and was satisfied that the omission had no bearing on the
circumstances of the man’s death. I make no recommendation here but the Head
of Healthcare will wish to review the co-ordination of referrals to NHS specialists
and ensure that they are timely and a follow up process is in place.
55. The review also recognised that there was an issue regarding the communication
between the healthcare centre at Frankland and external NHS services. The
clinical reviewer said:
“Throughout the medical records it is abundantly clear that the doctors and
administration staff of NHS hospital based care cannot appreciate the
inherent difficulties and problems for the medical and administrative team
based in a high security prison.”
56. Their lack of awareness resulted in Frankland not being able to meet every
request for outside hospital consultations. (This was one of the concerns raised
by the man’s family.) An example from his medical records showed that on 2
November 2006, a doctor’s team requested that another bronchoscopy be
performed the following day. It is clear to both the clinical reviewer and myself
that this was insufficient notice for the prison to put the necessary procedures in
place. The man subsequently had the bronchoscopy on 17 November 2006.
The Head of Healthcare should engage with the hospital trust to put into
place a robust communication strategy so that the requirements of all
stakeholders can be met and issues, when identified, can be addressed.
Family issues
Transfer to a prison closer to family
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57. Compassionate transfers within the high security estate may be granted for a
temporary period for various reasons One example would be to facilitate easier
access for family visits. The request for a temporary transfer has to be made by
the prisoner themselves. A family member or other individual may write to an
establishment to ask for a prisoner to be transferred, but the prisoner has to
agree and request to be transferred.
58. In December 2006, the man’s sister made a written request to the prison for him
to be moved closer to her home in West Sussex. The investigator found no
evidence that he wished, or had requested, a transfer from Frankland.
Consideration given for compassionate release
59. There is a formal process which has to be followed for a prisoner to be granted
compassionate release. This includes a recommendation by the Parole Board
and the approval of the Secretary of State for Justice.
60. In the man’s case the definite diagnosis of his illness was only received by the
prison in March and he died four days later. This was a very limited amount of
time within which compassionate release could have been arranged, subject to it
being approved.
Transfer to a hospice
61. The clinical reviewer has considered whether the man should have moved to a
hospice and makes comments that there are several factors which are relevant.
The points that would be considered include the nature of the disease and the
diagnosis for the patient and the place where the most suitable care can be
provided.
62. Many patients can spend their remaining days in a hospital, a hospice or at home
depending on their own wishes and the place where the best possible care can
be provided. The clinical reviewer comments that:
“It is my opinion that from the time the prison authorities received the definitive
diagnosis from the Consultant Thoracic Surgeon on 02/03/2009 there was an
accelerated and rapid deterioration in the man’s condition.
“It is my opinion that the care he received leading up to his death, by the
nursing and medical team, was common and acceptable medical practice.”
63. The investigator interviewed the fifth Nurse and asked about the efforts to secure
a hospice place for the man. The nurse said that she had personally asked the
MacMillan Nurse whether a hospice place was available but regretfully there
were no places at that time.
Contacting healthcare and keeping the family updated on the man’s
deteriorating condition
14
64. The man’s family asked why they were not informed when his condition
deteriorated and commented that they found it difficult to obtain information from
healthcare staff. From the interviews conducted, the investigator was able to
establish that there are clear differences between how prison records and
medical records are recorded and how information, if any, is shared. Healthcare
records do not include next of kin details. They contain confidential medical
information about a prisoner. Any contact with the family is made by the family
liaison officer from the prison, rather than by healthcare staff.
65. Frankland has a dedicated business unit which receives, logs and processes all
incoming written correspondence. There is also a dedicated safer custody hot
line for families and friends to contact with concerns over a prisoner’s well being.
My investigator has not been able to establish why the man’s sister had difficulty
in contacting the prison by telephone.
66. In the man’s case the definitive diagnosis was only received from the hospital
four days before his death. However the clinical reviewer said:
“By 29 January 2009 it was abundantly clear that his condition was further
deteriorating. Accordingly his case was referred to the MacMillan nurses
(who specialise in palliative care). Anticipatory palliative drugs were
considered and a care plan was drawn up.”
67. Provided that the man had given his permission, I believe that it was reasonable
for his family to have been informed of his worsening condition, certainly from 29
January. This would have provided the family with the opportunity to co-ordinate
visits and maintain dialogue with the prison. The end of life care pathway makes
specific reference to support for the family and no exception should be made for
the families of prisoners.
The Governor and Head of Healthcare should develop a proactive
communication strategy to ensure a prisoner’s next of kin are informed of
critical health matters, particularly when the prisoner is terminally ill.
68. I acknowledge the efforts of healthcare and prison staff in their attempts to
contact the man’s sister in West Sussex on 5 March. I also commend the work of
Governor Wales to put in place the authorisation for open visiting and allow his
family to remain in the prison until late at night.
Use of oxygen and the use of dampened bed sheets
69. The man’s family also asked why he was not given oxygen and the purpose of
the damp bed sheets. These issues have been specifically addressed by the
clinical reviewer who said:
“With regard to the use of oxygen, as to whether or not this was used would
be a medical decision at that moment in time. However, I would draw the
reader’s attention to the consultations on 4 March 2009, where a pulse
oximeter was being used on him. Basically this measures how well
oxygenated a person is. The man’s result was 91% showing that with
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breathing the air in the room he was adequately oxygenated and did not, at
that stage require additional oxygen.
“Finally, with reference to the use of dampened bed sheets on his radiator.
This may be a reference to an attempt to humidify the air, but this is pure
speculation on my part.”
The man’s physical condition and use of bedding
70. At interview the fifth Nurse said that duvets are not routinely available in the
prison, however a new one was obtained in the last few days before his death in
an attempt to increase the man’s comfort. The fifth Nurse apologised that the
duvet came without a cover, and that sadly the cover arrived after the man’s
death.
71. The fifth Nurse said that Frankland healthcare followed the end of life care
pathway. She explained that this focused on making the patient as comfortable
as possible and adhering to their wishes as far as possible. The man was nursed
in the ward area of healthcare as he enjoyed the company of fellow prisoners.
However, in the final few days of his life, he was moved to a single cell where he
was provided with a multi positional bed and a pressure relieving mattress. He
was allowed to be dressed as he wished and to have his own personal blanket.
72. The end of life pathway provides guidance on comfort measures which include
moving the patient for comfort only and use of a syringe driver (to administer pain
relieving medication) when appropriate. The fifth Nurse said that a syringe driver
was put in place on the day he died. It continuously administered small amounts
of very strong pain relief until his death.
CONCLUSION
73. I am pleased to endorse the clinical reviewer’s comments that the care and
treatment received by the man from staff at HMP Frankland was equitable to that
which he would have received in the community. Care and support was also
provided by hospital specialists and the visiting MacMillan cancer nursing
specialist. However the prison should ensure that it has robust communication
strategies in place to meet the needs of all healthcare stakeholders. This should
include the prisoners’ family and friends as well as the healthcare professionals
inside and outside the prison.
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RECOMMENDATIONS
1. The Head of Healthcare should engage with the hospital trust to put into place a
robust communication strategy so that the requirements of all stakeholders can
be met and issues, when identified, can be addressed.
2. The Governor and Head of Healthcare should develop a proactive
communication strategy to ensure a prisoner’s next of kin are informed of critical
health matters, particularly when prisoners are terminally ill.
At the time of issuing this report no response to the recommendations had been
received.
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