Individual at Norwich

Investigation into the circumstances surrounding the
death of a man
at HMP Norwich in May 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2010
This is a report of an investigation into the death of a man. He died aged 55 in
HMP Norwich. He had been in prison for over 25 years and, sadly, appeared to
be quite close to being released back into the community when he was
diagnosed with terminal cancer. He died a few short weeks later. I would like to
offer my condolences to his family.
The man’s case was investigated first by an investigator. Unfortunately, the
investigator had to retire from the Ombudsman’s office due to injury and the case
was passed a senior investigator, in June 2009. The Ombudsman’s Family
Liaison Officer remained the same throughout the investigation. I very much
regret the long delay in completing this investigation and offer my sincere
apologies to the man’s family. I recognise that the delay can only have added
further upset to what was an already distressing situation for them.
I would like to thank the clinical reviewer and her assistant from NHS Norfolk for
their help in providing a clinical review of the man’s medical treatment. I would
also like to thank two members of staff from HMP Wellingborough and HMP
Norwich for their co-operation with this investigation.
This is another investigation that highlights the lack of healthcare facilities within
the National Offender Management Service for terminally ill prisoners who
require 24 hour end of life care. At present only the Nelson Unit at Norwich offers
sufficient resources and expertise to cope with such prisoners. The healthcare
provided in prisons should be equitable with that provided in the community.
Therefore there is an urgent need for more facilities of this nature throughout the
country. I am aware that moves are afoot to remedy this situation but I am
concerned that the current guidance to staff may dissuade them from pursuing
applications for compassionate release when no definitive life expectancy can be
determined.
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 February 2010
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CONTENTS
Summary
The Investigation Process
HMP Wellingborough and HMP&YOI Norwich
Events leading up to the man’s death
Issues
Recommendations
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SUMMARY
The man was sentenced to life imprisonment in 1983. In May 2006 he was
transferred to HMP Wellingborough. In December 2007, he attended a
mandatory lifer oral hearing at the Parole Board. The hearing was adjourned to
30 April 2008 pending his completion of a training course and an escorted town
visit.
In March 2008, the man began asking more frequently for pain relief medication
because of back pain. On 3 April, a wing officer returned from leave and noticed
that he was looking unwell and had lost weight. The officer told a nurse that he
was concerned about the man’s health. The nurse examined the man and made
an appointment for him with the prison doctor. The man had reported weight loss
and altered bowel habits over the previous six weeks.
On 10 April, healthcare staff were called to the man’s cell because he was short
of breath. He was suffering from persistent vomiting and was unable to tolerate
food. He saw the prison doctor the following day. The doctor noticed pitting
oedema (swelling) in the man’s legs and a considerable heart murmur. The
doctor faxed an urgent referral to the General Hospital and an appointment was
made for 16 April.
Following his appointment at hospital the man was admitted the same day. He
underwent a number of tests over the next few days and, on 21 April, was told
that he had terminal cancer which had spread to his liver. He was given “months
(may be weeks)” to live. An application for compassionate release on medical
grounds was partially completed on 22 and 23 April but was not submitted to the
Governor for signature. On 24 April, Wellingborough contacted HMP Norwich
with a view to him transferring to the Nelson Unit – a unit specialising in end of
life care.
On 29 April, the man’s consultant told Wellingborough that he required 24 hour
hospice care. Norwich – the only prison able to cope with his healthcare needs –
agreed to accept him as soon as he was fit to travel. He was taken there by
ambulance on 7 May and died eight days later.
This case raises issues about compassionate release and the dearth of facilities
in the National Offender Management Service with the resources and expertise
to offer end of life care to terminally ill prisoners. I make a national
recommendation to amend the advice to staff in chapter 12 of PSO 4700 about
applications for compassionate release. I also address a number of issues
raised by the man’s family.
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THE INVESTIGATION PROCESS
1. The investigation was led by one of the Ombudsman’s investigators. A
Family Liaison Officer was appointed. Notices of the investigation were
sent to staff and prisoners at HMP Wellingborough and HMP Norwich
inviting them to contact the investigator if they wished. He obtained copies
of the man’s prison record and Inmate Medical Record (IMR). He visited
Wellingborough and Norwich and spoke to relevant staff. The Family
Liaison Officer and the investigator also visited the man’s two sisters and
brother-in-law at the home of one of the sisters. Their concerns were
incorporated into the investigation. The Family Liaison Officer remained the
family’s point of contact throughout the investigation.
2. The Ombudsman commissioned an independent clinical review into the
care received by the man at both Wellingborough and Norwich. An
infection control nurse working for NHS Norfolk undertook the review. Her
report appears at Annex 1. The medical care received by the man at
General Hospital is not within my remit but the Family Liaison Officer
advised his family of the procedure for addressing any questions they had
about this.
3. Unfortunately, the investigator left the Ombudsman’s employment due to ill
health before the investigation was concluded. The case was passed to
one of the senior investigators in June 2009. She visited Norwich and read
through all of the man’s prison record. She also spoke to the Principal
Officer (PO) and the nurse at Wellingborough by telephone. She visited the
Early Release and Recall Section of the Ministry of Justice and obtained a
copy of the documents concerning the man’s application for release on
compassionate licence.
Issues raised by the man’s family
4. The man’s family said that when they visited him at Wellingborough on
Lifer’s Day (15 April 2008) he looked seriously ill. Another prisoner came
up to them when they arrived and told them that the man had been ill for
some weeks. The family said they felt that Wellingborough did not know
how to cope with managing a terminally ill life sentence prisoner. They felt
that the prison would benefit from adopting processes to help them if they
faced the situation again.
5. The family were very concerned about an argument between prison and
hospital staff on the day that the man transferred from General Hospital to
Norwich (6 April). They said that the argument was about who would cover
the cost of the private ambulance and took place over the man’s bed. They
felt that it was inappropriate that such an argument should have take place
in front of him. His family were also unhappy about the behaviour of one of
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the hospital consultants. My family liaison officer advised them on the best
way to pursue their complaint.
6. The family said they were promised that they would be involved in the
decision about where the man spent the remainder of his life. However,
they did not feel that this had happened. They felt that the decision to move
him to Norwich was taken without discussion. They said that his strong
preference was to be moved to a hospice in the North West, close to them.
When they arrived at hospital on 6 April they thought that it was to discuss
the options for where he was going. Instead they found he was moving to
HMP Norwich that same day.
7. The man’s family said they had last visited him at Norwich on Sunday 11
May, and described their experience as “atrocious”. They said that they
had arranged to arrive at 11.00am but no one at the prison gate seemed to
be aware of that and they were told that they could not come in until
2.00pm. They saw him at 2.25pm. They were not able to see him in his
room, necessitating him being put in a wheelchair and being uncomfortable.
The family, whose round trip to Norwich was over 500 miles, were then
required to leave the prison at 4.00pm.
8. The family were also concerned that the man had been in hand cuffs while
in hospital. However, they had high praise for the escort staff from
Wellingborough whom they considered to have been polite, kind and
understanding. They were also complimentary about the communication
between themselves and Wellingborough, with the reservation that they felt
that they had initiated most of the contact.
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HMP WELLINGBOROUGH AND HMP&YOI NORWICH
HMP Wellingborough
9. Wellingborough is a category C training prison that holds adult men
including life sentence prisoners. The prison holds up to 646 prisoners.
Wellingborough offers a number of offending behaviour courses such as
Enhanced Thinking Skills (ETS) and assessment for others such as
Controlling Anger and Learning to Manage It (CALM). There are vocational
workshop spaces for 120 prisoners, running courses in painting and
decorating, carpentry, joinery, industrial cleaning and mechanics. A
purpose built learning and skills centre offers places on over 100 full time
and part time education courses. The healthcare centre does not provide
24 hour healthcare and there are no in-patient facilities.
HMP&YOI Norwich
10. Norwich is a local prison serving the courts of East Anglia. It holds remand
and sentenced adult men and young offenders. The adult men occupy the
area of the prison that includes the healthcare centre. The healthcare
centre provides 24 hour healthcare cover and has space for a maximum of
23 inpatients. On the ground floor of the centre is an elderly patients unit,
the Nelson Unit. This unit has been designed and equipped to enable older
and less able prisoners to be supported and cared for within the confines of
the prison environment.
11. The role of Nelson Unit means that the prison has good links with palliative
care teams and frequently employs the Liverpool Care Pathway (LCP) in
caring for prisoners. The LCP is a key recommendation in the National
Institute for Health and Clinical Excellence (NICE) guidelines for supportive
and palliative care. It is a continuous quality improvement programme for
the care of a dying patient. It has been developed in order to transfer the
hospice model of care into other settings, including prisons. The LCP
provides guidance on different aspects of care required, including comfort,
pain control and when to discontinue medical treatment. Because of the
level of expertise in end of life care at Norwich, it is quite common for
prisoners with very short life expectancy to be transferred there.
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KEY EVENTS
12. The clinical review at Annex 1 offers a more detailed account of the
chronology and nature of the man’s clinical interventions in the years before
his death. The review concentrates on his health since he transferred to
Wellingborough in 2006.
13. The man was transferred to Wellingborough from The Wolds on 9 May
2006. His clinical records show that he suffered from mild aortic stenosis (a
narrowing of the aortic valve in the heart), diagnosed in 2004, and was
being treated for symptoms of paranoid thought and obsessive/compulsive
disorder (OCD). He had been prescribed a low dose of Olanzapine (an
anti-psychotic drug) to treat his OCD. On reception at Wellingborough he
told healthcare staff that the only effect the Olanzapine appeared to have
was to make him sleep and he did not continue to take it. He had a history
of suffering from anxiety and depression but his clinical record reports his
symptoms as stable since 2006.
14. The man attended a Mandatory Lifer Oral Hearing on 13 December 2007.
Every life sentence prisoner who has exceeded the minimum time they
must serve in prison has regular Parole Board hearings to determine
whether they are suitable for release and, if not, what they need to
accomplish before they can be reconsidered. At this time he was part way
through a cognitive skills booster course and was preparing for a third
escorted town visit. (Escorted visits form part of the assessment of whether
a life sentence prisoner is suitable for release. His previous escorted
absence was in late 2006.) The panel decided to adjourn his parole hearing
until his course was finished and he could successfully complete a third
escorted absence from the prison. They also requested a report from a
psychologist specialising in autism. His hearing was adjourned until 30
April 2008.
15. In March 2008, the man’s clinical notes show that he asked more frequently
for pain relief medication. On 27 March, he was seen in the healthcare
centre because he had become unwilling to collect his weekly medication.
The notes do not record any signs of physical illness.
16. A mental health nurse who had not met him before interviewed the man on
1 April. He is recorded as telling the nurse that he was fine apart from
experiencing some backache that he said had recently improved.
17. Two days later, on 3 April, an officer returned to work after two weeks leave.
He thought the man looked unwell and had lost weight. The officer told a
nurse that he was concerned about him. The nurse spoke to the man on
the wing and noticed that he looked pale and had visibly lost weight. The
man told him that he thought he was suffering from a virus. The nurse
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established that the man had lost weight in the previous six weeks and his
bowel habits had altered. The man did not feel that his health warranted
further investigation and said he did not want to waste healthcare staff time.
18. Nevertheless the nurse made an appointment for the man to be seen in the
healthcare centre the following day. Staff took blood samples and clinical
observations (blood pressure, pulse and weight). An appointment was
made for him with the prison doctor.
19. On 10 April, wing staff called healthcare staff to see the man on the wing as
he had become short of breath. He had been vomiting persistently and
could not digest any food. He was reluctant to be treated and declined an
offer of ibuprofen. The following morning the doctor examined him in the
healthcare centre. The man did not want to attend his appointment but
healthcare staff escorted him from the wing. He appeared pale and the
doctor noticed he had pitting oedema (swelling) in his legs and a
considerable heart murmur. In the light of his previous heart problems, the
doctor referred him to the cardiology department at the general hospital by
fax the same day.
20. An appointment was made with the hospital for 16 April. Healthcare staff
visited the man daily and treated him for his oedema. On 11 April, he was
encouraged to tell his family that he was unwell and he telephoned them
with the news. His brother-in-law telephoned the prison afterwards but
healthcare staff refused to divulge information about him without first
obtaining his consent. He gave permission for staff to tell his family about
his symptoms and the nurse spoke to the brother-in-law later the same day.
21. The man met his family during a Lifer Day at the prison on 15 April. The
nurse told the brother-in-law that the prison would ensure that the man
received the same level of treatment and care that he would have if he were
in the community. The family told the investigator that they were shocked
by his appearance that day. He had lost a lot of weight, looked ‘yellow’ and
could hardly stand because of his swollen legs. They realised that he was
seriously ill.
22. On 16 April, the man was admitted to hospital following his outpatient
appointment and his family were told. A meeting was held at
Wellingborough to determine the level of restraint and how many staff were
required to remain with him while he was in hospital. The initial diagnosis
from the hospital was that his condition was serious but not life threatening.
It was decided that he should have restraints applied and be accompanied
by two members of staff. However, if resuscitation by medical staff was
required then the escorting officers could remove the restraints without first
obtaining permission from a governor.
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23. Between 17 and 19 April the man underwent several scans at hospital that
revealed deep vein thrombosis (blood clots) in his legs, multiple pulmonary
emboli (clots in his lungs) and indicated likely metastasis (malignant tumour
cells which have migrated from a primary tumour) in his liver. During this
period the nurse made repeated attempts to speak to medical staff at the
hospital and the man but little success. All of the information he received
about the man’s condition came from the shifts of escort staff when they
returned to the prison. On 19 April, the nurse visited the hospital. The man
asked him to telephone his brother-in-law, which he did.
24. Regular contact was maintained with the hospital and the man and staff
also visited him in their own time. On 21 April, tests confirmed the presence
of metastasis in his liver and he was told he had only “weeks or months” to
live. He asked the Principal Officer (PO) (the lifer manager at
Wellingborough) to tell his family. He asked that the prisoners on the wing
not be told. The PO gave hospital staff a copy of Chapter 12 of Prison
Service Order (PSO) 4700 (the application for compassionate release on
medical grounds) to complete. The following day a new risk assessment
was made and the restraints were removed from the man. He asked that
the other prisoners on the wing be told of his condition and a Notice to
Prisoners was prepared.
25. The hospital completed their section of the application for compassionate
release on 22 April. The man’s consultant described his life expectancy as
“months (may be weeks)”. He also wrote, “The patient is critically unwell
with reduced life expectancy. His condition will continue to deteriorate.”
The consultant added that he was unable to offer an opinion as to whether
the man was capable of re-offending.
26. The prison’s probation officer completed the relevant section of the
application the next day on 23 April. The officer wrote that he had been told
that the man was likely to die while still at hospital. The man and his family
had made the decision that he should not be resuscitated if his heart
stopped. He therefore did not include a release plan as he thought that it
was not appropriate given the expected imminence of the man’s death.
27. The PO also completed his section of the application on 23 April. He wrote,
“The man’s current medical condition severely inhibits his ability to move,
breathing is difficult and he finds it hard to walk more than 10 yards. Given
these severely inhibiting factors he is not capable of causing harm and
there is no risk [to the public]”. He concluded:
“The prognosis for the man is extremely poor, as stated in the Doctor’s
report life expectancy is measured in weeks. Taking into account all of
these factors I fully believe that he meets all of the criteria laid down in
Chapter 12 of PSO 4700 and have no hesitation in recommending he be
given early release under the auspices of the PSO.”
10
The section of the form that should be filled in by the Governor is not
completed. The PO told the investigator that he had passed the application
to the Governor for completion but the Governor and the Deputy Governor
did not think that the man fitted the criteria for compassionate release.
Consequently the application went no further.
39. On 24 April, the PO telephoned HMP Norwich and asked whether they
would consider the man for a place on Nelson Unit. The initial response
was positive. His cell was cleared and his property cards were taken to
hospital where he signed them. (His family collected his property when they
visited the hospital on 27 April.)
40. Also on 24 April, the man’s solicitors sent a fax to the Lifer Review section
in the National Offender Management Service (NOMS) asking that he be
considered for compassionate release during his scheduled mandatory lifer
oral hearing on 30 April. (This was the hearing adjourned from December
2007.) Lifer Review section in NOMS decides on the release of life
sentence prisoners on licence. It is a separate process from applications
for compassionate release on medical grounds, which are decided by the
Public Protection Casework Section in the Ministry of Justice.
41. The notes of a case review that took place in Wellingborough after the
man’s death show that, on 29 April, the nurse and the PO were told by the
consultant that he had only “weeks or more” to live. The consultant
confirmed that the man required the sort of care provided by a hospice and
agreed that, if he were to remain in prison, then Norwich would be suitable.
The nurse reported in the case review that he immediately discussed the
options for care with the man. He said:
“I discussed this in detail with the man who was not concerned where he
was to be cared for but more concerned that he would be comfortable.
During these discussions my feeling was he was anxious and nervous
about possible release to a community setting and was more accepting of
HMP Norwich. It should be noted that he had spent some 24 years in
prison. I subsequently completed the referral to HMP Norwich which was
faxed the same day.”
43. Also on 29 April, in response to the letter from the man’s solicitors, a
caseworker from Public Protection Casework Section telephoned
Wellingborough to ask if they had started the application process for his
compassionate release. The casework file shows that someone returned
the call and told the caseworker that it was not yet clear how seriously ill he
was. She said she would make enquiries about the hearing scheduled for
30 April and called back later to confirm that it had been cancelled. (The
hearing was cancelled because it was an oral hearing requiring him to
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attend in person and he was too unwell to do so.) The caseworker wrote in
the file that she would wait for a further update from the man’s solicitors and
added, “Prison are not inclined to pursue compassionate release.”
Applications for compassionate release must come from the prison in the
first instance and the caseworker made a note to check the position again
on 24 May.
44. An entry on EMIS (the man’s electronic clinical record), on 2 May reports
that the MacMillan nursing team at the hospital told Wellingborough that
they had talked to the man about his thoughts about dying. They reported
that he did not mind which environment he was in but was more concerned
with the nature of “the end”. The MacMillan team also said that he may only
have “days” left to live. The same day he was fitted with a syringe driver
and the hospital told Wellingborough that he was too poorly to be
transferred to Norwich. By 6 May he was sufficiently improved to make the
journey to Norwich and he was taken there by ambulance on 7 May.
45. The day after the transfer on 8 May, the nurse emailed Norwich to ask how
the transfer had gone. The Deputy Head of Healthcare replied that all was
well and the man was pleased to be with them and had passed a settled
night. On 11 May, the man’s family visited him at Norwich. The next day
she emailed the nurse to say that the visit had gone well but that there was
a noticeable deterioration in the man’s condition.
46. The caseworker in Public Protection Casework Section telephoned the lifer
manager at Norwich on 12 May to request an update on whether an
application for release on compassionate grounds was forthcoming. After
discussion it was decided that Norwich would complete a new application
for compassionate release. The application was received on 14 May.
47. On 13 May, an MP wrote to the Secretary of State for Justice asking that
the man be transferred to a hospice closer to his family for humanitarian
reasons. The letter was passed to the Parliamentary Under Secretary with
responsibility for prisons for reply. The Head of Casework in Public
Protection Casework Section and the Head of the Public Protection Unit
discussed the man’s case. His condition had deteriorated to the extent that
it was felt that he would not survive a six hour car journey to a hospice in
the North West. The Head of Casework asked the Lifer Manager at
Norwich to discuss with the man’s family whether they wanted him to move
to a hospice in the North West, or a hospice local to Norwich or for him to
remain in prison. The Lifer Manager at Norwich said he would discuss the
options with the family when they next visited three days later on 16 May.
The man died the day before.
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ISSUES
The man’s application for compassionate release on medical grounds
48. Chapter 12 of Prison Service Order 4700 gives guidance to staff about
applying for compassionate release for life sentence prisoners on medical
grounds. Paragraph 12.2.1 says:
“The criteria for compassionate release on medical grounds for those
prisoners serving a life or IPP sentence are as follows:
(cid:127) The prisoner is suffering from a terminal illness and death is likely
to occur very shortly (although there are no set time limits 3
months may be considered to be an appropriate period for an
application to be made to Lifer Review and Recall Section)
[bold in original – Lifer Review and Recall Section is now part of the
Public Protection Casework Section], or the lifer is bedridden or
similarly incapacitated, for example those paralysed or suffering
from a severe stroke: and
(cid:127) The risk of re-offending (particularly of a sexual or violent nature) is
minimal; and
(cid:127) Further imprisonment would reduce the prisoner’s life expectancy;
and
(cid:127) There are adequate arrangements for the prisoner’s care and
treatment outside prison; and
(cid:127) Early release will bring some significant benefit to the prisoner or
his/her family”.
49. The application form has a number of sections that must be completed by
the prison’s lifer manager, a registered medical practitioner, the probation
officer who works at the prison and the prison Governor. The application is
then passed to the Public Protection Casework Section in the Ministry of
Justice.
50. On 16 April, the man’s condition was described by hospital staff as “serious
but not life threatening”. This diagnosis changed, on 21 April, to “weeks or
months”. On the same day, the PO initiated an application for
compassionate release on medical grounds. The application was
completed by all parties, except the Governor, by 23 April. The consultant
wrote that the man had “months (may be weeks)” to live. The PO wrote that
the man’s life expectancy was “measured in weeks” and said he was
satisfied that he met all the criteria for compassionate release. On 29 April,
the consultant said that the man had “weeks or more”. On 2 May, it was
reported that the MacMillan nurses at the hospital felt he might only have
days to live.
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51. On 29 April, the same day that the consultant told the PO and the nurse that
the man had “weeks or more” another member of Wellingborough staff told
Public Protection Casework Section that it was not yet clear how seriously ill
he was. In a memo of 7 May to a caseworker in NOMS pre-release section,
the PO wrote that:
“Chapter 12 of PSO 4700 was completed however without a definite life
expectancy it was not submitted as it was felt that the man did not meet
the criteria in line with the PSO.”
52. It appears to me that by the end of April it was quite clear that the man was
terminally ill and had weeks to live. The consultant’s opinion that the man
had “weeks or more” was reiterated to the PO and the nurse on 29 April.
The MacMillan team at the hospital told the nurse that the man may have
“days” left to live on 2 May. The guidance in PSO 4700 requires that “death
is likely to occur very shortly”. It does not require a definitive life expectancy
to have been set, although it offers a guide of three months. I consider that
senior management at Wellingborough were mistaken if they believed that
he did not fit the criteria because a definitive life expectancy had not been
set. I consider that the application for his compassionate release should
have been pursued - although I note that there is some doubt as to the
man’s own wishes in this matter. In two conversations, reported by the
nurse and the MacMillan team at the hospital, the man appears to have
indicated that he was happy to remain in prison.
53. It is apparent from this sad case, and from many others the Ombudsman
has investigated, that it is extremely difficult to judge a terminally ill person’s
life expectancy. Diseases such as cancer are often unpredictable –
especially when a person has underlying medical conditions. Moreover the
medical profession is by and large unwilling to give a definitive opinion on
the length of time a person may have left. It is far more common for ‘weeks’
or ‘months’ to be given than a specific number of weeks or months. The
man offers an example of how a person’s prognosis can change rapidly
from day to day. On 16 April, he was told that his condition was not life
threatening and less than a month later he died.
54. I do not believe therefore that it is helpful that the current guidance gives a
guide period of three months. I believe it encourages prison staff to think in
terms of definite time periods rather than looking at each case on its merits.
I recommend that the guidance in chapter 12 of PSO 4700 on
applications for compassionate release on medical grounds be
revised to remove the guide period of three months or to otherwise
make clear that a definitive life expectancy is not required before an
application may be made.
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[The National Offender Management Service accepted this
recommendation in their response to the draft report.]
The man’s transfer to Norwich
55. The PO first contacted Norwich about the possibility of the man moving to
Nelson Unit (the prison’s specialist unit for elderly and infirm prisoners
which occupies the ground floor of the 24 hour in-patient healthcare centre)
on 24 April. At this stage he had been diagnosed with a terminal illness and
Wellingborough, which has no in-patient facilities, would be unable to
provide the level of nursing and care he required. On 29 April, the PO and
the nurse were told that the man required 24 hour care consistent with that
provided by a hospice. At present Norwich is the only prison with the
necessary resources and expertise to care for prisoners in this situation.
Given that the application for compassionate release was not being
pursued, Norwich was the only possible destination for him.
56. I have already said that I believe that the man’s application for
compassionate release should have been pursued (if indeed that was his
wish). His family are from the North West and in order to visit him in
Norwich they had to make a 600 mile round trip by car. Clearly this was
difficult for them. Not only did it add to the distress they were already
suffering but it also meant they could not spend as much time with him in
his last days as they would have liked. In June this year the Ombudsman
made a national recommendation to the Department of Health and Ministry
of Justice that they should jointly review the provision of healthcare facilities
for elderly, long term sick and terminally ill prisoners to ensure a better
geographical spread. This recommendation has been accepted and a
review is underway. Matters would be enormously eased in the meantime if
all prisoners requiring 24 hour hospice care were at least considered for
compassionate release.
The use of restraints at the General Hospital
57. The man’s family told the original investigator that they were concerned that
he had been hand cuffed to an officer when he was initially admitted to
hospital. I have not seen a copy of the escort risk assessment or bedwatch
paperwork completed by Wellingborough. The second investigator spoke to
staff at Wellingborough who looked for it in the prison but were unable to
find it. She was told that all of his prison records including the risk
assessments and bedwatch paperwork had been transferred to Norwich
with him on 7 May. She visited Norwich and examined all of his
considerable prison record but the risk assessment and bedwatch
paperwork was not there. Staff at Norwich had no memory of having seen
it.
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58. I am aware from the Family Liaison log completed by Wellingborough that a
risk assessment meeting on 16 April (attended by two governors, a prison
doctor, a prison nurse and the PO) decided that the man should be
escorted at the hospital by two officers and that restraints be applied. The
escort staff were told that, if a medical emergency required that he be
resuscitated, they were to remove the restraints without first asking
permission from the Duty Governor. This was a break from standard
practice that changes to the level of restraint or escort must be agreed by
the Duty Governor. On 22 April, the day after he had been told that he was
terminally ill, the restraints were removed. Further on 30 April the decision
was taken to reduce the escort to a single officer.
59. I am unable to examine the reasoning behind these decisions because I
have not seen the paperwork. However, in the circumstances I believe that
Wellingborough acted reasonably. When the man arrived at hospital on 16
April his diagnosis was not thought to be life threatening. Restraints and a
two officer escort is standard practice for any non-bedridden prisoner
staying in outside hospital. Regular reviews appear to have taken place
and the restraints were removed once it was made clear that he was
terminally ill. Later, when he deteriorated further, the escort was reduced. I
note too that his family were very complimentary about the staff who
escorted him at hospital.
The argument at General Hospital on 6 May
60. The man’s family told the investigator and family liaison officer that, on the
day he transferred to Norwich from hospital, prison staff and hospital staff
had an argument about who would pay for the escort in a private
ambulance and how the escort and the nurse would return. I share the
family’s view that it was wholly inappropriate for a discussion of this nature
to take place in front of a prisoner and his family. It can only have been the
cause of further distress at what was already a very upsetting time for them.
The first investigator wrote to the Governor of Wellingborough and asked for
his views on the incident.
61. He replied that he felt the argument was indeed “unseemly” and that he
would have “paid and sorted it out later”. He said that the investigator’s
points would be ‘taken on board’.
62. I am pleased that the Governor agrees that it was inappropriate to engage
in an argument about a relatively trivial sum of money in front of a gravely ill
patient and his family. There is no doubt it was. However, I also recognise
that the family are in general very complimentary about staff from
Wellingborough and this seems to be an isolated incident. There is
certainly a significant amount of evidence that the PO and the nurse in
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particular made every effort to be sensitive to the man’s needs. I make no
formal recommendation in this matter but I trust that Wellingborough’s
future management of terminally ill prisoners in outside hospital will be
informed by this report. [NB: the prison responded at draft stage that local
action had been taken over this matter and that in future the prison would
take responsibility for any transfers and liaise with the hospital about
payment at a later date.]
The visit to Norwich by the man’s family on 11 May
63. The man’s family were angry that they waited some three and a half hours
between arriving at Norwich and seeing him. They were unhappy that they
were then only allowed to see him for an hour and a half. My original
investigator contacted Norwich to ask for their comments. The Deputy
Head of Healthcare responded by email. She said that she had come into
the prison specifically to facilitate the visit on that Sunday. She had
arranged that the family could arrive at a time convenient to them but had
told them that they would not be allowed in the prison over lunchtime and
would have to leave by tea time roll check at about 4.00pm. She said that
she had given the family her on-call work mobile telephone number (also
against normal practice) but had not received a call from them saying that
they were having problems in gaining entry to the prison. She said the gate
and security had been briefed in advance as the visit would not be taking
place in the visits centre but in or near to Nelson Unit.
64. The Deputy Head of Healthcare said she had explained to the family that
decisions about whether visits could take place on the unit were reviewed
daily and depended in the main on the health of the prisoner. She said the
man was well enough to be moved around by wheelchair and so the visit
took place in the centre office, around the corner from Nelson Unit. Had he
been unable to leave his bed the family would have been able to visit him in
his room. She said she had arranged (against normal practice) for his
family to be shown around Nelson Unit. She said she arrived in mid-
afternoon and spent a significant amount of time talking to the family.
65. She said the man looked tired throughout the visit and she suggested
several times that he return to his room. However he and his family were
keen to be together. Eventually she said she was taking him back to his
room as he was “clearly exhausted”. She then showed his family around
the unit and his brother-in-law helped him back into his bed. She said she
escorted the family out of the prison and both the man’s sisters expressed
“heartfelt thanks” for the care that he was receiving and the effort that had
gone into the visit. She forwarded a copy of another email that she sent to
the nurse at Wellingborough the following Monday in which she described
the visit as having been very successful. She said she was disheartened to
hear the family’s subsequent account of their visit as they had not
complained to her at any point. She added that the man was very poorly at
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the time and she felt that he could not have coped with longer than the
amount of time his family had spent with him.
66. I am sorry that the man’s family felt unhappy and upset by their visit to
Norwich on 11 May. I am satisfied that the staff at Norwich, especially the
Deputy Head of Healthcare, made genuine efforts to ensure that the visit
went well for all parties and broke with established practice to do so.
Indeed I know from previous investigations that Norwich have considerable
experience with visits of this nature and I have praised them in the past for
the efforts that they make. It is also apparent that the Deputy Head of
Healthcare was not only unaware that the family were unhappy but was
under the impression that the visit had been successful. I do not believe
there is any redress that I can offer the family in this matter but I draw the
attention of the Governor to their view of what happened as a learning point.
The findings of the clinical review
65. The clinical review provides a comprehensive account of the man’s medical
history over the five years before he died. In summary, the review
concludes that overall he was cared for appropriately in Norwich and
Wellingborough. I share the clinical reviewer’s assessment that the care he
received was equitable with that he would have received in the community
with the exception of the fact that he was not transferred to a hospice near
his family once his life expectancy was deemed to be only months.
66. The review praises the officer for noticing the man’s weight loss and
referring him to healthcare. It is also noteworthy that the healthcare team at
Wellingborough held a review of his case once he had been transferred to
Norwich. He was the first life sentenced prisoner to be diagnosed with a
terminal illness at Wellingborough and I am pleased that there was a formal
review to learn from his case. As a result of this internal review several
recommendations were put forward to change practice at Wellingborough
including the introduction of a Well Man clinic and a review of how
information is shared with the next of kin. I welcome these changes in
practice and include a copy of the review in the annexes to this report.
67. The review makes a number of recommendations and I draw them to the
attention of the head of healthcare at Wellingborough for their
consideration.
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RECOMMENDATION
I recommend that the guidance in chapter 12 of PSO 4700 on applications for
compassionate release on medical grounds be revised to remove the guide
period of three months or to otherwise make clear that a definitive life expectancy
is not required before an application may be made.
[The National Offender Management Service accepted this recommendation in
their response to the draft report.]
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