Individual at Leeds

Investigation into the circumstances surrounding the
death of a man
at St James University Hospital,
whilst in the custody of HMP Leeds
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2010
The man died on 5 September 2009 at St James University Hospital Leeds.
He was 72 years old. He was admitted to hospital on 1 September after staff
found that he was confused and dazed. The man was a long time sufferer of
Chronic Obstructive Pulmonary Disease (COPD) related to smoking. His
cause of death was acute respiratory failure due to COPD. I offer my
condolences to the man’s family and friends affected by his death. I am sorry
that my report has been delayed and apologise for any additional distress that
this may have caused.
One of my colleagues was appointed to investigate the man’s death. I asked
for a clinical review to be carried out into the medical care and treatment the
man received in custody. A doctor was appointed by Leeds Primary Care
Trust (PCT) to undertake a clinical review on my behalf. The focus of this
investigation was primarily clinical because of man’s poor health and his
location in the health care centre. I have therefore relied greatly on the
clinical reviewer’s report. He judges that the man’s care was exemplary and
probably better than that which he could have expected to receive in the
community. I am grateful to the PCT and the clinical reviewer for their
assistance.
Since taking over responsibility in April 2004 for the investigation of all deaths
in prison custody, there have been 42 deaths at HMP Leeds, including that of
the man. Of those deaths, 17 were from natural causes. The man’s care was
very individual and therefore I do not identify any other similar
recommendations.
I made two recommendations in this investigation. The first related to
resuscitation and the other to dispensing medication during the night. At draft
consultation stage the prison accepted the recommendations (one fully and
one partially).
Jane Webb
Prisons and Probation Ombudsman June 2010
CONTENTS
Summary 4
The Investigation Process 5
HMP Leeds 6
Key Findings 8
Issues Considered 15
Conclusion 18
Recommendations 19
SUMMARY
Although sentenced to life imprisonment with a ten year tariff, which normally
means progression through the prison system to lower categories as
appropriate, the man remained at HMP Leeds for the entire eight years he
was in prison. This was in part because of his physical health and his hospital
appointments. In addition, Leeds experienced difficulty negotiating with other
prisons to accept him.
The man was in quite poor health when he arrived at prison. He suffered from
Chronic Obstructive Pulmonary Disorder (COPD), a lung disease,
predominantly as a result of smoking. The clinical reviewer explained in his
report how the damage to the man’s lungs was severe and would have
occurred over a long period. He also explained that sufferers experience
shortness of breath after minimal exercise, excessive mucus production, a
higher risk of infection and, when severe, general poor health.
Whilst in custody at Leeds, the man was under the care of a consultant
respiratory physician at Leeds Teaching Hospital Trust. He saw a consultant
several times in 2001 and was then required to attend for an annual review.
His disease progressed rapidly, primarily because he continued to smoke. In
the last three years of his life, he became increasingly dependant on oxygen
therapy1 and, in the year leading up to his death, used it almost constantly.
Along with the majority of suffers of COPD, the man’s damage to his lungs
was caused by smoking. To slow or halt the progression of COPD a patient
would need to stop smoking completely. There are a few recorded attempts
of him stopping smoking, but these were never for any significant period. In
fact despite repeated advice to stop smoking, the man remained stubborn and
quite vehement that he wanted to smoke, to the point where he would hide his
tobacco from staff. Medical staff could only treat his symptoms with the
necessary medication and equipment – such as oxygen, steroids and
inhalers.
From the records and discussions with staff and the man’s friend, it is clear
that he could be quite challenging to look after. He often refused to take
advice or help as well as his medication and treatment. The clinical reviewer
highlights that staff used various methods to attempt to get him to accept
assistance and treatment, and were tactful in their negotiation with him.
The clinical reviewer concludes in his review that, from a medical point of
view, he found the man’s care “excellent if not exemplary”. He added that if
the man had been in the community he would not have had the amount of
daily attention and review of his condition. As a result of the care and
attention received, the clinical reviewer believes that the progression of the
1The doctor has explained oxygen therapy for patients of severe COPD. The therapy is
necessary to maintain a sufficient amount of oxygenated blood to reduce breathlessness,
prevent hypoxic damage to major organs and treat acute deterioration of the condition. As
the disease progresses patients can become dependant on oxygen treatment to carry out
basic daily tasks such as dressing or washing.
man’s disease was slowed to some degree, thus prolonging his life.
THE INVESTIGATION PROCESS
1. All the man’s relevant prison documentation including medical and core
prison records were requested following notification of his death. The
man was in prison for over eight years. He suffered from ill health
throughout that time so as a result there was a lot of documentation. The
man was also a life sentenced prisoner which itself creates a lot of
documentation. For this reason, my investigation concentrated on the last
nine months of the man’s life in this report.
2. The records arrived in the Ombudsman’s office in October and were in a
confused order. Some paperwork appeared to be missing but there were
comprehensive electronic notes of the daily contact with healthcare staff in
the man’ medical record.
3. The investigator visited HMP Leeds to see where the man lived and met
some of the staff who had known him. She also examined the records
held by the Head of Healthcare but they too were in a rather confused
order and did not seem to be complete.
4. Notices to staff and prisoners were sent to the prison to be displayed.
They invited anybody with information to talk to the investigator. A
prisoner who had been a friend of the man wrote to this office about his
knowledge and information concerning the man. The man’s friend has
since moved prisons and another of my investigator’s interviewed him for
this investigation.
5. A clinical review into the man’s clinical care in prison was carried out by a
doctor on behalf of Leeds PCT. The clinical reviewer was not appointed
until November 2009. I am grateful that he was able to provide the
investigator with his report by February so as to avoid further delay.
6. HM Coroner for the County of West Yorkshire was informed of my
investigation and kindly provided my investigator with the man’s official
cause of death. The Coroner has received a copy of this report.
7. One of the Ombudsman’s Family Liaison Officers contacted the man’s
stepdaughter who was acting as the point of contact for the man’s wife
and family. They were offered the opportunity to be involved in this
investigation and raise any concerns they might have. The man’s
stepdaughter told my family liaison officer that the family did not have any
specific concerns about the care the man received. She added that they
were aware of the man’s ill health and believed that he had been well
looked after.
HMP LEEDS
8. HMP Leeds is situated in Armley, close to Leeds city centre. Built in 1847,
the prison has undergone a great deal of refurbishment and extended
from four to six wings. It has accommodation for up to 1,008 prisoners.
9. Leeds is a local prison serving the courts of West Yorkshire. As a local
prison it receives and discharges a large number of prisoners each day.
Healthcare is commissioned and provided by Leeds Primary Care Trust.
The healthcare services are now part of a cluster with HMP Wealstun and
HMP Wetherby.
10. The staffing make up of the in-patient wing (H3) is two senior officers
(discipline officers) with nurse training and 13 officers. Four of the officers
have nurse training (three general nursing and one mental health nursing),
and the remaining nine are discipline officers. The staff work according to
a shift pattern.
Her Majesty’s Chief Inspector of Prisons’ report
11. Her Majesty’s Chief Inspector of Prisons reports on all Prison Service
establishments. The majority of inspections are pre-announced and allow
the prison to prepare for inspection. However, a small number are
unannounced, meaning the prison concerned has no prior knowledge that
the Chief Inspector’s team is visiting until they arrive.
12. In December 2007, the Chief Inspector carried out an unannounced
inspection of HMP Leeds. In her summary the Chief Inspector wrote:
“This inspection showed that there were still fundamental problems that
needed to be addressed at Leeds. We did, however, find a
management team that was committed to working methodically and
vigorously to tackle the underlying causes as well as the symptoms.
This is no easy task, in a prison system that is creaking at the seams
and facing considerable challenges over the next few months. They,
and the many good and committed staff in the
prison, will need considerable support.”
13. Nearly two years had passed since the last inspection. In a busy local
prison there are continuing changes, therefore I have not reproduced the
HMCIP report here. Full details can be found on the HMCIP website
www.justice.gov.uk/inspectorates/hmi-prisons
Independent Monitoring Board (IMB) report
14. Each prison in England and Wales has an Independent Monitoring Board
(IMB). Their role is to monitor the prison and to report any concerns that
they have regarding the prison or how prisoners are treated. Board
members are able to visit any area of the prison at any time, and have
direct access to any prisoner who they wish to see or who asks to see
them. The Chair of the Board produces an annual report to the Secretary
of State for Justice.
15. The full 2008/09 IMB report can be found at www.imb.gov.uk. However,
the executive summary concluded:
“The Board judge that, within the constraints of budgets and staff
selection and recruitment, HMP Leeds is providing a generally safe
environment for prisoners and slowly improving the respect shown
to them by staff.”
KEY FINDINGS
16. The man was remanded into Leeds in May 2000. On his reception into
prison, he was already suffering ill health. In the clinical review, the
clinical reviewer noted that in view of the severity of the man’s condition
he was admitted to the healthcare centre for assessment. The man used
an inhaler but still became breathless with exertion. During the first few
weeks, his mood was low and he was prescribed anti-depressants which
improved his mood. His chest condition was sufficiently stable for him to
be moved to one of the residential wings. By August 2000, the man had
moved to B Wing.
17. In January 2001, he was referred to Leeds Teaching Hospital Trust where
he saw a consultant respiratory physician for a review of his condition.
His medical notes describe how his condition was deteriorating. The
clinical reviewer has described “exacerbations” of the COPD which
included increased breathlessness, reduced exercise tolerance and
coughing. They were dealt with using a variety of treatments.
18. Also that month one of the prison doctors wrote to the man’s solicitors. In
the letter, the doctor described the man’s condition and the outlook
prognosis. This was that the man would ultimately have a shortened life
span and would become a “respiratory cripple”. The doctor explained that
the man would need oxygen therapy to try to manage his condition and
improve his quality of life. He added that this was difficult in a custodial
setting. The man was a heavy smoker and continued to smoke
regardless of his health and the advice and support offered to him.
19. Later that month, the man received a life sentence for the offence of
murder. He initially received a tariff of eight years by the trial judge, but
this was later raised to ten years by the Secretary of State.
20. Between January and July 2001, the man saw the consultant physician
twice and underwent several tests which confirmed the diagnosis of
COPD. A computed tomography (CT) scan also showed small “asbestos
induced pleural plaques” which the clinical reviewer explains as markings
on the edges of the lungs. However, this was thought to be an incidental
finding and the man was told by the consultant physician that the COPD
was entirely a result of smoking. The man was only able to move about
50 yards before becoming breathless.
21. The following year, January 2002, the man saw the consultant physician
again for a review. The man continued to smoke and it was noted that his
exercise tolerance had reduced to 40 yards. The consultant physician
recommended a yearly review. In line with this the man saw the
consultant physician in February 2003. Again it was noted that he
continued to smoke and at this point his exercise tolerance was 30 yards.
He had by now been prescribed oral steroids to help with breathing
problems.
22. In November 2003, following a complaint of pain in the left side of his
chest, the man was referred back to the consultant physician. He was
seen again in December. The consultant physician was pleased to note
that there was no deterioration and concluded that the pain was due to a
recent bout of bronchitis. The annual review arrangement resumed. It
was also noted that the man’s exercise tolerance had risen to 100 yards
but the clinical reviewer highlights that the man’s lung function had
declined since the measurement taken in February 2003. It declined
further by the time of the man’s next review with the consultant physician
in December 2004. The man had also lost approximately 6kgs in weight,
which the consultant physician linked to the severe COPD.
23. Particularly being a life sentence prisoner, the man should have
transferred through the prison system on progressive moves working
towards his parole date. However, staff at Leeds struggled to move him to
another prison because of his medical conditions. Due to the inability to
transfer the man and because of his ill health, his participation in offence
focused programmes and other sentence planning work was limited. This
would ultimately have affected his chances of parole.
24. A transfer to HMP Manchester was arranged in 2005 but when the man
arrived there, he was returned straightaway to Leeds because of his
‘health needs’. The arrangement seems to have been inadequately
managed particularly as the prisons corresponded beforehand about the
man’s health needs. The clinical reviewer has also highlighted this
transfer in his report. The man was found to be unable to move 20 yards
without needing to stop. Manchester said that they could not locate the
man in a ground level cell or provide a single cell. (A single cell was
required so that the man’s nebuliser, which could be noisy, did not disturb
his cellmate.)
25. Whilst at Leeds, the man remained under the care of the consultant
physician and was reviewed by his team again in September 2005. The
clinical reviewer has considered the findings of the review and noted that
they are in keeping with the deterioration of the man’s medical condition.
Four months later, 20 January 2006, he was transferred to the healthcare
unit in the prison after staff became concerned for his health and welfare
because he found basic daily tasks increasingly difficult. The man had
become reliant on staff and prisoners to bring his meals and medication.
26. Although much of the man’s documentation was received by my office in a
muddled state, there are extensive medical notes during his time in the
healthcare unit. The clinical reviewer has commented that the man
appeared to settle well and was monitored regularly. The clinical reviewer
noted that appropriate interventions for the exacerbation of the man’s
COPD and increasing breathlessness took place. At this point the man
was smoking 30 – 40 cigarettes per day with no sign of giving up, despite
medical advice. Following another review with the consultant physician in
October 2006, the man was discharged from the routine follow ups. His
lung function had increased marginally and he was again given
encouragement to stop smoking.
27. One of the duty prison doctors noted in the medical record in March 2007
that the man still had no intention to stop smoking and would need oxygen
treatment on a more permanent basis. There was a period in 2007 where
the man did stop smoking, but only for a few months at most. Staff had
explained the combined dangers of smoking and using oxygen, but the
man ignored it. On one occasion he lit a cigarette whilst the oxygen was
still switched on. This resulted in burns to his face, although no serious
injuries were noted. As a result staff banned the man from having tobacco
in his cell. He responded to the ban by cutting his arms. He was
monitored under the suicide and self harm procedures for a couple of
weeks, but it would appear that his actions were solely a response to not
getting his own way rather than any self harm ideas. The man began to
hide his tobacco so that staff could not remove it. Eventually a
compromise was reached whereby the man only used oxygen when he
was not smoking.
28. The clinical reviewer described how by the end of 2007 the man had to
sleep in his chair due to excessive breathlessness. This was an issue that
the man’s friend raised in his letter to the investigator. Having spoken to
staff in the healthcare unit and taken into account the friend’s view, I am
satisfied that the man was offered a specialist bed but had declined it.
This appears to be characteristic of the man’s stubbornness at times.
29. In a Parole Board review in August 2008, the man was not recommended
to transfer to open prison conditions primarily due to not having completed
offence focused programmes. This was in part due to his physical
condition, partly the inability to transfer him and in part, the assessment
that his acceptance of responsibility for his offence was limited. In his
probation parole review in August 2008, the author wrote that there was
an opinion by various people who assessed the man that he believed his
ill health would secure his release without the need to be actively involved
in offence focused work. The writer referred to the efforts to move the
man from Leeds which had failed because of his physical care needs. It
was also noted that a transfer to HMP Wakefield had been requested and
that a space was awaited. It was felt by the report writer that the man
would spend whatever period he had left in custody, within a healthcare
centre.
30. In January 2009, the duty prison doctor prepared a summary for the man’s
sentence planning and review report. In this the duty doctor wrote,
“I have known the man for over 2 years in my capacity as
Medical Officer. He has very severe chronic lung disease and
gets extremely short of breath on the slightest exertion. He
sometimes requires oxygen even after using the toilet. I have
not seen him walk more than a couple of paces for 2 years. He
requires assistance with bathing and his food is taken to him.
He has leg swelling as a result of his immobility.“
31. By this stage, the man had been given a zimmer frame to assist his
mobility, although reports from staff would suggest that he only used it
when it suited him. As the duty doctor wrote in his report, the man had
swollen legs because of his immobility and so needed extra medical
attention. He was becoming increasingly frail and using oxygen much
more. His lack of mobility meant that he often neglected his personal
hygiene, and staff needed to coax him to look after himself.
32. In April 2009, the man was admitted to hospital with severe exacerbation
of the COPD. There appears to have been a Do Not Attempt
Resuscitation (DNAR) form with the ambulance paperwork. Neither the
clinical reviewer nor the investigator found any entry or other notes of a
discussion about this in the man’s prison records. The healthcare officers
the investigator spoke to were also unaware that it had been considered.
33. The following month, a respiratory consultant reviewed the man’s
condition. There were no new recommendations or changes to the man’s
treatment, but he was advised to make ‘lifestyle’ changes such as stop
smoking, increase his exercise and improve his diet. The clinical reviewer
noted that overall the man’s health was deteriorating quite quickly and he
spent more and more time in his cell sitting in his chair. He needed a lot
of assistance with daily activities but would often decline offers of help
from staff.
34. In the doctor’s view, it was obvious that the man was in the final stages of
his disease and any exacerbation could result in his death. However, he
survived two acute exacerbations in July and August 2009. He was
admitted to hospital on each occasion for treatment, remaining there for
two weeks in August.
35. The medical records show an entry at 5.30pm on 1 September, that the
man had raised his personal alarm because he had been incontinent of
faeces. He was advised that the best way to get clean would be to bath
but he refused and threw a mop bucket. In the end he was given a hand
wash by staff. It was noted that he was quite volatile and unhelpful
throughout.
36. A short while later a Healthcare Officer walked past the man’s cell. She
told the investigator that the man’s oxygen mask was not over his mouth
and that he looked cyanosed (bluish discoloration). She added that she
just felt something was “not right”. She called for a nurse and they went in
to the man’s cell. The nurse took the man’s clinical observations of his
pulse, blood pressure and temperature. She called the duty doctor for
advice because his oxygen saturation levels were low. The nurse thought
that he appeared confused and his eyes were “glazed”. The doctor
recommended that an ambulance be called to take the man to outside
hospital.
37. The escort log shows that the man left the prison at 7.00pm. Nearly an
hour later, he was still in resuscitation. One of the hospital doctors told
escort staff that it was unlikely the man would survive the night. The
doctor contacted the man’s wife, who visited him later that evening. The
escort risk assessment shows that restraints were not applied but two
officers remained with the man.
38. In the bedwatch log2 it is recorded that at 6.25am on 2 September, the
man was unconscious and was assisted to breathe by machines. A few
hours later man’s stepdaughter telephoned to check on his condition. At
11.25am, the man was breathing on his own but had a machine for
backup. He remained unconscious. Later that afternoon, at about
3.15pm, the man began to waken. He was given reassurance by the
hospital nurse.
39. At 9.15am on 3 September there is an entry by one of the escort officers
commenting that there was still no significant improvement in the man’s
health. He was continuously monitored by nurses but was recorded as
Not For Resuscitation. It is not clear where this information came from or
if it was discussed with the man or his family. The investigator asked
some healthcare staff if they were aware of this instruction because it was
not in his medical record. She was told that they were not aware and
indeed, if healthcare staff thought the man was not to be resuscitated,
they would not have called for an ambulance to take him to hospital on 1
September.
40. The records of the rest of the day show that the man was breathing with
the assistance of an oxygen mask, he spoke with nurses and the doctor
and then slept. At 6.05pm it is recorded that the doctor told the man he
would not be resuscitated if he deteriorated again. The man was
reported to be upset about this. Later that evening he was visited by his
wife and a friend.
41. The following morning the man’s family were asked to go to the hospital
as his condition had deteriorated. His wife and stepdaughter arrived at
approximately 10.35am and remained there for most of the day. That
evening his brother visited him.
42. Two Officers arrived at the hospital for duty at 6.30am on 5 September.
Officer 1 has written in the bedwatch log at 6.34am that the man’s
breathing was “shallow and quite heavy”. The man was given pain relief
on several occasions throughout the morning and slept intermittently. At
approximately 11.40am, the man woke in pain and was given more
painkillers, but his breathing became shallow and faint. The hospital
nurse tried to contact the man’s family but could not reach anybody on the
telephone. Officer 2 wrote in the bedwatch log that the man appeared to
2Alog kept by staff on escort during any prisoner’s admission to hospital. It logs all contact
and events involving the prisoner such as doctor’s rounds, treatment, risk assessment review
and visitors.
be more peaceful. At 12.30pm a hospital nurse said that the man’s
breathing had stopped but she needed a doctor to confirm death. The
man’s wife and stepdaughter arrived at 1.00pm. A doctor pronounced the
man’s death at 1.25pm.
43. A post mortem gave the man’s cause of death as “Acute respiratory failure
due to exacerbation of Chronic Obstructive Pulmonary Disease”.
44. Following notification of the man’s death, the Head of Healthcare
contacted the staff on duty at the prison to check their welfare. Staff were
also offered the services of the Staff Care and Welfare team.
Information received as part of the investigation
Health care officer A
45. HCO A was unfortunately not available the day that my investigator visited
the prison. He kindly arranged to telephone her the following week while
he was on night shift. HCO A has worked in the healthcare unit at HMP
Leeds since 2000. He also has a role working with life sentence prisoners
and as a Family Liaison Officer in deaths in custody. HCO A knew the
man well both in his capacity as a lifer officer and a personal officer.
46. HCO A told my investigator that the man initially lived on B wing – a main
residential wing but that due to his health, found it increasingly difficult
getting to the heathcare unit, which is where he used to bath. In 2004, the
man moved to live in the healthcare unit. HCO A, and other staff, said
that the man could be difficult and stubborn. For example he would not
accept that his ‘tariff’ was the minimum time he would spend in custody.
He did not appreciate that he would need to work towards parole by
addressing his offending behaviour. Naturally there were health
implications which would have prevented him attending some
programmes but he showed no willingness to engage in the process.
Additionally, HCO A said that the man did not show any remorse or
compassion over his offence and therefore would not, at any time thus far,
have been recommended for release.
47. My investigator asked HCO A about the prison’s efforts to transfer the
man to a different prison because he had been at Leeds for far longer
than is normal for a local prison. HCO A confirmed that attempts had
been made to transfer the man to HMP Manchester and HMP Wakefield,
but that it had been difficult to persuade another prison to take him,
probably because of his health needs. HCO A added that the man was
reluctant to move and was known to give different excuses why he should
remain at Leeds.
48. During their conversation, my investigator asked about the deterioration in
the man’s health and whether or not it had been sudden. HCO A
explained how the man’s condition deteriorated gradually over about two
years. He also spoke about the oxygen that the man needed to take and
how the prison had ensured that he could reach all parts of his cell, toilet
included, with his oxygen mask attached so that he could move around.
HCO A referred to the time when the man injured himself by smoking
while the oxygen was switched on and the staff tried to ban him from
smoking in his cell to reduce the risk. However, the man got around this
by hiding his tobacco – in some instances hiding it in his inhaler.
49. My investigator asked about care plans (a written record of the agreed
care to be given to a specific prisoner). They are mentioned in the
medical record but were not included in the documentation received by
this office or in the paperwork at the healthcare unit at the prison. It
appears that during the time the man was in Leeds, there was a move
from paper files to electronic and again onto a different electronic system.
The structure of healthcare has changed since the man’s death and the
primary care nurses are now based on the main residential wings rather
than with the in-patients. I can only assume that the paperwork has
become lost. However, HCO A said that although he did not know where
the care plans would be, he remembers that they did set out actions for
the man’s exercise, personal hygiene and diet – which HCO A described
as poor because the man would not eat fruit or vegetables.
The friend’s information
50. A friend of the man wrote to this office shortly after the man’s death
offering background information. My investigator spoke to the man’s
friend about four particular aspects of his letter.
51. The first was that the friend said the man always slept in a chair and had
asked for a bed. My investigator asked HCO A about this. He confirmed
that the man slept in a chair and refused to sleep in the bed as it was
more uncomfortable for him to breathe whilst lying down. HCO A added
that pillows and/or a specialist bed were offered but the man still refused.
The HCO said he went with the man to a community chest clinic
appointment in February 2008. He witnessed the man tell the nurse that
he needed a commode although his toilet was only about nine feet away.
Additionally, the man had been told by doctors and others that it would
help his health if he made the effort to walk to the toilet. There is already
a specialist bed in the healthcare unit and a more appropriate chair was
given to the man to make him comfortable. I am inclined to think that he
was perhaps being stubborn by refusing to get into a bed and told his
friend otherwise. The clinical reviewer also concluded that the man was
offered a specialist bed but was likely to have remained in his chair even if
the bed was in the cell.
52. Secondly, the man’s friend said that on occasions he would go to the
man’s cell in the morning and find his night medication on the floor. My
investigator asked the staff about this. HCO A said that the medication is
passed through the observation hatch at night. If a person is unable to go
to the hatch the door should be unlocked. HCO A did add that the man
chose his ‘friends’ amongst staff and would be defiant at times with those
he chose to be. It might have been on occasion with these staff that the
man did not collect his medication, but it is difficult to be sure. I go on to
discuss this later in my report.
53. In his letter the man also said that the man would refuse baths because
he believed the cleaners would steal items from his cell. There is no
suggestion of this in the medical notes. Both his friend and staff
commented that the man could be very stubborn and therefore I think it is
more likely he was just refusing to move to have a bath.
54. Lastly, my investigator asked about the man’s friend lay opinion of the
man’s general health. He confirmed that the man had generally poor
health and it was not a surprise to him to learn that he had died as a
result.
ISSUES CONSIDERED
Medical records
55. The Head of Healthcare explained that Leeds were trying to consolidate
handwritten and electronic medical notes from the previous system into
the current electronic system ‘System One’. There are often teething
problems in a process like this. As with some of the man’s paperwork,
documentation can be misplaced or lost.
56. The staff working on the in-patient wing said they needed training on
System One to ensure that they could effectively complete care plans and
other information. The Head of Healthcare has since told my investigator
that training is available for staff. This is crucial to ensure the continuity
and appropriate care of a patient, particularly if there are no primary care
staff based on the wing. Although, as the Head of Healthcare has said,
training has been undertaken and is available, staff clearly feel they are
missing some skills. I do not make a formal recommendation but invite
the Head of Healthcare to take further steps to identify any unmet training
needs amongst the staff group on the in-patient wing.
Administering medication at night
57. There may well have been occasions when the man did not get his night
medication because it was on the floor. As HCO A described, it is given
through the medical hatch at night but if a prisoner is unable to go to the
hatch, the door should be unlocked and the medication handed to the
prisoner. It is not possible to tell whether the man’s medication was
thrown on the bed and rolled off, he knocked it off or if he chose not to
take it and leave it on the floor. I am satisfied that the man was able to
move short distances and therefore could have collected the medication
from the hatch. However, I do not condone the practice of throwing
medication through a hatch, if that is what happened.
58. However, the fact that the man did not have certain medications in his
possession and was given them at night meant that he should have been
observed taking them. There should have been no reason for his
medication to have been found on the floor of his cell at any time.
The Governor and Head of Healthcare should ensure that medication
is appropriately dispensed and seen to be taken during the night.
Resuscitation
59. My investigator asked for a copy of the ‘not for resuscitation’ policy at
Leeds at the time of the man’s death. She was only able to obtain a more
recent NHS Leeds policy. That said, it is not clear whether or not the man
was ever subject to these procedures.
60. In April 2009, ambulance paperwork following the man’s admission to
hospital claims that at Do No Attempt Resuscitation (DNAR) order was
held on the man’s notes. It is not clear if this refers to the prison or the
hospital records. Neither is it clear whether the medical professional
responsible for the man’s care signed the DNAR or that the man or his
family were aware of it. There is no evidence anywhere else in the prison
records that confirms that this was the man’s wish or that it had ever been
discussed with him in the prison.
61. Additionally, when my investigator asked the prison if there was an agreed
decision not to resuscitate the man, she found that this was not the
understanding of staff. In fact, the response was the opposite, with staff
commenting that if he was not to be resuscitated they would not have
called for an ambulance on 1 September when he was subsequently
admitted to hospital.
62. The clinical reviewer also commented on the DNAR dated April 2009. He
found that it did not seem an unreasonable decision under the
circumstances. The man would have been aware of the severity of his
condition and those treating him would have known that he was in the
terminal stage of his illness. The clinical reviewer said that resuscitation
following any sudden collapse would probably have caused the man more
suffering or serious other damage. However, he too could not find any
documented evidence that these were the man’s wishes or that the matter
had been discussed thoroughly with him at any point.
63. I can only assume that the decision was made at the hospital in April
2009. Certainly in the bedwatch log in September 2009, it is the hospital
doctor who makes mention of it. Nonetheless, the DNAR order could and
should have been followed up by prison healthcare staff in April following
receipt of the ambulance paperwork. I therefore endorse the clinical
reviewer’s recommendation.
I recommend that Do Not Resuscitate Orders are clearly marked in a
patient’s medical file and that discussion and decisions surrounding
one are appropriately documented.
Smoking cessation
64. The clinical reviewer’s only additional comment about the man’s care was
what he has termed “historical issues” regarding the apparent lack of
documented smoking interventions in the man’s medical record during his
first years in prison. Although there are references to his smoking status it
was mostly at outpatient attendances.
65. That said (and the clinical reviewer also comments) the likelihood is that
the man’s smoking status was discussed in consultations and that he
declined to give up. Additionally, it is only in more recent years that
smoking cessation interventions have been widely available in prisons.
The clinical reviewer concluded that HMP Leeds has taken steps to
provide this service to the prisoners in its care. I agree with these
comments, particularly as trying to persuade the man to stop smoking was
a big focus of his care during his last few years. I therefore mention this
only as a finding of doctors’ and make no recommendations in respect of
this.
Length of time at Leeds
66. There is little dispute that the man was held at HMP Leeds for far longer
than he should have been. There were a number of attempts to transfer
the man but none came to fruition. One can speculate as to why this was
but one suggestion was that he was a difficult prisoner with complex
health needs. This should not be a reason for another, more suitable
prison not to take him.
67. However, the important factor for consideration in this investigation was
the appropriate care and treatment for the man’s health needs. There is
no evidence to suggest that his needs were not met at Leeds and indeed
he often gave excuses so that he could remain at the prison. The man
was elderly and frail. Keeping him in familiar surroundings with staff and
prisoners who he knew was, in my view, more decent than a transfer to
somewhere unfamiliar. I have already commented on the clinical
reviewers’ finding of the man’s care and treatment. I am satisfied that
remaining at Leeds was not detrimental to the man’s health and his death
was unavoidable.
CONCLUSION
68. The man was an elderly man in poor health. He suffered from a
respiratory disease for some considerable time and during his period in
custody was regularly reviewed by hospital consultants for the condition.
69. As the clinical reviewer explained, stopping smoking would have been the
best course of action for the man to prolong his life and slow the disease
but he chose to continue smoking despite this advice. As his condition
deteriorated, the man was cared for and treated well and appropriately by
healthcare staff at Leeds. He was sometimes difficult to manage but as
the clinical reviewer commented, the man would have had more daily
contact and reviews in prison than he would have had in the community.
This regular and close contact and treatment probably prolonged the
man’s life albeit perhaps for a short time.
RECOMMENDATIONS
1. The Governor and Head of Healthcare should ensure that medication
is appropriately dispensed and seen to be taken during the night.
At draft consultation stage Leeds accepted this recommendation and said, “All
staff are aware that unless given `in possession’ medication administration
should be supervised. Where possible healthcare staff will supervise this via
observation hatch at night, but where there is a clinical requirement night
orderly officer will be contacted and cell opened to facilitate supervision of
night medications. E mail to be sent to all inpatient unit staff communicating
this.”
2. I recommend that Do Not Resuscitate Orders are clearly marked in a
patient’s medical file and that discussion and decisions surrounding
one are appropriately documented.
At draft consultation stage Leeds partially accepted this recommendation and
said, “Accepted in principle, however, there was no DNAR for the man whilst
at HMP Leeds. DNAR was decided following his transfer to LGI. Any DNAR
in place at HMP Leeds has always been clearly communicated to all staff and
documented on records. Communication will be forwarded to all healthcare
staff informing of the importance of clear communication of any such clinical
instruction and referring them to NHS Leeds DNAR policy.”
I also draw paragraph 59 to the attention of the Governor and Head of
Healthcare.
At draft consultation stage Leeds said, “Following a training needs analysis at
the end of 2009, the majority of Inpatient staff have now received recent
SystemOne training, including the compilation of care plans using
SystemOne. Two staff still require training and will be trained by end March
2010.”