Individual at Hull

Circumstances surrounding the death of a man at a local
hospital, whilst in the custody of HMP Hull,
In March 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2008
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.
This is the report of an investigation into the death of a man who was a prisoner at
HMP Hull and who died from natural causes on 31 March 2008. He was 70 years
old. Prior to his arrival in custody, eight months earlier, the man had been diagnosed
with chronic renal failure. This meant that he needed to attend the local hospital for
dialysis treatment three times a week.
I would like to add my personal condolences to those already expressed to the
man’s family on behalf of this office by one of the Ombudsman’s Family Liaison
Officers.
This investigation was undertaken by one of the Ombudsman’s investigators. He
and I would like to thank the Governor of HMP Hull and his staff for their assistance.
A clinical reviewer was asked by Hull Teaching Primary Care Trust to undertake a
review of the man’s clinical care and I also much appreciate their help.
I have noted the clinical reviewer’s conclusion that the quality of care the man
received was in some instances better than that he would have received in a
community setting. I have also noted the issues highlighted by the clinical reviewer
and I endorse the recommendation made in the clinical review. The Primary Care
Trust and the prison will need to develop an action plan to address the matters
raised.
Jane Webb
Deputy Prisons and Probation Ombudsman October 2008
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CONTENTS
Summary 3
The investigation process 4
HMP Hull 5
Key events 6
Issues considered 10
Conclusions 13
Recommendation 14
2
SUMMARY
The man was 70 years old when he died at a local hospital on 31 March 2008. The
man died from natural causes as a consequence of a gastrointestinal haemorrhage
(bleeding in the tract that links the stomach and the intestine).
On 3 August 2007, the man was sentenced to seven years imprisonment. He
arrived at Hull the same day and on arrival it was noted that he had been diagnosed
with chronic renal failure which required him to have dialysis three times a week.
The man had been diagnosed previously with chronic bronchitis, a duodenal ulcer,
chronic obstructive pulmonary disease and coronary heart disease with congestive
cardiac failure. He had also suffered from depression in the past. Due to his
medical condition the man was located on the healthcare wing for the duration of his
time at Hull.
During his first health screen interview the man told staff that he wanted to refuse all
treatment. Accordingly, a self-harm observation and support regime was started.
This involved regular checks being carried out and recorded. The regime was
stopped on 13 August when the man agreed to attend his dialysis treatment. The
self-harm observation and support regime was started again from 19 to 22
November, 2 to 5 December and 12 to 17 March 2008 when the man again refused
treatment.
On 25 March 2008, the man was taken to a local hospital as he had been
experiencing rectal bleeding, had low blood pressure and his complexion was pale.
Whilst the man was in hospital, a bedwatch was carried out by prison staff. The
initial security risk assessment was that handcuffs were to be used and two officers
needed to be at his bedside. This was later revised on 26 March and handcuffs
were no longer used. Whilst the man was in hospital he was visited by his family.
At approximately 9:50am on 31 March, one of the officers on bedwatch duty noticed
that the man had stopped breathing. The officers immediately informed hospital staff
who established that the man had died. A doctor pronounced death at 11:10am.
The clinical review concludes that the man’s clinical care was good and in some
instances better than that available in the community. I have endorsed the clinical
reviewer’s recommendation and make no other recommendations.
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THE INVESTIGATION PROCESS
1. One of the Ombudsman’s investigators opened the investigation on 3 April
2008. He issued notices announcing the investigation to staff and to prisoners.
The notices included an invitation to those who wished to submit information
relating to the man’s death to make themselves known to my investigator. In
the event, nobody came forward. The investigator also studied all relevant
prison records relating to the man. These included his main prison record,
bedwatch logs, medical records and statements made by staff.
2. The investigator visited Hull on 12 May and discussed aspects of the man’s
treatment with staff at the prison.
3. The Hull Teaching Primary Care Trust (PCT) commissioned the Clinical
Governance Manager to carry out a review of the man’s clinical care. I am
grateful to the clinical reviewer for undertaking the review.
4. The investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of the 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. One of the Ombudsman’s Family Liaison Officers contacted the man’s family.
This gave them the opportunity to discuss the purpose of the investigation and
to raise any concerns or questions they would like explored or addressed. The
man’s family did not wish to raise any specific concerns about the treatment he
received while in custody. They asked the Family Liaison Officer to clarify
whether anyone was with the man when he died. I can confirm that two prison
officers were with the man at that time. The man’s family also asked to see a
copy of my report when complete. I hope that my report helps the family better
understand the events leading up to the man’s death.
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HMP HULL
6. HMP Hull opened in 1870 and is now a category B adult male and young
offender local prison serving the courts in East and North Yorkshire and North
Lincolnshire. There are eight residential units and a healthcare centre. The
maximum number of prisoners that can be held is 1,044 and the certified
normal accommodation is 723.
7. Provision of healthcare is the responsibility of Hull Teaching Primary Care Trust
with the General Practitioner (GP) service being provided by a local GP
practice. The healthcare centre has 18 beds and provides 24 hour nursing
care.
8. Medication is administered on a weekly and/or monthly basis to those prisoners
who have been risk assessed as suitable for holding it in their own possession.
It is administered on a daily basis to other prisoners, when either they are
judged to be at risk or the medication is considered unsuitable to be held in
their possession.
9. Her Majesty’s Chief Inspector of Prisons, Ms Anne Owers, carried out her last
full inspection in November 2005. Hull has changed considerably since the
time of that inspection due to the closure of a much-criticised unit. At that time,
Ms Owers found that “the healthcare centre provided a good service”.
10. The Measuring the Quality of Prisoner Life (MQPL) survey, carried out in
November 2007, found a small majority of prisoners negative about
relationships between prisoners and staff. This was in contrast to the
Independent Monitoring Board’s finding, in its annual report for 2006/7, who
found staff “dedicated and loyal”. A number of prisoners who participated in the
MQPL survey expressed frustration at the lack of employment opportunities.
The Inspectorate found “the overall quantity of purposeful activity remained
insufficient, with prisoners spending too long locked up in their cells”.
11. Since 2004, the Ombudsman’s office has investigated nine deaths through
natural causes at HMP Hull. There was no link between the circumstances
surrounding this investigation and the previous deaths at Hull.
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KEY EVENTS
12. The man arrived at Hull on 3 August 2007. On first reception in prison, it was
noted that he had a number of health issues and that he was a smoker. The
man had suffered for a number of years from chronic renal failure which
required him to have dialysis three times a week. The dialysis sessions would
last four hours. As the man’s own kidney function was virtually non existent, he
required the dialysis sessions in order to remain alive. The man also had a
long history of chronic bronchitis, chronic obstructive pulmonary disease and
coronary heart disease with congestive cardiac failure. It was recorded that he
had previously been diagnosed with a duodenal ulcer and that he suffered from
depression from time to time. The man was offered support to help him stop
smoking but he chose not to take up this offer. Due to his health problems the
man required a special diet and needed to have his fluid intake restricted to one
litre per day. The man was prescribed a range of medication to treat his
various conditions and was allowed to keep some medicine in his possession.
13. During his first health screening interview the man told staff that he wanted to
refuse all treatment so he could die. It was noted that he was upset at his
prison sentence. The consequences of refusing treatment were explained to
the man and a referral also made to the mental health in-reach team. As he
was refusing treatment, an Assessment, Care in Custody and Teamwork
(ACCT) self-harm observation and support regime was started. (ACCT is used
to monitor and support those prisoners who are felt to be at risk of suicide or
self-harm.) The ACCT was to remain open until there was an improvement in
the man’s mood and he cooperated with his medication and dialysis. A three
day psychiatric assessment was also carried out which did not identify a need
for any further mental health intervention. After his health screening interview,
the man was admitted to the prison’s healthcare centre.
14. Three days after his arrival at Hull, on 6 August, the man attended the local
hospital for dialysis. The ACCT document was closed a week later on 13
August as staff felt that the man had come to terms with his situation and was
complying with his medical treatment.
15. The man was an enhanced prisoner and he was compliant with the regime in
the prison. (The Incentives and Earned Privileged Scheme (IEPS) is a scheme
that is designed to encourage and reward good behaviour in prisons. There
are three tiers – Basic, Standard and Enhanced, the top level. Incentives
include access to in-cell televisions, more private cash to spend, wearing own
clothes, more time out of cell and community visits.)
16. He continued to accept treatment until 19 November, when an ACCT document
was opened as the man again refused all medication and dialysis treatment.
The man duly attended the local hospital again for dialysis on 21 November.
The ACCT document was closed the following day as the man resumed his
medical treatment.
17. During the evening of 25 November, the man was found crying on his knees on
the floor of his cell. He was helped up by a nurse. The man said he felt so
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unwell that he was finding it difficult to care for himself anymore. He was
worried about his personal hygiene and he hated being unshaven. The man’s
clinical observations were taken and they were within normal limits. He was
given a slice of buttered toast and a cup of tea. The man insisted that he felt
better afterwards. The following day, another nurse tried to assist with the
man’s personal hygiene needs but was told that his help was not needed.
18. The man refused dialysis treatment for a third time on 30 November. An ACCT
document was opened two days later after his condition started to deteriorate.
When staff spoke to the man he was coherent but also quite emotional. Due to
the deterioration in his health, arrangements were made for him to be admitted
to the local hospital. Around 4:00pm on 2 December, the man was taken by
ambulance to hospital. He returned to healthcare at Hull early the following day
as he had continued to refuse all treatment and had been acting aggressively
towards hospital staff. The man was located in a cell where he could be
observed by staff via closed circuit television. Around 9:00am on 3 December,
the man told staff that he would now attend dialysis treatment and he was
taken around midday to the local hospital. He returned to healthcare in the
early evening of the same day. The ACCT document was closed on 5
December as the man’s mood had improved and he was compliant with his
medical treatment.
19. Treatment continued until 12 March 2008, when another ACCT was opened as
the man had again refused to attend the local hospital for dialysis and he had
also asked not to be resuscitated. The ACCT document was closed on 17
March as the man had resumed dialysis and seemed much happier.
20. Whenever the man refused treatment staff would complete incident and
disclaimer forms. They also continued to liaise with the man with regard to his
choices and staff were able to persuade him to continue with his treatment. His
request asking not to be resuscitated was properly recorded and documented
by staff at Hull.
21. When interviewed, the Head of Healthcare at Hull confirmed that she had been
in liaison with the service manager of Hull and East Yorkshire Hospital Trust.
They had been investigating whether Hull could bring dialysis equipment into
the prison with individual external and internal support provided for the man.
This would make it easier for the man’s treatment regime to be accommodated
and would have meant that he did not need to leave the prison for dialysis.
However, this was hindered by the man’s refusal to comply with his medical
treatment. The Head of Healthcare said that they were exploring whether an
external private company could provide the equipment when the man died.
22. On 25 March, the man was again taken to the local hospital as he had been
experiencing rectal bleeding, had low blood pressure and his complexion was
pale. A gastroscopy (a gastroscope is an instrument which is used to examine
or view the interior of the stomach) was performed and the man was diagnosed
with a gastrointestinal haemorrhage (bleeding in the tract that links the stomach
and the intestine). An endoscopy was also performed. (An endoscopy is a test
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that looks inside the body. The endoscope is a long flexible tube that can be
swallowed. It has a camera and light inside it.)
23. Whilst the man was an in-patient at the hospital and attending dialysis, a
bedwatch was carried out by prison staff. The initial security risk assessment
identified that an escort chain should be used and two prison officers should be
in attendance. The risk assessment was revised on 26 March and restraints
were no longer used. Staff on bedwatch duty maintained a log of activities
whilst the man was an in-patient. During his stay in hospital, the man was
visited by his family.
24. At approximately 6:45am on 31 March, an officer commenced his bedwatch
duty and he was joined at around 7:05am by another officer. When interviewed
by the Ombudsman’s investigator, the first officer said that the man was
receiving fluids and that the hospital staff had washed him and made him
comfortable. The officer said that the man’s breathing was erratic and he
seemed very agitated but was still speaking to the hospital staff.
25. When the doctor did his rounds at 9:15am, he told the staff on bedwatch duty
that the man would be re-assessed on a daily basis and that his family would
be informed that he was very poorly. Someone from the healthcare centre at
Hull rang the hospital for an update on the man’s condition. They were told that
the man’s condition was not good, his blood pressure was dropping fast and his
oxygen saturation levels were falling even though he was receiving oxygen. A
staff nurse told the first officer that she would be contacting the man’s family to
advise them of the gravity of his condition.
26. The man’s condition continued to deteriorate and at approximately 9:50am the
first officer noticed that he had stopped breathing. The officers immediately
informed hospital staff who established that the man had died. The man was
pronounced dead at 11:10am by a hospital doctor. It is not clear why there was
such a delay before this happened.
27. Prisoners on the healthcare wing were told what had happened. Each prisoner
was asked whether they required anything or wanted to speak to a Listener (a
prisoner who has been trained by the Samaritans to give support to their
peers). When the officers who had been on bedwatch duty returned to Hull
they were offered support from the prison’s care team.
28. At around 1:00pm, a residential governor met the man’s family at the local
hospital. A senior officer was appointed as the prison’s family liaison officer.
She contacted the family the day after the man’s death to offer condolences
and support. The senior officer maintained contact with the family and assisted
with the arrangements for the funeral. The prison offered financial assistance
with funeral costs.
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29. The post mortem report records the man’s death as being due to natural
causes as a consequence of gastrointestinal haemorrhage caused by a
duodenal ulceration (bleeding in the tract which links the stomach and the
intestine) and lobar pneumonia end stage renal failure.
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ISSUES CONSIDERED
Clinical care
30. A review of the man’s medical care was undertaken by a clinical reviewer on
behalf of Hull Teaching Primary Care Trust. The review found that the man
had suffered from significant long-term chronic diseases. From the medical
records, it was clear that the man was seen regularly by healthcare staff and,
when necessary, referred to secondary care services.
31. The clinical reviewer recognises that, due to being in custody, the man was
unable to exercise the same choices as other patients in the wider community.
However, a review of his medical record indicated that the man was allowed to
choose options within these constraints. The clinical reviewer finds that the
man was able to request reviews of his medical needs by healthcare staff and
was also able to choose to be nursed in the main ward of the healthcare wing.
She concludes that the quality of care the man received was broadly similar
and in some instances superior to that he would have received in a community
setting. The clinical reviewer notes that referrals were made to appropriate
health care professionals and the man had access to advice regarding medical
issues on request. The clinical reviewer concludes that appropriate actions
regarding follow up and opening of ACCT documents were completed by staff.
She judges that if the man had been in the community, follow up of this nature
might not have been completed in such a timely manner.
32. The man was able to receive quick and convenient quality care for mental
health problems and learning disabilities. He was immediately referred to the
in-reach mental health team for review after his first reception health screen.
The man was able to access the mental health services which are available at
Hull. He was seen by a medical officer on many occasions due to his
fluctuating mood. The renal physicians at the local hospital told the clinical
reviewer that mood fluctuations and mild depression are a common symptom of
chronic renal failure.
33. The clinical reviewer observes that when the man arrived at Hull it was noted
that he was a smoker. He was offered smoking cessation advice but continued
to smoke. The clinical reviewer believes that this could have severely affected
the man’s quality of life due to his existing health conditions and may also have
increased the possibility of gastric ulcer disease.
Liaison between the healthcare centre and the hospital
34. The clinical reviewer finds that communication between health staff at Hull and
other external agencies was documented and that further action was identified
and followed up. Although the outcome for the man would not have been
affected, she concludes that it may prove beneficial in the event of similar
situations in the future if multi-disciplinary team case conferences are held.
The clinical reviewer suggests that the conferences could be between Hull,
acute hospital specialists and the next of kin and the patient, with the aim of
facilitating care planning.
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HMP Hull should consider multi-disciplinary case conferences to assist in
the clinical management of prisoners who have specialised health
requirements.
Consent to treatment
35. The clinical reviewer also draws attention to the man’s frequent refusals to
consent to dialysis treatment despite the consequences of such action being
explained. She says that staff would regularly complete incident forms and
disclaimer forms and continue to liaise with the man regarding his choices. The
clinical reviewer notes that on several occasions medical staff persuaded the
man to consent to his treatment continuing. Staff at Hull recognised that the
man’s actions might have been a display of risk of self-harm and frequently
opened ACCT documents so that he could be monitored for his own safety.
36. The clinical reviewer says that the man was not deemed to be lacking in
capacity to consent by either staff at HMP Hull or the local hospital. The clinical
reviewer judges that to treat the man against his wishes would have been an
infringement of his human rights. A decision to cease his dialysis treatment
was not made as the man frequently changed his mind and attended his
dialysis sessions after previously refusing to consent. As already mentioned,
depression and mood fluctuations are common symptoms of chronic renal
failure. Following discussion with the nursing team at the renal unit in the local
hospital, the clinical reviewer reports that it is common for patients to
recommence therapy after previously declining treatment.
37. The clinical reviewer draws attention to the man’s refusal to take his medication
on a number of occasions. She says that it is not clear from the man’s medical
records whether he refused medication for prolonged periods. The clinical
reviewer notes that one of the man’s prescribed medications, Omeprazole, is
used to prevent symptoms and complications of gastrointestinal ulceration and
excessive stomach acid.
38. The clinical reviewer says that it is impossible to be certain if the man would
have refused treatment so frequently if he had not been in prison. His refusal
to consent was not consistent as the man regularly consented to treatment
following initial refusal. The clinical reviewer judges that the man received
appropriate treatments and therapeutic interventions.
39. The clinical reviewer is not critical of any actions of healthcare staff and says
that all appropriate clinical procedures were followed. The clinical reviewer
believes that the man’s death could not have been avoided. The man had
been placed on appropriate preventative medication and the proper clinical
investigations were carried out.
Use of Assessment, Care in Custody and Teamwork procedures
40. Prison staff opened ACCT documents each time that the man withdrew his
consent to treatment. Although this is not the customary reason for the
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arrangements to be used, I consider it to have been a thoughtful and
compassionate way to ensure that he was supported and monitored at a time
when he felt distressed.
Restraints
41. I am also pleased to report that the man was properly assessed whilst he was
in hospital and, as a result, the level of restraints was reduced and the escort
chain removed. The bedwatch officers remained and I hope that it is a comfort
to the man’s family to learn that he was not alone when he died.
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CONCLUSIONS
42. The man arrived at Hull in August 2007 and he died of natural causes in a local
hospital in March 2008.
43. From the bedwatch log, I believe that the staff involved with the man’s care
behaved with compassion and sensitivity. The security arrangements at the
hospital seem to have been suitable, and to have struck a good balance
between public protection and respect for the man.
44. The man appeared to be a difficult patient to manage. On four occasions he
refused treatment. This was a very dangerous course of action by the man as
he needed dialysis regularly. I commend the action of staff at Hull in trying to
support the man through these difficult times when he refused treatment.
45. In light of the findings of my investigation and the clinical review, I conclude that
the care provided to the man was entirely appropriate. Indeed, I think that staff
at Hull treated the man with sensitivity and professionalism. I am encouraged
by the conclusion the clinical reviewer reaches in her clinical review - “The care
the man received at HMP Hull healthcare was broadly similar and in some
instances superior to that he would have received in a community setting.” The
clinical reviewer has made one recommendation, which I endorse. This will
need to be addressed by the Hull Teaching Primary Care Trust in partnership
with the Governor of Hull.
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RECOMMENDATION
Clinical
1. HMP Hull should consider multi-disciplinary case conferences to assist in the
clinical management of prisoners who have specialised health requirements.
Accepted - The Primary Care Trust are undertaking multidisciplinary meetings for
those clients with complex health needs.
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