Individual at Hull

Investigation into the circumstances surrounding the
death of a man
at HMP Hull in April 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2010
This is the report of my investigation into the circumstances surrounding the
death of a man at HMP Hull in April 2009. He was a life sentence prisoner aged
54 years and had been in Hull since January 2007. He suffered from a number
of serious health problems for several years and required a high level of medical
support. In March 2009, he was diagnosed with terminal cancer and his
condition deteriorated quickly. He died while asleep during the night in the prison
healthcare centre. A post mortem examination found that the cause of death was
heart disease.
I would like to offer my condolences to the man’s mother, children and wider
family. At the time of his death, he was awaiting a Parole Board hearing and it
was thought likely that he may have been judged suitable for release. In May
2008, he had been deemed suitable for open conditions but was unable to
transfer to an open prison because of his poor health. Staff at Hull believed that
he had made a genuine commitment to being fully rehabilitated into society and
spending time with his children. Unfortunately his untimely death came at an
otherwise hopeful time for him and his family.
My investigation was led by a senior investigator and a Family Liaison Officer
was appointed.
An independent review into the clinical care received by the man was
commissioned from the local Primary Care Trust. Clinical reviewers undertook
the review and their reports are annexed to mine. I am grateful to them for their
help and also to the Risk and Claims Manager for NHS Hull, for her liaison. I am
also grateful to the Governor and staff at HMP Hull, especially a duty governor
and a Principal Officer for their co-operation with this investigation.
I am disappointed that, despite being categorised as suitable for open conditions
for almost a full year before he died, it was not possible to find an open prison
able to take the man. I am pleased however that my investigation has found that
the care he received at Hull was of a high standard and that he himself said that
he was well looked after there.
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 Hull
Key Events
Issues
Conclusion
Recommendations
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SUMMARY
The man was 54 years old and serving a life sentence at HMP Hull. He had a
history of poor physical health and suffered from angina, diabetes and chronic
obstructive pulmonary disease (COPD). He also suffered from depression and
paranoid thoughts. Although a category C prisoner, he was transferred to Hull (a
category B prison) in January 2007 because of his need for 24 hour healthcare
support.
In May 2008, the Parole Board decided that the man was suitable for open
conditions and he was re-categorised to category D. Unfortunately his medical
needs meant that, despite efforts made by Hull staff, a suitable open prison could
not be found.
In February 2009, the man told the doctor that he had a lump in his right thigh
that was getting bigger and causing him pain. He was referred to the infirmary.
A succession of scans and biopsies revealed the presence of a malignant tumour
in his thigh and possible secondary tumours in his lungs. On 23 March, he was
told that his disease was terminal. He had an operation to remove the tumour. A
haematoma developed in the wound on his thigh and later became infected. He
was treated on the wing and in the healthcare centre in Hull but his condition
deteriorated rapidly and he died in April. A Home Office Consultant Forensic
Pathologist undertook a post mortem examination of the man. The pathologist
concluded that the cause of death was “hypertensive and ischaemic heart
disease”.
The clinical review of the treatment received by the man concluded that the care
he received was at least equitable to that he would have received in the
community. His physical and mental health needs were looked after promptly
and to a high standard. Issues about the communication between the infirmary
and the prison and housekeeping points concerning night records kept by
healthcare staff are raised but I conclude that they did not affect his diagnosis
and treatment.
The prison’s response to the man’s death was appropriate and timely and every
effort was made to provide a high standard of liaison with his next of kin.
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THE INVESTIGATION PROCESS
1. The investigation was led by a senior investigator. A Family Liaison
Officer was appointed. Notices of the investigation were sent to staff and
prisoners at HMP Hull inviting them to contact the investigator if they
wished. No response was received to these notices. She visited Hull on
19 May. She read the man’s prison record, clinical record and the
documents associated with his death. She obtained copies of documents
she considered relevant to the investigation. She visited the Healthcare
Centre, spoke to staff and saw where he died.
2. An independent clinical review into the care received by the man was
commissioned. A Registered General Nurse and a Consultant Physician
in General and Respiratory Medicine undertook the review. Their reports
appear at annex one. Both clinical reviewers visited Hull, read all of the
clinical records and interviewed staff.
3. The Family Liaison Officer spoke to the man’s brother by telephone. He
said that the family were happy with the care offered to his brother by Hull.
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HMP HULL
4. HMP Hull is a category B local prison holding remand and sentenced adult
male prisoners and young offenders. Since 2002 it has undergone a
period of expansion and now holds over a thousand prisoners. The
expansion included a purpose built healthcare centre offering 24 hour
healthcare and a multi-bedded in-patient ward and cellular
accommodation. This year a terminal care suite has been adapted.
Medical services are contracted out to the local Primary Care Trust.
5. The prison accepts indeterminate (life) sentenced prisoners sentenced in
the interests of public protection (IPP – known as the ‘two strikes’ system)
as well as the conventional mandatory life sentence. Hull runs a number
of offence-related courses and category B prisoners are often re-
categorised to lower security categories once they have completed them.
6. The 2008 report of the Hull Independent Monitoring Board (IMB)
highlighted the problem that an overcrowded prison system poses in terms
of moving these prisoners around the system. In common with other
category B prisons Hull also contains a number of category C and even
category D prisoners who are waiting for spaces at lower category prisons.
The man was a category C prisoner when he arrived at Hull in 2007 and
was re-categorised to category D (deemed to be suitable for open
conditions) in May 2008. He remained in Hull because it was not possible
to find another lower category prison that could manage his medical
needs.
7. In late 2008 Hull scored positively in Measuring Quality of Prisoner’s Life
(MQPL) survey and attained ‘Best in class for Diversity’. It was rated as a
“safe and decent prison”. The Prison Service raised its rating to level four
– awarded to “excellent establishments that are delivering exceptionally
high performance”.
8. Her Majesty’s Inspector of Prisons last inspected Hull in an announced
inspection in November 2008. Her report, published in March 2009,
complimented Hull on staff prisoner relations, activities, diversity,
resettlement and time out of cell. The healthcare offered was judged to
have “improved considerably” since the previous inspection.
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KEY EVENTS
9. The man suffered from a number of physical and mental health problems
for many years. These included chronic breathing difficulties, heart
disease and diabetes. The clinical reviews at Annex 1 offer a very
detailed account of the nature of his illnesses and chronology of care he
received from prison healthcare staff. In this section I concentrate on
significant events from February 2009 until his death.
10. On 16 February 2009, the man asked to see the prison doctor about a
lump on his right thigh that he said had been there for about one month
and was increasing in size. He said it had started to become painful and
cause numbness down his leg. He was examined by a prison doctor and
referred to hospital for an ultra sound scan.
11. Three days later, on 19 February, another prison doctor examined the
man because he said the lump had increased in size and was spreading
towards his lower thigh. The doctor sent him to the infirmary the same day
to exclude a haematoma (a collection of blood outside the blood vessels
as the result of internal bleeding) or abscess. An urgent ultra sound scan
was carried out on his right thigh but the prison was not contacted. Staff
made several calls to the infirmary to find out the results.
12. On 21 February, the man reported that he had “blacked out” out in his cell
and fallen, hurting his ankle. He attended the infirmary the same day for
an x-ray of his ankle which revealed a sprain. He had a follow up
appointment on 25 February but was able to walk normally at this point
and had no further ankle problems.
13. The hospital faxed the prison on 24 February referring to the lump as
highly suspicious and possibly malignant. The man was referred for a
formal musculoskeletal review.
14. On 1 March, the man complained of chest pains and pins and needles
down his right arm. He was taken to the infirmary by emergency
ambulance and was given a chest x-ray that revealed a possible infection.
15. The man returned to the infirmary for an appointment on 9 March with a
Consultant Plastic Surgeon. The consultant decided to undertake an MRI
scan of the man’s right thigh and core biopsies of the lump. The scan and
three biopsies took place on 13 March. At the same time he was given
chest x-rays and scans of his abdomen, thorax and pelvis.
16. The man saw the consultant again on 23 March. He was told that the
scan and biopsies had revealed that the lump was suggestive of a high
grade sarcoma (malignant tumour of the muscle). The diagnosis was not
definitive but the scans of his abdomen, thorax and pelvis had revealed
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multiple nodules in his lungs, which were thought to be lung tumours. The
consultant told the man that the only way to obtain a definitive diagnosis
was to remove the lump from his thigh. However, any further treatment
given would be palliative and the disease was terminal. The man agreed
to have the lump removed and is reported as saying that a definitive
diagnosis might help him come to terms with what was happening to him.
17. The lump was removed at the infirmary on 25 March. On his return to the
prison healthcare staff reviewed the man to check how he was coping with
the diagnosis that he was terminally ill. They reported that he appeared
relatively cheerful but that his wound was oozing blood on movement. On
31 March, it was recorded that his wound was bleeding when he moved
about and he was only really comfortable while in bed. He was reviewed
by the second prison doctor the same day and prescribed morphine for
pain relief.
18. The next day, the man went to the healthcare centre to have his wound
dressed and it was noticed that it was leaking and large clots of blood had
formed. He was sent to the infirmary by ambulance and he had a further
operation to remove a large haematoma from the site of the operation. He
was discharged back to prison on 4 April and said he did not want to be
admitted to the healthcare centre. A third prison doctor agreed that he
could remain on the wing and have his dressing changed twice daily. On
5 April, his morphine dose was increased. He remained on the wing but
was seen twice daily by healthcare staff to dress his wound and review his
pain management.
19. On 8 April, the man asked to be admitted to the healthcare centre because
his pain had increased. Staff completed the required paperwork to
support his release on compassionate licence. He had a parole review
date of 7 June but it was hoped to expedite this in the light of his now
rapidly deteriorating condition.
20. It was recorded on 11 April that the man’s wound was showing signs of
infection. The next day, he reported feeling very unwell and was given
antibiotics. A note on his clinical record said that if he got worse then he
should be taken to the infirmary. The following day he was seen to be in
obvious distress due to his clinical condition and was taken to the infirmary
by ambulance. The prison contacted his family to tell them. He was
found to have an acute infection that had exacerbated his breathing
problems and angina.
21. On 14 April, the man discharged himself from the infirmary against
medical advice. He attended an outpatient appointment at a hospital on
15 April and was reported to be in good spirits, despite the fact that his
wound remained badly infected. He remained in hospital for his wound to
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be stitched and drained and was returned to the prison healthcare centre
on 18 April.
22. The man complained of difficulty breathing three days later on 21 April. A
fourth prison doctor examined him and recorded that he was losing weight
and deteriorating quickly. The doctor increased the man’s morphine to
counteract his increasing pain. He went to an outpatient appointment at
hospital the following day but was very sleepy on his return due to the
amount of morphine in his system.
23. On 23 April, at about 7.40am, an officer began unlocking the prisoners in
the healthcare centre. He unlocked room F1-4, which was shared by the
man and his cellmate. In his statement the officer said that he spoke to
the man through the door but he did not respond. He looked at the
cellmate who said, “he’s out for the count boss”.
24. A nurse and the in-patient manager arrived at the cell and examined the
man. They found that he did not respond. He appeared cyanosed (that is
blue in colour because of lack of oxygen) and was not breathing. The in-
patient manager asked the officer to radio for paramedics and the doctor,
and to tell the orderly officer (the officer in charge of the operational
management of the prison) and the Duty Governor. Cardio-pulmonary
resuscitation (CPR) was attempted but the man’s airways were blocked
and his jaw was too stiff to be able to insert an airway. A defibrillator was
applied but it advised not to shock. He was cold, clammy and not
breathing. Paramedics arrived and, after further examination, he was
pronounced dead at 8.19am.
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ISSUES
Clinical care
25. The clinical reviews provided by two clinical reviewers are reproduced in
their entirety at annex one of this report. The first clinical reviewer
concludes that the general healthcare that the man received in Hull was
comparable to that he would have received in the community. The
management of his COPD, heart disease and diabetes was consistent
with national recommendations and he was offered smoking cessation
advice and lifestyle and dietary advice on a regular basis. He had suffered
from mental health problems including depression. Following his
diagnosis with a terminal illness, mental health staff spoke regularly to him
to assess his mood. He was also spoken to when he discharged himself
from the infirmary against medical advice.
26. The clinical reviewer is satisfied that the prison referred the man to
secondary care in a timely manner once he reported the lump in his thigh.
During interviews with staff at Hull it became apparent that they had found
it difficult to obtain information from the infirmary about the type of
treatment the hospital planned to give. Prison healthcare staff resorted to
asking the man. He would in turn ask his solicitor to ask the hospital and
then the solicitor would inform the prison of the answers by letter. This is
clearly a ridiculous and unsatisfactory state of affairs and one that may
seriously reduce the prison’s ability to provide prisoners with the care they
require. It is not within my remit to make a recommendation directly to the
hospital, therefore I must ask the Head of Healthcare at Hull and the
Primary Care Trust to pursue a memorandum of understanding or other
policy to improve communication between secondary care and primary
care in the prison.
I recommend that the Head of Healthcare and the PCT look at ways of
formalising communication between secondary care and prison
healthcare.
General clinical issues
27. Both clinical reviewers were satisfied that all emergency equipment was
checked on a daily basis and counter checked weekly. The first clinical
reviewer considers that training in basic and advanced life support and
CPR should be standardised and restructured to take place in one or two
days. I make no formal recommendation in this regard but draw the
attention of the Governor and the Head of Healthcare at Hull for their
consideration.
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28. Both reviewers commented that the electronic clinical record notes were
comprehensive and decipherable. They said however that notes kept by
night staff were on paper and only written up electronically on an ad hoc
basis. This led to gaps in the record. I am aware that the man was well
known to staff and his case was necessarily the subject of much
discussion. I do not feel therefore that any gaps in the record reflect a lack
of communication or failing in his case. However, it is important that an
accurate audit is kept and I make the following recommendation.
I recommend that the Head of Healthcare reviews the system of
record keeping by night staff with a view to standardising practice
among staff.
29. The first clinical reviewer also refers to the fact that Hull does not have a
formal Do Not Resuscitate (DNR) policy for terminally ill prisoners. Such
policies are common practice when caring for people who are terminally ill.
The man’s wishes in this respect were not discussed with him. I agree
that the prison should formally adopt such a policy and endorse the clinical
reviewer’s recommendation that one be implemented.
I recommend that the Head of Healthcare and the PCT implement a
formal Do Not Resuscitate policy for use in the care of terminally ill
prisoners.
The prison’s response to the man’s death
30. Prison Service Order 2710 Follow up to deaths in custody, requires that
prison staff inform the next of kin when a prisoner dies. In the man’s case
Hull decided that it would be quicker for staff from the prison nearest to his
mother to visit the family in person, than for staff to travel to
Middlesborough from Hull. Contact was made with HMP Holme House
and the Deputy Governor there visited the man’s mother at home to break
the news. I am satisfied that the decision for staff from Holme House to
break the news to the family was sensible. A governor from Hull prison
spoke to the man’s mother by telephone later the same day and visited the
family on 30 April to return his property. The governor also went to the
funeral and the prison met the costs. I am satisfied that every effort to
provide effective family liaison was made.
31. It is clear from the evidence of staff who saw the man on 23 April, that by
the time his room was unlocked by the officer, he was already dead. The
prisoner who shared the room appeared unaware that the man had died. I
am satisfied that the response by staff was efficient and appropriate.
32. I am also satisfied that all the persons required to be informed of a death
in custody were informed of the man’s death in a timely manner. All
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prisoners who were subject to the Prison Service’s self-harm monitoring
system (ACCT) were reviewed promptly. I am impressed with the notices
issued to staff and prisoners by the Governor and have annexed them to
this report. They were issued promptly and the tone and content are
excellent. I draw them to the attention of the Prison Service as examples
of good practice.
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CONCLUSION
33. The man had been in poor health for a number of years. He was
transferred to Hull in 2007 because he required access to 24 hour
healthcare provision. His health was already challenging to manage by
the time he was diagnosed with a terminal illness and suffered a major leg
wound that would not heal. I am satisfied that the care he received in Hull
was timely, appropriate and consistent with that he would have expected
in the community.
34. I am however disappointed that, despite attaining category C and then
category D status almost a full year before his death, an appropriate
prison providing the man with the healthcare and resettlement support he
needed could not be found. This is no reflection on Hull who made every
attempt to find a place for him in a lower category prison. It should
however be a subject of concern for the Prison Service as a whole. Whilst
I make no recommendation, I draw the matter to the attention of the
National Operating Officer.
35. The man was obviously popular with staff and his death, particularly its
suddenness, was obviously upsetting for all those who looked after him.
The way in which his needs were managed does credit to Hull prison.
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RECOMMENDATIONS
1. The Head of Healthcare at Hull and the PCT should look at ways of
formalising communication between secondary care and prison
healthcare.
2. The Head of Healthcare should review the system of record keeping by
night staff with a view to standardising practice among staff.
3. The Head of Healthcare and the PCT should implement a formal Do Not
Resuscitate policy for use in the care of terminally ill prisoners.
Good practice
4. The content and tone of the Governor’s Notices to staff and prisoners
following the man’s death are good practice.
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