Individual at Swaleside

Investigation into the circumstances surrounding the
death of a man
at HMP Swaleside in March 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2011
This is the report of an investigation into the circumstances surrounding the
death of a man who died from natural causes aged 77 years. He was serving
a life sentence and had been in prison since 1984.
The investigation was led by one of my colleagues. The man listed his friend
as his next of kin. Usually I contact the next of kin to offer the opportunity to
raise any issues for me to investigate. On this occasion both the prison and
the Coroner told me that the next of kin did not wish to be contacted by my
staff. I send my condolences to the next of kin and to all who were touched by
the man’s death.
I am grateful to the clinical reviewer for providing a clinical review of the
healthcare offered to the man in Swaleside. I received her final report on 1
July 2010. The delay in issuing this report is mine alone and I apologise for
any inconvenience which this has caused.
I am also grateful to the member of staff at HMP Swaleside who acted as
liaison for the investigator and to the Governor and staff for their co-operation
with the investigation.
The man died after a long period of ill health. He resisted accepting medical
treatment which contributed significantly to his death. He was looked after as
an inpatient in Swaleside’s healthcare centre for some three and a half years.
I conclude that he received a high standard of care there. Unfortunately I have
found that the issue of his wish not to be resuscitated was handled badly. The
result was a distressing experience for the member of staff who found him
apparently dead in March. I make one recommendation to prevent this
happening again.
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
Acting Prisons and Probation Ombudsman May 2011
2
CONTENTS
Summary
The investigation process
HMP Swaleside
Key events
Issues considered
Conclusion
Recommendations
3
SUMMARY
The man was sentenced to life imprisonment in 1984. He had no contact with
his family from this point on. He was a Jehovah’s Witness and had very
strong views about the treatment of certain illnesses.
He was diagnosed as suffering from bi-polar disorder (manic depression – a
condition in which sufferers experience violent mood swings) in 1990. He was
prescribed lithium to treat his condition. Prolonged use of lithium can cause
renal (kidney) impairment/failure and he had regular blood tests to monitor his
renal function.
He transferred to HMP Swaleside in 2003. In 2006 a blood test showed some
renal impairment and his lithium dosage was reduced. He began to suffer
from incontinence and was moved to the in-patient unit in November 2006.
His renal function continued to deteriorate. The prison doctor and other
healthcare staff consistently advised him that he required hospital treatment
but he refused to go to his appointments. Staff monitored him closely and
regular care plans were implemented.
On 3 February 2010, a blood sample revealed that he was suffering from
renal failure. He agreed to be admitted to hospital on 8 February. Following
an ultrasound scan he was diagnosed with renal failure due to high pressure
chronic retention of urine caused by an enlarged prostate gland. The
condition was treatable and required him to have a catheter to drain his
bladder and then prostate surgery, although the extent to which his kidneys
would recover was uncertain. He refused to be treated and the hospital
discharged him against their advice.
On 11 February a resuscitation status form was completed by staff from the
hospice. With the man’s consent, the form provided that he should not be
resuscitated if his heart stopped. This form was countermanded by the prison
doctor on 4 March because he erroneously believed that it was invalid.
The man died in March. Staff attempted to resuscitate him. I conclude that
he received overall a very good standard of care at Swaleside but the
confusion about his resuscitation status resulted in his wishes not being
abided by and distress for staff.
I make one recommendation that Swaleside adopt a policy regarding the
resuscitation status of terminally ill prisoners.
4
THE INVESTIGATION PROCESS
1. I was notified of the man’s death on 22 March 2010. The investigation was
allocated to an investigator on the same day. Notices were issued to staff and
prisoners at Swaleside telling them that an investigation would be taking
place, and inviting those who wished to see the investigator to make
themselves known. The investigator did not receive any response to these
notices. Another of my investigators, who was in the prison on another matter
on the day following the death, opened the investigation.
2. The investigator spoke to the liaison officer and arranged for the man’s prison
record to be sent by post.
3. A clinical review of the man’s medical care was commissioned from the local
Primary Care Trust (PCT). A clinical reviewer undertook the review.
4. The investigator and clinical reviewer visited Swaleside on 7 June and
interviewed five members of staff. They also met the Governor and gave him
detailed feedback from the interviews.
5. The man had not had any contact with his family since his conviction in the
1980s and had named a friend as his next of kin. Although listed as the next
of kin, his role was as executor and he was not in touch with him in a personal
capacity. His friend asked not to be contacted by my office.
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HMP SWALESIDE
6. Swaleside opened in 1988 and forms part of the cluster of three
prisons on the Isle of Sheppey in Kent. Each prison retains a
dedicated Governor and its own identity but the cluster is run by a
single Chief Executive. The establishment is primarily a Category B
Lifer Main Centre training prison but now also holds a number of lower
category prisoners serving shorter sentences who were transferred
from HMP Lewes. As a training prison it runs a number of educational,
practical and offending behaviour courses. At the time of the man’s
death it had an operational capacity (maximum overcrowded capacity)
of 1,132 and a certified normal accommodation (uncrowded capacity)
of 1,112.
7. The prison has an 18 bed in-patient unit in the healthcare centre (HCC)
providing 24 hour care for the most seriously ill prisoners. In addition
there is a GP service on Monday to Friday with out of hours care
provided by South East Health. The prison has primary and secondary
mental health care teams and good links with the palliative care team
in the local hospice.
8. Her Majesty’s Inspectorate of Prisons last inspected Swaleside in a full
announced inspection in 2008. Swaleside was found to be a safe and
respectful prison but it lacked sufficient purposeful activity for a large
training prison.
9. The Independent Monitoring Board (IMB - a voluntary organisation that
monitors standards in prison) report for 2009-2010 concluded that
Swaleside is a well run prison with good staff prisoner relations and an
effective personal officer scheme. Commenting specifically on health
care, the report said that staff had to meet the needs of some very
complex and challenging patients. Recruitment is a big issue because
of the relatively isolated position of the prison and agency staff are
used regularly.
10. Shortly after the man’s death General Practitioner (GP) services began
to be commissioned from the local hospital to try to ensure equivalence
with GP services in the community.
6
KEY EVENTS
11. The clinical review at annex 1 contains a detailed chronology of the
man’s mental and physical health during the entirety of his time prison.
This section of my report concentrates on events from September
2006, when he first showed signs of renal impairment, until he died in
March 2010.
12. He was first prescribed lithium to treat bi-polar disorder (a condition
then known as manic depression and characterised by severe mood
swings) in 1990. He was still taking lithium when he transferred to
Swaleside on 8 April 2003. Sustained use of lithium can impair renal
(kidney) function and his lithium levels and renal function were tested
regularly via blood tests. The mental health team reviewed him
regularly because of his bi-polar disorder.
13. On 4 September 2006, routine blood tests showed that his renal
function had become impaired. He had not been suffering from any
symptoms associated with bi-polar disorder so his lithium dose was
reduced in case this was affecting his kidneys. On 10 October wrote to
a consultant in renal medicine at hospital asking for advice. In his letter
the doctor said that the man’s GFR (glomerular filtration rate) indicated
stage three (moderate) renal impairment but that otherwise he was “fit
and sprightly” for his age. It is not clear from the man’s electronic
medical record what the outcome of this letter was as there is no reply
from the consultant on the record.
14. Less than a month later on 6 November, he was transferred to the
healthcare centre (HCC) as an inpatient. He had become incontinent
and was struggling to cope on a normal wing. At interview the Head of
Healthcare told my investigator that the man had been moved to the
HCC for reasons of decency as well as for medical reasons.
15. The man’s renal function appeared to stabilise but on 10 May 2007 a
blood test showed that his lithium level was raised. His dose was
reduced again. In early August, the prison doctor referred him to the
hospital when tests showed his renal function had diminished again.
He refused to go to hospital. According to his clinical record he told the
doctor that he was worried he would contract MRSA (methicillin
resistant staphylococcus aureus – the so called ‘super-bug’). The
doctor said at interview that he concluded that the man was a mentally
competent adult who was entitled to refuse treatment.
16. By late August, blood tests showed a further decrease in his renal
function. The doctor discussed his case with a consultant from the
hospital and he advised him to stop the man’s lithium and substitute it
with a mood stabiliser called lamotrigine. He accepted this change in
medication but continued to refuse to attend hospital to see a renal
specialist.
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17. On 21 September 2007, the doctor wrote to the consultant in the
department of renal medicine at the hospital. It is clear from the letter
that the doctor had contacted the consultant previously and it had been
arranged for the man to attend a renal clinic on 24 September and
have blood and urine tests. In his letter, the doctor told the consultant
that the man had refused to go to hospital. He said that he had quoted
to him the number of deaths from MRSA in hospitals and the number of
accidents in accident and emergency departments. The doctor again
accepted that he was a competent adult and entitled to refuse
treatment. He added that the man had allowed him to take blood
samples himself and asked the consultant to share the results with him
in due course.
18. The doctor wrote to the same consultant on 29 November 2007,
thanking him for his reply (which I have not seen) and telling him that
the man had now agreed to attend hospital for tests. I am not certain
from the record exactly what happened after this but he did not go to
hospital. Another blood sample was taken by the doctor on 11
December and the record shows that it was subsequently lost by the
hospital. On 5 January 2008, the man is recorded as telling Healthcare
Officer A (HCO) on several occasions that he remained convinced that
he would contract MRSA if he went to hospital.
19. In November 2007, the consultant psychiatrist who monitored the
man’s mental health had discussed drawing up an advance health care
directive (instructions given by individuals specifying what actions
should be taken for their health in the event they are no longer able to
make decisions due to illness or incapacity) with him. However in
January 2008, the man told a psychiatrist from the prison Inreach team
that he did not want to sign a directive.
20. The prison doctor drew up a new care plan for him on 8 February 2008.
The plan described the symptoms of renal failure that health care staff
should record and monitor. His blood pressure and weight were to be
measured weekly.
21. The doctor reviewed him again in March 2008. Another renal failure
care plan was devised. The man told him that he had not been taking
his lamotrigine because he blamed it for his decreasing renal function.
He refused to have any treatment or tests including further blood tests
to check his renal function.
22. On 23 May 2008, the doctor wrote a third time to the renal consultant at
the hospital. He described the man’s renal impairment as stage four
(severe). He told the consultant that the man had asked him to write
as he was now willing to go to hospital. He had not consented to a
blood test since the previous December. He continued to refuse to
give a sample. On 7 August another doctor, (a locum doctor), told him
that he needed to give a sample so that the consultant could treat him.
8
23. The prison doctor wrote a further letter to the consultant on 1
September, asking for advice. He said that the man had again asked
him to refer him to hospital but at the same time held firm in his desire
not to accept treatment. The doctor told the consultant that he felt the
best way forward was for an appointment to be offered and to see how
the man responded. An appointment was made for 20 October but he
refused to attend on the day.
24. A care plan review on 8 November 2008 reaffirmed that he continued
to refuse all medical intervention including going to hospital. The
doctor wrote in his clinical record on 27 November that the man had
told him he was even more determined to decline treatment as he had
been feeling better. He also refused a blood test. The doctor again
advised him that he needed to go to hospital.
25. On 31 December, the doctor spoke to him in an attempt to persuade
him to agree to treatment for his renal impairment. He wrote in the
man’s medical record that he had reiterated his determination not to
have treatment. He told the doctor that he was flushing out his kidneys
with fruit juices.
26. This situation continued throughout 2009. He remained in the HCC
and his care plan was reviewed regularly. On 2 February 2009, he was
examined by a locum GP because he was refusing to take an antibiotic
that had been prescribed for him. The GP told him that he would need
a blood test and unusually, he allowed a sample to be taken on 6
February. The results showed that he was suffering from uraemia (a
disease that often accompanies renal failure when urea – normally
secreted in urine – is retained in the blood due to poor kidney filtration).
He was also found to be anaemic and was prescribed iron tablets.
27. On 5 March, he told the locum GP that he was feeling low and
struggling to cope with his incontinence. The GP persuaded him to
take an anti-depressant and prescribed Mirtazepine. Later the same
month he reported that he was sleeping better as a result of taking
Mirtazepine.
28. The prison doctor reviewed him on 23 March. They discussed options
for managing his incontinence and he agreed to have another blood
test to measure his prostate specific antigen level (PSA - a test that
highlights whether prostate cancer may be present). This was taken
the next day and the results in April showed a low count. He had
another blood test on 20 April to determine his full blood count. The
results showed nothing new.
29. The doctor examined him on 28 May, 16 June and 3 August and again
discussed options to ease his incontinence. At the review on 16 June,
he reiterated to the doctor that he did not want any treatment or
interventions because his self-medication by drinking fruit juice meant
9
“everything is under control”. He specifically told the doctor that he did
not want to go to hospital. He repeated this assertion on 3 August.
30. His appetite decreased during September and October and he was
prescribed Fortisips (a high calorie drink for people who have difficulty
eating). The doctor reviewed him on 22 October. Once again he
advised the man that he needed treatment for his renal impairment and
once again he declined any treatment and said he would not go to
hospital.
31. By November 2009, he was complaining of fatigue and was
consistently losing weight. On 6 November, an entry in his electronic
medical record reads “the man is looking weaker day by day”. He
allowed staff to take regular blood samples. In December, he was
diagnosed with heliobacter pylori (a bacteria causing inflammation of
the stomach lining) but refused to take medication to relieve the
condition.
32. On 18 January 2010, the man agreed to have treatment for his
heliobacter infection but rejected any treatment for his renal failure.
The doctor saw him again on 25 January. He noted that he had told
him that he was worried about the deterioration in his health and would
prefer to be in a hospice. The doctor told him that he would have to be
referred to a hospice which was likely to want evidence of his current
state of health. This meant that he would have to have tests and
scans, probably in hospital. The doctor reported that the man’s
response was “I will have none of those, it’s all meaningless ritual”.
They left it that referral to a hospice would be difficult if he did not
agree to tests.
33. The man allowed another sample of his blood to be taken on 3
February 2010 and this revealed that his renal function had
deteriorated further and was consistent with stage five (failure - end
stage kidney disease). He agreed to be admitted to hospital on 8
February. Following an ultrasound scan he was diagnosed with renal
failure due to high pressure chronic retention of urine caused by an
enlarged prostate gland. The condition was treatable and required him
to have a catheter to drain his bladder and then prostate surgery,
although the extent to which his kidneys would recover was uncertain.
34. He refused the proposed treatment. The hospital doctors considered
he was of sound mental capacity and understood the consequences of
his actions. He was therefore discharged on 11 February and returned
to Swaleside. The hospital wrote to Swaleside the same day outlining
what had happened and confirming that he had discharged himself
against their medical advice. The prison doctor was on leave and a
senior nurse responsible for palliative care at Swaleside completed a
referral form to a hospice the same day. Because he refused to be
treated, his condition was deemed to be terminal.
10
35. The next day, on 12 February, the man was visited by the Clinical
Nurse Specialist from the hospice. She spent some time with him and
advised him that his condition could deteriorate quite rapidly. With his
consent, she completed a resuscitation status form (a form used for
terminally ill patients setting out their cardio pulmonary resuscitation
status – in this case stating that he did not wish to be resuscitated in
the event his heart stopped).
36. The form was signed by the Clinical Nurse Specialist and by an
Associate Specialist from the hospice. The man and the senior nurse
were also given advice on the medication appropriate for terminal care.
The form was left for the prison doctor to see when he returned from
annual leave.
37. The man’s medical record shows that he received regular checks from
healthcare staff and nurses. On several occasions staff recorded
conversations in which he reiterated his wish not to receive the
treatment recommended by the hospital.
38. On his return from leave, the doctor visited him on 2 March. He told
the doctor that he had been unable to accept the treatment proposed
by the hospital because it did not “match his principles or beliefs”. The
doctor wrote that he appeared more mentally and physically vigorous
than when he had been taken to hospital on 8 February.
39. On 4 March, the doctor wrote in the man’s electronic medical record
that he had read the ‘not for resuscitation’ form completed on 12
February by staff from the hospice. He said that it appeared that the
man had been referred to the hospice without the blessing of a doctor
in charge of his care from either the prison or the hospital. He added:
“Resuscitation form is invalid.
“This form … is invalid for:
1. Not verified by name of the appropriate person, not
signed, not dated.
2. The section ticked ‘the patient is already fully aware that
he is dying” is rather contentious. This man ha always
been fully mobile without physical disability. He is
capable of physical and mental self-caring.
“Resuscitation form as it stands should be ignored by all staff.
For clarity the man reverts to the default position for normal
patients: i.e. he is for resuscitation until such a time that a valid
status form is in place.”
40. At interview, the doctor said that he was not familiar with the particular
type of form used and thought that it had needed a signature from a
doctor or consultant. He said that he had not approved of the senior
11
nurse referring the man to a hospice in his absence. He felt he had
built up a good relationship with him over a number of years and had
often been the only doctor who he would accept treatment from. The
doctor felt that he should have been involved in the process. He told
my investigator that he had returned the form to the nurse and told her,
“If you are going to do this, then get it done properly.”
41. He said he did not follow up what had happened to the form after he
spoke to the nurse and neither did he make any alternative
arrangements to ascertain the man’s wishes. With hindsight he
realised that he should have done so, but said that he did not think of
him as being close to death. At the time he thought that the
involvement of hospice staff was premature. He was aware that the
man did not want to be resuscitated and thought that, clinically, this
was the correct decision.
42. The doctor examined him again on 8 March. He recorded in the
electronic medical record that he complained of swollen legs, nausea
and shortness of breath. Two days later, on 10 March, he agreed to
have blood and urine samples taken. By 15 March, it was noted that
he appeared increasingly frail and weak. Staff checked him every hour
during the day and regularly during the night. On 18 March, his clinical
record shows that he was eating very little but was not in pain. He was
described as lethargic and disorientated.
43. The duty doctor examined the man on 19 March and found him to be
very confused. The doctor asked that he should be transferred to the
hospital for assessment. Healthcare Officer B wrote in the electronic
medical record that he agreed to be taken to hospital but was
“confused and cantankerous”. The next day the Head of Healthcare
wrote in the record that the man had once again refused treatment at
hospital and so he was taken back to the prison.
44. Nurse A was on duty on the HCC on the night of 21/22 March. At
interview she said she was usually based on the out-patient unit but
worked on the in-patient unit some evenings. Although not responsible
for his care, she had come into contact with the man previously. She
described him as a lively character and said that she got on well with
him.
45. She said he was sitting on the end of his bed when she made her first
check of every patient on 21 March. (The checks were made by
looking through the observation panel and did not include direct contact
with the prisoners.) The nurse described him as looking “grey and
ghastly”. She asked him how he was and he replied, “Not too good”.
After she had completed her count of the patients she went back to see
him and he told her that he did not feel well. She said she asked him if
he wanted to go to hospital but he replied he did not. She told my
investigator that she was aware that he held strong views about going
to hospital and usually refused to go. She said that if she had not
12
known about his views she would have asked the night orderly officer
to arrange an escort to hospital that night.
46. The nurse described him as “fidgety” and said he looked as though he
could not get comfortable. She checked him frequently and each time
he was sitting on the edge of his bed, awake and with the light on. She
offered him pain relief medication but he refused. At about midnight
and again at 00.30am she said she saw him sitting on his toilet. She
told him that she was worried about him and that he could not spend
the whole night on the toilet in case he fell. She watched him get back
into bed. He was drinking lots of water but told her he did not want to
lie down as it was too painful.
47. She said that she checked on him again at about 4.00am. He was still
sitting on the edge of his bed and told her he was “too frightened to lie
down”.
48. When she checked again for the morning roll check at 6.15am, he was
lying back on the bed as if he had fallen backwards from the position
he had been sitting in. At interview she said that when she saw him
lying back on his bed she realised that he had died. She knew that he
did not want to be resuscitated but that there was an instruction on his
medical record that staff should attempt resuscitation.
49. The nurse did not carry keys to open the cell and so she used her radio
to call for the night orderly officers. She said they arrived within a
minute and unlocked the door. She said his pupils were fixed and
dilated. The staff began to administer cardio pulmonary resuscitation.
She used a face mask to begin recovery breaths and one of the night
orderly officers did chest compressions. They continued to do this until
the paramedics arrived and attached a defibrillator to him. There was
no electrical activity in his heart and the paramedics pronounced that
he had died.
13
ISSUES CONSIDERED
The general clinical care afforded to the man
50. From reading the man’s extensive prison clinical record and from
interviewing some of the staff who cared for him, it is apparent that he
had very definite views on what medical treatment he would accept.
He was a Jehovah’s Witness and this informed some of his principles.
The prison doctor told my investigator that the man was an avid reader
of newspapers and retained a lot of information from them on certain
health related subjects. A case in point was his extreme reluctance to
attend hospital because he was afraid of catching the MRSA super-
bug.
51. As the clinical reviewer points out, under General Medical Council
Guidelines and case law, the man was entitled to refuse medical
treatment and the doctor was required to respect his decision.
Although his strong views meant that caring for him was sometimes
challenging for healthcare staff, it is clear that significant effort was
made to look after him within the limits which he himself imposed. In
her clinical review she gives credit to the doctor for continually
reviewing the options for treatment with the man and documenting
what he would and would not accept at various times.
52. The clinical reviewer also comments that it was good practice to admit
him to hospital once his renal function had deteriorated significantly. At
interview the doctor spoke in detail about his relationship with him.
Clearly their relationship was good with regular contact which meant
that he was sometimes able to persuade him to accept blood tests and
other treatment.
53. The man’s clinical record contains copies of regularly reviewed care
plans. Entries in the record clearly show that a number of staff spent
considerable time talking to him and trying to find ways of best
managing his symptoms, especially his incontinence. He was provided
with pads and more regular laundering of his clothes and bedding was
organised. During the last months of his life, the senior nurse and
other staff made significant efforts to provide him with a diet that he
could tolerate. Milk and yoghurts were ordered specially for him from
the kitchen and clear instructions were written to staff to make sure that
he had access to them.
54. I consider that the healthcare provided to the man was of a high
standard. Staff spoke with obvious affection for him and with tolerance
of his views about treatment. In her clinical review the clinical reviewer
commented that:
“The nursing staff caring for the man respected his rejection of
medical care and sympathetically helped him deal with his
incontinence.”
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The man’s resuscitation status
55. The man’s refusal of life saving treatment from the hospital in February
2010 meant that his renal failure was deemed to be terminal.
Accordingly the senior nurse contacted staff from a hospice. They
spoke at length to him about the implications of his refusal of treatment
and what was likely to happen to him in his final weeks or months. As
a result, a resuscitation status form was completed that indicated that
restarting his heart would not provide any benefit. The form was
completed with his consent.
56. I consider that the nurse’s decision to involve staff from the hospice in
February was reasonable. The man was by that stage very ill and his
refusal of potentially life saving treatment meant that his condition was
likely to prove fatal in a relatively short space of time. By all accounts,
including that of the prison doctor, his wish was that he should not be
resuscitated. He is not on record specifically stating this but I have no
reason to believe that it was not the case. I am satisfied that
completing the resuscitation status form was therefore also reasonable.
57. The form was left in the doctor’s in-tray pending his return from leave in
early March. He told my investigator that he did not approve of the
nurse contacting the hospice as he thought that her action was
premature and he should have been involved in the decision. He also
thought that the paperwork needed to be signed by a doctor or
consultant and was therefore invalid. He returned the form to the nurse
and did not follow up what had happened to it. He wrote on the man’s
medical record that the form was invalid and staff should attempt to
resuscitate him if his heart stopped.
58. The head of healthcare told my investigator that when he saw the
doctor’s entry on the medical record he asked staff from the hospice for
advice. He was informed that the fact the form had not been signed by
a doctor did not affect its validity. He said that it had been difficult to
know how best to advise staff in these circumstances. After
consideration, he decided not to contradict the doctor and so staff were
advised to resuscitate the man should the need arise. There is no
record whether the man was aware that the doctor had changed his
resuscitation status back to ‘resuscitate’ or what he thought about it.
59. In her review the clinical reviewer comments that, in her opinion, the
doctor should have been guided by the fact that he knew that
resuscitation would be futile. The doctor could then have planned a
dignified and pain-free end to the man’s life. The very unfortunate
consequence of his action was that the man was resuscitated against
his wishes by staff who knew that he would have been opposed to their
actions. The doctor accepted this at interview and said that, with
hindsight, he realised that this must have been distressing for staff,
especially Nurse A who knew the man well. The nurse herself told my
15
investigator that she had found the experience of trying to resuscitate a
man, who she judged to have died and who she knew did not want to
be resuscitated, very distressing.
60. Clearly there was some confusion at Swaleside about the validity of the
resuscitation status form. I do not make a judgement on the Head of
Healthcare’s decision not to contradict the doctor. The situation was
obviously delicate. However, I believe that as a general principal a
patient’s wishes in this matter should be respected. The doctor was
not familiar with the form used by the hospice and believed erroneously
that it was invalid without a doctor’s signature. Swaleside is a prison
with a significant number of life sentence prisoners. It stands to reason
that some of these lifers are liable to die in prison and it would
therefore be sensible for Swaleside to adopt a policy on the question of
the resuscitation of terminally ill prisoners.
I recommend that the Partnership Board of the Primary Care Trust
ensures that the prison has an effective policy on do not
resuscitate decisions for terminally ill prisoners. The policy
should be consistent with the British Medical Association
guideline ‘Decisions regarding cardio-pulmonary resuscitation’.
The policy should include guidance to healthcare staff on how to
document such decisions.
The prison’s response to the man’s death
61. The control room incident log shows that a Senior Officer (SO), the
Night Orderly Officer, was informed that the man was unresponsive at
6.17am. The SO and two officers went directly to the healthcare centre
and went into the cell. In his statement the SO said that his first
impression was that he was dead. He used his radio to ask the control
room to call for an ambulance and then he and Nurse A and Officer A
began cardio pulmonary resuscitation (CPR). The nurse had received
refresher training in CPR and the use of a defibrillator in February
2010.
62. The control room log shows that the ambulance arrived at the prison
gate at 6.33am and in healthcare at 6.35am. Two paramedics
attached a defibrillator to the man but it showed there was no electrical
activity in his heart. The paramedics pronounced him dead at 6.43am.
63. The friend identified by the man as his next of kin was contacted by a
Principal Officer. The friend confirmed that he did not know him well
but was acting as his executor. He did not want to be involved in any
investigation into his death.
64. I am satisfied that the prison’s response to the man’s death was timely
and efficient, notwithstanding my comments above about the question
of whether resuscitation was appropriate.
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CONCLUSION
65. The man’s firmly held views on medical treatment meant that he could
be a challenging patient. Despite this, I have found that staff at
Swaleside offered him a high standard of care. Whilst respecting his
views, they tried throughout his long illness to persuade him to accept
medical treatment. They treated issues such as his incontinence
sympathetically. The prison doctor was his regular doctor and they
clearly had a good relationship. Unfortunately the doctor’s decision that
the resuscitation status form was invalid meant that attempts were
made to resuscitate him, against his previously expressed request.
This was very distressing for staff, as well as being a demeaning and
undignified response to his clearly expressed wishes. Swaleside has
many life sentenced prisoners and I hope that my recommendation will
benefit others who are terminally ill.
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RECOMMENDATIONS
1. I recommend that the Partnership Board of the Primary Care Trust
ensures that the prison has an effective policy on do not resuscitate
decisions for terminally ill prisoners. The policy should be consistent
with the British Medical Association guideline ‘Decisions regarding
cardio-pulmonary resuscitation’. The policy should include guidance to
healthcare staff on how to document such decisions.
The National Offender Management Service accepted this
recommendation at draft report stage and commented:
“The NHS South East Coast, End of Life Care, Clinical Advisory
Group overarching principles for NHS and voluntary sector
organisational policies on Do Not Attempt Cardio-Pulmonary
Resuscitation (DNACPR) has been ratified and implemented as
policy for Sheppey Prison Healthcare.”
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