Individual at Cardiff

Investigation into the circumstances surrounding the
death of a man in April 2010, at hospital while in the
custody of HMP Cardiff
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2011
This is the report of the investigation into the circumstances surrounding the
death of a man at hospital. He was a Cameroon national and was admitted to
hospital on 22 March 2009. Hospital staff carried out tests and discovered
that he was human immunodeficiency virus (HIV) positive with hepatitis B.
(HIV is a serious disease affecting the immune system and hepatitis B is a
liver disease.) On 1 April, medical notes record that he had contracted
tuberculosis (TB). The following day, he died suddenly at 4.45pm. He was 29
years old. I extend my sincere condolences to his partner, family and friends.
Her Majesty’s Coroner for Cardiff held an inquest into the man’s death in
September 2010. The inquest found that his death was due to natural
causes, specifically tuberculosis and HIV.
An investigator was appointed to investigate the circumstances of the man’s
death on my behalf. Healthcare Inspectorate Wales (HIW) was
commissioned to carry out a clinical review of his medical care whilst at
Cardiff. I am grateful to HIW for its review, which is the first annex to this
investigation report. HIW has identified missed opportunities before he was
referred for specialist treatment and also that his care was un-coordinated.
I would like to thank the Governor of HMP Cardiff and his staff for their help
and assistance with this investigation. Furthermore, I would like to thank the
safer custody manager for his support in the role of liaison officer. Enquiries
were made with the United Kingdom Border Agency (UKBA) and I would like
to acknowledge their help and that of a caseworker.
I make seven recommendations: six are for the Head of Healthcare and refer
to the transfer of prisoners for specialist treatment, nursing and care plans,
appointments with healthcare services, tracking secondary care services,
secondary healthcare screening and prisoner’s medical history. The last
recommendation is for the attention of the Governor and relates to the use of
restraints which were left in place whilst the man was having invasive medical
tests. I acknowledge two areas of good practice and two additional
recommendations made in the clinical review.
In this final report one recommendation has not been accepted regarding the
secondary health screen, one recommendation has been partially accepted
relating to prisoners’ previous medical history and the remaining five
recommendations have been accepted. The man’s family could not be traced
therefore a copy of this report will stay on file should they contact my office at
a later date.
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 March 2011
2
CONTENTS
Summary
The investigation process
HMP Cardiff
Key findings
Issues
Conclusion
Recommendations
3
SUMMARY
The man was remanded to HMP Cardiff following a court appearance for
fraud on 14 October 2009. He was a foreign national prisoner from
Cameroon and would have been deported at the end of his sentence.
A first reception health screen form to assess the man’s current and medical
history was completed. He told the nurse that he was not registered with a
doctor and had not seen one for some time. He added that he did not have
any physical illnesses. His weight was 89 kilograms (14 stone) and he was
1.90 metres (six feet two inches) tall. He was allocated a shared cell on a
wing. A routine follow up health screen was not completed and so further
medical observations were not taken.
The doctor treated the man for a groin abscess on 20 October, with antibiotics
and pain relief. The following day, it was noted that the abscess had reduced
in size. He did not attend a follow up appointment on 28 October, as he had a
visit from his family.
On 4 December, the man was examined by the doctor after he complained of
acne spreading across his face and chest. A further course of antibiotics was
prescribed. He did not attend a follow up appointment in January 2010, but
was seen on 12 February where his acne was reviewed and the prescription
of antibiotics continued.
The man was examined by Prison Doctor A on 15 March. He was unwell with
bleeding gums, vomiting, a sore mouth and blood in his urine. He told the
doctor that he had lost 19kgs since his arrival at Cardiff. The doctor took a
blood test to be sent for analysis. He told the doctor that he had had an HIV
test the previous year which was negative. (In fact, it is clear from his
immigration file that he was diagnosed with HIV in 2007.)
The following week, the man was examined again by the doctor. He had lost
more weight and his symptoms were persistent. The doctor recorded that she
rang the hospital for the results of the blood tests taken the previous week, as
they had not arrived at Cardiff, and was told that they could not trace a patient
of that name or date of birth, so she took a full set of tests and asked for them
to be urgently analysed. A second doctor at Cardiff who saw the man later
that same day spoke to the hospital and was given the results of the blood
tests from 15 March. He was transferred to the healthcare unit that afternoon.
Later that evening, he was escorted to hospital, as the blood test results
revealed that his condition was cause for urgent concern.
The man underwent medical investigations and he was confirmed as HIV
positive. Following a minor surgical procedure, he was further diagnosed
with tuberculosis. On receipt of this information, the restraints were removed
and escort staff monitored his security through an adjacent room. On 2 April,
he deteriorated and did not respond. Cardio pulmonary resuscitation (CPR)
was started by hospital staff but he died at 5.45pm.
4
I make seven recommendations for the attention of the Governor and Head of
Healthcare, particularly regarding delays before specialist treatment was
obtained and lack of coordination. I also comment on the use of restraints
whilst the man was undergoing an invasive medical procedure. I note two
areas of good practice and acknowledge two recommendations made in the
clinical review.
5
THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened on 15 April 2010,
when the investigator visited Cardiff. She met the Governor, the
Deputy Governor, the Safer Custody Manager, and a representative of
the Prison Officer’s Association. No member of the Independent
Monitoring Board (IMB) asked to see her but her contact details were
made available to them. (The IMB are volunteers from the local
community who monitor the day to day life of the prison and prisoners.)
2. Notices of the investigation and the Ombudsman’s terms of reference
were sent in advance of the investigator’s visit. (At the time of
circulation of this report no responses have been received to those
notices.) Later, she informally spoke to the Head of Healthcare and a
doctor.
3. The investigator reviewed the man’s prison and medical file and asked
for copies of those documents to be sent to her. A review of his
medical care was commissioned from the Healthcare Inspectorate
Wales (HIW).
4. On 20 April, the investigator telephoned a case worker at the UKBA
and asked for documents from the man’s immigration file to be sent to
her. The investigator spoke to a bedwatch officer on the telephone on
17 May to clarify the use of restraints and protective measures taken
during a surgical procedure.
5. One of my family liaison officers attempted to contact the man’s
partner. He eventually spoke to a friend who said that she had gone to
France for several months and was not in contact. The friend asked
him to contact another friend of the man’s. The liaison officer
telephoned the number which had been passed to him and left a
voicemail message. However, no contact has been forthcoming from
the friend. A copy of this report will be retained by the Ombudsman’s
office should any of the family or friends request it in the future.
6. Another of my investigators and HIW’s clinical reviewer spoke to the
Head of Healthcare and a doctor.
7. I apologise to the Coroner for the delay in issuing this report which
meant that it was not available before the inquest. Unfortunately, the
clinical review was not completed until October.
6
HMP CARDIFF
8. Cardiff is a local prison with a maximum population of 784 adult men. It
is located very close to the city centre and was originally built in 1827.
As a local prison, the majority of the prisoners have arrived at Cardiff
after making court appearances in South East Wales. As well as
prisoners remanded into custody and those serving short sentences, a
significant number are serving life sentences.
9. The prison has 24 hour nursing cover and 16 inpatient beds. During
weekdays the core healthcare staff work until 5.00pm. Four nurses
continue to work between 5.00pm and 8.00pm. Two nurses then work
between 8.00pm and 9.00pm and from 9.00pm overnight one nurse
remains in the healthcare centre with a member of the prison staff.
That nurse will respond to emergencies and can contact the healthcare
manager out of hours if need be. Using an out of hours’ telephone
service, the nurse on night duty can obtain medical advice, ask a doctor
from a local surgery to attend or summon an ambulance if they have
serious concerns about a patient. All prisoners undergo a health
screening during the first night reception process upon arrival at Cardiff.
10. HM Chief Inspector of Prisons completed an inspection of Cardiff in
January 2008. She found that prisoners were “much more likely to
report feeling safe than at other local prisons”, in the most part due to
“good relationships between staff and prisoners”. The support offered
to newly arrived prisoners was praised and the healthcare offered to
prisoners was thought to generally be of a good standard.
11. The most recent Annual Report by the IMB 2007-2008 noted in its
conclusion:
“The Independent Monitoring Board finds that overall, HMP Cardiff
is a well-run establishment with good relationships between staff
and prisoners. We are aware that financial constraints have
affected the profiling and work-loads of both uniformed and
administrative staff. Since further savings will be demanded of the
prison during the next reporting period, we hope that the effects
will not be detrimental to the positive work that is currently being
carried out. There is only so much extra commitment that can be
expected of the staff who keep the prison running smoothly.”
12. There have been five previous deaths at Cardiff from natural causes
since the Ombudsman’s office took over investigations from the Prison
Service in 2004. None of those deaths had any similarities to that of
the man’s.
7
KEY EVENTS
13. The man arrived at HMP Cardiff on 14 October 2009, following an
appearance at Magistrates’ Court. A first reception health screen form
was completed and it was noted that he was not registered with a
doctor in the community. His weight was 89kgs and he was 1.90
metres tall. He told the nurse that he had been in HMP Hull in 2005
and had harmed himself by scratching his wrists. However, he said
that he did not have any feelings of self harm, no physical illnesses and
was not taking any medication.
14. A routine follow up health screen was not completed. (This health
screening usually takes place up to 72 hours following reception into
prison.) On 20 October, the man had an appointment in the healthcare
unit because of a large abscess in his groin, which had burst two hours
prior to him seeing the nurse practitioner. A doctor prescribed an
antibiotic and pain relief medication of paracetamol and ibuprofen.
15. The following day, the doctor examined the abscess and noted that it
had decreased in size. An appointment was made for the man to
return to the healthcare unit in one weeks’ time. However, he failed to
attend the appointment because of a family visit.
16. The man was next examined by the doctor on 4 December, with facial
acne that was spreading across his chest and back. An antibiotic was
prescribed along with Panoxyl, a treatment for acne. A follow up
appointment for a month later did not take place. My investigator has
seen no record of why he did not attend or if he knew about the
appointment. He was prescribed another course of antibiotics for his
acne on 12 February 2010, following examination by Prison Doctor B.
He was suffering from flu like symptoms but no clinical observations or
tests were undertaken at this consultation. He was advised to return
for a review of his symptoms in four week’s time.
17. On 15 March, Prison Doctor A examined the man in the healthcare unit.
She wrote that he was complaining of a loss of taste in his mouth,
bleeding gums and a dry tongue. He was weighed and it was noted
that he had lost nearly 19 kilograms (three stone) since his reception
into Cardiff five months earlier. His blood pressure was recorded as
167/74 (an average reading is 130/80), and there were traces of blood
and protein in his urine. He told her that he had an HIV test the
previous year which was negative.
18. The doctor prescribed a mouthwash and a steroid paste. She asked
for blood, stool and urine tests to be taken for analysis. An urgent
appointment was made for him to be seen in the genito-urinary
medicine (GUM) clinic, later that day and to be weighed in one weeks’
time. (The GUM clinic specialises in sexually transmitted diseases and
BBV [blood born viruses, hepatitis] conditions.) It was recorded in his
8
medical notes that he did not attend his GUM appointment and went to
another family visit instead.
19. According to his medical records, the man’s blood sugar levels were
tested on 20 March. It is unclear why this was done and nothing else is
noted in his records relating to this test.
20. Two days later, on 22 March, he was examined by Prison Doctor A who
noted that he had lost another five kilograms in weight and there were
still traces of blood and protein in his urine. A blood pressure reading
of 105/77 was recorded and his temperature was normal at 36 degrees.
He told the doctor he was not in pain or experiencing any new
symptoms. She recorded that she made contact with the hospital to
track down the whereabouts of the test results from the previous week
but was told that the hospital was unable to trace the results. The
doctor repeated the tests, which were immediately sent for analysis.
21. The man was transferred from his wing cell to the healthcare unit for
observation at 4.30pm. His medical notes recorded that he was feeling
lethargic and had a poor appetite. A short while later, healthcare staff
received the results from the hospital, taken the previous week, which
had been untraceable a few hours earlier. The result of the tests
indicated an abnormality. Another doctor arranged for him to be
transferred to UHW for further investigations. He left the prison at
6.00pm, escorted by two officers and restrained by an escort chain.
(An escort chain is a 1.8 metre length of chain with one cuff attached to
an officer and the other cuff to the prisoner.)
22. The man was admitted to an assessment ward for tests and
observations. On 23 March, it was recorded in the bedwatch notes that
he asked for money from his prison account to be sent to him at the
hospital so that he could telephone his partner. He was given
intravenous fluids (fluid passed into the body via a drip in the arm) and
observation checks by doctors and nursing staff.
23. The following day, a hospital doctor told the escorting officers that they
should wear a protective apron and gloves when entering the man’s
room. The doctor explained that his blood tests indicated that he had
HIV. This advice was also extended to his visitors. At 4.10pm, he was
visited by his partner and four hours later, he was moved to a general
ward.
24. On 26 March, the man’s partner visited him for two hours during the
afternoon and visited again with a friend the following day. At another
visit two days later, his friend and partner brought some food for him to
eat. Prison regulations do not allow visitors to bring in food and so the
bedwatch officers told them that it was not permitted. The officers
noted that the man, his partner and friend then became hostile. The
officer telephoned the prison to confirm this regulation and was told that
under no circumstances should he be allowed to accept the food. The
9
bedwatch officer offered details of the prison’s complaints procedure
should the visitors wish to challenge the decision. (There are no
documents in his prison file to indicate whether a complaint was made.)
25. Three days later, on 29 March, the bedwatch notes record that the
man’s condition was deteriorating and he was weak, with poor mobility.
26. During the morning of 30 March, the bedwatch officers were told by
hospital staff that he would be taken to another hospital the following
day, for an endoscopy. (An endoscopy is a procedure where a camera
is inserted down the throat to examine the chest and lungs.) One of the
officers, Officer A, telephoned the prison to inform them of this
procedure and that an ambulance would transfer the man to the other
hospital.
27. A governor carried out a management check later that day at 1.25pm.
(Management checks are daily visits by senior prison staff to ensure
the welfare and security of both the prisoner and officers.) No
reference was made to the man’s transfer to the other hospital or the
need to review his security risk assessment. (A risk assessment is a
form completed by a manager to assess the prisoner’s risk to the public
whilst away from the prison. The assessment should be reviewed
when the prisoner’s circumstances or the location changes.)
28. At 9.15am the following day, the man and the bedwatch officers were
taken as planned by ambulance to the other hospital for the endoscopy.
His bedwatch notes said that whilst he was weak, he was still mobile.
The escort chain was used during the journey. It was not removed
during the endoscopy, and remained attached to Officer B, who had to
stay in the room, whilst the procedure was carried out. The second
officer stayed outside the room.
29. Officer B said that the man was lightly sedated during the procedure.
The officer was given full protective clothing to wear (a matter of routine
during surgical procedures). Hospital staff asked him if the escort chain
was essential and he explained that the man was still a prisoner in
custody. The officer was not authorised to remove the chain without
permission and he did not seek advice from prison managers. The
man’s security risk assessment had not been updated since he was
first admitted to hospital one week earlier. The hospital staff expressed
no further concerns about the restraints remaining in place. The man
and the officers returned to the first hospital at 3.30pm.
10
2 April
30. On 2 April at 1.50am, a nurse visited the man in his room. She was
wearing a surgical mask, as well as gloves and an apron. The nurse
told the bedwatch officers that he was moving to an acute ward for
closer observation, as his condition had deteriorated. She also
instructed that all the prison staff should wear face masks when in his
presence as he was being tested for tuberculosis.
31. The Head of Healthcare started an application for the man to be
released on compassionate grounds. (This application was not
completed before his death.)
32. Officer C telephoned the prison to speak to the night orderly officer,
Senior Officer (SO) A. The officer told the SO that both officers on
bedwatch were uncomfortable about being so close to the man as an
airborne infection, thought to be tuberculosis, had been diagnosed.
The SO agreed that the restraints should be removed and he should be
observed from outside his room by looking through the window.
33. At 5.30am, the man was moved to an isolation room on ward A7. (An
isolation room is designed to protect the spread of infection.) Both
officers continued their bedwatch duties from outside this room and
they wrote on the bedwatch notes that a new risk assessment should
be completed. This was done by Senior Officer (SO) B who noted that
he should only have three visitors at a time, they must be escorted and
should wear masks and protective clothing provided by the hospital.
The SO also noted that the consultant had told him that a review of
security arrangements should be undertaken in a week by which time
the man should have responded to treatment.
34. A governor visited the hospital at 12.45pm to make a management
check with the next set of bedwatch officers.
35. Officer D wrote in the bedwatch notes that at 4.22pm, the man went
into cardiac arrest and an emergency response hospital team treated
him. A short time later, hospital staff told the officer that he had died.
His death was certified at 4.45pm.
36. At about 6.00pm, the family liaison officer from the prison’s chaplaincy
and the safer custody manager visited the man’s partner at her home.
Many of his friends were present and his partner declined to speak in
private with them. They left their contact telephone numbers with one
of the friends after breaking the news of the death.
37. Four days later, the family liaison officer left a voice message for the
man’s partner asking her to make contact. On 7 April, the liaison officer
telephoned again. The man’s partner did not wish to talk to her but did
pass on the number of one of his friends. The liaison officer
telephoned the friend and left a message. The friend returned the
11
telephone call and spoke to her, who told him of the prison’s
responsibility to offer assistance with funeral expenses. The friend told
her that the man’s body would be flown back to the Cameroon. She
asked for the name of the funeral directors dealing with his body so that
any financial arrangements could be made directly through them. As
yet this information has not been provided.
38. On 8 April, a meeting was held at the prison between prison staff,
public health officers, hospital staff and other National Health Service
personnel. The purpose of the meeting was to assess whether there
were any public health issues following the man’s diagnosis of
tuberculosis, particularly for prisoners and prison staff. Arrangements
were made for his cellmates and bedwatch officers to be screened for
the disease. It was agreed there was minimal risk to the public but
precautionary measures should be taken.
39. The family liaison officer met the man’s friend at the prison gate on 13
April and handed him the man’s personal possessions. No further
contact has been made by prison staff with any of his relatives or
friends.
12
ISSUES
Clinical care
40. A review of the man’s medical care while in Cardiff was commissioned
with the Healthcare Inspectorate Wales (HIW). For the review, HIW
considered the following points:
(cid:127) Was the level of care provided to the man appropriate and
timely?
(cid:127) Was the man provided with adequate information about his
illness, diagnosis and care options?
(cid:127) Were appropriate care pathways and pain management
arrangements put in place?
Was the level of care provided to the man appropriate and timely?
41. HIW evaluated the information held in the man’s clinical notes whilst he
was in custody at Cardiff. He had told healthcare staff, on his reception
into prison, that he was not registered with a doctor nor had he seen
one for sometime. No medical records were available for healthcare
staff to trace any of his medical history. He had said he had been a
prisoner in Hull. However, their healthcare unit have no record of him
being in custody. A full medical assessment was not undertaken
following his arrival at Cardiff.
42. The man denied suffering from any physical illness when his first
reception health screen was opened by healthcare staff. Prisoners with
underlying medical conditions, such as tuberculosis, HIV or other
potentially serious illness may be reluctant to reveal them. The letter
confirming his diagnosis of HIV in 2007 was held in his UKBA
immigration file which did not contain any other medical notes. The
prison did not have access to the immigration file and therefore
accepted his account that he did not have any contagious medical
conditions.
43. I am careful not to apply hindsight in my investigations and there is no
evidence to suggest the nurse completing the healthscreen should
have doubted the man’s account. I accept that it can be difficult to
balance patient confidentiality with effective controls of contagious
diseases. I therefore acknowledge the recommendation in the clinical
review regarding routine screening of prisoners for tuberculosis and
HIV. However, I am aware that this cannot be enforced because
prisoners cannot be tested against their will.
44. A routine secondary health assessment was not completed and this
should be undertaken as a matter of course for every prisoner. It is
particularly important when a prisoner has not seen a doctor for
sometime and/or his medical history is unavailable. A routine follow up
health screen normally takes place up to 72 hours after the prisoner
13
has arrived in prison. The Head of Healthcare explained to my
investigator that Cardiff does not routinely undertake these
assessments. She described them as “voluntary” and said that most
prisoners, especially younger men, often refuse. HIW’s report notes
that there was no evidence in his medical notes that the man was
offered a secondary health assessment
45. Prison Service Order 3050, continuity of healthcare for prisoners says,
“In the week following first reception, every prisoner must be
offered a general health assessment. This assessment is
equivalent to a primary care assessment when registering with a
new practise in the community.”
46. Furthermore, the man’s medical records from his sentence at Hull were
unavailable, with their healthcare unit saying that they had no record of
him being there, despite him telling the reception nurse that he had
harmed himself whilst in their custody. I therefore endorse the
following recommendations by HIW:
The Head of Healthcare should ensure that secondary health
assessments or general health assessments are undertaken for all
prisoners.
The Head of Healthcare should ensure that every effort is made to
trace a prisoner’s medical and mental health history.
47. On 15 March, after five months in prison, the man told Prison Doctor A
that he had had an HIV test the previous year but it had proved to be
negative. (As I have reported, this information was not correct.) Whilst
he was not seen regularly, he was treated for infections, which could
have indicated a poor immune system, including an abscess and
infected rash (acne). People with HIV are vulnerable to infections,
which are known as ‘opportunistic infections’ as they weaken the
immune system. (Opportunistic infections are caused by bacteria, viral
or fungal. Tuberculosis is a common HIV opportunistic infection.)
48. HIW concludes that the man’s symptoms should have raised suspicion
and he should have been referred earlier for the appropriate tests. The
tests might well have established whether any serious underlying
illness was causing his infections.
49. In October 2009, he was treated for a scrotal abscess. Neither a blood
or urine test was carried out. I understand from HIW’s report that it
would have been good practice to complete a blood count. HIW writes
that “a swab of the infected area of his abscess would have indicated
bacteria” and therefore “highlighted his serious health status”. I agree
with HIW’s recommendation:
14
The Head of Healthcare should introduce mechanisms for the
timely follow up and tracking to secondary care and specialist
services (including diagnostic and microbiology services).
50. Nursing plans for his abscess were not identified in the man’s medical
notes. He did not attend a healthcare appointment after receiving
treatment for his abscess, preferring to have a visit, and there is no
evidence that a follow up appointment was offered or if he had asked
for an alternative appointment. Visits are an important part of prison life
and it is understandable that he wanted to see his family. At that time,
healthcare staff were unaware of the seriousness of his condition. If a
nursing care plan had been in place, it would have recorded the
treatment he received and whether any was outstanding. I endorse
HIW’s recommendation:
In liaison with Cardiff and Vale University Health Board, the Head
of Healthcare should develop appropriate referral pathways to
ensure timely access to specialist services and second opinions.
This should include ‘fast track’ referral processes for prisoners
with suspected serious/terminal illness.
51. The man’s serious weight loss was not noticed until 15 March 2010
when he was examined by Prison Doctor A. He had only been seen
once between December 2009 and March 2010, when he did not tell
the doctor of his weight loss, and neither was he weighed. However, I
believe that losing 19 kgs in five months is excessive given he was so
tall and was not overweight when he came into prison. I acknowledge
that imprisonment can cause stress, which might lead to weight loss.
However, the extent of his weight loss over such a short time was a
clear indication that he was in need of medical attention.
52. I therefore endorse the recommendation made by HIW.
The Head of Healthcare should ensure that plans are in place for
prisoners with on-going health problems to ensure that holistic
care is provided. These plans should include tools for monitoring
weight loss, nutrition and other symptoms such as pain.
53. The man was in denial of his HIV status when he arrived at Cardiff and
still when he saw Prison Doctor A on 15 March 2010. It is evident that
he was treated for seemingly minor illnesses following his reception into
Cardiff. However, he did not report his serious medical problems to
healthcare staff until he experienced severe symptoms. Once it was
noted that he had lost a large amount of weight and was obviously
unwell, like the clinical reviewer I believe that actions should have been
taken to ensure that he attended clinical appointments, or they should
have been re-arranged. I therefore endorse the following
recommendation.
15
The Head of Healthcare should put in place a mechanism for
flagging prisoners with serious and deteriorating health, so that
priority is given to their attendance at clinics and healthcare
related appointments.
54. HIW considered that there were unnecessary delays referring the man
for a specialist review and treatment for his presenting symptoms of
severe weight loss, bleeding gums and dry tongue. The delay getting
the results of his blood tests should have been explored before 22
March when they were found missing. An earlier enquiry should have
been a priority, given his poor physical health when Prison Doctor A
saw him the previous week. Additionally, HIW said:
“It is concerning that the prison doctor leading on the man’s care
appeared not to have noticed the seriousness of his condition
earlier. Investigations undertaken on his admission to hospital
showed that he had advanced HIV/AIDS and he was also
considered to have disseminated tuberculosis.”
55. In the clinical review, HIW said:
“If blood tests had been ordered earlier when the man presented
with abscesses and wide spread acne, his HIV status and
immune system issues would have been known earlier.
Admission to the hospital for specialist assessment and
investigations would have been timelier.”
56. The clinical review raises serious concerns about Prison Doctor A’s
approach to the man’s care. While I do not repeat it, I acknowledge
HIW’s recommendation that the doctor undertakes further training.
Was the man provided with adequate information about his illness,
diagnosis and care options?
57. The man knew about his diagnosis long before he came into Cardiff
prison but he chose not to share the information with the medical
practitioners. He was not told of the seriousness of his medical
condition and the care options until he was admitted to hospital. It then
became quickly apparent that he was extremely ill. In these particular
circumstances I do not believe that more information could have been
shared with him or with his family.
Was there appropriate follow up after the man’s transfer to hospital?
58. There was little proof of care pathways and care plans in the man’s
medical notes. HIW commented:
“The absence of any evidence of nursing input and care plans is
of serious concern, as is the lack of any sense of urgency with
16
regard to seeking a specialist opinion of hospital referral, up until
the afternoon of 22 March 2010.”
59. The transfer of a prisoner to hospital for in patient care should be
regularly followed up by healthcare staff to record their treatments and
ongoing medical care. There is a gap in the medical notes from 23 to
31 March, where no information is recorded as to the man’s condition in
hospital. HIW noted that there was no explanation as to why the
medical notes show no contact between hospital and healthcare staff.
However, it is evident that the bedwatch notes indicate that there were
five points of contact between the healthcare unit and the hospital.
Therefore it would have been appropriate for those points of contact to
have been noted in his medical record.
60. HIW concludes the review by saying:
“There are many aspects of the man’s care that we (Healthcare
Inspectorate Wales) consider to have been questionable and
flawed. Opportunities were missed that would have helped to
achieve an earlier diagnosis and more timely treatment. Further
we consider his care to be fragmented and un-coordinated with
no evidence of care planning or nursing input.”
Use of restraints on 31 March 2009
61. The man was transferred from the first hospital to another for an
endoscopy on 31 March. This is an invasive procedure which is
conducted in sterile conditions. Throughout the procedure, the escort
chain remained in place and was attached to one bedwatch officer who
had to wear protective clothing and stay in the same room. The officer
wrote on the bedwatch notes that although hospital staff asked if the
chain was essential, they did not express any issues about it remaining.
The previous day, Officer A had informed the prison of the appointment
at another hospital. A management visit had taken place after the
information was passed on and before the procedure took place.
Nevertheless, the security risk assessment was not updated to reflect
that an endoscopy was to be carried out.
62. Whilst the security of the public and hospital staff is fundamental, I
believe that using an escort chain during a medical procedure such as
an endoscopy is inappropriate. The man was weak and his mobility
was poor. The risk assessment should have been reviewed and
considered the removal of the restraint during the procedure. The
escort chain could have been removed, then re-applied after the
endoscopy. I do not criticise Officer B who was obliged to keep the
restraint on although either bedwatch officer could have alerted their
managers.
The Governor should satisfy himself that risk assessments are
reviewed when invasive medical procedures are planned.
17
Release on compassionate grounds
63. The Head of Healthcare began the application process for the man to
be released on compassionate grounds once the severity of his
medical condition was known. I acknowledge that her consideration for
his release was good practice.
Actions following the man’s death
64. Following the man’s death from tuberculosis, a multi agency meeting,
of public health officers, prison and hospital staff, was held to ensure
that all prisoners and staff who had been in contact with him and with
their consent, would be screened for the disease. These actions
ensured that the disease was monitored and the health and well being
of staff and prisoners was not compromised.
18
CONCLUSION
65. The clinical reviewer comments that the man’s healthcare was “flawed
with missed opportunities”. When he was seen by the doctor on 15
March, he was obviously very unwell having lost 19kgs in five months.
Although medical tests were taken and sent for analysis there was no
follow up by healthcare staff for seven days as to whether his health
was improving or declining. When he was finally admitted to hospital,
he was seriously ill and his HIV status was identified. Following further
medical investigations he was diagnosed with tuberculosis.
66. The escort chain was not removed when the man underwent a surgical
procedure whilst temporarily transferred to another hospital, despite the
security department being informed of this planned procedure. I
believe that arrangements should have been made to review his risk
and whether it was necessary to use the escort chain.
67. I acknowledge the start of an application for a compassionate release
and I am also pleased to note the multi disciplinary approach to ensure
the well being of prisoners and staff following the man’s death from
tuberculosis. However, I make one recommendation for the attention of
the Governor and six for the attention of the Head of Healthcare.
19
RECOMMENDATIONS
For the Head of Healthcare
1. The Head of Healthcare should ensure that secondary health
assessments or general health assessments are undertaken for all
prisoners.
Not Accepted – “A routine health secondary screen should be offered
to prisoners but it is not mandatory (PSO 3050 2.12.) This assessment
is equivalent to a primary care assessment when registering with a new
practice in the community.”
2. The Head of Healthcare should ensure that every effort is made to
trace a prisoner’s medical and mental health history.
Partially Accepted – “A full medical reception screen was completed
by a Registered Nurse. It is noteworthy that the man stated he had
been a prisoner at HMP Hull. Their medical record department have
no record of him. HMP Cardiff do attempt to obtain relevant medical
information which includes confirmation of medication. He was not
registered with a GP.”
3. The Head of Healthcare should introduce mechanisms for the timely
follow up and tracking to secondary care and specialist services
(including diagnostic and microbiology services).
Accepted – “HMP Cardiff has appropriate referral pathways to ensure
timely access to specialist services and second opinion. The man was
not suspected as having a serious terminal illness. He hid his
diagnosis from the GP and other healthcare professionals. There are
fast referral processes for suspected serious or terminal illness.”
4. In liaison with Cardiff and Vale University Board, the Head of
Healthcare should develop appropriate referral pathways to ensure
timely access to specialist services and second opinions. This should
include ‘fast track’ referral processes for prisoners with suspected
serious/terminal illness.
Accepted – “HMP Cardiff does have appropriate referral pathways.
However, we will check our systems to ensure robust systems in
place.”
5. The Head of Healthcare should ensure that plans are in place for
prisoners with on-going health problems to ensure that holistic care is
provided. These plans should include tools for monitoring weight loss,
nutrition and other symptoms such as pain.
20
Accepted – “Care plans, tools for monitoring weight loss, nutrition and
pain are in place.”
6. The Head of Healthcare should put in place a mechanism for flagging
prisoners with serious and deteriorating health, so that priority is given
to their attendance at clinics and healthcare related appointments.
Accepted – “We have a comprehensive palliative care policy and risk
register in place. There are fast track referral processes for suspected
serious or terminal illness in place.”
For the Governor
The Governor should satisfy himself that risk assessments are
reviewed when invasive medical procedures are planned.
Accepted – “Risk assessments are in place and reviewed prior to
invasive procedures.”
21