Individual at Durham

Investigation into the circumstances surrounding the
death of a man,
a prisoner at HMP Durham, in October 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2010
This report considers the circumstances of the death of a man at HMP Durham in
October 2009. He was 61 years old when he died. A post mortem showed that he
died from bronchopneumonia (infection of lungs and linked airways) and
disseminated carcinoma oesophagus (cancer of the oesophagus).
I offer my sincere condolences to the man’s family and friends for their loss. One the
Family Liaison team had contact with the family during the investigation. I apologise
for the delay issuing my report and any additional distress this may have caused.
The man’s family told the investigator that they did not believe that he received good
care whilst he was in prison. They believe that a terminally ill man, such as he,
should not have been in custody at the end of his life. They are also concerned
about communication between the prison and the hospital, the use of restraints,
visiting arrangements and information provided for them. I have considered their
concerns carefully in the report.
The investigation was carried out by my colleague. We would like to thank the
Governor and his staff for their co-operation during the course of our enquiries.
I also thank the local Primary Care Trust for appointing a clinical reviewer. As the
man died from natural causes, the findings of the clinical review play an essential
part in my report. The reviewer judges that he received good care whilst he was in
custody which was equitable to what he could have expected in the community.
I make one recommendation concerning prisoner’s medication when they are
discharged from hospital.
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 April 2010
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CONTENTS
Summary
The investigation process
HMP Durham
Key findings
Issues
Recommendations
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SUMMARY
The man was born in May 1948 and lived in Cumbria. He was married and was 61
years old when he died. He appeared at Magistrates Court on 1 June 2009 and was
remanded into custody. He was sent to HMP Durham and, because of his medical
condition, he was admitted straight to the healthcare centre as an inpatient.
On 15 July, he appeared at Crown Court and was convicted of a sexual offence and
remanded in custody until 27 August. Seven days later he complained of being
unable to swallow. The prison doctor made a preliminary diagnosis of cancer and
referred him immediately to the specialist consultant at the local hospital.
He was admitted to hospital on 27 July and the specialist confirmed the diagnosis of
cancer of the oesophagus and upper spine. He was offered radiotherapy and
chemotherapy but declined both. A stent (a tube to prevent constriction within the
body) was fitted in his oesophagus to allow him to eat soft food. He was discharged
from hospital back to the prison healthcare. The hospital’s palliative care team
visited him and his wife in prison to review and discuss his needs. He was offered
radiotherapy and chemotherapy but declined both.
Due to throat infections, he returned to hospital on the 3 September and 24
September. On each occasion he was discharged back to the prison after being
treated for the infections.
On 8 October, he was taken back to hospital as his condition had deteriorated
rapidly. His family were informed of his deteriorating health before he left the prison
but, due to the distance and the time for the journey, they arrived after he died.
I am satisfied that the care and attention he received at Durham was equitable to
that he could have expected to receive in the community. He exercised his right to
refuse palliative treatment.
I make one recommendations concerning prisoners receiving prescribed medication
on discharge from hospital.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 9 October 2009 when an investigator issued
notices announcing the investigation to staff and prisoners. The notices
included an invitation to those who wished to submit information relating to the
man’s death to make themselves known to the investigator. No prisoners came
forward as a result.
2. The investigator contacted HMP Durham on 10 October to obtain copies of all
relevant documentation relating to the man. The investigation was reallocated
to another investigator on 24 February 2010. He visited Durham on 17 and 18
March and interviewed eight members of staff.
3. The local Primary Care Trust (PCT) asked a clinical reviewer to review the
man’s clinical care. The Ombudsman’s investigator liaised with the clinical
reviewer to discuss the care the man received.
4. The investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation and request a copy of the post mortem report.
Upon completion, my report will be sent to the Coroner to assist his enquiries
into the man’s death.
5. One of the Family Liaison team was in contact with the man’s family during the
investigation. Both she and the original investigator met the family on 14
December 2009. They expressed their wish for him to be referred by his
nickname in the report.
6. The family raised the following concerns which they wished the investigator to
address:
(cid:127) They believe the man did not received good care whilst he was at HMP
Durham, and that prison healthcare was an inappropriate setting for
him to receive the necessary care that he required.
(cid:127) They believe that there was a lack of communication between the
prison and the hospital.
(cid:127) They believe that the level of escort and use of restraints was
inappropriate given the man’s medical condition.
(cid:127) They believe that the visiting arrangements at the prison were not
acceptable.
(cid:127) They can not understand why they were not informed sooner of the
man’s deteriorating health in the period leading up to his death in
October 2009.
7. I have attempted to address the issues raised within the report. I hope that it
provides a better understanding of the treatment he was given and the events
leading up to the man’s death.
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HMP DURHAM
8. HMP Durham is a Category B local prison built in the early 19th century. It
serves the courts in the local area and it holds just under 1,000 prisoners. The
prison comprises seven wings as well segregation and healthcare units.
9. The local PCT commissions and provides primary care health services and the
NHS Trust provides specialist mental health services. There is 24 hour
healthcare provision, which includes a clinical director and a general
practitioner, supported by a primary care nursing team. Inpatient facilities in the
prison are located on E wing.
10. Following a full announced inspection of Durham in September 2006, Her
Majesty’s Chief Inspector of Prisons published a report which found that the
new management team was “driving forward some significant and much needed
improvements,” that “relationships between staff and prisoners were good,” and
that the prison was an “improving establishment”.
11. The Inspectorate carried out an unannounced inspection of Durham in October
2009. The report of this inspection is still at draft stage but I understand that it
will reflect the improvements made since 2006.
12. The Independent Monitoring Board (IMB) comprises lay people from the
community who monitor the day-to-day life in their local prison and ensure that
proper standards of care and decency are maintained. In their report for the
year 2007 to 2008, the IMB made the following comments concerning
healthcare at Durham:
“Prisoners referred to specialist services in neighbouring hospitals receive
treatment within target times as per the local general population.
“Over £900,000 has been spent during 2007/8 on a limited upgrade of the
existing building resulting in some improvement. The Board believes the
health care centre building still presents some challenges for staff in the
delivery of 21st century primary care & Inpatient care.
“The Board remains of the opinion that the building is not totally suitable to the
provision of modern healthcare. The Board does appreciate that with the
expenditure that has taken place there is, disappointingly, little chance of a
new health centre in the foreseeable future.”
13. The IMB also commented that:
“Throughout the period of this report HMP Durham has retained its level 3
status in the Prison Service’s performance ranking. This implies that the
prison is ‘meeting the majority of targets, experiencing no significant
problems in doing so, delivering a reasonable and decent regime.’”
14. The Prison Service’s performance ranking system referred to in the IMB report
is a quarterly data driven performance assessment for each prison. The
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assessment results in prisons being rated at one of four levels: rating 4 equals
exceptional performance; rating 3 equals good performance; rating 2 equals
development required; rating 1 equals serious concerns. Durham’s rating
remained at 3 following the period covered by the IMB’s report and remained at
3 for the time the man was there.
15. The man’s death was the 21st to occur at Durham since the Ombudsman
became responsible for investigating deaths in custody in 2004, nine of which
were due to natural causes. There was no link between the circumstances
surrounding his death and those of other prisoners.
16. On each occasion a prisoner is escorted outside of the prison to hospital a risk
assessment is completed which considers the risk to the public, potential for
escape and likelihood of outside assistance. The assessment informs the
decision about the number of escorting officers and the type of restraint to be
used (single cuffs or two metre long escort chain with cuff at either end). It also
determines the circumstances and the authority required for the restraints to be
removed. The risk assessment is reviewed each day that a prisoner is in
hospital and amended where necessary.
17. Prisons do not routinely inform the next of kin that their relative has been
admitted to hospital. The decision is made after considering the prisoner’s
health and any security issues and whether the prisoner would be returned to
the prison that same day.
18. Early release on compassionate grounds is subject to the instructions contained
in PSO 6000 which states that:
“Early release may be considered where a prisoner is suffering from a
terminal illness and death is likely to occur soon. There are no set time limits,
but three months may be considered to be an appropriate period. It is
therefore essential to try to obtain a clear medical opinion on the likely life
expectancy. The Secretary of State will also need to be satisfied that the risk
of re-offending is past and that there are adequate arrangements for the
prisoner’s care and treatment outside prison.”
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KEY FINDINGS
19. The man was born in May 1948 and lived in Cumbria. He was married and was
61 years old when he died.
.
20. He appeared at Magistrates Court on 1 June 2009 and was remanded into
custody. He was sent to HMP Durham where an initial healthscreen was
conducted by a nurse. The nurse recorded that he had a history of heart
disease and had experienced three heart attacks in the past. He was an out
patient at hospital. He also told the nurse that he suffered from vertigo and had
a duodenal ulcer. The nurse further recorded that he was prescribed Ezetimibie
(for treatment of cholesterol), Atrovastatin (for treatment of high cholesterol),
Ramipril (for treatment of high blood pressure and heart failure), Omeprazole
(for treatment of gastric conditions), Bisoprolol (for treatment of cardiac
disease), Prochlorperazine (for treatment of vertigo) and aspirin. Due to his
medical condition the nurse decided that he should be seen by the doctor the
following day.
21. Rather than being located in the prison’s first night centre with other new
prisoners, the man was admitted as an inpatient in the healthcare centre where
nursing and medical staff could monitor his condition.
22. The next day a Prison Doctor A saw the man and confirmed that he was a
patient at hospital. The man had an implantable cardioverter-defibrillator (ICD)
fitted in his chest. (An ICD is a small battery-powered electrical impulse
generator which is implanted in patients who are at risk of sudden cardiac
death.) The doctor confirmed his medication prescription. Healthcare staff
contacted the hospital later in the day to ascertain details of the ICD and the
care that he needed. It was established that he was scheduled to attend a
follow up monitoring appointment at the hospital on 7 July.
23. On 3 June, healthcare staff contacted the man’s doctor in the community and
received a fax giving details of the treatment he had received. It was noted that
he had not attended his six monthly cardiac heart disease blood tests and the
prison doctor authorised that they should be carried out by the nurses. Prison
Doctor B reviewed the blood test results on 12 June and all tests were normal.
24. The man went to the appointment at hospital as arranged on 7 July. A security
risk assessment was completed, assessing that a two officer escort should be in
place together with a long escort chain (a two metre chain with a single cuff at
either end). The hospital confirmed that the ICD was working well, there was no
change required in his medication and that he should have a further
appointment in three months time.
25. On 15 July, the man appeared at Crown Court where he was convicted of a
sexual offence and remanded in custody until 27 August for reports and
sentencing.
26. He next saw Prison Doctor A on 22 July when he complained of being unable to
swallow. The doctor made the preliminary diagnosis that this could be due to
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cancer of the oesophagus. He made an immediate referral under the National
Health Service “Two week rule” to the specialist consultant at hospital.
27. Three days later, the man saw Nurse A and complained again of being unable
to swallow properly. He was anxious about his hospital appointment. The
nurse examined him but did not find any swelling. He was able to swallow sips
of tea and water and was encouraged to continue and to inform staff of any
change in his condition.
28. The next day, the man’s wife called the prison to express her concern about her
husband who had told her about his difficulty swallowing and also said that he
had not had his medication. As a result of these concerns Nurse B and Prison
Doctor A examined him again. They found no physical abnormalities or other
apparent symptoms. He was told that his hospital appointment was the next
day and that the hospital had requested that he should not eat or drink anything
from that evening.
29. The man was admitted to hospital on 27 July. A bedwatch risk assessment was
completed and the same arrangements were put in place. The escort chain
was to be removed for treatment as directed by the hospital staff.
30. The next day a hospital consultant confirmed the diagnosis of advanced cancer
of the oesophagus and upper spine, deciding that no surgical intervention was
appropriate. The man was offered radiotherapy and chemotherapy but declined
both. He was transferred to an Infirmary where a stent was fitted in his
oesophagus to allow him to eat soft food.
31. On 3 August, healthcare staff at Durham were informed that the man was to be
discharged from hospital later that day. Prison Doctor A wrote to a consultant in
palliative care, to refer the man to their services. The doctor also contacted the
man’s solicitors to make them aware of his diagnosis.
32. Later that evening, the man was discharged from hospital and returned to the
prison’s healthcare centre. Advice was given that he should be having a soft
diet, with fizzy drinks before and after food. Tramadol was prescribed for
moderate to severe pain relief but it was not issued by the hospital and was not
available in the prison until the following morning.
33. The next day, Prison Doctor B saw the man who said that he knew the
diagnosis and had been told that there was no cure. The doctor recorded that
he was in some discomfort following the stent insertion but had no bone pain.
The doctor added the Tramadol to the man’s prescription and sent a memo to
the kitchen regarding a soft food diet. To increase his comfort and assist the
nurses look after him, he was transferred to a cell with a multi position electric
hospital bed. The bed had a pressure relieving mattress designed to prevent
bed sores. The nursing staff monitored his pain levels every two hours. As his
medication included controlled drugs, it was administered by two nurses
working together.
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34. Later that afternoon the man’s wife contacted healthcare because she was
concerned about her husband’s care. Prison Doctor A spoke to her at length to
explain his condition and the care that he was being given. At the same time,
the man’s brother-in-law sent a letter of complaint to the Primary Care Trust
concerning his care and treatment in prison. The family believed that his care
fell below what was required for a terminally ill person needing palliative care.
They did not believe that the prison environment was the appropriate location
for him.
35. On 5 August, Prison Doctor B prescribed further pain relief in the form of
morphine sulphate granules (a long acting pain relief used to control severe
pain) and Oramorph (an opioid pain relief used to control severe pain). Later
that day, the man’s sister rang the prison to enquire how he was and arrange to
visit him.
36. Prison Doctor B reviewed the man’s pain relief medication the following day and
decided to stop the Tramadol. He did not complain of discomfort in the
following days with the exception of 9 August when he complained of pain but
said that he did not want any additional pain relief medication.
37. The consultant in palliative care and Nurse C from the palliative care team at
the hospice came to see the man and his wife in the prison on 10 August. They
discussed his illness and that the cancer was inoperable. The consultant
advised an increase in the dose of morphine sulphate and also prescribed
Temazapam (to treat sleeplessness and anxiety). The doctor also agreed to
explore end of life care options including palliative chemotherapy. The man and
his wife were given the telephone number to access the palliative care team
directly.
38. On 12 August, Nurse D talked to the man about the complaint received from his
brother-in-law. Because the complaint had been sent by a relative rather than
his next of kin, he had to provide his written consent for it to proceed. It was
recorded that he was shocked and upset when he read the content of the
complaint, and so he was allowed to speak to his wife about it. Nurse D spoke
with the man’s wife and sister to inform them that he had to decide whether to
proceed with the complaint was his and that he had not given his consent. The
nurse also recorded that the family said that the complaint was no reflection on
the prison’s healthcare services and staff.
39. The same day, the man saw Nurse E. He had two visits that day and told the
nurse that he had enjoyed the exercise going from healthcare to the visits area
and wanted to the arrangement to continue. Nurse E explained that
consideration would be given to visits within healthcare if the exertion became
too much for him. The nurse also recorded that the man had tried different diets
over the past few days and said that he was happy with the variety.
40. The consultant in palliative care contacted healthcare on 13 August to say that
the man’s sister had been in touch about her concerns that he was not receiving
appropriate palliative care. The consultant was assured that the treatment was
in place and the doctor said she would inform his sister accordingly. Prison
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Doctor A saw the man the same day and noted that his overall level of comfort
was good although he did get a burning sensation in the throat. The next day,
the consultant contacted healthcare again to say that she intended to visit on 18
August and would like the man’s wife to be present for the consultation.
41. On 15 August, Nurse F recorded that the man had taken all his medication and
accepted all his food and drinks. Two days later, Prison Doctor A saw him. The
doctor thought that he looked and sounded better, and there were no problems
with his pain management. The man had not reported any problems or
concerns, had eaten well and said he was comfortable in his bed.
42. The consultant in palliative care and Nurse G visited the man and his wife as
arranged on 18 August. The hospice doctor found that his pain relief had
improved but he complained of having stiff joints. Ibruprofen (used to control
pain associated with inflammation) was prescribed and some changes to his
pain relief were recommended. The wife and sister expressed their concerns
about his healthcare. They stated that they were not concerned about the
services provided by the prison, but complained about the handover process
that occurred when he was discharged from hospital back to the prison.
43. Following the visit, Nurse D recorded in the medical records:
“I witnessed significant pressure being applied by his visitors for him to
reconsider this decision and sign the consent form, despite the man being in
tears and clearly upset. There was also a verbal outburst from his sister at
the end of the visit when they were informed that future visits would not be
facilitated in HCC but in normal visits.”
44. On 20 August, Prison Doctor A saw the man to review his medication for pain
relief and recorded that he experienced pain around the lower right rib area. He
told the doctor that he was able to swallow and found most of the food
palatable. The doctor encouraged him to go outside for some exercise as it was
a pleasant day.
45. The following day, Nurse H recorded that the man appeared confused. On one
occasion he informed a member of staff that he needed the door opening as he
had some worktops to pick up. Later that day the consultant in palliative care
contacted healthcare to say that the man’s family had contacted her. The family
said that he had called them in tears, saying that he had asked for pain relief the
day before but had to wait four hours for it. The clinical record was checked
which showed that his pain levels were reviewed every two hours and he had
not asked for any extra pain relief medication. The consultant recommended
that he should be prescribed Haloperidol to relieve his confusion. The doctor
also said that he could be referred for palliative chemotherapy, as his “mental
cloudiness” might indicate the possibility of secondary tumours in the brain.
46. On 24 August, Prison Doctor A reviewed the man’s pain relief again. The
doctor explained the benefit of additional pain relief but the man refused any
increase in dosage. The night healthcare staff recorded an improvement in his
confusion from the preceding days as a result of the prescription of Haloperidol.
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47. Three days later, the man appeared at Crown Court via video link and was
sentenced to two years in custody.
48. He was re-admitted to hospital on 3 September following Prison Doctor B’s
assessment that he had a chest infection and needed hospital treatment. A
bedwatch risk assessment was completed and he was accompanied by two
escort officers using a long escort chain, which was to be removed for treatment
as directed by the hospital staff.
49. The same day a meeting took place between the man’s family and the
Healthcare Manager at Durham and a Principal Officer (PO) as a result of the
complaint made on 3 August.
50. On 8 September, the man was discharged from hospital back to healthcare at
Durham. The Healthcare Manager recorded the actions that staff were to take
to assist with his care and comfort. They were:
(cid:127) He would use the telephone nearest his cell and be provided with a chair
to sit on whilst he was doing so.
(cid:127) Medication would be provided in a form that is easy to swallow, i.e.
crushed or in liquid form.
(cid:127) Medication information be given.
(cid:127) He would be assisted with eating, drinking and maintaining his personal
hygiene as required.
(cid:127) A wheelchair would be provided for him to use should he need to go to
other areas of the prison.
(cid:127) A review would take place prior to every visit from his family and a
decision made as to where it should take place.
(cid:127) He would be given the correct diet.
(cid:127) He was to be encouraged to express his own needs.
51. The following day, the Healthcare Manager spoke to the man’s sister to
reassure her that he had received his pain relief medication and that her
concerns about his healthcare had been documented. Prison Doctor B also
saw him the same day and noted that he lacked the confidence to move around
the healthcare centre and agreed to use a walking stick.
52. Prison Doctor B next saw the man on 10 September and reviewed his pain
relief. He told the doctor that he had been in pain for most of the night but had
not vomited or felt sick. The doctor contacted the consultant in palliative care
and they agreed that the dose of morphine sulphate should be increased.
53. Nurse G visited the man the next day, and then discussed the changes in his
pain relief with Prison Doctor B. The level of morphine sulphate was to be
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increased every two to three days and Diclofenac added to his prescription (for
treatment of pain and inflammation of the joints).
54. On 14 September, Nurse G visited the man at the same time as his family were
present. He was unsure whether to commence palliative chemotherapy
treatment and wished to discuss it with his wife over the next seven days.
55. Prison Doctor B saw the man the following morning as he complained of severe
pain. The doctor increased the level of morphine sulphate. Later that morning,
he told Nurse F that the pain had eased after about an hour of taking his
medication. The nurse recorded that he had ate his breakfast and was
encouraged to drink fluids.
56. A Healthcare Support Worker (HCSW) A recorded on 15 September that the
man had had a settled day and ate all his meals and fluids. He told the HCSW
that he was in very little pain and asked to have his hair cut before his next
family visit. The nurse organised the wing barber to trim his hair.
57. The next day, Prison Doctor B saw the man to discuss his pain control. He told
the doctor that he felt it was adequate at that time and he had no other concerns
other than that he no longer liked the milk based drinks. The doctor arranged
for him to have fruit based drinks instead.
58. Prison Doctor B reviewed the man again on 18 September. He told the doctor
that the pain relief was working although he felt uncomfortable first thing in the
morning. He told the doctor that he preferred the new juice flavoured drinks.
The doctor prescribed an increase in morphine sulphate.
59. On 21 September, the Acting Deputy Governor wrote to the man’s wife
regarding visits to her husband whilst in Durham. He confirmed that weekly
visits were allowed and were to be booked in the usual way through the prison.
The letter specifically stated:
“Healthcare staff will make an assessment before each visit of which is the
most suitable venue for the visit, i.e., main visits room or the healthcare
centre.
“It is my expectation that visits will normally be held in the main visiting room
and when this is the case we will endeavour to hold the visit in a quieter part
of the room.
“This arrangement will be reviewed as necessary in collaboration with Senior
Managers in the healthcare department.”
60. The same day, Prison Doctor A talked to the consultant in palliative care and
the saw the man again. The doctors agreed to add Metoclopramide (for
treatment of nausea and vomiting) and Dexamethasone (an anti-inflammatory
medication) to his prescription.
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61. The consultant in palliative care and a physiotherapist saw the man the
following day. The consultant changed the order of the medication so that
Oramorph was taken with the morning dose of morphine sulphate and the man
was to wait 20 minutes before moving around. The doctor also prescribed 4mg
Dexamethasone each morning for a week followed by 2mg each morning for
three weeks and 10mls Metoclopramide three times a day. The physiotherapist
assessed that the man was able to walk and negotiate stairs without difficulty.
He should be encouraged to exercise twice a day to maintain his mobility.
62. On 23 September, Nurse I saw the man at 11.20am as he was complaining of
pain around his neck and found it difficult to swallow. The nurse gave him the
prescribed Oramorph and encouraged him to spend time walking around. He
would be seen by the doctor later that afternoon.
63. At 1.00pm, the man’s wife contacted healthcare staff to express her concern
that her husband might be depressed. She sought reassurance that he was
seeing a doctor regularly. She also said that when they spoke on the
telephone, she was unable to hear him due to a rattling sound in his throat.
Nurse I returned the call to the man’s wife and made the following entry in the
prison medical records:
“I contacted the man’s wife as she had spoken to HCSW B and requested I
call her. She was very upset as she had just received a telephone call from
the man and found it difficult to hear him due to a rattling sound. I reassured
her that I had just been in to him to give him some pain relief and that
neither myself or the nurse with me were aware of a rattling noise. I also
informed her that I had seen him earlier today and that he had a rattle in his
throat when he coughed and it was not his chest rattling. I also reassured
her that should we become at all concerned about him that we would ask the
doctors to see him immediately.”
64. Later that afternoon, as arranged, Prison Doctor A saw the man noting that he
experienced pain in the neck and the back of the head, had difficulty in
swallowing and a rattle in his throat. The doctor decided that, because of the
previous chest infection, it was appropriate to prescribe Amoxicillin oral
suspension (an antibiotic). As well the doctor changed the morphine sulphate to
Fentanyl patches (used for severe pain requiring round the clock, ongoing relief)
in case he was not getting enough of the former.
65. The next day, Prison Doctor B assessed the man and decided to admit him to
hospital as his ability to swallow had reduced further. Another bedwatch risk
assessment was completed, again confirming that he was to be accompanied
by two escort officers using a long escort chain, which was to be removed for
treatment on the direction of hospital staff. He was discharged from hospital
back to healthcare at Durham on 26 September and had been prescribed
Nyastatin (an antifungal medication) for oral thrush.
66. Later that day the man’s wife and sister arrived for a visit. They were told that
the visit would take place in the main visits room, rather than in healthcare.
They were described as abusive to Nurse D on the telephone and then to have
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confronted two healthcare support workers in the prison car park, returning from
lunch. They complained about the visiting arrangements.
67. In interview, the Governor A said that she had a telephone call from Nurse D to
say that the man’s family were angry that the visit would be in healthcare and
were abusive on the telephone. The governor explained that there were
insufficient staff in the establishment, either in the healthcare or the prison, to
facilitate a visit taking place in healthcare. The man had been asked if he was
happy for the visit to take place in the visits hall and said that it was fine.
However the governor said that his visitors demanded that the visit took place in
healthcare.
68. Governor A said that she received a further telephone call about the contact
between the healthcare support workers and the man’s family in the car park.
The governor decided to speak to the family personally to explain that the prison
was doing everything possible to facilitate the visit in the most comfortable
surroundings, but that if their behaviour continued they would not be allowed
into the prison at all. The family were not satisfied and showed the letter stating
that, where possible, the prison would facilitate visits in healthcare. She said
that she stressed to the family that, on this occasion, it was impossible for the
visit to be in healthcare. Although the family were unhappy with the situation,
the visit took place and lasted the duration of the visits period.
69. Prison Doctor B saw the man on 29 September to review his pain relief. He told
the doctor that he experienced difficulty swallowing at times. His wife rang later
that morning to ask to speak to Prison Doctor A. The doctor returned the call
and had a lengthy conversation with the man’s wife, at the end of which she told
him that the nursing staff in the prison had been kind and helpful. The doctor
also spoke to the Governor B regarding the man’s condition and they agreed to
call a multidisciplinary meeting when the consultant in palliative care returned
from leave. The man’s condition did not fall within the guidelines for
compassionate release as there was no indication of his life expectancy.
70. Two days later, on 31 September, Prison Doctor B saw the man to review his
medication. He told the doctor that he felt uncomfortable in the mornings for
about two hours but his pain control was fine for the rest of the time and he was
able to eat more than previously. Later that day the man’s wife contacted
healthcare staff to say that she and her husband had discussed palliative
chemotherapy treatment, but had decided together that he did not want to have
the treatment.
71. The man had a comfortable day the next day. He was independent and able to
see to his personal hygiene needs himself. He was mobile around the
healthcare unit and used the telephone to speak to his family.
72. On 5 October, Prison Doctor B saw the man as he complained he could not
swallow. The doctor asked him to drink some water which seemed to pass
easily, but he needed to bring up a small amount of saliva afterwards. The
doctor discussed this with Prison Doctor A and they decided to prescribe a
small dose of Diazepam (for treatment of seizures and muscle spasms).
15
73. Nurse G came to the prison on 6 October and saw the man to review his
medication. He reiterated that he did not want to commence chemotherapy
treatment. The nurse recommended the use of a saline nebuliser (which
converts liquid medication into an aerosol that the patient breathes).
Events of 8 October
74. Prison Doctor A saw the man in the morning and noticed that he was sweaty
and clammy, had been sick, and his throat rattled. The doctor took his
temperature which was normal and said that he would review him later in the
day after he had used the saline nebuliser.
75. The doctor next reviewed the man’s condition at approximately 2.40pm. As he
was still sweaty and clammy, the doctor decided to admit him to hospital as his
condition had not improved. Arrangements were made for him to be taken to
hospital. The bedwatch risk assessment reduced the restraints to two escort
officers without any restraints in place.
76. Prison Doctor A discussed the man’s condition with the Acting Governor and
they explored the possibility of release from custody on medical grounds. He
also spoke to the consultant for palliative care about transferring him to a
hospice.
77. Nurse I contacted the man’s wife, recording in the prison medical records:
“I contacted the man’s wife and made her aware of his imminent admission
to hospital. She is aware of how seriously ill her husband is and she
obviously became very upset. She asked me to inform her sister-in-law.
Attempted to contact her but no reply. I left a message for her to contact
us.”
78. The man’s sister returned Nurse I’s call after the ambulance had left the prison.
The nurse prison recorded in the medical records:
[The man’s sister] returned my call and I have made her fully aware of the
situation. She informed me that they are coming over to see him in hospital.
I have informed Governor C and he confirmed that the escorting staff have
been informed of this.”
79. Healthcare staff were told by the hospital that the man had died at 5.45pm. The
Mental Health Nursing Manager at Durham went to the hospital to meet the
man’s family who, due to the long journey, had not yet arrived at the hospital.
When he arrived at the hospital, two officers from Durham Constabulary were
present in addition to the two prison escort officers. (The local police are called
following the death of any prisoner.) When the man’s family arrived they were
met by the Manager and two prison family liaison officers.
80. The prison complied with the requirements of Prison Service Order 2710
“Follow up to death in custody” and offered financial assistance towards the cost
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of the funeral. In the days that followed, the prison family liaison officers
maintained contact with the man’s family who expressed their thanks for their
sensitive and professional manner.
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ISSUES
Clinical care
81. The clinical review considered the treatment and care that the man received
whilst he was in custody. The report made the following comments:
“The clinical records show that the man was referred to secondary services
for investigations into a potential diagnosis of cancer on the same day that his
symptoms came to the attention of prison healthcare staff. He was
subsequently assessed and a diagnosis made within a few days. This is in
line with the requirements of the ‘two week wait’ standard in place nationally
for people with suspected cancers and constitutes very good practice.
“He had good access to specialist services within secondary care and was
visited within the prison by McMillan nurses and the Consultant from the
palliative care service.
“There is good evidence of consistent communication and joint working
between prison health care professionals and colleagues from secondary
care services and that advice from specialist clinicians was appropriately
followed.
“There is good evidence that prison healthcare staff and the palliative care
team had regular contact with the man’s wife and that she was involved, as
far as possible, in decisions about his care.
“The clinical notes demonstrate that his level of pain was appropriately and
regularly assessed and that changes were made to his prescription when
pain increased and it appeared that the prescription was insufficient.”
82. The clinical review did raise about the medication prescribed when the man was
discharged from hospital. The clinical reviewer said:
“The man was discharged from hospital on 3 August 2009 with discharge
medication including painkillers. However, due to security restrictions and a
possible breakdown in communication, he was not given any pain relief until
the following day after his wife called to complain. The need for security
precautions is understood but such a delay is nonetheless unacceptable.”
I recommend that the Head of Healthcare ensures that a robust process
is in place so that prisoners receive their prescribed medication as
soon as possible after they are discharged from hospital.
83. The overall assessment by the clinical reviewer is that the treatment and care
given to the man whilst he was in custody was equitable to that which he could
have expected in the community.
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Use of restraints
84. Unfortunately there have been too many reports in which the Ombudsman has
criticised the level of restraints used when prisoners are taken to outside
hospital. I have evaluated the restraints used each time the man went to
hospital. The prison has to balance the prisoner’s need for privacy and dignity
with their own duty to protect the public. He was recently sentenced for a
sexual offence and as such was assessed as a risk. Even though he was
terminally ill, he was mobile and independent.
85. I judge that the bedwatch risk assessments were appropriate each time that the
man was admitted to hospital on 27 July, 3 September and 24 September. I am
also satisfied that on 8 October, for what was to be his last admission, no
physical restraints were used and he was just accompanied by two staff. It is
pleasing to recognise the good practice adopted by Durham to ensure that he
was treated with dignity and respect on his final admission to hospital on the
day of his death.
Complaints procedure
86. The clinical reviewer also considered the handling of the complaint made by the
man’s family to the Primary Care Trust and made the following comment:
“There was not a policy in place that outlined the requirements of the health
and social care complaints legislation that came into force in April 2009 at the
time of this incident. However, a policy has since been developed by the
Primary Care Trust.”
87. Complaints about prisoners’ healthcare are properly directed to the Primary
Care Trust’s internal complaints procedure. From the evidence I have seen and
heard, I am also satisfied that the healthcare staff, prison doctors and the
Governor took steps to ensure that his needs were met. I recognise that
families of prisoners can be remote from decisions about sick relatives.
However, on this occasion, I believe that the prison made every effort to involve
him and his next of kin, his wife, in decisions about his treatment. It is
unfortunate that his illness was unpredictable. A clear life expectancy was not
given and so consideration of compassionate release was impossible. His
sentence was a matter for the court and so he had to remain a prisoner until his
death. Regrettably he deteriorated quickly on 8 October and his family could
not be at his bedside when he died.
Visiting arrangements
88. The man’s family felt that the visiting arrangements to see him were
unreasonable and had caused upset, although he himself did not express any
concerns. I appreciate that families may find it difficult to understand the
requirements of running a prison safely and securely. The family had been
given written assurance that an assessment would be made for the location of
each visit. He was mobile and a wheelchair was available, and on 26
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September there were insufficient staff for a visit in healthcare. I find that, given
the circumstances, staff at Durham acted reasonably in facilitating his visits.
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CONCLUSION
89. I judge that attention was paid to the man’s health needs and appropriate
treatment and care was provided. I am satisfied that the standard of care he
received in Durham prison was equitable to that which he could have expected
to receive in the community. Except when in hospital, he remained in the
inpatient’s wing where he had special equipment and frequent consultations
with doctors and nurses. As well he was referred to the community palliative
care specialists who saw him several times. The prison doctors regularly
consulted the palliative care specialists about how best to look after him. He
exercised his right to refuse to accept palliative radiotherapy and chemotherapy.
90. I acknowledge the frustration families may feel in understanding the care that
their loved ones receive whilst in prison. However, I do believe that Durham
responded both to his changing needs and to the concerns raised by his family.
Ultimately he was an independent adult able to deal with his health and
personal needs without his family’s involvement. I have found that he was
treated with dignity and respect both at Durham and when he was in hospital.
Following his death Durham appropriately followed the guidance given in PSO
2710, “Follow up to death in custody”.
At the consultation stage of the report the man’s sister and brother-in-law
wished it noted within the report that they disagree with certain points as
outlined in individuals’ transcripts of interview. Specifically the fact it has been
stated his sister was abusive towards healthcare staff in person and over the
telephone. She found this information very distressing and upsetting. They
also wished it noted that a huge amount of their frustration was with staff at
Durham due to an apparent lack of communication between them and the staff
and that this ultimately resulted in additional upset and distress being caused to
the family in relation to their understanding of processes in regard to his care,
and their ability to visit him at regular occasions.
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RECOMMENDATIONS
1. I recommend that the Head of Healthcare ensures that a robust process is in
place so that prisoners receive their prescribed medication after they are
discharge from hospital.
Accepted - Healthcare members of staff are aware of and adhere to SOP 20
Procedure for the re-use of patients own drugs (PODs) after prescribing in
prison.
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