Individual at Leicester

Investigation into the circumstances surrounding the
death of the man in November 2009,
after compassionate release from HMP Leicester
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2010
This is the report of an investigation into the circumstances surrounding the
death of a man. The man died at Cedar Court Nursing Home, Leicestershire,
on 11 November 2009. He was 86 years old. A post mortem showed that the
cause of his death was coronary artery failure and diabetic ketoacidosis
(meaning a lack of insulin in the body).
I offer my sympathy and condolences to the man’s family, as I do to all of his
friends and acquaintances who have been touched by his death.
The investigation was carried out on my behalf by my colleague. Both he and
I would like to thank the Governor of HMP Leicester and her staff, particularly
the prison liaison officer for their co-operation during the course of our
enquiries. I also thank Leicestershire Primary Care Trust (PCT) for the
appointment of a doctor as clinical reviewer.
The Ombudsman’s Terms of Reference give the discretion to investigate the
death of people recently released from prison. I decided to exercise that
discretion in this case to consider how compassionate release had been
granted, when I am aware that it is not always possible. The man was
granted compassionate release from prison on 20 October 2009 because of
his deteriorating health. My report commends the actions taken by the
Governor and staff for the care and dignity given to the man in the period
leading up to his death. I believe that there are lessons which could be learnt
across the prison estate. I also ask the Governor to share this report with the
nursing home in recognition of their willingness to look after him.
Jane Webb
Deputy Prisons and Probation Ombudsman March
2010
CONTENTS
Summary
The Investigation Process
HMP Whatton
HMP Leicester
Key Findings
Issues
Conclusion
Good Practice
SUMMARY
The man was born in1923, and lived predominately in the London area. He
was sentenced to death on 26 November 1956, having being convicted of
murder. However he was granted a royal pardon on 24 January 1957 and
sentenced to life imprisonment. He was granted early release under licence
in 1971, but recalled to prison 25 years later following a conviction for sex
offences.
The man spent time at various prisons, including HMP Norwich and HMP
Elmley, before arriving at HMP Whatton on 15 May 2007. He had a medical
history of diabetes, angina, high blood pressure, gastric acid and depression
and was prescribed appropriate medication.
Whilst at Whatton he was seen every day by healthcare staff to ensure that he
took his medication. He frequently refused to take it and there were
occasions when he took his diabetes medication but refused to take the rest.
He would also frequently refuse food despite encouragement from staff.
On 10 March 2009, a prison doctor saw the man and recorded that he was
intermittently drowsy and appeared to have some loss of control of his right
side. The doctor assessed that this was a sign of a probable acute
cerebrovascular attack (commonly known as a stroke) and immediately
referred him to hospital. He remained in hospital until 7 May when he was
discharged back to Whatton.
Daily nursing care continued for the next three weeks when the man’s
condition deteriorated and he was taken back to hospital for further
assessment. The Matron at Whatton asked the Governor at HMP Leicester to
accept the man on his discharge from hospital, as Leicester has 24 hour
healthcare facilities.
On 14 July the man was discharged from hospital to healthcare at Leicester.
In consultation with the hospital, healthcare staff put a care plan in place to
meet his needs and give 24 hour care. There were many occasions where he
would refuse all food and drink and medication despite encouragement from
staff. He would sometimes decline assistance with personal care, for
example having a wash or shave.
A prison doctor saw the man on 9 October and recorded that he had refused
anything to drink. The doctor considered that his health was deteriorating and
he was not expected to live more than four weeks. The doctor advised the
healthcare manager that a nursing home setting was more appropriate for his
continuing care.
The man moved to the nursing home on 14 October. The Deputy Governor
completed the compassionate release application and submitted it to the
Ministry of Justice the following day. The prison liaison officer attempted to
contact the man’s next of kin to inform them of his transfer to a nursing home
but without success. On 16 October, the Ministry of Justice granted the man
compassionate release. He was released from custody by the liaison officer
on 20 October once an offender manager had been allocated by
Leicestershire Probation Service. The prison liaison officer eventually
contacted the man’s son and arranged to meet him at the nursing home.
On 11 November, the prison was contacted by Cedar Court to say that the
man had died. The prison liaison officer contacted the man’s son by
telephone to offer condolences. His son said he wanted the funeral to take
place in the Leicester area and the governor offered to make the necessary
arrangements.
In the days that followed the prison liaison officer maintained contact with the
man’s son, as well as liaising with the funeral directors and chaplaincy. He
gave the man’s belongings to his son after the funeral on 3 December. The
post mortem showed the cause of death was coronary artery failure and
diabetic ketoacidosis (absolute lack of insulin in the body).
This investigation commends the best practice shown by the Governor at
Leicester, and her staff, both whilst the man was in prison and especially by
successfully applying for compassionate release.
THE INVESTIGATION PROCESS
1. The investigation was opened on 13 November 2009 when the
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.
No prisoners came forward as a result.
2. The investigator visited HMP Leicester on 1 December. During his visit he
was given copies of all documentation relating to the man. In addition, he
received excellent assistance from the doctor who was appointed as the
clinical reviewer.
3. The investigator contacted HM Coroner to inform him of the nature and
scope of the investigation and to request a copy of the post mortem
report. Upon completion, this report will be sent to the Coroner to assist in
his enquiries into the man’s death.
4. The Ombudsman’s senior family liaison officer contacted the man’s son to
inform him of the investigation. The man’s son had expressed concerns
about the care provided by the nursing home, but this falls outside the
remit of the Prisons and Probation Ombudsman. I hope that my report
provides his son with a better understanding of the treatment given to his
father prior to his compassionate release.
HMP WHATTON
5. HMP Whatton is a category C training prison for prisoners convicted of a
sexual offence or offences, or who have a sexual element in their
offending history.
6. In response to overcrowding across the prison estate, Whatton underwent
rapid expansion in 2006, increasing the operational capacity from around
400 prisoners to 841 by 2008. Up to this point, the main focus of the
prison was in accepting prisoners who had been assessed as suitable for
sex offender treatment programmes because they were not in denial of
their offence. (These courses are designed to the lower risk of re-
offending.) In response to the rapid expansion and to fill the new places,
the admission criteria were changed. The prison began to accept
offenders who denied their offence and so were assessed as unsuitable
for undertaking specialist offending behaviour courses.
7. Healthcare at Whatton is provided by Nottinghamshire County Teaching
Primary Care Trust (PCT). The Independent Monitoring Board report for
the period June 2007 to May 2008 praises the healthcare department for
delivering a “high level of healthcare to one of the most demanding and
diverse sections of society”. (It should be noted that the average age of
prisoners at Whatton is far higher than elsewhere in the Prison Service.)
The prison does not have 24 hour healthcare facilities and medical staff
are not on site during the night or at weekends. Out of hours medical care
is provided by Nottingham Emergency Medical Services (NEMS).
8. In her last inspection report dated March 2007 the HM Chief Inspector of
Prisons, said that many aspects of the regime at Whatton which were
applauded in a previous inspection remained in place. She acknowledged
that the prison had to fully adapt to the changes it had been asked to take
on so rapidly.
9. The Chief Inspector specifically commented on healthcare services at
Whatton as follows:
“Funding for health services had not kept pace with the growth in size
of the establishment. The health services department was a clean and
clinical environment but was at some distance from most residential
wings, including those for the older population. The findings of a PCT
health needs assessment were used to plan services. Health services
staff were developing systems and processes in line with the health
needs assessment, but waiting times for the GP and dentist were
unacceptably long and were a major concern. We found some
examples where a positive duty of care was absent, and also where a
lack of communication had the potential to compromise patient care.”
10. There have been improvements in healthcare services at Whatton since
this HMCIP report, as highlighted by the IMB report.
11. HMP LEICESTER
12. HMP Leicester is situated close to the city centre. Originally built in the
Victorian era, it has undergone extensive refurbishment. The
establishment is a local prison, which generally means it is used to
accommodate remand prisoners, However there are a number of
sentenced prisoners. The prison has a 24 hour healthcare cover, with
inpatient facilities, which are run by Serco Health.
13. Her Majesty’s Chief Inspector of Prisons, Dame Anne Owers, reports on
all Prison Service establishments. In June 2008, the Chief Inspector
carried out an announced inspection. In the introduction to her report, she
describes it as a small, crowded Victorian city centre prison, which has
had to manage an ever changing population, many with significant needs,
in ageing and inadequate accommodation.
14. The Chief Inspector goes on to say that, although previous inspections
had been critical, she detected some early signs of improvement with a
greater emphasis being placed on safety and resettlement. However, the
Chief Inspector acknowledged that more needed to be done.
15. The Chief Inspector specifically commented on the in-patient facilities as
follows:
“There were a total of 11 inpatient beds available, all the beds were
listed as certified normal accommodation, although health services
staff told us that admission was on the basis of clinical need. At the
time of the inspection, there was a mix of patients with both physical
and mental health needs.
“Patients were unlocked for the majority of the day and could attend the
gym on request. Education staff ran sessions on the unit twice a week.
The association room included a small library, electronic games and
board games. The GP attended the inpatient unit daily and the
detoxification nurse and Mental Health Inreach Team continued to work
with those prisoners in their care who were admitted to the unit.”
16. The Independent Monitoring Board (IMB) monitors the prison and to
reports any concerns about how prisoners are treated. Board members
are able to visit any area of the prison at any time and have direct access
to any prisoner who they wish to see, or who requests to see them. The
IMB holds regular meetings in the prison and produces an annual report
for the Secretary of State for Justice.
17. The IMB’s latest report, for the 12 months to 31 January 2009, made the
following comments regarding healthcare:
“The provision of Healthcare services and Clinical Governance have
suffered from poor and disrupted Healthcare management during the
reporting year. There has been poor communication the various
Healthcare departments, and also between Serco, the PCT, and the
prison. Morale has been low amongst the staff, with a high level of
absenteeism, chaotic shift patterns, and lack of discipline in hand-over
meetings and clinical appointments have not always been kept.
18. This is the 17th death to have occurred at Leicester since April 2004, when
the Ombudsman began investigating all deaths in prison custody in
England and Wales. One of the earlier cases investigated concerned
another man who also suffered from cancer. That report also commends
the healthcare staff team for their dedication in delivering a high quality
nursing service.
KEY FINDINGS
19. The man was born in March 1923, and lived predominately in the London
area. He had been sentenced to death 26 November 1956, having being
convicted of murder. However he was granted a royal pardon from
execution, on 24 January 1957, on the condition that his sentence was
commuted to life imprisonment. He was granted early release under
licence on 28 May 1971, but was recalled to prison 25 years later on 29
March 1996 following conviction for sex offences.
20. The man spent time at various prisons, including HMP Norwich and HMP
Elmley, before arriving at HMP Whatton on 15 May 2007. He had a
medical history of diabetes, angina, high blood pressure, gastric acid and
depression. He was prescribed Gabapetin (for pain relief and a mood
stabiliser), Enalapril (for treatment of high blood pressure), Metformin (for
treatment of type 2 diabetes), Simvastatin (for treatment of cholesterol),
Lansoprazole (for treatment of gastric acid), Gliclazide (for treatment of
diabetes), Isosorbide mononitrate (for treatment of angina), co-codamol
and aspirin.
21. Throughout 2007 and 2008 the man was seen every day by healthcare
staff to ensure that he took his medication. He frequently refused to take
all his medication and there were occasions when he would take his
diabetes medication but refuse to take any others. This happened despite
encouragement from healthcare staff, who also explained the
consequences of not taking his medication. The man would also say that
he did not feel like eating and refused some of his meals, again despite
encouragement from staff.
22. On 30 January 2009, healthcare staff were concerned about the man’s
condition as he had suffered a headache all day, felt dizzy, had vomited
and was clearly confused. A prison doctor saw the man at 5.16pm and
assessed that he needed to be referred to the Queens Medical Centre
(QMC) in Nottingham. The man was taken to hospital by ambulance.
23. Two days later the man returned to Whatton after he had discharged
himself from the hospital. This was against the advice of the medical staff
at the QMC. Nurse Davies saw him on his return and recorded that he
was rude and confrontational and said he would not take his medication.
24. Between 3 February and 8 March the man continued to be seen every day
by one of the nurses from healthcare. He repeatedly took his diabetic
medication but refused the others despite advice from healthcare staff.
He also refused to eat on many occasions, again against medical advice.
25. On 9 March another nurse and the prison doctor responded to a request
for urgent medical assistance at 4.00pm, as the man had been found on
the shower floor. He did not respond to the staff and the doctor checked
his blood pressure, pulse and temperature which were all normal. The
paramedics had been called and their assessment was that the man was
deliberately being uncooperative. Nevertheless he was taken to hospital
but discharged himself at 7.20pm and returned to Whatton.
26. Another prison doctor assessed the man the following day and recorded
that he was intermittently drowsy and appeared to have some loss of
control of his right side. The doctor decided that this was a sign of a
probable acute cerebrovascular attack (commonly known as a stroke) and
referred him immediately to the QMC.
27. The man remained at the QMC until he transferred to the Stroke Unit at
the City Hospital on 20 March, where he stayed until he was discharged
back to Whatton six weeks later on 7 May. During his time in hospital he
developed pressure sores on both heels which were painful and made it
impossible for him to stand. In advance of his discharge, prison
healthcare staff liaised with the hospital to ensure that an appropriate care
plan was put in place so that he had the appropriate equipment, which
included a hoist, hospital bed, and commode, and that overnight and
weekend care was provided by care assistants organised by ythe PCT.
28. Over the next week the man received daily care from nurses and care
assistants. There were again occasions where he refused his medication,
and food and he would not allow some care assistants to assist him.
29. On 15 May a prison doctor reviewed the man’s condition. The doctor
recorded that since his stroke he had become increasingly frail and
rehabilitation was not a realistic option. He was effectively bed bound and
likely to remain so. The doctor noted that it was too soon to decide how
he was likely to decline as it was complicated by the man’s erratic
behaviour in taking his medication. The doctor also recorded that the man
was turned over in his bed every three to four hours to help relieve the
pressure sores, and that he consistently refused food and food
supplement drinks. The doctor assessed that he would need a 24 hour
nursing facility and that there would be chronic care issues, potentially for
many months.
30. Daily nursing care continued for the next eight days until 23 May, when
the man’s condition deteriorated and he returned to the QMC for further
assessment. Following a request from the Clinical lead/Matron at
Whatton, the Governor at HMP Leicester agreed to accept the man to
their 24 healthcare facility. The transfer would take place once Leicester
had everything in place to meet his needs.
31. On 25 May the man was discharged from the QMC and returned to
Whatton. His daily nursing care continued, pending his transfer to
Leicester, until on 30 May his condition deteriorated further. A nurse
recorded that the area around his pressure sores was red and swollen, he
was very pale, complained of pain and asked to be sent to hospital. The
nurse sought advice from the Nottingham Emergency Medical Service
who agreed that the man should be re-admitted to hospital. He was taken
later that day back to the QMC.
32. The man remained at the QMC until 14 July. Whatton healthcare kept in
regular contact with the hospital to enquire about the man’s condition.
They were informed that he continued to refuse medication and food
despite being told of the seriousness of his actions by both the medical
consultant and the dietician. On 23 June, the hospital confirmed that the
senior physiotherapist had assessed the man as not suitable for any
rehabilitation and he was now permanently confined to bed.
33. The man was discharged from hospital on 14 July to healthcare at
Leicester. The staff had arranged for a hospital bed and special bi-wave
mattress to be in place for his arrival. In consultation with the hospital
healthcare staff prepared a care plan to meet his needs. He complained
that he felt sick and did not eat anything on his first day at Leicester.
34. The following day the man suffered from sickness and diarrhoea, and
healthcare staff questioned whether this was an infection contracted whilst
at the QMC. As a precaution the man was barrier nursed (avoiding
contact with the patient’s skin and body fluids by using medical gloves,
face masks, goggles and gowns) and samples were sent to the local
hospital for analysis. Five days later it was confirmed that the man had
clostridium difficile (bacterial infection that can cause bloating,
constipation, and diarrhoea with abdominal pain). As a consequence the
prison doctor prescribed Metronidazole (for treatment of clostridium
difficile). He continued to be barrier nursed until 6 August when the prison
doctor was satisfied that the infection had cleared.
35. From 7 August to 8 October the man continued to receive 24 hour care.
There were many occasions where he would refuse all food and drink and
medication despite encouragement from staff. He sometimes would
decline assistance with personal care, for example having a wash or
shave.
36. A prison doctor, saw the man on 9 October, and recorded that he had
declined fluids. In the doctor’s opinion, his health was deteriorating and
he was not expected to live more than four weeks. The doctor advised
the healthcare manager that a nursing home setting was now more
appropriate his continuing care. Discussion took place between the
doctor and the prison liaison officer, head of residence, with regard to
applying for compassionate release for the man.
37. On 13 October the prison doctor and the Head of Healthcare approached
the manager of Cedar Court Nursing Home, Wigston Leicestershire, about
a place for the man, who said that an assessment was required before
they could accept him. The following day a member of staff from Cedar
Court came to Leicester, and agreed that they would be able to provide
the care that he required. The man was moved that afternoon to Cedar
Court by ambulance. A full risk assessment was undertaken. Due to the
man’s poor state of health and because he was confined to bed, it was
assessed that no restraints were required and one officer, in plain clothes,
would be on duty at Cedar Court and remain in the day room.
38. The Deputy Governor completed the compassionate release application
and submitted it to the Ministry of Justice for consideration on 15 October.
The man was now at Cedar Court, the prison liaison officer wrote to his
son to inform him where his father had been moved to, and also
attempted to contact him by telephone but without success.
39. On 16 October, the Ministry of Justice granted the man compassionate
release. It took three days to organise the allocation of an offender
manager at Leicestershire Probation Service, as the man’s original
offender manager was based in Kent. During this period the prison
continued try and contact the man’s son but without success. As the last
known contact details were an address in Kent, the decision was taken to
approach Kent Constabulary to locate his son and ask him to contact the
prison.
40. The man’s son contacted the prison’s liaison officer on 19 October, and
confirmed that he had received the letter from Leicester but had not made
contact straight away. The prison liaison officer had a long conversation
with his son giving a full account of the treatment that his father had
received the doctor’s prognosis of life expectancy, and his compassionate
release. The prison liaison officer assured him that the Prison Service
would assist with the funeral costs in due course. The man’s son said that
he would visit his father in two days, and the prison liaison officer
arranged to meet him at Cedar Court.
41. The next day the prison liaison officer went to Cedar Court and released
the man from custody, having completed the necessary documentation.
The escort officer returned to the prison. The prison liaison officer also
contacted his son to inform him that his father had been released from
custody. Arrangements were confirmed for the meeting the following day
at Cedar Court.
42. On 21 October the man’s son met the Governor at Cedar Court. After
introductions with the nursing home staff the prison liaison officer left the
man to be alone with his son.
43. Three weeks later, on 11 November, Leicester were contacted by Cedar
Court to say that the man had died at 6.45pm. The prison liaison officer
contacted the man’s son by telephone to offer condolences, and arranged
for the Roman Catholic chaplain to contact him. The man’s son wanted
the funeral to take place in the Leicester area and the prison liaison officer
offered to make the necessary arrangements. In the days that followed
the Governor stayed in contact with the man’s son, as well as liaising with
the funeral directors and the chaplaincy. The prison liaison officer handed
over the man’s money and belongings to his son after the funeral on 3
December.
ISSUES
Clinical care
44. I believe that the care received by the man during his imprisonment at
both Whatton and Leicester prisons was well organised and of a high
standard. He was skilfully and compassionately looked after by doctors,
nurses and other healthcare and related staff, with an appropriate and
detailed care plan put in place. There is strong evidence of team working
within the prison healthcare unit but also effective partnership working with
the PCT and senior management at Leicester.
45. The man frequently, despite encouragement, refused all his medication,
personal care, food and fluids. He discharged himself from hospital on
two occasions. The man had a responsibility for his own health and could
have sought medical attention but was entitled to exercise his right to
refuse treatment. The clinical review specifically stated:
“The man’s age and diabetes meant that he had a very high risk of
stroke. Once he had had a stroke and became immobile his prognosis
was very poor.”
46. The clinical reviewer summarised the man’s care as follows:
“The man’s medical and nursing care was challenging and healthcare
staff at both HMP Whatton and HMP Leicester appear to have risen to
the challenge. My review of the man’s records suggests that the
Prison Service has effective mechanisms in place for dealing with
elderly prisoners with chronic illnesses and with terminal conditions and
that the healthcare staff have the skills to deal with them.”
Compassionate release
47. Senior management and the doctor at Leicester acted swiftly and
appropriately in making representations to the Secretary of State
regarding the man’s compassionate release. I have often found that
prison’s encounter problems finding somewhere suitable for a terminally ill
prisoner to live outside of prison, which in turn are prepared to accept
them. The doctor’s and Head of Healthcare’s close and prompt liaison
with Cedar Court is also a matter to be commended. The outcome
ensured that the man was treated sympathetically and with dignity during
his last few days in the nursing home.
I commend the actions taken by the Governor, Doctor, Head of
Healthcare and staff at HMP Leicester for the care and dignity
given to the man in the period leading up to his death.
I recommend that the Governor draws by report to the attention of
the nursing home in recognition of their acceptance of the man as
a patient.
Contact with the man’s family
48. Leicester ensured that the man’s next of kin was informed about his
transfer to a nursing home, the seriousness of his illness and his
compassionate release from custody. The prison liaison officer met the
man’s son face to face on his first visit to the nursing home. The prison
appropriately followed the guidance given in Prison Service Order (PSO)
2710, “Follow up to death in custody”. The prison liaison officer also
made the arrangements for his funeral. The Governor maintained contact
with the man’s son to update him on the progress of the funeral
arrangements to ensure his wishes were complied with.
I commend the work carried out by the Governor in following the
best practice contained in PSO 2710 and undertaking additional
work on behalf of the man’s and his family.
CONCLUSION
49. This investigation was undertaken using the Ombudsman’s discretionary
pwers to consider the deaths of prisoners after their release from custody.
I decided to carry out the investigation as, unfortunately it is relatively
unusual, for a nursing home to be found and compassionate release to be
granted particularly for prisoners who have committed serious offences.
50. I have found that at every stage of his deteriorating health the man was
looked after professionally and with dignity. The care provided firstly at
Whatton and then at Leicester is a credit to both prisons. I hope that the
National Offender Management Service will draw these examples of good
practice to the rest of the prison estate.
GOOD PRACTICE
1. I commend the actions taken by the Governor, Doctor, Head of Healthcare
and staff at HMP Leicester for the care and dignity given to the man in the
period leading up to his death.
2. I recommend that the Governor draws my report to the attention of the
nursing home in recognition of their acceptance of the man as a patient.
3. I commend the work carried out by the Governor in following the best
practice contained in PSO 2710 and undertaking additional work on behalf
of the man.