Individual at Parc

Investigation into the circumstances surrounding the
death of a man at HMP Parc,
in December 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2009
This is the report of an investigation into the death of a prisoner at HMP Parc.
He died at hospital in December 2008, having been taken ill at the prison two
days earlier. He was 81 years old. The cause of death was found to be
ischaemic heart disease (a lack of oxygen to the heart muscle) due to
coronary atheroma (build up of fatty lumps on the arteries) with a secondary
condition of chronic bronchitis and emphysema (disease of the lungs). I offer
my sincere sympathy and condolences to the man’s family and all who have
been affected by his loss.
The investigation was carried out by one of my colleagues. An independent
review of the man’s medical care in prison was carried out by a doctor on
behalf of the Healthcare Inspectorate Wales. As ever, I am most grateful to
the clinical reviewer for her assistance.
I would also like to thank the Director and staff of Parc for their full and ready
co-operation during the course of the investigation. My particular thanks go to
the prison liaison officer for his working with my investigator.
The man received appropriate medical care whilst in prison. I am saddened
however that, despite his age and frailty, he was cuffed in hospital until just a
few hours before his death. I make six recommendations and highlight one
example of good practice.
Jane Webb
Deputy Prisons and Probation Ombudsman September 2009
CONTENTS
Summary 4
The investigation process 5
HMP & YOI Parc 6
Key findings 7
Issues 13
Conclusion 18
Recommendations and good practice 19
SUMMARY
The man was remanded into custody at HMP Cardiff on 22 December 2006.
He had several long standing health problems, including heart disease and
kidney disease. He had suffered a heart attack around four years earlier.
After being sentenced to seven years imprisonment in January 2007, he
transferred to HMP Usk.
Throughout the first half of 2008, the man suffered from cellulitis (an infection
of the skin) in his legs. In May, concern was raised about his ability to care for
himself after it was reported that he was unable to shower without assistance
and was unable to dress himself. When there was no improvement by the
end of the month, staff began to look at the possibility of transferring him to a
prison with 24 hour healthcare facilities. He was assessed and accepted by
the healthcare manager from HMP Cardiff on 1 July, but the prison did not
have room for him at the time.
After experiencing some vomiting in mid July, the man was admitted to
hospital for tests. He was diagnosed with chicken pox. After his discharge on
25 July, he transferred to HMP Parc. He lived on the inpatients unit at Parc
for his first two months at the prison. His health was poor for the first five
weeks but he began to improve in early September. On 29 September, he
was well enough to move to a ground floor cell on D wing.
His cell mate told the investigator that he asked a nurse to see the man on 15
December, as his chest did not sound well. He said that the nurse just gave
him paracetamol. Two days later, the cell mate asked another nurse to see
the man. On this occasion, he said that the nurse did not visit him. Neither of
the nurses in question recalled these events.
On 18 December, a nurse was called to see the man in his cell after a
“rattling” noise was heard from his chest. The nurse took him to the
healthcare centre where he was examined by a prison doctor. The doctor
admitted the man to an outside hospital later that afternoon.
In hospital, the man was escorted by two officers and cuffed to one of them by
means of an escort chain (a long chain with a handcuff at both ends). After a
suspected heart attack, the chain was removed at around 9.20pm on 19
December. He did not recover and was pronounced dead a few hours later.
I am pleased to record that the clinical reviewer concludes that the medical
care the man received whilst in prison was good. I am disappointed however
that he, an older, frail man, was restrained in hospital when his mobility was
clearly very limited. Amongst my six recommendations, I ask the Director to
consider revising the risk assessment for cuffing older prisoners in hospital.
THE INVESTIGATION PROCESS
1. The investigation was opened on 22 December 2008 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
to the investigator. Three prisoners came forward as a result.
2. The investigator was given access to the man’s prison files, including the
medical record. He visited Parc on 23-24 February 2009 and interviewed
five members of staff and one of the prisoners. He had previously
interviewed the other two prisoners at HMP Rye Hill, where they had been
transferred.
3. An independent clinical review of the man’s health care whilst he was in
custody was carried out by a doctor on behalf of the Healthcare
Inspectorate Wales.
4. One of the Ombudsman’s family liaison officers contacted the man’s son
on 15 January, to inform him of the investigation and to give him the
opportunity to raise any questions or concerns he had about his father’s
death. He said that he felt Parc had treated his father very fairly and
spoke positively of the support he had received from the prison’s family
liaison officer.
5. The Ombudsman’s family liaison officer also wrote to the man’s daughter
on 5 February to advise her of the investigation. At the time of writing this
report, she had not raised any issues about her father’s death.
6. The report was sent out in draft to the Director of Offender Management
for Wales, Healthcare Inspectorate Wales and the man’s son in July 2009.
Comments by each party, including an official response to the
recommendations, are incorporated in this final report. An additional
section was added to the draft report, in paragraphs 75-81, following
concerns raised by the man’s son regarding the time it took for him to be
notified of his father’s hospital admission. A sixth recommendation was
added to the report, which was sent to the Director of Parc for her
comments. No response was received at the time of writing this report.
7. I hope that this report hopes to clarify any issues that might remain
unclear for the man’s children and helps them to better understand what
happened in the time leading to his death.
HMP & YOI PARC
8. Parc is a category B local prison for men which is situated on the outskirts
of Bridgend, Wales. The prison opened in November 1997 and is
operated by Group 4 Securicor. It is the only private prison in Wales.
Parc holds up to 1,126 adults and young offenders.
9. Healthcare services at Parc are provided by Primecare Forensic Medical
Services. There is an inpatient facility with 17 beds and care is provided
by a team of three doctors and 25 nurses employed by Primecare.
Medical services are also provided by a visiting dentist, optician and
psychiatrist.
10. HM Chief Inspector of Prisons last inspected Parc in July 2008. She found
that “prisoners had good access to a wide range of clinical services, which
were at least comparable with those found in the community”. She went
on to say that the health needs of older prisoners were well catered for
and highlighted as good practice the use of a drop-in clinic on the
vulnerable prisoner’s unit (where the man lived).
11. In their annual report for 2007/08, the prison’s Independent Monitoring
Board (IMB, a group who independently monitor and report on a prison)
expressed the view that the healthcare unit provided “generally good and
wide-ranging services”.
12. The man’s death was the 11th to occur at Parc since April 2004, when I
began investigating all deaths in prison custody in England and Wales.
This was the eighth death due to natural causes. There have
subsequently been two further deaths at Parc, both due to natural causes.
In the case of a gentleman who died around two weeks after the man who
is the subject of this report, the clinical reviewer recommended that the
NHS ensure that comprehensive discharge summaries are sent to Parc
following a prisoner’s attendance at hospital. She makes a
recommendation in this report regarding the collection of blood test results
from hospital.
KEY FINDINGS
13. The man suffered from a number of significant health problems at the time
of his imprisonment. His doctor in the community wrote to his solicitor
around two months before the man’s conviction highlighting ischaemic
heart disease (a lack of oxygen to the heart muscle), chronic kidney
disease and mascular degeneration (deterioration of the retina). He also
reported that the man had suffered a heart attack in June 2002. A list of
his medication was provided, including aspirin (to thin the blood and
prevent a heart attack), atenolol (for high blood pressure), GTN spray (to
relieve chest pain due to angina), ramipril (to treat high blood pressure or
heart failure) and simvastatin (to reduce cholesterol and hence the risk of
a heart attack).
14. Following his arrival at Cardiff on 22 December 2006, the man saw a
nurse for a reception health screen (a routine health screen for all new
arrivals into prison). His medical conditions and prescription medication
were recorded. The nurse noted that he was frail but had been living in
his own flat and caring for himself. He asked for a place on the vulnerable
prisoners’ unit on account of his offences and was allocated a cell there
on the ground floor. The following day, the man said he was worried that
he would struggle to collect his own meals, and another prisoner was
assigned to help him.
15. On 13 January 2007, the man was visited by a nurse to review his
progress. He said that he was managing with the support of staff and had
been using a seat to help him shower. He also said that he had been
using his GTN spray three times a week on average. Nine days later he
was again seen in his cell and, on this occasion, said that just slight
exertion made him breathless. A request for a chest x-ray was faxed to a
local hospital. (There is no record of such an examination taking place.)
16. Having been sentenced on 26 January, the man transferred to Usk three
days later. It was noted at a reception screen that he could not manage
stairs, became short of breath from walking and needed help to collect
meals. He was assessed again on 1 February, when it was noted that he
was unable to manage his activities of daily living (washing, collecting
meals, cleaning cell etc) without assistance.
17. A week later, the man was reviewed by a prison doctor. As well as the
medical problems previously listed, the doctor highlighted that he had
minor arthritis. On 20 February, an older prisoner assessment was
completed. It was now noted that he could walk unaided and care for
himself.
18. Over the following months, the man was seen by a chiropodist and
attended an outpatient appointment with an opthamologist (eye specialist).
The consultant noted that he was “severely sight impaired”. The man
developed a chest infection in October 2007, and was prescribed a course
of amoxicillin (an antibiotic). The chest infection returned three months
later, and he was prescribed a further course of amoxicillin on 16 January
2008.
19. On 22 January, the man was called to attend healthcare after wing staff
reported concerns about his health. His legs were very dry and he was
losing a lot of skin. It was also reported that he was not showering. He
was given moisturiser to use and assured the nurse that he would shower
the next day. The nurse advised the man that if he was unable to care for
himself he would be transferred to a prison with 24 hour healthcare
facilities.
20. The man was diagnosed with cellulitis on 13 February. He was seen
regularly by nursing staff over the following weeks regarding dry and
broken skin on his legs and feet.
21. On 19 February, the man was told that his son had died over the
weekend. He decided not to travel to the funeral, but did attend a service
in the prison chapel.
22. Two days later, the man told a nurse that his chest was “bubbly”. He was
asked to bring a sputum (mucus coughed up from the lungs) sample for
analysis, but refused. The following day he also declined an appointment
with a prison doctor. Despite this, a request for a chest x-ray was made
and he went to an outside hospital on 7 March. The results indicated that
“the lungs show evidence of chronic disease and are over inflated”.
23. By 14 March, the man again developed cellulitis. He was prescribed a
course of flucloxacillin (an antibiotic), with a further course prescribed on
25 March as there was no improvement. He continued to use cream on
his legs throughout April, with some improvement noted later in the month.
24. The man had been assessed as suitable to collect his medication on a
weekly basis and store it in his cell to use as prescribed. On 21 April,
however, it was noted that he was not collecting his medication every
week. He was advised of the importance of taking his medication as
prescribed.
25. Concerns were raised on 7 and 8 May about the man’s ability to look after
himself. He said that he was unable to shower without assistance and
found it difficult to dress himself. His cell mate, who had helped him
considerably, had recently been released. The nurse thought he had lost
weight, although he refused to be weighed. She also thought that he was
“visibly frailer”. It was agreed that the man should start to take Fortisips (a
nutritional supplement).
26. Over the following days, the man’s blood pressure dropped and a change
to his prescription of ramipril was made following a review by a prison
doctor on 12 May. Two days later, he reported a lesion on his left ear. He
was referred to a dermatologist at the hospital on suspicion of having skin
cancer.
27. On 15 May, the man was noted to have developed cellulitis again. He
was prescribed a further course of antibiotics. Twelve days later, his cell
mate told nursing staff that he had chest pain. He went to the healthcare
centre and said that he was just wheezing and had no pain. He declined
an ECG (a test to measure the electrical activity of the heart) as he said
he was not feeling any pain.
28. At the end of the month, officers on the man’s wing raised more concerns
with healthcare staff regarding his personal hygiene. They said that he
needed assistance with washing and dressing, walking to healthcare and
sometimes needed help getting to and from the toilet. This was discussed
by senior managers at the prison, who decided to investigate transferring
him to an establishment with 24 hour healthcare facilities.
29. In June, it was again noted that the man was not always taking his
medication as prescribed. He attended an appointment with a wound care
specialist at the outside hospital on 18 June, and was diagnosed with
contact dermatitis (a skin rash). He returned to the hospital a week later
for a biopsy of the lesion on his ear. The results showed no evidence of
cancer.
30. A nurse and the healthcare manager from HMP Cardiff visited Usk on 1
July to assess the man. They agreed that he needed to be in a prison
with 24 hour healthcare, but had no room for him in Cardiff at the time.
They said they would consider him for transfer should space become
available.
31. The man remained in bed on 15 July, saying he felt unwell and eating
little. The healthcare manager at Cardiff was contacted and again said
they had no space for him. Three days later, he complained of feeling
nauseous and said he had vomited. Following discussions with the on-
call doctor, the man was admitted as an inpatient to the outside hospital
for further investigation. He spent a week in hospital, during which time
he was diagnosed with a urinary tract infection and chicken pox.
32. Whilst the man was in hospital, arrangements were made for him to
transfer to Parc following discharge. He arrived at Parc on 25 July and
was allocated a cell in the healthcare inpatients wing. He was assessed
by a nurse shortly after his arrival. The nurse noted the man’s history of
coronary heart disease, kidney disease and mobility problems. A care
plan was started the same day, with aims that included providing a safe
environment for him, monitoring his food and fluid intake and assessing
his mobility. The following morning, he was assessed by a prison doctor.
The doctor requested that the man’s blood pressure, pulse and
temperature should be monitored daily and he should be weighed weekly.
33. Over the following days, the man was noted to have settled in well at
Parc. On 31 July, he told staff he had fallen out of bed and bruised his
head. A blood sample was taken and the results showed that he had mild
anaemia (a low level of iron in the red blood cells) and mild dehydration.
He also told staff he had vomited. He continued to report vomiting over
the following days, and his blood pressure fell as low as 70/40 on 3
August. He was therefore admitted as an inpatient to another hospital, on
3 August.
34. The man returned to Parc on 6 August, having been prescribed a course
of cyclizine (to treat nausea and vomiting). The hospital discharge note
recorded that he had been diagnosed with mild anaemia and low blood
sodium (needed to regulate the amount of water in the body). His blood
pressure on discharge had improved to 118/72.
35. A revised care plan was produced on 10 August, on account of a general
deterioration in the man’s health. Over the following week, he began to
improve and was seen eating and drinking well. On 17 August, he was
visited by his son. The visit took place in healthcare rather than the main
visits hall (which meant that he did not have to walk as far).
36. On 24 August, an ‘open door’ policy was initiated for the man during the
night because of his poor health. (This meant that healthcare staff were
able to have immediate access to the room overnight.) He continued to
experience some episodes of vomiting during the remainder of the month,
and was prescribed further doses of either cyclizine or maxolon (also used
to treat nausea and vomiting).
37. In early September, the man’s health improved and he was noted to be
walking round healthcare and eating well. He reported no further
episodes of vomiting. For several days he was invited to go to D wing for
association, in preparation for a move to a cell on that wing. On some
occasions he attended, but on others he said that he felt too unwell. On
account of his improving health, the overnight ‘open door’ policy was
stopped on 7 September.
38. A risk assessment to consider the man’s needs, were he to move to D
wing, was completed on 9 September. This followed a multi-disciplianry
meeting attended by healthcare staff and the senior manager in charge of
D wing. It was noted that the man was now able to wash himself, take
showers and get dressed without assistance. A ground floor cell near the
staff office was requested and also a share of a cell in case he was to fall
when the cell was locked. The assessment also said that he would
require help to collect his meal tray. In a meeting held prior to the
completion of the risk assessment it was also mentioned that he needed a
wheelchair to travel long distances. Two days later, an entry in the man’s
nursing notes said that he was now “independent to all of his needs”.
39. On 20 September, the man fell over and grazed his right temple. The
following day he said that he felt well and had no problems. On 29
September, a space became available on D wing and he moved there
later that day.
40. The man had a flu vaccination on 14 October and saw an optician on 4
November. A nurse was called to D wing to see him on 28 November
after he said that he had been suffering from diarrhoea for a few days. He
told the nurse he felt better and was therefore advised to inform staff if he
felt worse again.
41. His cell mate told the investigator that the man’s chest sounded like a
“bucket of bolts” on 15 December. The cellmate said he went to the
treatment hatch on the wing and asked the nurse to see the man. He
went on to say that the nurse gave the man some paracetamol. The
nurse told the investigator that he did not recall seeing him on this
occasion. He explained that he is experienced in dealing with chest
problems. If the man’s chest had sounded as described he would have
noted it in the medical record and arranged for him to see a prison doctor.
The nurse said that the most likely scenario was that the man had just
said that he was feeling under the weather and wanted some
paracetamol.
42. The cellmate told the investigator that he again went to the treatment
hatch on the morning of 17 December to ask a nurse to see the man. He
said the nurse told him that she would come when she had finished
distributing the medication, but did not do so. The treatments nurse said
she did not recall the cellmate speaking to her about the man. She added
that if he had done she would have gone to see him, assessed and dealt
with his complaint, and made an appropriate entry in his medical record.
43. At around 1.00pm on 18 December, a prison custody officer (PCO) was
outside the man’s cell and could hear him wheezing. The PCO went in
and found him sitting on his bed. The PCO said that he could hear that
the man’s “chest was rattling”. He called for nursing staff to attend.
44. Two nurses went to D wing to see the man. He said that he had been
feeling unwell for around a week and one of the nurses observed that his
chest sounded “bubbly”. The nurses therefore took him to healthcare for
further checks. His pulse, blood pressure, temperature and oxygen
saturation levels (a measure of the oxygen level in the blood) were taken.
He had low saturation levels and was therefore given oxygen through a
mask.
45. Shortly afterwards, the man was assessed by a prison doctor. The doctor
observed that he was extremely short of breath and unable to walk. He
thought that he might have fluid on his lungs and may have experienced
some degree of heart failure. The doctor therefore arranged for the man
to be admitted to an outside hospital for further investigation. He arrived
at the hospital at around 3.30pm.
46. A risk assessment was completed later that day, which concluded that the
man was unlikely to try to escape and was of a low to medium risk to the
public or hospital staff. He was also noted to be mobile but physically frail.
The form was approved by the Head of Security at Parc. He concluded
that the man should be accompanied by two officers at hospital and cuffed
to one of them by means of an escort chain.
47. Shortly after the man’s arrival at hospital, blood samples were taken and
he had a chest x-ray. That evening he was given oxygen through a mask
and, later, through a tube in his nose. He had earlier been moved to a
private room. In the early hours of the morning on 19 December, he
complained of feeling unwell. One of the bedwatch (a prison term
referring to the escort of hospital inpatients by prison officers) officers
called a nurse in to see him. The nurse took his blood pressure (the
results of which are not recorded in his prison records) and encouraged
him to get some sleep. That afternoon, it was reported that fluid was
taken from his chest (to help his lungs expand).
48. A revised risk assessment was completed on 19 December, again signed
off by the Head of Security. The revised form was completed because the
man’s status had changed from a hospital outpatient to an inpatient. The
medical assessment section of the form is blank and it contains no
additional information to that provided in the previous day’s risk
assessment. The Head of Security again concluded that an escort chain
should be used.
49. At around 8.00pm, the man was given oxygen by nursing staff following
fears that he might have had a heart attack. Shortly afterwards he was
able to breathe by himself again. At around 9.20pm, the escort chain was
removed, although the officers remained. Permission to remove the
escort chain was given by the orderly officer (the person in charge of the
prison overnight) following a request from the escorting staff. An hour
later the man’s son arrived at the hospital to visit, having been informed of
his condition earlier that evening by hospital staff.
50. The man died at 1.55am the following morning. The prison family liaison
officer telephoned his son to break the news of the death. (This had been
agreed with the man’s son during his visit a few hours earlier.)
51. A post mortem revealed the cause of death as ischaemic heart disease (a
lack of oxygen to the heart muscle) due to coronary atheroma (build up of
fatty lumps on the arteries) with a secondary condition of chronic
bronchitis and emphysema (disease of the lungs). The man’s funeral was
held on 19 January 2009. The investigator found that the prison’s
contribution to the funeral costs was in accordance with PSO 2710 (the
Prison Service Order that sets out the actions to be taken following a
death in custody).
ISSUES
Findings from the clinical review
52. The clinical review was carried out by a doctor on behalf of the Healthcare
Inspectorate Wales. The clinical reviewer makes the following comment
regarding the standard of care that the man received whilst in prison:
“The health care given by staff at HMP Parc and HMP Usk appeared to
be good. Staff were conscientious about obtaining primary care
records, secondary care opinions and for dressing his legs as
prescribed. Efforts were made to transfer [the man] to a prison with 24
hour healthcare when the seriousness of his physical condition was
recognised. The progressive deterioration in his health and mobility
was likely due to his old age.”
53. The clinical reviewer goes on to say that the man’s medical records were
illegible in places and his blood test results were not always filed in the
record. She makes the following recommendation:
Healthcare staff should ensure that blood results are obtained from
hospital pathology departments, reviewed and filed correctly, and
that medical records are legible.
Care received by the man on D wing
54. Prior to his move from healthcare to D wing, a multi-disciplinary meeting
was held on 9 September to highlight any specific needs that the man
would have were he to live on the wing. The group concluded that he
should have a ground floor shared cell near to the staff office. It was
noted that he was able to wash, shower and dress himself without
assistance but that he would require help collecting his meal tray.
55. One other measure to help the man prepare for life on D wing was to
allow him to attend evening association on several occasions. This gave
him the opportunity to get to know wing staff and his fellow prisoners prior
to his move. It also allowed staff to develop an understanding of his
requirements. I consider this to be an example of good practice.
The man was given the opportunity to attend association on D wing
prior to moving from healthcare to the wing.
56. On the day of his move to D wing, an entry was made in the man’s
medical record saying that he was to attend healthcare weekly for a bath.
It is not clear whether this took place. His cell mate told my investigator
that arrangements were made for their cell to be unlocked at 7.00am on
Monday, Wednesday and Friday mornings so that he could help the man
to shower. The cellmate said, however, that this did not happen on a
regular basis and the man therefore went without a shower. Two other
prisoners said that he never came out of his cell and was given no help by
the staff on the wing.
57. The manager of D wing, told my investigator that she thought staff on the
wing had very good support from healthcare staff. She was sure that any
arrangements with healthcare regarding the care of individuals would be
adhered to, although it may have been forgotten some days because of
operational issues.
58. The manager of D wing went on to say that there are some older
prisoners who do not come out of their cells very often. She tried to
encourage them to come out for association at least once a day. In
addition, she said that she expected staff to check on anyone who was
staying in their cell to see that they are alright.
59. At interview, the PCO said that the man preferred to shower in the
adapted showers on the wing rather than go to healthcare for a bath. The
PCO said there was a note on a board in the office to remind staff to
unlock the man but they relied on someone remembering to do this. He
also said that he did not come out of his cell much because he was
concerned about being knocked over due to his lack of mobility. The PCO
said that staff tried to encourage the man to come out of his cell more. He
began to come out of his cell more often in October and November 2008,
but would usually return after an hour.
60. Regular baths and showers were especially important to the man, who
had a recurrent skin complaint. It should be easy to monitor whether
prisoners who need assistance to bath or shower receive the help that
they require. For example, staff could have been asked to sign his wing
record or the wing observation book to confirm that he had been unlocked
for a shower. Alternatively, a reminder could have been written on the
office white board, for staff to initial on Monday, Wednesday and Friday
mornings. In lieu of such arrangements, I have to conclude that it is
unlikely that the man was able to shower three times a week, as arranged.
The Director should implement means of monitoring the personal
care arrangements for those prisoners who require assistance.
61. The man’s medical record reveals little contact with healthcare staff during
the three months that he lived on D wing. At interview, the prison doctor
suggested that it would be appropriate to hold a monthly review of older
prisoners who had been in healthcare as an inpatient. I agree. A regular
review would give the patient the opportunity to raise any concerns about
their care or their daily living arrangements.
The head of healthcare should ensure that older prisoners living on
wings who have previously spent time as inpatients in healthcare are
reviewed by a doctor on a regular basis.
Events in the week leading up to the man’s death
62. The cellmate told my investigator that he asked a nurse to see the man on
15 December because his chest sounded like a “bucket of bolts”. He
added that the nurse gave him some paracetamol. The treatment nurse
said he did not remember seeing the man on this occasion but that if his
chest had sounded as described he would have arranged for him to see a
prison doctor. He thought it likely that the man had said he was feeling
under the weather and had asked for paracetamol.
63. The cellmate said that he again asked a nurse to see the man on 17
December. On this occasion, he said that the nurse did not come to the
cell, despite saying that she would. The treatment nurse on duty on that
occasion said she did not recall the cellmate speaking to her about the
man. She added that if he had done she would have gone to see him,
assessed and dealt with his complaint, and made an appropriate entry in
the medical record.
64. It is unfortunate that neither of the two treatment nurses recall the events
that the cellmate describes. Had they seen the man and observed the
symptoms described by his cell mate, I would expect them to carry out a
medical assessment and make a record of the findings. As it is, I cannot
say for certain what did happen on these occasions. The Director may
wish to satisfy herself that healthcare staff do attend prisoners when
healthcare needs are reported.
65. After reading the draft report, the man’s son told the Ombudsmans family
liaison officer he was concerned that healthcare staff did not take his
father’s cell mate more seriously when he approached them on 15 and 17
December. He felt healthcare staff could have done more to examine and
treat his father and that it was not enough to have simply given
paracetamol to a man of that age and history of ill health.
Use of restraints
66. The man was admitted to hospital on 18 December 2008. He was
accompanied by two PCOs and cuffed to one of them by an escort chain.
The decision regarding whether or not to cuff a prisoner in hospital is
made by means of a risk assessment, with the final decision being signed
by the Director, Deputy Director or the head of security or operations. The
risk assessment considers factors such as the prisoner’s escape risk and
the risk to the public if they did escape. An assessment of the prisoner’s
physical capacity to escape unaided is also considered.
67. The risk assessment completed on 18 December concluded that the man
was unlikely to try to escape and was of a low to medium risk to the public
or hospital staff. A prison nurse completed the medical assessment
section of the form. She noted that he was “mobile but physically frail”.
The head of security at Parc made the final decision on the cuffing level
and instructed that restraints should be in place.
68. This decision was reviewed on 19 December, once it became clear that
the man would stay in hospital as an inpatient. On this occasion the
medical assessment section of the form was blank. The head of security
decided that there should be no change to his cuffing status.
69. The escort chain was removed at around 9.20pm on 19 December.
Permission was given by the orderly officer following a request from the
escorting staff. Just over an hour earlier, the man had been given oxygen
by nursing staff after he had a suspected heart attack. He had also been
given oxygen therapy the previous day, firstly through a mask and then
through a tube in his nose.
70. The man was a frail 81 year old man with an extensive medical history.
His mobility was poor and, prior to his hospitalisation on 18 December, he
had to be taken from his cell to healthcare in a wheelchair. The prison
doctor, who assessed the man on 18 December, told my investigator that
“he couldn’t walk, [his mobility] was bad”. The doctor also said that the
man was “extremely short of breath”. There is no evidence to suggest
that he was an escape risk.
71. The decision about whether to cuff a prisoner at hospital is a difficult one
and the balance between decency and security can be hard to find.
Nevertheless, in these circumstances I do not think that it would have
been unreasonable to escort the man in hospital without the use of
restraints. Given his condition, I judge that the presence of the two prison
officers would have been an adequate security arrangement. This
conclusion could have been more easily reached at Parc had the medical
assessment section of the risk assessment been completed prior to its
review on 19 December.
The Director should remind staff that the medical assessment
section must be completed whenever the risk assessment is
reviewed.
The Director should encourage senior managers to take less risk
averse decisions when determining the cuffing levels required for
seriously ill, older prisoners with very limited mobility.
Contacting the next of kin when the man was admitted to hospital
72. The man was admitted to hospital in the afternoon of 18 December 2008,
after complaining of shortness of breath. The prison doctor, thought he
might have fluid on his lungs and may have experienced some degree of
heart failure. He therefore arranged for his admission so he could
undergo tests and further investigation.
73. Over the following 24 hours, the man was given oxygen and had some
fluid drained from his lungs. On the evening of 19 December, he had a
suspected heart attack. His son was then contacted by hospital staff and
was able to visit later that night.
74. After reading the draft report, the man’s son told the Ombudsman’s family
liaison officer that his father was being kept alive by a life support machine
when he arrived at the hospital to visit on the night of 19 December. He
felt he could have been contacted sooner so that he might have had a
chance to say goodbye to his father.
75. It is a policy at Parc to contact the next of kin 24 hours after a prisoner is
admitted to hospital. This is done by chaplaincy staff, who are given a list
on a daily basis by the orderly officer (a senior member of uniformed staff
who responds to situations arising in the prison during the day).
76. A chaplain at Parc tried to contact the man’s next of kin on the afternoon
of 19 December. It does not appear as though he had any next of kin
recorded at Parc. The chaplain therefore got a telephone number for one
of his sons from his prison telephone account. He left a message on an
answerphone that afternoon.
77. Unfortunately, it later emerged that the son who the chaplain tried to
contact had recently died. The man’s other son had by then been
contacted by hospital staff. It would appear that the man himself gave his
son’s contact details to staff at the hospital.
78. The policy at Parc to contact the next of kin 24 hours after a prisoner is
admitted to hospital is a commendable one. It is unfortunate that, on this
occasion, up to date contact details were not held. The Director will wish
to ensure that contact details are held for all prisoners who are willing to
provide them. This is particularly relevant for older prisoners with long
standing health problems who, like the man, might be at greater risk of
hospital admission.
The Director should ensure that up to date next of kin details are
held for all prisoners and that these are accessible to chaplaincy
staff.
CONCLUSION
79. The man was an older prisoner with several long standing health
problems. On account of his declining health he transferred to Parc in
July 2008, in order that he might benefit from their 24 hour healthcare
facilities. His physical health improved greatly during his two months as
an inpatient in Parc’s healthcare centre. I am pleased to see that he was
given the opportunity to spend time on his future wing whilst waiting for a
cell to become free, giving him the chance to get to know staff and his
fellow prisoners.
80. My investigation found that the man received good and appropriate
medical care whilst in prison. However, I believe that it was inappropriate,
given his age and frailty, that he was handcuffed in hospital until around
four and a half hours before his death. As the Ombudsman has expressed
in a number of previous reports, escort risk assessments should pay more
attention to the physical capabilities of the patient and less to the type of
offences they have committed.
RECOMMENDATIONS
1. Healthcare staff should ensure that blood results are obtained from
hospital pathology departments, reviewed and filed correctly, and that
medical records are legible.
Accepted – the healthcare manager will ensure that protocols are in place
for dealing with blood results and that all medical records are legible.
2. The Director should implement means of monitoring the personal care
arrangements for those prisoners who require assistance.
Accepted – a review will be conducted and procedures implemented to
ensure that prisoners who require assistance with personal care are
monitored and cared for appropriately.
3. The head of healthcare should ensure that older prisoners living on wings
who have previously spent time as inpatients in healthcare are reviewed
by a doctor on a regular basis.
Accepted – a review will be carried out by the healthcare manager to
implement systems that ensure all prisoners over the age of 65 are to be
reviewed regularly to access their healthcare needs.
4. The Director should remind staff that the medical assessment section must
be completed whenever the risk assessment is reviewed.
Accepted – staff will be reminded of the need to ensure this requirement is
met.
5. The Director should encourage senior managers to take less risk averse
decisions when determining the cuffing levels required for seriously ill
older prisoners with very limited mobility.
Accepted – all necessary information will be taken into consideration when
assessing the level of security required on hospital escorts. However,
senior managers will be advised of the need to pay particular attention to
mobility and health status of older, seriously ill prisoners.
6. The Director should ensure that up to date next of kin details are held for
all prisoners and that these are accessible to chaplaincy staff.
No response received.
GOOD PRACTICE
1. The man was given the opportunity to attend association on D wing prior
to moving from healthcare to the wing.