Individual at Send

Investigation into the death of a woman at Royal County
Surrey hospital whilst in the custody of HMP Send in April
2009
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2010
The woman died in Royal County Surrey Hospital in April 2009 while in the custody
of HMP Send. She had been suffering from cancer and was 40 years old. I offer my
sincere sympathy and condolences to the woman’s family and friends for their loss.
The investigation was carried out by one of my investigators. In addition, a clinical
review of the woman’s healthcare at HMP Send was undertaken by the clinical
reviewer on behalf of NHS Surrey. I am grateful for her review. I would like to thank
the Governor of Send and his staff for their co-operation and assistance.
The woman had spent a long time in prison by the time she went to Send in 2006. It
appears that she valued her friends and the staff and did not want to move to
another prison. She was diagnosed with cancer in 2006 and, although she
underwent treatment, she was told that her illness had spread over the coming
years. Although Send does not have 24 hour healthcare provision, staff were keen
to accede to the woman’s wishes and keep her in the environment she felt
comfortable for as long as they could. I am pleased to record these efforts as it is
clear that the woman was adamant that she did not want to leave Send.
I include one recommendation regarding recording family histories of cancer, and
three areas of good practice regarding support from prisoners, multi-disciplinary
meetings and restraints.
The version of my report, published on my website, has been amended to remove
the names of the woman who died and those of staff and prisoners involved in my
investigation
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2010
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CONTENTS
Summary
The Investigation Process
HMP Send
Key Findings
Issues
Conclusion
Recommendations
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SUMMARY
The woman was born in October 1968. In 1997 she was sentenced to life
imprisonment with a 15 year tariff for murder. She spent time in a number of prisons
before transferring to HMP Send in 2006. Shortly after arriving there, she
complained of a lump in her breast. Following a referral to hospital, she was
diagnosed with advanced breast cancer.
The diagnosis shocked her, and she was angry that it was not investigated earlier as
she had complained of a lump in her breast in a previous prison in 2004. The
woman underwent treatment in the forthcoming months. However, she was
diagnosed with further cancer in April 2007 and June 2008. This upset her and the
prison’s suicide monitoring process was used on a number of occasions to provide
her with some extra support.
As the woman’s health declined, staff began to consider whether she should move to
a prison with 24 hour healthcare. The woman was very against this idea as she was
settled at Send, and valued having friends and staff she knew around her. The
prison was willing to look after her at Send until it became necessary for her to have
constant healthcare.
The woman’s health declined rapidly in early April 2009 and she was taken into
hospital. Her nominated next of kin was contacted and was present at the hospital
when she died. Prison staff told the other prisoners of her death, and showed her
cell to her next of kin.
I believe that Send acted well to support a woman with a succession of serious
illnesses by recognising her wishes to remain at Send as long as possible. The
clinical reviewer comments that the woman’s care was generally equitable to what
she would have received in the community. I include one recommendation and three
areas of good practice in this report. I hope that this report provides answers to any
questions from the woman’s friends and relatives.
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THE INVESTIGATION PROCESS
1. One of my investigators led the investigation into the circumstances
surrounding the woman’s death. He contacted HMP Send and requested the
relevant documentation. The paperwork took a long time to be sent to my
investigator but, once it was received, my investigator reviewed it and planned
the interviews.
2. My investigator wrote to NHS Surrey to request a review of the clinical care
received by the woman while in custody. A clinical reviewer was appointed to
carry out this review.
3. My investigator travelled to Send on 30 July with the clinical reviewer from
NHS Surrey to undertake the interviews. The clinical reviewer was provided
with the transcripts of the interviews.
4. One of the family liaison team contacted the person nominated as the
woman’s next of kin to inform her of the investigation. She declared that the
woman was happy at Send and did not raise any specific concerns. My family
liaison officer also contacted the woman’s sister who asked why she had not
been told about the woman’s illness and death, and wanted to know if she
had been on day release while in prison.
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HMP SEND
5. Send was originally an isolation hospital, before becoming a junior detention
centre in 1962. It was reclassified as a category C adult male training prison
in 1987 but, having been re-rolled and rebuilt, opened as a female training
prison in 1999. The capacity is 282. Send does have a healthcare unit in the
main block but does not offer full 24-hour healthcare.
Assessment, Care in Custody and Teamwork (ACCT)
6. The ACCT process is used by the Prison Service to monitor and support
prisoners deemed at risk of suicide or self-harm. It replaced the system
known as F2052SH.
7. Once ACCT procedures are begun, the prisoner is observed at predetermined
intervals according to the perceived level of risk. Each prisoner is assessed
within 24 hours and then reviewed at intervals decided on an individual basis.
The ACCT guidance says that, to be effective, the review should involve the
key people who know the person at risk or are involved in their care. The key
questions for each review are listed as:
(cid:127) have the problems that caused the ACCT plan to be opened now been
resolved?
(cid:127) if not, what needs to be done to resolve them?
(cid:127) have any further problems arisen that are now causing distress and more
risk?
(cid:127) if so, what action can be taken to address these?
(cid:127) is the person at risk now in contact with friends, family or other support?
(cid:127) does the person at risk now have something in their lives that they feel
good about?
(cid:127) if not, how can this be improved?
8. Over time, the reviews should also consider other factors such as:
(cid:127) distress – has anything changed to make the person at risk more or less
desperate?
(cid:127) resources – has anything changed that makes the person at risk now feel
more or less alone?
(cid:127) previous suicidal behaviour – has anything changed that makes suicide
more familiar or more acceptable to the person at risk?
(cid:127) suicide intention or plan – has anything changed to show that the person
at risk is more or less prepared to kill themselves?
(cid:127) pattern of self harm – is self harm becoming more or less frequent?
Use of restraints
9. When a prisoner is escorted outside of a prison a risk assessment has to be
made on the methods used to maintain security. The assessment will
consider the number of staff to escort the prisoner, and whether the use of
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restraints is advisable. The issues taken into account include medical
concerns, behaviour in the prison, specific areas of concern and criminal
history.
Contacting a prisoner’s next of kin
10. PSO 0500 (reception) makes clear that “Staff must ask prisoners for the
name, address and telephone number of their next of kin and accurately
record the information”. PSO 2710 (follow-up to deaths in custody) instructs
prisons to “Arrange notification to the next-of-kin and any other person
reasonably nominated by the prisoner … “. The prison will only contact the
next of kin, and would often not have details or knowledge of anyone else.
Independent Monitoring Board
11. Each prison has an Independent Monitoring Board (IMB) made up of
members of the community. The Board’s role is to ensure that the prison is
properly run and that prisoners are treated decently. Each Board produces an
annual report for the Secretary of State. The most recent report from the
Send IMB covers the period April 2008 to March 2009.
12. The IMB comment that the prisoners are treated fairly and humanely at Send.
However, it accepted that the large amount of building redevelopment and
staff shortages had made consistent care for prisoners difficult. The shortage
of staff was particularly prevalent in the healthcare department. The report
did say that the belated appointment of a new head of healthcare had
improved matters.
HM Chief Inspector of Prisons
13. HM Chief Inspector of Prisons undertook a short unannounced inspection of
Send from 18 to 22 August 2008. The previous inspection, conducted in early
2006, resulted in a report that described Send as “being very safe and
respectful, with reasonable purposeful activity and resettlement provision”.
However, the follow-up inspection revealed problems stemming from a less
settled population, and difficulties in staff recruitment and retention.
14. The prisoners’ induction routine was reported to be haphazard, and self-harm
had increased throughout the prison. Although relations between staff and
prisoners were still described as positive, this was threatened by the turnover
of staff. Prisoners were described as dissatisfied with healthcare, which also
suffered from a difficulty in recruiting permanent nursing staff.
Previous deaths at Send
15. Send experienced two self-inflicted deaths in 2007, and one since the death
of the woman. There was also another death due to cancer in May 2009
where Send were praised for their approach to the use of restraints in
hospital.
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KEY FINDINGS
16. The woman was arrested in 1996 and convicted of murder in 1997. She was
sentenced to life imprisonment with a 15 year tariff and moved to HMP
Durham, HMP Buckley Hall and HMP Foston Hall. While at Durham, in
August 2004, the woman was assessed in healthcare with a lump in her
breast. Nothing abnormal was found, and she was not referred to an outside
hospital for treatment. She was transferred to HMP Send on 15 May 2006.
17. The woman approached healthcare staff on 26 May complaining of pain and a
lump in her breast. The doctor referred her to the Royal Surrey County
Hospital under the two week referral system (where the patient is seen by a
specialist within two weeks), and in June she was diagnosed with breast
cancer. She was reported as being upset and tearful in the days following her
diagnosis. She was understandably resentful that her illness had not been
diagnosed at other prisons earlier in her sentence. In her documentation,
staff referenced the support they offered her, including helping her write a list
of questions to ask the hospital doctors.
18. A F2052SH form was opened on 29 June. (This was the document the prison
service used to monitor those at risk of self-harm or suicide. It has since been
replaced by the ACCT process). The form was opened because the woman
said she had thought of ending her life. The documentation included
references to her being supported by other prisoners. Her mood was again
reported as being very low on 3 July as she had been told by the hospital that
the cancer had spread. She underwent chemotherapy at the Royal Surrey
County Hospital from July to October.
19. A meeting was held on 7 November with attendees from healthcare and
prison staff to discuss her care. The prison provided her with new pyjamas
and a DVD player in order to make her more comfortable. During her time at
Send, she was also moved to a larger cell with a hospital bed. She
underwent a mastectomy with simple reconstruction in December. She had a
course of radiotherapy from March to April 2007.
20. In April, she was diagnosed with a brain tumour. She underwent surgery at St
George’s Hospital in early May to treat the tumour. This was followed by a
further course of radiotherapy at the Royal Surrey County Hospital.
21. She appears to have been in dispute with the healthcare department in
September who began to reduce her morphine dosages. This was done in
response to a request from her hospital consultant to prevent her having too
much which could mask the symptoms of her illness, but it still upset her.
22. On18 February 2008, she collapsed on the wing and had a seizure. During
this attack she also bit her tongue. She was told in April 2008 that her cancer
was no longer curable. This upset her and staff arranged for two of her
friends to stay and support her. Support from her friends continued
throughout her time at Send.
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23. A senior officer (SO) wrote in the woman’s records that she was authorised
two additional telephone calls each week. She was again recorded as feeling
low in May 2008. Staff noted that the woman fainted again in May although
she told them that she was alright.
24. The woman had an escorted absence in Woking on 25 June 2008. (The
purpose of escorted absences include enabling prisoners to familiarise
themselves with community life, making resettlement arrangements and
showing their ability to behave responsibly. Prisoners are escorted by prison
staff who monitor their adherence to the expectations set out for them.)
25. In July 2008, the woman received further bad news about her health from the
hospital. They confirmed that she was also suffering from bone metastases
(cancer that has spread from the original site to the bones) and was to
undergo a course of radiotherapy. She complained about being in pain and
collapsed again on 23 July which necessitated a visit to an outside hospital.
The woman was visited by a specialist palliative care nurse on 28 July and
these visits continued throughout the rest of her life at Send. Another meeting
was held in late July to discuss her care and it was decided to schedule a
follow-up meeting as her treatment continued.
26. A further meeting was held on 18 August when staff discussed the safety
implications of the woman staying at Send. A letter was received from a
palliative care consultant, on 11 September which indicated that the woman’s
health needs were becoming increasingly difficult to manage in a prison
setting. Another meeting was held on 7 October to discuss the prospect of
the woman going to HMP Holloway where 24 hour healthcare could be
provided.
27. Another meeting was held on 1 December and staff agreed that ultimately the
woman would need to transfer to Holloway. However, it was decided to
postpone this move until a specific need arose as the woman was not keen to
leave Send. She agreed to this course of action.
28. The ACCT process was begun on 17 December as the woman’s mood was
very low following the decision of the healthcare department to reduce her
pain relief medication. This was done due to security information suggesting
that the woman was trading her medication. It was deemed necessary to
remove her liquid Oramorph at nights and reduce her pain relief medication in
the day. Staff were concerned that if she had traded some of her medication,
she might no longer have been used to the amounts that she was prescribed.
The prison GP was consulted, and it was noted in the medical record that the
hospital consultant would be contacted to explain the situation. The woman
said to an officer that, when she was told about the reduction, she threatened
to cut herself. When told the ACCT process would be started the woman was
initially against the idea, but eventually agreed to the extra support.
29. A second officer filled out the Immediate Action Plan part of the ACCT form
which set out what actions should be carried out with regard to the woman’s
location, staff support, phone and Listener access. (A Listener is a prisoner
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trained by the Samaritans to provide confidential emotional support to other
prisoners.) With regard to her location in the prison, the second officer wrote
that the woman wanted to stay in her own cell. The second officer stated that
the woman should be observed every hour, and staff must have at least one
conversation with her each shift. She should have access to the telephone
and a Listener should she wish to.
30. Although she felt low, the woman told staff that she did not have any specific
thoughts of suicide. She was reviewed on a regular basis and the first ACCT
review meeting was held on 19 December. The offender supervisor was
unable to attend and submitted written notes in advance. She commented
that, although the woman was stable, she would soon need 24 hour
healthcare. The offender supervisor noted that the woman would prefer to
remain at Send or be released on compassionate grounds. However, the
offender supervisor wrote that she was unlikely to be released. The woman
was reported as being tearful and in pain at the review. She was angry about
the reduction in her pain relief medication but was persuaded to go to
healthcare for a further assessment.
31. Another ACCT review was held on 24 December and the woman was
described as much happier as her morphine had been increased. She asked
for the ACCT to be closed, but a second SO explained that this was not
possible as he was not the case manager. However, the number of
observations was reduced and the caremap was updated. The ACCT was
closed at the next review meeting which was held on 30 December.
32. On 6 January 2009, the woman reported that she had fallen in the shower and
had bruised her buttocks but had no other injuries. She told staff that she had
discharge from her left breast and lumps in her breast on 12 January. She
was seen in the Royal Surrey County Hospital as part of her routine follow-
ups and for her Herceptin infusions. (Herceptin is a drug used to treat breast
cancer.)
33. During January 2009, the woman told healthcare staff she was experiencing a
cough with thick yellow sputum. Her appetite was poor and two different anti-
nausea drugs were prescribed. She also complained of chest and head pain,
and was still having chemotherapy.
34. The woman learned she had been refused parole on 13 January and this
upset her. She was late for her Herceptin treatment on 23 January because
prison staff were unaware that she was going out of the prison on that day.
Her blood sample had not been taken the previous day which meant that she
could not receive all of her treatment. She was told at the hospital that she
needed to have further radiotherapy and chemotherapy as there was a mass
in her chest. Blood samples were taken the following day and she returned to
hospital on 26 January to have her Herceptin treatment.
35. On 2 February, the woman reported pain in her hip and knee following a fall
during a seizure but there were no further injuries. She underwent
radiotherapy and Herceptin treatments throughout February at the Royal
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Surrey County Hospital. When she was seen at the hospital at the end of
March it was noted that she was beginning to look unwell and quite frail.
36. A third officer wrote in the woman’s file on 25 February that her health was the
main concern and she was “living day to day”. A case conference was held
on 2 March where staff discussed that other prisoners may have been having
access to the woman’s morphine as other prisoners had tested positive for the
drug. It was decided to fix a box in the woman’s room that could only be
opened by the woman in the presence of an officer.
37. The woman was visited by a Macmillan nurse every week as her illness
progressed. Staff told the investigator that she greatly valued these visits.
She suffered another seizure on 28 March, but this did not present any
additional complications.
38. It was documented on 2 April that the woman’s tumour markers had risen
markedly and new lumps were noted in her chest and neck. (Tumour markers
are substances in the body that can become elevated during cancer.) In
addition, she was not well enough to go to hospital for the Herceptin to be
administered. She remained in bed coughing and vomiting, and became
increasingly sleepy.
39. Healthcare staff told prison staff on 3 April that the woman had deteriorated
and requested that they check her throughout the night. In the morning
healthcare confirmed that her health had worsened and that she needed to go
to hospital. The woman left the prison at 2.00pm escorted by two officers and
went to the Royal Surrey County Hospital in Guildford. A third SO described
her on 4 April as very weak, unable to walk properly or digest food and fluids.
40. The escort procedures stated that the chain restraining the woman was only
to be used when there was only one officer present or if she was being
moved. The hospital doctor asked for the woman’s next of kin details at
9.30pm. The prison had one person nominated in the woman’s records as
her next of kin, and did not have details for anyone else, including any
relatives. The investigator did not discover any evidence that the prison
asked her if there was anyone else she wished to be contacted. The
governor called the escort staff at 10.25pm to say that the restraints could
remain off and should not be reapplied. The woman was moved into the
Intensive Care Unit at 11.30pm.
41. The woman’s nominated next of kin was telephoned and updated about her
condition at 1.00am on 5 April. (The woman’s sister has asked if there was a
written directive that the woman had expressly said that she did not want her
family informed of her illness or death. The investigator has found no record of
such a wish and the prison had no record of the woman having a sister.) The
woman was intubated (a tube inserted into the throat) at 6.40am to help her
breathe. The woman’s next of kin was again updated, and arrived with her
partner at the hospital at 12.15pm. The chaplain arrived at 2.15pm and spent
some time with her and her next of kin. The chaplain and the woman’s next of
kin left the hospital at approximately 3.45pm.
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42. The escort staff spoke to the woman several times throughout the night to
reassure her of their presence. The hospital doctor told the escort staff at
5.45am that the woman had deteriorated since midnight and was unlikely to
live beyond the morning. The doctor informed the woman’s next of kin of the
prognosis.
43. Another prison chaplain spent time with the woman at approximately
10.45am. The prison chaplain told the escort staff that the woman had been
given communion and the last rites and had taken confession earlier that
week. At approximately 12.30pm, a second governor met some of the other
lifer prisoners at Send to update them about the woman’s condition.
44. The woman’s next of kin returned to the hospital at 1.40pm and the woman
died at 2.00pm. The first governor and the prison family liaison officer arrived
shortly afterwards to meet the woman’s next of kin and her partner. The
governor took them back to Send at 3.00pm and showed the woman’s cell.
They were also introduced to the woman’s friends who wished to meet her.
45. The second governor had another meeting at 4.10pm for those prisoners who
had not yet heard that the woman had died. A third officer told the
investigator that the prison organised a group meeting following her death for
those staff involved in the woman’s care. The officer only received the letter
regarding the meeting on the day of the event, but explained that the intention
was that all who wished to attend could. She also said that the care team was
available to all staff who wished to have further support.
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ISSUES
Clinical care
46. The clinical reviewer wrote that:
“In the main the health care provided for the woman followed an
expected pathway for any woman of that age with a similar grade of
disease and prognosis. … Overall the care provided for the woman by
all the staff and some of the other prisoners appears to have been
appropriate at the different stages of her disease progression and
similar to that which could be expected by any woman with the same
disease. Apart from the natural history of metastatic breast cancer I
have been unable to identify any adverse incident which contributed to
the death of the woman.”
47. The clinical reviewer did note that the woman varied from the expected
treatment pathway for people with cancer in some respects due to her being
in prison. These were:
(cid:127) “reduced access to other women with breast cancer
(cid:127) the inevitable constraints on the availability of some types of pain
and other symptom relief
(cid:127) a lack of access to 24 hour nursing care, which might have resulted
in her being admitted to hospital more frequently than would
normally be expected had she been living in another environment.
(cid:127) The subsequent support for the staff and other prisoners may have
been less than that available to health care staff, family and friends
of patients in other environments who had the same outcome from
their disease process.”
48. These divergences from the expected pathway were largely unavoidable
given that the woman was in custody. The lack of access to 24 hour
healthcare could have been achieved but the woman was keen to remain at
Send as long as she could. The clinical reviewer’s opinion was:
“Overall the care provided for the woman by all the staff and some of
the other inmates appears to have been appropriate at the different
stages of her disease progression and similar to that which could be
expected by any woman with the same disease.”
49. The woman was unhappy that her cancer had not been diagnosed despite her
raising it with healthcare in her previous prisons. The lack of early diagnosis
is disappointing and the clinical reviewer considers that it was a contributory
factor to her death:
“[The] Possibility of disease being detected earlier if significance of
family history had been recognised, though this may have been due to
the poor and inconsistent family history provided by the woman.”
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50. The clinical reviewer commented that a lesson to be learned from this is:
“Where appropriate the relevant screening programme should be
available to a prisoner where there is a strong family history of cancer.”
51. She also made a recommendation regarding this:
Records of the health of close family members should be kept up to date
especially where there is a history of cancer in the family.
52. I will be writing to HMP Durham to make them aware of this recommendation.
Security concerns over the medication
53. As the woman’s illness spread and the pain grew, she required pain relief
medication. Staff were adamant that control of the woman’s pain was a key
security concern. The nurse said:
“ … it was always made clear that the woman was to have her
medication. There was some medication that she’d have in possession
overnight on and off, and even though that’s not in the policy of the
prison, it was always made security tight and made sure that the
woman had access to those medications when she needed them.”
54. The clinical reviewer stated:
“Attempts were made to control her pain even during the times when
she appeared to be trading her morphine which made assessment of
her symptoms and pain very difficult.”
55. The woman was allowed to hold her own medication in order to manage her
pain through the night. A second nurse explained the reason behind this:
“ … in order to maintain her pain relief over a 24 hour period while we
weren’t here, it meant that she had to have some Morphine in
possession, small Morphine in possession, which obviously goes
against the grain in a prison setting to have medications like that in
possession. And so we worked out, with the team of us and obviously
the Pharmacist and the Pharmacy Lead, a safe way for her to have
access to painkillers over a 24 hour period when we weren’t here.”
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56. There was suspicion amongst staff that the woman was trading some of this
medication. The issue was discussed in the multi-disciplinary meetings and
the prison provided a locked box in her cell. The second nurse explained the
system:
“ … when she had her supervised Morphine tablets with the Nurses
before we went home in the evening, she would then pick up two vials,
plastic vials with Oramorph which would be counted out and put in her
box which was, the outer box was locked by an officer and she had the
key for the inner box, so that when she required pain overnight, she
would ask the officer who would come to her room, open and supervise
her taking the Oramorph. She would then bring back the empty vials in
the morning, if she hadn’t used it we’d count it back in, if she had used
it we’d mark off and at what time.”
57. The box appears to have minimised the risk of the woman trading her
medication. I consider this to be a proportionate response to the problem
posed by the security concerns.
Whether the woman should have remained at Send
58. Send does not have 24 hour healthcare provision and prisoners requiring
such care are moved to other prisons. The woman’s prognosis meant that a
transfer to a prison with 24 hour healthcare was a way of ensuring she
received the appropriate care.
59. However, the woman was adamant that she did not want to leave Send. The
third officer told the investigator that “ … she would get very upset at the
thought of being sent to another prison”. She had friends at Send that she did
not want to be away from. She had also built up a rapport with some of the
staff. Staff were willing to keep the woman at Send until her illness meant that
she required 24 hour healthcare support. The second nurse told the
investigator “ … if she did suddenly deteriorate, we wouldn’t be able to look
after her here, she would need to move to a 24 hour unit“. The woman
declined rapidly after she was taken to hospital for the last time. I am satisfied
that there is no indication that she should have been moved earlier. The
nurse said that prior to her last removal to hospital “ … there was no reason to
move her at that stage, and we kind of took her thoughts into that, into
consideration for that reason”.
60. During her illness the prison made several changes to her living arrangements
to provide her with more comfort. She was given new pyjamas and a DVD
player and moved into a cell that had been modified for prisoners with
disabilities. The first nurse described the differences a cell of this type offers
as it being bigger with a larger bathroom door. It also has rails and room for a
hospital bed.
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61. The woman also had access to a Macmillan Nurse who visited regularly. The
first nurse did not remember the woman ever asking for anything else that
might add to her quality of life. The clinical reviewer said that:
“The woman appears to have been supported by the health care staff,
prison chaplin and selected prisoner buddies. She had ongoing
support from the neurological team for her epilepsy and specialist
palliative care team for her metastatic cancer. Overall the evidence
provided shows that the woman chose to stay at HMP Send with the
staff and prisoners who were able to provide her with support during
her illness, this allowed her to be cared for in the place of her choice,
recognising her limited choices, this is in line with the pathway of care
available for any woman living outside of prison.”
62. The clinical reviewer also commented on the help provided by other prisoners:
“Although the woman, as a prisoner, was unable to access a breast
cancer patient support group she was allowed to have a group of
“buddies” who were other prisoners and they seem to have provided
her with support throughout her treatment and during the palliative care
phase of her disease. I feel that this is an example of notable practice
which should be shared with other prisons.”
Allowing other prisoners to act as a support group to the woman is an
example of good practice.
Information sharing and multi-disciplinary working
63. The prison held regular meetings of both prison and healthcare staff to
discuss the woman’s care. This was a valuable means of ensuring that all
relevant staff were kept informed of her progress, and able to voice any
concerns. All too often in other cases the Ombudsman has commented on
less satisfactory communication between prison and healthcare staff but this
has not been the case here.
The use of multi-disciplinary meetings is an example of good practice.
Compassionate release
64. The Ombudsman has had cause to comment on the lack of consideration of
compassionate release in other cases. The Secretary of State is able to
release a prisoner early on compassionate grounds under certain
circumstances. PSO 6000 (Parole, Release and Recall) explains the
background to a compassionate release on medical grounds:
“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.”
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65. In the woman’s case, it appears that her sudden decline in April was rapid.
Prior to this, it is not clear that she had no more than three months to live. It is
important to note that there is no guarantee that any application will be
granted as several factors are taken into account when making the decision.
Although it is the prisoner who applies for release, the application must be
supported by the medical practitioner, probation officer and the Governor.
The investigator saw no evidence that the woman began the application
process for compassionate release towards the end of her life.
Use of restraints
66. The prison initially requested that the escort chain be applied to the woman in
the hospital but the decision was later made for the chain to be removed. The
Ombudsman has frequently been concerned about the excessive use of
restraints and it was encouraging to hear of the approach taken by Send. It
granted the woman more dignity in her last hours without compromising
security.
The removal of restraints, once the risk had been assessed, is an
example of good practice.
Support for staff and prisoners
67. Although, the clinical review commented favourably on the help provided by
the other prisoners, the clinical reviewer was concerned that support should
also be given to them. I am happy to reflect the work of the second governor
undertook in informing the other lifer prisoners of the woman’s condition. The
prison also sought to provide support to staff affected by the woman’s death
although, as the testimony of the third officer revealed, not all staff were
actually able to attend the meeting arranged for this purpose.
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CONCLUSION
68. The woman had spent a long in time in prison before she was diagnosed with
cancer. Despite treatment, the cancer spread and the woman was told that it
was inoperable. I am satisfied that Send acted well to maintain the woman’s
quality of life, as far as was possible. The report contains one
recommendation regarding the recording of family history of cancer, but I am
also glad to record several instances of good practice. The regular meetings
held at Send were an effective means of ensuring communication between
different areas of the prison. Allowing other prisoners to support the woman
provided some comfort during her time in prison. I was also reassured to see
that Send removed the woman’s restraints in hospital once it was clear that
this would not create a security risk.
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RECOMMENDATIONS
1. Records of the health of close family members should be kept up to date
especially where there is a history of cancer in the family.
The National Offender Management Service accepted this recommendation:
“This has been fed back to the PCT.”
Good practice
2. Allowing other prisoners to act as a support group to the woman is an
example of good practice.
The National Offender Management Service commented:
“This was deemed appropriate for her and if it is seen to be appropriate in
future case, we would allow it again.”
3. The use of multi-disciplinary meetings is an example of good practice.
The National Offender Management Service commented:
“This is standard practice for any prisoners at risk of self harm (which she
was) as well additional meetings as part of her palliative care team to address
any other issues or concerns.”
4. The removal of restraints, once the risk had been assessed, is an
example of good practice.
The National Offender Management Service commented:
“This is standard practice and has been highlighted again as best practice in a
subsequent death at HMP Send from terminal cancer.”
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