Individual at Frankland

Investigation into the circumstances surrounding the
death of a man at HMP Frankland
in July 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2010
This is the report of an investigation into the death of a man, a prisoner at
HMP Frankland. He died in his cell in the prison’s healthcare centre in July
2009. He was 44 years old. The cause of death was recorded as
biventricular failure (heart failure) caused by hypertensive heart disease (heart
disease related to high blood pressure) and chronic renal (kidney) failure. I
offer my sincere sympathy and condolences to his family and all who have
been affected by his loss.
The investigation was carried out by my colleague. An independent review of
the man’s medical care in prison was begun by the clinical reviewer on behalf
of the local Primary Care Trust (PCT). Unfortunately, due to unforeseen
circumstances, she was unable to complete the review. I am most grateful to
the patient safety and integrated governance manager at the local PCT for
concluding the review. Regrettably, this led to a significant delay to receipt of
the clinical review and subsequent issuing of this report, for which I must
apologise.
I would also like to thank the Governor and staff of Frankland for their full and
ready co-operation during the course of the investigation. My particular
thanks go to the head of the business unit and her colleague for their work in
liaising with the investigator.
The man is described as a disruptive prisoner whose failure to cooperate with
his treatment plan meant that staff found him difficult and challenging to
manage. I am satisfied that staff did all they could to persuade him to co-
operate with his recommended medical care, and commend them for their
efforts to resuscitate him on two occasions. His reluctance to follow his
treatment plan led to a continual deterioration in his health. The clinical
reviewer concludes that his life might have been prolonged had he accepted
all his treatment.
I make six recommendations, regarding diet and exercise, the use of care
plans and the use of ACCT (Assessment, Care in Custody and Teamwork,
the process used to monitor and support prisoners assessed as at risk of
suicide or self-harm).
This version of my report, published on my website, has been amended to
remove the names of the man who died and those of staff and prisoners
involved in my investigation.
Jane Webb
Acting Prisons and Probation Ombudsman November 2010
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CONTENTS
Summary
The investigation process
HMP Frankland
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
When he was first imprisoned in June 1999, the man had already suffered
from high blood pressure for several years. He was said to refuse to take his
prescribed medication before coming into prison, and so his blood pressure
did not improve during his time in custody. By the time of his transfer to HMP
Frankland in August 2007, he had developed advanced kidney disease.
The man’s conduct in prison was reported to be poor prior to his arrival at
Frankland. Records indicate that he was regularly abusive and threatening to
staff and he was reported as someone who “easily loses his temper and
cannot see any viewpoint other than his own”. He was subject to numerous
adjudications (prison disciplinary hearings) and spent a lot of time in the
segregation unit and on the basic IEP level (Incentives and Earned Privileges,
a system designed as an incentive to reward good behaviour in prison which
has three tiers; basic, standard and enhanced).
On account of his worsening kidney disease, the man was required to start
dialysis in July 2008. This meant that he had to visit hospital three times a
week for dialysis treatment, each session lasting for several hours. He did not
accept all his dialysis treatment. He regularly refused to go to hospital for his
scheduled sessions, or would terminate the sessions early. His conduct in
hospital was often described as poor, and it was reported on several
occasions that he was abusive to hospital staff.
Although the man went through periods where he attended dialysis more
regularly, the combination of his missed sessions and refusal of medication
meant that his condition continued to deteriorate. He was warned on
numerous occasions that if he did not co-operate the consequences were
likely to be serious. He seemingly ignored this advice and eventually he
developed severe heart disease. On a morning in July 2009, he was found
collapsed in his cell. Healthcare staff attempted to resuscitate him and an
ambulance was called, but he was pronounced dead at 12.02pm. The cause
of death was established by a post mortem as biventricular failure (heart
failure) caused by hypertensive heart disease (heart disease related to high
blood pressure) and chronic renal (kidney) failure.
I am told that the man was a very difficult and challenging prisoner for staff at
Frankland to manage. Nevertheless, I am satisfied that staff did all they could
to encourage him to comply with his treatment plan. The clinical reviewer
describes the care he received as being to a “very high standard”. Indeed, on
two occasions the prompt actions of staff in resuscitating him helped to
prolong his life further. The report makes a total of six recommendations, in
areas including diet and exercise, the use of care plans and the use of ACCT.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 9 July 2009 when the investigator issued
notices announcing it 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. Two prisoners
submitted statements as a result.
2. The investigator first visited Frankland on 15 July 2009. He toured the
establishment, including the healthcare centre, segregation unit and G
wing, all of which the man had lived on during his time at the prison. The
investigator was also given copies of the man’s prison files. The
investigator and a colleague returned to Frankland on 24-26 November
and interviewed 11 members of staff. A third visit planned for January
2010 was cancelled due to adverse weather conditions. The investigator
eventually returned on 2-3 March when he interviewed a further three
members of staff.
3. An independent clinical review of the man’s health needs whilst he was in
custody was initially undertaken by a clinical reviewer on behalf of the
local Primary Care Trust (PCT). She is employed by Primecare, a
provider of primary care services, who were contracted to undertake
several clinical reviews for the local PCT. She visited Frankland with the
investigator in both November 2009 and March 2010 and participated in a
number of interviews. Unfortunately, due to unforeseen personal
circumstances, she was unable to complete the review. The patient
safety and integrated governance manager for the local PCT was
subsequently appointed in June 2010. I am grateful to her for taking on
and completing this work at short notice. Unfortunately, this disruption
meant that the clinical review was not completed until July 2010, a year
after the man’s death.
4. One of my family liaison officers spoke to the man’s brother over the
telephone on 27 July 2009, during which he set out some initial concerns
that the family had regarding his treatment at Frankland. The man’s
mother subsequently wrote a full statement which she sent to the
investigator, via her solicitor, in November 2009. She raised the following
issues that she wished the investigation to address:
(cid:127) She asked why her son did not receive dialysis three times. She
gave examples of him being treated unfairly by prison officers whilst
in hospital. She also said that on two occasions her son was
denied dialysis due to the conduct of prison officers. On the first
occasion, he asked hospital staff if he could have dialysis in a
different arm to usual, as his arm was hurting. The prison staff
escorting him refused this request and he therefore returned to
prison without dialysis. On the second occasion, he was taken
straight back to prison after arriving at hospital after being told he
had “assaulted a nurse”.
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(cid:127) She said that on one occasion her son was assaulted by an officer
when a cell door was shut on his finger.
(cid:127) Her son spent a large proportion of his time on a basic regime and
in the segregation unit. She asked whether this could have
exacerbated his health problems.
(cid:127) The post mortem report revealed a number of scars and marks on
his body. She asked how he received these marks.
(cid:127) His property was not returned to the family, despite several
requests. She was particularly keen to obtain any correspondence
that her son had in his cell.
5. The man’s sister telephoned the family liaison officer in February 2010
and subsequently spoke to another of my family liaison officers in March
2010. She raised the following issues for the investigation to address:
(cid:127) She did not hear of her brother’s death until seven months after he
died. She said she was not named as next of kin as she was
estranged from her mother and other brother, and asked how the
prison normally deals with such issues.
(cid:127) He did not speak to any family members for a week or two before
he died. His sister queried whether he was asked if he wanted one
of his relatives to be contacted when his health deteriorated.
(cid:127) If he had refused contact with his family, this could be evidence that
he was suffering from dementia as a result of end stage renal
failure.
(cid:127) Whether he was on an organ transplant list, as she had offered one
of her kidneys to her brother?
(cid:127) Why he was not moved to a prison closer to his family when he
became ill and why his security category was not reviewed as he
had not always been in a high security prison?
(cid:127) She was concerned that all of her brother’s correspondence had
been returned to her estranged family, and that this included
personal letters she wrote to him.
6. The report was sent in draft to the man’s mother, via her solicitor, in
September 2010. Her solicitor subsequently replied in November that she
did not wish to make any comments on the draft report. The man’s sister
contacted another of my family liaison officers shortly before the draft
report was issued to say that she did not wish to receive a copy.
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HMP FRANKLAND
7. HMP Frankland is one of eight high security prisons in England and
Wales. Frankland holds convicted category A and B adult male prisoners,
and also holds high risk remand prisoners. G wing, where the man lived
for some time, is for prisoners who are suitable for a normal prison wing.
The operational capacity of the prison is 750.
8. Frankland has a large segregation unit, where the man also lived for some
time. The purpose of a segregation unit is to hold prisoners separately
from the rest of the population. This is usually as a disciplinary measure
or punishment for a breach of prison rules. Frankland’s segregation unit
has 27 single cells.
9. Healthcare services at Frankland are provided by the local Primary Care
Trust. The healthcare centre provides 24 hour inpatient care, consisting of
two wards, holding a total of seven patients, and ten single cells. The man
lived in one of these cells for the last two and a half weeks of his life.
10. HM Chief Inspector of Prisons conducted a full announced inspection of
Frankland in February 2008. Her report was broadly positive about health
services provided at Frankland, and found the provision was equivalent to
that which prisoners could expect to receive in the community.
11. She also found that black and minority ethnic and Muslim prisoners were
over-represented in the segregation unit. She recommended that a full
review be carried out to improve the operation of the unit and treatment of
prisoners. A second recommendation was for the consistent over-
representation of black and minority ethnic prisoners in areas such as
segregation to be investigated and addressed.
12. The Independent Monitoring Board (a body of local people who
independently monitor and report on the prison) report for 2007-08 noted
that there had been several beneficial changes in the healthcare
department recently. However, they highlighted staff shortages and a
higher proportion of missed outside hospital appointments than expected.
13. This was the fourth death that the Ombudsman has investigated at
Frankland in 2009. There have subsequently been a further seven deaths
at the establishment. All but one of the other deaths were due to natural
causes. One of the earlier deaths also involved a prisoner with a long
term medical condition. The Ombudsman’s report recommended that
such prisoners should be regularly reviewed in accordance with national
guidelines.
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KEY FINDINGS
14. The man was first imprisoned in 1991, when he received a 30 month
sentence for wounding. He served shorter sentences of less than six
months on two further occasions in the 1990s. After being remanded into
custody at HMP Nottingham on 22 June 1999, the man was convicted of
wounding with intent on 17 September. Two weeks later he was
sentenced to life imprisonment with a tariff (the minimum time that must
be served before a prisoner is eligible for release) of three and a half
years.
15. The man arrived at Nottingham on 22 June 1999. He had suffered from
high blood pressure and high cholesterol for a number of years and was
prescribed a variety of medications for these conditions. From his first
months in prison, his compliance with his medication was poor. There
were also numerous examples of him being reported as abusive and
threatening to staff and failing to obey prison rules.
16. The first sign that the man might be suffering from kidney disease came in
May 2000, when a urine test at HMP Gartree (where he had recently
moved to undertake some of the courses necessary to progress through
his sentence) showed an absence of proteins in his urine. An
appointment was made for a scan of his kidneys at a local hospital.
However, he refused to attend this appointment.
17. In October 2001, the man moved to HMP Parkhurst ,which was arranged
to “allow a fresh start”. He was referred to a local hospital in early 2002
after his blood pressure began to rise. This was seemingly as a result of
him refusing to take his medication. He continued to refuse to take his
blood pressure medication for several months.
18. The man was persuaded to visit a local hospital in December 2002 for a
scan of his abdomen. This showed that he had small kidneys and,
therefore, likely kidney impairment. A scan of his chest several months
later showed the left side of his heart was enlarged (a condition usually
associated with high blood pressure).
19. After two years at Parkhurst, the man transferred to HMP Dovegate in
November 2003. Dovegate is closer to his family, and the aim was to
make it easier for him to maintain his ties. However, he did not settle at
Dovegate and moved to HMP Garth after four months, again, for a “fresh
start”. In August 2004, he moved again, after threatening to kill the deputy
governor. On this occasion he moved to HMP Swaleside.
20. After attending an outpatient appointment with a kidney specialist at a
local hospital in early 2005, the man was provisionally diagnosed with
hypertensive nephropathy (kidney disease resulting from high blood
pressure). However, he refused to provide the blood and urine samples
necessary to confirm this diagnosis. Throughout his time at Swaleside, he
regularly failed to take his prescribed medication and declined scans that
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would diagnose his kidney condition. His blood pressure continued to be
poorly controlled, partially because he did not take his medication
regularly.
21. By late 2006, the man’s kidney disease had worsened and was now
described as “advanced renal [kidney] disease”. He continued to refuse
the weekly blood tests that would monitor his condition. In January 2007,
he transferred to HMP Whitemoor, a high security prison. It is not clear
why he moved to the high security estate, although it appears from the
records that he continued to be abusive to staff before moving.
22. The man’s conduct was reported to be poor during his seven months at
Whitemoor. In late March he assaulted an officer and, in July, set fire to
his cell and was subsequently moved to the segregation unit. Shortly
afterwards, he refused food and drink for several days. A mental health
assessment described him as someone who “easily loses his temper and
cannot see any viewpoint other than his own”.
23. As a result of the difficulties described at Whitemoor, the man moved to
Frankland on 23 August 2007. At the time, his medication was listed as:
(cid:127) simvastatin (to reduce cholesterol and the risk of a heart attack)
(cid:127) aspirin (to thin the blood and prevent a heart attack)
(cid:127) nifedipine (usually known by the brand name Adalat, for
treatment and prevention of high blood pressure and angina)
(cid:127) valsartan and doxazosin (both used to treat high blood
pressure)
(cid:127) mirtezapine (an anti-depressant).
24. In early October, the man told a prison doctor he had been feeling unwell
recently and experienced chest pains when smoking. The doctor sent a
referral to the renal unit at the local Infirmary, in which he detailed the
man’s medical history. In his referral, the doctor said the man had small
kidneys and had been suffering from chronic kidney disease for a number
of years.
25. On 11 October, the man was moved to the segregation unit after he
threatened to set fire to his cell. He remained on the unit for two weeks
before returning to a cell on F wing. During his time on the segregation
unit, he stopped taking his medication. He told staff this was because he
was no longer given his medication ‘in possession’ (where a prisoner is
given a supply of medication, in this case one week at a time, to keep in
their cell and take as prescribed). The rules of the segregation unit are
that all medication is given out by nursing staff at the time it is due to be
taken.
26. The man returned to the segregation unit on 5 November, after being
found guilty at an adjudication hearing (a prison disciplinary hearing) of
using abusive language towards a member of staff. His punishment was
to spend a week in cellular confinement. On his return to F wing, he was
9
initially reported to be quiet and compliant with the wing regime. However,
after an adjudication hearing on 4 December, he was again sent to the
segregation unit. On this occasion his punishment was 12 days cellular
confinement after he was found guilty of a number of breaches of prison
rules.
27. The requested appointment at the renal unit at hospital was made for 27
December. However, the man refused to attend the appointment and
signed a disclaimer to this effect. There is no record of the reason why he
did not wish to attend hospital.
28. Over the following weeks, the man continued to refuse his medication. He
told healthcare staff he was worried about the side effects that the
medication might cause. Prison Doctor A wrote a second referral to the
Infirmary on 17 January 2008 after blood tests taken provided some
abnormal results. He wrote that the man was “clearly in renal failure”.
29. The prison doctor thought at the time it was “almost certain” that the man
would require dialysis to treat his severe renal failure. (Dialysis is the
artificial replacement of kidney function for people with renal failure. This
is usually done by a process known as hemodialysis, whereby a patient is
connected to a machine in hospital for around four or five hours at a time.
Blood is drawn from the body, usually from the forearm, and ‘cleaned’ by
the dialysis machine, before being returned to the body through a second
access point in the forearm. An access point can also be made in the
chest instead of the forearm.)
30. The prison doctor saw the man in his cell on 20 January to explain that he
might require dialysis in the future. However, the man was described as
“very reluctant” to discuss the matter and walked out of the meeting. The
doctor therefore wrote to him a week later to explain that his kidneys were
seriously damaged and he was likely to require dialysis. He also
recommended to him that he should begin taking his medication again,
although it does not appear that he did so.
31. The results of a blood test taken on 29 January were again abnormal. It
was feared that the man might be at risk of a heart attack or stroke, and
he was admitted to the Infirmary. When a prisoner is taken to hospital,
either as an inpatient or outpatient, a risk assessment is completed to
determine the level of security needed on the escort. The risk
assessment determines the number of staff who must accompany a
prisoner and the level of restraints to be used. In his case, the outcome of
the risk assessment was that he should be accompanied by three prison
officers and double cuffed (meaning that his hands were handcuffed
together and one hand was also cuffed to one of the escorting officers).
32. The man returned to Frankland on 1 February, having been prescribed a
course of epoetin injections (to increase red blood cells). It was planned
that he would be admitted to hospital again on 6 February for surgery to
insert a catheter in preparation for peritoneal dialysis. (This is a form of
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dialysis whereby fluid is inserted into the abdomen. The abdomen is
drained and any waste products are removed with the fluid.)
33. On account of the man’s reluctance to take his medication or discuss his
treatment, the prison doctors requested that he should be assessed by a
member of the mental health in-reach team. He subsequently saw
Community Psychiatric Nurse A on 5 February. He told the nurse that he
had stopped taking his blood pressure medication because he thought the
effects of smoking counteracted the benefits of the medication. He
explained that he did not wish to stop smoking and therefore did not take
his medication. The nurse concluded that there was “no obvious mental
health concern”. It is not clear whether he received advice on the effects
that smoking might have on his medication.
34. The following day, the man refused to go to the Infirmary for his scheduled
surgery. As part of the preparation for surgery, he was required to take a
laxative. However, he refused to travel once he had taken the laxative
and refused to sign a disclaimer that he took responsibility for his non-
attendance. Two days later, the clinical team leader in the prison’s
inpatient facility saw him in his cell to talk about his future treatment. He
refused to discuss his treatment options and insisted that he should not
have been given a laxative before travelling to hospital.
35. However, on 3 March the man saw Prison Doctor B and said he now
wanted the catheter inserted. An appointment was made at the renal unit
for 7 March. On the day of the appointment, however, he again refused to
attend. The reason for his refusal is not recorded. He also refused to sign
a disclaimer.
36. Towards the end of March, the man’s incentives and earned privileges
(IEP) level was reduced from standard to basic. (IEP is a three tier
system designed as an incentive to reward good behaviour in prison.
Incentives include access to in-cell television, more private cash to spend
and more time out of cell.) The reduction followed several warnings to
him about his failure to follow prison rules and regulations and his
threatening and abusive behaviour towards staff.
37. The man’s conduct continued to be disruptive and, on 15 April, he was
moved to the segregation unit for two days after setting fire to his cell. He
was reportedly unhappy with the medical treatment he was receiving and
said he did not take his medication because it “disagreed with him”. Four
days after he returned to F wing, his IEP level was upgraded to standard
to encourage him to improve his conduct. The following day, however, he
was segregated for seven days after being found guilty at an adjudication
hearing of using threatening and abusive language towards an officer.
Shortly after arriving in the segregation unit, he flooded his cell.
38. The then healthcare manager wrote to the man on 2 June regarding his
future treatment. The manager acknowledged that the man was unhappy
with his treatment at the Infirmary and said it would be possible to refer
11
him to another renal unit. However, he asked the man for assurance that
he would engage in his treatment and asked him to respond in writing
before a referral was made. It does not appear that he replied.
39. Prison Doctor A talked with the man about his treatment on 10 June, the
day after he had moved into a new cell on G wing. He again said he did
not think he should have been given a laxative before his appointment in
January. He also complained about a swab that was taken in hospital
around that time. He thought this was a DNA swab, taken as part of a
conspiracy against him. The doctor advised that the swab was taken as
standard practice to check for MRSA (methicillin-resistant staphylococcus
aureus, a bacteria that often occurs in people who are ill in hospital). He
repeated the healthcare manager’s offer of referral to another local renal
unit and advised him that he was in severe danger because of his high
blood pressure and kidney failure. However, he declined the offer of
referral to another hospital. The doctor noted his belief that the man had
the mental capacity to make this decision. The following day the
psychiatric nurse asked to see the man to formally assess his capacity to
refuse treatment. He said he did not wish to participate.
40. In early July, the man’s condition began to deteriorate. He said he had
vomited and felt short of breath. He was given an inhaler to use as
required. When he did not improve, he was admitted to hospital on 11
July. On the same day he moved to the Infirmary so that he could be
assessed in their renal unit.
41. The following day, the man underwent a procedure to insert a neckline in
preparation for hemodialysis. (A neckline in this case is a permanent
access site in the patient’s chest for the purpose of dialysis.) He started
dialysis on 13 July. However, on 16 July, he discharged himself from
hospital against medical advice.
42. The man was expected to return to the Infirmary for dialysis three times a
week, on Tuesdays, Thursdays and Saturdays. He attended the first four
appointments but, on 29 July, refused to attend. He said this was
because he had to wear a high visibility suit when he attended hospital as
part of the prison’s security measures to prevent an escape. The risk
assessment was reviewed and it was decided that he did not need to wear
the high visibility suit. It remained the case that three staff should
accompany him to hospital, including a senior officer who was in charge of
the escort. He was double cuffed on his way to hospital but, during
dialysis, the handcuffs joining him to the officer were replaced by an
escort chain (a long chain with a handcuff at each end). He subsequently
went to his next dialysis appointment which was on 31 July.
43. On 6 August, the man’s IEP level was reduced from standard to basic.
This followed several recent warnings about his behaviour, including one
the previous day for being abusive to nursing staff at the Infirmary. The
following day, he refused to attend hospital for dialysis. He said he was
unwell as he had been vomiting and had diarrhoea. He was told that his
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dialysis was important and he should attend if he could, but he said he did
not feel up to it.
44. A week later, the man again refused to have dialysis. On this occasion he
went to hospital but changed his mind following his arrival. It is not clear
why he declined dialysis on this occasion. On 21 August, he refused to
attend hospital. He said this was because he did not like the staff who
were escorting him. The potential consequences of refusing dialysis were
explained to him by healthcare staff, but he did not change his mind.
45. The man missed two dialysis sessions in a row on 30 August and 2
September. On both occasions he was taken back to the prison before
dialysis started on account of what was described as abusive and
aggressive behaviour towards staff. (It is not clear from the records
whether he was abusive towards escorting staff, hospital staff, or both.)
At the request of the renal consultant, healthcare staff attempted to take a
blood sample so the effects of missing the sessions could be monitored.
However, he refused to provide a sample.
46. After these two missed sessions, the man had dialysis as scheduled
during the next fortnight. He again missed two sessions on 18 and 20
September. On the first occasion he threatened one of the escorting
officers and refused to be taken to hospital. It is not clear from the records
why he did not attend the second appointment.
47. The day after the second of these missed dialysis sessions, the man
complained of shortness of breath and feeling “terrible”. His blood
pressure was very high, at 221/148. He was admitted to the Infirmary for
monitoring. He was discharged two days later when his condition had
stabilised.
48. The man again refused to have dialysis on 27 September. He told a
nurse at the hospital that the treatment made him feel suicidal. One of the
escorting officers therefore opened an Assessment, Care in Custody and
Teamwork (ACCT, the process used by the Prison Service to monitor and
support prisoners assessed as at risk of suicide or self-harm). On his
return to Frankland, he saw a member of staff trained in the ACCT
procedures for the mandatory opening assessment. He expressed
concerns regarding his health problems and being on an indeterminate
sentence with no sign of release. He also said his mental health problems
were exacerbated by being on the basic regime as he did not have a
television or stereo.
49. An action plan (known as a caremap) was written by Senior Officer (SO)
A, who was appointed as the man’s ACCT case manager. The caremap
included the request that he see a member of the prison’s mental health
in-reach team. He subsequently saw Community Psychiatric Nurse B, on
29 September. He told her that it was not his dialysis that made him feel
low. He said it was because he had nothing to stimulate him as he was
not allowed a television and stereo whilst he was on the basic regime. He
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was concerned that he could not therefore listen to his religious music. At
a review later that day, SO A gave permission for him to be provided with
a stereo.
50. Prison Doctor C discussed the man’s care over the telephone on 30
September with a consultant nephrologist at the Infirmary. They
discussed the possibility of reducing the frequency of dialysis to twice a
week. (It remained at three sessions a week.) They also discussed the
potential of a kidney transplant. The consultant said that the man was not
on the transplant list because he had high blood pressure.
51. On 10 October, the man was taken to the segregation unit after he
threatened to set fire to his cell if he was not unlocked for association. (As
he was on the basic IEP level, he received limited association compared
to prisoners on standard or enhanced levels.) On the same day, he was
found guilty at an adjudication hearing of assaulting a prison officer on 30
August. His punishment was ten days cellular confinement, which he
served. However, the guilty verdict was later quashed by the Briefing and
Casework Unit of the National Offender Management Services (NOMS).
The verdict was quashed because, whilst he had refused to attend the
hearing, there was no clear record that he had been advised that it would
proceed in his absence.
52. At an ACCT review on the day he moved to the segregation unit, the man
said he “hates” every officer on G wing. He refused to go to hospital for
his next two planned dialysis sessions. On the evening of the second of
these refusals, 14 October, he was short of breath and told healthcare
staff that his lungs were full of fluid. The renal unit at the Infirmary was
contacted, who advised that he should attend hospital urgently for dialysis.
He agreed, and remained as an inpatient until 17 October. During his stay
he was warned by the consultant that if he carried on missing dialysis
sessions at his current rate there would be a “significant impact on his
prognosis”.
53. Despite the consultant’s warning, the man asked for his dialysis session
on 21 October to be terminated after just ten minutes. It is not clear why
he refused to continue. However, he returned to hospital in an emergency
admission later that day when he became short of breath and required
oxygen. He remained in hospital as an inpatient for four days. He was
advised to stay in the prison’s healthcare centre on his return, but
preferred to go back to his cell on G wing.
54. An ACCT review was held on 27 October, led by SO A. Prisoners should
be invited to the reviews and, although he often declined to attend, the
man did attend on this occasion. He said his situation had not changed
and asked to see a member of the mental health in-reach team. The SO
noted in the caremap that he made a referral on 29 October, although it
does not appear that a member of the team saw him for some time. The
SO also noted that the next ACCT review should be more comprehensive,
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with representatives of the Independent Monitoring Board and mental
health in-reach team present. This did not happen.
55. At a review on 7 November, it was noted that the majority of entries in the
man’s ACCT document were positive. He had made no mention of
thoughts of suicide or self-harm and the only unresolved issue was a
return to standard IEP. After a period of improved behaviour, his IEP level
was upgraded to standard on 19 November.
56. The man also attended more of his dialysis sessions in November and
only missed two during the month. It is not clear why he refused to attend
the first of these. On the second occasion he said it was because he did
not wish to be restrained by an escort chain during dialysis. (An escort
chain is a long chain with a handcuff at each end. During dialysis the cuff
between him and the escorting officer was replaced by an escort chain.)
On both of these occasions, he was subject to an emergency admission to
hospital the following day when his symptoms exacerbated. He was
discharged the same day both times, although on the second occasion he
reportedly became angry and claimed he was being refused treatment.
57. The ACCT document was closed on 28 November, when the man was
described as “more positive of late” and it was noted that he had attended
most of his dialysis sessions. He said he was happier now he was back
on the standard IEP regime.
58. On 4 December, however, the man again refused to go to hospital for his
dialysis session. Later that day he felt pain in his chest and an ambulance
was called. He refused to remain in the healthcare centre and returned to
his wing. He did not wish to be seen by the paramedics when they
arrived. Three days later, he again complained of chest pain and, on this
occasion, agreed to go to hospital. He was diagnosed with unstable
angina. Although he was advised to remain in hospital for treatment, he
discharged himself and returned to Frankland.
59. The following day, the man returned to the Infirmary for a scheduled
dialysis session. He started dialysis but, about half way through, said he
wanted to stop and return to the prison. An ACCT post-closure review
was held the same day, at which he said he felt better now he was on the
standard regime and had a television.
60. SO A opened a new ACCT document on 10 December, as he was
concerned that the man had missed a number of dialysis sessions and
was not taking his prescribed medication. The man did not agree that
ACCT procedures should be opened and refused to take part in the
assessment interview. The caremap listed just one issue which was to be
addressed, that is his compliance with his dialysis treatment.
61. The man agreed to attend an ACCT review the following day. He said he
had no thoughts of harming himself and could not see why the document
had been opened. He said he wanted to attend his dialysis sessions but
15
he “had issues” with certain senior officers and would not go if they were
on the escort. He attended his first dialysis session after this review but at
the next, on 16 December, he refused to go to hospital when he
discovered the identity of the senior officer in charge of the escort.
62. Following his refusal to have dialysis on 16 December, Prison Doctor C
wrote to him. She reminded him of the significant risk to his health if he
continued to miss dialysis sessions. She strongly encouraged him to
ensure his medical treatment took preference over any other issues he
might have.
63. On the same day, an enhanced case review was held to discuss what was
recorded as the man’s “difficult and challenging behaviour and refusal to
accept kidney dialysis treatment”. The meeting was chaired by the
residential manager with responsibility for G wing. It was also attended by
the head of healthcare and representatives from the mental health team
and safer custody teams. The panel concluded that he should remain on
an open ACCT document as long as he did not co-operate with his
treatment. They also agreed to try to arrange a group of escort staff who
he would agree to go to hospital with. A mental health assessment was
also arranged.
64. During a dialysis session on 22 December, the man complained of chest
pains and was therefore admitted to the hospital’s coronary care unit
(CCU). When the escort staff changed over in the evening, he asked to
be discharged and taken back to the prison as he did not like the SO who
was now in charge of the escort. This was against the advice of the
consultant in the CCU.
65. The following day, Community Psychiatric Nurse A visited the man to
assess his capacity to refuse treatment. He said he did not wish to attend
the interview as he considered himself to be mentally well. His next
dialysis session was scheduled for 24 December. On the morning of the
appointment, he said he would not go unless he was taken by ambulance
as he still had chest pain. (It was usually the case that he was taken to
hospital in a taxi.) Healthcare staff did not agree this was necessary and
he therefore refused to attend the appointment. However, his condition
later deteriorated and he agreed to go to hospital for dialysis. On account
of his worsening condition, an ambulance was called. He remained in
hospital until he was discharged on 27 December. During his inpatient
stay he had an angiogram (a scan of the chest and heart) which showed
nothing unusual.
66. On 31 December, the man wrote to healthcare staff at Frankland to say
that he no longer wished to attend the Infirmary for treatment. He said this
was due to “medical negligence and serious breach of patient doctor
confidentiality”. He said he was happy to receive treatment at any hospital
except the Infirmary. The following day, he said he would not co-operate
with blood pressure checks until the transfer of his care to a hospital was
arranged.
16
67. A case conference was held at Frankland on 2 January 2009 to discuss
the man’s request. It was agreed to refer him to another hospital and he
was subsequently put on their waiting list for treatment. It was noted that
Prison Doctor C had discussed him with the local Primary Care Trust’s
legal advisors, who judged that prison healthcare staff had fulfilled their
legal obligations to him and his treatment. In the meantime, staff were
advised to try to persuade him to attend his scheduled appointments at
the Infirmary. It does not appear as though he received an appointment
for the other hospital.
68. The man refused to attend his scheduled dialysis appointment at the
Infirmary on 3 January. However, later that day, he was admitted to a
hospital after suffering chest pain. After his admission, he agreed to move
to the Infirmary for dialysis. He was discharged from hospital the same
day.
69. Two days later, the man was again admitted to a hospital. After
admission to healthcare with shortness of breath, he pulled out his
Hickman line (a tube inserted into the chest for various treatments, in this
case to perform dialysis) as the cell he moved into for observation did not
initially have a radio. On the advice of the consultant, he was admitted to
hospital so the Hickman line could be correctly inserted. He was
discharged the same day.
70. The head of healthcare contacted the local NHS Trust on 7 January to
discuss the man’s regular refusal of treatment from a legal standpoint.
She was advised that the key factor was the patient’s ability to understand
the decisions they were making and, if they had the capacity to make such
a decision, their wishes should be respected. She was also advised that
staff should clearly record all attempts to convince him to accept
treatment. Following this discussion, Community Psychiatric Nurse A
visited him to assess his capacity. He did not engage fully and the nurse
was therefore unable to make a full assessment.
71. The following day, the man refused to attend hospital for dialysis. He later
complained of chest pain but refused to stay in the healthcare centre for
observations. On 9 January, he again complained of chest pain and
shortness of breath. He was admitted as an emergency to the Infirmary
before being discharged the following day.
72. The man went to his next dialysis session on 13 January, but refused to
attend two days later. On 16 January, he complained of chest pain that
was spreading to his left arm. He refused to go to healthcare for
observation as he could not be guaranteed a cell with a television. He
was later admitted to hospital when his symptoms worsened. He
discharged himself the following day against the advice of the consultant.
73. On 20 January, the man went to the Infirmary for dialysis. However, he
refused to begin the procedure as he was not happy with the arm on
17
which his handcuffs were placed. He wanted the escort chain to be
placed on his left arm, but was told that it had to be on his right arm due to
the position of the dialysis machine. Later, following his return to
Frankland, he changed his mind and said he wanted to return to hospital
for dialysis. He had now missed his appointment slot and therefore
dialysis could only be provided in an emergency. Blood tests had to be
taken in order to determine if this was appropriate. He refused to provide
blood as he thought he should still be eligible for his routine appointment.
He did not therefore receive dialysis.
74. Two days later, the man again refused to go to the Infirmary for dialysis.
On this occasion he said it was because of the presence of a particular
senior officer on the escort. Again he changed his mind later in the day.
The hospital was contacted to see if they had room for him, but they did
not. The consultant told Frankland that they had a number of new dialysis
patients and therefore could not provide any degree of flexibility in future.
75. The man declined to attend his dialysis session on 27 January as he had
a legal visit booked for the same time. Three days later, he said he was
feeling light headed. His blood pressure was taken and had fallen to
100/78, lower than the normal range. It was thought this might be related
to verapimil (medication for high blood pressure and angina), a drug he
had recently started taking. This medication was stopped. His blood
pressure was checked overnight and, by the following morning, had
increased to 139/107. Later that day, he refused to go to the Infirmary for
his scheduled dialysis session.
76. An ACCT review was held on 2 February, at which the man reiterated his
view that he should not be subject to ACCT procedures. However, it was
noted that he continued to miss treatment sessions for various reasons
and the ACCT therefore remained open. The following day, he again
refused to attend his dialysis session. He said it was because he wanted
the escort chain to be on his left wrist rather than his right.
77. At a mental health assessment with Community Psychiatric Nurse A on 9
February, the man said that he felt “panicky” and anxious on account of
his illness. The nurse recommended the use of an anti-depressant and
fluoxetine was subsequently prescribed by a prison doctor. On the same
day, Prison Doctor C wrote to a consultant nephrologist at the Infirmary.
She noted that a number of anti-hypertensive medications (to control high
blood pressure) had been tried but, for various reasons, the man had
declined them all at some stage. She went on to say that it was difficult to
prescribe a medication that he would accept and he was not currently
taking any such medication.
78. Three days later, the man declined to attend hospital for dialysis as he
had a legal visit booked. On the same day, his IEP level was reduced
from standard to basic. This followed a “lengthy period of poor and
abusive behaviour [meaning that he] no longer met criteria for standard
prisoner”. He was downgraded for a minimum of 28 days. His behaviour
18
did not improve through the remainder of the month. However, other than
one session on 24 February, he accepted his dialysis sessions.
79. A dietician saw the man on the dialysis unit at the Infirmary on 17
February, as he had recently lost some weight. She recommended that
he should be given a course of nutritional supplements, and take four per
day.
80. The improvement in the man’s compliance with dialysis was noted at an
ACCT review on 23 February. There was some discussion as to whether
he should be allowed a television to improve his state of mind. (It is
normally the case that prisoners on the basic IEP level are not allowed a
television in their cell.) SO A, who led the review, agreed to look into this
further but, seemingly, he did not get a television.
81. Two days later, the man was taken to the healthcare centre in the early
hours of the morning after complaining of shortness of breath. The out of
hours doctor was contacted, who advised that he should be observed
overnight but did not need oxygen therapy. He refused to stay in
healthcare unless he was given oxygen, and returned to G wing. Later
that day, he complained to Prison Doctor C that he was not allowed a
television. She explained that she could not affect this decision.
82. Other than on 3 March, when he said he did not like the escorting officers,
the man went to the Infirmary for all of his scheduled dialysis sessions in
March. He also started to take medication to control his blood pressure,
namely perindopril and aliskiren. However, his general conduct did not
improve. He was discharged from the mental health team’s caseload on 6
March after he was described as threatening and abusive to Community
Psychiatric Nurse A during an assessment. There were also reports of
him being abusive towards wing staff during the month.
83. At an ACCT review on 17 March, the man said he had been going for
dialysis recently because the staff on duty were ones whom he liked. At
his next review, on 23 March, it was confirmed that he had not missed an
appointment for three weeks and the “issues surrounding his non-
compliance have now been resolved”. The ACCT document was closed
on the same day.
84. On 29 March, the man made a serious threat against an officer. The
officer said that he felt “extremely threatened and intimidated” in the
aftermath. As a result of this incident, and a general deterioration in the
man’s behaviour over the month, he was moved to the segregation unit on
30 March. The post-closure ACCT review scheduled for the same day did
not take place.
85. It was noted on 1 April that he was not taking the nutritional supplements
that were recommended in February. Around 40 portions were removed
from his cell. He was encouraged to eat more. His blood pressure was
noted to have improved.
19
86. The man continued to attend most of his dialysis sessions in April, when
he was in the segregation unit. (The sessions were now on Mondays,
Wednesdays and Fridays rather than Tuesdays, Thursdays and
Saturdays.) He missed one session on 3 April, for reasons that are not
recorded. He missed another session on 10 April, apparently because he
refused to comply with the normal searches that take place before a
prisoner can leave the establishment. At around this time, he began to
refuse to take his medication again. His general conduct was reported as
poor and his weekly basic IEP reviews described threatening behaviour
and a poor attitude.
87. During his dialysis session on 13 April, the man was warned by the
consultant that his condition had deteriorated to the extent that he risked
“sudden collapse” were he to refuse any further sessions. This was
reiterated by Prison Doctor A the following day, who noted in the medical
record that his opinion was that the man had full mental capacity to refuse
treatment if he wished.
88. On 17 April, the dietician from the Infirmary provided a suggested meal
plan for the days when the man went out of the prison for dialysis. This
included a packed breakfast (as he often left before breakfast was
available). The dietician also advised that the packed lunch must include
a protein filling (such as meat, egg or cheese).
89. The consultant nephrologists wrote to Frankland on 23 April with an
update on the man’s progress. His blood pressure continued to improve,
to the extent that the consultant was prepared to consider creating an
arteriovenous fistula. (An AV fistula is the surgical process by which an
artery and vein in the forearm are directly connected, allowing the vein to
grow larger and stronger. As a result, repeated needle insertion for
hemodialysis treatment is easier. The fistula can take some weeks or
months to develop following surgery.) An appointment for him to undergo
this procedure was subsequently made for 12 May.
90. Before the treatment could be given, the man’s condition deteriorated
dramatically on 27 April. He was successfully resuscitated by nursing
staff after he stopped breathing. He was taken to hospital by emergency
ambulance, and returned two hours later. At 4.00am the following
morning he again stopped breathing and was again successfully
resuscitated by prison staff. As before, he was taken to hospital by
emergency ambulance and returned later.
91. Despite the deterioration in his health, the man refused to attend his
scheduled dialysis session on 29 April. He also refused to sign a
disclaimer. He attended his next session, on 1 May.
92. After suffering chest pain in the early hours of 3 May, the man was taken
to healthcare for an ECG (a test to measure the electrical activity of the
heart). The test was faxed to the out of hours GP, although the advice
20
given is not recorded in the medical record. He refused to wait in
healthcare for the results of the ECG. He reportedly threw furniture at a
door and was verbally abusive to staff after demanding that they give him
extra milk.
93. Prison Doctor D wrote to the man on 7 May after they had earlier
discussed his dietary requirements. He reminded him of his responsibility
to make meal choices from the menu based on the advice he had been
given from the dietician. He added that kitchen staff were also aware of
this advice and were able to supply packed meals to meet the
requirements on the days that he attended hospital.
94. The man refused to go to the Infirmary on 12 May for the surgery to create
a fistula. No reason for this refusal is recorded in his notes. He also
refused to sign a disclaimer. Although he declined to have the surgery, he
attended all of his scheduled dialysis sessions in the first two weeks of
May. However, he continued to reject his prescribed medication.
95. On the morning of 18 May, the man suffered a bout of diarrhoea and said
he felt generally unwell. He went to the Infirmary for his scheduled
dialysis session and was admitted as an inpatient due to his weakness.
He was diagnosed with sepsis (blood poisoning) and treated with
intravenous antibiotics. He continued to deteriorate and an ECG showed
he had endocarditis (inflammation of the inner lining of the heart, usually
as a result of a bacterial infection).
96. The man therefore moved to the hospital’s coronary care unit on 22 May.
He was told on the same day that his prognosis was “very grave”.
However, on 25 May, he discharged himself from hospital despite being
advised that he should remain and continue the course of intravenous
antibiotics. On his return, he moved into a cell in the prison’s healthcare
centre.
97. When he moved to the coronary care unit, the then head of business unit
and Frankland’s family liaison officer, telephoned his mother to update her
on his condition. She updated his mother on her son’s condition for the
remainder of his life. (Telephone records show that the man himself
contacted his family regularly during his time at Frankland, often several
times a week.)
98. Following his return to Frankland, the man discussed his treatment with
the clinical team leader in the prison’s inpatient facility. He said he would
not accept any treatment at Frankland and thought he should be treated in
hospital. When she asked why he had therefore discharged himself from
hospital, he said it was because he did not agree with the use of restraints
in hospital.
99. The man went to the Infirmary on 27 May for his scheduled dialysis
session and for a course of intravenous antibiotics. However, he refused
to start the session as he thought his handcuffs were too tight. The cuffs
21
were checked by the escorting staff, including a senior officer, who
considered them to be reasonable. It was noted that the handcuffs had
already been loosened by a principal officer prior to departure from
Frankland, after which he had said they were comfortable. He
subsequently became verbally abusive to hospital doctors and nurses, as
well as the escorting staff. The senior officer in charge of the escort, after
consulting the duty governor, decided to take him back to Frankland
immediately.
100. Later that evening, the man complained of chest pain and shortness of
breath. An ECG was taken with the result faxed to the out of hours
doctor. He recommended that the man be admitted to hospital. After
undergoing tests at hospital, he was discharged and returned to Frankland
at 5.30am on 28 May.
101. On the morning of 28 May, the man sustained an injury to two fingers on
his left hand. Healthcare Officer (HCO) A described the events at
interview with the investigator. The HCO said that he went to the man’s
cell to answer a call bell. As is standard practice when the door is locked,
he spoke to him through the observation flap in the cell door. He said that
the man asked “for something he wasn’t entitled to”. He went on to say
that when he told him he was unable to provide this item, he “stepped
forward and threw a punch”. The HCO said he instinctively stepped back
and pushed the flap shut. The man’s fingers became trapped in the flap.
He sustained lacerations and damage to the nail on the middle and ring
finger of his left hand. The wounds were treated and dressed by a nurse.
102. On the same morning, the man continued to complain of chest pain and
requested re-admission to hospital. Prison Doctor D discussed the
symptoms with a nephrologist at the Infirmary, who advised that the man
should be admitted for review. He remained in hospital until 22 June and
was treated with intravenous antibiotics as well as his usual dialysis.
Towards the end of his stay in hospital, he was prescribed warfarin
(medication used to thin the blood to prevent it from clotting). His conduct
in hospital was said to be disruptive. He was described by the doctor in
charge of his care as being “verbally abusive and aggressive to staff”.
103. On his return to Frankland, the man again stayed in the healthcare centre.
The day after his return he refused to take his medication as he did not
have a carbonated (fizzy) drink to take it with. He said he would not drink
water or milk. The following day, he declined to go to hospital for dialysis
as he wanted to make a legal telephone call. He also refused to have his
International Normalised Ratio taken (INR, a measure of the effectiveness
of warfarin treatment) and was not therefore permitted his dose of
warfarin. (Clinicians are not allowed to give warfarin without first checking
the INR as otherwise they might give an ineffective or dangerous dose.)
104. On 27 June, the man requested to go to hospital for dialysis to make up
for his missed session the day before. This was not possible as the
22
dialysis unit at the Infirmary was already fully booked. He again refused to
have his INR taken and was again not given his dose of warfarin.
105. Two days later, he again refused to attend hospital for his dialysis session.
He had earlier “demanded” to see the Governor of the prison. When he
was told that this was not possible, he said he would not go to hospital.
He later changed his mind and said he was prepared to go out for dialysis.
However, he had by now missed his slot and the unit was full.
106. The man went to the Infirmary for dialysis on 1 July. This was the last
session he attended. He refused to attend his next session, two days
later, as he had a legal visit planned. Later that day, he told Principal
Officer (PO) A and the then Head of the Business Unit that he was losing
weight and did not have enough food. After discussing the matter with a
prison doctor, it was agreed that he should receive extra portions.
However, he declined the extra portions and said he considered the food
to be “slop”.
107. On 4 July, the man vomited and said he felt “hot and sweaty”. He refused
to take his evening medication. He was more settled the following day,
but vomited twice in the early evening. He refused to attend his dialysis
session on 6 July and again refused his medication. On 7 July, he
refused his morning medication as he did not have a carbonated drink to
take it with.
108. The following morning, the man refused to go to hospital for dialysis and
did not sign a disclaimer. He again declined his morning medication. At
around 11.11am, Healthcare Assistant (HCA) A went to check on him in
his cell. She looked in the cell and saw that he was “slouched” on his bed.
Upon entering the cell, she examined him and found that he had no pulse.
She began cardio pulmonary resuscitation (CPR) and was joined by a
prison nurse. A radio call for an emergency response was made by HCO
B.
109. An ambulance was called, and paramedics arrived at the prison at
11.30am. Prison Doctors C and D also attended, and took over CPR from
the nursing staff. Their efforts were unsuccessful, and the man’s death
was pronounced at 12.02pm by one of the paramedics.
110. A family liaison officer from HMP Birmingham, which is nearer to the man’s
family home, was asked to break the news of his death to his mother. She
visited the man’s mother at her home on the afternoon of 8 July. No other
family members were told of the death by prison staff.
111. The funeral took place on 23 July. Although the man had converted to
Islam some years previously, he had not left a will or any indication of his
wishes following his death. At his mother’s request, the funeral consisted
of a Christian service and burial. The investigation 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
23
death in custody).
24
ISSUES
Acceptance of dialysis treatment
112. After suffering from deteriorating kidney function over a number of years,
the man began dialysis treatment in July 2008. The treatment involved
thrice weekly outpatient visits to the Infirmary. Each dialysis session
lasted for several hours.
113. The man’s compliance with his dialysis treatment was variable. Although
there were some periods where he attended most of his scheduled
sessions, notably in February, March and April 2009, he missed a session
a week on average. These missed sessions were often followed by
emergency hospital admission.
114. The man gave a number of different reasons for missing the dialysis
sessions. He often said that he did not like the senior officer in charge of
the escort or the level of restraints used (I discuss this in more detail
later). He also declined dialysis because, he said, the treatment was not
helping him or he thought the hospital staff were “negligent”. A number of
prison staff told the investigator at interview that he would refuse dialysis
for what they thought were trivial reasons, such as disliking the content of
his packed lunch. It is also recorded that he sometimes refused dialysis
because he had a telephone call scheduled.
115. There were also occasions when the man would go to hospital for dialysis,
only to change his mind immediately or shortly after the procedure started.
Some sessions were terminated by the escorting staff on account of his
abusive behaviour towards hospital staff. On other occasions, he would
refuse to go to hospital in the morning, only to change his mind later in the
day. On such occasions he was accommodated by the hospital where
possible, subject to a free slot being available.
116. It is clearly recorded in his notes that the man was warned on a number of
occasions that his refusal of treatment was likely to result in serious
consequences to his health. These warnings came from a variety of
sources, including the consultant nephrologist at the Infirmary and prison
doctors. I am satisfied that hospital and prison staff made numerous
attempts over a significant period of time to persuade him to cooperate
with his treatment plan.
117. The man’s mental capacity to refuse treatment was formally assessed on
a number of occasions, although he often refused to participate in the
assessment. Indeed, he was discharged from Frankland’s mental health
team caseload in March 2009 after being described as threatening and
abusive during an assessment. Nevertheless, all those interviewed by the
investigator who expressed a view on the subject, including Community
Psychiatric Nurse A and prison doctors, were confident that he had full
capacity to refuse treatment and full understanding of the likely
consequences.
25
118. The clinical reviewer refers to National Institute of Clinical Effectiveness
(NICE) guidelines, which state:
“Treatment and care should take into account people’s needs and
preferences. People with chronic kidney disease should have the
opportunity to make informed decisions about their care and treatment,
in partnership with their healthcare professionals.”
119. She goes on to say:
“Good communication between healthcare professionals and the man
was evident throughout [his] time in Frankland and every effort was
made to engage him in his clinical care and subsequent management
plan.”
120. It is clear from prison records and interviews with staff that they found the
man to be a difficult and challenging patient to manage. She concludes
that he received a “very high standard of care” at Frankland. I am
satisfied that staff at Frankland could have done nothing further to
encourage him to engage in and comply with his treatment plan.
Provision of in-house dialysis at Frankland
121. Over the same period that the man attended the Infirmary for dialysis,
another prisoner at Frankland was also going to the same hospital for
dialysis three times a week (on different days to the man). These visits
and the escorts involved for both prisoners used considerable resources
and the prison therefore looked into the possibility of providing in-house
dialysis in the healthcare centre.
122. The healthcare manager told the investigator that a cell was prepared to
house a dialysis unit. However she described several obstacles to
progressing the work further. Firstly, the commissioning team at the
Primary Care Trust were unable to secure specialist consultants to carry
out the work. Secondly, a number of healthcare staff would have to be
trained to carry out dialysis, which would be time consuming and costly.
Thirdly, the other prisoner was discharged from custody and it was not
considered feasible to run the scheme for just one patient. She added
that the man’s non-compliance was not a consideration in this decision,
although Prison Doctor A said he thought it unlikely that the man would
co-operate with dialysis in prison.
Hospital escorts
123. One reason that the man regularly gave for not attending his scheduled
dialysis sessions was that he did not like the staff who were escorting him
in hospital, particularly some of the senior officers who were in charge of
the escorts. He also refused dialysis on some occasions because the
26
escort chain was attached to his right wrist, whereas he sometimes
preferred it to be attached to his left.
124. The level of security required when a prisoner attends an outpatient
appointment at hospital is determined by means of an ‘escort risk
assessment’ form, which is authorised by a senior manager. In the man’s
case, the judgement was that three staff should accompany him to
hospital, including a senior officer who was in charge of the escort. He
was double cuffed on his way to hospital (meaning that his hands were
handcuffed together, with another pair of handcuffs joining his wrist to that
of a prison officer). During dialysis, the handcuffs joining him to the officer
were replaced by an escort chain (a long chain with a handcuff at each
end).
125. Given the man’s long history of abusive, violent and threatening behaviour
both in prison and, on occasion, towards nursing staff at the hospital, I
think that the security procedures in place were reasonable. Whilst he
might have had a preference for having the escort chain on his left rather
than right wrist this was, apparently, not feasible due to the position of the
dialysis machine in hospital. (The machine is positioned to the patient’s
left, hence the officer on the escort chain had to sit to the man’s right.)
126. On several occasions, the man refused to go to dialysis on account of the
particular staff who were assigned to escort him. Principal Officer (PO) B,
who said he got on well with him because of a shared interest in keep fit
and the gym, told the investigator that the number of staff that the man did
not get on with far outweighed those that he did. SO A, who knew the
man well on G wing, said that it was usually staff who had placed him on
report or had been involved in ‘control and restraint’ procedures that he
did not like. I have considered the evidence carefully and found nothing to
suggest that staff escorting him to hospital behaved in anything other than
a professional manner.
127. A case review was held in December 2008, to discuss the man’s
behaviour and his frequent refusal to participate in dialysis. This identified
the need to create a group of staff who he got on with. This is seemingly
one of the reasons why his compliance with his dialysis sessions
improved in February, March, April and May 2009. Indeed, he said
himself at an ACCT case review in mid March that he had been going
more often because the staff he did not like had not been on duty. It was
only following his return from a four week hospital admission on 22 June
that he began to consistently refuse dialysis again.
128. Ultimately, it is not for a prisoner to decide which staff accompany them on
a hospital escort. Numerous factors have to be considered in determining
which officers are available for escort on a particular day, most notably the
shift patterns at the establishment. It is commendable that Frankland
were able to provide escort staff on a regular basis with whom the man
was prepared to co-operate.
27
129. The man’s family raised other issues about his treatment whilst on escort.
His mother said there were several occasions on which her son was
treated unfairly by prison staff at the hospital. She described an occasion
when he asked if he could have dialysis in a different arm to normal, as
his usual arm was hurting him. She said that the escorting officers
refused this request.
130. Although dialysis is often administered through the forearm, the man’s
dialysis was through an entry point in his chest. As I have already
explained, he sometimes requested that the escort chain be moved from
his right wrist to his left. This was not practical because of the position of
the dialysis machine. The decision about which arm to use for dialysis
would have been made by medical staff at the hospital rather than the
prison officers.
131. A second incident described by the man’s mother referred to her son
being taken back to prison straight after his arrival at hospital, having been
told he had “assaulted the nurse”. She does not give a date when this
incident was supposed to have happened. The closest similar incident
described in the prison records occurred on 27 May 2009. On this
occasion, he reportedly refused to start the dialysis session because he
felt his handcuffs were too tight. The handcuffs were checked by
escorting staff, who thought they were acceptable. The handcuffs had
earlier been checked and loosened by a principal officer prior to departure
from Frankland, after which he had said they were comfortable. He
became verbally abusive to doctors and nurses at the hospital. After
consulting the duty governor, the senior officer in charge of the escort took
him back to Frankland. Given that he had been verbally abusive to
hospital staff, I believe that this decision was reasonable.
132. The man’s mother described an occasion on which her son took £10.00 to
spend in the hospital canteen before dialysis. She said that the money
was taken off him by the escorting officers, who told him he could not buy
food or drink. She said that her son told her that the officers proceeded to
eat and drink in front of him.
133. Prisoners at Frankland are not allowed to take any money with them on
external outpatient appointments. The man was provided with a packed
breakfast and packed lunch in order that he had something to eat and
drink on his dialysis days. Moreover, given the length of the
appointments, it is not unreasonable to expect that the escorting staff
would also want to eat and drink during these hospital visits.
134. The man’s mother described another occasion that she said occurred
when her son was an inpatient at hospital. He had six bottles of fruit juice
with him but, when he returned to the hospital room following a dialysis
session, he said that the juice was gone. In these circumstances, the
prison escorting staff would have accompanied him to the dialysis suite
and would not have remained in his hospital room. Thefts from within the
hospital are a matter for the hospital and are outside the Ombudsman’s
28
remit. It should be noted, however, that he did not submit a ‘request and
complaint’ form (the prison’s internal complaints system) on this occasion
or on any of the others I have described above.
The man’s request to transfer his care to hospital
135. On 31 December 2008, the man wrote to healthcare staff and said he no
longer wished to be treated at the Infirmary. He said this was due to
“medical negligence and serious breach of patient doctor confidentiality”.
The following day he requested that his care be transferred to hospital.
136. At a case conference to discuss this request, held on 2 January 2009, it
was agreed to refer the man to hospital. He was subsequently put on
their waiting list. In the meantime, it was agreed that healthcare staff
should continue to encourage him to attend his scheduled appointments
at the Infirmary.
137. The man missed six of his scheduled dialysis sessions in January. It is
not clear whether any progress was made with the referral to hospital.
However, it does not appear as though he himself pursued his request to
transfer his care. As I have noted earlier, he began to attend dialysis
sessions regularly in February and March 2009 and did not make any
more complaints about the quality of care he received in hospital.
Possibility of organ transplant
138. The man’s sister said that she had offered one of her kidneys to her
brother, and asked whether he was on an organ transplant list. In
discussion with Prison Doctor C on 30 September 2008, a consultant at
the Infirmary explained that the man was not on a transplant list because
his high blood pressure precluded it. This does not appear to have
changed throughout the remainder of his life. His frequent non-
compliance with blood pressure medication would not have helped.
139. The clinical reviewer notes that patients with cardiovascular disease are a
higher risk for transplantation. She goes on to say that the man was
“thought suitable for a kidney transplant but due to his treatment non-
compliance he developed severe cardiovascular disease”. She concludes
that had he been more compliant with his treatment “his life may have
been prolonged by giving him a kidney transplant”.
Management of blood pressure medication
140. The man suffered from high blood pressure in the years before his arrival
in prison in 1999. His compliance with his blood pressure medication was
reportedly poor prior to coming into prison. This continued from his first
months in prison, and remained so for the rest of his life. A number of
different medications were tried but, for various reasons, he declined them
all. Even when he regularly attended his dialysis sessions, he frequently
refused his medication.
29
141. Prison Doctor A described the man’s compliance with his medication as
“unpredictable”. He went on to say:
“We had some difficulty in getting him to engage with the idea of
allowing us to treat his blood pressure as we thought it should be
treated … I never found a reason why he didn’t engage with the
treatment … I strongly feel that we tried everything we could do to
engage with him.”
142. Prison Doctor C described how healthcare staff tried to engage with the
man:
“We all tried to be nice and we all tried to reason with him and tried to
negotiate a middle position for him. But it became so impossible … he
would just be so unreasonable.”
143. The clinical reviewer notes that the man had “intractable high blood
pressure which was very difficult to bring down and manage to an
acceptable level without [his] full compliance”. He sometimes kept his
medication ‘in possession’ (meaning that one week or several weeks
supply was issued for him to store in his cell and take as prescribed) and
sometimes collected it on a daily basis. Although he seemingly preferred
to keep his medication in possession, neither method was consistently
successful in encouraging his compliance. Nonetheless, the clinical
reviewer comments that his medication programme “appeared to be good
practice and in line with the Nursing and Midwifery Council Standards of
Medicines Management”.
144. The man was warned on a number of occasions, by both prison and
hospital staff, that it was important that he control his own blood pressure
better. I have earlier noted the clinical reviewer’s conclusion that he
received a “very high standard of care” at Frankland. I am satisfied that
nothing further could have been done to encourage him to comply with his
medication regime.
Diet and fluid intake
145. Although he had been receiving dialysis for several months at the time, it
is first recorded that the man saw a dietician on 17 February 2009. This
was after he said he had lost weight. The dietician recommended that he
start a course of nutritional supplements. He seemingly did not take many
of his supplements as a large number were found in his cell on 1 April.
146. On 17 April, the dietician provided a suggested meal plan for the days the
ma went to hospital for dialysis. Three weeks later, he met with Prison
Doctor D to discuss his diet. The doctor reiterated that kitchen staff were
aware of his needs, and encouraged him to make meal choices based on
the advice he had been given by the dietician.
30
147. The man told staff on 3 July that he was losing weight and did not have
enough food. After they discussed this further with a prison doctor, he
was allowed extra portions of food. However, he declined this offer.
148. It was reported that the man sometimes refused to go to hospital for
dialysis as he did not like the filling in his packed lunch. SO B, the
catering manager at Frankland, told the investigator that the kitchen
began to contact the man’s wing on the morning of each dialysis session
to ensure that they were able to provide the sandwich filling that he
requested that day. He added that the man still refused to eat the
sandwich on occasions.
149. The clinical reviewer notes that, although the multiple choice menu
selections were not specific to his renal condition, “healthy options and
suitable choices were available and indicated to him”. She goes on to say
that there is no set renal diet and:
“Advice will vary depending on things such as [the patient’s] weight,
blood tests and dialysis choice … patients who are prescribed
haemodialysis may require a slightly higher protein diet”.
150. It is difficult to fulfil individual needs in a mass catering establishment such
as a prison. However, there were indications that the man was losing
weight over a period of time. Although he was offered supplements to
help, he seemingly did not take them regularly. It does not appear as
though his weight was recorded on a regular basis. The clinical reviewer
makes the following recommendation:
Where dietary intervention is agreed, this should occur within the
context of education, detailed dietary assessment and supervision,
to ensure that malnutrition is prevented. Dietary advice should be
offered to people with progressive chronic kidney disease
concerning potassium, phosphate, protein, calorie and salt intake,
when indicated.
151. Towards the end of his life, the man began to refuse to take his
medication unless he had a carbonated drink to take it with. He said that
he did not like the prison water or milk. This was not recorded as an issue
before the last few weeks of his life. Indeed, he had previously requested
extra milk on occasions.
152. The clinical reviewer comments that there is “no rationale that he should
receive [carbonated drinks] as part of his dietary regime”. However, she
goes on to say:
“In a patient who is prescribed haemodialysis the fluid allowance often
needs to be quite strictly controlled. Too much fluid accumulation will
raise a patient’s blood pressure and will require a longer dialysis
programme to reduce the blood pressure to an acceptable level. This
situation had occurred on several occasions when he continued to
31
drink but refused dialysis treatment, requiring the need for him to be
admitted to hospital as an emergency rather than routine planned
care.”
153. She makes the following recommendation:
Patients receiving haemodialysis who are on a strict fluid intake
regime should have their intake monitored.
Use of nursing care plans
154. The man was clearly a complex person who had several significant
medical conditions and deteriorating physical health. Although he was
seen virtually on a daily basis by healthcare staff, it is clear that they
struggled to encourage his compliance with his treatment plan. On
occasion the ACCT processes were used to encourage him to accept
healthcare treatment. In addition, case conferences were held to discuss
his treatment and compliance. However, he did not have a nursing care
plan. Such a document would formally set out what interventions
healthcare staff will deliver and what the patient could be expected to do
for himself.
155. The clinical reviewer comments as follows:
“A care plan initiated by healthcare staff to address the man’s medical
problems that could have been transferred [around the prison] with him
may have assisted the continuation of care more readily.”
156. He lived in the healthcare centre inpatients unit for the last three weeks of
his life. The clinical reviewer quotes Prison Service Standard 22, ‘Health
Services for Prisoners’, which seemingly was not implemented:
“Each patient has a named doctor and healthcare worker and a care
plan. The plan is initiated within 24 hours of admission [to the prison’s
inpatient facility] and reviewed within one week in consultation with the
patient and named healthcare worker.”
157. The Department of Health publication ‘Guidance Notes – Prison Health
Performance and Quality Indicators’ also suggests that “all patients have
an up to date care plan”. She makes the following recommendation:
All prisoners with complex care needs should have a care plan,
generated by prison healthcare, that can be transferred with the
prisoner throughout the various wings of the prison to aid
continuation of care.
Use of the ACCT procedures
158. Assessment, Care in Custody and Teamwork (ACCT) is the process used
for monitoring and supporting prisoners at risk of suicide or self-harm. An
32
ACCT form was opened on 27 September 2008, when the man told a
nurse at the Infirmary that his treatment made him feel suicidal. The
ACCT was closed on 28 November, as he had been “more positive of
late” and had attended most of his dialysis sessions. However, a new
ACCT was opened on 10 December by SO A, as he had now missed a
number of dialysis sessions and was not taking his medication. This
ACCT was closed on 23 March 2009, as he had not missed a dialysis
session for three weeks and the “issues surrounding his non-compliance
have been resolved”. I am pleased that staff recognised his refusal of
treatment as potential self harm, and acted accordingly.
159. When an ACCT is opened, a case manager must be appointed. The case
manager is responsible for leading case reviews. Prison Service Order
(PSO) 2700, regarding suicide prevention and self-harm management,
provides the following mandatory instruction:
“ACCT Case Managers must be a minimum grade of Senior Officer or
Nurse Band 5 and have successfully completed the training for ACCT
Case Managers.”
160. SO A was appointed as case manager during both of the man’s periods of
monitoring under ACCT procedures. However, he is not trained as a case
manager and has only received the basic foundation training course. He
said he was asked to lead the case reviews because the man would not
participate if one of the other senior officers or principal officers was
responsible. Whilst I agree that it is eminently sensible to try to encourage
the prisoner’s participation in the ACCT process, I am concerned that the
man’s case reviews were led by an untrained member of staff.
The Governor should ensure that all ACCT case managers are
trained in the role, in line with PSO 2700.
161. When the man’s second ACCT form was closed on 23 March 2009, a post
closure review was set for 30 March. This did not take place. On the
same day, he moved to the segregation unit following a period of poor
conduct. SO A told the investigator that the ACCT form should have
followed him to the segregation unit, and it would then be the
responsibility of the unit manager to ensure that the post closure review
went ahead. Seemingly this did not happen.
The Governor should ensure that ACCT post closure reviews take
place as scheduled, regardless of the individual’s location in the
prison.
162. SO A told the investigator that he opened the second ACCT form on the
advice of the safer custody team at Frankland, as the man was regularly
refusing his dialysis treatment. An enhanced case review, held on 16
December, corroborated this view and recommended that he remain on
an open ACCT document as long as he failed to co-operate with his
treatment.
33
163. It appears that the man did not like being supervised under ACCT
procedures. However, it is likely that the process, and its focus on
improving his compliance with treatment, contributed to the increase in
dialysis sessions that he attended from February to May 2009. When he
began to regularly refuse dialysis again, following his discharge from
hospital on 22 June, the ACCT procedures were not re-opened.
164. There seems to have been some inconsistency in whether the man’s non
compliance with treatment was viewed as being self harm. In practice, the
use of the ACCT process as a care planning tool apparently had some
success on occasion. However, a clinically-led care planning approach,
as I have already recommended, may have improved consistency in his
management and care which would have been good practice.
Time spent on basic IEP level and in Frankland’s segregation unit
165. The man’s mother said she was concerned that the time her son spent on
the basic IEP level and in the segregation unit could have exacerbated his
health problems. Incentives and Earned Privileges (IEP) is a three tier
system designed as an incentive to reward good behaviour in prison.
Incentives include access to in-cell television, more private cash to spend
and more time out of cell.
166. All new prisoners to Frankland enter the IEP scheme on the standard level
(unless they were an enhanced prisoner at their previous establishment).
Prisoners can be placed on the basic level on the authority of a principal
officer or higher grade, through not complying with the prison’s expected
standards of behaviour. They must receive two warnings about their
behaviour before they are downgraded to basic.
167. Prisoners can be moved to the segregation unit for various reasons. The
most common are as a punishment measure (known as ‘cellular
confinement’) following an adjudication hearing, or for ‘Good Order or
Discipline’ (known as ‘GOOD’, a measure which provides for the removal
of a prisoner from associating with others “for the maintenance of good
order or discipline or in his own interests”). Prisoners in the segregation
unit may apply each day for various activities including exercise, a
shower, a telephone call or visit from a prison doctor or nurse.
168. The man spent three periods on the basic IEP level whilst at Frankland.
The first period was from 26 March 2008 until 21 April 2008. His second
period on basic was from 6 August 2008 until 19 November 2008. He
started his third period on basic on 12 February 2009 and was not
upgraded before his death. He also spent several periods of time in the
segregation unit. The most significant was over seven weeks from 30
March 2009 until he was admitted to hospital on 18 May.
169. During his time on the basic IEP level the man had weekly reviews of his
progress, in line with the local policy. During his final period on basic,
34
virtually all of his weekly reviews were negative and described his poor
attitude and threatening and abusive behaviour. His segregation was
reviewed regularly from 30 March, all of which indicated consistent
abusive behaviour.
170. The man’s IEP was upgraded to standard on two occasions at Frankland,
the first of which was specifically to encourage an improvement in his
conduct. These upgrades were unsuccessful in the long term. Although
he spent a lot of time on the basic IEP level and in the segregation unit, I
have seen no evidence to indicate that the correct procedures were not
followed.
171. I am satisfied that the man was a volatile prisoner who, due to his
persistently disruptive and abusive behaviour, spent considerable time on
the basic IEP level and in the segregation unit. A consistent improvement
in his conduct was the only means by which he could avoid these
penalties. Although he was made fully aware of this, he chose not to
follow the advice.
172. On the basic IEP level, the man was allowed one session of exercise per
day (a minimum of 30 minutes) and one session in the gymnasium per
week. When he was on the standard IEP level, he was allowed the same
amount of daily exercise, plus up to six gymnasium sessions per week.
173. In addition, the man spent a considerable amount of time in the
segregation unit at Frankland. His longest period in the segregation unit
was seven weeks from 30 March 2009 until he was admitted to hospital
on 18 May. Whilst in the segregation unit he was allowed to apply for
exercise on a daily basis (again, a minimum of 30 minutes) but did not
have access to the gymnasium. Records show that he regularly declined
exercise over this period.
174. The clinical reviewer notes that it is unclear from the records whether a
particular exercise regime was identified for the man’s condition. I
recognise that prison and healthcare staff found him to be a demanding
prisoner, and I am satisfied that decisions about his IEP level and location
were made appropriately. However, it is not clear that the requirements of
his health condition were considered, including the impact of a restricted
regime. I agree with the clinical reviewer’s recommendation and extend it
slightly:
Regardless of their IEP level or their location, prisoners with chronic
kidney disease should be encouraged to take exercise to help them
achieve a healthy weight.
Successful resuscitation on 27 and 28 April 2009
175. On 27 April 2009, the man stopped breathing and was resuscitated by
staff at Frankland. He was taken to hospital by ambulance and returned
to the prison two hours later. At 4.00am the following morning, he again
35
stopped breathing and was resuscitated by prison staff. As previously, he
went to hospital by ambulance and returned to the prison later.
176. It is commendable that staff were able to act promptly on these two
occasions to save the man’s life. Had he been living alone in the
community, it is likely that the outcome would have been different.
Incident in which the observation flap on the cell door was shut on the
man’s finger
177. The man’s mother described an occasion in which he was assaulted by a
prison officer by having a cell door shut on his finger. This would appear
to refer to an incident on 28 May 2009. Healthcare Officer (HCO) A
described the events as follows:
“We were talking through the flap in the door. I can’t remember what
he was asking for but it was something he wasn’t entitled to, probably
pop or milk. I said I didn’t have any to give him. He started shouting.
He then stepped forward and threw a punch … through the flap but my
face was close to the flap because I was talking. I moved my face
back and pushed the flap up. It was purely instinct. He then started
pushing against the flap so I pushed harder. He said something like
‘you hurt my fingers … they’re trapped in the flap’. At that time I let the
flap go and his fingers were trapped in the flap. I didn’t realise at the
time, I thought he was just pushing to try and get at me through the
flap.”
178. The man sustained lacerations to his fingers and damage to the nail on
the middle and ring finger of his left hand. The wounds were treated and
dressed by a nurse. He did not make a formal complaint about this
incident. From the evidence available, I believe that HCO A’s actions
were reasonable.
Scars identified by the post mortem report
179. The post mortem report revealed a number of scars and marks on the
man’s body. His mother asked how he received these marks. This is not
clear from his records, although the findings of the post mortem indicate
that they might not have been reported anyway due to their “trivial” nature.
The full finding of the post mortem is as follows:
“The post mortem examination showed that there were no fresh injuries
present. There was a small number of healing lacerations and
abrasions on the back. No deep bruising was present at this site.
These injuries are essentially trivial. Their aetiology [origin] is uncertain
but they are entirely consistent with normal day to day activity.”
36
Transfer from Frankland closer to the man’s family
180. The man’s sister asked why he was not moved to a prison closer to his
family when he became ill, and added that he had not always been in a
high security prison. I have explained the details of her brother’s transfers
earlier in my report. He moved to the high security estate in January
2007, when he transferred from Swaleside to Whitemoor. His conduct
and attitude was described as very poor throughout his time in prison,
despite transfers between lower category establishments to allow a “fresh
start”. He moved to Frankland in August 2007, following a period in which
he assaulted an officer and set fire to his cell.
181. Given that the man’s conduct did not improve during his time at
Frankland, it is likely that, were he to move to another establishment, he
would remain in the high security estate. This would restrict the options
available and opportunity to transfer, as places are limited. Were he to
move, it would be at the prison’s prerogative. Given his medical condition
and the importance of maintaining continuity of care, this would not be
prudent. Alternatively, he could request a transfer. There is no evidence
to suggest that he did so.
Contact with his family in the week before the man’s death
182. The man’s sister said that he did not speak to any members of his family
in the week or two before he died. She queried whether he was asked if
he wanted one of his relatives to be contacted when his health
deteriorated. She also asked whether any refusal to such a request might
be evidence he was suffering from dementia as a result of end stage renal
failure.
183. The prison’s family liaison officer telephoned the man’s mother on 22 May
2009, when her son was admitted to the coronary care unit at the
Infirmary. The liaison officer updated her on her son’s condition. She told
the investigator that she telephoned the man’s mother with further updates
on an average of a weekly basis for the remaining weeks of his life.
184. Telephone records show that, following his return from hospital on 22
June 2009, the man telephoned his mother’s house five times. The last
was on 2 July, when the call was terminated as he had run out of credit on
his telephone card. He topped up his credit on the morning of 7 July, but
did not make any further calls.
185. Given the above, I am satisfied that the man had reasonable opportunity
to contact his family in the last weeks of his life. In addition, the clinical
reviewer concludes that “there does not appear to be any evidence to
support [the suggestion] that he was suffering from dementia”.
37
Notifying his family of the man’s death
186. All prisoners are asked to nominate their next of kin on arrival into prison.
The man nominated his mother as his next of kin. On account of the
distance she lives from Frankland, it was not practical for staff from the
prison to visit her to break the news of his death. A family liaison officer
from HMP Birmingham, which is near to where she lives, was asked to
break the news to her. The family liaison officer visited her on the
afternoon of 8 July 2009, within hours of her son’s death. I am satisfied
that this is in line with the practice recommended in PSO 2710, which sets
out the actions to be taken following a death in custody.
187. The man’s sister told one of my family liaison officers that she did not hear
about her brother’s death until seven months afterwards. She said she
was not named as next of kin as she was estranged from her mother and
another brother, and asked how the prison normally deals with such
issues.
188. PSO 2710 provides the following mandatory guidance to prison
Governors:
“[They must] arrange notification to the next of kin and any other
person reasonably nominated by the prisoner as soon as possible in a
suitable manner.”
189. The accompanying guidance for prison family liaison officers provides
advice for managing the circumstances described by the man’s sister:
“A family may be large, split geographically, at odds amongst
themselves … there may be several branches all with equal rights to
information. The [prison] family liaison officer may be able to get the
family to nominate a single point of contact who undertakes to keep
other family members up to date. This may not always be possible, or
may not work in practice, so the family liaison officer should be
prepared to deal with different sections of one family if necessary.”
190. However, the above guidance is reliant on prison staff being aware of
such family dynamics. There is no indication that the man asked that his
sister be notified of his death or that the prison were aware that she was
not in contact with her mother. Were they to be aware of this scenario, I
would expect his sister to have been contacted as soon as possible after
his death. I regret the delay before his sister learnt of her brother’s death
but believe that the prison took the appropriate actions at the time.
Return of the man’s property to his family
191. The man’s mother said that her son’s property was not returned to the
family, despite several requests. She said she was particularly keen to
obtain any correspondence that her son had in his cell. His sister, on the
other hand, said she was concerned that all of his property had been
38
returned to his mother and brother, including personal correspondence
that contained her contact details. As I have said, I do not think that the
prison could have been expected to know of the rift in the family.
192. Frankland’s then family liaison officer told the investigator that she sent
the man’s mother a list of his property, with a stamped envelope in which
she could return a list of the items she wanted. She said she did not
receive a reply. This could have been followed up further, but this does
not appear to have happened. Some time later she received a letter from
the man’s mother’s solicitor asking for any legal paperwork. This was sent
to her. As it was only legal papers, correspondence from the man’s sister
was not included.
39
CONCLUSION
193. The man’s time at Frankland, particularly in the last year of his life, was
dominated by his advanced kidney disease. He did not comply with his
treatment plan and was regularly described as abusive and threatening.
Both of these issues were a constant challenge to staff throughout the
prison. I am satisfied that they did all that could reasonably be expected
of them to support and encourage him to engage with his treatment.
Indeed on more than one occasion I have found that staff made great
efforts to provide individualised support to encourage him to accept his
treatment.
194. The clinical reviewer concludes that the man was “treated to a very high
standard of care” whilst at Frankland. She goes on to say that “if he had
been more compliant his life may have been prolonged by giving him a
kidney transplant. As such, due to his continued non compliance, there
was little else the Prison Service could have done to prolong his life”. I
agree with this conclusion and do not believe that Frankland could have
done any more to promote his wellbeing.
40
RECOMMENDATIONS
1. Where dietary intervention is agreed, this should occur within the context
of education, detailed dietary assessment and supervision, to ensure that
malnutrition is prevented. Dietary advice should be offered to people with
progressive chronic kidney disease concerning potassium, phosphate,
protein, calorie and salt intake, when indicated.
Accepted – on diagnosis of a long term/chronic condition a routine referral
will be initiated by nursing staff for a full nutritional assessment.
2. Patients receiving haemodialysis who are on a strict fluid intake regime
should have their intake monitored.
Accepted – due to the significant periods of unsupervised time it is only
possible to maintain an accurate fluid balance with the full co-operation of
the patient. In the event of a fluid balance being recommended, education
will be provided to the patient that emphasises the importance of its
maintenance and subsequent fluid regime.
3. All prisoners with complex care needs should have a care plan, generated
by prison healthcare, that can be transferred with the prisoner throughout
the various wings of the prison to aid continuation of care.
Accepted – when a patient is discharged from healthcare, if there are
continuing healthcare needs that may involve wing staff, healthcare will
provide a sanitised care plan to the wing officers with the consent of the
patient.
4. The Governor should ensure that all ACCT case managers are trained in
the role, in line with PSO 2700.
Accepted – all SOs and above with prisoner contact to be trained as case
managers.
5. The Governor should ensure that ACCT post closure reviews take place
as scheduled, regardless of the individual’s location in the prison.
Accepted – a daily list of case reviews is to be kept by the ECR, this is to
be communicated to staff through the morning briefings to managers.
6. Regardless of their IEP level or their location, prisoners with chronic
kidney disease should be encouraged to take exercise to help them
achieve a healthy weight.
Accepted – the importance of exercise will be highlighted at all LTC
reviews.
41