Individual at Belmarsh

Investigation into the circumstances surrounding the
death of a man at hospital
In October 2009, while in the custody of HMP Belmarsh
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2010
In October 2009, the man was found at 00.20am in his cell at HMP Belmarsh
suffering from complications relating to diabetes. He was assessed by a doctor in
the morning and taken to hospital. He was 60 years old. I offer my sincere
sympathy and condolences to the man’s family and friends for their loss.
The investigation was carried out on my behalf by my colleague. A clinical review of
the man’s healthcare was undertaken by the clinical reviewer on behalf of NHS
Greenwich. I am grateful for their review. I would also like to thank the Governor of
Belmarsh and his staff for their co-operation and assistance. Particular thanks go to
a duty governor for his help during the investigation.
The man was arrested in 2003 and charged with serious offences. He did not cope
well in prison and made attempts to harm himself. Staff intervened and he was
monitored using the Assessment, Care in Custody and Treatment (ACCT)
processes. Following his sentencing in January 2005, he was diagnosed with
diabetes. He frequently refused treatment and ate unsuitable food. Despite staff
attempts to care for him, his physical health deteriorated over the years and he spent
time in hospital. In October 2009, he was taken to hospital where he died three days
later.
The man was serving a long sentence. Healthcare staff found him a difficult patient
as he was inconsistent about accepting treatment. However, I am satisfied that they
responded appropriately to give him the care he required. This report contains four
recommendations regarding record keeping, training and the use of advance
directives.
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 September 2010
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CONTENTS
Summary
The investigation process
HMP Belmarsh
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was born on 15 July 1949. He was arrested in 2003 regarding a number of
serious offences. He told the police that he had attempted to take an overdose
earlier that day and was taken to hospital. His early time in prison featured several
instances where he expressed self-harming thoughts or actions. Staff intervened
and he spent some time in a mental health clinic in London.
He was sentenced to 16 years in prison in January 2005. Soon afterwards he
became lethargic and complained of being thirsty. He underwent tests and was
diagnosed with diabetes in the summer. He reacted badly to the news and refused
to accept treatment. Despite being told repeatedly by staff to moderate his diet, he
regularly ate large amounts of sugary food.
At the start of 2007, the man signed an advance directive explaining that he did not
wish to be treated for diabetes. (This is a document which outlines the actions the
person would like to happen should they become incapacitated and unable to make
decisions for themselves.) He did not cooperate with his treatment until August 2008
when he was taken into hospital. Once there, he began to accept insulin treatment.
The investigator was told by the Head of Healthcare at Belmarsh that, once he
began accepting insulin treatment, it invalidated his advance directive. From this
time on, he was treated as any other patient who refused treatment.
For the next year, the man gradually became weaker and was taken into hospital on
a number of occasions. His attitude towards treatment varied, but the prison
healthcare staff continued to offer the options available. The prison also provided
him with several practical items to aid his well-being such as a new bed and a
walking frame.
The man spent much of the last year of his life in bed which presented other
concerns, such as bed sores. In the early hours of 17 October 2009, he was heard
by another prisoner to be in pain. Staff went to him but he refused any pain relief
medication. He was reviewed throughout the night and, following an assessment by
a doctor, taken to hospital in the morning. His brother, his next of kin, was contacted
and travelled to the hospital to be with him in his last days.
Three recommendations are made in this report regarding record-keeping, staff
training and the management of advance directives.
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THE INVESTIGATION PROCESS
1. The investigation was carried out by my colleague. He arranged for HMP
Belmarsh to send him the documents relating to the man. Notices of the
investigation were issued to staff and prisoners, inviting those who wished to
provide information regarding his death to make themselves known to the
investigator. No-one came forward with regard to the notices.
2. The investigator asked NHS Greenwich to undertake a review into the clinical
care received by the man. The clinical reviewer coordinated the writing of this
review with her colleague. The clinical review was received in April 2010
which resulted in a delay in the publication of my report.
3. The investigator and the Ombudsman’s Senior Family Liaison Officer tried to
contact the man’s brother to discuss the investigation, but he did not respond
to the letters sent to him.
4. The investigator travelled to Belmarsh on 26 November to interview
healthcare staff. The clinical reviewer accompanied him.
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HMP BELMARSH
5. HMP Belmarsh was opened in April 1991, and operates as a local prison
serving the courts of South East London and South West Essex. It contains a
healthcare centre with beds for 33 prisoners.
Assessment, Care in Custody and Treatment
6. Assessment, Care in Custody and Treatment (ACCT) is a care planning tool
used by the Prison Service to help support and monitor those prisoners
identified as being at risk of suicide or self harm. The ACCT process
encourages staff to work together to provide individual care to prisoners in
distress and help to diffuse circumstances where self harm or suicide may
occur.
Advance directive
7. An advance directive is a document outlining the actions the person involved
would like people to take in the event that they are incapacitated and unable
to make decisions for themselves.
Independent Monitoring Board
8. Each prison has an Independent Monitoring Board (IMB) made up of
members of the community. The Board’s role is to ensure that the prison is
properly run and that prisoners are treated decently. Each Board produces an
annual report for the Secretary of State. The most recent report from the
Belmarsh IMB covers the period 2007 - 2008. The report makes reference to
security issues being paramount at Belmarsh, something understandable in a
category A prison. However, the IMB make the point that the prison now
needs to focus more on the needs of individuals.
Her Majesty’s Chief Inspector of Prisons
9. HM Chief Inspector of Prisons conducted an unannounced full follow-up
inspection from 27 April to 1 May 2009. The report said that: “Healthcare
services had deteriorated since the last inspection, and there was an urgent
need for re-engagement between the prison and the primary care trust.” It
went on to explain that, at the time of the inspection, primary health could be
improved due to the ending of the current GP contract, poor management of
clinical records and some problems in the pharmacy service. However, the
report noted that in the in-patient unit: “Relationships between staff and
prisoners appeared appropriate and relaxed.”
Previous deaths at Belmarsh
10. Prior to the man’s death, there were two deaths due to natural causes in
2008. In one case in particular, the prisoner, like the man, did not cooperate
with his treatment and would not take his medication. Both of these men also
died in an outside hospital.
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KEY FINDINGS
11. The man was born on 15 July 1949. He left school aged 15 and worked as a
carpenter throughout his life. He suffered from alcoholism and had been
assaulted in the past, suffering a head injury from a hammer.
12. On 30 June 2003, he was arrested and taken to hospital as he told the police
that he had taken an overdose of paracetamol and vodka. He was remanded
into custody at HMP High Down on 5 July. Although his initial healthscreen
did not reveal any concerns about his physical health, he was admitted into
the healthcare centre due to concerns about his alcoholism and depression.
A F2052SH form was opened on 8 July as staff were concerned that he might
harm himself. (The F2052SH form was the process prisons used to use to
monitor those at risk of harming themselves. It has now been replaced by the
ACCT process.) He made a noose and showed it to staff in the early hours of
9 July. He returned from court on 14 July and was described as appearing
very down. He was taken back to the healthcare centre where he threatened
to kill himself should he get the opportunity.
13. The man was transferred to HMP Belmarsh the following day. Up until 24
July, he continued to make veiled references to committing suicide. On 17
December 2003 he underwent an urgent psychiatric assessment by a
psychiatrist. He was found to have a low mood and strong suicidal ideas and
was placed on the waiting list to the mental health centre at the local hospital.
14. In the early hours of 26 February, the man made a noose and activated his
cell bell. He told staff that he wanted to kill himself as he had no faith in the
outcome of his trial. He was moved to a special observations cell. He was
transferred to the mental health centre on 4 March due to his disturbed sleep,
poor appetite and threats to kill himself. At the end of April, it was decided
that he was not suffering from any mental illness and he returned to Belmarsh
in May.
15. He was convicted and sentenced to 16 years in prison in January 2005,
(although having served 18 months on remand, his tariff was 14 years six
months.) A report was made in his medical record on 16 September 2005,
noting that his physical health appeared to have deteriorated. He was tested
for diabetes as he complained of being thirsty and lethargic. He was told in
June 2006 that he was suffering from diabetes. A nurse described the events
prior to his diagnosis:
“it was leading up to him having semi passing out periods where he
complained of being very thirsty, very lethargic. And that’s when we
decided the symptoms were similar to that of diabetes, let’s test him
and do the full test. And then it was confirmed.”
16. The nurse remembered that the man took the news badly:
“Negative, he was very angry and at that time when he first came into
the prison system, up to his sad death. He was very defiant, very
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argumentative, very angry. And at times would be very hostile in
nature to anybody who attended to his care, i.e. the nurses at one
point.”
17. The man was admitted to the healthcare centre following his diagnosis. Staff
advised him to reduce his intake of sugary foods, drink plenty of water and eat
healthily. Despite this advice, it was noted by staff that he did not follow
medical advice and restrict his diet. The nurse told my investigator that the
man was generally uncooperative and said that he was not interested in
moderating his diet:
“To the point where we had care plans implemented by myself and my
colleagues. And we would sit down with him and explain to him the
negative aspects of non-compliance. … And most of the time would tell
you ‘just leave me alone, get out of my cell’.”
18. At the start of November, the man refused to have a sample of his blood
taken for testing, and later refused to go to hospital. He wrote a letter to the
coroner on 16 November explaining that he was entirely responsible for the
timing and nature of his death. He praised the staff and explained that
everything that happened was his decision.
19. He refused to go to hospital on 4 December to discuss changes to his
treatment and signed another disclaimer, stating that he did not want to take
his medication. However, he was taken to hospital on 17 January 2007 as he
was found semi-conscious in his cell. Insulin treatment was given. He
returned to the healthcare centre on 19 January, with no signs of ill health.
Two days later, he refused his insulin medication, despite staff explaining the
consequences to him. He refused the insulin again the following day, and this
led to ACCT monitoring procedures starting on 23 January. The nurse
explained to the investigator the reason for the ACCT being started:
“ … his ACCT document was opened as a form of precaution and
because of his negative aspect saying I just want to die.”
20. The psychiatrist wrote that, in his view, the man was fully competent to make
his own decisions and was not suffering from depression. (Competent, in this
context, is used to describe people who are of sound mind and able to take
responsibility for their own actions.) The nurse recalled that he would buy a
lot of sugary foods despite staff advice about the consequences:
“Well at that time, he started having a lot of sugary substances and he
started buying in the canteen which all prisoners are entitled to. And
he starts stocking up his sugar and would constantly take sugar,
excessive amounts of sugar, and not taking his insulin, he would from
time to time go into a diabetes coma.
21. On 28 January, the man spoke to the Head of Healthcare and explained that
he was sure that, in a medical emergency, he did not want any intervention
other than pain relief. He said that he would write this down so that it was
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clear. Two days later, in the presence of the Head of Healthcare, he signed
an advance directive outlining his wishes.
22. A case review meeting was held with the man, the prison GP and the nurse
on 7 February. The doctor explained the implications of refusing insulin to the
man. The man accepted responsibility for his actions, and the doctor believed
that he understood the consequences. At a further meeting a week later, he
confirmed that he did not want his diabetes medication. Staff discussed his
decision with him again on 9 March. Although he said that he wished to die,
staff explained that refusing insulin might not result in death but could lead to
blindness or other degenerative conditions that could limit his independence.
He agreed to consider this advice. Staff met again later in the month to
consider the implications of his wishes.
23. The man asked to vary the terms of his advance directive in mid-April. The
previous directive had requested that no contact be made with his family until
after his death. He explained that his brother was living in the United
Kingdom again, and he wished his brother to be told if his condition worsened.
He also said that he did not want to be taken to hospital. The staff explained
that, if he was taken there, hospital staff would presume he would want
treatment unless they were told otherwise.
24. In June, a letter was received from the medical director at the hospital
explaining that both the prison and the hospital would adhere to the man’s
wishes. A case conference was held on 31 July and the medical director was
present. It was reported that the man had been assessed by psychiatrists
who agreed that “he has capacity and is able to make this decision of his own
volition”.
25. It was agreed that, should the man’s health worsen, he should be transferred
to hospital with a copy of his advance directive. Another case conference
took place in December and noted that the man’s physical health had
deteriorated. He had been prescribed morphine to counter the pain. The
prison agreed to provide him with a walking frame, new mattress, pillow and
duvet, and invite his brother into the healthcare centre for a visit. He was also
offered a telephone call to his brother.
26. Throughout the first six months of 2008, the man’s health continued to
decline. He refused his insulin medication, although he did accept morphine.
He was given Fortisip drinks to provide him with extra nutrition. He agreed to
go into hospital in August as he felt unwell. He was emaciated and suffering
from painful feet. During his stay in hospital, he accepted insulin treatment.
He returned to Belmarsh on 2 September, and continued to take his insulin.
His acceptance of insulin was spasmodic but it appears that, by October, he
generally accepted it.
27. The man spent another day in hospital in February 2009 suffering from a
respiratory infection. The nurse explained that, in his view, the man’s decision
to start taking his insulin again was prompted by a realisation of how easily he
could die.
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28. However, the man signed a form in March again refusing treatment for
diabetes. In May, he said that he wished the advance directive to be binding
on the hospital when the time came. A second prison doctor explained that,
as he was now taking insulin, the directive no longer applied. The doctor said
that once the man accepted some treatment, the advance directive was
nullified. The Head of Healthcare at Belmarsh explained this to the
investigator:
“At that point in time, our view was that the advanced directive was no
longer valid, and although after that period he often refused treatment
or was uncooperative, we dealt with that in the normal way that we
would in terms of someone withholding consent. Not as someone who
was on an advanced directive, just a difficult to manage patient. But
generally speaking, from that point, the central element of his
treatment, the injections of insulin, he did accept and he allowed
nurses to test his urine and test his blood etc. So the central tenet of
his treatment was, he was consenting to.”
29. The man was taken back to hospital on 21 May after being found in his cell in
pain. However he discharged himself from hospital the next day, against
medical advice. A further case conference was held on 31 May. It was
confirmed that the advance directive remained invalid. He spent much of the
last year of his life in his bed. The nurse explained that this amount of time in
bed resulted in sores on his body, which could be helped by time spent out of
bed. Tissue viability nurses from the hospital visited him to attend to these
problems.
30. He was taken to hospital again on 14 July as he had been vomiting. He
discharged himself against medical advice on 21 July. He was described as
frail, dehydrated and unsteady on his feet. A note in his medical file written in
August said that he continued to decline as he was not taking his medication
properly and had a poor diet. He returned to hospital on 3 September
suffering from diarrhoea and vomiting.
31. A case conference was held the next day and staff considered whether to
refer the man for end of life care at hospital. The nurse explained to the
investigator that the man was not keen on this idea:
“I think he was scared. He didn’t want to die anywhere strange and
even when at times we mentioned going out for palliative care, he
would say ‘I don’t want to go, I would rather stay where I am’. But I
think basically it was that because he knew while he is in the prison,
there are people around him.”
32. A letter was written by a third doctor on 25 September which said that, as the
man was contradicting his advance directive and it was no longer valid.
Belmarsh continued to treat him as any other prisoner withholding consent.
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33. Staff were alerted by another prisoner that the man required assistance at
00.20am on 17 October. Although he said that he was in pain, he refused to
take any pain relief medication. His blood pressure was recorded as 96/77
(this is a low blood pressure reading) with a pulse of 125 beats per minute
(this is a high pulse reading). Staff checked on him every 30 minutes and told
him that he would see a doctor in the morning. The findings of the 30 minute
checks were not recorded.
34. The doctor went to the man’s cell at 8.45am. He did not respond and so an
ambulance was called which took him to hospital. The hospital staff asked for
his next of kin details at 1.45pm and they were provided at 3.00pm. His
brother was contacted at 7.15pm, and he said that he would decide whether
to visit once the consultant had reviewed him. The escort staff made a note
on the morning of 18 October that restraints were not required as he was so
poorly. His brother arrived at 2.00pm. His breathing was assisted by a
ventilator.
35. The man’s brother returned to the hospital at 7.15am the following morning as
his brother’s condition had worsened. At 4.50pm, the man’s brother asked if
the prison chaplain could come to the hospital. The man died at 1.20am, after
his ventilator was switched off.
36. The prison met the man’s brother and offered to contribute to the costs of the
funeral.
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ISSUES
Clinical care
37. The clinical review noted that:
“Although the man accepted treatment only intermittently he was
always offered medical care that was appropriate to his needs. When
he developed diabetes in 2006 and subsequent complications, the
health care team endeavoured to work with him proactively and
intensively.”
38. Therefore, the clinical reviewer’s overall opinion of the care the man received,
was that:
“In the opinion of the clinical review team, other than those areas
highlighted elsewhere in this report, the man received care that in the
main was equitable to that which he could have expected to have
received in the community.”
39. However, as noted, there were several aspects that the clinical review draws
attention to.
The advance directive
40. The clinical review report raised no concerns that the man was incapable of
deciding whether to implement an advance directive. The Head of Healthcare
at Belmarsh, explained this further to the investigator:
“ … all the way through the advanced directive, we went back and re-
tested the assumption that he had capability to consent to that process.
… And there was never any indication that that wasn’t anything other
than the case. The second element that you have to be able to
demonstrate within that process that the man was aware of the
implications of his decisions. And we did that through one of the GPs
who had a particularly good relationship with him. And she sat and
talked to him about the implications of having a blood sugar level of a
very high level for a long period of time and what that might do to his
eyesight and to the condition of his veins and arteries, in the most
minute detail. To make sure that he understood the implications of his
decision, and he did. So he had in place an advanced directive, which
was a document that he signed that was witnessed, and we dealt with
issues of capacity and issues of understanding.”
41. However, the clinical review does raise concerns that the staff involved in the
man’s care were not always aware of the conditions of the advance directive.
Despite the continuous efforts of the Head of Healthcare to share
understanding of the man’s situation, one element of confusion was caused
by the advance directive lapsing when he began to accept insulin treatment.
The Head of Healthcare commented that he frequently went to case
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conferences which said that the man was subject to an advance directive,
although it was actually invalid. The clinical review make the
recommendations which I include as:
There should be a policy for the development and management of
advanced directives. Training and support should be given to staff who
implement and manage advanced directives.
Managing the man’s diabetes
42. I am told that the man was not an easy prisoner to treat as he frequently
refused treatment. Despite this, I am satisfied that staff tried hard to engage
with him and ensure that he was always offered the appropriate treatment.
Also, it is pleasing to hear that the prison made practical adjustments to aid
his physical well-being such as providing him with a special mattress and
walking frame. However, the clinical review notes the opinion of the prison
doctor who said that staff required further training in the treatment of the
condition. I endorse the recommendation made by the clinical review team:
Healthcare staff should receive ongoing training and supervision in
chronic disease management such as diabetes.
Quality of healthcare records
43. The clinical review report says that the healthcare records were not always
legible, and were not always clearly dated and signed. This is an issue that
has appeared in many of the Ombudsman’s reports. Record keeping was not
helped by the lack of a computerised system at Belmarsh. I encourage the
Head of Healthcare to consider the recommendation made in the clinical
review regarding this issue. I make the following recommendation:
The Head of Healthcare should review record keeping and ensure that
records are consistent with the Nursing and Midwifery Council
guidelines.
Healthcare response on 17 October
44. The clinical review team consider that the man should have been assessed by
a doctor when he was first found at 00.20am on 17 October. This would have
advised healthcare staff on the most appropriate treatment of his symptoms
and declining health. Despite their judgement, the reviewers are satisfied
that, even if a doctor had been called, there is no certainty that the outcome
would have been any different. In response to the draft report, the Head of
Healthcare said:
“ … it is Belmarsh’s policy is to provide an immediate nursing
assessment and if necessary summon an emergency ambulance and
transport the patient to A&E.”
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45. The clinical reviewers describe the emergency clinical response at 8.45am as
reasonable and appropriate. The man was taken quickly to hospital.
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CONCLUSION
46. The man was serving a long sentence and clearly considered suicide at the
start of his time in custody. He did not follow these thoughts through, but did
refuse to accept treatment once he was diagnosed as suffering from diabetes.
The care of a prisoner suffering from a long term illness is challenging, and
this is made more so where the prisoner refused to accept treatment.
However, the report shows how the healthcare staff at Belmarsh consistently
tried to help him and encourage him to accept treatment. The use of an
advance directive over such a long time is unusual in a prison setting and the
findings of this case may be useful learning points for the service.
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RECOMMENDATIONS
1. There should be a policy for the development and management of advanced
directives. Training and support should be given to staff who implement and
manage advanced directives.
The National Offender Management Service partially accepted this recommendation:
“The management of a prisoner involving an advance directive is
extremely rare, if not unique. The management of the man presented
an immense challenge and in many ways was groundbreaking. Any
policy development and subsequent training and support must be
nationally coordinated.”
2. Healthcare staff should receive ongoing training and supervision in chronic
disease management such as diabetes.
The National Offender Management Service partially accepted this recommendation,
but wanted it to be more specific. I hope that the PCT and Head of Healthcare
continue to take this forward.
3. The Head of Healthcare should review record keeping and ensure that
records are consistent with the Nursing and Midwifery Council guidelines.
The National Offender Management Service accepted this recommendation:
“System 1 has been implemented as of May 2010, which significantly
addresses the concerns raised in the recommendation.”
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