Individual at Frankland

Investigation into the circumstances surrounding the
death of a man at HMP Frankland
in November 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2011
This is the report of an investigation into the death of a man, a prisoner at HMP
Frankland. He died in his sleep in November 2009, following a lengthy period of
illness. He was 62 years old.
I offer my sympathy and condolences to the man’s son and daughter. I am pleased
that they were able to visit their father shortly before he died, as he had previously
chosen to limit contact with his family. I apologise for the delay in issuing this report
and for any additional distress caused.
An investigator carried out the investigation on my behalf. A review of the man’s
medical care in prison was carried out by a clinical reviewer on behalf of the local
Primary Care Trust. I am grateful to her for her assistance. I would also like to thank
the Governor and staff at Frankland for their help during the investigation.
The man had been in prison for nearly 23 years. He chose to have limited contact
with others, including healthcare staff for the majority of his time in custody. Staff
first noticed that he was unwell in May 2009, but he refused to go to hospital for any
treatment. A post mortem examination confirmed the cause of his death as
ischaemic heart disease and an underlying coronary artery atheroma. He was also
found to have diverticular disease and colonic fistulae.
The clinical reviewer concludes that, whilst he was challenging to care for in the last
months of his life, staff were dedicated to making him comfortable. I, too, note the
care taken by healthcare staff to manage his medical condition over a considerable
period and acknowledge their dedication in spite of his lack of cooperation.
I judge that his death could not have been prevented given his reluctance to be
treated and that the care given by staff was at least to the standard a person would
expect to receive outside of prison. However, I endorse three recommendations by
the clinical reviewer concerning adherence to policies relating to assessing mental
capacity, treatment of pressure sores and record keeping.
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 June 2011
2
CONTENTS
Summary
The investigation process
HMP Frankland
Key events
Issues
Conclusion
Recommendations
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SUMMARY
The man was convicted on 16 February 1987 and sentenced to life imprisonment.
He spent time in several prisons before moving to Frankland. He had little contact
with healthcare staff until May 2009, when they became concerned about his health
and his unwillingness to engage with them. After initially refusing over two weeks to
allow the doctor to examine him, he agreed to an examination in mid-June. He had
a large swelling below the umbilicus (navel), which he said had been present for
several months. They immediately arranged for him to be taken to hospital as an
emergency admission, where he was x-rayed. He discharged himself the following
day. On his return to Frankland, staff advised him on several occasions that his
condition was potentially serious and needed further investigation. However, he
declined to go to hospital.
His refusal of treatment led to staff monitoring him under the suicide and self-harm
prevention provisions for nine days in June. It was stopped as he agreed to remain
resident in the healthcare centre and accept nursing care and assistance.
In August, he agreed to go to hospital for a scan. It showed that he was probably
suffering from inflammatory bowel disease but the consultant would need to see him
again. He subsequently refused to see the consultant to discuss the diagnosis.
In October, one of the prison doctors was concerned about his mental state. An
attempt was made to carry out a dementia screen but he would not cooperate. A
few days later, arrangements were made for him to be examined by a consultant
forensic psychiatrist but he again declined to allow this.
Doctors and healthcare staff told him several times that he probably had cancer and
needed treatment in hospital but each time he declined medical intervention.
Towards the end of October, he agreed to go to hospital. However, he discharged
himself the following day, despite being told by the consultant that his condition
would deteriorate and his prognosis was poor. Doctors in Frankland reinforced this
message. He repeatedly made it clear that that he did not wish to go to hospital and
continued to refuse treatment.
During the evening of 9 November, a nurse noticed that he had not moved since he
had checked him half an hour earlier. When clinical and discipline staff went into the
cell, they found no signs of life. Around an hour and a half later, an out of hours
doctor confirmed that he had died. The news was broken to his family that night. A
debrief was held and staff were offered support. A post mortem subsequently
showed the cause of death as ischaemic heart disease and an underlying coronary
artery atheroma.
I am satisfied that his death could not have been prevented, particularly as he
refused to accept treatment. However, I make three recommendations in respect of
procedural weaknesses identified by the clinical reviewer. They are to ensure that
clinical staff follow guidance in respect of mental capacity assessments and the
treatment of pressure sores as well as maintaining a complete record of all of their
discussions and actions.
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THE INVESTIGATION PROCESS
1. The man died in November 2009. Notices were issued to staff and prisoners
to inform them of the investigation process and give them the opportunity to
speak with the investigator. In the event, no one responded.
2. The local PCT commissioned a review of the man’s clinical care and
treatment at Frankland on my behalf. I am grateful to the clinical reviewer for
her report.
3. She spoke to the investigator at the start of the review. She examined the
medical records, including those on the computerised system. They both
jointly interviewed a number of staff during a visit to Frankland on 7 June.
4. Given that the man spent many years in prison, I have taken the decision not
to investigate events over the whole of his sentence. My report focuses on
the period from mid 2009 when concern was first expressed about his
physical health.
5. One of my family liaison officers made several attempts by telephone and in
writing, to contact the man’s daughter, his next of kin. After the investigation
had been completed, it came to light that his daughter had moved house and
the correspondence had not been forwarded to her until October 2010.
6. After reading the draft report, the family contacted to make two points:
(cid:127) A diagnosis of mental illness was made very early in his prison
sentence. However, they feel this was never sufficiently followed up.
They acknowledge their father could be difficult and disengaged but
questioned the correlation between his behaviour and his mental
health. They understand this matter is not directly linked with the
circumstances of their father’s death but they are deeply concerned by
what they believe was a failure by the authorities to provide appropriate
mental health intervention.
(cid:127) The family would like to have been able to re-establish contact with
their father at a much earlier stage. Then they could have provided a
valuable source of support for their father. The daughter wrote to the
prison in June 2009 asking for information about her father’s health.
She was upset to receive a brief response suggesting she would have
to take this up with her father directly. She later found out he was in
the infirmary at the time and not able to respond himself. She felt that
had staff checked his records, they would have seen that he had
received no visits for years. This could have been an opportunity to
establish contact with his family when his health was in decline. She
feels that staff could have let her know, without betraying any medical
confidence, that her father’s health was poor.
5
HMP FRANKLAND
7. HMP Frankland is one of eight maximum security prisons in England and
Wales. Frankland holds convicted category A and B adult male prisoners, as
well as high risk remand prisoners. On arrival in prison, prisoners are risk
assessed and given a category based on their offence and the risk that they
pose to the public should they escape. There are four categories: A, B, C and
D. Category A are prisoners whose escape would be highly dangerous to the
public or the police or to the security of the state. Category B are prisoners
for whom the highest security conditions are not necessary but for whom
escape must be made very difficult. The operational capacity of the prison is
859.
8. Healthcare services at Frankland are provided by the local Primary Care
Trust. The healthcare centre provides 24 hour inpatient care, consisting of
two wards with capacity for four and three prisoners respectively and ten
furnished rooms. The man lived in one of these rooms for the last months of
his life.
9. The most recent full inspection of Frankland by HM Chief Inspector of Prisons,
dated February 2008, describes the prison as “drifting in some key areas,
notably in relation to safety with a lack of evidence of a robust reduction
strategy and effective staff-prisoner relationships”.
10. In regard to the healthcare unit and caring for the health of prisoners, the
inspection found that healthcare services were, in general, good although
staffing levels were low. The inpatient unit was a good environment and
patients were well cared for, although a new day centre to support mentally ill
prisoners was much needed. There was excellent collaborative work between
the local Primary Care Trust and the prison, with prisoners able to access
equitable NHS services whilst in prison.
11. All prisons in England and Wales have an Independent Monitoring Board
(IMB). IMB members are volunteers who monitor day-to-day life in the prison
to help ensure proper standards of care and decency are maintained. The
Board’s report for the year 2008 to 2009 does not contain any issues which
are relevant to the circumstances of the man’s death.
12. Since my office took responsibility in 2004 for investigating deaths in prison
custody, there have been a number of deaths at Frankland which are
attributed to natural causes including the man’s death. The circumstances of
his death are different to those previously investigated but there are similar
themes.
6
KEY EVENTS
13. The man was born in 1947 and brought up in Cheshire. He was the second
youngest of six but also had five half-siblings from both of his parents’
previous marriages. His mother committed suicide when he was 15 years old.
He joined the army at the age of 20 where he remained for three years. He
married whilst he was in the army. He and his wife had a son and a daughter
but decided to separate in 1985 and subsequently divorced. In 1976 he
established his own property repair business which he ran for ten years
before getting into financial difficulties.
14. A few months before he committed his offence, he was assessed by a
psychiatrist who suggested that the appointments should continue, but he
declined. After his trial, a consultant forensic psychiatrist diagnosed that he
was mentally ill and recommended that he should be transferred to a high
security psychiatric hospital, but this was later withdrawn.
15. He was convicted of murder and sentenced to life imprisonment by a Crown
Court on 16 February 1987. He was initially detained at HMP Manchester
(then called Strangeways) and spent short periods in a number of prisons
before transferring to HMP Frankland in February 1992. He isolated himself
from staff and other prisoners. On several occasions staff expressed concern
about his mental health but he declined to allow any assessments to be
made. He also regularly declined, most recently in 2008, to participate in
Parole Board hearings and Sentence Plan Boards or to cooperate with the
Probation Service in planning his future.
16. He had little contact with the healthcare department until May 2009, when
staff expressed concerns that he was neglecting his personal hygiene. Nurse
A told Prison Doctor A on 28 May that she was concerned as he appeared to
be unwell, losing weight and had bowel problems. When the doctor visited
him in his cell but he refused to be examined or be admitted to the healthcare
centre. He told the doctor that he had lots of problems but did not wish to
discuss them and had been feeling better in the last two days. The doctor
noted in the medical record that “The man did not mention any particular
problem, seemed to have mental capacity to make decisions, will refer to
Mental Health Team for assessment”. To assess mental capacity, the
individual is initially asked a series of simple questions to establish whether
their level of awareness regarding who and where they are, their condition
and treatment etc. Depending on their response, a more formal assessment
would then be made.
17. Nurse B wrote to the man on 29 May to tell him that staff were concerned
about his health and his refusal of treatment. He reminded him that a note he
had written previously, saying that he would not wish to be resuscitated in the
event of collapsing, was not legal and would need to be validated by a
solicitor. He was told that, in these circumstances, staff would intervene and
provide treatment.
7
18. A week later, on 3 June, Nurse A visited him in his cell to weigh him. Staff
had reported that he appeared to have suffered further weight loss and were
concerned that he might be throwing away his meals. The staff also believed
that he had become incontinent. He allowed himself to be weighed (which
was 62kg) but was otherwise uncooperative about any further examination.
The medical record noted that, “I believe the man received a letter from the
mental health team wishing to discuss certain matters but he immediately put
it in the bin.” The nurse proposed that a member of the mental health team
(Nurse B) should visit him as she considered that he would not initiate any
contact with the team. (There is no record as to whether this visit took place.)
19. The following day, 4 June, he refused to go to the general practitioner (GP)
clinic, allow his blood pressure to be taken or give blood and stool samples.
He did not give a reason for refusing to cooperate with medical staff.
20. On 10 June, he asked to see a nurse as he was experiencing a lot of pain.
He was examined by Prison Doctor B in the healthcare wing and agreed to go
to hospital as an urgent admission. In her referral letter to the hospital of the
same day, she reported that he had previously declined any medical
intervention. He had lost significant amounts of weight and had a large
reddened and inflamed irregular swelling below the umbilicus (navel) which
was protruding on the abdominal wall, and he had told her had been present
for several months. He also had diarrhoea and blood in his faeces. She
suspected that he had a tumour.
21. He was admitted to hospital on 10 June. The consultant surgeon reported to
Frankland’s doctor that he was clinically anaemic and cachectic. (Anaemia is
the result of not having enough red blood cells in the blood. Cachectic is a
general physical wasting resulting from any debilitating chronic disease.) The
consultant radiologist confirmed that the x-ray of his chest showed that his
lungs were clear. However, the x-ray of his abdomen showed soft tissue
density in the pelvis above the abdomen which suggested erosion of the
sacroiliac joints bilaterally (that is wearing away of the joints in the pelvis
area). The radiologist recommended further investigation by way of a
computerised tomography (CT) scan of the abdomen or pelvis area. (A CT
scan uses x-rays and a computer to generate detailed images of the inside of
the body.)
22. The following day, 11 June, he discharged himself from hospital before the CT
scan could be taken. On return to Frankland, he was admitted to the
healthcare centre but discharged himself. He signed a statement that he did
not wish to have any nursing contact when he returned to the wing, his
decision was taken against the advice of nursing staff and he understood the
potential adverse consequences for his health. Nurse A told him that, if he
needed any assistance from her or any other nursing staff, he should let staff
on the wing know. He told her that he would not take up the offer.
23. Later that day, he fell when collecting his meal. The clinical record described
the injury as “a red area on his forehead”. He told staff that he had lost his
balance before falling. He declined the offer made by Nurse A to be admitted
8
to the healthcare centre, and again signed that he understood he was refusing
treatment against medical advice. He agreed to staff collecting and bringing
his meals for him. On the following day, the nurse visited him in his cell to
offer any help but he declined and told her to leave.
24. On 13 June, Officer A noticed that his condition appeared to have worsened.
Faecal fluid was running from the mass on his abdomen and he said he was
in pain. He agreed to go to the healthcare centre where he was examined by
Prison Doctor B, who prescribed codeine phosphate (a pain killer) and
domperidone (which regulates nausea and vomiting). The following day, he
refused to have the dressings changed on the open wound on his abdomen
and so dressings were left with him to use.
25. The next day, 14 June, staff put in place an Assessment, Care in Custody and
Teamwork (ACCT) plan because of his refusal to accept any treatment at
hospital or in the healthcare centre despite medical advice. (ACCT is used to
monitor and support prisoners assessed as at risk of suicide or self-harm.
Once placed on ACCT, the prisoner is subject to regular case reviews that will
decide the level of observations/conversations to be carried out at intervals
determined by their perceived level of risk.) As part of the process, staff were
required to conduct observations on him once an hour and have quality
conversations with him four times a day. An assessment interview took place
the following day, 15 June.
26. It is recorded in the medical note for 15 June that Prison Doctor B had tried to
explain to him about the result of the x-ray taken at hospital and that his
condition was potentially serious. He told the doctor that he believed he was
suffering from an abscess, although he also said it might be cancer. Nurse C,
Clinical Team Leader, and Nurse A spoke to him about returning to hospital
for further investigation of his abdomen. However, he refused and also
declined to remain in healthcare.
27. Nurse C led an ACCT case review on 16 June, which was attended by him
and Officer B. She recorded that he had been “admitted to healthcare for
observation and support due to his deteriorating condition”. She added that
he was very selective about accepting any care. Although he had accepted
help with some aspects, he refused any intervention from the doctor.
28. Over the next few days, nursing staff changed his dressing each day and
helped with his personal hygiene. He was offered but declined the
opportunity of a Macmillan nurse to visit him. (Macmillan nurses provide
support for people diagnosed with cancer.) He refused to allow Prison Doctor
B to examine him on 23 June. He told the nurses that he was aware that the
discharge from his abdomen was abnormal but did not want any treatment or
further input from the doctor. In regard to his mental state, the clinical record
shows “He appears to have the capacity to make this decision [to refuse
treatment] and can recall events from past conversations that we [with Nurse
C] have had”.
9
29. An ACCT review took place on 25 June. He was deemed not to have any
active thoughts of suicide or self-harm and had never expressed such
thoughts. He had accepted most of his care but continued to decline
treatment for or investigation of his condition. Detailed entries of events and
observations were made in the ACCT plan. The clinical record shows
“Appears to have the capacity to refuse treatment.” The ACCT was closed
and he remained in the healthcare centre to be “observed and supported”. A
post closure review of the ACCT took place on 2 July and it was recorded that
he continued to be nursed within the healthcare department.
30. On 7 July, Prison Doctor B told him that his diagnosis was unresolved and
therefore required further examination, but it was thought that he had cancer.
He refused to allow her to examine him on that occasion but did agree to be
examined when she saw him two weeks later on 21 July. A further reddened
small swelling was noted below the umbilicus cord. He was told that the
underlying lesion was serious and needed further treatment in hospital, which
he declined.
31. When seen by Nurse C on 25 July, he accepted that he would need treatment
in hospital and agreed to go there. He expressed anxiety about the number of
discipline staff who would be required to accompany him and was told it would
be the same as when he attended hospital on 10 June for an x-ray.
32. Prison Doctor B reviewed him on 28 July and a referral note was faxed to the
hospital on the same day. In her letter to the consultant surgeon, the doctor
asked whether arrangements for a CT scan could be fast tracked with
admission on the same day as she thought this would encourage him to agree
to treatment. She decided to see him again the following day as she had
been told by staff that he was non committal about having the CT scan and, if
required, an operation. He confirmed that he remembered speaking to her
the previous day and still wished to have treatment in hospital. As there had
been no response from the hospital by 5 August to the request for an urgent
scan, she asked staff to check progress with the hospital. The hospital
explained that the relevant staff were both on holiday.
33. He was checked by an out of hours doctor on 16 August as staff had reported
that he had not eaten anything over the past four days and had only drunk
minimal amounts of fluid. The doctor reported that he was stable, well
hydrated, not in any obvious discomfort and responded appropriately to
questions.
34. On 18 August, he appeared to staff to be in a lot of pain, but he denied this
and initially refused to see a doctor. Later in the day, he agreed to be
examined by Prison Doctor B who noted that the holes in his abdomen wall
continued to discharge faecal matter. He accepted codeine and
domperidone.
35. He was taken to hospital on 19 August for the CT scan. When the consultant
colorectal (bowel) surgeon contacted Frankland on 26 August to confirm that
the result of the scan was available, he refused to agree to see the consultant
10
either at hospital or Frankland. Instead, the consultant was asked to put the
results in writing.
36. On 1 September, he asked for medication to relieve abdominal pain. Pain
relieving medication (codeine and domperidone) was prescribed and he
continued to take the medication on most days afterwards. He refused to be
examined by Prison Doctor B on 7 September but agreed to see the
consultant colorectal surgeon provided that the appointment was not at a
meal time. The doctor broached the subject again with him on 9 September
as she had understood from staff that he had implied that he would not see
the consultant. He would not commit to seeing the consultant.
37. Healthcare Assistant (HCA) A noted on 12 September that he appeared a
little confused. He was not cooperative with Prison Doctor B when she tried
to examine him on 14 September. Later that day, he told Officer C he would
see the consultant colorectal surgeon at some point, and on 28 September
and 5 October told her he would see the consultant if he visited the prison, but
was not keen to go to hospital.
38. In the course of the doctor’s examination on 5 October, he told her that the
holes in his abdomen had been caused by being stabbed recently. She was
concerned about the comment and arranged for him to undertake a dementia
screen. Arrangements were made for Nurse A, who is a registered mental
health nurse, to conduct a “mini mental health test”. However, he refused to
complete the test as he did not want to recall certain earlier parts of his life.
The doctor researched his medical history in regard to previous mental
assessments. The record showed that in 1987, before his trial, there had
been some concern about his mental state but no mental disorder had been
diagnosed. After his trial, he was considered for transfer to a secure hospital
but his mental state was found to have stabilised. Further concerns about his
mental state were occasionally raised but the doctor did not identify any
further references after 1998. She recorded that she would discuss the
matter with the mental health team.
39. The consultant colorectal surgeon wrote to Frankland’s doctor on 6 October,
confirming that the CT scan (taken on 19 August) showed that the man was
probably suffering from inflammatory bowel disease and diverticular disease
(abnormal pouch in the colon) and that an underlying malignancy (cancer)
could not be ruled out. He added that it was difficult to be sure of the exact
cause of the problem and he would need to see him again.
40. Prison Doctor B saw him on 9 October as he had been vomiting during the
previous night. He told the doctor that he felt better and denied experiencing
any pain. He declined medication to treat nausea and told her that he did not
wish to see her again.
41. Following a review of his medical notes on 9 October, arrangements were
made for a psychiatrist to examine him. A consultant forensic psychiatrist
assessed him in Frankland on 15 October. He did not give straight answers
to questions from the psychiatrist and shouted and swore at him, before the
11
interview was terminated. The medical record notes “No evidence of formal
mental illness detected. No follow up required.”
42. Nurse C had a meeting on 20 October with a specialist palliative care
consultant and a palliative Macmillan care nurse. The palliative team noted
that there was no definitive diagnosis but nevertheless felt that, due to his
deteriorating condition, their services might be needed in the future. Nurse A
tried to assess his mental state but he told her that he was too tired to
cooperate.
43. The consultant colorectal surgeon saw him on 21 October and told him that
without surgery the outcome was poor. He said he would not agree to have
any surgery to his stomach. The consultant was asked to provide an early
written report.
44. Prison Doctor B told him on 26 October that surgery would help but he said he
was not interested in any further intervention. The doctor, with Officer D,
asked him whether he would wish to be resuscitated in the event of becoming
unconscious and he was adamant that he would not wish to be.
45. The following day, he was referred to the same doctor as he had fallen. He
refused to let her examine him in regard to the fall or go to hospital for
treatment of his abdominal problem. On 28 October, he was reviewed by
Prison Doctor C and confirmed that he did not wish any further medical
intervention. Nurse C contacted the Macmillan nurse to report on the man’s
general deterioration.
46. Prison Doctor A examined him on 29 October, though he was not keen to be
examined. He said that was in pain all over and agreed to be admitted to
hospital for treatment. The doctor spoke to a surgical registrar at the hospital
and they agreed that he should be urgently admitted to the accident and
emergency department. He was taken to hospital by ambulance later that
day. Whilst awaiting a CT scan, he accepted antibiotics and was given four
units of blood as he was anaemic.
47. The following day, he discharged himself from hospital. The consultant
general surgeon told him that without treatment the prognosis (likely outcome)
was poor. He replied that he understood the risk and did not want treatment.
It is noted in the clinical record that he was ”deemed competent by the team
and therefore discharged back to healthcare [Frankland]”.
48. In the course of giving him a shower on 31 October, the staff noticed that he
had a “small 5p size sacral [pressure] sore”. He initially refused any dressing
for the sore but agreed to one on 2 November.
49. On 2 November, he was noted to have a swollen left ankle and a lump on his
left hip. He refused to allow medical staff to examine him and was
aggressive, threatening to bite anyone who came near to him. The following
day, he asked to go to hospital but would not confirm that he would remain
12
there and Prison Doctor B was reluctant to refer him to hospital without an
assurance that he would accept treatment.
50. Prison Doctor A examined him on 4 November and discussed the
management of the pain he had been experiencing in his left hip and thigh
during the previous two days. He refused to go to hospital for an x-ray which
the doctor considered necessary to identify whether there had been any
injury. The doctor also raised the matter of treatment of the wound on his
abdomen, advising him that without treatment the wound would worsen. The
medical record shows “seems to be mentally competent to make decision,
refusing to go out for any further investigation and intervention”.
51. The Macmillan nurse and Nurse C spoke to him on 5 November. He refused
investigation or treatment and told them that he preferred to stay in healthcare
rather than go to hospital. The Macmillan nurse agreed to liaise with the
palliative care consultant regarding placing him on the end of life pathway.
(The purpose of the pathway is to provide high quality care for people
approaching the end of life.)
52. Prison Doctor A saw him twice on 7 November. The doctor told him that he
was probably suffering from abdominal cancer and that his condition would
deteriorate without treatment. The doctor asked him whether he would wish
to be resuscitated in the event of his heart stopping or if he stopped breathing.
He now said that he would wish to be resuscitated and the doctor informed
the governor of his wishes. (This was a change from his earlier wish not to be
resuscitated.) His son and daughter visited him which he appeared to
appreciate. They were upset about his long term prognosis, but thanked the
staff for the care which they were giving their father.
53. On 8 November, he appeared confused as to where he was, the time and
what he was doing. He gave incoherent answers to basic questions. He
cooperated with staff when they sought to make him comfortable in bed and
change his clothes.
54. The following day, he seemed to be confused and tired. He was seen twice
by Prison Doctor B and confirmed that he did not want to be admitted to
hospital. She discussed his deteriorating state with his daughter, who thought
that, if her father was not going to get better, then he should not be
resuscitated. In a subsequent conversation with the doctor, the daughter said
she was upset about having the responsibility for any decision regarding
resuscitation and might visit her father again as he had improved as a result
of her previous visit. The doctor explained that, medically, he did not meet the
criteria for resuscitation as he was unlikely to recover from his illness and was
not fit for surgery (which he had refused), which was the only treatment that
would help. The doctor signed a “Not for Resuscitation” document.
55. At 7.00pm, he was in a semi-conscious state and unable to talk or react to
being spoken to. Earlier in the day, he had been able to drink small amounts
of fluid but by the evening could not swallow sips of fluid or medication in
13
tablet form. Staff then decided to begin the end of life pathway, to ensure that
he was comfortable and was not in pain.
56. Nurse D started night duty at 7.15pm and took over from the day staff. He
told the investigating team that at approximately 7.30pm he carried out a
routine check of prisoners and the man “appeared to be asleep on his bed. I
did note some movement in him”. When he checked again at approximately
8.00pm, he noted that the man had not changed position from the previous
check. He summoned a colleague from the healthcare department, HCA B.
The HCA called for assistance from the principal officer acting as Oscar 1.
(Oscar 1 is the senior officer on duty who can be contacted by radio to
respond to emergencies.)
57. Nurse D told the investigating team that the Principal Officer, the Oscar 1
officer, arrived within two or three minutes of the call and unlocked the room.
The nurse went into the room with the HCA and, on checking him, found no
signs of life. The nurse confirmed that he was aware that the medical notes
stated that he should not be resuscitated. An out of hours doctor was called
who attended at 9.30pm and, after examining him, confirmed his death.
58. The family was told of his death later that evening. The family had expressed
a preference to be notified by telephone. The Macmillan nursing team was
informed the following morning. The prison paid for the funeral and their
family liaison officer attended with a colleague.
59. A debrief was held at 10.30pm and the prison care team was asked to provide
support for staff. Police attended Frankland and found nothing suspicious
about the death. A subsequent post mortem examination revealed the cause
of death to be ischaemic heart disease and an underlying coronary artery
atheroma.
14
ISSUES
60. The clinical review was conducted by a clinical reviewer on behalf of the local
Primary Care Trust. She identified areas where improvements to the delivery
of care could be made. She adds that it is important to note that there is no
reason to believe the issues she identifies in any way contributed to the death
of the man and she concludes that he received “much more care than he
would probably have accessed if living at home”.
Treatment of the man’s anaemia
61. The clinical reviewer was unable to find any evidence of his anaemia either
being treated or treatment discussed with him. She adds that effective
treatment might have resulted in him experiencing higher energy levels and
less confusion, dizziness and risk of falls. She asked Prison Doctor B
whether she had prescribed any medication to treat his anaemia. The doctor
recalled that she could not remember precise details of consultations and that
treatment might have been discussed. The doctor acknowledged that a
record was not kept and that, in the scheme of his overall condition, treating
his other conditions was more important but was still refused.
62. I endorse the following recommendation made by the clinical reviewer.
The Head of Healthcare should remind clinicians that all conversations
with patients about medication must be recorded in the clinical record,
even if the patient refuses the treatment proposed and it is subsequently
not prescribed.
Sacral (pressure) sores
63. The clinical reviewer reported that the PCT policies for the treatment of sacral
sores were not followed. (A sacral sore was seen on him when he was taking
a shower on 31 October 2009.) She asked Prison Doctor B whether she had
been asked to treat the sore. She replied “I might well have had it mentioned
in passing … I think their care [of pressure sores] is very good in healthcare”.
The Head of Healthcare told her that she was aware of the PCT policy for
dealing with pressure sores.
64. At interview, the clinical reviewer asked HCA A how the pressure sore had
been treated. She said “we used to wash it [the sore] and put a dressing on
and then our manager used to come and assess it”. The medical record
shows that he had refused a dressing on the sore when it was first identified
on 31 October but on 2 November had a dressing on his sacrum (the large
bone at the base of the spine).
65. The clinical reviewer asked her whether specialists would be engaged to deal
with the sore. She confirmed that would happen if the sore was “really bad,
but it wasn’t”.
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66. I endorse the following recommendation made by the clinical reviewer, slightly
recast.
The Head of Healthcare should put in place processes to ensure that
staff comply with the PCT policy for the Prevention and Treatment of
Pressure Ulcers.
Assessing the man’s mental capacity
67. The clinical reviewer considered that at no time was a formal assessment
made of his mental capacity to make a decision to refuse medical treatment.
She asked the Head of Healthcare whether there was a formal process for
assessing a person’s mental capacity. She confirmed that there was a
process and she described the procedure leading up to it. Initially the
prisoner would be asked simple questions to assess his awareness of where
he was and other general things. If there was a concern, there are more
stages which would be covered before going on to the formal assessment.
68. The clinical reviewer asked Prison Doctor B how she would assess a person’s
mental capacity. The doctor told her that she would make a preliminary
assessment to see if the prisoner understood. With regard to the man, the
doctor did not think that an assessment needed to be documented. She said
that mental health staff would undertake a more formal assessment.
69. The clinical reviewer noted that references had been made in the clinical
record indicating that he had the mental capacity to make decisions. Prison
Doctor B took several actions to have his mental capacity assessed (including
researching his medical history, asking the mental health team to carry out a
capacity assessment and a dementia screen and referring him to a
psychiatrist). However, the clinical reviewer considered that it would have
been beneficial for the healthcare team to have assured themselves of his
capacity through the use of the PCT policy procedures. She makes the
following recommendation which I endorse and slightly recast.
The Head of Healthcare should ensure that healthcare staff are aware of
their responsibilities in relation to the Mental Capacity Act 2005 and PCT
policy and that they assess prisoners appropriately.
Compassionate release
70. Prisoners can be released on compassionate grounds. This was not
considered for him and was not possible as there had been neither a formal
diagnosis, nor a firm prognosis of life expectancy.
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CONCLUSION
71. It appears that throughout the man’s 22 years in prison he isolated himself and
had little contact with others. In addition, he did not cooperate when medical
staff attempted to assess his mental state. He had been in prison for over 20
years when his health seriously declined. When he was told that he would
need to go to hospital for diagnosis and treatment, he persistently refused and
was aware his decision would probably lead to death. It is possible he had
given up on life; however he did accept a limited amount of nursing care in his
final weeks.
72. By all accounts, he was a difficult and challenging patient for the staff at
Frankland. Nevertheless, as my report shows, I have found that they made
great efforts to encourage him to accept treatment and make him comfortable.
Although the clinical reviewer has identified the need for improvements in some
clinical processes, I am satisfied that these omissions did not impact adversely
on the condition which led to his death.
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RECOMMENDATIONS
1. The Head of Healthcare should remind clinicians that all conversations with
patients about medication must be recorded in the clinical record, even if the
patient refuses the treatment proposed and it is subsequently not prescribed.
The recommendation was accepted. The response was:
“To be raised during the next full staff meeting on 22nd February 2011.”
2. The Head of Healthcare should put in place processes to ensure that staff comply
with the PCT policy for the Prevention and Treatment of Pressure Ulcers.
The recommendation was accepted. The response was:
“PCT Policy to be re circulated to all clinical staff for review and signing of reading
list.
Template for the assessment and treatment of Pressure Ulcers to be explored for
Systemone.” (SystmOne is a medical computer record system used by many
PCTs.)
3. The Head of Healthcare should ensure that healthcare staff are aware of their
responsibilities in relation to the Mental Capacity Act 2005 and PCT policy and
that they assess prisoners appropriately.
The recommendation was accepted. The response was:
“PCT Policy to be re circulated to all clinical staff for review and signing of reading
list.”
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