Individual at Gloucester

Investigation into the circumstances surrounding
the death of a man
at a local Hospice
whilst in the custody of
HMP & YOI Gloucester in June 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2010
This is the report of an investigation into the circumstances surrounding the death of
a male prisoner at HMP & YOI Gloucester. The man died on 12 June 2010. A post
mortem showed that his death was caused by cancer.
I would like to offer my sincere sympathy and condolences to the man’s family for
their loss.
The investigation was carried out by an investigator from my office. Both he and I
would like to thank the Governor of Gloucester and all his staff for their full co-
operation during the course of our enquiries.
Gloucestershire Primary Care Trust (PCT) were commissioned to conduct a clinical
review of the healthcare the man received whilst in custody. I would like to thank
them for appointing a doctor from the local PCT as the clinical reviewer. I would like
to thank the clinical reviewer for his timely report.
As the man died from natural causes the findings of the clinical review play an
essential part of my report. I am pleased that the review shows that the man
received an exemplary standard of care. Neither I, nor the clinical reviewer, make
any recommendations but I do recognise the efforts made by the Governor to obtain
compassionate release for the man.
Thea Walton
Acting Deputy Prisons and Probation Ombudsman October 2010
2
CONTENTS
Summary 4
The investigation process 5
HMP Gloucester 6
Key findings 8
Issues 15
Conclusion 17
3
SUMMARY
On 9 June 1980 the man was convicted of murder and remanded into custody. He
was sentenced to life imprisonment on 19 June 1980. In the years that followed the
man moved to several establishments across the prison estate until he was
transferred HMP Gloucester on 20 January 2009. The man had a history of illicit
drug use whilst in custody.
A prison doctor saw the man on 2 February 2009 as he complained of rectal
bleeding. The doctor wanted to refer him to the specialist at the local hospital but the
man refused.
The man saw a prison doctor on 17 June, complaining of bleeding piles. He told the
doctor that he had experienced this off and on for the previous six months. The
doctor referred him to the hospital for further assessment.
Initial examination by a consultant colorectal surgeon at the local hospital indicated
the likely presence of a malignant tumour in the rectum. A biopsy on 10 August,
confirmed that the man did have rectal cancer and he remained in hospital for
surgery.
The man was discharged from hospital back to Gloucester on 20 August. The
hospital precribed appropriate pain relief and made arrangements for the man to
have a course of chemotherapy treatment. However after only three sessions of
chemotherapy the man refused any further treatment.
On 12 February 2010, the man was referred back to the hospital as he had
complained of worsening abdominal pain and vomiting. Further tests were
undertaken which confirmed the man had cancer in the liver and lungs. He was
offered further chemotherapy but he refused.
The man was admitted to the local hospice on 11 April to receive pain relief
management. He returned to Gloucester on 10 May but refused to stay in the
healthcare centre as it operates a no smoking policy. The man insisted he return to
his original wing (where smoking is allowed in designated cells).
On 1 June, a nurse saw the man as he felt his pain relief was not effective. He was
admitted to the local hospice two days later. His condition deteriorated and he died
on 12 June.
The prison followed the guidance given in Prison Service Order (PSO) 2710, “Follow
up to death in custody” maintaining contact with the man’s family and offering
assistance towards the funeral expenses.
I am satisfied that the care and attention the man received at Gloucester was
equitable to what he could have expected to receive in the community. I recognise
the good practice in family liaison, the effective and sensitive assessment of the use
of restraints and the efforts made to attempt to obtain compassionate release.
4
THE INVESTIGATION PROCESS
1. I appointed an investigator to investigate the man’s death on 12 June 2010.
Notices were issued to staff and prisoners, inviting those who wished to submit
information relating to the man’s death to make themselves known to the
investigator, however no one came forward.
2. The investigator visited Gloucester on 24 June to collect copies of relevant
documentation relating to the man. The investigator also saw where the man
lived during his time at the prison. In addition the investigator met with a
member of the Independent Monitoring Board (IMB) who wished to have
placed on record the recognition of the efforts made by the Governor and his
staff in attempting to obtain compassionate release for the man and the care
that he received during his time at Gloucester.
3. The Chief Executive of Gloucester Primary Care Trust (PCT) commissioned a
doctor to review the man’s clinical care. The investigator and the clinical
reviewer discussed the man’s care. I am grateful to the clinical reviewer for his
timely report.
4. The investigator contacted Her Majesty’s Coroner for Gloucestershire, to
inform him of the nature and scope of my investigation and request a copy of
the post mortem report. Upon completion, the investigation report will be sent
to the Coroner to assist with his enquiries into the man’s death.
5. One of my family liaison officers contacted the man’s sister at the beginning of
the investigation and offered the opportunity to raise questions and concerns
for consideration. The man’s sister did not formally raise any issues for the
investigation to consider in regards to the care her brother received in prison. I
hope this report offers more insight of the events leading to her brothers death.
At the consultation stage of the report the man’s sister, wished it noted within
the report that she disagrees with certain points as outlined in the report. The
man’s sister found it very distressing and upsetting to be asked to look after her
terminally ill brother. She also wished it noted it was her belief that due to the
length of time her brother had been in custody he should have been released.
She found the security arrangements that were in place whilst he received care
outside of prison ultimately resulted in additional upset and distress being
caused to her. She also stated that she felt the way her brother’s belongings
were returned in prison service bags was insensitive. The investigation found
that HMP Gloucester appropriately followed PSO 2710 ‘Follow up to death in
custody’, which included the return of the man’s belongings.
5
HMP & YOI Gloucester
6. HMP& YOI Gloucester is an adult male prison and young offender remand
centre. It is an old Victorian prison in the centre of Gloucester and has an
operational capacity of 315 prisoners. Part of the accommodation dates back
to the eighteenth century. The prison is established to serve the Crown Courts
of Gloucester and Hereford together with the associated magistrates’ courts.
In practice, prisoners come to HMP Gloucester from a far wider area.
7. Gloucester provides 24 hour healthcare cover with inpatient facilities for eight
prisoners. At night healthcare is staffed by nurses supported by on call
doctors. Healthcare is located in a separate two-storey building, equipped by
Gloucestershire PCT. It has an assessment and treatment unit, including the
inpatient facilities upstairs, outpatient facilities downstairs, and a hot food
servery for inpatients.
8. HM Chief Inspector of Prisons last conducted an announced inspection of the
prison in April 2007. The Chief Inspector noted that the prison was “safe and
respectful” and that the health services that were provided “were good”.
9. The Independent Monitoring Board (IMB) (a body of local people who
independently monitor and report on the prison) monitors day-to-day prison life
to ensure proper standards of care and decency for all prisoners. In their
latest annual report for the period ending November 2009, the IMB at
Gloucester made the following comments regarding healthcare:
“The progress and work of the Healthcare and Primary Mental Health
teams have been acknowledged by awards from the local Criminal Justice
Board and the winning of the Chief Executive’s award for 2009. The low
incidence of Swine Flu in the prison, only 2 suspected cases up to the end
of the report year, is attributable to a rigorous and well promoted
awareness and hygiene campaign.
“The concern over GP access and waiting times, expressed in last year’s
report, has been allayed: an audit in the 2nd quarter of 2009 showed
waiting times less than 24 hours.
“In line with the increase of prisoners over 50 in HMP Gloucester – there
were 40 of them on a spot check - an Older Man’s Care Pathway has
been introduced (a plan that is adapted to the particular needs of
individual older prisoners, both in prison and on release).
“HMP Gloucester is the first prison in the area to take part in the
‘Productive Community Workplace’ project, part of the productive
community hospital programme looking at working efficiency. This
showed that the healthcare team spend a higher proportion of their time in
direct patient care than local community hospitals (32% am; 25% pm).
This is all the more encouraging as there is a lack of space for 1:1
contact.”
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10. On each occasion a prisoner is escorted outside of the prison to hospital a risk
assessment is completed which considers the risk to the public, potential for
escape and likelihood of outside assistance. The assessment informs the
decision about the number of escorting officers and the type of restraint to be
used (single cuffs or two metre long escort chain with cuff at either end). It
also determines the circumstances and the authority required for the restraints
to be removed. The risk assessment is reviewed each day that a prisoner is in
hospital and amended where necessary.
11. Early release on compassionate grounds is subject to the instructions
contained in Prison Service Order (PSO) 6000 which states that:
“Early release may be considered where a prisoner is suffering from a
terminal illness and death is likely to occur soon. There are no set time
limits, but three months may be considered to be an appropriate period. It
is therefore essential to try to obtain a clear medical opinion on the likely
life expectancy. The Secretary of State will also need to be satisfied that
the risk of re-offending is past and that there are adequate arrangements
for the prisoner’s care and treatment outside prison.”
12. Since the Ombudsman office took over responsibility in 2004 for investigating
all deaths in custody, there had been eight deaths at Gloucester prior to that of
the man. Five of these were apparently self inflicted with the others attributed
to natural causes. There are no similarities between the previous natural
cause deaths and the man’s death.
7
KEY EVENTS
13. In June 1980 the man was convicted of murder and remanded into HMP
Wandsworth. He was sentenced to life imprisonment in June 1980.
14. In the years that followed the man moved to several establishments across the
prison estate until he was transferred HMP Gloucester on 20 January 2009.
The man had a history of illicit drug use whilst in custody.
15. On arrival at Gloucester the man saw a nurse who conducted an initial
healthscreen check. The man told the nurse that he had taken heroin within
the previous 24 hours. The nurse did a urine test which was positive and
referred the man to the detoxification (detox) team (specialised team dedicated
to provide treatment and support to prisoners withdrawing from drugs or
alcohol). The nurse also recorded that from his medical records the man had
both Hepatitis B and Hepatitis C but had refused to have any treatment. The
nurse also noted that the man had been previously prescribed tramadol (for
moderate pain relief) for arthritic pain in his knees.
16. The next day the man saw an unidentified member of the detox team who
placed the man on a Subutex detoxification programme. This was reviewed
by a prison doctor, on 29 January who agreed with the man a reduction in the
amount of Subutex (for drug withdrawal) every four days.
17. Another prison doctor, saw the man on 2 February as he was experiencing
rectal bleeding. The doctor wanted to refer the man to the specialist at the
local hospital but he refused. Despite the doctor’s explanation for the referral
and encouragement to seek further medical assistance the man signed a
disclaimer stating that he refused further treatment. The doctor referred the
man to the Mental Health Team.
18. On 13 February, a nurse from the Mental Health Team, (that conducted his
initial screening) saw the man in his cell. He told the nurse that he had been in
prison for 30 years and just wanted to sit in a corner, read his book and mind
his own business. He told the nurse that occasionally arthritis flared up in his
knees and tramadol was the only drug he would take for the pain, he also
wanted to avoid taking any antidepressants.
19. The nurse saw the man two weeks later. He told the nurse that the reason
that he refused to attend the hospital was due to the personal nature of the
examination. He reiterated his refusal of any further treatment.
20. On 4 March, the man saw a doctor as he complained of pain in his knees and
shoulder. The doctor prescribed tramadol at 100mg. Eight days later the
doctor, saw the man to review the level of pain relief. The man said that he
was still in pain so the doctor increased the prescription of tramadol to 200mg.
8
21. The doctor saw the man again on 9 April to review his pain relief. The doctor
discussed with the man the benefits of physiotherapy but he said that he did
not feel that he needed any at that time. The doctor made no changes to the
man’s medication.
22. On 13 May, the nurse that did his initial screening saw the man for a mental
health review. The nurse recorded that there were no causes for concern and
no mental health issues therefore the man was discharged from the Mental
Health Team caseload.
23. Two weeks later the man saw another prison doctor, as he complained of
bleeding piles. He told the doctor that he had experienced this off and on for
the previous six months. The doctor also recorded that the man had varicose
veins in his right leg. The doctor saw the man again on 17 June, and as he
presented with the same symptoms, the doctor referred him to the hospital for
further assessment.
24. As a result of the referral the man saw a consultant colorectal surgeon, at the
Gloucestershire Royal Hospital (GRH) on 9 July. A risk assessment was
completed which authorised an escort by two officers and the use of the long
escort chain which was to be removed for treatment purposes as directed by
hospital staff. Following his initial examination the consultant arranged for the
man to have a flexible sigmoidoscopy (telescopic visualisation of the lower
bowel). This was carried out on 23 July and the procedure indicated the likely
presence of a malignant tumour in the rectum.
25. The man was admitted to hospital on 10 August for a biopsy with the same risk
assessment arrangements put in place. The biopsy confirmed that the man
did have rectal cancer and he remained in hospital for treatment. The
consultant colorectal surgeon recommended that, due to the nature of the
cancer, an anterior resection (part or whole removal of the bowel) was needed
along with an ileostomy (surgically-created opening in the large intestine that
allows the removal of faeces out of the body, bypassing the rectum, to drain
into a stoma bag or other collection device).
26. Following the surgery the man was discharged from hospital back to
Gloucester on 20 August. The hospital precribed methadone for pain relief
and made arrangements for the man to have a course of chemotherapy
treatment after he had received treatment for Hepatitis. A care plan was put in
place to meet his needs which included regular observations to ensure
appropriate pain relief management, dietry intake, and other personal needs.
27. Between 21 August and 5 October, the man had regular medical interventions
with prison doctors and healthcare staff. There were no additional concerns
raised during this period, although the man said that he had reservations about
having the chemotherapy treatment.
28. On 6 October, a nurse saw the man to discuss the proposed chemotherapy
treatment. The man said that he was concerned about the side effects. The
nurse discussed with him the treatment and the plan for his treatment following
9
his chemotherapy session. This included his medication to be administered to
him in his cell for four days, the correct procedure for the disposal of his stoma
bags and a light diet of his choice. The man wished to have toast with either
beans or scrambled egg. He also told the nurse that he did worry about the
pain he might endure as time went by but would not consider taking his own
life.
29. Three days later the man went to the GRH as an outpatient for his first session
of chemotherapy. A risk assessment was completed which authorised an
escort by two officers and the use of the long escort chain which was to be
removed for treatment purposes as directed by hospital staff.
30. From 10 October to 29 October, the man continued to have regular
interventions with healthcare staff. He told the Nurse that he had previously
seen to discuss his chemotherapy treatment that he did not wish to continue
with the chemotherapy treatment and would refuse to go to the hospital. It
was explained to the man the importance of the treatment and he should
attend the hospital appointment and, once he had talked it through with the
hospital doctor, he could still exercise his right to decline treatment. The nurse
made arrangements to accompany the man when he went for his appointment
and he appreciated this.
31. The man saw a Consultant Clinical Oncologist, at a local hospital on 30
October, accompanied by the nurse he had previously seen to discuss his
chemotherapy treatment and the escorting officers. (A risk assessment was
completed which authorised an escort by two officers and the use of the long
escort chain which was to be removed for treatment purposes as directed by
hospital staff). At this consultation the man did agree to continue with his
chemotherapy treatment, however nine days later he changed his mind and
refused to continue with the treatment.
32. In the weeks that followed the man continued to receive frequent interventions
with healthcare staff. On the 15 December, the man sent a letter addressed to
the doctors and nurses at Gloucester in which he wrote:
“I would like to thank you all for helping me face up to my recent diagnosis
of bowel cancer, nursing me after my operation and generally putting up
with my moods and sulks.”
33. On 12 February 2010, the man was referred to the hospital by the doctor he
had previously seen on the 2 of February, as he had complained of worsening
abdominal pain and vomiting. The man attended the local hospital on 17
February. A risk assessment was completed which authorised an escort by
two officers and the use of the long escort chain which was to be removed for
treatment purposes. An abdominal ultrasound scan was conducted, the
results of which, indicated the possibility that the man’s cancer had spread.
34. The man attended the local hospital on 17 March for a computed tomography
(CT) scan (a medical imaging method created by computer processing). The
previous risk assessment conditions were applied. The results were examined
10
by his Consultant Clinical Oncologist who explained to the man that the cancer
had spread to his lungs and liver and that the prognosis was poor. The
consultant discussed the treatment options, but the man told the doctor that he
did not wish to have any palliative chemotherapy, even though this would
prolong his life. The consultant referred the man to another consultant a
Colorectal surgeon at the hospital that same day. The initial consualtant wrote
to healthcare at Gloucester to indicate the likely prognosis that the man had
six months to live, though his health could deteriorate rapidly.
35. As a result of that referral the man was admitted to the local hospital for further
surgery the following day. The same risk assessment conditions were applied.
Whilst he was in hospital the man was visited by healthcare staff.
36. On 22 March the Governing Governor chaired a meeting to discuss the man’s
care once he was discharged from hospital. Based on the Consultant Clinical
Oncologist prognosis that the man’s death was not iminent it was agreed that
when he was discharged from hospital he would be located in healthcare and
healthcare staff would actively seek a place in a hospice. The Governor said
that the current level of restraint would remain the same. A family liaison
officer was appointed by the prison.
37. The man returned to Gloucester on 24 March, and was seen by a prison
doctor. The doctor recorded that the man had made a good recovery following
surgery but he was still weak and debilitated. The man told the doctor that he
had six months to live as the cancer had spread to his lungs and liver. The
doctor prescribed clarithromycin (for cellulitis – skin infection), tramadol, and
increased the dosage of methadone (both for pain relief).
38. The same day the nurse that had previously discussed chemotherapy with him
contacted the man’s nominated next of kin, his sister as the man had given his
permission for the prison to inform her of his condition. His sister said that due
to her own ill health she would be unable to look after her brother if he was
released from custody. The nurse asked if the man’s sister had a preference
for a local hospice, if a place could be secured. His sister said that there was
a hospice near to where she lived.
39. Later that afternoon the nurse contacted the hospice near the man’s sister and
spoke to the Inpatient Manager. The hospice said that they did not accept
patients from out of the area.
40. The nurse saw the man on each of the next four consecutive days. The nurse,
in agreement with the doctor he has last seen, made a referral to palliative
services at the the local Hospice and the community palliative care nurses.
The nurse recorded that the man’s operation wound had to be continually
cleaned and redressed. The nurse also contacted the man’s sister to give her
an update on his well-being.
41. The Governor chaired another review of the man’s care and well-being on 26
March. At this review it was decided, given the man’s condition, if he was to
go to outside hospital or hospice then no restraints would to be used. He
11
would be escorted by two officers to act as support to the man, liaison with the
prison and support to each other.
42. On 29 March a prison doctor that had previously seen him on the 17 June saw
the man to review his condition. The man told the doctor that he was still
getting pain despite being on methadone. The doctor prescribed an increase
in methadone, the addition of Oramorph (for severe pain), diazepam (for
insomnia) and another seven day course of clarithromycin.
43. The next day the man was visited by the community palliative care nurses who
also met with the doctor he had seen initially on the 2 February. The
community nurses offered advice on the man’s pain control, in particular,
ensuring that methadone was not given more frequently than every three
hours.
44. Over the next eleven days the man received regular interventions from
healthcare staff. It was recorded that he still complained of pain despite
having taken the prescribed amount of pain relief. As a result of this the nurse
that initially discussed chemotherapy with the man contacted the local Hospice
to arrange admission for the man to receive pain relief management.
45. The man was admitted to the local Hospice on 11 April. He was escorted by
two officers but no restraints were used. A nurse contacted the man’s sister to
inform her of his admission to the hospice. His sister visited him later that day.
In the days that followed healthcare staff visited the man in the hospice as well
as visits made by his sister.
46. On the 14 April, the Governor of Gloucester chaired a further review of the
man’s condition. At this meeting it was recorded that the hospice near his
family was unable to offer a place, and that the local Hospice would not give
permission for their address to be given as a discharge address for the
compassionate release application. Also as the man’s sister was unable to
look after him, due to ill health, compassionate release was no longer an
option. It was agreed that when the man was discharged from the hospice he
would be located in healthcare. A special mattress and air flow pillows were
obtained to make him more comfortable.
47. The Healthcare Manager contacted the local Hospice to check on the man’s
progress and the potential date of return to the prison. A hospice doctor said
that the man would return to Gloucester on 10 May.
48. The man returned to Gloucester on 10 May. The doctor provided the prison
with the detail of the man’s discharge medication which was as follows:
(cid:127) paracetemol
(cid:127) lansoprazole (for gastric acid)
(cid:127) diazepam (for insomnia and muscle spasms)
(cid:127) zopiclone (for insomnia)
(cid:127) cyclizine (for nausea, vomiting and dizziness)
(cid:127) methadone (for pain control)
(cid:127) dexamethasone (anti-inflammatory and immunosuppressant)
12
(cid:127) nortriptyline (antidepressant)
(cid:127) simple linctus (for throat & chest)
49. The Healthcare Manager, the prison’s family liaison officer and a Principal
Officer (PO) met with the man to explain the management of his care now that
he had returned from the hospice. The man refused to be located in the
healthcare centre as it had a no smoking policy. The man initially agreed to a
compromise where by he would spend his daylight hours on C wing with his
friends and peers, and then he would spend the night hours in a cell on A wing
so that healthcare staff could easily be available to meet his night time pain
control needs. A care plan was put in place to meet the man’s needs and he
was happy with this.
50. That evening, however, the man refused to go to A wing as previously agreed.
The next morning the Healthcare Manager, the prison’s family liaison officer
and the PO met with the man to listen to his concerns for not spending the
night on A wing. The man said that he “wanted to stay where he was”. It was
agreed that that he could remain on C wing and that he would be checked
hourly by wing staff throughout the day and night. The man accepted that this
arrangement would mean that there would be a small delay in nurses
responding to any request for pain relief medication. It was stressed to the
man that the arrangement for him remaining on C wing would be regularly
reviewed and he accepted this.
51. The same day the prison’s family liaison officer contacted the man’s sister,
who confirmed that she would still act as his next of kin. It was agreed that in
the event of her brother’s death occurring between the hours of 10.00pm and
7.00am they would not to be contact her until later the following morning.
52. From 12 May to 31 May, the man received care from healthcare staff through
the day and night as required. His pain relief management was also reviewed
by prison doctors and the community palliative care nurses. During this period
the man was mobile and able to attend to his own personal needs.
53. On 1 June, the man saw a nurse as he complained that this pain relief was not
effective. He told the nurse that he was pain free for ten to fifteen minutes
before he required top up medication. The nurse contacted a doctor at the
local Hospice who advised an increase in the prescribed nortriptyline and said
that a place for the man could be available in two days if required. The nurse
also contacted the community palliative care team to discuss the man’s
ongoing care and it was agreed that a place at the hospice was appropriate.
54. The next day the Governor wrote to the local Hospice to outline that due to the
man’s condition he posed no risk to the public. The Governor also confirmed
that if the man was located in the hospice he would be accompanied by a
single officer whose role was to offer support to the man and not for security
purposes. The Governor explained that as the man was a life sentence
prisoner it was not within his authority, as Governing Governor, to authorise
release on temporary licence.
13
55. The man was transferred to the local Hospice on 3 June. He was
accompanied by a single officer who was in plain clothes, as detailed in the
risk assessment authorised by the Governor. In the days that followed the
nurse he had seem about his pain relief regularly visited the man in the
hospice. Healthcare staff continued to attempt to secure a nursing home or
hospice place in north London without success.
56. By 8 June, the man’s condition had deteriorated and he had become
unconscious. The nurse that he had seen about pain relief contacted the
man’s sister to inform her of her brother’s condition, and she visited later that
day accompanied by his nephew.
57. On 12 June, a Nurse from the local Hospice, called Gloucester to say that at
7.00pm the man had died and his death had been certified by the doctor. Staff
at the hospice had already contacted the man’s sister to inform her of his
death.
58. In the days that followed the prison’s family liaison officer maintained regular
contact with the man’s sister to offer support and assist with organising the
funeral arrangements, which was held in the area where the man’s family
lived. Financial assistance was offered towards funeral expenses.
14
ISSUES
Clinical care
59. Both the clinical reviewer and I are satisfied that the care the man received
was equitable to what he could have expected in the community. The clinical
review makes the following comments regarding the man’s clinical care:
“It is clear that the man had an aggressive Carcinoma of the rectum.
There may have been a delay of up to 2 years before he revealed his
symptoms of rectal bleeding, there was certainly a delay of 6 months while
he initially refused to attend a Specialist appointment, and the man also
declined chemotherapy at an early stage. Whilst all of these factors may
have contributed to the failure to cure the problem, the rapid progression
of the disease suggests that the outcome was (with hindsight) likely to be
poor.
“Following the diagnosis of terminal cancer specialist care teams were
recruited and used extensively, and it is clear from the records that much
effort was made by the prison healthcare team to ensure the man was
given the best care possible during his final weeks of life.
“In my opinion the medical and nursing care given to the man throughout
his illness was exemplary.””
I am pleased that the prison made all the arrangements necessary for the
man to receive the specialist care that he required.
Use of restraints
60. Unfortunately there have been too many reports in which the Ombudsman has
criticised the use of restraints when prisoners are in hospital outside of the
prison. It is pleasing therefore to recognise the good practice adopted by
Gloucester. I believe that the Governing Governor effectively and sensitively
assessed the use of restraints and put minimum levels in place. This ensured
that the man was treated with dignity and respect during both his treatment
and his last days.
Compassionate release
61. I do recognise the efforts made by the Governing Governor and his staff in
their attempts to facilitate compassionate release for the man. As a discharge
address could not be obtained either locally or near to the man’s family a
compassionate release application could not be submitted. In addition as the
man was a life sentence prisoner he could not be considered for release on
temporary licence. I do believe that the Governing Governor did everything
possible within his authority to assist the man.
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Family liaison
62. I also recognise the work as the prison’s family liaison officer when the man
was diagnosed as terminally ill. I also recognise the work of the Nurse that
had initially discussed chemotherapy with the man who supported both the
man and his sister. By appointing a family liaison officer to keep in touch with
the man’s sister at the end of his life, I believe that the prison exceeded the
guidance given in PSO 2710, “Follow up to death in custody”. It is good
practice for family liaison officers to be appointed for the families of all
terminally ill prisoners and I commend Gloucester for their initiative. The
man’s sister told my family liaison officer, that she was thankful for the care
provided by the local Hospice.
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Conclusion
63. During his time at Gloucester, the man had regular contact with healthcare
staff and doctors which was well documented. I believe that the care the man
received was of a good standard and was well co-ordinated with the hospital
and the hospice. I judge that it was equitable to what he could have expected
in the community. The clinical review confirms that his medical treatment was
appropriate and that his death could not have been prevented.
64. I recognise the good practice adopted by Gloucester in the effective and
sensitive assessment of the use of restraints, the early appointment of a family
liaison officer and the efforts made in the attempt to obtain compassionate
release.
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