Individual at Frankland

Investigation into the circumstances surrounding the
death of a man, a prisoner at HMP Frankland, at hospital
in February 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2011
This is the report of an investigation into the death of a man, a prisoner at
HMP Frankland. He died in February 2010 at hospital, having been admitted
nearly two weeks earlier. He was 68 years old. His cause of death was found
to be acute bronchopneumonia. He was escorted by three officers and had
been restrained with an escort chain until ten minutes before he died.
I offer my sincere sympathy and condolences to the man’s family and all who
have been affected by his death. I am sorry that my report has been delayed
and regret any additional distress this may have caused.
The investigation was carried out by my colleague. 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 most grateful to her for her assistance.
I would also like to thank the Governor and staff of Frankland for their full and
ready co-operation during the course of the investigation. My particular
thanks go to the member of staff in the Business Unit for her work in liaising
with the investigator.
By the time the man arrived at Frankland in 2003 he had been diagnosed with
a number of medical conditions. He suffered from painful leg ulcers during
the majority of his time at the prison. Although he did not always comply with
his treatment plan, the clinical reviewer concludes that he was treated
appropriately. The report makes three recommendations for healthcare.
The man was convicted of serious offences. However, he was very poorly
during his last stay in hospital and could not move about on his own. For the
chain to have been removed at such a late stage is, in my mind, undignified
and I recommend that the Governor give greater weight to a prisoner’s
mobility when deciding what restraints are required.
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 February 2011
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CONTENTS
Summary
The investigation process
HMP Frankland
Key findings
Issues
Family response to the draft report
Conclusion
Recommendations
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SUMMARY
The man arrived at HMP Frankland in July 2003. He had already served
nearly 20 years in prison, considerably longer than his seven year tariff (the
minimum time that a life sentence prisoner must serve before release can be
considered). He had a number of medical conditions, including high blood
pressure, asthma and diabetes. He had also developed an ulcer on his lower
left leg. The clinical reviewer describes this as his “most significant and
enduring health problem” for the remaining six and a half years of his life.
A year after his arrival, the man was selected for the dangerous or severe
personality disorder (DSPD) programme at Frankland. He therefore moved to
the Westgate Unit, a specialist unit in the prison for the assessment and
treatment of prisoners deemed suitable for the programme. During his time
on the Westgate Unit, staff continued to manage his leg ulcer, which
eventually healed in late 2006.
The leg ulcer recurred in January 2008 and healed around six months later.
In May 2009, he was removed from the DSPD programme, and moved from
the Westgate Unit to a standard prison wing. In early June, his leg ulcer
recurred for a third time. It had not healed before his death eight months
later.
In the last week of January 2010, healthcare staff were called to the wing to
see the man on three occasions. On the first of these occasions he had
reportedly collapsed and on the other two occasions he was “feeling unwell”
and “distressed”. On 29 January, he moved to Frankland’s healthcare unit
after developing a suspected chest infection. The following day, his blood
pressure and pulse fell significantly, and he was sent to outside hospital. That
evening he had a heart attack and was unconscious for three days. Once he
regained consciousness, he remained very unwell and bed bound. During
this period, restraints (in the form of an escort chain, a long chain with a
handcuff at each end) were applied in hospital as well as a three officer
escort. Even though he was a prisoner in the highest security category, my
view is that the presence of the officers would have been an adequate
arrangement at this time. He did not recover and died at 9.50am in February.
The restraints were removed shortly before his death.
The man was sometimes a difficult patient to manage and did not always
comply with his treatment. Nevertheless, the clinical reviewer concludes that
he received an “acceptable level of care” at Frankland. However, she
highlights some areas that could have been improved. In particular, she
notes that his leg ulcer and high blood pressure were not always managed in
line with national guidelines. I make two recommendations in relation to this
and a further recommendation about the use of care plans for prisoners with
complex care needs.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 10 February 2010 when the investigator
issued notices announcing the investigation to staff and prisoners. The
notices included an invitation to those who wished to submit information
relating to the man’s death to make themselves known to the investigator.
No one came forward as a result.
2. The investigator visited Frankland on 2 and 3 March as part of the
investigation into a previous death in custody. During this visit he
collected copies of the man’s prison files, including the medical record.
He returned to Frankland on 21 May and interviewed four members of
staff.
3. An independent clinical review of the man’s health care in prison was
carried out by a clinical reviewer on behalf of the local PCT. She and her
colleague joined the investigator for the interviews at Frankland on 21
May.
4. During one of his visits to Frankland, the investigator met the man’s sister,
his nominated next of kin, and a family friend who was also visiting the
prison at the time. On behalf of the Ombudsman’s family liaison officer
the investigator explained the purpose of the investigation. The man’s
sister was also given the opportunity to raise any concerns she wished the
investigation to address. At the meeting and via a subsequent email to
the family liaison officer, she raised the following issues:
(cid:127) He had ulcers on his legs for a number of years. When she visited
him she said that her brother’s legs were “smelly” and he told her
he was not receiving appropriate care.
(cid:127) She asked that the report include details of her brother’s last few
days, as she lives abroad and was unable to be with him. She
asked particularly about the apparent rapid deterioration in health
before her brother was admitted to hospital.
5. I hope that my report clarifies any issues that might remain unclear for the
man’s sister and helps her better understand what happened in the time
leading to his death.
6. The post mortem report was not completed until October 2010, on
account of additional tests that had to be carried out to establish the cause
of death. This led to a delay in issuing the investigation report.
7. The man’s sister received a copy of my draft report as part of the
consultation process. Her response to the investigation findings can be
found on page 22. I have also addressed some additional issues in
separate correspondence.
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HMP FRANKLAND
8. HMP Frankland is one of eight high security prisons in England and
Wales. Frankland holds convicted category A and B adult male prisoners,
and also holds high risk remand prisoners. E wing, where the man lived
for around two months in 2009, is usually for category A remand prisoners.
(Category A prisoners are those whose escape would be highly dangerous
to the public or to national security.) B wing, where he lived from August
2009, is for vulnerable prisoners (those who request to be separated from
other prisoners for their own safety). The operational capacity of the
prison is 750.
9. Healthcare services at Frankland are provided by the local Primary Care
Trust. The healthcare centre provides 24 hour inpatient care, consisting of
two wards, holding a total of seven patients, and ten single cells. The man
moved into one of these cells the day before his admission to hospital in
January 2010.
10. The Westgate Unit is one of two prison sites in England and Wales
providing specialist assessment and treatment for prisoners with
dangerous or severe personality disorders (known as a DSPD unit). The
unit works in tandem with Rampton Special Hospital. It is a self-contained
facility within Frankland for 80 prisoners who live in four separate units.
The unit has its own facilities, including a library, canteen, sports hall,
classrooms and an outpatient healthcare facility. The man was one of the
first prisoners to move to the Westgate Unit following its opening in 2004.
11. HM Chief Inspector of Prisons conducted a full announced inspection of
Frankland in February 2008. The then Chief Inspector was broadly
positive about health services provided at Frankland, and found the
provision was equivalent to that which prisoners could expect to receive in
the community. She found that relationships between staff and prisoners
were reasonably good on B wing and very good on the Westgate Unit.
12. The Independent Monitoring Board (a body of local people who
independently monitor and report on the prison) report for 2008-09
described the Westgate Unit as “outstanding” and praised the commitment
of staff who worked on the unit. They noted that the healthcare rooms on
individual wings were “working satisfactorily”.
13. This is the ninth death that the Ombudsman has investigated at Frankland
since January 2009. There have subsequently been a further four deaths
at the establishment. All but one of the other deaths were due to natural
causes. An earlier investigation also highlighted the lack of nursing care
plans for a prisoner with significant medical problems.
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KEY EVENTS
14. At the time of his move to Frankland in July 2003, the man had been
diagnosed with a number of medical conditions. They included
hypertension (high blood pressure), asthma, type 2 diabetes (non-insulin
dependent diabetes) and varicose veins. As a result of his diabetes and
varicose veins, he had developed an ulcer on his lower left leg. It
measured approximately 3cm x 4cm and had been present for many
months. He was prescribed antibiotics to treat the ulcer, which was also
redressed twice weekly. Shortly after his arrival at Frankland, he was
referred to a consultant vascular surgeon at hospital. As well as the
antibiotics, he was also prescribed atenolol (for high blood pressure) and
amiodarone (to treat an abnormal heart rhythm).
15. The man had a chest x-ray in January 2004, the results of which showed
that he had an enlarged heart. In a referral letter to a cardiologist (heart
specialist) in April, it was noted that changes had been made to his
medication. He was no longer taking amiodarone but was prescribed
simvastatin (to lower cholesterol), bendrofluazide and cozaar (both used
to treat high blood pressure). He also saw a consultant vascular surgeon
in April, who recommended that the treatment for his ulcer should
continue. Two months later it was noted that he often removed his
dressings, despite being advised to leave them in place.
16. On 19 July, the man saw a cardiologist at hospital. For several years he
had complained of breathlessness when walking or climbing stairs. The
cardiologist did not think that the cause was related to his heart and
requested no further investigations or follow up.
17. A week later, the man moved onto the newly opened Westgate Unit at
Frankland. Following an assessment a month earlier, he had been found
to meet the criteria for DSPD services (meaning that he had been
diagnosed with a severe personality disorder which was considered
potentially treatable). He was allowed to keep his medication ‘in
possession’ on the Westgate Unit (meaning that he was given a week or
several weeks supply at a time to keep in his cell and take as prescribed).
18. Nursing care plans were written in December 2004 and January 2005
following an assessment by a consultant vascular surgeon. The care
plans provided detailed instructions about how to change the man’s
dressing, which was to take place every third day.
19. In May 2005, the man was admitted to outside hospital overnight after
experiencing chest pain spreading down his left arm. On his return to
Frankland, he was given a cell on the inpatients wing for observation, but
discharged himself against the advice of healthcare staff. He had a follow
up x-ray in August, which showed no change to the previous x-ray of
January 2004.
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20. Later that month, the man was admitted to hospital for five nights after
suffering pain in his groin. A scan revealed the presence of a deep vein
thrombosis in his left leg (DVT, a blood clot). He was treated with a
course of warfarin (to thin the blood), which continued following his
discharge from hospital. The warfarin prescription was stopped in April
2006 as his symptoms had resolved. His ulcer was also reported to be
much better at the time with the wound described as “very healthy”.
21. The man complained of chest pain on two occasions later in 2006. Both
times he saw a nurse, who took clinical observations (clinical observations
include measuring the heart rate, blood pressure and respirations). The
pain subsided on the same day and he did not need to go to hospital on
either occasion. In November, he said he had vomited and felt sick. He
was advised to remain in the healthcare centre whilst blood tests were
taken, but refused. He said he felt better later that day.
22. During 2007, the man complained on several occasions of feeling
nauseous and dizzy. On each occasion the symptoms seemed to resolve
after a short period of time. In November 2007, he attended an outpatient
appointment with a consultant colorectal surgeon. This followed a referral
made by a prison doctor after he said he had been bleeding from his
rectum. The consultant found nothing significant but referred him for a
flexible sigmoidoscopy (an examination with a micro camera of the rectum
and colon). This took place the following month and identified
haemorrhoids, which were considered to be the cause of the bleeding.
23. In December, the man told clinical nurse manager on the Westgate Unit
that his leg ulcer was recurring. She examined his leg and could find no
evidence of the ulcer, but noted that it should be monitored regularly. In
January 2008, he began to experience swelling and dry skin on his lower
left leg. This soon developed into an ulcer and he was prescribed a
course of flucloxacillin (an antibiotic for skin and soft tissue infections).
Nursing staff on the Westgate Unit dressed his wound as previously.
24. The man reported to staff on 16 February that he had not eaten for six
days, although a prison nurse noted that he did not present like a person
who had not eaten for this period of time. A food refusal log was opened
but was closed two days later as he had been seen collecting meals from
the servery.
25. On 21 February, it was noted that the man was reluctant to use the
recommended type of dressing, known as a compression dressing. The
results of a swab taken of his wound showed that he had put faeces into
the wound. The clinical nurse manager said at interview with the
investigator that the results suggested that the faeces came from his
budgerigar, which he kept in his cell. She added that he denied this when
questioned. He was told that he should not remove the dressing.
26. In March, the man contacted the Prison Reform Trust and complained that
none of the proposals to treat his ulcer had come to fruition, including the
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availability of compressed support stockings. The clinical nurse manager
replied later that month. In her letter, she wrote that he had had
compression stockings for some time and his dressings were changed
three times a week. She added that she had explained to him that
treating an ulcer like his can be a lengthy process which was not helped
by him mistreating the wound as he had done in February.
27. The man was visited on 27 March by a tissue viability nurse. As his leg
was not infected, she recommended that a particular compression
dressing be used. On 20 April, he told a nurse that he had blood stains on
the dressing. On checking the wound, the nurse could find no indication
of bleeding on the inside of the dressing. Her conclusion was that he had
put blood on the outside of the dressing. She considered that he might
have done this as a recent adjudication (a prison disciplinary hearing) had
reduced his association time (when he was allowed out of his cell) for a
period of seven days.
28. Through May and June, the man’s ulcer was reported to be healing well
and, on 3 July, it had healed and no further treatment was required. In
August, he began to complain of pain in his left heel and was prescribed a
pain killer. An x-ray of his left foot and ankle in September showed
nothing abnormal. In October, he confirmed that his heel pain had
improved.
29. In December, the man told a nurse that his chest had felt tight for two to
three weeks and this tightness was followed by a “pin prick” sensation
down his left arm when he rested. An electro-cardiogram (ECG, a test of
the electrical activity of the heart) was taken, which showed nothing
abnormal. He was advised by staff not to rush around, as he often did,
and to take his time over activities.
30. The man saw the clinical nurse manager on 10 February 2009 and told
her he had experienced shortness of breath on exertion for several weeks.
She took his clinical observations, which were normal other than an
irregular pulse and slightly low blood pressure at 110/50. An ECG was
performed, which showed possible atrial fibrillation (irregular heart beat).
31. Two days later, concerns were raised that the man might be being bullied
by another prisoner. He apparently put £40 into a kitty with another
prisoner to buy food for meals. (An arrangement made by some prisoners
to supplement meals provided by the prison.) However the other prisoner
was reportedly not putting in his share and the man had been seen doing
chores for him. He insisted that he was not being bullied and that he and
the other prisoner were friends.
32. On 12 March, the man saw Prison Doctor A in relation to the suggested
diagnosis of atrial fibrillation. He told the doctor that he had suffered
“palpitations” for three to four weeks and became breathless after walking
100 paces or on climbing stairs. He also said that exertion brought on
chest pain, which was relieved if he lay down. The doctor examined him
9
and referred him to a cardiologist (heart specialist) at a local hospital. In
the meantime, he advised him not to do any “hectic” work and to inform
staff if the chest pains returned. Ten days later, he was prescribed a
course of aspirin (to prevent blood clots from forming and reducing the
flow of blood to the heart). He was also given a glyceryl trinitrate spray
(GTN, a spray used as required to ease angina pains).
33. Following a review of his position on the Westgate Unit, the man was
removed from the DSPD programme on 12 May. The corresponding
report noted that he “did not demonstrate a sufficient level of progress to
conclude that the treatment in the Westgate Unit was of meaningful
benefit to him”. As a result, he left the Westgate Unit on 25 May and
moved into a cell on E wing.
34. In early June, the man’s leg ulcer recurred. He was given a compression
dressing as previously and the wound was cleaned and changed regularly
by nursing staff. Over the course of the following two months the ulcer
went through fluctuating periods of improvement and deterioration. He
started a course of flucloxacillin on 2 July.
35. On 9 July, the man went to an outpatient appointment at the cardiology
clinic at hospital, following his referral in March. The cardiologist found
nothing abnormal and concluded that the chest pains were “clearly non-
cardiac” and might be due to an “element of anxiety”. However, the
cardiologist made an appointment for an additional scan to check for
underlying heart disease.
36. From mid to late July, the man’s ulcer began to deteriorate and he
reported significant pain in his leg. On 31 July, it was noted that his
mobility was poor. Although not explicit, it seems that the deterioration in
his mobility was related to his ulcer.
37. The man moved to a ground floor cell on B wing on 1 August. He was
slightly breathless on arrival and had very high blood pressure, at
196/102. He was advised to rest for a while. That evening a nurse
returned to check on him and noted that he seemed better. The nurse
also noted that his blood pressure would be checked again the following
day, although this does not appear to have happened. The next recorded
blood pressure reading was four days later on 5 August, when it had fallen
to 157/76.
38. At a review with Prison Doctor A the following day, the man was
prescribed co-codamol for the pain from his ulcer (prior to this he had
been taking ibuprofen). As the ulcer showed no sign of healing, the doctor
referred him to a tissue viability nurse. In addition, the man said he was
urinating much more frequently in the last month and so the doctor also
referred him to a consultant urologist.
39. When he next saw Prison Doctor A, on 14 August, his ulcer wound was
improving and nurses were to continue dressing it at the same frequency.
10
The doctor also agreed that he could take oromorph (a stronger painkiller)
before his dressing was changed to counteract the additional pain he
experienced whilst it was treated.
40. Over the following week, the man’s ulcer continued to improve. However,
he was reported to be unhappy with his treatment and disputed that it was
improving. He was subsequently reviewed by Prison Doctor A on 19
August, who noted the view of the nursing staff that the wound was
improving. The doctor also noted that the man had seen the tissue
viability nurse in the previous week, although it is not clear when this
happened or who the nurse involved was.
41. On 25 August, he saw a consultant urologist via a telemedicine link at the
prison (whereby the patient sees a doctor or consultant via video
conferencing facilities). Given the symptoms he described, the consultant
thought he might have a urinary tract infection and recommended a two
week course of antibiotics. However, on 1 September, it was noted that
he had not collected his antibiotics since they were prescribed.
42. The man visited the hospital on 28 August for the first part of the scan
recommended on 9 July. He returned to complete the scan a week later.
After examining the results, the cardiologist concluded that he was
unlikely to have heart disease and that no further action was necessary.
43. In early September, the man’s ulcer wound was noted to be slowly
improving. He saw Prison Doctor A on 9 September for a review of his
urination problems. Although he said his symptoms had improved, a test
confirmed that he had a urinary tract infection. The doctor prescribed
another course of antibiotics. However, a week later, it was noted that he
had not taken the antibiotic and had returned his supply to healthcare.
During the course of this week he also declined an appointment with
Prison Doctor B, to discuss the results of a further urine test. He
apparently told a member of staff that he “didn’t need the doctor”.
44. At his next review with Prison Doctor A, on 17 September, the man’s leg
ulcer was noted to be much improved. The doctor discussed it over the
telephone with the tissue viability nurse and agreed to continue with the
current treatment plan. Eleven days later, the same nurse saw him via the
telemedicine link. She made some suggested changes to his treatment,
including reducing the changing of dressings to twice weekly, and later
faxed an updated treatment plan to the prison.
11
45. On 30 September, a request for the man to be assessed for a wheelchair
was faxed to the County Durham Wheelchair Service. The referral gave
the following reasons for assessment:
“The man is under the care of tissue viability nurse specialist. He has a
leg ulcer on his right leg. He is able to walk independently (although
can get out of breath) whilst on the wing. He has problems with
walking when long distances are involved. I was wondering if you
could assess for this. He currently uses the emergency wheelchair that
is kept on the wing.”
46. The man reportedly became aggressive towards nursing staff on 18
October after demanding that his dressing be changed. He was told by
Nurse A that his dressing was clean and dry and did not require changing
at the time. However, his ulcer did appear to deteriorate around this time.
On 19 October, Prison Doctor A wrote a referral letter to a consultant
vascular surgeon at the hospital. The following day, Nurse B dressed his
leg and noted that it was “much deteriorated”. He was visited by a
physiotherapist on 28 October, to assess his mobility. The physiotherapist
noted that his mobility improved when he used two walking sticks and
recommended that he should continue to do so.
47. The consultant vascular surgeon visited the man at Frankland on 4
November. In his follow up letter, he said he initially planned for him to be
admitted to the prison’s inpatient unit for strict bed rest. However, the
man did not agree and so the consultant instead recommended that he
should be admitted to hospital for a scan and surgical removal of the dead
tissue. An appointment was subsequently made for 10 November.
However, on the day of the appointment he declined to attend. He
apparently told staff that he was concerned about his budgerigar and
whether someone would take care of it while he was in hospital.
48. The external appointments manager at Frankland telephoned the
consultant vascular surgeon’s secretary on 9 December to see whether an
alternative appointment had been made. She was told that admission
was not possible at present but that the man might be seen in the New
Year.
49. At a review with Prison Doctor B on 22 December, the man said that he
thought his wound was more like cellulitis than an ulcer. (Cellulitis is an
infection of the deep layers of the skin and underlying tissue which is
usually caused by particular bacteria.) She examined the wound but
considered that there was no sign of cellulitis. However the wound had
deteriorated over the previous two weeks, during which a different type of
dressing had been used. She suggested they resume using the previous
type of dressing. She also discussed the upcoming hospital admission
with him and he agreed that he would go this time.
50. The man’s wound improved through the remainder of the year and into the
first days of 2010. On 6 January, he told a Healthcare Officer (HCO) that
12
he felt short of breath and could not use his inhaler properly (He had an
inhaler for his asthma). The HCO noted that he did not appear to be
breathless and advised him how to use his inhaler correctly.
51. The consultant vascular surgeon visited Frankland on 7 January and saw
the man at one of his regular clinics. In his follow up letter, the consultant
noted that the ulcer had “cleaned up considerably” with less evidence of
infection and swelling. Although it is not specifically mentioned in his
letter, it appears that the consultant no longer considered hospital
admission for surgery to be necessary. He recommended a four layer
compression bandage as “what [the man] really needs to treat his leg
ulcer”. The consultant suggested that the tissue viability nurse should be
contacted to arrange this. Notes in his medical record through the
remainder of the month indicated that the dressings were changed “as per
care plan” but he was “awaiting compression therapy”. (Compression
therapy is the use of a particular type of dressing to treat the ulcer wound,
known as a compression dressing.)
52. On 23 January, the man fainted whilst walking on his wing. A ‘code black’
was called by wing staff (code black is a radio call for emergency medical
response) and Nurse C responded. When she arrived on B wing, he had
regained consciousness. She took his clinical observations and noted
that his pulse and blood pressure were low. She returned to see him later
that afternoon, by which time his blood pressure and pulse had improved.
He said that he felt much better.
53. Two days later, an officer on B wing telephoned healthcare regarding the
man’s health. The officer said the man was feeling unwell and had said
that he was “going down hill”. Nurse D visited him in his cell. She noted
he had been incontinent of urine, which he explained was because he had
slept in the wrong position and struggled to get out of bed. He said he felt
fine and was reassured by her. The following day, she returned to see
him after another code black call when he was reportedly “distressed”.
She took his clinical observations, which were described as “satisfactory”.
54. Nurse C changed the man’s dressing on 28 January. She noted that the
wound was “foul smelling”, which was attributed to him removing the
dressing to shower. She warned him that removing the dressing could
damage his wound, and advised him to cover it with a plastic bag whilst in
the shower. He also said he felt unwell, got short of breath easily and was
tired. On account of this, and his recent collapse, she made an
appointment for him to see a prison doctor.
55. The following day, Friday 29 January, staff on B wing contacted
healthcare again and said that the man was “walking badly”, had slurred
speech and sounded vague and confused. Later that morning, he saw
Prison Doctor B for a review. He told her that he was “chesty” and more
short of breath than usual. He also said that it hurt when he coughed or
breathed deeply. She examined him and noted crackling noises from his
chest and that he was coughing regularly. She considered that the
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symptoms should be treated as a chest infection and prescribed a course
of amoxicillin (an antibiotic). She also asked that blood and urine tests be
carried out. It was later agreed that he should remain in healthcare over
the weekend for observation.
56. At around 11.00am the following morning, the man’s pulse was checked
by Nurse E. It was low, at 45 beats per minute, although his blood
pressure was normal, at 141/81. She also noted that he was “chesty” and
was coughing, but not producing phlegm. Around an hour later, Nurse F
checked his clinical observations and found that his pulse and blood
pressure had both fallen: to 34 beats per minute and 107/57 respectively.
She made a call for an emergency ambulance and he was admitted to
hospital in the early afternoon. He was reportedly reluctant to go to
hospital initially, but was persuaded to do so by her.
57. Before taking the man to hospital a standard risk assessment was carried
out. It was judged that he should be accompanied by three officers,
including one senior officer. His hands were cuffed together and one of
his wrists was cuffed to that of an officer by means of an escort chain, a
long chain with a handcuff at each end. (Similar arrangements had been
made on the previous occasions that he went to hospital.)
58. At 9.20pm that evening, the man had a heart attack. The escort staff
removed the restraints and hospital staff successfully resuscitated him.
Shortly afterwards, he was moved to the hospital’s intensive therapy unit.
He was unconscious and the restraints were not reapplied at this time. He
regained consciousness on the afternoon of 2 February. He was given an
oxygen mask to assist with his breathing. After consulting with the duty
governor at Frankland, the escort staff reapplied an escort chain.
59. The following day, a member of healthcare staff contacted the hospital to
ask for an update on the man’s condition. She was told that there was no
diagnosis at present and staff “remain puzzled” about his symptoms. He
underwent various tests in the first week of February.
60. On 4 February, the man moved from the intensive therapy unit to a ward.
He was thought to have a chest infection. It was noted the following
morning that his low body temperature was giving hospital staff cause for
concern. Some entries in the bedwatch records (the record of events
made by the escort staff) over the following days noted that he was
confused and disoriented, although one entry indicated that it might not be
genuine as he was also coherent for periods. The risk assessment was
reviewed on 6 February, with no changes recommended to the staffing
levels or the use of restraints. On 7 February, it was confirmed that he
was diagnosed with bilateral consolidation (a disease of the lung whereby
it becomes a firm, solid mass).
61. Two days later, doctors at the hospital were concerned about the man’s
fluctuating temperature and were considering whether to conduct tests on
his brain. It was considered likely that he would remain in hospital for at
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least another week. That afternoon, he was able to get out of bed, with
the help of a hoist, and spend some time sitting in his bedside chair. He
was unable to move about independently.
62. The following morning, at around 9.40am, the escorting officers noticed
that the man was foaming at the mouth. They alerted nursing staff, who
began to resuscitate him. At the same time, the escort chain was
removed. The resuscitation attempts were unsuccessful and he was
pronounced dead at 9.50am.
63. The man’s next of kin was his sister. As she lives abroad, the news of her
brother’s death was broken to her over the telephone. She subsequently
visited Frankland on 2 March, shortly before her brother’s funeral. The
investigation found that the prison’s contribution to the funeral costs was
in accordance with PSO 2710 (the Prison Service Order that sets out the
actions to be taken following a death in custody).
64. A post mortem examination was carried out on 12 February and was
supplemented by a neuropathological examination (examination of the
brain) on 16 June. In the post mortem report, completed in October 2010,
the pathologist made the following comments:
“The man’s last illness, which in essence involved treatment for a chest
infection, was unexpectedly complicated by hypothermia and there
was, I think, a clinical suspicion that this might indicate some other
underlying disease process potentially involving the brain. Whilst the
brain was by no means normal the abnormalities present appear either
to predate his final illness or to be consequences of his final illness,
and do not [therefore] explain [the final illness].
“…Thus we are brought back to his original problem when he was
admitted to hospital, which was thought to be a chest infection for
which he was treated. Post mortem certainly confirmed that at the time
of his death he did have a chest infection (acute bronchopneuomina)
… Infection can itself cause hypothermia and can also cause
septicaemia and relatively sudden death. In the absence of any other
explanation in my opinion his death has probably been the result of
acute bronchopneumonia.”
15
ISSUES
Management of the man’s leg ulcer
65. The clinical reviewer describes the man’s leg ulcer as his “most significant
and enduring health problem”. His sister also referred to her brother’s leg
ulcers and said that he had told her that he did not think he was getting
the “right care”.
66. The ulcer was already present when the man arrived at Frankland in July
2003. It eventually healed in late 2006 but recurred in January 2008 and,
on this occasion, healed around six months later. A year later, the ulcer
developed for a third time.
67. The clinical reviewer’s comments that “chronic leg ulcers are extremely
difficult to resolve”. She notes that the man did not always cooperate with
his treatment and so managing his care was more difficult than it might
otherwise have been. Despite this, she considers that he “appears to
have had an acceptable level of care” and notes some areas that were
managed well, such as the referral to the tissue viability nurse and
consultant vascular surgeon.
68. However, the clinical reviewer identifies some areas of poor record
keeping by prison healthcare staff:
“There is no evidence that an initial assessment took place when the
man’s leg ulcer developed in June 2009, or that subsequent routine
management was provided in accordance with national guidelines such
as SIGN – The Care of Patients with Chronic Leg Ulcers, and The
Royal Marsden Hospital Manual and Clinical Nursing Procedures.
“National guidance also states that ABPI [ankle brachial pressure
index, a simple measure of the blood pressure of the arteries supplying
the legs] readings should be undertaken on initial assessment and then
every 12 weeks until the ulcer is healed. In diabetic patients they
should be undertaken every six months when the ulcer is healed.
There is no evidence of any Doppler assessments [a means of
calculating ABPI] having been undertaken.”
69. A nursing care plan for the management of the man’s ulcer was created in
early 2005. However, the clinical reviewer has found no evidence that
subsequent care plans were initiated and implemented when the ulcer
redeveloped in 2008 and 2009. She comments that nursing care plans
“are essential to the provision of safe and effective care”. Moreover, such
documents formally set out the interventions which healthcare staff will
deliver and what the patient could be expected to do for himself.
The healthcare manager should review staff training regarding the
management of leg ulcers and ensure that national guidelines are
followed.
16
The healthcare manager should audit the leg ulcer care plans and
ensure that all prisoners with such care needs have a care plan.
Monitoring the man’s blood pressure
70. The clinical reviewer notes that the man’s blood pressure was raised
during July and August 2009. On 1 August, his blood pressure was
recorded as 196/102, which is a very high reading. Although it was noted
that it should be checked the following day, the next reading was actually
four days later on 5 August. No further blood pressure readings are
recorded until 4 November, when it was again high, at 190/100. The next
recording was on 24 December, when a reading of 136/60 is noted, which
is within the normal range.
71. Although she considers that he was “maintained on the appropriate [blood
pressure] medication”, she notes:
“All blood pressure observations were taken as a result of an acute
episode and not as routine clinical observation of hypertension, as
would be expected … NICE [National Institute for Health and Clinical
Excellence] Guidelines for the Management of Hypertension (2006)
suggest, for an initial diagnosis, readings should be made at monthly
intervals for three months before a diagnosis is made and treatment
commences, followed by annual reviews.”
The healthcare manager should review the protocols for managing
hypertension and audit clinical staff awareness of the national
protocols and guidance.
Overall standard of care
72. The clinical reviewer summarises the man’s time at Frankland as follows:
“He appears to have been a sometimes difficult patient to manage,
demanding attention and occasionally non-compliant with his medical
care and treatment … He was not always happy with the care he
received. It is also apparent that he was not always compliant with the
advice given to him by healthcare staff.”
73. She concludes as follows:
“He received an adequate standard of care whilst a prisoner at
Frankland. He was referred appropriately for specialist advice and his
limited mobility was taken into consideration when determining his
location within the main prison.
“Whilst the documentation regarding the management of his leg ulcer is
poor, it seems from the information available that his care was
appropriate.”
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Use of restraints
74. The Prison Service has a duty to protect the public and hence restraints
and escort staff are routinely used when prisoners are taken out of the
prison for any reason. An individual risk assessment is completed on
each occasion and regular management checks are made. The
assessment will consider the offences and the risk of further offending, as
well as the prisoner’s health and mobility.
75. A risk assessment was conducted when the man was taken to hospital on
30 January 2010. His mobility was poor and he used walking sticks to
help him move around the prison. He was described in the assessment
as a high risk to public and hospital staff and a “dangerous man who will
carry out threats”.
76. The assessment concluded that the man should be accompanied by three
officers, including one senior officer. The risk assessment also concluded
that his hands should be cuffed together and one of his wrists should be
cuffed to that of an officer by an escort chain. Given his history of
offending, even though he was not fully mobile, I think that this level of
caution on the part of the prison was understandable and I do not criticise
the level of restraints.
77. I am satisfied that the restraints were rightly removed on the evening of 30
January when he had a heart attack and had to be resuscitated by
hospital staff. They remained off whilst he was unconscious. He regained
consciousness on 2 February, and the escort chain was re-applied.
Despite regaining consciousness, I believe that his condition was not good
throughout the last week of his life. He used an oxygen mask to help his
breathing and could not get out of bed until a hoist was used on 9
February to lift him into a chair. Nevertheless, the escort chain was only
removed when he had to be resuscitated on the morning of 10 February.
78. The man was a category A prisoner, which is the highest security
category, meaning that his escape would be “highly dangerous to the
public”. It is understandable that prison staff would want to take the
greatest precautions when he was outside the prison. However, even
after regaining consciousness on 2 February, he remained bed bound and
very unwell.
79. In these circumstances I think it would have been reasonable to escort
him in hospital on this occasion without the use of restraints. Given his
condition, I judge that the presence of the three officers would have been
an adequate security arrangement. Were his mobility to have improved,
the risk assessment could have been revised and use of restraints
reconsidered.
80. I appreciate that the man’s death was not expected. He had been well
enough the day before to be lifted out of bed to sit in an armchair. The
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doctors expected that he would stay in hospital for a week before
returning to Frankland. Nevertheless, in my view, it is not dignified for a
prisoner – even one convicted of serious offences – to be restrained in
these circumstances.
The Governor should review the use of risk assessments and
encourage senior managers to give greater weight to a prisoner’s
mobility when they assess risk and consider the use of restraints on
a bedwatch.
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Family response to the draft report
84. In response to the draft findings of my report, the man’s sister expressed
concern that he was bullied at Frankland and that prison staff were aware
of this. I would like to assure her that I take such an allegation very
seriously. His prison records indicate one occasion on which it was
highlighted that he might be the victim of bullying. This followed an
incident observed by staff in February 2009 (and described in paragraph
34 of this report). Staff spoke to him, who insisted he was not being
bullied. He did not report any incidents of bullying to staff throughout his
time at Frankland.
85. The man’s sister also said she was concerned that her brother was the
victim of prejudice on account of his ethnic origin. There is no indication
from the records that this might be the case and he did not make any
complaints, either formally or informally, about such actions. Nevertheless
I would, of course, expect staff to conduct themselves in a professional
and appropriate manner at all times.
86. In her feedback, the man’s sister also said she did not feel her brother
received appropriate treatment for his leg ulcer, and referred specifically to
a visit in 2009 when his leg was infected and discoloured. As I have
noted, his leg ulcer was his most significant and enduring health problem.
The clinical reviewer concludes that he received an appropriate standard
of care at Frankland and that some areas were managed well. However,
she does identify some areas that could be improved and made relevant
recommendations. These recommendations were accepted (see page
23).
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CONCLUSION
87. The man spent the majority of his adult life in prisons or special hospitals.
By the time he arrived at Frankland in 2003 he had been diagnosed with a
number of medical conditions. The most significant and long term of these
was a recurring leg ulcer, which affected him for most of the rest of his life.
Although he did not always comply with his treatment plan, the clinical
reviewer concludes that he was managed “to an adequate standard”.
However, there were some areas that could have been improved, notably
in relation to the application of national clinical guidelines at Frankland.
88. Following a deterioration in his health in the last week of January 2010, the
man was admitted to hospital for investigation. The report considers the
question of the appropriate use of restraints on category A prisoners. It is
my view that a bed bound and very unwell prisoner, even one who is
category A, should not be restrained except in extreme circumstances. I
encourage the Governor to give greater weight to a prisoner’s mobility
and, as such, their real and current threat, when considering the use of
restraints.
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RECOMMENDATIONS
1. The healthcare manager should review staff training regarding the
management of leg ulcers and ensure that national guidelines are
followed.
Accepted – clinical management of leg ulcers is provided by the PCT and
the head of healthcare will ensure that all clinical staff attend this training.
2. The healthcare manager should audit the leg ulcer care plans and ensure
that all prisoners with such care needs have a care plan.
Accepted – head of healthcare to commission an audit from the PCT
tissue viability nurse.
3. The healthcare manager should review the protocols for managing
hypertension and audit clinical staff awareness of the national protocols
and guidance.
Accepted – current review of NICE guidelines is underway and any
recommendations will be implemented.
4. The Governor should review the use of risk assessments and encourage
senior managers to give greater weight to a prisoner’s mobility when they
assess risk and consider the use of restraints on a bedwatch.
Accepted – this issue has already been addressed. Discussion with
regards to prisoners on a bedwatch, their condition and restraints now
takes place systematically at the Governor’s 9.00am meeting, which is
attended by all senior managers. We currently have a prisoner located at
an outside hospital. His condition is reviewed daily which has resulted in
his security status being reduced to no restraints being applied and
supervised by two prison officers.
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