Individual at Dovegate

Investigation into the circumstances surrounding the
death of a man in January 2010
at outside hospital
while in the custody of HMP Dovegate
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2011
This is the report of an investigation into the circumstances surrounding the death of
a man in January 2010 whilst in the custody of HMP Dovegate. The man, who was
58 years old, died at outside hospital as a result of a neuro-endocrine tumour
(cancer). His health was good when he first arrived in prison in 2004 but he was a
heavy smoker. In 2008, having previously been seen only rarely by prison doctors,
he started to complain of persistent diarrhoea. After several months of investigation,
following an emergency admission to outside hospital, the man was diagnosed with
cancer of the liver in January 2009.
The man initially allowed doctors at the hospital to treat him, but in May 2009 he
refused all further treatment. He continued to be looked after by healthcare staff at
Dovegate, without the intervention of palliative care services from the community
until his death in January 2010. I do not believe that prison healthcare staff always
fulfilled the standards expected of their profession most notably on 6 November
when he was attended four times because of severe pain, but without further action
being taken to relieve it.
I would like to extend my personal condolences to the man’s family and friends for
their loss. I apologise for the delay issuing my report and any additional distress this
may have caused the man’s family.
This investigation was carried out by my colleague. A clinical review, for which I am
most grateful, was undertaken by a clinical reviewer on behalf of South Staffordshire
Primary Care Trust (even though they are not the commissioners of health services
at Dovegate as this is a private prison). I also thank the Director of HMP Dovegate
and his staff for their help and co-operation during this investigation.
I make seven recommendations in this report together with a suggestion that the
Director considers the implications of the further recommendations made by the
clinical reviewer in her review. My most significant recommendation relates to what I
believe was the inappropriate and regrettable use of handcuffs on a dying man and
the need for the Director to reconsider his instructions to his bedwatch staff. I also
repeat recommendations about record keeping which I have made in previous
investigations at Dovegate.
I am happy to report that all the recommendations that I made in the previous draft
version of my report have been accepted.
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 Dovegate
Key findings
Issues
Clinical Care
Early release on compassionate grounds
Use of restraints
Conclusion
Recommendations
3
SUMMARY
The man was sentenced to ten years imprisonment by a crown court on 25 May
2004 for serious sexual offences. He was first sent to HMP Liverpool, but was
transferred as part of his sentence plan on 16 November 2004, to HMP Dovegate.
At the time of his initial sentence, the man had no recorded physical health
problems, although he was prone to depression and anxiety.
His progress in offender programmes terms was hampered initially by the man’s
inability to read and write so much of his time was occupied in learning these skills.
He refused to engage fully with sex offending programmes throughout his sentence
because he maintained his innocence. He was therefore refused parole on the basis
that he had not made any attempt to show that he had reduced the risk he posed to
the general public which would justify early release.
In October 2006, the man’s wife died as a result of cancer. His friends described
how this had a devastating effect on him and they suggested that he lost the will to
live, although they made it clear that he was not actively suicidal.
The man began having bowel problems in March 2008. Tests were undertaken by
doctors at the prison to determine the cause of these problems, but no definitive
diagnosis was reached. In October 2008, the man went to the accident and
emergency department at outside hospital with chest pain and pain in his abdomen.
He was thought to have a viral infection and was sent back to prison the same day.
On 21 October, one of the doctors at the prison (whose signature is illegible)
suggested that the man might have gastrointestinal cancer. Despite the NHS
procedure for urgent referrals of suspected cancer patients, no referral for the man
was sent. On 9 November, the man was taken back to A&E because of severe pain
(he had been suffering increasingly since the end of October). He was found to have
a perforated duodenal ulcer and was operated on by surgeons at outside hospital.
During the operation, surgeons saw what they believed to be tumours on the man’s
liver, and recommended that further investigations and tests be carried out. A
consultant gastroenterologist subsequently confirmed that the man did indeed have
cancer of the neuro-endocrine system. (This is a rare form of cancer in that it acts to
overproduce hormones throughout the body, rather than the more common over
production of cells that lead to a ‘mass’ within the body.) He was informed of the
diagnosis on 12 January 2009.
The man was initially reluctant to cooperate with the clinicians at the hospital
because he was anxious about the treatment he might require, but staff at Dovegate
managed to reassure him. He went to the hospital for follow up consultations during
the next few months but declined all further opportunities of treatment or re-referral
to consultants after 19 May. Dovegate healthcare staff looked after the man’s
prescription needs to keep him pain free over the following months, but it does not
appear that he was ever formally referred to palliative care services. On 7
November, he was in severe pain and nurses attended four times during the night,
but without taking any further action to relieve his discomfort. No ‘End of Life Care
4
Package’, a guideline laid down for terminally ill patients, was ever instigated for this
man.
He continued to deteriorate over the following months and, in January 2010, was
taken back to outside hospital because of severe pain in his abdomen. Doctors at
the hospital assessed him as being close to death and made him as comfortable as
possible. The man’s nominated next of kin were contacted but he died at 11.55pm,
before they could arrive. Regrettably, he was still handcuffed to a prison officer and
the restraints were only removed three minutes after he passed away.
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THE INVESTIGATION PROCESS
1. This investigation was undertaken by one of my investigators. He first visited
Dovegate on 2 February 2010 and was given access to the man’s prison
records. My investigator saw the healthcare unit and the unit where the man
lived during his time at the prison.
2. During this initial visit, my investigator met members of the Independent
Monitoring Board (IMB), the prison chaplain and the Prison Officers
Association (POA). He invited them to provide any information regarding the
prison or the circumstances surrounding the man’s death that they thought
pertinent to my investigation. (Each prison has an Independent Monitoring
Board. IMB members are unpaid and monitor day-to-day life in the prison to
ensure that proper standards of care and decency are maintained. The IMB
produces an annual report of its work.) My investigator also interviewed a
former roommate of the man’s.
3. South Staffordshire Primary Care Trust (PCT) was asked to undertake a
clinical review of the care that the man received whilst he was in custody,
particularly during his time at Dovegate. They appointed a clinical reviewer to
undertake the review on their behalf. The clinical reviewer was asked by the
investigator to particularly consider whether the prison health authorities had
acted correctly in identifying the man’s condition and whether there had been
any delay in his treatment.
4. One of my family liaison officers contacted the man’s brother, as his listed
next of kin, to explain the purpose of my investigation and invite him to ask
any questions or raise any issues for consideration. The family raised no
issues of concern at the outset of the investigation. They were also offered an
opportunity to receive and comment on the draft version of the report,
however, to date, have chosen not to do so. I hope that the findings of my
investigation answer any questions they may have, should they receive the
report in the future.
5. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation and to request a copy of the post mortem
report. Upon completion of this investigation, a copy of my report will be sent
to the Coroner. The inquest into the man’s death was held on 8 September
2010 when the jury returned a verdict that he had died of natural causes. The
Coroner did not request a post mortem report as the man died whilst in the
care of doctors at outside hospital. He was confident that the cause of death
was hypovaleamic shock due to a perforation of bowel viscous as a result of
metastatic liver disease (meaning that the man died of cancer of the liver).
6
HMP DOVEGATE
6. Dovegate opened in 2001 as a prison for adult male prisoners sentenced to
over four years. It now also caters for local remand prisoners from
surrounding courts. It is a private prison managed by Serco under contract to
the National Offender Management Service (NOMS). It currently holds up to
1,146 prisoners, 946 men in the main prison and 200 in the Therapeutic
Community (TC). Serco Healthcare has a contract to provide healthcare at
HMP Dovegate. They directly employ two doctors who work Monday to
Saturday (and are on call on Sunday). There are 18 nurses and 11
healthcare assistants available to work shifts that cover the 24 hour day, with
two qualified nurses on duty at night. There are 11 single rooms in their in-
patient unit. The local Primary Care Trust is not responsible for delivering
healthcare at HMP Dovegate, but does provide clinical guidance support.
7. Her Majesty’s Chief Inspector of Prisons last reported on Dovegate following
an announced inspection in October 2008. The Chief Inspector made the
following comment about healthcare:
“Primary health services were reasonable, but were compromised by
shortages of staff and accommodation, which needed a substantial
increase in funding for healthcare to move forward. Chronic disease
management was maintained despite staff shortages, but staff needed
more time to give a quality service to prisoners. Many NHS appointments
were cancelled or rearranged, and pharmacy services needed further
development.”
8. The latest Independent Monitoring Board Annual Report, for the period 2008-
09, made the following comments regarding healthcare services:
“Applications to the IMB regarding healthcare are the second highest
number, being 14.01% of all applications. The complaints are about
medication, or lack of medication, long waits to see consultants and claims
they are ignored by staff.
“During the last reporting year, the healthcare centre has had a reworking
of the facility to reduce it from dormitory sized rooms to single cell
accommodation. The centre was closed in July 2009 and all in-patients
were transferred to HMP Birmingham. Recently re-opened it now has
improved facilities, including pharmacy and waiting rooms.
“A new healthcare manager, additional administrative staff, pharmacy
assistants and more nurses have been recruited. Hopefully this will bring
some much needed stability to this important facility.”
9. The man’s death was the 12th to have occurred at Dovegate since April 2004
when the Ombudsman began investigating deaths in custody in England and
Wales. Of the 11 previous cases, eight were due to natural causes. In three
of my previous investigations I recommended that the Director and Healthcare
Manager ensure that medical records are maintained to the standard required
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by the General Medical Council and Nursing and Midwifery Council. I am
disappointed to repeat my recommendation again.
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KEY FINDINGS
10. The man arrived at HMP Liverpool from a crown court on 25 May 2004 having
been sentenced to ten years imprisonment. His first reception health screen
identified that he had never been to prison before and had not recently seen a
doctor. He told healthcare staff at Liverpool that he suffered from depression
and panic attacks and had been receiving treatment for the past seven years.
He had no other medical problems or concerns.
11. For his first few years at Dovegate (from November 2004 until March 2008),
the man spent most of his time engaged with educational services and
learning to read and write. He did not wish to participate in any reducing re-
offending courses because he maintained that he was innocent of the crimes
for which he had been convicted. His risk of re-offending did not therefore
diminish in the eyes of the Parole Board. The Parole Board reviewed his case
in April 2009 and refused his application for release on licence.
12. In health terms, the man remained well, with little need to be seen by doctors
or nurses at the prison except for occasional panic attacks or short bouts of
depression.
13. On 22 October 2006, following a long illness, the man’s wife died from cancer.
14. The earliest indication in the man’s clinical record that he was beginning to
become unwell is contained in an entry dated 11 March 2008 (made by an
unidentified doctor). It states that the man had recently started having bowel
problems. The doctor examined him and decided that, if the problems were
not resolved within two to three weeks, the man should be seen again for
further investigations. There are no other entries until July.
15. When the man was seen on 22 July, he complained of diarrhoea and a doctor
diagnosed this was due to an infection. On 10 September, the man was seen
by a nurse who referred him to a doctor due to his continued diarrhoea. He
was seen again on 4, 7, 8 and 11 October and four times on 15 October for
problems relating to loose stools (diarrhoea) and abdominal pain.
16. The man was admitted to outside hospital on 16 October with chest pain and
pain in his abdomen. He was treated with antibiotics and discharged back to
the prison that day with a diagnosis of a chest infection (pneumonia).
17. Three weeks later, on 4 November, the man was admitted to the healthcare
in-patients unit at Dovegate because wing staff were becoming increasingly
concerned about his abdominal pains. He was examined by a nurse who
found that he had swelling of both his feet. She wondered if he might be
suffering from heart failure and therefore referred him to a doctor (the record
does not indicate which doctor). Her entry in the clinical record goes on to
say ‘GP reviewed today and concerns of crackles to chest. GP has faxed off
urgent referral query bowel and lung disease’.
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18. Later that day, the same nurse reviewed the man’s care. In an entry at
8.50pm she reported that he was complaining of pain and had been given
paracetamol, with a further dose held in his own possession to take as
required during the night. She recorded his blood pressure as 159/86 and his
pulse as being 87 (both results are more or less within normal limits, albeit
slightly on the high side). She left instructions for the night nurse to review
him, although there is no record that this was done.
19. The next entry in the clinical record was dated 6 November at 5.15pm by an
unidentified doctor who examined the man and prescribed Buscopan (a
muscle relaxant) and diazepam. The doctor concluded his entry thus ‘If
deteriorating during this night I told staff to send to A&E’. The entry from the
night nurse says ‘[The man] managed to sleep tonight following diazepam and
Buscopan administration around 22.00’. At 2.00am on 7 November, the night
nurse was called again by the man and she gave him paracetamol.
20. On 9 November, the man was admitted to outside hospital as a medical
emergency. He was diagnosed as having multiple duodenal ulcers, some of
which were bleeding internally. He required an operation to rectify this and
following the laparotomy (that is the operation) on 14 November, he was
discharged back to Dovegate five days later on 19 November. During the
operation, the surgical team noticed that the man had ‘lesions’ attached to his
liver (liver lesions are small masses that grow within the liver). It was
therefore arranged that he would have a CT scan (a CT (computed
tomography) scan, uses x-rays and computers to take pictures of the internal
structures of a person’s body). The man had the CT scan at outside hospital
on 31 December.
21. The man went back to outside hospital on 12 January 2009, accompanied by
a nurse. He was to have an oesophogastroduodenoscopy (OGD, or a
camera that looks at a person’s digestive system and enters the body via the
mouth) as a follow up to his CT scan. After the OGD he was told by a
consultant gastroenterologist that he had cancer of the liver which might have
spread from elsewhere in his body, possibly including his pancreas.
22. On 27 January, the man was due to receive chemotherapy, but he refused to
go because, according to his medical notes, he was anxious about the
treatment. Despite the efforts of the then healthcare manager, he was
adamant that he did not want to go to the hospital for treatment. Over the
following week or so, staff at the prison worked hard to reassure the man that
he should go to the hospital, initially so that he could be given more detailed
information about his condition. He eventually agreed to go and on 11
February, duly went to outside hospital.
23. Throughout February, March and April, it appears from the clinical record that
the man was constantly reviewed and attended a number of hospital
appointments. On 19 May, he declined any further hospital appointments.
There is no explanation in the record as to why this was, nor is the entry
signed by the doctor who recorded the man’s decision. The entry does say
that the doctor offered to write to the hospital team but that the man declined
10
his consent. It does not appear from the records that the man went to hospital
out patients appointments again after this date, although he had several
inpatient admissions. The entries in the clinical record from this point on are
restricted to recording physiotherapy sessions and repeat prescription entries.
24. In interview with my investigator, the man’s former roommate described
occasions when his friend complained of severe pain. He told my investigator
that, on one occasion, the pain had reduced the man to tears during the night
but the nurse who came to see him rebuked him for persistently calling her
out. It appears, from the man’s former roommate’s account of events, that the
nurse was only able to offer mild pain relief such as paracetamol and was
reluctant to call a doctor for something stronger to alleviate the man’s pain. It
is unclear when this incident happened and there is nothing in the records to
substantiate the man’s former roommate’s account.
25. On 25 January 2010, an unidentified doctor wrote in the man’s clinical record
that he was complaining of abdominal pain which had persisted for four days.
The doctor examined him and found that his temperature (36.8) and pulse
(70) were normal, but he looked “pasty” and had tenderness of the abdomen
when touched. The doctor recorded that the man was not prepared to go to
the hospital outpatients’ department, but would agree to go to ‘AAU’, (which I
take to be a medical admissions unit at the local hospital). No immediate
arrangement was made to take the man to hospital.
26. During the early hours of the day of his death, the man pressed his cell call
bell. The agency nurse (who again cannot be identified from the record)
wrote in the clinical record that he was:
‘complaining of abdominal pains. On palpitation [meaning to touch and
move] around the umbilical region it felt very hard and he would scream in
pain.’
The nurse called for an ambulance and the man was admitted to outside
hospital. He was handcuffed to an escort officer who, with a colleague,
carried out the bedwatch duties.
27. From the entries in the clinical notes, and the record supplied by officers on
the man’s bedwatch, it is evident that he was examined by doctors at the
hospital who decided that palliative care, rather than active treatment, was
required. A decision ‘not to operate’ on the man was made by clinicians at
outside hospital. They determined that the appropriate treatment was to
ensure that he had sufficient pain relief and fluid intake to make him as
comfortable as possible.
28. A management check of the bedwatch arrangements was made at 7.20pm
and the duty manager said that they should remain in place. Two hours later,
hospital staff advised the bedwatch staff that the man was very poorly and
suggested that his family should be told about his condition. The escort
officer told staff at the prison, presumably including the duty manager, and
were advised to contact the prison again every half hour.
11
29. At 11.55pm that evening the man passed away, although he was not certified
dead until 1.30am the following morning by doctors at the hospital. The
handcuffs were not removed until 11.58pm after permission was given by the
Duty Governor at Dovegate.
30. On the day of the man’s death, staff from Dovegate attended a debriefing
session to consider whether there were any lessons they could learn in
respect of his death. I hope this report contributes to that ongoing process.
31. There was initially some confusion as to who should be considered as the
man’s next of kin. It was originally thought that he had identified some friends
to be his next of kin, but might also have living relatives who would wish to be
involved in the funeral arrangements. In the event, the man’s friends were
involved in his funeral arrangements and his family have been kept informed
of events concerning the funeral and this investigation. Dovegate paid the
costs of the funeral in line with the Prison Service instructions.
12
ISSUES
Clinical care
32. The man was a reasonably fit 52 year old when he came into prison in May
2004. He remained physically well until March 2008 when he first started
having bowel problems. He was initially treated conservatively with antibiotics
as the doctors at Dovegate thought that an infection might be causing his
diarrhoea.
33. On 16 October 2008, the man was sent to the Accident and Emergency
department at outside hospital complaining of chest and abdominal pain. He
was discharged back to Dovegate after a few hours with a diagnosis of an
infection. No discharge letter accompanied him on his return, and health
services at Dovegate did not follow this up.
34. This was important on a number of levels, not least of which is that the man’s
doctors at Dovegate should have known how he had been treated at A&E and
what tests had been performed. Had they made enquiries, they would have
become aware of the blood test results that the man had had whilst at A&E. A
crucial result was for his C-reactive protein (CRP) which is a standard blood
test for proteins which are present in the blood when there is an infection
present. In this man’s case his CRP level was raised when he attended A&E
on 16 October. The clinical reviewer says that this was to be expected if the
man did indeed have an infection such as pneumonia (which is what he had
been diagnosed with).
35. However, doctors at the prison repeated the blood test for CRP on 21 October
which showed a significant increase in the levels of CRP. The levels should
have significantly decreased if the original diagnosis of pneumonia and its
subsequent treatment had been correct. In fact, doctors at Dovegate failed to
review the findings of those later blood tests, and in any event, they did not
have the earlier blood tests to help guide them.
36. A similar state of affairs existed in regards to the man’s liver function tests.
Liver function tests (LFT’s) were asked for and might have shown that the
pain in the man’s lower abdomen was the result of problems with his liver.
However, doctors at the prison did not know the results of the tests they had
asked for. It is fair to say however, that even if doctors at the prison had been
more aware of the blood test anomalies, the clinical reviewer is of the view
that:
”Had the continuity and progression of symptoms been noted it is feasible
that his cancer could have been diagnosed earlier. Certainly his
presentation demanded earlier and more comprehensive investigations
than appear to have been done. I think it would be unreasonable to have
expected the GP’s to diagnose a neuro-endocrine tumour but simple
investigations would have revealed abnormalities in liver function and
biochemistry which may have led to the metastases and other
abnormalities being discovered sooner. These investigations,
13
colonoscopy, abdominal Ultra-sound scan, blood tests, are routine in
patients who present with unexplained symptoms. It must be said
however that even had his cancer been diagnosed sooner this may have
made no difference to the man’s final prognosis and terminal illness.”
37. However, I believe that inadequate systems at Dovegate led to doctors at the
prison failing to enquire about the absence of a discharge letter from the
man’s visit to A&E in October and their failure to recognise that no one had
checked blood test results when they arrived. I therefore make the following
recommendation.
The healthcare manager should review the systems for communication
with outside health service providers, including secondary care
services, to ensure that they are robust and meet the needs of patients
at Dovegate.
38. After some months, it became clear to the doctors treating the man that the
cause of his health problems might be something more grave than an
infection. On 4 November, he was admitted to the prison in-patient unit
because staff were concerned about the continuing deterioration of his health.
The swelling of his lower legs suggested to a nurse that he might be suffering
from heart failure. When the prison doctor saw him, he made an urgent
referral to outside hospital for a consultant assessment of the possibility of
bowel or lung disease. On 9 November, the man was admitted to outside
hospital as a medical emergency and found to have internal bleeding from
duodenal ulcers, requiring an operation.
39. During the operation, surgeons discovered what they believed to be
cancerous lesions on the man’s liver. Further tests after his discharge back to
prison confirmed that he did indeed have a neuro-endocrine tumour and that
he would require treatment for that cancer if he were to survive.
40. The clinical reviewer considers that during the man’s early illness, nursing and
medical staff should have been more alert to the symptoms that he was displaying.
She writes:
“Nursing and medical staff failed to notice a significant change in [the man’s]
health and need for healthcare input … The significance and seriousness of
[the man’s] subsequent deterioration in health does not appear to have been
noted by medical or nursing staff alike.”
The clinical reviewer’s opinion is that:
”the persistence of [the man’s] symptoms demanded a specialist referral and
should have alerted the medical staff to the possibility of an underlying serious
cause, given the patient’s age and previous good health.“
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41. The clinical reviewer adds:
”I believe that such a significant increase in health problems, in a 57 year old
male smoker, should have triggered suspicion of serious underlying pathology.
It would have been clinically appropriate to undertake more comprehensive
investigations, as mentioned above [such as blood tests, colonoscopy, referral
to a gastroenterologist or abdominal ultra-sound scans] after his symptoms had
persisted for more than six to eight weeks.”
42. The clinical reviewer believes that there were a number of contributing factors
to this failure, the most important being the lack of an electronic patient record
system. I support her recommendation to implement a computerised patient
record system.
The Director of Dovegate, in conjunction with the providers of
healthcare services to the prison, should install a computerised clinical
patient record system.
43. I am disappointed to learn of the actions of nursing staff when the man
became acutely unwell in November 2008. He was seen on a number of
occasions by nursing staff when he complained of persistent and excruciating
abdominal pain between 6 and 9 November. On 6 November, (a Thursday),
the on call doctor was asked for advice regarding the man’s severe epigastric
pain and swollen legs. The advice to nursing staff from the doctor was that if
his symptoms became worse he should be sent to A&E. That night the man
called for nursing staff to help him at 11.00pm, 2.00am, 3.00am and 4.20am
because of the severe pain.
44. On 7 November, there is no entry in the man’s clinical record to suggest he
was seen by a doctor, but his blood pressure was recorded as being 150/105
(which is a high reading). No pulse or other observations were recorded.
According to the clinical reviewer, the man’s swollen legs, together with his
high blood pressure, could have indicated a life-threatening renal, cardiac, or
vascular condition. However, there is no evidence of any appropriate further
monitoring or positive action being taken, and no evidence that the man was
reviewed by a doctor.
45. The following day his blood pressure was recorded as being 90/45 (extremely
low). The clinical reviewer says that:
”With the combination of epigastric pain and a low BP urgent hospital
admission should have been arranged immediately with the possible
differential diagnosis of perforated gastric ulcer, aortic aneurysm, acute
Myocardial Infarction (heart attack) or other serious abdominal pathology.
Instead the BP is repeated at 0400hrs, and at 0500hrs when a reading of
110/50 is recorded. No pulse rate is recorded. This either represents
poor clinical record keeping or a failure of the nurse, or nurses, on duty to
recognise serious acute medical illness and to understand the basic
physiology they were measuring.“
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46. The clinical reviewer’s analysis points to an element of incompetence or lack
of training on the part of nursing staff on duty at this time. I have been
informed that the nursing staff concerned were agency staff who are no longer
employed at Dovegate. Had they still been employed at Dovegate I would be
recommending a comprehensive assessment of their competence and
consideration of referral to the NMC (Nursing and Midwifery Council, nursing’s
professional body). Instead I recommend that the healthcare manager sends
a copy of my report to the agency concerned so that the registered manager
can determine what action should be taken.
The healthcare manager should ensure that good standards of record
keeping in the medical record are maintained, in compliance with the
Nursing and Midwifery Council Guidelines for Records and Record
Keeping and Department of Health and NHS Code of Practice Records
Management.
The healthcare manager should ensure that patient observations are
made and recorded.
The healthcare manager should provide a copy of this report to the
agency which employed the nurses who treated the man.
47. During the early part of 2009, the man went to outside hospital for care and
treatment (although it is unclear from the records exactly what treatment he
had), but in May 2009, he refused all further treatment. It is also unclear from
the records whether health services at Dovegate asked for the advice of
palliative care specialists for the man after this date. What is clear is that
nursing and medical staff tried to persuade him on many occasions to engage
more fully with secondary health services in the community. The clinical
reviewer pays tribute to the compassion of the clinical staff:
”The consultations recorded in the IMR show that [the man’s] input from
the healthcare department showed compassion and were in many cases
professionally undertaken and recorded.”
48. However, it is disappointing not to see any evidence of ‘end of life’ care being
planned from the point when the man’s condition was diagnosed as terminal
in January 2009. It does not appear that any attempt to provide specialist
palliative care services was made for the man once he refused to go to
hospital in May 2009. I cannot be sure whether this was because the man
refused all offers of help or because the systems and processes were not
present at Dovegate at this time. I recommend therefore that:
The healthcare manager should ensure there is a robust system in place
for palliative care patients at Dovegate.
49. The clinical reviewer’s report establishes the need for a review of the
pharmacy arrangements for non-standard medication provision. The clinical
reviewer observes that the man was discharged from outside hospital on 11
16
November 2008 and should have had a few days’ supply of medication.
Healthcare staff at Dovegate should have obtained further supplies of his
essential pain relief medication, oramorph. However, three days later, on 22
November, his medication had run out and it took several more days to
organise further supplies. I can only imagine the pain and discomfort the man
must have been subjected to as a result of this failure.
Early release on compassionate grounds
50. Due to the nature of their offence, it is often difficult to grant applications for
release on compassionate grounds to some prisoners. However, even at
Dovegate and other similar category prisons, it is by no means certain that all
applications, even from those convicted of offences of a sexual nature, will be
refused. The possibility of release on compassionate grounds should
therefore be discussed with prisoners and they should be given the
opportunity to apply for such release if they wish. I understand that
healthcare staff might well be focussed on the medical care and not on the
prospects of early release on compassionate grounds. Nevertheless,
discipline staff should be aware of the process and procedure to facilitate
such release.
The Director should ensure that all prisoners who are terminally ill have
the opportunity to apply for release on compassionate licence if they
wish.
Use of restraints
51. The final matter on which I comment is the use of restraints. The man was
taken to outside hospital on the morning of his death. His initial risk
assessment said that he should remain handcuffed to an officer and this
remained the position throughout the day. At 7.20pm a management check
was undertaken by the duty manager who re-affirmed that hand cuffs should
remain applied to the man. The entry by an officer at 9.25pm in the log book
kept by the escorting staff says:
”The sister of the ward approached me and stated that he would not make
it through the night and asked if his family had been contacted due to the
severity of [the man’s] condition.”
Escorting staff contacted the prison and were asked to make further
contact at half hourly intervals. The man remained in handcuffs up to and
beyond the moment of his death. It was only three minutes after he had
passed away that staff removed the handcuffs.
52. The inappropriate use of physical restraints on gravely ill offenders in hospital
is a recurring theme in my reports. I understand why decision-making has
become so risk-averse, but I believe there are many occasions when earlier
decisions to remove restraints would be more consistent with the Prison
Service’s own ‘decency’ agenda. I consider that this is indubitably one such
case. It was clear from the information supplied by the ward sister at 9.25pm
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that the man’s prognosis was extraordinarily grave. He had two officers at his
bedside and I believe that action to review the use of restraints could and
should have been taken more quickly. In other cases I have investigated,
restraints have been removed following a telephone call to the duty governor.
Here I think the bedwatch officers should have been given permission to
remove the restraints after the ward sister’s approach.
53. I should make it clear that my concern relates to Dovegate’s risk assessment
systems rather than to the decisions made by the duty manager and the
escorting officers on the last evening of the man’s life. It was not appropriate
for the man to be in handcuffs at the time of his death and I recommend that
the Director commissions a review of his bedwatch and escort instructions to
ensure that such an unseemly situation does not arise again.
The Director of HMP Dovegate should conduct a review of bedwatch and
escort instructions. They should include explicit guidance for staff on
the action to be taken when a prisoner is gravely ill.
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CONCLUSION
54. The man was 52 years old and in relatively good health when he was sent to
prison in 2004, although he was a heavy smoker. He remained in good health
until early 2008 when he started having prolonged periods of diarrhoea and
related stomach problems. When he was operated on for a perforated
duodenal ulcer, it was found that he had cancer of the neuro-endocrine
system. The clinical reviewer says this is a difficult cancer to diagnose.
55. The man’s cancer was initially treated at outside hospital but in May 2009 he
refused all further help and assistance from the hospital. Notwithstanding
that, staff at the prison continued to support him throughout his illness.
However, they failed to put in place an important element of care for him
which was a palliative care pathway. This resulted in a lack of engagement of
community Macmillan services which might have been of benefit to the man
in the end stages of his illness.
56. On the day of his death, the man was admitted to outside hospital and was
found to be dying. Staff at the prison were advised of this and were asked to
contact the man’s friends and family (which they did). I regret that the man
was not afforded a dignified death free from handcuffs. These were not
removed until after he had died just before midnight, despite a clear indication
that he posed no security risks. I am critical of that decision in this report.
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RECOMMENDATIONS
For the healthcare Manager at Dovegate
1. The healthcare manager should review the systems for communication with
outside health service providers, including secondary care services, to ensure
they are robust and meet the needs of patients at Dovegate.
Service response: Recommendation accepted. The HCC department since
March 2010 has changed all processes for hospital communication and
referrals. All blood tests are now recorded and reported on when returned
from hospital. All referrals are screened, noted and followed by the
administration team. Two systems in place to ensure all hospital
correspondence is recorded. All letters are now seen by the resident doctor
prior to filing. One member of staff maintains the referral processors.
2. The healthcare manager should ensure that good standards of record keeping
in the medical record are maintained, in compliance with the Nursing and
Midwifery Council Guidelines for Records and Record Keeping and
Department of Health and NHS Code of Practice Records Management.
Service response: Recommendation accepted. This is an ongoing issue,
however with new staff, new clinical leads and new management record
keeping and documentation has increased. All staff are fully aware of the
importance of record keeping and maintaining medical records. This will be
audited in 2011.
3. The healthcare manager should ensure that patient observations are made
and recorded.
Service response: Recommendation accepted. As above, all the clinical staff
are fully aware that they must maintain correct information in the medical
record.
4. The healthcare manager should provide a copy of this report to the agency
which employed the nurses who treated the man.
Service response: Recommendation accepted. Report will be sent to the
required Agency and the Clinical Governance Lead for Serco Health for
further action as required.
5. The healthcare manager should ensure there is a robust system in place for
palliative care patients at Dovegate.
Service response: Recommendation accepted. Palliative care policy being
confirmed by Senior Management at Serco Health. A dedicated cell in AAU
now allocated to deal with this. Dedicated AAU nursing staff and clinical team
available as required.
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For the Primary Care Trust
6. The Primary Care Trust should install a computerised clinical patient record
system.
Service response: Recommendation accepted. This is the responsibility of
the PCT. However, it should be noted that the PCT have arranged for the
installation of the system – scheduled for January 2011.
For the Director of Dovegate
7. The Director should ensure that all prisoners who are terminally ill have the
opportunity to apply for release on compassionate licence if they wish.
Service response: Recommendation accepted. Eligible prisoners have the
opportunity to all apply for release on compassionate licence. Applications will
be processed appropriately and the Controller’s Team would be involved in
this process. It should be noted however that any decision whether to
grant is not within the remit of the establishment.
8. The Director of HMP Dovegate should conduct a review of bedwatch and
escort instructions. They should include explicit guidance for staff on the
action to be taken when a prisoner is gravely ill.
Service response: Recommendation accepted. We will revise our local
protocol to ensure that the actions currently taken in respect of terminally
ill/dying prisoners are formally recorded as per “end of life”
procedure/protocol.
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