Individual at Frankland

Investigation into the circumstances surrounding the
death of a man
at HMP Frankland in May 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2011
This is the report of an investigation into the death from natural causes of a man at
HMP Frankland on 4 May 2010.
The man had not been in contact with his family for several years and, when asked
about them by prison staff, he would say that he had no next of kin. Nevertheless, I
offer my sympathy to all those touched by his death. I am sorry that my report has
been delayed and hope that this had not caused any additional distress.
A clinical review of the man’s care and treatment was undertaken by a registered
mental health nurse, supported by a doctor, from the NHS County Durham Primary
Care Trust. I am grateful to the clinical reviewer and the doctor for their assistance.
A post mortem examination confirmed the cause of death to be acute
bronchopneumonia (a chest infection). The man had a complex history of mental
and physical health problems and at times refused to go to prison healthcare and to
outside hospital for necessary medical treatment.
The clinical reviewer concludes that the man received intensive nursing care of a
high standard in Frankland, and comments that the nursing staff should be
commended for the care and attention they gave the man.
I, too, note the care taken by the prison and healthcare staff when looking after the
man. I would be grateful if the Governor and healthcare manager would share my
report with all the staff and pass on my thanks for their patience and dedication
towards the man.
I make one recommendation about checking the weight of prisoners who, like the
man, are in poor health.
Jane Webb
Acting Prisons and Probation Ombudsman February 2011
2
CONTENTS
Summary 4
The investigation process 5
HMP Frankland 6
Key events 7
Issues 15
Conclusion 18
Recommendations 19
3
SUMMARY
The man had a difficult childhood and committed his first offence when he was 12
years old. In 1978, he was convicted of the murder of a fellow prisoner in the young
offender institute where he was awaiting sentence for an earlier conviction. At the
time of his death, the man had been either in prison or NHS secure hospitals
continuously for 33 years.
The man had a history of mental illness (paranoid schizophrenia), from which he
suffered intermittently throughout most of his life. He also had several physical
health problems, including type 2 diabetes (non insulin dependent diabetes), deep
vein thrombosis (blood clots in veins) and peripheral vascular disease (the blood did
not reach the extremities of his body, resulting in the death of the body tissue). He
also had a history of non compliance with medical treatment.
It was in 1996 that the man was diagnosed with type 2 diabetes. He was prescribed
medication, but did not take it regularly. In early 2008, the man’s toes became
gangrenous and he required what was to be the first of a number of operations on
his toes, feet and legs. Each time that treatment was proposed, the man accepted in
principle the need, but would delay going into hospital, or discharge himself from
hospital against medical advice.
Towards the end of 2009, the man was told that he needed an operation to remove
his leg above the knee. Although he seemed to understand the consequences of not
having surgical intervention, he refused to have the operation. The man told staff
that he wanted to remain in prison, rather than hospital. In his final months he
received intensive nursing care in Frankland’s healthcare unit.
The man seems to have been a difficult and challenging patient for staff at
Frankland. Nevertheless, as my report shows, I believe that they did all they could to
make this time more comfortable for him and I consider that he received a high
standard of care. I am satisfied that the care the man received was at least to a level
expected in the community.
This report includes one recommendation with regard to prisoners on the chronic
disease register receiving regular weight checks.
4
THE INVESTIGATION PROCESS
1. The Ombudsman’s appointed investigator first visited HMP Frankland on 14
May 2010 when he met one of Frankland’s managers, one of the nurses
involved in the man’s care and the principal officer in healthcare. The
investigator also met a representative from Frankland’s Independent
Monitoring Board.
2. County Durham Primary Care Trust agreed to carry out a review of the man’s
clinical care and treatment at Frankland and I am grateful to the clinical
reviewer and the GP advisor for their report.
3. The clinical reviewer spoke to the investigator at the start of the review and
kept in regular contact throughout. The clinical reviewer examined the
medical records, including those recorded on the computerised system, and
made two visits to Frankland to familiarise himself with the practices and to
interview staff. He also spoke with the consultant vascular surgeon at the
local hospital who was responsible for the man’s treatment in hospital.
4. Given the number of years that the man spent in custody, I have taken the
decision not to investigate events over the whole of his sentence. I have
focussed on the time that the man spent at Frankland, from when it was
identified that he needed treatment, including an operation, for peripheral
ischaemic vascular disease.
5
HMP FRANKLAND
5. HMP Frankland is one of eight high security establishments in England and
Wales. Frankland holds convicted category A and B adult male prisoners,
and also holds high risk remand prisoners. The operational capacity of the
prison is 859.
6. Healthcare services at Frankland are provided by the County Durham Primary
Care Trust. The healthcare centre provides 24 hour inpatient care, consisting
of two wards with capacity for three and four prisoners respectively and ten
single rooms. The man lived in one of the single rooms for the last months of
his life.
7. The most recent full inspection of Frankland by the Chief Inspector of Prisons,
is dated February 2008, describes Frankland as “drifting” in some key areas,
notably in relation to safety with a lack of evidence of a robust violence
reduction strategy and effective staff-prisoner relationships.
8. In regard to the healthcare unit and caring for the health of prisoners, the
report found that healthcare services were generally good although staffing
levels were low. The in-patient unit was a positive environment and patients
were well cared for, although a new day care centre to support mentally ill
patients was much needed. There was excellent collaborative work between
County Durham Primary Care Trust and the prison with prisoners able to
access equitable NHS services while in prison.
9. All prisons in England and Wales have an Independent Monitoring Board
(IMB). IMB members are volunteers who monitor day-to-day life in the prison
to help ensure proper standards of care and decency are maintained. The
Board’s report for the year from 2008 to 2009 does not raise any issues that
are relevant to the circumstances of the man’s death.
10. The clinical reviewer found that Frankland is in the process of moving to a
new system of recording healthcare information. The existing system in use
at Frankland is known as EMIS. This is being replaced by a product known
as “System One” which, I understand, the Prison Service is introducing in all
prisons. This will provide for easier exchange of information when a prisoner
moves between prisons. The clinical reviewer’s report highlights the need to
ensure that all staff are fully trained to use System One.
11. Since my office took over responsibility for investigating all deaths in prison
custody in 2004, there have been 39 deaths attributed to natural causes at
Frankland up to and including the man’s death. None of the issues arising in
any of those cases are directly relevant to the circumstances surrounding the
man’s death.
6
KEY EVENTS
12. The man was the youngest of five boys and also had nine older half-siblings
from both of his parents’ previous marriages. He described his childhood as
difficult. He spent time in local authority residential care and, by the age of
14, was placed in a residential school. Following a conviction for assault
occasioning actual bodily harm, the man was sentenced to three months in a
young offenders institute (YOI).
13. While at the YOI, the man was involved jointly in a fatal attack on another
young person. He was subsequently convicted of murder and sentenced to
be detained at Her Majesty’s pleasure1. The trial judge described him as “not
unintelligent”. (The man has since been described by clinicians as having an
IQ at the lower end of ordinary intellectual functioning.) He was 17 when he
committed the offence. At the time he was awaiting sentencing for sexual
offences and theft.
14. During the early years of the man’s time in custody he spent time at several
YOI’s as well as time in NHS secure hospitals. In May 1988, the man was
transferred to the acute psychiatric unit at HMP Grendon. He left Grendon in
December 1991 and was unable to settle at a number of prisons before being
moved to Frankland in January 1994. The prison records indicate that,
throughout his time in prison, staff expressed concern regarding the man’s
mental health and his ability to comply with the regime. Towards the end of
1994, the man was diagnosed as suffering from mental illness (paranoid
schizophrenia) and, in May 1995, transferred from prison to an NHS secure
hospital.
15. In 1996, the man was diagnosed with type 2 diabetes (also known as non-
insulin dependent diabetes mellitus). The diabetes was controlled by close
dietary management and Metformin medication. He also had a history of
deep vein thrombosis (formation of a blood clot in a deep vein) for which he
was prescribed anti-coagulants (which stop the blood from clotting).
16. The man remained in a secure hospital until January 2001 when he
transferred back to Frankland, following a change in his psychiatric diagnosis.
He returned to a secure hospital between January 2003 and February 2004,
returning to Frankland in March 2004. At the end of 2005 and in early 2006,
the man was considered again for transfer to secure hospital but the clinical
assessment was that he did not require further treatment in a secure hospital
setting. Although the man’s mental illness was assessed in 2007 as in
remission, he was treated for paranoid schizophrenia (risperidone) right up
until his death. The man had a life long history of obesity, and is reported to
have been a heavy smoker from a young age.
17. In January 2008, in Frankland, the man complained of numbness in his toes.
On 14 January, he was seen by one of Frankland’s doctors who determined
1 Being detained at Her Majesty’s Pleasure is the sentence given to a person under 18 years of age
who is convicted of an offence for which an adult would receive a mandatory life sentence (such as
murder).
7
that he should be a referred to a vascular clinic for assessment for suspected
peripheral ischaemic vascular disease. He was seen by healthcare staff on a
number of occasions during the following two weeks, although on one
occasion, 24 January, he refused to go to healthcare for his feet to be
assessed.
18. Following a visit to the vascular clinic at the local hospital on 29 January, a
consultant general vascular surgeon telephoned the prison to say that he
would admit the man for an amputation of a toe on the left foot and possibly
further surgery. However, the man refused to consent to treatment, and, on
31 January, signed his own discharge from hospital, despite being told that
lack of treatment might cause him to lose his leg.
19. On return to prison, the man refused to stay in healthcare and said this was
because he could not smoke there. The policy on smoking in the healthcare
centre of Frankland is the responsibility of County Durham Primary Care
Trust. On 1 June 2007, a total ban of smoking was introduced anywhere in
healthcare, including the inpatient area and garden. From 1 July 2007,
Frankland became a no smoking prison, with the exception of prisoners being
able to smoke in their own cells. Smoking cessation clinics are available at
Frankland and prisoners are offered nicotine replacement therapy.
20. The man was offered nicotine products to help give up smoking, but he
declined. The doctor from the prison that recommended he should be
referred to a vascular clinic liaised with the surgeon on the treatment he
advised, which was flucloxacillin and sodium fusidate medication (used to
treat infections). A mental health capacity test was undertaken on 1
February2. The man was shown to understand the consequences of his
decision to refuse treatment. He told a nurse, that he found the local hospital
environment stressful due to being handcuffed to prison staff3 when nurses
were giving personal care, and this led to him discharging himself.
21. The man had regular consultations with the doctors in Frankland over the
following few months. The doctor who recommended referral to the vascular
clinic examined the man on 4 February and confirmed that he was accepting
his medication. When Frankland’s medical officer (the doctor in charge)
reviewed the man on 3 March, he warned him of the risk of refusing surgical
intervention. The man continued to receive his medication for paranoid
schizophrenia by the depot method and his mental state remained stable.
(Depot is the method of administering the medication by injection to guarantee
compliance.)
2 The Mental Capacity Act 2005 requires that a person must be given appropriate help and support to
enable them to make their own decisions or to maximise their participation in any decision making
process.
3 If a prisoner is admitted to outside hospital, depending on the risk assessment carried out by the
prison, they are generally escorted by two officers who stay beside their bed at all times. Two or
three daily shifts of officers will stay with the prisoner until treatment is completed. In addition
restraints, such as handcuffs, may be used.
8
22. When the man consulted another of Frankland’s doctors in early June he said
that his toes, which were gangrenous, were causing him pain. He agreed to
be admitted to hospital and was referred to the consultant general vascular
surgeon at the local hospital. On 12 June, the great (big) and the small toe of
his left foot were amputated. On return from hospital the man spent a week in
Frankland’s healthcare centre before asking to return to the wing so that he
could smoke. The medical officer from Frankland agreed to him returning to
the wing for 24 hours for that purpose.
23. The clinical record shows that in the following months the man was regularly
reviewed by healthcare staff to have the dressing on his foot changed, for
injecting his medication, and monitoring his diabetes. When assessed on 23
October, the small toe was noted to be 98 percent healed and the great toe
was 20 percent slough (dead body tissue). The record notes the occasions
when the man failed to go to medical appointments. On 8 January 2009, he
refused to attend the consultant general vascular surgeon’s clinic in Frankland
for blood tests (periodically the surgeon held a clinic in the prison), and on 12
January he refused to go to a medical review. When asked why he failed to
attend, on each occasion the man said he “couldn’t be bothered”. When he
was reviewed on 17 January by a nurse, it was noted he had replaced the
dressing on his foot with a milk and bread poultice (a homemade dressing).
24. In February 2009, the man told a nurse that he was very worried about the big
toe area on his left foot which he found very painful. He was examined by
another of Frankland’s doctors, who prescribed oral antibiotics and referred
him to the consultant general vascular surgeon.
25. The consultant general vascular surgeon reviewed the man on 11 March and
decided that he should be admitted to hospital for surgery. The man went into
the local hospital on 13 March where preparation for further surgery was
started by first taking action to stabilise his diabetes. Two days after
admission to hospital, the man discharged himself against medical advice.
26. On 6 May, at the consultant general vascular surgeon’s clinic at Frankland,
the man agreed to be readmitted to hospital. He was admitted to the local
hospital on 8 May and two days later his right forefoot was amputated. On 15
May, he once again discharged himself from hospital against medical advice
and returned to Frankland’s healthcare centre. Nine days later, on 24 May,
he discharged himself from healthcare despite being advised that it would be
beneficial to his recovery to remain there.
27. On 4 June, he was readmitted to healthcare suffering from pain where the
great toe of his left foot had been amputated. The man was given appropriate
treatment but, on 8 June, he refused further help and to remain in healthcare.
28. A multidisciplinary case conference was held on 12 August at which the
medication prescribed to the man was reviewed. He continued to be
prescribed Metformin (for diabetes) and risperidone (for schizophrenia), as
well as aspirin and antibiotics on an intermittent basis. The record of the
meeting notes that there were no concerns about the man’s mental state
9
which was assessed as stable. (The record does not include any further
detail of the meeting.)
29. On 11 September, the man refused an appointment to attend healthcare to
see the consultant general vascular surgeon even though an officer offered to
take him there in a wheelchair. He also refused to see the surgeon when the
consultant went to the wing where the man lived. The surgeon told the staff
that, if they had any further concerns, the man should be admitted to the local
hospital as an emergency.
30. Ten days later, on 21 September, the man told the healthcare senior officer,
that he was willing to see the consultant general vascular surgeon. She noted
in the medical record that she believed he was frightened due to the pain,
discomfort and general deterioration he was experiencing. The man had
begun to suffer loss of bladder control the previous week, and now spent the
daytime sitting in a chair. He declined the offer to be admitted to healthcare.
He was admitted to the local hospital on 24 September, but discharged
himself on the same day.
31. On 30 September, the County Durham Wheelchair Service agreed to supply a
wheelchair for the man, which was delivered to Frankland on 3 October. On
the same day (3 October) staff on the wing raised concerns with healthcare
staff about the man’s personal hygiene. Staff were taking his meals to him as
his hygiene problems were affecting other prisoners.
32. An appointment was made for the man to see a doctor on 5 October, but he
refused to attend. The staff on the wing considered it necessary for him to be
admitted to the healthcare wing as his wounds were weeping freely and he
was incontinent of urine. He also now required nursing intervention on a daily
basis. In addition, he had not been complying with any of the suggestions to
help him, such as spending time out of his wheelchair where he now
remained day and night. The man told a registered mental health nurse, that
he felt his mental state had deteriorated because of what the other prisoners
said about him. The clinical record noted that the man “is already under the
care of the mental health team and a member of staff is to have him
reassessed further”. There is no record of whether the assessment took
place.
33. The man was admitted to healthcare on 5 October, though he went
reluctantly. He initially declined the offer to wear a nicotine patch to help him
stop smoking.
34. Another of Frankland’s doctors reviewed the man on 6 October. The clinical
record noted that the doctor had a ‘frank’ discussion with him about the
consequences of refusing medical intervention. The man told her he believed
he would be worse off having further treatment in hospital, but agreed to be
admitted to hospital for surgery.
10
35. The local hospital confirmed on 8 October that a bed was available on the
surgical admissions ward. However, the man was not taken to hospital as no
staff were available to escort him.
36. Following further deterioration in the man’s condition, the doctor that
examined him in February and gave him oral antibiotics decided on 14
October that he should be taken to accident and emergency at the local
hospital as an urgent GP admission. In his letter to the hospital the doctor
reported that the man “admitted to being frightened about the future
consequences of further treatment“. He also noted that the man was “now
generally unwell with nausea and vomiting and increased pain in his leg”.
Two days after admission, on 16 October, the man discharged himself against
medical advice. He had been told that he would need an above knee
amputation which he did not want.
37. The medical record on 17 November, states that the man “continues to want
to stop smoking however finding [nicotine] patches unsuitable therefore will try
inhalator”. (The medical record does not record the date on which a nicotine
patch was provided.)
38. On 8 December, one of the health support staff observed that the man looked
unwell. He appeared confused and his lips were dry. She noted that he was
taking little food or fluid. He declined to drink tea or to lie down to relieve the
pressure on his buttocks. Separately another of Frankland’s doctors saw the
man and determined that he needed to go to hospital for treatment as an
emergency admission. A staff nurse explained the consequences of not
going to hospital and told him that there was a strong possibility that he could
die if his gangrene was left untreated. The man continued to refuse to go to
hospital. The clinical record noted that the staff satisfied themselves that the
man had been given sufficient information and had the capacity to make an
informed decision.
39. The following day, 9 December, Frankland’s medical officer told the man that
he could become dangerously ill because of his high potassium level. The
doctor said that the prison healthcare did not have the facilities to treat his
condition. The man said he would agree to go to hospital if he could be
allowed to smoke three cigarettes. He was not allowed to smoke in the
healthcare centre and staff were unsuccessful in finding a vacant cell on the
wings where the man could smoke. Staff continued their efforts to persuade
the man to go to hospital, and he agreed. He was admitted to accident and
emergency of the local hospital on 9 December as an urgent GP admission.
40. During his stay in hospital, the man was diagnosed with tachycardia
(accelerated heart rate) and given intravenous antibiotics. (Antibiotics
administered intravenously results in a more rapid effect.) He was discharged
back to Frankland on 22 December.
41. On 30 December, the man was assessed for a hoist to help him get in and out
of bed and a pressure relieving cushion for a chair. Healthcare staff gave bed
11
baths (as he continued to be incontinent) and the wound dressing on his foot
was changed regularly.
42. A consultant psychiatrist saw the man on 7 January 2010 and changed the
administration of the medication for his paranoid schizophrenia from the depot
injection to an oral form. This was because the deterioration in his physical
state meant that it was no longer possible to give an injection.
43. On 27 January, the man was seen by Frankland’s medical officer who noted a
general deterioration in his health. The man said he was unable to swallow
solid food and so soft foods and food supplement drinks were provided. The
medical officer referred him to the consultant general vascular surgeon who
told him that, in view of the deteriorating condition, he needed to be admitted
to hospital. On 29 January, he was admitted to the local hospital for possible
surgery on his leg.
44. During the following week the man remained stable in hospital while a
decision on surgery was being considered. On 8 February, he discharged
himself from hospital despite being warned that such action might result in
further deterioration of his health. On return to Frankland, the man told an
officer that he knew the consequences of his action and said “I will die”. That
evening, he refused medication. The officer told my investigator that he had
asked the man about his next of kin and was told he had no one who should
be contacted. (His mother died in 1976. His father, who had visited him on a
fortnightly basis until his own death, had died in 1989. Other members of the
family did not visit and, in recent years, he received neither visits nor letters.)
45. Over the next few days the man refused food but took a little fluid of milk and
water. On 15 February, he again refused his medication and also declined
any help with his personal care. (The staff had continued to assist him with
personal care as he had become doubly incontinent.)
46. On 22 February, Frankland’s medical officer told the man that he might die if
he did not accept medical intervention. The man said he would not attend an
out patient appointment for an MRI scan (which visualises a detailed internal
structure of the body) which had been arranged for him.
47. The consultant general vascular surgeon saw the man on 17 March and noted
that he was continuing to refuse food, losing weight, and his leg ulcers had
worsened. The consultant recorded “[he] is markedly deteriorating”. The
following day, a mental capacity test was undertaken by the doctor who had
initially examined him in February and prescribed him oral antibiotics, along
with a Registered General Nurse (RGN) who was the clinical team leader and
another RGN. A palliative care Macmillan nurse was also present.
(Macmillan nurses provide specialist advice and support for people who are
near the end of their lives.) The man was offered information about his
condition but did not want to discuss anything and declined any further
management or treatment and transfer to hospital. The clinical record noted
that he fully understood the seriousness of his medical condition, that he knew
he would die if he refused treatment, and was able to retain the information
12
given to him and convey it back. The man said that the consultant general
vascular surgeon had told him he would die without treatment and the man
knew that he “would not make it without treatment”. The officer he spoke to
on his return to Frankland and the RGN who was the clinical team leader
reported that they had asked the prisoners on the man’s wing about visiting
him in the healthcare centre but none of them wished to do so.
48. The doctor who had previously reviewed him on the 6 October saw the man
on 26 March and noted that he was gaunt and sallow and continuing to lose
weight. The following day, he was seen by Frankland’s medical officer who
arranged an emergency admission to the local hospital. At the local hospital
he was told that he should have an amputation of part of his leg and was
taken on the surgical admissions ward.
49. On 29 March, the man discharged himself from the local hospital against the
counselling and advice of hospital staff. On his return to healthcare at
Frankland, he told the doctor he had most recently seen that he appreciated
the risk that the deterioration in his condition could result in death unless
treated, but he still did not want to return to hospital. The consultant general
vascular surgeon also saw him and noted he was continuing to refuse food,
losing weight and that his health was deteriorating. His psychiatric state was
assessed as reasonable. Frankland’s medical officer and the consultant
general vascular surgeon discussed whether to use a nasogastric feed (using
a tube passed down the nose into the stomach to feed) but it was not felt to
be a viable option in a prison setting. They agreed that the man should be
placed on the end of life pathway. (The purpose of the pathway is to access
high quality care for people approaching the end of life.)
50. The doctor he had seen last saw the man on 30 March and explained the risk
that deterioration in his condition would result in death. The man repeated
that he understood the risk but did not want to go to hospital.
51. Another doctor saw the man the next day, 31 March. The man said he was
receiving adequate pain relief and did not need any further medical
management. The clinical record states “[mental] capacity has been
assessed by nursing staff and found to be present”. The clinical team leader
contacted the Macmillan nurse the man had seen previously, who agreed to
provide a palliative care plan.
52. A palliative care plan meeting took place on 1 April between the doctor who
first saw him in February and prescribed oral antibiotics, the clinical team
leader and the palliative care Macmillan nurse. The man was present, alert
and responsive, though fatigued and unwell. He was told about the options
for further treatment, and transfer to hospital but said that he did not want
intervention, such as a blood transfusion. With regard to his recent self
discharge from the local hospital, he said that his preferred place of care was
in prison. He signed a “Not for Resuscitation” document and said that
everything is “just being too much”. He asked for a cigarette and became
agitated when he was not allowed to smoke. It was agreed the healthcare
team would review him every day.
13
53. The man was visited by the Roman Catholic chaplain on 2 April who gave him
Holy Communion. The chaplain reported that the man both appeared, and
stated, that he felt more relaxed and at peace afterwards.
54. Between 2 April and 4 May the man was seen each day by healthcare staff
who administered his medication, gave him oral fluids and regularly changed
his clothes and provided personal care. There were occasions when he
declined any help from nursing staff, and refused to take liquids. He had been
scheduled to go to hospital on 14 April for a gastroscopy (a procedure that
visualises the upper part of the gastrointestinal tract) but refused to go. In
addition, the doctor who initially saw him in February considered that he was
not well enough to travel. An appointment to see the doctor on 22 April was
cancelled with the doctor’s agreement as the man was too poorly to go to the
surgery. On 23 April, a “dynamic overlay mattress” was delivered to the
prison and the following day a nimbus mattress was placed on the base of the
bed to make sleeping more comfortable for the man.
55. At about 2.00am on 4 May the man was given his usual medication. He was
checked by staff two hours later at 4.00am when he appeared to be
comfortable. At 4.40am, a staff nurse made a routine check of prisoners and
saw the man lying on the floor. The nurse went into the room with another
staff nurse and on checking the man, found no apparent signs of life (no sign
of breathing and no pulse). An emergency ambulance was called, which
arrived at 5.15am. The staff nurse who found the man also called an out of
hours doctor who examined him and confirmed death. The Macmillan nurse
was also informed.
56. The police attended Frankland and found nothing suspicious about the death.
A post mortem examination, made at the request of the coroner, revealed the
cause of death to be acute bronchopneumonia (chest infection). The
pathologist noted that Type 2 diabetes was known to hasten peripheral
vascular disease (of which gangrene and ulcers are ultimately complications)
and should be regarded as having contributed to the man’s death.
14
ISSUES
The length of time the man served in custody
57. The man was sentenced in November 1978 to be detained at Her Majesty’s
Pleasure with a minimum term to be served of 12 years and one day. The
term to be served was reached on 19 April 1990. After that date he was
eligible to have his case for release considered by the Parole Board. (The
Parole Board is responsible for the release of prisoners serving a life
sentence, or sentence equivalent to a life sentence. A case cannot be
referred to the Board until a prisoner has served the minimum term. The
Board is empowered to direct release if satisfied that it is no longer necessary
for the protection of the public that the individual should remain in prison.)
The man also spent periods in NHS secure hospitals. Prisoners are not
eligible to apply to the Parole Board whilst in a secure hospital.
58. The man’s case was considered by the Parole Board in September 2004 and
they decided not to direct his release from prison. The Board accepted the
view given to them by a clinician that the man was not ready for release and
should be rehabilitated through the health service system. From 1995 to
February 2004, the man spent considerable periods in NHS secure hospitals
being treated for his mental illness. He was again considered for transfer in
late 2005 and early 2006 but was not transferred. The Parole Board last
looked at the man’s case in 2009 when it decided that it was not safe to direct
his release from prison or to recommend that he should be moved to
conditions of less security (Frankland is a high security prison). The grounds
for their decision was that the man had not completed offending behaviour
work and further work was required to address areas of risk. I am satisfied
that proper consideration was given to whether he could be released and that
the appropriate decision was made.
The man’s refusal of medical intervention
59. The doctors at Frankland referred the man for medical treatment to the local
hospital on six separate occasions between January 2008 and his death in
May 2010. On five of those admissions, the man discharged himself from
hospital. The clinical record shows that the man was warned three times by
hospital staff about the consequences of refusing medical treatment. He
signed a disclaimer to confirm that he understood what he was doing. The
reasons which the man gave for discharging himself included that he felt
stressed about receiving personal care whilst handcuffed to prison officers
and that the hospital had made him sit around and were “mucking him
around”. He also said he was frightened about further treatment. When told
that an above the knee operation was required, he told medical staff that he
did not want the operation.
60. In the same period the man discharged himself four times from the healthcare
centre at Frankland. The clinical record shows that he was warned each time
of the consequences and signed a disclaimer to that effect. The reason why
he discharged himself is recorded on one occasion, this was because he
15
could not smoke there. It also is apparent that, on some of the occasions
when he refused to go to healthcare, it was also because he could not smoke
there.
61. The clinical reviewer considers whether anything more could have been done
by prison staff to make the man accept treatment. He finds that the man had
received repeated counselling that he would die without further surgical
intervention. He also comments that the man was mentally stable during the
last two years of his life and continued to receive appropriate psychiatric
treatment and oversight up until his death. The clinical reviewer concludes:
“It is clear from the records, and interviews with staff, that [the man] was
very much aware of the consequences of not having treatment … [and]
there is no doubt that [he] had the capacity to make his own decision
about his future”.
62. After so many years in prison and secure hospitals, I can understand that the
man may well have been reluctant to leave what was a familiar environment.
Smoking seems to have been an important consideration but I believe that
Frankland’s staff attempted to meet his needs.
The man’s weight loss
63. It is evident from the medical records that the man had experienced severe
weight loss prior to the start of the deterioration in his health in 2008. The
clinical reviewer reports that when the man returned to Frankland from an
NHS secure hospital in March 2004, he weighed 133kg. Ten months later, in
January 2005 he weighed 146kg. But by March 2008, his weight had fallen to
79kg. The clinical reviewer concludes that the significant weight loss is
consistent with, and probably due to, the man’s non compliance with the
treatment for diabetes.
64. The clinical reviewer also highlights that he was unable to find a record of the
man’s weight between January 2005 and March 2008. He is unable to say
whether this is because the man was not weighed or because he refusal to
attend diabetic reviews. The clinical reviewer adds that not all the records
were available when he researched this issue as they were being archived in
connection with the move to the new electronic recording system.
65. The clinical reviewer has recommended that the Head of Healthcare ensure
that prisoners on the chronic disease register have a regular weight check. I
endorse this recommendation.
The Head of Healthcare should ensure that prisoners on the chronic
disease register have a regular weight check and that this is recorded in
the prisoner’s medical record.
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Use of restraints
66. The man told the staff at Frankland that he did not like being handcuffed to
prison staff when he was in hospital and whilst nurses were attending to his
personal care. A risk assessment is always made when prisoners attend
hospital appointments. This determines the level of escort and the restraints
(handcuffs) required for the safe custody of the prisoner. Restraints are
applied if the risk assessment states that they are necessary, and prison staff
are allocated to escort the prisoner. The risk assessment considers the
prisoner’s medical condition, their behaviour in prison, the nature of the
offence, any risk to the public and hospital staff, the prisoner’s motivation to
escape, and the physical security of the hospital.
67. Following the risk assessment on the man, staff at Frankland decided that
restraints should be used. It is unfortunate that he felt so concerned about
being handcuffed that it affected his decision whether or not to accept
treatment in hospital. However, given the man’s history, I believe that the
correct decision was made and the restraints were appropriate.
Clinical care
68. The man’s clinical care was compromised by his frequent lack of co-operation
with treatment. Nevertheless, he received extensive and detailed care. It
included regular medical reviews including revisions of his medication, timely
referrals to a consultant vascular surgeon, and engagement of the Macmillan
palliative care team at the appropriate time.
69. There was one occasion when the man missed a hospital appointment
because of a lack of staff available to escort him. Whilst there is no
suggestion that this affected his care, the Governor will wish to satisfy himself
about the adequacy of arrangements for provision of escorting staff.
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CONCLUSION
70. The man had lived in prison and NHS secure hospitals continuously since the
age of 16. He had complex physical and mental health needs. Whilst he
accepted some surgical intervention, he had a history of refusing medical
treatment. In 2009, when he was told that he would need an amputation of a
leg above the knee, he refused any further surgery despite knowing that his
decision would probably lead to his death.
71. I am satisfied that the man was fully aware of the consequences of his
decision to refuse this treatment. I am also satisfied that he was cared for
appropriately and with compassion by wing, healthcare and chaplaincy staff at
Frankland.
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RECOMMENDATION
1. The Head of Healthcare should ensure that prisoners on the chronic disease
register have a regular weight check and that this is recorded in the prisoner’s
medical record.
Response from Service: Recommendation accepted. Healthcare have now moved
IT systems to Systemone with clinical templates for all Long Term conditions. Within
these templates are requirements for regular weight checks and dietary advice.
These are now fully operational.
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