Individual at Foston Hall

The death in custody of a woman at
HMP Foston Hall - 2 June 2004
Report by the Prisons and Probation Ombudsman for England and
Wales
3 November 2004
Foreword
This is the report of an investigation into the circumstances of the death of a
married woman who died on 2 June 2004 while in the custody of HMP Foston
Hall. She was serving a life sentence at Foston Hall at the time of her death.
All deaths of prisoners in custody are investigated, including those due to
natural causes. The responsibility for carrying out these investigations
traditionally fell to the Prison Service itself, but has now been passed to the
Prisons and Probation Ombudsman (PPO) to bring independence and greater
consistency to the task. In this case, the investigation has been carried out by
one of my Assistant Ombudsmen.
An independent clinical review was commissioned jointly by Derbyshire Dales
and South Derbyshire PCT and HMP Foston Hall in April 2004. They were
requested to examine the standards of care received by the woman during her
stay in the Health Care Centre at HMP Foston Hall and as an in patient at
nearby hospital.
My colleagues and I would like to extend our condolences to the family for
their loss. We would also like to thank the Governor of Foston Hall, and the
other members of her staff who assisted us during the investigation. We found
all the staff at Foston Hall most helpful, in particular the PA to the Governor,
who organised our visits and gathered together all the documentation we
required.
Stephen Shaw
Prisons and Probation Ombudsman
3 November 2004
Contents
FOREWORD 2
CONTENTS 3
SUMMARY 4
INVESTIGATION PROCESS 6
EVENTS LEADING UP TO THE DEATH 7
POST INCIDENT RESPONSE 8
LEVEL OF COMPLIANCE 9
RELEASE ON COMPASSIONATE GROUNDS 10
FINDINGS 11
CONCLUSIONS 12
RECOMMENDATIONS 13
GOOD PRACTICE 14
Summary
This woman died of renal failure at the age of 62 at a hospital in Burton-on-
Trent. She had been a life sentence prisoner for 17 years and had been at
HMP Foston Hall since 13 May 2003.
The woman had complex health needs. She suffered from diabetes, and
several of its complications, including retinopathy, vascular disease and renal
failure. The clinical review of her care while at Foston Hall described the
prison’s Health Care Centre as not being designed, staffed or equipped to
meet this woman’s needs.
She left a son and two daughters who recognised that 17 years of
institutionalisation had taken its toll on their mother. However, they felt that
the prison staff were helpful and had done what they could for her.
There are a number of lessons to be learned from this death, in particular,
about how prisoners with complex healthcare needs are cared for by the
Prison Service, communication between hospitals and prison Health Care
Centres and the issue of compassionate release of prisoners with terminal
illness.
This version of my report, published on my website, has been amended to
remove the name of the deceased and the names of any staff or prisoners
who were involved in this investigation.
Investigation process
All the indications were that this was a death from natural causes. In
accordance with the Terms of Reference for investigating deaths, my
approach in cases of apparent natural cause deaths has been to conduct an
initial review to determine if a full investigation is justified. In this case, there
has already been a full clinical review covering the period 1 January 2004 to 3
April 2004. The team also examined the records up to 2 June 2004 and they
concluded that the Health Care Centre at Foston Hall was not sufficiently
equipped to care for prisoners with such complex health needs as this woman
They made a number of recommendations to be followed should Foston Hall
take on prisoners with these needs in the future. There had also been some
communication failures between the hospital and the prison and that these
had increased during the period from April to June 2004. I decided in the
circumstances that I did not require a further full investigation.
The investigators visited Foston Hall and had a very helpful discussion with
the Governor as well as with the Healthcare Manager, a doctor, an officer, the
representative of the Prison Officers Association (POA), and the Chair of the
Independent Monitoring Board.
They were given access to all the woman’s records, including her medical
records, and we were given copies of everything requested.
The investigator spoke to the woman’s son, who said that he would like to
thank all the staff at Foston Hall for the care given to his mother.
The Stafford Coroner noted that he had no particular worries about the
circumstances of this death and listed the inquest to take place on 15 July
2004. This was later adjourned, due to other inquest schedules, and is to be
listed again.
Events Leading up to the Death
The woman was admitted to a hospital in Burton–on-Trent on 7 April 2004,
suffering with hypoglycaemia and a problem of recurrent vomiting. It was also
noted that she had a decrease in kidney function. The hospital noted that ‘her
management and monitoring have been complicated by the fact that she has
refused on several occasions to have blood tests taken’ and therefore they
were unable to closely monitor her kidney function.
On 13 May 2004, the Consultant Renal Physician wrote stating that in his
opinion Mrs Ali had quite severe chronic renal failure due to her diabetes. He
noted also that, due to her very weak condition and multiple complications
related to the diabetes, she would not be able to tolerate any form of dialysis
treatment. ‘It is therefore likely that her kidney function will continue to
deteriorate and that she will die from kidney failure.’
From 11 May 2004, the hospital were trying to discharge the woman, as there
was no further treatment they could give for her renal failure. The prison were
reluctant to have her returned and were trying very hard to secure
compassionate release for her into a hospice.
The woman was eventually returned from hospital to Foston Hall on 27 May
2004 where her condition was recorded as 'okay', until the night of 30 May
2004 when she deteriorated and was returned to the nearby hospital.
Post Incident Response
On Wednesday 2 June 2004 the Governor broke the news of the death to
staff and the Muslim Minister. On afternoon unlock, residential staff informed
the woman’s close friends.
At association the same day, prisoners on each wing were gathered in their
association room, with Listeners on stand-by, and told of the woman’s. They
were allowed an extra half hour association and the Chapel and Multi-faith
room were made available.
On Thursday 3 June 2004, the woman’s son, visited the prison for a time,
talked to the Governor and staff, and collected his mother’s property.
The funeral was held on Friday 4 June 2004. Three staff attended and
flowers were sent from prisoners and staff at Foston Hall. These we are told,
were particularly welcomed by the family.
On 10 June 2004 a memorial service was led by the Muslim Minister at
Foston Hall. This was well attended by both staff and prisoners.
Later the Governor found some photographs of the woman at the 2003 Eid
celebrations, and she sent them to her son on 12 July 2004.
Level of Compliance
Standards of health care in prisons are intended to mirror those available in
the outside community. Because of concerns about the woman’s care during
her recent stay in the in-patient bed at the Health Care Unit at Foston Hall, a
clinical review was commissioned jointly by Derbyshire Dales and South
Derbyshire PCT and Foston Hall. The review team were:
The Clinical Governance Lead from Derbyshire Dales, South Derbyshire PCT
The Clinical Governance Manager from, Derbyshire Dales, South Derbyshire
PCT
And a representative from East Midlands Prison Health Task Force.
However, the review team have made a number of recommendations relating
to the health care at Foston Hall and the hospital in Burton all of which I
endorse.
Release on Compassionate Grounds
The Head of Resettlement and Lifer Governor at Foston Hall wrote to the
Senior Medical Officer on 12 March 2004. She asked whether the woman
met the criteria for early release on compassionate grounds. The Deputy
Healthcare Manager verbally confirmed that the woman was very ill and that a
doctor would support the application.
The Head of Ressetlement wrote again on 11 June 2004 stating that she had
submitted an application for early release on compassionate grounds to the
Parole Board, Lifer Unit and Area Office, on 19 April 2004. She stressed that
the application was urgent as this woman was very poorly. A member from
the Lifer Unit, e-mailed a governor grade at the prison on the same day. He
said that: 'Unfortunately, as a lifer, the Secretary of State will not consider
such an application unless there are 2 medical reports, including 1 from the
outside consultant, giving a prognosis/diagnosis of death within the next 3
weeks.' He recommended bringing forward the parole process.
On 13 May 2004 the governor grade received a report from the hospital
consultant confirming the woman’s chronic renal failure and suggesting that
her survival was suspected to be a few weeks to a few months. They
supported early release.
On 28 May 2004 the parole dossier was sent to Lifer Unit but the governor
grade was unable to obtain the requirement of 2 doctors giving a prognosis of
death within 3 weeks.
On 2 June 2004, just after 11.00 hrs, HMP Foston Hall were notified that the
woman had died. At 13.07 on the same day, they received a fax from the
consultant at the hospital stating that he would be surprised if the woman lived
for another 12 months.
Prison Service Order 6000 (12.4) covers the requirements for granting early
release on medical grounds. This has been a consistent issue arising with
terminally ill prisoners and in due course, I hope to bring together my findings
on all the difficulties encountered by staff trying to secure release on
compassionate grounds.
Findings
The woman died of natural causes as a result of renal failure. The clinical
review team found that 'Foston Hall’s Health Care Centre was not designed,
staffed or equipped to meet her complex health needs.’ They found that the
Centre was not equipped to monitor diabetes and its complications
satisfactorily, and staff had major responsibilities to other prisoners, which
meant that they could not give the woman their full attention.
The communication difficulties in trying to return the woman from hospital to
the Health Care Centre, when they felt under equipped to cope with her
needs, must have been stressful for both staff and the woman.
Difficulties encountered in trying to secure compassionate release from prison
were frustrating and distressing for both staff and doctors.
Conclusions
Despite being a difficult patient, the woman was well cared for at Foston Hall.
However, I support the recommendations of the clinical review which detail
the reforms needed at Foston Hall if they are to care adequately for patients
with similar complex healthcare needs.
Recommendations
I fully support the recommendations detailed in the clinical review.
I also recommend that the Prison Service should review the processes for
agreeing compassionate release of terminally ill prisoners whose risk to the
public has been reduced to nil by the nature of their infirmity, and ensure
these processes are communicated to all establishments.
Good Practice
I would like to commend the Governor’s handling of the announcement of the
death. I found this to have been sympathetic to the emotional needs of the
prison as a whole.
Stephen Shaw CBE
Prisons and Probation Ombudsman