Individual at Parc

Investigation into the circumstances surrounding the
death of a man, who was a prisoner at HMP Parc,
in January 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
July 2006
This is the report of an investigation into the death of a man who died in
hospital from natural causes on 13 January 2006. He was 72 years old.
I would like to add my personal condolences to the man’s family to those
already expressed by one of my Family Liaison Officers.
This investigation has been undertaken by one of my investigators. I am
grateful to the Director of HMP & YOI Parc and his staff for their participation
and support. A Nurse was commissioned to undertake a review of the man’s
clinical care. She worked alongside staff from the Healthcare Inspectorate
Wales (HIW). I much appreciate their assistance
As is the case with many of my investigations following a death from natural
causes, I am much influenced by the findings of the clinical review. In the
case of the man, the review raises a number of concerns that the prison and
its healthcare supplier will need to consider seriously. I endorse the
recommendations made in the clinical review.
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 the investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2006
CONTENTS
Summary 4
The Investigation Process 5
HMP & YOI Parc 6
Key Findings 7
Liaison with the man’s family 11
Post Mortem and Clinical Review 11
Conclusions 13
Recommendations 15
SUMMARY
The man was born in 1933. He was 72 years old when he died on 13
January 2006.
The man was received into custody after being sentenced to 11 years
imprisonment. He was initially held at HMP Gloucester. The man was then
moved to HMP Usk before being transferred to HMP & YOI Parc on 12
December 2003.
On 11 May 2005, the man had an ultrasound scan and a tumour was
discovered in the left side of his bladder. Two days later, the prison doctor
wrote a letter to the urology department at the local hospital, referring to the
discovery of a bladder tumour and requesting an urgent review.
On 25 May, the hospital wrote to the man to inform him that there was a ten
week wait for urology appointments.
On 3 August, the man attended a consultation with a Specialist Registrar at
the hospital. After the consultation the Registrar arranged for the man to
come in for a cystoscopy (examination of the bladder) and trans-urethral
resection of bladder tumour, under general anaesthetic. The man was
admitted for these procedures on 31 August.
On 5 October, the man was told he had an invasive tumour which would be
likely to require radiotherapy or further surgery. A letter from the hospital
dated 19 October said that the man’s MRI (Magnetic Resonance Imaging)
scan showed not only the primary bladder tumour but also lymph duct
involvement. The oncologists were recommending chemotherapy and the
man was referred for an appointment with the consultant.
The consultant oncologist saw the man on 16 November. In a letter sent the
following day the consultant said that she was making arrangements for
radical radiotherapy for the man.
On 7 December, the man was taken to hospital. Whilst he was an in patient
at the hospital, a bedwatch was carried out by prison staff. The security risk
assessment was that a closeting (escort) chain was to be used. However,
this was removed on 2 January 2006 after a further security assessment
when the man’s condition started to deteriorate. The man died in his sleep
in the early hours of 13 January 2006.
The clinical review concludes that the man’s clinical care in prison was
overall of an appropriate standard. However, it was also critical of a number
of matters. The review makes four recommendations which I endorse.
One of my Family Liaison Officers contacted the man’s family. This was to
give them the opportunity to meet with the investigator to discuss the
purpose of the investigation, and to raise any concerns or questions that
they would like explored and addressed. In the event, the family raised no
specific matters of concern.
THE INVESTIGATION PROCESS
1. My investigator studied all relevant prison records relating to the man.
These included his main prison record, his medical records and
statements from prison staff.
2. A nurse who works for my office and staff from the Healthcare
Inspectorate Wales (HIW) carried out a review of the man’s clinical
care. I am grateful both for the contents of their review and for the fact
that it was completed in a most timely manner.
3. 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, this report will be sent to the Coroner
to assist him in his enquiries into the man’s death.
4. One of my Family Liaison Officers contacted the man’s family. They
did not raise any specific concerns about his care and treatment whilst
he was in custody.
5. My investigator discussed aspects of the man’s treatment with staff at
Parc and with the clinical reviewer.
HMP & YOI PARC
6. Parc is a modern Category B local prison on the outskirts of Bridgend
and 25 miles from Swansea. The prison opened in November 1997
and is the only private prison in Wales. It is managed by Group 4
Securicor (G4S) and employs 391 members of staff, many of whom are
recruited from the local area.
7. The prison offers a range of activities that aim to equip offenders with
the key skills necessary to reduce the risk of re-offending after release.
It currently has space for 1,036 prisoners on different wings.
8. The provision of healthcare within the prison is the responsibility of
Primecare Forensic Medical Services. The latest staffing profile
describes a team comprising three doctors and 25 nurses. Primary
care is delivered by medical staff and registered nurses and the
healthcare centre has the opportunity to draw upon the broader
expertise of the range of healthcare services within Primecare Forensic
Services. The in patient ward has 17 beds, all with integral sanitation.
KEY FINDINGS
The man’s time in custody
9. The man arrived at HMP Gloucester on 28 February 2003. During his
reception health screen interview, the nurse noted that the man had
high blood pressure, gout and stomach ulcers. The man had no history
of taking illicit drugs, but he admitted that he drank alcohol to excess.
The man had never been in prison before and had no psychiatric
history. He expressed no thoughts of self harm. However, the nurse
found the man to be excessively anxious and depressed on admission.
10. On 1 March, the man saw a doctor for an initial assessment. The
doctor reiterated many of the nurse’s findings but noted there were no
alcohol or drug problems. The doctor ordered that the man’s blood
pressure be checked daily and information about his medication
obtained from his home General Practitioner (GP).
11. On 17 July, the man was reassessed by a doctor after he was
sentenced. The consultation was supportive and noted that the man
had expected the sentence.
12. On 4 August, the man transferred to Usk. The healthcare worker who
assessed him noted, in addition to his known chronic conditions, that
he had blood in his urine of unknown cause. The doctor’s assessment
noted that he had had recurrent episodes of haematuria (blood in the
urine) since 1964. The doctor ordered a series of blood and urine tests
and certified the man fit for work.
13. When the man transferred to Parc on 12 December, it was noted that
he suffered from high blood pressure, gout and a lack of calcium. The
doctor continued the man’s prescribed medication and noted his recent
history of anaemia (inadequate red blood cells and/or low levels of
haemoglobin) and haematuria.
14. At the well man clinic on 3 February 2004, the man was found to have
blood in his urine. The nurse performed an electrocardiogram (ECG)
examination, but noted no findings. A ‘full check of bloods’ was
conducted by the nurse and the man was referred to the doctor. There
was nothing significant found in the blood tests. Prescribing records
show that the man was given a course of trimethoprim (an antibiotic
used to treat urinary tract infections).
15. On 28 September, the man complained of ‘burning’ when passing
urine. He was again prescribed trimethoprim and further investigations
were ordered. There was blood and protein present in the urine, but no
evidence of an infection was found.
16. On 4 October, the doctor noted that he wanted the man to come to
clinic to discuss his test results. On 12 October, a doctor noted the
man had mild anaemia and his blood tests would be repeated in three
months. However, it is evident from the records that this did not
happen.
17. On 14 February 2005, the man complained of being light headed and a
further ECG was performed. A diagnosis of sinus bradycardia (slow
heart beat) was reached.
18. On 16 February, the man’s pulse was still very slow and his blood
pressure was low. He was referred to the medical registrar at the local
hospital. He was admitted and commenced on warfarin (to prevent
blood clots) and further tests were conducted, including a step test (to
test heart rate response to exertion) and a 24-hour ECG.
19. The man returned to Parc on 23 February. From later correspondence,
it was established that he had been diagnosed with atrial fibrillation (a
fast and irregular heartbeat).
20. On 25 February, the man was passing fresh blood in his urine. Blood
and urine investigations were ordered and an appointment made to see
the prison doctor.
21. On 1 March, the man was again complaining of pain on passing urine.
There was no doctor available, so the nurse sent off a urine specimen
to the laboratory. The laboratory report asked for a repeat specimen,
but no relevant further report was found and it is therefore difficult to
establish if in fact the test was repeated.
22. On 15 March, the prison doctor referred the man for an ultrasound
scan of his bladder at the local hospital. The referral request does not
indicate that it was an urgent request or a referral under the NHS
Cancer Plan which would have necessitated an appointment within two
weeks.
23. On 11 May, the ultrasound report for the man stated, “... fronded
polypodial tumour in the left side of bladder … Urgent urological
referral is advised.”
24. On 13 May, the prison doctor made a referral to the Urology
Department at the local hospital. The referral letter did note that an
urgent appointment was required.
25. On 25 May, the man had a diagnostic coronary angiogram at the local
hospital. A letter was also sent to him by the hospital the same day to
say that there was a 10 week wait for urology appointments.
26. A letter on the file from a Specialist Registrar, dated 3 August, reports
on his consultation with the man that day. The man had waited 82
days for this appointment instead of the 14 days required by the cancer
standard. Due to his findings and the ultrasound result in May, the
Specialist Registrar arranged for the man to come in for a cystoscopy
(examination of the bladder) and trans-urethral resection of bladder
tumour under general anaesthetic on an urgent basis. The man was
admitted for these procedures on 31 August.
27. On 3 September, the man returned from hospital after the surgery for
the removal of the growth in his bladder. The doctor’s letter confirmed
he was arranging a two week review in out patients as well as a kidney
x-ray. The man was offered a bed in the healthcare centre, but
preferred to go back to the wing.
28. On 20 September, the man complained to the nurses about his bladder
problems. The prison doctor started the man on a trial dose of
doxazosine to improve his urinary flow. On 4 October, the prison
doctor prescribed paracetamol to be kept in possession. Blood tests
were taken and the results showed increasing anaemia. In response, a
doctor increased the dose of ferrous sulphate.
29. Despite the Specialist Registrar’s reference to a review in two weeks,
correspondence showed that the man was not seen again for four
weeks - on 5 October. However, records show that on 7 September
the man had declined to go into the healthcare centre for preparation
for his hospital appointment, which had therefore been postponed.
30. At his hospital appointment on 5 October, the man was told he had an
invasive tumour which would be likely to require radiotherapy or further
surgery. He was to have an urgent CT (Computed Tomography) scan
and be seen again once they had discussed the results. A letter from
the Specialist Registrar dated 5 October was stamped as received at
Parc on 10 October. In the letter, the Registrar told the prison doctor
what the man had been told. There was no reference to the diagnosis
in the man’s continuous medical record.
31. By 10 October, the man’s pain was much worse and he was again
referred to the doctor. He was seen in the pain clinic next day and
started on co-dydramol three tablets twice daily. He was given a diary
to record his pain and an appointment for one month.
32. A letter from the hospital dated 19 October stated that the man had had
an MRI (Magnetic Resonance Imaging) scan which showed not only
the primary bladder tumour but also lymph duct involvement. The
oncologists were recommending chemotherapy and referred the man
for an appointment with the consultant.
33. There was no correspondence relating to an appointment with the
oncologist in the period up to 10 November, when the man showed the
nurse at the medicines hatch that he had a large lump on the left side
of his neck. An appointment was made for him to see the doctor. On
15 November, the doctor thought the lump might be a secondary
tumour and made a further urgent referral.
34. A letter dated 17 November from the consultant oncologist confirmed
she had seen the man on 16 November. She referred to a CT scan
and its results. She also noted that she had not been able to find any
evidence that he had had an MRI scan. She was making
arrangements for the man to receive radical radiotherapy.
35. On 23 November, healthcare staff informed the security department at
Parc that the man would be attending another hospital for an extensive
course of medical treatment. They emphasised how essential these
appointments would be and warned that he might have side effects
such as tiredness and nausea.
36. On 27 November, the prison doctor prescribed dihydrocodeine for the
man’s worsening pain. On 30 November, the man was seen by the
night nurse because he had vomited twice in the night.
37. On 5 December, the man’s left calf was swollen, hot and red. A doctor
saw him and wondered if it was lymphoedema (swelling due to an
obstruction of the lymph vessels) caused by secondary disease in the
pelvic glands. The doctor ordered a blood test, but the result indicated
that the blood collected the next day had not been collected according
to the necessary protocol.
38. When the prison doctor saw the man on 6 December, he thought he
had deep vein thrombosis (DVT) and sent him to the local hospital.
The man returned to prison after treatment with an appointment to
return next day for an ultrasound.
39. On 7 December, the man returned to hospital for this agreed
appointment and was admitted. Whilst he was an in patient at the
hospital, a bedwatch was carried out by prison staff. The security risk
assessment was that a closeting (escort) chain be used. Nursing staff
from Parc kept in touch with the local hospital and learned that the man
was being referred to another hospital. They correctly pointed out he
was already under the care of the other hospital.
40. The man was described as ‘rather unwell’ on 15 December. The
following day, he was reported to be having a blood transfusion in
preparation for transfer to the other hospital once stable.
41. On 19 December, the man was still in the local hospital. He was
having further CT scans before going to the other hospital. The man
was at this stage walking with a Zimmer frame. The nurse informed
the security department of this, in case it affected their risk
assessment. Due to the nature of his conviction, the man was not
considered suitable for release on temporary licence (ROTL) on
compassionate grounds. However, in order to be as sensitive as
possible, the prison arranged for him to be escorted by just one officer
whilst he was in hospital.
42. The nursing staff continued to keep in regular contact with the ward
staff at the local hospital over the coming weeks. On 2 January 2006,
following a security risk assessment, it was decided to remove the
mechanical restraints. While in he was an in patient, the man was
visited on a number of occasions by his daughter and staff from the
prison.
43. The man did not improve sufficiently to be transferred to another
hospital for radiotherapy. The man died in his sleep at 2:25am on 13
January 2006.
Liaison with the man’s family
44. The prison immediately tried to inform the man’s family of his death.
Unfortunately, the man was estranged from his sons and the prison
was unable to contact his daughter as she was in hospital herself.
45. The Head of Drug Strategy and Resettlement Manager, was appointed
as the prison’s family liaison officer. He made arrangements for the
funeral and provided financial help. The prison chaplain later
conducted the funeral service. There was also a service held on the
wing of the prison, where the man was housed.
Post Mortem and Clinical Review
46. The post mortem states that the cause of death was due to natural
causes as a consequence of metastatic bladder carcinoma (cancer).
47. The clinical review concludes that the man’s overall clinical care in the
three prisons was of a good standard, although instructions for
monitoring or investigations were occasionally missed. This included
the man’s very longstanding history of haematuria which was not
apparently investigated in depth at an early stage. His condition might
also have been made worse by being prescribed warfarin, as doctors
might not have known about his pre-existing health problems.
48. The reviewers note that the prison doctor acted expediently in referring
the man for a bladder ultrasound examination. However, it is a great
concern that the man had to wait for nearly two months for that
ultrasound appointment, and the question is raised of whether this was
the norm at the local hospital at that time.
49. The reviewers say that it was particularly regrettable that the prison did
not question the letter from the urology department which stated that
the average wait for an appointment was 10 weeks. The man was
being referred because the ultrasound scan had showed a tumour and
recommended an urgent urology referral. National standards require
all referrals for suspected cancer to be seen within two weeks. In the
event, the man waited 82 days for his first appointment with the
urologist and another four weeks for surgery on a known cancer.
50. The reviewers could find no evidence that the man received care of a
lower overall standard whilst in prison than he would have received had
he been living in the community. However, they say that the delay in
processing his referral for an urgent urology appointment was
unacceptable.
51. The reviewers also point out that records and recordkeeping left
something to be desired. It is noted that there were no prescription
cards from Gloucester or Usk prisons, and entries in the continuous
medical record were not in chronological order. The reviewers also
note that tests and correspondence were filed rather at random, and no
record was made in the continuous medical record of significant
correspondence received.
Conclusions
52. The man was first imprisoned in February 2003. He died of cancer of
the bladder in January 2006.
53. The man had arrived in prison with a number of heath problems. He
had a history of gastro-intestinal disorders which were explored, with a
focus on his upper abdomen. Nothing abnormal was found. His
anaemia was also diagnosed and treated.
54. In August 2003, the prison doctor noted that the man had blood in his
urine (haematuria) of an unknown cause, and that he had had
recurrent episodes of this since 1964. The clinical review notes that
the doctor requested a series of clinical investigations.
55. When the man transferred to Parc in December 2003, doctors again
noted his history of haematuria. At a check up in February 2004, it is
recorded that the man had blood in his urine. Nothing significant was
found in blood tests and he was subsequently treated for a urinary tract
infection.
56. In September 2004, the man was again treated for a urinary tract
infection after various investigations which showed blood and protein
present in his urine.
57. In October 2004, the man was noted to have mild anaemia following a
blood test. The test was to be repeated in three months, but this was
not done.
58. On 25 February 2005, the man was passing fresh blood and was
referred to see the prison doctor but no appointment occurred until 15
March. Meanwhile, the man complained of pain when passing urine,
and tests arranged by the nurse showed a quantity of blood and protein
present.
59. On 15 March, the prison doctor referred the man for an ultrasound
scan of his bladder. The referral request did not indicate that it was an
urgent request.
60. It was not until 11 May, a delay of about eight weeks, that the
ultrasound scan was carried out. It is very regrettable that it took so
long to obtain an appointment, but the hospital was not notified of any
urgency or suspected cancer diagnosis. Prison healthcare staff noted
a number of times that the scan was awaited, but do not appear to
have pursued the appointment. The scan found that the man had a
tumour in his bladder and an urgent urological referral was advised.
The prison doctor made the referral on 13 May, clearly noting the
bladder tumour found on the ultrasound and requesting an urgent
referral.
61. On 25 May, the local hospital sent a letter to the man saying there
would be a ten week wait for an appointment. I agree with the clinical
reviewers that it is a matter of regret that the prison did not question
this wait. The man had a provisional diagnosis of cancer, and the
matter was therefore urgent and he should have been seen within two
weeks as laid down by the NHS Cancer Plan.
62. The man eventually saw a consultant on 3 August, and was admitted to
hospital on 31 August for the tumour to be removed. A two week follow
up appointment was not kept, but this may have been because the
man declined to go to healthcare to prepare for the original
appointment.
63. On 5 October, the man was told the tumour was invasive and further
tests showed that the cancer had spread.
64. In reviewing the bed watch log, it is clear that the staff involved with the
man’s care behaved with sensitivity. The decision to remove
mechanical restraints, following a risk assessment, was entirely
appropriate given the circumstances. The security arrangements at the
hospital seem to have been suitable, and to have struck a good
balance between public protection and respect for the man.
65. The view of the clinical reviewers is that the man received care akin to
that he would have received had he been living in the community.
However, the delays in processing his referral for an urgent urology
appointment were unacceptable. I make four recommendations.
RECOMMENDATIONS
Medical
1. Primecare Forensic Health Services should consider why their
staff did not question the letter indicating that the man would wait
at least 10 weeks for an appointment in response to their urgent
referral.
Accepted by prison – The Primecare Manager will implement a system
whereby urgent referrals to any Department are chased if the waiting
time is deemed to be excessive.
2. Primecare Forensic Health Services should bring to the attention
of the Local Health Board the delay in the man’s urgent urology
referral to establish whether this was the norm at that time and
what action is being taken to ensure cancer referrals are
processed within two weeks.
Accepted by prison – Letter sent to Local Health Board by Primecare
Manager.
3. Primecare Forensic Health Services should bring to the attention
of the Local Health Board the eight week delay in the man’s
ultrasound referral to establish whether this was the norm at that
time.
Accepted by prison – Letter sent to Local Health Board by Primecare
Manager.
4. Prison Health and the Welsh Assembly should take steps to
ensure their clinical staff working in prisons adhere to the
guidance on records and recordkeeping issued variously by the
General Medical Council, the Nursing and Midwifery Council and
the Royal Pharmaceutical Society of Great Britain.
Accepted by prison – Letter sent to Prison Healthcare Project Co-
ordinator in the Welsh Assembly.