Individual at Frankland

Investigation into the death of a man at a hospice
whilst in the custody of HMP Frankland on 2 June
2006
Report by the Prisons and Probation Ombudsman for
England and Wales
August 2007
This is the report of an investigation into the circumstances surrounding the
death of a man on 2 June 2006. The man was a prisoner at HMP Frankland
and had been diagnosed with terminal cancer of the colon. He spent his last
hours in an outside hospice. The man was 44 years old when he died.
I extend my condolences to the man’s family and to all those touched by his
death.
The investigation was undertaken by one of my colleagues. Both my
colleague and I would like to thank the Governor of Frankland, and his staff
for their cooperation during the investigation. We are particularly indebted to
the prison’s liaison officer, who gathered relevant documentation and ensured
it was made available in a timely way.
As in previous investigations, I must also thank the clinical reviewer for
undertaking a review into the clinical care the man received on behalf of
Durham and Chester-le-Street Primary Care Trust.
The man was a high risk prisoner and I am in no doubt that decisions over
how best to care for him were at times difficult. I have been impressed by the
careful consideration that was given to managing the potential risk he posed
outside of a custodial environment, against the rapid decline in his health and
pending healthcare needs. The man received a high level of care both at
Frankland and when transferred to the hospice where he died.
I make four recommendations and highlight two areas of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2007
CONTENTS PAGE
Summary 4
The Investigation Process 5
HMP Frankland 6
Key Findings 7
Issues 13
Recommendations 16
SUMMARY
The man who died was convicted of a very serious offence in 1991. He was
sentenced to discretionary life imprisonment, with a minimum tariff of three
years. He had spent a total of 16 years in high security prisons before his
death.
The man was sent to HMP Wakefield to begin his sentence and remained
there for the next five years. In 1997, he was transferred to HMP Whitemoor
until his move to HMP Frankland two years later. He returned to Whitemoor
in 2001 and, following a psychiatric assessment, was sent back to Frankland
where he spent his last few years.
On 18 April 2006, he was diagnosed with cancer of the colon. It had spread
to his lungs and liver and, after a number of tests and exploratory procedures,
he was diagnosed as terminally ill. Having spent two periods in hospital, the
man returned to Frankland for the last time on 27 May.
He spent a further four days back in the healthcare unit before deteriorating
so rapidly that he was moved to an outside hospice in his final hours. This
was with the agreement with the MacMillan nurse caring for him, the prison,
the Directorate of High Security Prisons, and the man himself.
The man died peacefully at 10.30pm on 2 June 2006.
THE INVESTIGATION PROCESS
1. The investigation was opened on 5 June 2006. My investigator began
by requesting all relevant prison records relating to the man. These
included his medical and core records covering the 16 years he spent
in high security prisons.
2. Notices to staff and prisoners were supplied and displayed around the
prison. These invited anybody with information to talk to my
investigator. In this instance, no staff or prisoners came forward. My
investigator examined the records and noted significant events. On the
basis of what she found, my investigator judged that it would not be
necessary to visit the prison and no formal interviews took place.
3. Durham and Chester-le-Street Primary Care Trust was invited to
undertake a review of the clinical care the man received while in
custody. The review is included as an annex to this report.
4. The Coroner was informed of the Ombudsman’s investigation. In
consultation with the family, the Coroner took the view that this was not
a case requiring a post mortem examination or toxicology. No such
examination took place and the attending physician at the hospice
noted the cause of the man’s death as metastatic colorectal cancer.
5. The man’s brother and sister were contacted by one of my Family
Liaison Officers, to ask whether they or other members of the family
had any comments or concerns about the man’s death. They did not
and I sent a draft copy of my report.
HMP FRANKLAND
9. HMP Frankland is one of six maximum security establishments within
the Directorate of High Security Prisons. Frankland holds category A
and B adult male prisoners in normal location on two residential wings.
Vulnerable prisoners are located on four other wings, and all
accommodation is single cell. Frankland also holds a small number of
category C prisoners and has an operational capacity of 653.
10. The most recent full inspection report by HM Chief Inspector of
Prisons, dated March 2003, describes Frankland as offering a safe
environment, based upon good relationships between staff and
prisoners. The inspection found good staff understanding of individual
prisoners and their needs.
11. Following a short unannounced follow up inspection on 25 October
2005, the Chief Inspector recorded that healthcare services at
Frankland had improved since the full inspection. Primary care still
needed development but staffing shortages had hindered progress. Of
the 12 healthcare recommendations made during the full inspection,
nine had been fully achieved, one partially achieved, and two had not
been achieved.
12. The healthcare services at Frankland are commissioned by the
Durham and Chester-le Street Primary Care Trust. The prison’s
healthcare centre has 18 beds, all of which are linked to the office with
a call bell system. Adjacent to the centre is the Listeners suite which is
a large and comfortable two bedded room.
KEY FINDINGS
13. On 18 April 2006, the man was seen by a doctor in the healthcare unit,
although his record does not clarify whether he referred himself or was
referred by staff. The man had not presented any symptoms prior to
that day and the doctor noted in his medical record that he looked
anaemic. His blood was taken and sent to an outside hospital for
analysis. He was placed under observation by nurses and the
observations were recorded.
14. The following day, the prison doctor wrote a referral letter to the
consultant colo-rectal surgeon at University Hospital of North Durham.
The letter explained that the man had presented symptoms including
abdominal pain, nausea and the loss of some blood and that during an
examination, the doctor also discovered tenderness of his liver. The
letter stated that the man may have hidden his symptoms from
healthcare staff. The doctor noted he was concerned that the
symptoms were an indication of significant bowel cancer.
15. On 20 April, the man was seen by a doctor during morning rounds and
observations were recorded in his medical record. The doctor’s entry
stated that he ‘looks ill and vomits after eating’. The man was admitted
to University Hospital North Durham for further tests the same day. My
investigator could not locate a bedwatch log or Prisoner Escort Record
form (PER) recording the transfer to hospital although the prison has,
subsequently, found both documents.
16. The man spent the next week in hospital and underwent a series of
tests. His medical record notes the calls made to the hospital for
clinical updates on his condition. The record says that, on 21 April, he
had a CT scan which indicated cancer and that he would be seen by a
bowel specialist in due course. He was also x-rayed and underwent a
biopsy that week. He apparently presented as withdrawn after being
told of the possible diagnosis.
17. On the morning of 26 April, healthcare staff rang the hospital to
determine when the man was likely to be discharged back to
Frankland. The hospital said that he would not be discharged
immediately as he was receiving medication intravenously.
18. At 5.00pm on 28 April, the man was discharged from the hospital. On
his return to Frankland, he was located in the healthcare unit and given
a single occupancy room. The hospital summary listed the exploratory
procedures he had undergone during his eight days on the surgical
ward. The summary also informed healthcare staff that the man had
been placed on 15 minute observation, was tolerant of fluids and was
in receipt of drugs to manage his pain.
19. The man was made comfortable in his room. The nurse on duty
observed that he presented as pale and short of breath. The prison
doctor was notified of his condition and his prescribed medication. In
response, the doctor asked to be contacted if any problems arose and
confirmed that he would visit the healthcare unit the next morning. The
nurse then contacted the hospital to check the correct dosage of
morphine to administer as part of the man’s pain management care.
The advice was noted in his medical record as two doses per day,
morning and night. At 10.00pm, he was given his first dose and his
abdominal wound was cleaned and dressed. The night duty nurse
explained to him that if he felt any pain during the night, he should let
staff know.
20. For the next few days, the man’s pain was effectively managed and he
was made as comfortable as possible. Healthcare staff also made
contact with the McMillan nurse at the hospital to find out who would be
responsible for his care.
21. On 1 May, another prison doctor saw him. Whilst the doctor found him
to be poorly, he was communicating well. He was seen again the
following day and the doctor took that opportunity to discuss his
condition with him. An entry in the man’s medical record notes that he
was fully aware he had cancer of the colon and that it had spread to his
liver.
22. On 4 May, the man complained of abdominal pain and healthcare staff
noticed his loss of appetite. Despite his deterioration, he was able to
attend an occupational therapy (OT) session and fully engaged in
activities while he was there. The man’s OT report for the day said that
he had expressed concern to the therapist, over his future, and had
been encouraged to enjoy each day as much as possible.
23. The man was seen by the doctor the next day and appeared quite
settled. He had a quiet night watching television and reported only
slight feelings of sickness. At around lunchtime on 7 May, healthcare
staff noticed his abdomen was swollen and he was suffering from
breathlessness. A nurse ensured he was made more comfortable by
moving him to a bed with a backrest so that he could sit up. The nurse
noted that the man remained poor in complexion and was still feeling
sick. Later that afternoon, he was given a nutritional risk assessment
and the results were entered into his medical record. Healthcare staff
were made aware that he was to eat small amounts regularly and to
replace missed meals with high protein drinks.
24. The man had another bad night and complained of swelling to his left
leg. A nurse administered his medication for the night and also
elevated both his legs to help reduce the discomfort. On closer
examination, his legs were found to be very swollen due to excess
lymph fluid. He was advised to keep them in the elevated position and
a note was made for the doctor to review his condition.
25. On the morning of 8 May, the man saw the doctor who noticed the
bloating. His medication was reviewed and he took both his
prescription and his diet for the day. No other concerns were noted
and he remained settled but feeling sick.
26. The man was seen again by the doctor on 10 May. He complained of
the bloated feeling again, but said that his pain was under control and
he did not want to take the morphine. The doctor wrote in his medical
record that he seemed to have developed a sore and dry mouth but
looked more settled.
27. The man attended another OT session on 11 May and continued with
the group activities he had begun during his previous visit. The
occupational therapist spoke with him at length and noticed he was in a
very low mood. According to the man’s medical records, he explained
that he wanted to die to relieve himself of the pain of his condition. He
also said he felt he had nothing to live for. The OT encouraged him to
keep his mind as occupied as possible and prompted him to carry on
with the afternoon session. The OT passed on the details of her
conversation to the Community Psychiatric Nurse and to the man’s
psychiatrist.
28. For the next seven days, the man was monitored for pain, sickness and
the infection to his throat. He was seen by a MacMillan nurse on 13
May and the nurse carried out an assessment of his symptoms. The
man also received treatment for his throat, following confirmation that
he had developed an oral infection. He was given a gargle and
lozenges and a nurse noted that this seemed to give him some relief
from the discomfort he had previously felt. The man continued to
appear quite pale, but took a small diet and the rest of his pain
management medication.
29. At 11.00am on 18 May, he spoke to the OT again. He explained that
his medication had been reviewed to stop his feelings of sickness, but
that he had developed the mouth and throat infection instead. He was
observed throughout both morning and afternoon sessions as being
withdrawn from the group, but still able to participate in the project. An
entry in his medical record stated that he told the OT that he was
thinking of contacting his estranged family to inform them of his illness.
30. The man spent the weekend of 20 and 21 May in some pain and
healthcare staff noticed that the swelling to his stomach and leg had
worsened. His daily record of nursing care was updated with an entry
that described his complexion as ‘yellow’. The man also found it
difficult to sleep and healthcare staff arranged for him to use a Parker
Knoll chair for more comfort. He slept in his chair for some of the night.
A nurse wrote in his medical record that, despite being very ill, he
offered no complaints and would be seen by the doctor on Monday 22
May for assessment.
31. Following his assessment on the morning of 22 May, the man
deteriorated and was referred to an outside hospital for a review of his
condition by the hospital consultant. Before he could be transferred in
a category A vehicle, his clothes were x-rayed and he underwent a full
search in the reception area of the prison.
32. At approximately 12.15pm, the man left Frankland for University
Hospital North Durham. He was escorted by two prison officers using
restraints, and arrived at the out patients department at 12.35pm. He
was seen by a doctor within 10 minutes of arriving and was cuffed
throughout the examination. The doctor decided to admit him as an in
patient, and at 1.10pm he was moved to a surgical ward. Escort
officers notified the prison of his admission in order for a bedwatch to
be arranged. The PER form accompanying him on the visit to hospital
showed that he had been risk assessed and restraints would be
applied. The form also said that an F2052A booklet had been opened.
My investigator found no bedwatch log for the duration of this stay in
hospital although the prison has, subsequently, located it.
33. The man remained in hospital for five days. Healthcare staff at
Frankland made regular contact with the hospital to obtain updates on
his condition, and made entries to his medical record on a daily basis.
34. On the evening of 23 May, a nurse contacted the ward and was
informed that the man had received two litres of blood and further pain
relief. The same nurse was contacted three days later by a Macmillan
nurse who confirmed that he had been placed on a Palliative Care Plan
and was very poorly. The entry in his medical record explained that he
wanted to return to Frankland as soon as possible and had been given
a syringe driver to administer his pain relief. MacMillan nurses would
provide follow up input to help manage his condition, and a nurse
would arrange to visit him back at the prison on 31 May.
35. At approximately 4.15pm on 26 May, the Healthcare Manager was
informed of the man’s condition and his wish to return to Frankland.
The healthcare manager held a meeting with healthcare staff to
discuss the man’s needs and to prepare the healthcare unit for his
return. According to his medical record, the prison chaplain and a
probation officer liaised with his next of kin to inform them of the
deterioration in his health. The daily record of nursing care confirmed
that a Palliative Care Plan was in place.
36. At 9.30am on 27 May, healthcare staff at Frankland contacted the
hospital. The staff nurse on the ward explained that the precise
discharge details had not been confirmed, but that the registrar would
review the man’s condition that afternoon. The hospital would contact
the prison once the decision had been made to return him to the
prison’s healthcare unit.
37. At 3.00pm, the hospital confirmed that the man would be discharged
later that day and that arrangements were put in place for his transfer.
The Discharge Notification Letter contained full pharmacy instructions
to dispense seven days worth of medication to Frankland on his
discharge. The letter explained that this would give healthcare staff
enough time to plan ahead and order a full supply for the following
week. The letter also stated that he would be placed in the care of the
community cancer nurse, with no further hospital appointments
required.
38. At 6.45pm, the man was discharged by the hospital consultant and
prepared for his return to Frankland. His summary discharge plan from
the hospital said that he was alert and could dress himself, was able to
take fluids, and was not in any pain. The care plan also informed
healthcare staff at Frankland that he was to continue with his pain
management following a pain control assessment made in hospital.
The form stressed that he was in an advanced stage of cancer and
could no longer take oral medicine. A syringe driver would therefore
commence once he had settled back in the healthcare unit.
39. At 7.00pm, the man was transferred back to Frankland under
restraints. He arrived at 7.15pm and was strip searched before being
located straight into the healthcare unit. A PER form, originally
completed on 22 May to record his transfer from Frankland to the
hospital, was re-used to record his return journey.
40. In the early hours of the morning of 28 May, a night nurse noticed that
his syringe driver was empty. It had been full on his return from the
hospital at 7.00pm the previous evening. His nursing care record notes
that a nurse contacted the hospital for advice and was told to refill the
driver. The nurse then contacted the on call prison doctor, and was
advised to leave the syringe driver for his attention the following
morning.
41. At 9.25am on 28 May, a prison doctor saw the man as part of his
morning rounds. At 10.00am, his syringe driver was re-sited and
replenished and he was made comfortable by healthcare staff. He ate
a small breakfast and told staff he was pleased to be back at
Frankland. The Palliative Care Plan, devised by the MacMillan nurse,
instructed healthcare staff to keep his wounds infection free and to look
for signs of inflammation. The plan also instructed nursing staff to
encourage the man to report any feelings of pain, and to support him
emotionally now that he was in an advanced stage of illness.
42. At 1.30pm, one of Frankland’s Governors spoke to a nurse and told her
that the man’s brother had been informed of his poor physical health.
An entry in his medical record notes that his brother had been
contacted via the police.
43. By late afternoon, the man was made aware of the terminal nature of
his illness and his religious needs were determined in order to provide
him with some emotional support. The Palliative Care Plan was also
discussed and agreed with him. He was made comfortable for the
evening and saw the prison chaplain. Unfortunately, he had a restless
night.
44. At 10.30 am on 30 May, a prison doctor saw the man and approved the
‘no resuscitation’ policy. The doctor noted that he remained pain free
and took diet and fluids. Later that afternoon, the healthcare manager
came to see him to discuss hospice care and the man asked him to
explore the possibility of a move. The healthcare manager made a
note in his medical record for the MacMillan nurse to look into the
option of transferring him to a local hospice.
45. The man had another bad night and deteriorated throughout the
morning of 31 May. At approximately 7.50am, the MacMillan nurse
assessed his condition and became concerned about his deterioration.
The nurse asked for arrangements to be put in place for his move to
hospice care, and for nurses to monitor his pain levels in the meantime.
46. The next day, at approximately 11.45am, a Senior Officer sent a fax to
the Directorate of the High Security Prisons and attached an
application and risk assessment for the man to be cared for at a
hospice without restraints. The application listed the medical reasons
for the request and said that the man, still a category A prisoner, would
be accompanied by at least two plain clothed officers assigned 24 hour
bedwatch duties. The request also stated that bedwatch officers would
contact Frankland if his mobility improved, and that visitors to his
bedside would be agreed by the duty governor in advance.
47. The application was granted and, following a thorough search, the man
was discharged from the healthcare unit. At 5.25pm, he left Frankland
for the hospice. The PER from accompanying him clearly stated that
any risk he posed had been reduced to ‘virtually nil’ due to his terminal
illness.
48. On arrival at the hospice, the officers on bedwatch duty carried out a
physical security checklist of the man’s room and noted that it was a
low risk environment. Within a few minutes of arrival, a Senior Officer
began a bedwatch log. The log said that officers were in possession of
restraints and that the man had been examined and spoken to by the
doctor. Before handing over bedwatch duty to another member of
staff, the SO also confirmed that the hospice exit points would be
secured at night.
49. On the morning of 2 June, officers carried out a bedwatch check and
re-checked the policy of no restraints to be used whilst the man
remained in hospice care. The checklist also stated that officers had
all emergency contact numbers and were to provide Frankland with
updates every three hours.
50. At 9.30am, the man’s father visited his bedside unannounced. The
man confirmed to officers that the visitor was his father and that he had
not seen him for many years. An unofficial visits form was completed
and recorded that his father left the hospice at 9.40am, visibly upset.
The document recorded that his father was offered support from staff
and thanked them for doing so. An SO made an entry in the man’s log
that full details of the unofficial visit by his father would be entered in
his history sheet.
51. At around 2.15pm, the prison chaplain arrived to see him. There was
no record of when the chaplain left the hospice. The log recorded a
change in shift at 7.25pm; three officers arrived to relieve the daytime
officers of their duties.
52. At 10.30pm, the man died peacefully in his room. All three officers
were at his bedside. Hospice nurses confirmed the time of death and
an SO informed the prison that he had passed away. He recorded the
time on his escort record.
53. Shortly after the man’s death, the prison’s liaison officer (PLO)
contacted his next of kin to break the news of his death. Over the next
few days, the PLO also spoke to his father and discussed funeral
arrangements with him. The PLO explained that Frankland would
arrange the funeral and meet the costs. The prison chaplain attended
on behalf of the prison.
ISSUES CONSIDERED DURING THE INVESTIGATION
54. The man had remained a potential high risk to himself and others
throughout his 16 years in the high security estate. There were times
when he made a concerted effort to participate in the regime and, when
he attended workshops, education and occupational therapy sessions,
he did make some progress. However, the man presented with
challenging behaviour throughout his time at Frankland. This resulted
in a disproportionately high number of adjudications, and several
moves to other wings including the segregation unit.
55. Bearing in mind his challenging behaviour and category A status, I
have been impressed by the extent to which healthcare and discipline
staff responded to the man’s illness and made his life as comfortable
and dignified possible. He was encouraged to participate in a limited
regime, and received 24 hour inpatient care. When he deteriorated
rapidly, he was compassionately managed and transferred to an
outside hospice in a timely way.
56. That said, although there would have been no effect on the ultimate
outcome for him, the investigation highlighted a number of areas where
practice could be improved.
Record keeping
57. The Prison Service expects a high standard of individual prisoner
record keeping. Prison officers are required to make regular and
considered entries on a prisoner’s demeanour, and interaction with
staff and others, and to record any other noteworthy events in all
records. In this man’s case, there were examples of good record
keeping from some individual members of staff, but in general the
record keeping fell short of the expected standard. Records were
disorganised, difficult to read and not presented in chronological order.
I make the following recommendation:
The Governor should develop a self-audit programme for
monitoring standards of record keeping and provide appropriate
training to staff as necessary.
58. The man stayed in hospital twice before being moved to the hospice in
his final hours. On all three occasions, escort officers were deployed to
remain at his bedside and to maintain a bedwatch log. In this man’s
case, the only bedwatch log made available to my investigator at the
time of the investigation was the hospice log. Subsequently, the
bedwatch logs for the period 20 to 28 April and 22 to 27 May were
found by the prison. Whilst the bedwatch logs were completed for all
three periods, it is disappointing that it took approximately three months
for the prison to notify my investigator that the remaining bedwatch logs
had been found.
The Governor should review and revise the record storage system
to ensure that bedwatch and escort information about particular
prisoners is filed correctly.
Healthcare records
59. Healthcare staff at Frankland showed great determination and
commitment in caring for the man during the last six weeks of his life.
It is clear from his medical record that nurses overcame difficulties
quickly to ensure he was made as comfortable as possible. When
unsure of how to administer certain medication, nurses sought the
advice of medical practitioners in a timely way. What is not clear from
the record is whether handover meetings took place regularly during
the change from night to day shift, and who his primary carers were for
the duration of his stay in the healthcare unit. The man’s medical
records were often difficult to read, incorrectly initialled and signed, and
below the expected standard.
The Healthcare Manager should remind staff that, in accordance
with the Nursing and Midwifery Council’s guidelines for records
and record keeping, all medical records should be legible, up to
date and in chronological order.
CLINICAL REVIEW
60. The clinical review conducted on behalf of Durham and Chester-le-
Street PCT comments that the man’s deterioration was relatively rapid.
The reviewer is satisfied that all that could be done for him was done.
The review notes that, whilst the man might have had some symptoms
that would have suggested the need for investigation, it would appear
that he either ignored them or chose not to report them. The clinical
reviewer stresses that the man’s diagnosis of anaemia resulted from
observations made by staff.
61. The clinical reviewer also highlights the good standard of symptom
control the man received, especially latterly following the use of the
syringe driver, and the further advice sought from the MacMillan Nurse.
62. The clinical review does comment adversely on the presentation and
content of the man’s medical records. It says of his transfer to the
hospice that, “He must therefore have been transferred on 1 or 2 June,
but the clinical record had no details of the transfer.”
63. The clinical reviewer makes the following additional comments
regarding clinical records, and I urge the PCT in partnership with
Frankland to consider them carefully and look for a way forward to
improve records and record keeping:
Prison manual clinical records remain of poor quality and the filing in
this case was quite chaotic. This not only makes them extremely
difficult to review but also must be problematic for clinical staff in
finding the information that they require. I regard this as a potential
clinical risk.
It is frequently stated that the introduction of the electronic patient
record will rectify this problem, but, without initial work to tidy up the
manual records, the new electronic system will suffer from “rubbish in,
rubbish out”.
I have commented on this before and fear that little is currently being
done to address this concern. It is an issue for the service as a whole
and not just HMP Frankland. I believe this issue should be raised with
Primary Care Trusts with prisons as an issue of clinical governance.
The PCT in partnership with the prison should consider the points
raised in the clinical review with regard to records and record
keeping and develop an action plan to address these in a timely
way.
RECOMMENDATIONS
OPERATIONAL
1. The Governor should develop a self-audit programme for
monitoring standards of record keeping and provide appropriate
training to staff as necessary.
The Prison Service accepted this recommendation.
2. The Governor should review and revise the record storage system
to ensure that bedwatch and escort information about particular
prisoners is filed correctly.
The Prison Service accepted this recommendation.
CLINICAL
3. The Healthcare Manager should remind staff that in accordance
with the Nursing and Midwifery Council’s guidelines for records
and record keeping, all medical records should be legible, up to
date and in chronological order.
4. The PCT in partnership with the prison should consider the points
raised in the clinical review with regard to records and record
keeping and develop an action plan to address these in a timely
way.
GOOD PRACTICE
5. Senior management and staff should be commended for
arrangements they made for the man to be treated with dignity
during his final hours in the hospice. Compassionate
management of a category A prisoner was shown in implementing
a ‘no restraints’ policy and by ensuring that escort staff remained
in civilian clothes whilst he was in the hospice. A careful balance
was struck between the man’s potential high risk and the need for
dignified care due to his terminal illness. This was done in a
sensitive and timely way.
6. I commend the occupational therapist, for the attempts she made
to keep the man’s spirits high in light of his terminal condition.
The occupational therapist provided him with additional emotional
support and encouraged him to remain as active as possible in
the final weeks of his life.