Individual at Stocken

Investigation into the circumstances surrounding the
death of a man in hospital in March 2008 whilst in the
custody of HMP Stocken
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2009
This is the report of an investigation into the death of a man. The man died of
natural causes in March 2008 in hospital, whilst in the custody of HMP
Stocken.
I would like to offer my personal condolences to the man’s family. One of my
family liaison officers was contacted by the man’s brother. She informed him
of our role and invited his participation in the investigation. The man’s brother
did not have any matters concerning his brother’s death that he wanted to
bring to my attention, but he asked to see a copy of my report when it was
completed. I am sorry for any distress caused by the delay in doing so.
This investigation was undertaken by one of my investigators. Both he and I
would like to thank the Governor and staff of HMP Stocken for their
assistance. A medical practitioner was asked by Leicestershire and Rutland
Primary Care Trust to undertake a review of the man’s clinical care, and I also
appreciate his help.
When a prisoner has died of natural causes I must look closely at the clinical
review before compiling my report. In the man’s case, the clinical reviewer
has found that he died from a rapid progression of an aggressive form of
cancer. In his opinion, the quality of care the man received was equivalent to
that he could have expected in a typical doctor’s surgery. I do not make any
recommendations to the Governor.
There were three deaths of prisoners at HMP Stocken that I had investigated
before that of the man. Sadly, the prison suffered another death two days
after the man passed away. None of the circumstances of these other deaths
has similarities those covered in this report.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2009
CONTENTS
Summary 4
The Investigation Process 5
HMP Stocken 6
Key Findings 7
Issues 12
Conclusion 13
Annexes
Clinical review
Transcript of interview with the Head of Healthcare at Stocken
Transcript of interview with the man’s personal officer at Stocken
SUMMARY
The man died in hospital whilst a prisoner at HMP Stocken. He had been in
hospital for 19 days prior to his death.
The man had served previous terms in prison before he was sentenced to life
imprisonment in 1997. He moved through the prison system, and during that
time made efforts to address his offending behaviour. He undertook a
number of therapeutic courses, including some that were very demanding.
The man was not in the best of health. He suffered from diabetes and
epilepsy. Heart disease had caused him to have a heart attack and triple
bypass surgery in the past. Through the course of his life he had sustained a
number of head injuries. He had also misused alcohol and drugs for a
number of years, and was a longstanding heavy smoker.
Early in 2008, the man’s health began to deteriorate rapidly. He was referred
for tests but, before the results were fully available, he was so ill that he
required a transfer to hospital. Once in hospital, it was confirmed that he had
cancer.
The prison remained in contact with the hospital during the man’s time there.
The man was largely unconscious, and the prison took the decision that he
did not need to have restraints attached to him. The hospital began a course
of chemotherapy, but the man’s condition continued to worsen. In mid March
2008, medical staff at the hospital agreed that the man’s treatment should be
discontinued. He died peacefully the following morning.
The man was not in contact with any of his family. When the prison contacted
both the man’s ex-wife and his brother they said that they were content for the
prison to arrange the funeral. The arrangements were therefore made by the
prison. The Governor and two other members of staff from the prison
attended. At the same time as the funeral, a service was held in the prison to
allow fellow prisoners to pay their respects.
THE INVESTIGATION PROCESS
1. My investigator visited HMP Stocken. He spoke to a number of staff
there, including the Governor, and was shown around the prison. He
formally interviewed two members of staff. These interviews were
recorded and both interviewees signed a copy of their transcripts
confirming the accuracy of the record. The transcripts are annexed to
this report. Notices were posted to staff and prisoners about the
investigation, inviting contributions. No responses were received. My
investigator studied all available relevant prison records relating to the
man, including his security record, medical records and prison records.
2. Leicestershire County and Rutland Primary Care Trust asked a medical
practitioner to carry out a review of the man’s clinical care. I am
grateful to him for undertaking this review. My investigator discussed
aspects of the man’s treatment with both healthcare staff at Stocken
and with the clinical reviewer.
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. As is my practice, upon completion my report will be
sent to the Coroner to assist in his enquiries into the man’s death.
HMP STOCKEN
4. HMP Stocken was built in 1985 and is a category C closed prison.
New wings have been built a number of times and the prison now holds
over 800 prisoners.
5. Nurses provide healthcare cover in the prison between 7.30am and
5.30am Monday to Friday and from 8.00am until 5.00pm at weekends.
Doctors are available for three hours each day Monday to Friday.
Her Majesty’s Chief Inspector of Prisons
6. The last inspection of Stocken by HM Chief Inspector of Prisons before
the man died was an announced inspection in May 2005. The Chief
Inspector’s subsequent report does not raise any issues of relevance to
this investigation.
Independent Monitoring Board (IMB)
7. Each prison in England and Wales has an Independent Monitoring
Board responsible for monitoring day-to-day life in the prison and to
ensure that proper standards of care and decency are maintained. The
annual report published by the IMB for Stocken covering the year up to
April 2008 also does not raise any issues affecting the investigation
into the death of the man.
KEY FINDINGS
8. The man was arrested in February 1996 and remanded in custody
pending trial. Whilst on remand the man suffered an epileptic seizure.
9. At Teesside Crown Court on 11 November 1997, the man was
sentenced to life imprisonment. A psychiatric opinion produced for the
court said that the man had a serious and violent past, an anti-social
personality disorder, and a history of significant alcohol abuse.
10. In August 1998, the man was transferred to HMP Wormwood Scrubs.
Whilst there, he undertook an Enhanced Thinking Skills programme
and a relationships skills course, although he later said that heroin use
at the time had restricted his memory of the latter. He was reported as
being willing to partake in any course that would help him, and applied
for courses to address anger management and drink and drug abuse.
He also applied to be a Listener (prisoners who have been trained by
the Samaritans to provide support for their peers).
11. The man continued to progress through the prison system, largely
without incident. In February 1999, a knife blade was found in his cell.
In February 2001, he lost his job as a red band cleaner (a position of
higher than usual trust) in Healthcare when he was suspected of
involvement in drug dealing. But aside from these instances he
received good reports for his work. His behaviour on the wing did not
cause any problems. He was generally held to maintain a fairly low
profile but did get on well with other prisoners. After his mother died,
the man gave up his job as a Listener as he felt that it had become too
difficult for him to cope. He embarked upon a Social Sciences degree
and had completed his first five assignments with good marks.
12. Early in 2001, the man complained of chest pains. Tests were
conducted on his heart and in April 2001 results indicated that that he
was suffering from ischaemic heart disease.
13. After completing another thinking skills course in October 2001, the
man accepted that he was in the early stages of rehabilitation and that
he needed to do more in-depth work on a number of issues. For this
reason, he expressed a wish to be transferred to the therapeutic
community at HMP Grendon. He was accepted for a place and
transferred on 5 November 2001. Located on C wing, he initially found
it difficult to settle. However, he conformed to the rules and policies
and was not seen as a control problem.
14. The man had a good relationship with both staff and prisoners at
Grendon. He was described as polite, and willing to give his time to
help others. He made significant efforts to overcome his fear of
crowds, deliberately involving himself in Grendon’s family days and
social evenings. He succeeded in mixing with large numbers of his
peer group as well as with other people.
15. After reporting chest pain in December 2002, the man was taken to
hospital as an emergency admission. He subsequently discharged
himself, but after further problems (including angina) over the following
months he underwent further tests. This resulted in triple heart bypass
surgery in September 2003.
16. On 26 April 2004, the man suffered a heart attack. On his return from
hospital to prison he was unable to engage in therapy fully but was
reported to have made good progress in addressing his risk factors.
He was said to be working hard in group sessions and making
progress, and was keen to address his offending behaviour and reduce
his level of risk. In November 2004, the Sentence Planning Review
Board recommended that the man was ready to be transferred to
category C conditions.
17. Following that recommendation, the man was re-categorised to
category C in February 2005. He had a successful small group
assessment and was set therapeutic and treatment objectives. The
man was reported to be feeling energised and optimistic about the
continuation of his work in Grendon.
18. However, in April 2005, the man suffered a transient ischaemic attack
(sometimes described as a mini stroke). His therapeutic treatment at
Grendon was disrupted and, when it became apparent that Grendon
could not provide the healthcare the man required, he was transferred
to HMP Littlehey in September. Once again, reports showed that the
man maintained a fairly low profile but interacted with staff and
prisoners when he needed to. Compliant with wing rules and
respectful to others, the man did not have any adjudications during his
time at Littlehey. He took part in a programme provided by the
Rehabilitation for Addicted Prisoners Trust (RAPt).
19. As part of his offending behaviour related work, the man wanted to
transfer to open conditions. He hoped to demonstrate that he was
ready for the next stage in his sentence. He was advised to defer his
application until he had completed his current programme. He
completed the RAPt Substance Abuse Treatment programme in
September 2006, and his case was considered by the Parole Board on
22 November. The Board recommended that the man should remain
in closed conditions and undertake further offence-based work to show
that he was continuing to address his risk factors.
20. In January 2007, the man completed the RAPt Peer Support
programme. He had been made a peer supporter and this reflected
the progress he had made in a position of responsibility.
21. The man was transferred to HMP Stocken on 16 April 2007. Once
again, he was reported to be a quiet and private person. He was
friendly with one other prisoner, whom he had known from a previous
establishment, but beyond that did not associate much. He worked as
an education orderly and was well thought of in what was a trusted
position. Although he had done well in education previously, he did not
want to continue with his own education.
22. The man’s personal officer at Stocken told my investigator that the man
wanted to return to Grendon to continue his therapeutic treatment.
When he was in Grendon, a number of courses had been identified for
him, including an Enhanced Thinking Skills course, the Controlling
Anger and Learning to Manage it (CALM) course, and potentially a
Healthy Relationships Programme (HRP). The HRP was subject to a
two-year waiting list. The applicant would then undergo assessment
and, if found to be suitable, there was a further two-year waiting list.
Prisoners serving life sentences do not have an automatic right to
release but must serve a minimum period of imprisonment before
release can be considered. This period is known as the tariff. The
man knew that he was close to his tariff date and accepted that he
would be likely to remain in prison beyond it. He therefore thought it
would be beneficial to return to Grendon and finish his therapy. He
applied for a transfer, but Grendon was unable to accept him because
of his health problems.
23. Following complaints of dizziness, the man was admitted to Leicester
General Hospital in September 2007. A computed tomography (CT)
scan (a specialised x-ray test to give clear pictures of the inside of the
body, particularly of the soft tissues) was normal and his symptoms
were treated. He returned to prison on 9 September. On 22 October,
the man again complained of chest pain. His hypertension was noted
to be poorly controlled, and he was suffering from bronchitis. He was
prescribed medication to treat this.
24. The man’s personal officer told my investigator that she observed the
man’s health deteriorating over this period. She noticed that the man
was not eating at lunchtimes and, knowing that he had diabetes, this
caused her some concern. She said that the man had lost a bit of
weight, and she talked to him about going to Healthcare. He told her
that he had already consulted them and they were addressing it. The
man’s medical notes indicate frequent contact with Healthcare through
November and December. Shortly after Christmas 2007, the man
mentioned to the first officer that he was a bit concerned about a
growth he had found on his neck. She said that she again told him that
he should go to Healthcare. He said that he had an appointment that
same day.
25. Medical records for late December carry frequent entries relating to
problems including episodes of central chest pain, erratic diabetic
control and shortness of breath. In January 2008, the man complained
of pain around his jaw and throat area and it was noted that he had lost
weight. On 6 February, it was noted that his health was continuing to
deteriorate and chest x-rays were requested. On 22 February, a
review of the x-rays showed a possible malignant disease in both lungs
and the man was referred for further assessment within two weeks.
26. However, by 28 February, the man’s health had significantly
deteriorated. A nurse was called to see him on the wing and was
concerned enough about his condition to arrange for an emergency
transfer to a Royal Infirmary. Once in hospital it was noted that the
man had a high heart rate and a number of swollen glands. He was
transferred to the infectious diseases unit where he was diagnosed
with pneumonia. On 1 March, the man’s health had deteriorated to
such an extent that he was admitted to the Intensive Treatment Unit
(ITU) with respiratory failure.
27. Test results were received on 3 March. They confirmed that the man
had cancer and he was informed of the diagnosis.
28. The Head of Healthcare at Stocken contacted the hospital on 5 March
and spoke to the Royal Infirmary Infectious Disease Unit Registrar
Specialist. The man was unconscious and ventilated. An attempt had
been made to extubate the man (remove medical tubes supporting
him) at the beginning of the week. His condition deteriorated and he
had to be re-intubated (re-applying the medical tubes) and put on life
support. At that time the man had also had a degree of kidney failure,
and hospital staff were considering whether he might need dialysis.
The man also had some cardiovascular failure and was receiving
medication through intravenous tubes. The Head of Healthcare at
Stocken told my investigator that a biopsy had been taken and
histology was awaited, but the prognosis at this point was quite poor.
29. The following day, the Head of Healthcare at Stocken visited the man
in hospital. She told my investigator that he remained ventilated and
sedated. She said that the consultant in charge of the ITU told her that
the man’s medical condition had improved slightly from the previous
day, and ongoing treatment was being considered. The man had been
unconscious virtually since he arrived in hospital. On 7 March,
chemotherapy was begun but his condition continued to deteriorate.
30. The man’s condition fluctuated over the following days, sometimes
slightly improving, at other times deteriorating. On 12 March, it was
decided that his sedation and ventilation should be discontinued. The
Head of Healthcare at Stocken told my investigator that during the
weekend of 14/15 March the man suffered a heart attack, and was
resuscitated and consequently re-intubated.
31. Monitoring of his condition revealed on 16 March that the man had
developed septicaemia (a poisoning condition of the blood). On 17
March, healthcare staff from the prison spoke to hospital staff. The
man was still ventilated at this stage, but the consultant had made the
decision to withdraw treatment if his condition deteriorated as further
treatment would not be in the man’s best interests. At that point, there
would be no more treatment that could benefit the man and
resuscitation would not be attempted. Treatment was discontinued on
17 March 2008, and the man died at 11.20am the next day.
32. Notices were posted in Stocken about the man’s death. Because of
the circumstances of his death a debrief session was not held, but the
first officer said that the staff care team were available if anybody
required support. She was not individually offered support. The Head
of Healthcare at Stocken told my investigator that all healthcare staff
were offered good support from the Prison Service as well as from
clinical colleagues.
33. The prison held a memorial service for the man to allow his fellow
prisoners to pay their respects. This was held at the same time as his
funeral, which the prison arranged. The prison held a bereavement
workshop on the man’s wing.
ISSUES
34. The clinical reviewer finds that the treatment the man received was
entirely appropriate. He says that access to healthcare was adequate,
and assessments were made by appropriate clinicians. Although he
died of cancer, the man’s ischaemic heart disease was so severe that
he could have died at any time. His heart problems may have
contributed to his rapid physical deterioration, and the post mortem lists
his heart disease as a secondary cause of his death.
35. In view of the man’s medical history and symptoms, the reviewer raises
the issue of why chest x-rays and blood tests were not considered
earlier. He notes, however, that the man’s cancer was an aggressive
form of the disease and earlier treatment would not have prevented
him from dying. He also notes that the lack of an earlier diagnosis was
not the result of a systematic failure but of individual decisions. He
does not consider that there is any need to recommend a change of
process or the level of clinical expertise at Stocken that could prevent
similar deaths in future.
36. Bearing in mind his health problems, the man seems to have been well
cared for in Stocken. Despite his wish to return to Grendon, he
seemed settled at Stocken, and I entirely understand why a transfer to
Grendon was not a realistic possibility. The personal officer took her
duties seriously and appears to have formed a good relationship with
him.
CONCLUSION
37. The man had been unwell for many years. He had suffered from
diabetes for most of his life, had a history of multiple head injuries
which he had sustained during fights and road traffic accidents,
suffered from epilepsy which was controlled with medication, and had
abused drugs and alcohol for a number of years. He was described by
his personal officer as a “chain-smoker”, and had smoked heavily for a
number of years.
38. The form of cancer that led to the man’s death caused a rapid
deterioration in his health. The clinical reviewer notes that an earlier
diagnosis would not have prevented the man from dying, and the care
he received was appropriate.
39. I have been pleased to note that the prison took the decision that, while
the man was unconscious, he did not need to have security restraint
chains applied,
40. I have made no recommendations in this report. Sadly, the man’s
lifestyle over the years had taken its toll on him. I do not believe that
his death could have been prevented or that there were any systematic
failings in his care.
41. I also judge that Stocken’s response to the man’s passing was
appropriate, sensitive, and in line with Prison Service guidance.