Individual at Norwich

Investigation into the circumstances surrounding the
death of a man, a prisoner at HMP Norwich,
in April 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2009
This is the report of an investigation into the circumstances of the unexpected death
of a man in Norfolk and Norwich University Hospital on 5 April 2008. The man was
aged 55 years at the time of his death and was a prisoner at HMP Norwich.
I would like to offer sincere condolences to the man’s family. The Man’s suicide
attempt in May 2000, the serious disablement he suffered as a consequence, and
finally his death while still a prisoner, must be particularly difficult for the family to
bear.
My colleague conducted the investigation on my behalf. An independent review into
the man’s care was undertaken by a Clinical Governance Manager, Norfolk Primary
Care Trust. I am particularly grateful to the clinical reviewer for her very valuable
contribution. I would also like to thank the Governor and Deputy Governor of HMP
Norwich, as well as Head of Healthcare, for their cooperation with the investigation. I
am particularly grateful to an officer who provided a very high standard of liaison.
I conclude that the care the man received while at the Norwich Nelson Unit was very
good. The staff demonstrated a high level of care and commitment to him. The
clinical reviewer has inferred that the man did not enjoy a similar level of care and
commitment while a patient at Norfolk and Norwich University Hospital, but this is
outside my remit. The Chief Executive of the Norfolk Primary Care Trust, may wish
to draw my report to the attention of her counterpart at the hospital.
I make four recommendations in my report. Three relate to poor liaison between
healthcare, the prison and the family. The fourth proposes that a memorandum of
understanding should be agreed between the prison and Norfolk and Norwich
University Hospital setting out clear boundaries regarding the respective roles and
expectations of prison and NHS nursing staff.
The Prison Service response to my recommendations is at page 18 of this report.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2009
2
CONTENTS
Summary 4
The investigation process 6
HMP Norwich 9
Key findings 10
Issues 15
Recommendations 18
3
SUMMARY
On 19 November 1998, the man was convicted of murder and sentenced to life
imprisonment. Records show that he found prison a very difficult experience. He
lacked the necessary coping skills and this, combined with family problems in the
United Kingdom and bereavement in India, appeared to increase his frustration and
heighten his sense of isolation. Throughout 1998 and up until an attempt to take his
own life in May 2000, a number of F2052SH documents were opened by staff who
were concerned by his state of mind and consequent behaviour. (An F2052SH was
a document opened by any member of staff concerned about a prisoner who was
believed at risk from self harm. This has since been replaced by the Assessment,
Care in Custody and Teamwork (ACCT) document and process.)
On 4 May 2000 at 9.25am, at HMP Swaleside, the man attempted to take his life by
ligature. He was resuscitated in his cell by staff but suffered anoxic brain damage as
a result of the attempt. Records show that he spent around a month in hospital but
his recovery would never be complete and he was returned to Swaleside where he
received 24 hour nursing care.
In 2005, the man’s condition deteriorated and Swaleside were no longer able to meet
his needs. He was accepted into the Nelson Unit at HMP Norwich following a
referral by Swaleside.
The Nelson Unit managed the man’s physical and psychological needs very well. I
judge that he received a very high standard of care delivered by committed and
caring staff. Appropriate referrals were made for expert advice on issues such as
dealing with his challenging behaviour and his diet (as he was unable to swallow
normally due to his injuries).
Despite every effort, the man ingested food into his lungs (silent aspiration) at times.
This meant that he regularly suffered chest infections. Following significant weight
loss in September 2007, a referral was made to Norfolk and Norwich University
Hospital. A subsequent scan in March 2008 showed that the likely cause was
tuberculosis (TB), a communicable disease. This could not be confirmed as the man
was too unwell to give samples.
In hospital, the man became reluctant to take his medication. The bedwatch log
records that a bedwatch officer assisted nursing staff in giving medication. It is not
clear whether the man had given his consent or if the officer wore any protective
clothing such as a mask when entering the man’s room. I have made a
recommendation that a memorandum of understanding governing codes of
behaviour and setting clear boundaries between the prison and the Norfolk and
Norwich University Hospital should be agreed.
A mental health capacity review was held at the Nelson Unit on 19 March 2008. The
review was held in order to decide whether it was in the man’s best interests to be
resuscitated following a heart attack. It was concluded it was not. The family were
neither informed of, nor invited to the review, and I make a recommendation in that
regard.
4
Just after midday on 5 April 2008, the man was found dead by a member of hospital
staff. The man’s brother was told of his death by a telephone call from the Head of
Healthcare. I make a recommendation that best practice should be adhered to and,
wherever possible, such news should be delivered in person, usually by the prison’s
Family Liaison Officer and another member of staff.
I note with disappointment that the man’s brother was not invited to the memorial
service held in Healthcare. He would have been happy to have attended, and I
make a recommendation that invitations to memorial services should be extended to
the family whenever those services are held in the prison.
My recommendations aside, I judge that the care the man received before his
admission to hospital was of a very high standard. Staff at the Nelson Unit are to be
commended for the level of commitment and care they demonstrated. I am unable
to comment on the care he received at the Norfolk and Norwich University Hospital
as this is beyond the remit of my office.
No post mortem was held.
5
THE INVESTIGATION PROCESS
1. My office was notified of the man’s death on 5 April 2008. Terms of Reference
and Notices were issued to staff and prisoners at Norwich telling them that an
investigation would be taking place, and inviting those who wished to see the
investigator to make themselves known. My investigator requested copies of
the man’s core record, medical record and other records relevant to his time in
custody and to his death.
2. My Investigator also contacted HM Coroner. The purpose was to inform him of
the nature and scope of the Ombudsman’s investigation. I understand that a
post mortem was not undertaken as the cause of death was given by the
Norwich and Norfolk University Hospital where the man died. The cause of
death is recorded as:-
a) 1a. tuberculosis
b) 1b. anoxic brain injury
c) 1c. disseminated malignancy.
3. A clinical review of the man’s medical care was commissioned by Norfolk
Primary Care Trust. It focuses on the medical care the man received at HMPs
Swaleside and Norwich and at the Norfolk and Norwich University Hospital
where he died.
4. The Clinical Governance Manager Norfolk Primary Care Trust (PCT) and my
investigating colleague visited the Nelson Unit at Norwich prison on 23 June
2008. They met the Head of Healthcare and were given a tour of the unit. The
facilities available to the unit and equipment purchased specifically for the man
were shown and explained. The Clinical Governance Manager Norfolk Primary
Care Trust (PCT) and my investigating colleague met informally with prisoners
on Nelson Unit who knew the man.
5. One of my Family Liaison Officers together with my investigator met the man’s
brother at his home. He raised a number of concerns on behalf of the family.
My investigator and FLO also received a copy of a letter from another brother in
India, addressed to my office, in which he raised additional concerns. I am
unable to address matters relating to the man’s immigration difficulties or his
appeal against conviction and sentence as these are outside my terms of
reference. The matters I have investigated on behalf of the family are:
a) Was there an investigation into the man’s near fatal attempt to take his
own life at Swaleside?
b) Was it in the man’s best interests to be moved to Norwich from
Swaleside?
c) Why representatives from the prison were not present at the funeral
even though the prisons were aware of the dates?
d) Why was the man’s brother not invited to the prison to attend the
memorial service held in Healthcare and meet with other prisoners who
knew his brother?
e) Was the man well looked after at Norwich because, to his brother, he
appeared to deteriorate after the transfer?
6
f) How did the man contract TB and what treatment was offered?
6. The FLO made a number of unsuccessful attempts to reach other members of
the man’s family. She spoke with his daughter who chose not to raise any
concerns for consideration at that point. The family will be given an option of
receiving the draft report and can participate in the investigation at that stage.
7. My Investigator contacted HMP Swaleside and spoke with the Deputy Governor
to ask if there had been an investigation in respect of the man’s attempt to take
his life in 2000.
8. My investigator has consulted investigation reports relating to the deaths of
prisoners at Norwich since 2004. The investigator has also read the reports by
HM Chief Inspector of Prisons, of an announced inspection of Norwich in 2006
and an unannounced follow-up inspection. A copy of the prison’s Independent
Monitoring Board (IMB) report dated 1 March 2007 to 29 February 2008 was
also consulted.
7
HMP NORWICH
9. HMP Norwich is a local male training prison and young offender institution
holding remand and sentenced prisoners. It serves the courts of East Anglia.
10. The prison comprises nine units (formerly known as wings) with an operating
maximum capacity of 823 prisoners. Healthcare is located over two floors. The
upper floor has 32 beds for inpatient care; the ground floor accommodates the
Nelson Unit, a special unit for older prisoners. The upper healthcare centre
also provides inpatient care for HMP Wayland and HMP Blundeston. In
addition, it has an x-ray facility and provides regular clinics in chiropody,
dentistry, asthma and opticians.
11. The 15 bed Nelson Unit, where the man was located, is based on a residential
home model. It is an example of good practice and a national resource for the
Prison Service. It is dedicated to providing intensive nursing care, mostly for
life sentenced prisoners over the age of 60 years. Palliative care, such as the
man would have received, is delivered through a multi-disciplinary approach,
and there are good links to health services in the community to aid delivery of
care. In the Independent Monitoring Board’s report for 2007-08, the Board
have commented that, “The Nelson Unit for elderly prisoners has introduced an
innovative ‘open door’ policy … It has also used the voluntary sector to develop
various social activities.”
8
KEY FINDINGS
12. On 13 March 1998, the man was remanded to HMP Wormwood Scrubs. He
transferred to HMP Highdown on 15 October 1998 during his trial. On 19
November, he received a life sentence following his conviction for murder.
13. Prison records show that, from the start, the man found prison a very difficult
experience. He stated his innocence to staff and became increasingly
frustrated with the prison regime. It was also clear that, in the early stages of
his sentence, some staff found his poor coping skills demanding of their time
and patience. My investigator noted that some entries in the wing sheets were
frank in expressing that view. A more positive entry on 2 November 1999
showed that, “overall … he has worked hard for staff and is generally respectful
to all staff. He does suffer ‘bad’ days when he is down … He is on enhanced
level of IEP.” (IEP refers to the Incentives and Earned Privileges Scheme.)
14. At Wormwood Scrubs on 10 April 1998, a F2052SH self-harm document was
opened by staff who had received a faxed letter from the man’s solicitor raising
concerns about him. (The letter was not attached to the document and
therefore the precise contents are now unknown.) The F2052SH records that
the man had told staff that in 1995 he was in a psychiatric hospital and had
been prescribed anti-depressants in the community. They were therefore
aware of his previous mental health difficulties. In order to deal with his
isolation and distress, staff found a suitable prisoner willing to share his cell to
combat the loneliness he said he felt at the time.
15. On 14 January 1999, while at Highdown, the man received notification that his
‘tariff’ (the ‘tariff’ is the minimum time that has to be served in prison before
release on licence can be considered) was set at 18 years. Wing records show
that the next day the man harmed himself by cutting. He attended the
healthcare centre for treatment and another F2052SH was opened. The
probation officer who chaired the review referred to a “multiplicity of other
problems which are receiving attention by the relevant people”. On 5 March
1999, the F2052SH document was closed.
16. Another F2052SH was opened on 19 April 1999 because information given to
staff indicated that the man intended to take his life. The doctor who spoke with
the man on 19 April noted he was “angry with the system” and was threatening
to refuse food. The document was closed on 11 May when the crisis appeared
to have subsided. A further F2052SH document was opened again on 26
October in response to concerns raised by staff and the Sikh minister. The
man said that while he would not harm himself, he had received “three lots of
bad news” including difficulties with his family, the loss of his appeal and a
transfer to HMP Swaleside. The support plan said that the man and a member
of staff were to make a referral to psychiatric services. There is no evidence to
show that this was done, but detailed entries in the F2052SH say that he was
closely observed by staff in view of their concerns he might harm himself
because of his imminent transfer.
9
17. The man was transferred to Swaleside on 4 November 1999. A further
F2052SH document was opened by Swaleside on 3 March 2000 because of
the difficulties the man had expressed to staff at Highdown in coping with his
family relationships, his appeal and his sense of hopelessness. Staff allowed
him a telephone call to India to speak to his mother and made referrals to the
psychiatrist and wing psychologist for continued support. Swaleside also
offered a healthcare admission but the man declined this. A F2052SH review,
held on 8 March 2000, noted that his depression had passed and he had been
seen by the psychiatrist who was “now aware of his situation and placed him on
medication”. It was felt by staff and the man that the support provided by the
F2052SH was no longer necessary as he was more focussed, and the
document was closed.
18. On 18 April 2000, the man’s mental state and behaviour deteriorated. He was
admitted to the healthcare department and a F2052SH document was opened
detailing a suicidal gesture on the previous night. He was placed in a protected
cell and on continuous watch by staff. A review of the F2052SH was held the
following day. Those attending included the duty governor and two members of
the prison healthcare staff, but there is no evidence that mental health care
staff were present. The review concluded that poor relationships with staff and
anxiety regarding his mother being in a coma in India were the contributing
factors to his attempt to take his life. Recommendations on the man’s
management included the need for him to be seen by counsellors and “to do
anger management course in due course. Review by wing psychologist in view
of his extreme uncontrollable anger.” It is notable that there is no evidence of a
referral to psychiatric services for an opinion.
19. On 4 May 2000 at 9.25am, the man was relocated to the segregation unit from
healthcare for an adjudication upon a matter which he disputed. At 1.30pm, the
man was found hanging in his cell. (Once more in one of my reports I must
draw attention to the special riskiness attached to segregation.) Staff
conducted cardio pulmonary resuscitation (CPR) and an emergency ambulance
was called. Records show that the man was breathing unaided by the time he
left the prison for the hospital. Sadly, he suffered irreversible anoxic brain
damage.
20. Anoxic brain damage is caused by a severe lack of oxygen to the brain. The
clinical reviewer has identified a range of symptoms including problems with
thinking skills, emotional and behavioural difficulties. Physically, the man was
severely incapacitated and needed 24 hour nursing care until the end of his life.
21. During her investigation, my investigator spoke with the Deputy Governor at
Swaleside to ask whether an investigation had been conducted into the
circumstances of the man’s near fatal attempt to take his life in 2000. Following
enquiries, the investigator was told that no report was found and healthcare
staff who were at Swaleside at the time confirmed that, to their knowledge, no
investigation took place. At the time, there was no national requirement that
such ‘near deaths’ should be investigated. Current guidance is that they should
be, and the terms for such investigations (including their compliance with Article
10
2 of the European Convention on Human Rights) are currently the subject of a
case that is before the House of Lords.
22. After a lengthy period in hospital, the man returned to Swaleside where he
remained until 2005 when his condition deteriorated. He was bedridden, and
needed 24 hour nursing and personal care, and the prison met these needs
with difficulty. Staff found the man to be a difficult individual because, at times,
he presented with challenging and inappropriate behaviour, particularly towards
female staff. (In interview with my investigator, the Head of Healthcare at HMP
Norwich said that she found the man easy to manage. However, records
suggest that this was not the experience of all staff and the man’s challenging
behaviour continued with some staff at Norwich.) Swaleside made a referral for
the man to be transferred to the Nelson Unit at Norwich, which could provide
the more specialist and intensive care that the man needed. The Head of
Health Care informed my investigator that she had visited Swaleside with a
colleague in order to assess the man for the Nelson Unit. She accepted him
into the unit despite the fact that he did not meet the unit’s minimum age
criterion of 60. She told my investigator that she did this because she felt the
unit would be better able to meet his challenging and complex needs.
23. The man’s medical record shows that staff at the Nelson Unit had a consistent,
dedicated and multidisciplinary approach to his care, with regular monitoring of
his physical and emotional wellbeing. This included best practice in seeking
advice in managing his aggressive and inappropriate behaviour with staff by
identifying possible trigger factors. Specialist equipment such as a hoist and a
special chair were purchased in order to meet his specific physical needs.
24. A letter dated 20 December 2005 from the Adult Speech and Language
Therapy, Sheppey Community Hospital, to Speech and Language Therapy,
Norwich Community Hospital, shows appropriate continuity of care from
Swaleside to Norwich. The man was regularly reviewed by the speech and
language service and his abilities and dietary needs were adjusted as
necessary. His speech was limited to ‘yes’ and ‘no’ responses and he made
his basic needs known to staff through his facial expressions. His difficulties
swallowing were managed through a ‘soft’ diet with liquid taken from a spouted
cup to encourage him to feed himself.
25. The family told my investigator and the Family Liaison Officer in this case that
they felt the quality of care the man received at Norwich was less than at
Swaleside where he had a designated carer. The family raised a concern that
the man had been ”parked” in front of the television in the lounge and left. My
investigator discussed this issue with the Head of Healthcare. She told my
colleague that on some days, with his consent, the man was placed in the
lounge in front of the television to stimulate him and to encourage him to
socialise with other prisoners. From the medical record, my investigator saw
that when the man indicated to staff that he wished to remain in bed this was
respected. My Investigator visited Nelson Unit and noted there was a television
in the man’s room for his sole use.
11
26. An entry in the medical record dated 11 September 2007 says that the man had
experienced significant weight loss since his previous weight observation on 24
August. Chest problems persisted and his appetite varied from day to day.
The medical record shows very good entries detailing efforts by staff to
encourage him to eat. Staff closely monitored his health and appropriate
prescriptions were given to address his weight loss.
27. On 31 January 2008, the man attended an appointment with the Doctor a
Consultant Physician. This followed a referral by the prison because of
concerns regarding his numerous chest infections, recurrent silent aspiration
(food going into the lungs) and significant weight loss. A member of the Nelson
Unit nursing staff, who knew the man well, attended the appointment to assist
with communication. This was good practice.
28. On examination, the consultant physician found that the man was “emaciated
and cachectic” (weakness associated with chronic illness) with,” muscle
wasting of all limbs”. The Physician arranged for further investigation including
a high resolution computerised tomography chest (CT) scan. An appointment
was made for 19 March 2008. The report of the scan found that, “there
appears to be a large mass in the left upper quadrant’” and recommended that
an enhanced scan be carried out for further assessment. There was “extensive
bronchiolitis throughout both lungs” with the conclusion that tuberculosis (TB)
was the most likely cause. The Head of Healthcare confirmed that it was not
possible to pinpoint exactly when and how the man contracted TB. From
hospital records, the clinical reviewer has noted that a TB specialist nurse went
to the Nelson Unit to assess the risk of infection to staff and prisoners.
Screening was offered to those who were in contact with the man for a period
of time in excess of eight to ten hours.
29. On the morning of 19 March 2008, a mental health capacity review was held at
the Nelson Unit. This was attended by a locum doctor, Head of Health Care,
Senior Nurse, the man himself, and a Doctor who would speak for him. The
review concluded that, in the event of a heart attack, the man would not be
resuscitated because cardiopulmonary resuscitation (CPR) was unlikely to be
successful. Even if it were successful, it was judged that it would not be in the
man’s best interests to sustain the quality and length of his life. My investigator
noted that the family was neither consulted regarding the review nor informed
of the decision. This was a regrettable omission.
30. The man was admitted to the Norfolk and Norwich University Hospital for
treatment for TB on 23 March 2008. On 26 March, the hospital confirmed that
they were treating the man for active TB. They said this was a working clinical
diagnosis as they were unable to take samples from the man and he was not
well enough to withstand invasive procedures such as a bronchoscopy. (This is
when a thin flexible tube is passed down the throat to diagnose some
conditions of the airways.)
31. On 26 March, Head of Health Care informed the man’s brother by telephone
that the man was very unwell. The brother visited the man on 27th March. He
12
told the bedwatch escort staff that he would probably visit again at the
weekend.
32. A Principal Officer (PO) was on bedwatch duty on 3 April. The bed watch log
says that he assisted a nurse to give the man his medication. While well-
intentioned, it is not clear whether this was with the man’s consent and the
clinical Governance Manager of Norfolk has addressed the issue in her clinical
review attached to this report. The PO said he assisted because the man had
refused his medication the day before and the nurse was concerned.
33. My investigator spoke with a Senior Officer (SO) who was on the same
bedwatch as the PO. He told her that patient confidentiality is paramount and,
respectful of that, staff were not told the nature of the man’s illness. The man
had a working diagnosis of TB, a serious communicable disease. If staff have
to enter a room where a prisoner has a serious communicable disease for any
reason, appropriate protective clothing must be worn. By example, a note on
the bedwatch log handover dated 31 March clearly states that “mask to be worn
when entering room”. In interview, the PO was unclear as to whether or not he
placed himself at a risk of infection.
34. The bedwatch log records that the man was fed by nursing staff at the hospital
at 8.00am and was not seen again by any member of staff until 12.20pm when
a nurse entered the room and found he had died. This is supported by another
Senior Officer who was on bedwatch duty outside the room. In his statement
he said that at about 8.00am nursing staff went into the room to give the man
his medication and food, and to attend to his personal hygiene. The SO
remained outside the man’s room. He described hearing the man during the
morning as if he was moving his head from side to side and groaning. The SO
said that at midday he could no long hear anything and thought that the man
must be “motionless”. He said that at 12.40pm the nursing staff entered the
room and said that the man had died. Although the matter is outside my terms
of reference, it is both a sadness and a cause for concern that hospital staff
apparently did not check the man for over four hours and that he died alone in
his room.
35. Head of Health Care told my investigator that she had been surprised to learn
of the man’s death as it had come sooner than the prison had expected. She
said that they had been preparing for the man’s return on or around 8 April.
They had started preparations for end of life care, as they suspected the mass
found on the scan might have been an underlying malignancy.
13
ISSUES
Clinical care
36. The clinical review was undertaken by the Clinical Governance Manager,
Norfolk Primary Care Trust. She concludes that, “the quality of care provided
by the team at Norwich was of a very high standard. Up to the point of his
transfer into the Norfolk and Norwich University Hospital, the man had thorough
multi-disciplinary assessment and care.” The inference to be drawn from the
clinical review is that the standard of care the man received at HMP Norwich
was superior to that he received at Norfolk and Norwich University Hospital. I
am unable to investigate the matter of the man’s care at the hospital as this
goes well beyond the terms of reference for my office.
37. The family has raised concerns regarding the man’s transfer from Swaleside to
Norwich. In the clinical Governance Manager’s judgement, the transfer was in
the man’s best interests and I agree. In the clinical Governance Manager’s
view, Norwich demonstrated a high level of care ensuring the purchase of
equipment, appropriate referrals and a holistic approach. Challenging
behaviour was managed through referrals to other expert agencies for advice
and guidance in identifying trigger factors.
38. The clinical reviewer visited Norfolk and Norwich University Hospital and spoke
with the TB specialist nurse who had visited the prison on 2 April 2008 to
assess the risk of infection to staff and prisoners. Screening was offered to
those who had been in direct contact with the man for a period of time in
excess of eight to ten hours. While the clinical reviewer was able to view
hospital records relating to the TB nurse’s visit, she was unable to find such an
entry in the prison medical record.
Family Liaison
39. My investigator judged that some aspects of the liaison between Healthcare,
the prison’s Family Liaison Officer and the family were disappointing. In
particular, Healthcare did not invite the man’s brother to the mental capacity
review when important decisions regarding whether the man should be
resuscitated in the event of a heart attack were discussed.
The Head of Healthcare should consider inviting the next of kin to
meetings and reviews where decisions regarding resuscitation of
prisoners and end of life care are discussed.
40. The brother of the man expressed some dismay at not being invited to the
memorial service held in Healthcare for the man. He said that, had he received
an invitation, he would have liked to have attended to speak to those who knew
his brother. I share the man’s brother’s disappointment. I believe this oversight
on the part of HMP Norwich was unintentional, but there are lessons to be
learned.
14
In the event of a prisoner’s death, the Governor should invite the
deceased’s next of kin are invited to any memorial service held at the
prison.
41. My investigator spoke with the liaison officer, the prison’s Family Liaison
Officer, regarding the brother’s concern that the prison was not represented at
the man’s funeral. The Liaison Officer explained that the undertaker had
spoken with her over the telephone and told her the date of the funeral. She
said that the undertaker then rang back and told the liaison officer that they had
made a mistake in telling her the date as this was not for release. In the
circumstances, the prison was not represented at the funeral, but a condolence
wreath was sent to the family.
42. A further concern is that the Head of Healthcare acted alone when she told the
man’s brother of the man’s death over the telephone. Guidelines regarding
support for the family of deceased prisoners are to be found in chapter 4 of
Prison Service Order 2710. Supplementary guidance to FLO’s recommends,
“that the family should be informed face to face as soon as possible after a
death. Wherever possible this should be done by a dedicated Family Liaison
Officer.” Good practice would have been for the prison’s Family Liaison Officer
to have been informed and a joint visit made with the Head of Healthcare to the
family. Paragraph 4.13 states that, “using the telephone is too impersonal to
use in delivering news of a death to the family and should be used only as a
last resort.” There is no evidence that all other methods of informing the family
had been exhausted in the man’s case.
The Head of Healthcare should inform the prison’s Family Liaison Officer
of expected as well as unexpected deaths, whether in the prison
healthcare unit or in hospital, so the family can be informed appropriately
and in accordance with the Prison Service Order.
Roles and responsibilities of bedwatch staff
43. The bed watchlog completed immediately before the man’s death records that
the PO assisted a member of the hospital nursing staff to administer medication
(an antibiotic injection) to the man. In interview, the PO was unclear as to
whether this was with the man’s consent or not. I conclude that on the balance
of probabilities (particularly taking account of the bedwatch log entries
indicating that the man had refused medication previously) that it was
administered without his consent. In her clinical review, the clinical governance
manager says that, while this was with the best of intentions, “it is imperative
that consent is always clearly established before treatment goes ahead”. In
speaking with my investigator, the clinical governance manager indicated that
there are very clear National Health Service guidelines regarding consent and
these should be observed.
44. My investigator was told that bedwatch staff are not informed of the nature of a
prisoner’s illness. It is clear from the bedwatch log that, while prisoner/patient
confidentiality is respected, staff are told whether or not they should wear
protective clothing. The PO says he cannot recall whether he wore protective
15
clothing or not when he entered the man’s room to assist the nurse. However
well-intentioned his actions, I think it most likely that he did not wear
appropriate protective clothing, thereby placing himself at risk of contracting a
communicable disease.
The Governor and the Primary Care Trust should agree a memorandum of
understanding setting out very clear boundaries governing the respective
roles, responsibilities, expectations and codes of behaviour between
nursing and prison bedwatch staff.
45. I have reported on many occasions on the excellent end-of-life care provided by
the Nelson Unit at HMP Norwich. In large part, this report into the death of the
man continues that tradition. Nevertheless, some matters were not handled as
well as they might have been and this is reflected in my four recommendations.
Even centres of excellence should be looking to improve further.
46. The Prison Service’s response to my recommendations follows each of my
recommendations as set out on page 18 of this report.
16
RECOMMENDATIONS
1. The Head of Healthcare should ensure next of kin are invited to attend
meetings and reviews where decisions regarding resuscitation of
prisoners and end of life care are discussed.
‘Partially accepted. While it is accepted that it is good practice to involve next
of kin in end of life decisions, in line with UK Resuscitation Guidelines, this is
advisory. In this case, there was difficulty in establishing next of kin, and the
Independent Mental Health Capacity Advocate acted on behalf of the decision
making.’
2. The Head of Healthcare should inform the prison’s Family Liaison Officer
of expected as well as unexpected deaths, whether in the prison
healthcare unit or in hospital, so the family can be informed appropriately
and in accordance with published guidance.
‘Accepted. All expected deaths are notified in advance to a designated Family
Liaison Officer (FLO). Unexpected deaths are notified as an immediate action.’
3. In the event of a prisoner’s death, the Governor should ensure that the
deceased’s next of kin are invited to attend any memorial service held at
the prison.
‘Partially accepted. Because of the nature of L wing, Norwich held a memorial
service for the benefit of the patients that reside there. This was distinct to the
memorial service for the family as set out in PSO 2710. Family members will
be invited to memorial services at Norwich in future.’
4. The Governor and the Primary Care Trust should agree a memorandum of
understanding setting out very clear boundaries governing the respective
roles, responsibilities, expectations and codes of behaviour between
nursing and prison bed watch staff.
‘Accepted. A memorandum of understanding will be drafted and agreed with
the local Acute Trust.’
17