Individual at Lewes

Investigation into the death of a man in April 2009 whilst in
the custody of HMP Lewes
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2009
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 my investigation.
This is the report of an investigation into the death of a 60 year old prisoner at
HMP Lewes. He died on 9 April 2009 in a hospice from natural causes. The
man had been admitted to the hospice two days earlier. He had suffered from
chronic ill health for many years but the illness that led to his death was only
diagnosed a month beforehand.
I would like to add my personal condolences to those already expressed to
the man’s family on behalf of this office by one of the Ombudsman’s Family
Liaison Officers.
A post mortem examination was not carried out as the Coroner was satisfied
that there were no suspicious circumstances surrounding the death.
This investigation was undertaken by one of the Ombudsman’s investigators.
In addition, a doctor was asked by East Sussex Downs and Weald Primary
Care Trust to undertake a review of the man’s clinical care. I am grateful for
the assistance they received from staff at HMP Lewes and would ask the
Governor to pass on these sentiments.
I have noted that the clinical reviewer concluded that the quality of care the
man received was in some instances better than that he would have received
in a community setting. I hope that his family are reassured by the
conclusions of my report.
I make no recommendations in this case.
Jane Webb
Deputy Prisons and Probation Ombudsman October 2009
SUMMARY
The man was born in 1948. He was 60 years old when he died at a hospice
on 9 April 2009. The man’s death was from natural causes as a consequence
of gastric carcinoma with liver metastases (stomach cancer).
The man was received into custody (on remand) at HMP High Down on 30
April 2008. He transferred to HMP Lewes on 8 August and was sentenced to
16 years imprisonment in January 2009. At his first health screening
interviews it was recorded that the man had history of diabetes and angina.
The man was a smoker but he chose not to accept assistance to help him to
stop smoking.
After he was sentenced, the man wrote a suicide note which was intercepted
by staff at Lewes. Accordingly, a self-harm observation and support regime
was started. This involved regular checks being carried out and recorded.
The regime was stopped on 20 February when the man appeared to have
accepted his situation.
The man collapsed in his cell on 2 March and was taken by ambulance to a
local hospital. After his admission to hospital, the man was told that he was
terminally ill and that his life expectancy was a matter of weeks. Although he
was discharged on 4 March and returned to Lewes, the man collapsed again
on the following day and returned to the hospital. He returned to Lewes on 6
March but refused to be admitted to the healthcare centre.
Whilst the man was in hospital, a bedwatch was carried out by prison staff.
The initial security risk assessment concluded that an escort chain was to be
used and two officers needed to be at the man’s bedside.
On 31 March, the man was released on temporary licence (ROTL) and taken
by ambulance to a hospice. The revised security risk assessment concluded
that handcuffs were not be used and prison staff were not required to be at his
bedside. On 1 April, hospice staff requested that the man leave the hospice
as they regarded him as terminally ill but not in need of hospice care. The
man returned to Lewes and was admitted to the healthcare centre. He
continued to deteriorate and six days later, on 7 April, the man returned to the
hospice. He was visited by his family whilst he was there. He died on 9 April
and his death was pronounced at 1.20pm.
The clinical review concludes that the man’s clinical care was good and in
some instances better than that available in the community. Consequently I
make no recommendations in this report.
THE INVESTIGATION PROCESS
1. The investigation was opened on 20 April 2009 by one of the
Ombudsman’s investigators. He issued notices announcing the
investigation to both staff and prisoners. The notices included an
invitation to anyone who wished to submit information relating to the
man's death to make themself known. In the event, no one came
forward. The investigator also studied all relevant prison records, which
included the man’s main prison record and his medical records.
2. The investigator visited Lewes on 1 May, 5 May and 9 June and
discussed aspects of the man’s treatment with staff. He interviewed
staff and a fellow prisoner on the wing where the man had lived. The
investigator also met a member of the Independent Monitoring Board at
Lewes and a member of the Prison Officers Association.
3. The East Sussex Downs and Weald Primary Care Trust commissioned a
General Practitioner/Reviewer to carry out an independent review of the
man’s clinical care. I am grateful to him for undertaking the review.
4. The investigator contacted HM 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.
5. One of the Ombudsman’s Family Liaison Officers contacted the man’s
family. This gave them the opportunity to discuss the purpose of the
investigation and raise any concerns or questions that they wanted to be
addressed. The man’s family did not raise any concerns at that time
about the care he received at Lewes. I hope that this report provides the
family with a better understanding of the events leading up to the man’s
death.
HMP LEWES
6. HMP Lewes is a category B local prison serving the courts of East and
West Sussex. It accepts both adult men and young adults, and has an
operational capacity of 723.
7. The prison has a 19 bed healthcare unit under the responsibility of the
East Sussex Downs and Weald Primary Care Trust. Mental health
services are provided by Sussex Partnership NHS Trust and General
Practitioner services by Sussex Forensic Medical Services.
8. The investigator reviewed the Ombudsman’s reports into earlier deaths
from natural causes at Lewes. He found no common issues with his
own investigation into the death of the man.
Independent Monitoring Board
9. Each prison has an Independent Monitoring Board (IMB) made up of
members of the community. The Board’s role is to ensure that the
prison is properly run and that prisoners are treated decently. The
Board produces an annual report for the Secretary of State. The most
recent report from the Lewes IMB commented on how population
pressures across the prison estate had resulted in the retention of life
sentenced prisoners due to the lack of capacity at lifer centres. The
Board said that lifers were waiting a long time at Lewes before moving to
an appropriate lifer unit.
10. The IMB report summarised the healthcare at the prison in the following
way:
“HMP Lewes appears to have a relatively unique relationship
with its local PCT (East Sussex Downs and Weald), where
healthcare staff are employed by the local PCT and the PCT
actively manages prison healthcare. As a result there has been
a concerted attempt to bring prison healthcare up to NHS
standards which, not yet fully achieved, has resulted in
significantly higher standards in staffing and delivery of services.
There also appears to be strategies to take improvements
forward.”
Her Majesty’s Chief Inspector of Prisons
11. The most recent inspection of Lewes by Her Majesty’s Chief Inspector of
Prisons, Dame Anne Owers, was in August 2007. The Chief Inspector
described Lewes as “reasonably safe”, but with weaknesses in anti-
bullying and suicide prevention measures. Drug and alcohol work was
described as effective and as having good links with the local
community.
12. With regard to healthcare, the Chief Inspector wrote: “Health services
were improving, but there were gaps and deficiencies in inpatient care in
primary mental health services”. The Chief Inspector’s report particularly
commended the extremely good relationships between staff and
prisoners.
KEY EVENTS
13. The man was born in 1948 in Sussex. He had been married twice and
was a father and grandfather. He had retired due to ill health before
coming into custody and had previously worked as a decorator and a
security guard.
14. In January 2009, the man was sentenced to 16 years imprisonment for
sexual offences. He had previously been remanded into custody at
HMP High Down and transferred to HMP Lewes on 8 August 2008. This
was his first experience of prison.
15. During the man’s first reception health screening interviews at both
prisons, it was recorded that he had been diagnosed with diabetes, had
a history of arthritis of the hips and suffered from angina. It was noted
that he had a heart attack in 1998. It was also recorded that the man
had taken an overdose in 1985 as a result of a marital breakdown and
that he was claustrophobic. After a risk assessment, he was allowed to
keep his medication in his possession. The man was a smoker but
chose not to accept help to stop smoking.
16. On 3 June 2008, the man was found to have “left sided weakness and
erratic breathing” and he was admitted to outside hospital where he was
thought to have possibly had a transient ischaemic attack (a temporary
mini stroke). He went back to High Down on the same day. The man
returned to the hospital on 11 June due to heart problems and, again,
went back to prison the same day.
17. On 1 July, the man complained of nausea and vomiting and general
debility and was taken to the Accident and Emergency (A&E)
Department of the local hospital the following day. He returned to High
Down the same day. The man subsequently complained on 7 July of
abdominal pain and vomiting. He began to take medication on 11 July
to correct his blood calcium levels. On 29 July, it was recorded that the
man declined to attend a hospital outpatient appointment, signing a
disclaimer.
18. A week later, on 8 August, the man transferred to Lewes and on his
reception at the prison it was noted that he had “reduced mobility,
reduced physical capacity and difficulty with physical co-ordination”. A
care plan in respect of his diabetes and other medical conditions was
prepared.
19. Due to the nature of his offences the man had been identified as a
vulnerable prisoner, and he was located in a single cell on M wing, which
is part of the Vulnerable Prisoners Unit. It was noted in his prison record
that he had previously been given enhanced prisoner status and he
retained this after his transfer. (The Incentives and Earned Privileged
Scheme (IEPS) is a scheme that is designed to encourage and reward
good behaviour in prisons. There are three tiers – Basic, Standard and
Enhanced. Incentives include access to in-cell televisions, having their
own private money to spend, being able to wear their own clothes, more
time out of the cell and community visits.)
20. On 23 September, the man complained of abdominal pain and of feeling
generally unwell. Three days later he developed epigastric pain (the
epigastrium is the area of central abdomen lying just below the sternum)
and vomiting. On 28 September, a prison medical officer recommended
hospitalisation after checking the man’s urine and finding evidence that
his diabetes was less than adequately controlled (abdominal pain can be
a manifestation of uncontrolled diabetes).
21. The man was admitted to hospital on 2 October for 24 hour observation
after a bout of diarrhoea and vomiting. On 13 October, the man was
again admitted to hospital after complaining of chest pains. He was
given intravenous therapy and discharged on 17 October to Lewes
where he was admitted to the healthcare centre.
22. On 6 November, the man again complained of nausea, vomiting and
diarrhoea. It was recorded on 18 November that he refused to go to his
gastroscopy appointment (a gastroscope is an instrument used to
examine or view the interior of the stomach).
23. Three days after he was sentenced, on 30 January 2009, to 16 years
imprisonment, staff on the wing intercepted a suicide note from the man.
As he was identified as an ongoing suicide risk, an Assessment, Care in
Custody and Teamwork (ACCT) self-harm observation and support
regime was started. (The Prison Services describes ACCT as a flexible,
prisoner-centred assessment and care planning system, which aims to
identify individual needs and offer personalised care and support before,
during and after crisis, in a safe and caring environment.) It was
recorded that the man was not only “suicidal” but also had “Type 1
Diabetes, Angina, Magnesium and Calcium deficiencies, Gastric Ulcer
and kidney problems”.
24. At 8.45am on 11 February, the man was found comatose in his bed. He
was given glucose and responded. A care plan was instigated to treat
his diabetes. Two days later on 13 February, the man was referred to
the diabetic nurse for reassessment.
25. On 20 February, the ACCT document was closed when the medical
assessment identified that the risk of self-harm had abated and that the
man had come to terms with his situation. An ACCT post closure
interview took place as required a week later, on 27 February.
26. The man was found collapsed in his cell on 2 March and taken to
hospital by ambulance. A tentative diagnosis of pancreatitis (an
inflammation of the pancreas which is a soft, elongated gland situated at
the back of the upper abdominal cavity behind the stomach) was made
soon after he arrived. Hospital doctors informed the man the following
day that he was terminally ill and that his life expectancy was a matter of
weeks. He returned to Lewes on 4 March but refused to be admitted to
the healthcare centre. A staff nurse was asked to see the man at
around 5.30pm because he did not want to be admitted to healthcare.
The nurse wrote the following entry in the man’s medical record:
“He declined healthcare as he feels he will benefit from the
support of his peers on M wing who have been helping him to
clean his cell. Objectively the man appears lucid and rational
offering appropriate and valid reasons why despite his shock he
is not planning on taking his own life. No need to move to HCC
[healthcare centre] at this time although the man acknowledges
that if his health deteriorates rapidly this may have to be
considered.”
27. On the following day, 5 March, the man collapsed and was taken back to
the hospital. Whilst the man was an inpatient at the hospital, a
bedwatch was carried out by prison staff. The security risk assessment
said that an escort chain should be used and two prison officers should
be in attendance. Staff on bedwatch duty maintained a log of activities
whilst the man was an inpatient. He returned to Lewes the next day and
again declined to be admitted to the healthcare centre.
28. When interviewed as part of this investigation, a matron who works in
the prison’s healthcare centre said:
“The reason that he declined to come to healthcare was
because he felt that he had a lot of support from his friends on M
wing that was one of the reason. He had a very nice single cell
which was nice and quiet at night so he could rest, whereas
healthcare tends to be noisy and … quite a big reason is that he
was quite a heavy smoker, if I remember rightly and in
healthcare it’s totally no smoking. … he signed the disclaimer to
say that he refused to come into healthcare. We did try, we tried
to say to him … you know you would be far better off in the
healthcare, the nurses are there they can give you the pain
medication you know regularly and be there if you need them for
anything. But he was adamant there was no way he wanted to
come into healthcare.”
29. During a telephone call on 11 March, a consultant from the hospital
informed the matron that the man’s stomach biopsy was negative, but
that an ultrasonic scan of his liver had revealed “multiple cancer
metastases”. A liver biopsy on 15 April confirmed the cancer but the
source of the primary tumour was not known.
30. A referral was made on 22 March for the man to be moved to a hospice.
A consultant from the hospice visited him a week later, on 27 March, to
carry out an assessment. He advised the man that his prognosis was
between three and four weeks. The following day the man was
described as “deteriorating rapidly” and being “very jaundiced”.
31. When interviewed as part of this investigation, a member of the
Independent Monitoring Board (IMB) at Lewes said that the IMB have
good access to prisoners. He described the Governor as “quite positive
and he is visible around the prison and has an open door policy”. The
member of IMB staff produced a log entry completed by a fellow board
member after she spoke to the man on 27 March. She wrote: “Spoke
to the man who is terminally ill, but unlikely to be released early because
of his offence. He said that everyone was being very kind, and thought
that a hospice placement might be possible.”
32. In his letter to the Governor dated 30 March, a prison doctor wrote:
“I can confirm that the above prisoner has advanced widespread
cancer and is now expected to die within days. … His condition
has deteriorated over the past few days – he is now unable to
leave his bed due to weakness.”
33. When interviewed as part of this investigation, a fellow prisoner on M
wing and a Listener talked about events on 30 March. (Listeners are
trained by the Samaritans to provide confidential emotional support to
fellow prisoners in distress.) The Listener recalled that the man was not
eating or drinking. The Listener spent most of the day with him as he
was concerned about his health. He was due to be relieved by another
prisoner at 9.00pm but the man wanted him to stay. The Listener stayed
with the man all night with a member of healthcare staff sitting outside
the cell door. The Listener said:
“He felt more comfortable with me being there with him. And as
it transpires a nurse can’t be in the cell with an inmate at night,
so they’re outside. So I went inside and made sure he was
comfortable and kept his fluid intake up, so in the morning he
was a little brighter. … In the morning Governor … was there
and some of the officers and then the ambulance arrived and
they came to take him away. And he did brighten up because
he knew he was going to a nice place.”
34. The man was released on temporary licence (ROTL), on 31 March, and
taken by ambulance to a hospice. (ROTL can be granted to permit
prisoners to be released for temporary purposes. A security risk
assessment must be carried out before a licence can be issued.) The
security risk assessment for the man concluded that handcuffs were not
to be used and prison staff were not required to be at his bedside. The
licence included a range of conditions including:
(cid:127) To permanently reside at the hospice.
(cid:127) Not to seek or approach or communicate with the victims without the
prior approval of his supervising officer or their manager.
(cid:127) To confine himself within the boundaries of the hospice.
35. The following day, hospice staff asked the man to leave the hospice.
Although they knew that he was terminally ill, they did not consider that
he needed hospice care. They were also concerned about the absence
of an escort for him.
36. When interviewed the matron said:
“I was quite upset the next day (1 April) because I was informed
with various phone calls and e-mails that the hospice were quite
unhappy. Because his condition when he actually got there,
improved to the extent that he was able to sit outside on the
bench and smoke his cigarettes and drink his cups of tea and
look at the lovely view. And the hospice felt that they weren’t
happy that he didn’t have an accompanying officer … they were
worried with regard to young children visiting other patients and
the fact that they said there was nothing to stop him wandering
off and they wanted him to return to the prison.”
37. The man returned to Lewes in an ambulance around 4.00pm on 1 April.
An officer escorted him from the hospice and drove behind the
ambulance. The officer had been given permission by the Governor to
wear his own clothes whilst on the escort. As the man’s cell on M wing
had already been allocated to another prisoner, he was admitted to the
healthcare centre when he got back to the prison.
38. With regard to his admission to healthcare, the matron said:
“He returned to the prison and he was admitted to healthcare
because we explained to him that (a) somebody else had now
moved into his cell on M so he couldn’t go back there and the
better location for him was to be on the healthcare where there
is 24 hour nursing care. So he wasn’t happy about it and we did
say to him that at any time if he wanted a cigarette we would
provide a member of staff and if it couldn’t be a nurse we have
two porters as well, one of them would take him outside into the
garden, obviously not at night but during the day so that he
could have a cigarette.”
39. The man’s condition continued to deteriorate and on 6 April he was seen
again by the consultant from the hospice who agreed that he should be
admitted to the hospice.
40. The Governor wrote to the Public Protection Casework Section of the
Ministry of Justice the same day, enclosing an application for early
release on compassionate grounds.
41. On the following day, 7 April, the man returned by ambulance to the
hospice accompanied by the matron. The security risk assessment for
the man still concluded that handcuffs were not necessary and prison
staff were not required to be at his bedside.
42. The man was visited by his family and healthcare also contacted the
hospice every day to check on his condition. He died at 1.20pm on 9
April.
43. The prisoners on M wing were told the following morning about the
man’s death and asked whether they required anything or wanted to
speak to a Listener.
44. A member of the chaplaincy at Lewes was appointed as the prison’s
family liaison officer and the prison gave financial assistance with the
funeral costs. A memorial service was held at the chapel at Lewes.
45. A post mortem did not take place as the man died of an existing
condition and there were no suspicious circumstances surrounding his
death. His cause of death was stomach cancer. The Coroner decided
not to hold an inquest.
ISSUES CONSIDERED
Clinical care
46. As noted above, a review of the man’s medical care was undertaken by
a doctor on behalf of East Sussex Downs and Weald Primary Care
Trust. In his review, the doctor records that staff at Lewes carried out
regular reviews and monitored the man’s condition and medication.
47. The reviewer notes that the man had several major medical problems
prior to being remanded into custody. He began to complain of
abdominal symptoms at the beginning of July 2008, just over two
months after he came into prison. He subsequently went into hospital
on a number of occasions and investigations were carried out by
hospital staff. The tests revealed diabetes, heart and kidney problems to
which, the reviewer believes, his gastro-intestinal symptoms were
apparently and quite understandably attributed.
48. According to the man’s medical records there appeared to be no specific
gastro-intestinal investigations carried out until he collapsed in March
2009. In the reviewer’s opinion, the man’s care was hampered at least
to some extent by his own occasional unwillingness to comply with
investigations and appointments, or be admitted to healthcare for
observation. It appears that following the man’s collapse in early March
2009 the hospital investigations discovered the presence of an already
wide spread cancer. The man’s health subsequently deteriorated very
rapidly and he died within a month of the diagnosis being made.
49. The reviewer comments that it is a matter for speculation whether earlier
investigation of the man’s gastro-intestinal tract might have affected his
life expectancy. In the reviewer’s opinion, the man’s general symptoms
of nausea and vomiting were probably related to a combination of his
upset body biochemistry and the secondary spread of his primary
tumour. The reviewer believes that the man’s death could not have
been avoided. He concludes that a fatal outcome was inevitable when it
became apparent that the man’s cancer was so widespread. The
reviewer wrote in his clinical review:
“The non-specific symptoms of nausea, vomiting and abdominal
pain can be features of generalised biochemical disturbance,
and this was certainly true of the man with his history of renal
disease, calcium and magnesium disturbances and diabetes.
Also, the primary cancer was “silent” producing no specific
symptoms and indeed has never been located, no post mortem
having been carried out. … I am of the opinion that even with
gastro-intestinal investigation at an earlier stage, when for
example he first complained of nausea and vomiting, the
outcome would have been the same.”
50. I am pleased to concur with the reviewer’s conclusion that the man was
referred, investigated, treated and cared for by staff at Lewes in a
manner equalling, if not surpassing, standards that would be expected in
the community. After receipt of the draft report the man’s family gave
their thanks for the support and help their father received from the
nursing staff at Lewes.
Transfer to the hospice
51. When the man was admitted to the hospice on 31 March, he had been
granted release on temporary licence (ROTL). This meant that
restraints were not used and that no officers were on bedwatch duty. On
the following day staff at the hospice contacted Lewes and requested
that he should return to the prison. The hospice staff said that, although
the man’s condition was terminal he was not in need of hospice care.
His condition continued to deteriorate and after a further assessment by
the consultant from the hospice, the man returned to spend his last few
days at the hospice. Restraints were still not used and there were no
officers on bedwatch duty.
52. When interviewed as part of this investigation, a member if staff from the
chaplaincy at Lewes said:
“I actually saw him at the hospice on 1 April, and he’d actually
improved his condition to such an extent that he’d eaten the best
breakfast he’d had in some time and he was walking and
enjoying the grounds. So he was much improved physically and
in his mood as well.”
53. The member of chaplaincy staff spoke to the man after his return to
Lewes. He confirmed that the man did not expect to return and it had
been a shock for him. The member of chaplaincy staff said:
“I spoke to him subsequently, to explain that often people don’t
die at the hospice, they prefer to die in their own homes and so
people come to the hospice, get their pain relief and symptom
control right and then go back home. So he wasn’t too pleased
to come back to home here [to Lewes].”
54. When interviewed as part of this investigation, a matron from Lewes
said:
“You know I just wish that they’d kept him the first time so that
he could have had his last week in the hospice because
certainly it was just the psychological impact I think of, of when
he got out to the hospice, it’s in a beautiful place and lovely
fields with animals, donkeys and flowers and I’m sure that had
such a positive effect on him that he did perk up. And he
admitted to me when he came back, he said I did it myself, you
know he said it was my fault but you know I said, there was
nothing he could do about that. … when he was sent back it
had the opposite effect because he didn’t think he would come
back to prison, he just lost the will to fight anymore I think and
he deteriorated very quickly.”
55. It is commendable that the Governor of Lewes had assessed that the
man would be allowed to stay at the hospice without an escort. I am
also pleased to note that the prison officer was out of uniform when he
took the man back to Lewes. This again displayed sensitivity with
regard to how the man was treated by Lewes.
56. It is pleasing that the man improved, albeit temporarily, when he went to
the hospice on the first occasion. However it is unfortunate that hospice
staff then raised concerns about the absence of an escort. Their worries
would have been better dealt with if they had been considered before
the man’s arrival. In the event, Lewes was obliged to return the man to
the prison. Although I make no recommendation, the Governor and
matron will wish to ensure that the hospice has a complete
understanding of a prisoner’s situation before any others are moved.
57. It is sad that the man had to endure this additional distress in the last
days of his life. As mentioned by the matron in her interview, the man’s
spirits were lifted by leaving the prison and going to the hospice.
Unfortunately he then appeared too well to staff at the hospice and had
to return to custody. After the man returned to Lewes his condition
deteriorated very rapidly and this led to his return to the hospice. When
he returned to the hospice for the last time he was confined to bed as his
condition had progressed to such an extent that he was no longer
mobile. I am pleased to note that his family were able to visit him there
in his final days. After receipt of the draft report the man’s family said
that they were concerned about a comment made by a nurse at the
hospice. The comment was about why the man was at the hospice.
The family felt that this was more to do with his offence rather than about
his care.
CONCLUSION
58. The man arrived in HMP Lewes on 8 August 2008. He moved to a
hospice on 7 April 2009 and he died there of natural causes two days
later.
59. As I have already mentioned, it is sad that a very poorly man’s health
improved when he left prison and then he had to return as he appeared
too well. I am sure that his subsequent return to custody was difficult
and did not slow the decline in his health.
60. In light of the findings of this investigation and the clinical review, I
conclude that the care provided to the man was entirely appropriate.
Indeed, I think that staff at Lewes treated the man with sensitivity and
professionalism. I am encouraged by the conclusion reached by the
clinical reviewer, that “the man was referred, investigated, treated and
cared for by all concerned in an exemplary manner, equalling, if not
surpassing standards that would be expected in the community”.