Individual at Foston Hall

Investigation into the death of a woman
in February 2006 whilst in the custody of
HMP Foston Hall
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2006
This is the report of an investigation into the circumstances of the death of a
woman who died in Queen Elizabeth Hospital, Birmingham in February 2006.
The woman died from bronchopneumonia (a chest infection) which she
developed after complications during complex and difficult abdominal surgery. At
the time of her death, she was on compassionate temporary release from HMP
Foston Hall. She was 45 years of age.
I would like to extend my personal condolences to the woman’s family and to all
those touched by her death.
Both my investigator and I would like to thank the Governor of Foston Hall and
her staff for their cooperation during this investigation. I am also grateful to
Derbyshire Dales and South Primary Care Trust who carried out a clinical review
of the care the woman received during her time in custody and whilst at hospital.
I conclude that the clinical care the woman received during her time at Foston
Hall was satisfactory in terms of the management of her condition on a reactive
basis. However, the healthcare team missed opportunities to be more proactive
– although this would probably not have altered the outcome.
This report makes three clinical recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2006
2
CONTENTS
Summary 4
The investigation process 6
Crohn’s disease 7
HMP Foston Hall 8
Events leading up to the woman’s death 9
Events following her death ` 20
Findings and conclusions
Clinical 21
General 25
Recommendations 27
3
Summary
The woman was remanded into the custody of HMP Brockhill in October 2005.
After sentencing, she moved to HMP Foston Hall in November 2005.
The woman suffered from Crohn’s disease. On reception to HMP Brockhill, she
was noted as being underweight and requiring medical attention. She was seen
by the prison doctor.
On 1 November, the woman required medical attention during the night as she
was in pain and discomfort. She told the nurse that she had previously been
treated at Queen Elizabeth Hospital in Birmingham for the management of her
Crohn’s disease. This had included surgery on her colon. She was then seen by
the prison doctor on 3 November. He sent an urgent referral letter to Queen
Elizabeth Hospital. In the meantime, he prescribed medication to ease the
symptoms. A letter confirming an appointment for 21 December was sent on 17
November. By this time, the woman had transferred to HMP Foston Hall, but the
appointment was forwarded.
Despite the woman requiring healthcare attention for her illness during
December, she refused to attend her hospital appointment on 21 December.
Although healthcare staff succeeded in persuading her to change her mind, it
became too late for her to be able to attend. The appointment was rescheduled
for 16 January 2006. She was taken by prison escort to Queen Elizabeth
Hospital for her appointment on 16 January. Two officers initially accompanied
her as a bedwatch escort and she was required to wear restraints.
The woman was admitted on a ward and seen by a doctor. It was assessed that
she had a ‘mass’ in her stomach and she was taken for an x-ray and scan. The
woman was kept in hospital whilst awaiting the results. She was visited
frequently by prison and healthcare staff. Significant efforts were made at this
stage to identify her next of kin. These were unsuccessful as information in her
prison and probation records was inaccurate.
The woman was very unhappy about remaining in hospital and did not like
having to wear the restraints. Her behaviour towards both prison and hospital
staff was at times difficult and abusive.
The woman’s condition began to worsen. On 24 January, she was informed that
she required keyhole surgery. The woman was frightened of surgery and did not
consent until 27 January. The operation was scheduled for 30 January.
During the evening of 27 January, the woman was released on temporary licence
and the restraints were removed.
4
Keyhole surgery towards the end of January revealed that the woman required
urgent further surgery. The operation was scheduled for the weekend and her
consent was needed. Her health continued to deteriorate. She still had not
consented to the further surgery. A psychiatric assessment took place to
ascertain her capability to make the decision. It was concluded that she was
able to decide for herself.
Early in February, she was granted compassionate release on temporary licence
and the bedwatch escort was removed.
Foston Hall discussed the possibility of early compassionate release if the
woman was discharged from hospital. The search for her adoptive family
continued to no avail, despite having enlisted the help of the police.
The woman moved to the intensive care unit. She agreed to have surgery, and
this was scheduled for the following day. Complications during surgery resulted
in a collapsed lung. Her condition deteriorated rapidly and some time later she
passed away from bronchopneumonia, as a result of the collapsed lung.
Staff at Foston Hall succeeded in tracing the woman’s adoptive parent. A
memorial service was held at the prison chapel on 2 March. Her family were
invited, but chose not to attend.
The clinical review concludes that the woman’s care at Foston Hall was
satisfactory in terms of managing her condition on a reactive basis, until she was
admitted to hospital on 16 January 2006. However, there were missed
opportunities for the healthcare unit to be more proactive in the management of
her needs.
5
The investigation process
The investigation was opened at HMP Foston Hall a few days after the woman’s
death. My investigator arranged with the Governor to visit the prison on 2 March.
The Governor made the deceased’s prison and medical records available for
examination. Notices of the investigation were displayed in the prison informing
staff and prisoners of the process.
My investigator contacted Her Majesty’s Coroner to discuss the nature and scope
of this investigation. Although the woman had died in a Birmingham hospital, it
was decided that the Derbyshire Coroner would hold the inquest as she was in
the custody of a prison in his jurisdiction at the time. My investigator requested a
copy of the post mortem report. Two post mortems took place, an external and a
full internal. Copies of both were made available for examination.
On 6 April, my investigator revisited Foston Hall to formally interview six
members of staff, both uniformed and healthcare.
Derbyshire Dales and South Primary Care Trust conducted a clinical review of
the medical care and treatment that the woman received during her time at
Foston Hall. They also interviewed members of staff at the prison.
One of my Family Liaison Officers spoke with the woman’s family and offered to
meet with them. They did not wish to meet but were grateful for contact being
made. The family raised a number of questions:
 What illnesses was the woman suffering from?
 When was she diagnosed with these illnesses?
 Did she have an operation shortly before her death?
The clinical review and two post mortems provide answers to the family’s
questions surrounding her medical care. The Governor of Foston Hall has been
in touch with the woman’s family regarding the return of her property.
6
Crohn’s disease
Crohn’s disease is mainly a disease of the small intestine, but it can affect any
part of the bowel. Symptoms of Crohn’s disease are:
 fever
 diarrhoea
 pain in the abdomen
 loss of appetite and weight
 feeling generally unwell
 rectal bleeding; and
 a feeling of fullness and pain in the lower part of the abdomen.
There may be long periods where the condition is inactive, but flare-ups are
always liable to occur and can be helped by appropriate treatment. This can
involve medication to manage the disease. In cases where the disease
frequently flares up and is difficult to control, drugs that influence the immune
system might be used. Surgery might be required to remove damaged parts of
the bowel. However, surgery usually prompts a flare-up of the disorder and
repeated operations, usually on the same area, are often required.
7
HMP Foston Hall
Foston Hall is a closed female prison. It was originally a hunting estate. The
present Hall was built in 1863, but the estate is 14th Century and many parts of
the 17th Century house remain. The Prison Service acquired the Hall and
grounds in 1953. In 1996, it was closed for major refurbishment and building
work before being re-opened in its present guise on 31 July 1997.
The prison has six wings: A, B, C, D, E and Fwings. A, B & C each hold 40
prisoners. The cells are referred to as rooms. Each has integrated toilet and
shower room. D wing is the induction wing. Accommodation on this wing
comprises double and triple-bedded rooms, holding a total of 44 prisoners. Each
room has integral sanitation. E wing comprises three rooms holding a total of 10
prisoners. This wing is for enhanced prisoners requiring minimal supervision. F
wing in the voluntary testing unit (VTU).
The prison has a healthcare centre with two sites, one on the remand side and
one on the sentenced side. Both have 24 hour nursing, and Derby Medical
Service provides GP cover. There is an inpatient facility on the sentenced side
with five beds in three rooms. These beds are largely reserved for prisoners with
mental health problems and tend to be used as single occupancy rooms. In
these circumstances, the inpatient capacity is reduced from five beds to three.
Facilities for patients with disabilities on the healthcare centre are both
inadequate and inappropriate. However, there are plans to improve these
facilities in accordance with recommendations made in Her Majesty’s Chief
Inspectorate of Prisons’ report of August 2004.
In addition to 24 hour nursing care, there are 25 members of discipline staff with
current first aid training. This is proportionate to the number of prisoners, which
stands at 274 at full operational capacity.
8
Events leading up to the death of the woman
The woman was remanded into custody at HMP Brockhill in October 2005. On
reception at Brockhill, she asked to be allocated a single cell as she required
privacy due to her Crohn’s disease. This was allowed and she was given a
single cell on a flat location on D wing.
Part of the reception process into prison before being moved to a wing is to have
a first screen health check. A nurse conducted the healthscreen. During the
assessment, the woman told the nurse that she had Crohn’s disease,
osteoporosis and rheumatoid arthritis. She also said that she was asthmatic, had
chest pain and suffered from tuberculosis. The nurse noted that the woman was
underweight (45kg, 7 stones) and gave specific instructions to the kitchen staff to
provide her with extra milk and sandwiches. Sandwiches were something the
woman said she had less trouble digesting. Additional sanitation provisions were
provided for her Crohn’s disease. The nurse referred the woman to the prison
doctor for a second healthscreen. Unfortunately this assessment is not dated
and appears incomplete.
On 24 October, the woman was seen by the Mental Health Team clinical
manager at Brockhill. The woman said she was a paranoid schizophrenic and
heard voices. She also discussed her history of substance misuse which
included taking heroin intravenously. The clinical manager noted that the woman
did not display any overt mental health problems. However, she wrote to the
woman’s last known GP to clarify whether any medication for mental health
problems had ever been prescribed. A reply was later received stating they no
longer had the woman’s medical notes.
The woman appeared at Birmingham County Court in October for sentencing.
She was given two years imprisonment and returned to Brockhill until
arrangements were made to move her to another establishment.
At 12:45am on 2 November, the woman asked to see a nurse. She was
suffering with abdominal distension and discomfort, and wanted additional
painkillers. Healthcare staff advised that the woman had received her medication
at 10:30pm and could not have another dose at that time. However, wing staff
were told to contact healthcare should her symptoms persist.
At 2:30am, the woman was still in discomfort and healthcare were again called.
During her conversation with the nurse who attended, the woman stated she was
under the care of Queen Elizabeth Hospital in Birmingham for the management
of her Crohn’s disease. She had been admitted to hospital in September 2005
and part of her colon had been removed. During this time she also suffered from
a ruptured bowel. The nurse reassured the woman that she would be seen by
the prison doctor in the morning. In the meantime, an out of hours GP was
contacted for advice. The woman was then given some Paracetamol
9
On 3 November, the woman was seen by the prison doctor. It was noted that
she had lost 5lbs in weight, was vomiting intermittently and that her pain was not
being managed by her current prescribed dose of Tramadol. However, Ibuprofen
taken during the night was helping. The woman was not able to tolerate her food
supplements and had developed a central abdominal hernia. The doctor sent an
urgent referral letter to the gastroenterology department at Queen Elizabeth
Hospital. He noted that she had been admitted to the Queen Elizabeth Hospital
on two occasions in the last couple of months, and that on both times she had
been told she need an operation. In the meantime, the doctor prescribed
Rabeprazole for gastric protection. He also wrote to the kitchen staff re-
emphasising that the woman should be given sandwiches for meals and be
provided with extra milk.
On 10 November, a nurse declared the woman fit for transfer to HMP Foston
Hall. She was sent with five days of prescribed medication. On reception to
HMP Foston Hall, the woman was seen by healthcare. It was assessed that due
to her condition she should be in single cell. She was allocated a room on D
wing set aside from the communal rooms. This guaranteed her some privacy.
The woman was referred to see a prison doctor the following day for a second
health check. This further assessment has not been well documented although
the doctor has noted that she was unfit for work.
On 17 November, Selly Oak Hosptal, which is part of the University Hospital
Birmingham NHS Foundation Trust, wrote to confirm that an appointment had
been made for the woman on 21 December. Attempts were made to try and
secure an appointment more local to Foston Hall, but these were not successful.
During early December, the woman was seen on a couple of occasions by
healthcare staff, including the prison doctor. Her prescribed pain relief was no
longer proving sufficient. No action was taken to bring forward her hospital
appointment. In the meantime, at her request, she was given a plastic bottle with
ice in it to rest on her stomach. Healthcare staff encouraged her to try and eat a
normal diet and instructed the kitchen to stop sending sandwiches for her meals.
On 15 December, risk assessment and escort paperwork was prepared for the
woman’s appointment at Selly Oak Hospital. A taxi was ordered to take her and
escort staff to the hospital on the morning of 21 December. Prior to departure,
the woman decided that she no longer wanted to attend the appointment. She
was frightened of having further treatment, particularly surgery. The taxi was
cancelled and the hospital contacted. On hearing that this had occurred a senior
nurse telephoned the hospital. The senior nurse wanted to know whether, if they
could persuade the woman to attend her appointment, the hospital would keep
her appointment. Selly Oak agreed. The importance of the appointment was
explained to the woman and she agreed to attend. Healthcare staff tried to
10
rearrange the taxi. Unfortunately, it was not possible to organise a taxi that could
get her to hospital in time. The appointment was rescheduled for the 16 January
2006.
Whilst waiting for the hospital appointment, healthcare staff at Foston Hall
continued to manage the woman’s pain. She spent most of her time in her room,
apart from going to collect her medication from healthcare. On the occasions
when she was not fit enough to do this, healthcare staff would take her
medication to the wing.
On 1 January, the woman refused to take one of her prescribed medications,
Fosamax. She said that she had never taken it before and did not want to take it
on this occasion. Healthcare staff stressed the importance taking specifically
prescribed medication and her name was put on the doctor’s list for a review
following non-compliance. Her prescription chart indicates that she continued to
refuse this medication.
On 5 January, the woman was seen by the doctor as she was suffering with pain.
She requested a month’s supply of Ibuprofen to have in possession rather than
collecting it on a daily basis. The doctor suggested she try different painkillers.
She was reluctant and insisted on taking ibuprofen. The doctor prescribed
paracetamol to take in conjunction with Ibuprofen to manage her pain. It was
noted in her medical records that the woman should cease taking the ibuprofen
and that she needed her surgical referral.
Eleven days later, on 16 January, the woman was taken by prison escort to
Queen Elizabeth Hospital for her appointment. A security risk assessment was
completed prior to departure. This recommended that she remain in standard
cuffs and on a closeting chain whilst outside the establishment. The woman was
unhappy with having to wear restraints. However, as she had made attempts to
escape on previous sentences, removing them for any reasons other than
medical procedures was not an option.
Two prison officers were required to stay with her on bedwatch duty whilst she
remained in hospital. The officers would change shifts every twelve hours. The
same pair of officers would continue alternating shifts until relieved of duty by
new staff. Due to the distance from Foston Hall, HMP Birmingham agreed to
share the responsibility of daily management checks at the hospital and provide
any immediate response if required. Foston Hall retained the responsibility for
any security decisions.
The woman arrived at the hospital at 9:30am. She was admitted to a single room
opposite the nurses’ station on West Ward 4. It was noted during interviews with
staff on bedwatch duty that, although the room gave her privacy, it was situated
in a noisy part of the ward. This became a problem for the woman during her
stay in the hospital as she was unhappy with the level of noise.
11
The woman was first seen by the doctor at 12:30pm. The doctor advised that a
clinical team meeting would take place at 2:00pm to discuss what treatment
would be required. At 2:45pm the doctor returned. It had been assessed that
she had a ‘mass’ in her stomach and would need a chest x-ray and a scan before
diagnosis. She was taken to the x-ray department at 4:45pm.
During the early evening, the woman complained of being in continuous pain and
asked for some morphine. Nurses were not able to administer morphine at this
stage as the woman had not had a formal diagnosis. However, it was
administered later that evening by the doctor’s instruction and then given at
intervals of two hours as and when required.
The following morning, the woman continued to receive morphine to manage her
pain. She was seen by a nurse at 10:45am who informed her that she would be
given a blood transfusion and that a CT scan had been booked.
At 4pm, the woman was taken for a scan of her stomach, chest and lower back.
After the scan, a nurse told bedwatch staff that the woman required surgery and
she would need to stay in hospital for at least a week. At this stage the prison
attempted to notify her next of kin. Unfortunately, information supplied in the
woman’s prison and probation records proved to be inaccurate.
On 19 January, the scan results arrived. Bedwatch staff were informed that the
woman was very ill and a clinical meeting would take place to discuss whether
surgery was possible.
The woman continued to question the need to wear restraints. She was unhappy
with the security policy and asked the hospital to write to Governor of Foston Hall
about having them removed. A bedwatch officer telephoned Foston Hall to
inform them of the woman’s intentions. Later that evening, the next shift of
escort staff were advised to keep a close eye on her as she was making attempts
to slip out of the cuffs.
The woman also began to question the frequency of administration of her
medication. One of the nurses spoke with the woman about her keeping notes of
when she was receiving her medication. The woman said that she was doing so
under the instruction of her doctor and that she was to make note of when she
did not receive medication when she had asked for it. The nurse explained that
she could not have her medication more frequently than at two hourly intervals.
The woman was unhappy with this response and refused to have her blood
transfusion. However, 30 minutes later she did agree to have the transfusion.
She had a very unsettled night and spent much of the time in the bathroom.
Her condition began to worsen. She was making more frequent and longer visits
to the bathroom. Bedwatch staff were concerned by this and asked nursing staff
12
to check on the woman when she was in the bathroom. This constant checking
agitated her. It would appear that prison escort staff were not fully aware of the
symptoms of Crohn’s disease and this led to a lack of appreciation for the
woman’s need for privacy. There was also little communication between medical
staff and prison staff regarding the woman’s condition. Issues of confidentiality
prevented nursing staff sharing information with the prison escort staff who had
to rely on what information the woman was willing to share.
The woman’s difficult behaviour continued. She told the day escort staff that the
night staff were negligent and slept, and told night staff that day staff went for
frequent cigarette breaks. In addition, she continued to complain about wearing
restraints and again asked the doctors to write to the Governor to have them
removed. This behaviour concerned the escort staff and phonecalls were made
to Foston Hall to seek advice. Staff were advised to keep the restraints on.
On 20 January, a Governor from HMP Birmingham visited the woman. She
asked to speak with the governor in private to discuss her issues with escort
staff. The Governor explained to the woman that staff were only doing their job
and that she should not be concerned. The woman settled down after the visit
and remained quiet for the rest of the day.
On 21 January, the woman’s condition worsened. She was experiencing more
pain, vomiting and spending increasing time in the bathroom. This continued
throughout the following day.
The woman’s abusive behaviour towards staff worsened during the night
bedwatch on 22 January. When the escort staff changed over for night duty, an
officer noticed that she had a bandage on her left arm. The woman said a
needle had been inserted underneath by the nurse. The officer spoke with the
nurse who stated that there was no needle and that the woman had requested a
bandage. The officer checked the cuff on her arm and it was loose. The padding
given by the bandage made the cuff appear tighter than it was. The cuff was
adjusted. The woman was very unhappy at this and became abusive towards
the officer. The officer offered to loosen the cuff, but she refused to respond.
The woman became increasingly vocal and aggressive during the night. Both
escort officers removed themselves from the room and sat outside. One officer
remained on the closeting chain. The woman removed the bandage from her
arm and her hospital identification tag. She calmed down at 11pm. The officers
asked her again if she would like the cuff loosened, but she said that she was
fine. She calmed down and apologised to the staff for her behaviour in the
morning.
At 2:15pm on 23 January, a doctor informed the woman that more tests were
required before her surgery could take place. It was noted in the bedwatch log
that the woman was very unhappy with this and that she did not want to be given
13
anaesthetic. The next day she was told that they needed to drain some fluid
from her stomach in preparation for keyhole surgery later in the week.
During night bedwatch on 24 January, the woman spent over two hours in the
bathroom. This was longer than usual. A nurse checked on her. The nurse told
one of the officers that the woman was sitting on the floor doing nothing. The
woman had told the nurse that she preferred to stay in the bathroom, as she did
not like the officers. She spent most of the night in the bathroom.
An officer who came on duty at 7:55am was told by the woman that she was not
sleeping as she was worried about having surgery and what would happen to her
next. Nursing staff asked the woman to limit her time in the bathroom as it was
affecting other patients’ access to the facilities. She did not comply and a
commode was provided. At this stage the woman was also refusing to comply
with her prescribed medications and had to be spoken to by the doctors.
During the evening bedwatch shift it was noted that the woman continued to be
non-compliant. She was unhappy about having to use a commode. Her
behaviour worsened and a nurse reported that the woman was disposing of her
cups of coffee into a bowl to pretend that she had vomited. A doctor came to
speak with the woman at 8:25pm. It was noted in the bedwatch log that he
believed that her behaviour was strange, but he could not pinpoint why. The
woman continued to have another restless night.
On 25 January, a doctor informed the woman that she had been put on the list
for surgery. She refused surgery and asked to speak with her other doctor. It
was decided that she would not have any more procedures for the rest of the
week, as she needed additional time to get used to the idea of surgery. It was
noted by an officer in the bedwatch log that the officer felt that the woman might
be being forced into having the surgery. During an interview with the officer, my
investigator asked about this comment. The officer elaborated and said that she
felt that the woman was only being encouraged to have the surgery as it was for
her own benefit. Without it, the woman had been told that she would die.
The woman continued with her pattern of sleeping more in the daytime and being
more active during the night. She was relatively quiet in her behaviour. She
spent less time occupying the bathroom. Instead, she created a screen between
herself and the officers in her room using the bed curtain to maintain some
privacy.
At 10:20am on 27 January, the woman was seen by the surgical team regarding
her surgery. She maintained that she was still not ready to make a decision
about having surgery and asked them to return during the afternoon. The
woman’s behaviour became difficult after seeing the doctor; she was rude to the
bedwatch officer and verbally aggressive when challenged about this. The
officer commented in the bedwatch log that she believed this behaviour was due
14
to being pressurised about surgery. A nurse informed the officer that the
womanwould have to decide whether to agree to surgery by lunchtime; if she did
not, she would be discharged from hospital.
At 12:15pm, a routine management check of the bedwatch took place. During
this visit it was confirmed that the woman had now been released on temporary
licence (ROTL) until the completion of her treatment. As of 9pm that evening, the
escort would be reduced to one officer. The officer would remain with the woman
to offer her support and assist the nursing staff, who often became distressed at
her behaviour.
At 3:45pm, the bedwatch officer rang Foston Hall to inform them that the
woman’s surgery had been rescheduled for Monday 30 January. At 9pm, her
restraints were removed and the conditions of her temporary licence explained.
The woman’s condition was visibly deteriorating. She was spending more time
asleep either in her chair or sitting on the commode. She continued to vomit
frequently and require constant pain relief. Her legs were starting to swell and
she was encouraged by the doctor to spend more time in her bed. The woman
did not want to do this and admitted that she was stubborn.
On 29 January, the woman was put on a ‘nil by mouth’ diet and only allowed
clear fluids in preparation for her surgery. She was largely compliant, but did eat
the occasional piece of food. When the bedwatch officer informed nursing staff
of this, the woman became angry and said that the officer was interfering. At
5:30pm, the anaesthetist saw the woman.
During the evening, the woman suffered with constant pain and vomiting. She
was seen by a doctor at 7:10pm. Her behaviour became more demanding as the
evening progressed. She was unhappy at only being allowed fluids. The woman
was given a sleeping tablet to help her sleep.
On the morning of 30 January, the woman was abusive to staff on being found
with a milky drink. She continued to be difficult and insistent on trying to drink
during the course of the morning. This became progressively worse until the
ward sister spoke with the woman and told her that her behaviour was
unacceptable.
At 2:20pm the woman was taken to theatre for exploratory keyhole surgery. After
the surgery it was explained to her that she needed further surgery urgently. It
was emphasised that if she did not undergo the operation then she would die.
The operation was scheduled for the weekend.
The bedwatch officers changed shift at 7:40pm. The woman was in a pain that
evening and asked that her room be left in darkness as she was embarrassed
about her condition. The bedwatch officer sat outside the woman’s room until
15
10pm to give her some privacy. It was noted in the bedwatch log at this stage
that the woman was very ill and frail.
At 10:40pm, the officer rang Foston Hall for advice on what to do about being
asked by the woman to remain outside the room for privacy. The advice given
was that the officer should remain in the room. The woman was not happy with
this decision and became verbally aggressive and abusive towards the officer.
She remained difficult with both prison and nursing staff.
The woman continued to display difficult behaviour with all staff during the
following day. She wanted to be left alone and resented the presence of escort
staff, making it difficult for them to carry out their duties by requesting they leave
the room and switch the lights off.
At the beginning of February, the Head of Healthcare at Foston Hall rang West
Ward 4 to receive a clinical update on the woman’s condition. She was told that
woman was very ill and needed surgery within 48 hours. For this to occur, the
woman needed to have a drip and catheter in place, however she refused to
keep them in. The Head of Healthcare was told that she could not have a more
in-depth briefing of the woman’s condition over the phone, and would need to
visit the hospital.
The woman’s pain was worsening and she was still having difficulty sleeping
through the night. She was then granted compassionate release on temporary
licence and the bedwatch was removed. This meant she was temporarily
released for the duration of her ill health. However, on discussion with medical
staff an agreement was reached, that should the woman become disruptive and
nursing staff felt they needed additional support, then an escort officer would be
reinstated. It was also agree that should her condition considerably deteriorate
then an officer would return to provide the woman company. Arrangements were
made with Birmingham prison to supply officers if they were required until staff
from Foston Hall could attend.
As Foston Hall was still unable to trace her next of kin and did not want the
woman to be left on her own, a member of staff remained with her to keep her
company and provide support.
The Head of Healthcare visited the Queen Elizabeth Hospital and spoke with the
woman’s doctor The surgical team were still hoping to operate, but were
conscious of the obvious risks in doing so given her fragile health. They were
still experiencing difficulty in getting the woman’s consent to operate. She was
unsure of whether she wanted the treatment. The doctor explained that the ward
sister was responsible for informing Foston Hall should her condition change and
a decision be taken to discharge her. This would give Foston Hall the
opportunity to consider next steps and make appropriate arrangements for the
woman’s needs.
16
Over the next few days, the healthcare unit at Foston Hall continued to maintain
contact with the Queen Elizabeth Hospital regarding the question of surgery.
The information given over the telephone by nursing staff was limited, however it
was clear that the woman was still undecided over her treatment. Her condition
continued to be unsettled and her levels of pain increased.
During the first week of February, the Governor, Head of Healthcare, the
Resettlment Manager and a Probation Officer met at Foston Hall to discuss the
woman’s deteriorating condition and their next steps. Despite enlisting the aid of
the police, the woman’s family could not be traced.
Later that afternoon, the Head of Healthcare spoke with a nurse at the Queen
Elizabeth Hopital, who gave an update on the woman’s condition. Her health
was deteriorating by the day. It was decided that a psychiatric assessment
should be undertaken to ensure that the woman was capable of make a decision
regarding surgery. It was also agreed to arrange for the hospital’s social worker
to speak to her. In addition, a case conference would take place before the end
of the week between the Head of Healthcare and the Resettlement Manager and
Probation Officer from Foston Hall. This would determine the options available,
and also look at the possibility of a discharge from hospital on Early
Compassionate Release. Both the woman and her consultant’s permission
would be required for the case conference to go ahead. This was sought and
agreed.
The psychiatric review was scheduled for the next morning. This was postponed
until the afternoon as the woman refused to meet at the arranged time. After the
meeting, it was agreed that she was capable of making her own decision about
surgery.
At 5pm, the Head of Healthcare contacted West Ward 4 on information that the
woman was to be moved to an intensive care unit (ICU). The ward sister told the
Head of Healthcare that the woman was being moved as she was very
dehydrated. She had agreed to have the operation and she would go into
surgery the following day. The Governor of Foston Hall was asked to ring the
hospital during lunchtime to find out what time the surgery would take place.
On the morning that the woman went into surgery, a message was left for Foston
Hall to let them know. She would be transferred to the ICU after surgery. The
Head of Healthcare made several phone calls to the ICU during the day to check
up on the woman. However, it was not until 8:50am on the next day that she
succeeded in getting any news. The woman was on a ventilator and under mild
sedation. She had been fitted with a colostomy bag. It was not clear at this
stage whether this would be a permanent or reversible.
17
At midday the woman was assessed by the doctor, she had been taken off the
ventilator. It was decided that it was not necessary to reinstate prison officer
escorts. Nursing staff were advised to contact HMP Birmingham or Foston Hall
should they feel this decision needed revisiting. A governor from Birmingham
was due to visit the woman the next day.
The search for the woman’s family continued. Back probation records were
traced and efforts were made to find reference to any family members.
Reception at Foston Hall checked the woman’s property card and stored property
to see if there was anything that could assist in the search. An adoption
certificate, medical card and post office card were among her belongings. The
Deputy Governor asked staff to try and trace the woman’s father using the
adoption certificate as it stated that he used to be a Lance Corporal in the Army.
Contact was made with the Army’s Casualty and Compassionate Centre who
made enquires with the Disclosures Branch of the Army Pension Centre. They
were unable to make a trace without a date of birth. Enquires were made with
Hampshire Country Adoption Team, but they had no record of the woman’s
adoption.
Two days before she died, the woman’s condition was reported as being stable.
Unfortunately, she deteriorated rapidly the next day when fluid began to collect
on her lungs. She was taken for a chest x-ray where it was discovered that she
had a pneumothorax on the top left-hand side of her lung. Her lung had
collapsed and a chest drain was inserted.
At 8:50pm, a nurse called Foston Hall to report that the woman was fully
conscious and that she had become hostile and agitated. Two members of
nursing staff had to sit with her. The nurse was concerned that this was unduly
occupying valuable ICU nursing resources. She was equally concerned for her
staff’s safety. Two prison officers from Birmingham were sent on bedwatch duty
for the night. The officers were in uniform but no restraints were used.
The following day, the Head of Healthcare visited the woman. An update on her
condition was provided. The surgery had resulted in the woman requiring a
colostomy due to a blockage caused by adhesions within the bowel. Her health
was generally very poor, and this was impairing her recovery. Whilst the woman
had been taken off the ventilator, she still required 80% oxygen which was not an
encouraging sign.
It was decided that prison officers were not required to stay with the woman.
They added little or no benefit to her care as she was receiving one to one
nursing. A nurse asked whether the prison had succeeded in finding the
woman’s next of kin. They had not at this stage.
During her visit, the Head of Healthcare noted that the woman recognised her.
She was unable to communicate verbally, but had written a note asking that the
18
Head of Healthcare take her back to Foston Hall. She reassured the woman that
they would when she was in better health. The woman was frail and very thin in
appearance.
On morning that the woman died, the Head of Healthcare telephoned the ICU.
The woman had a settled night and slept well. There was no change in to her
condition. At 4:05pm, the Head of Healthcare was informed that the woman had
passed away at 4pm.
19
Events following her death
The Head of Healthcare contacted the ICU and thanked the nursing staff for all
the care and support given to the woman. Her medical records were collected
and sealed. The ICU nurse advised that the woman would be referred to the
coroner due to her recent surgery at the hospital. The coroner would be
informed the following day.
Staff and prisoners at Foston Hall were informed of the woman’s death. Those
close to her were told first and in person.
Further attempts were made to try and trace the woman’s next of kin. A Principal
Officer found a telephone number for the woman’s Prison Project Worker in her
records. The Project Worker had known the woman for a number of years, but
said that she had no information about her adoptive parents. The day after she
died, the Principal Officer and Resettlement Manager phoned all the numbers
stored in a mobile phone found in the woman’s property. Unfortunately, they did
not speak to anyone who could help. The Police Liaison Officer at Foston Hall
searched through the woman’s belongings again to try and find a link to her next
on kin. The next day, he contacted Birmingham Police and the Army for
assistance. Eight days later, he successfully traced the woman’s adoptive
parents and they were informed of her death.
An external post mortem examination was carried out at Derby Royal Infirmary.
A full internal examination did not take place, as the pathologist was unwilling to
do so given his belief that the woman was HIV positive. HM Coroner for Derby
and South was dissatisfied with not having a full post mortem and instructed one
to be carried out at a later day. This took place on 6 March.
The Governor of Foston Hall wrote to the woman’s adoptive parents on 2 March,
offering her condolences and explaining that staff from both prison and the
Queen Elizabeth Hospital provided care and support to their adopted daughter.
A letter was also sent to the Coroner formally advising him of the woman’s death
and providing background information on her circumstances.
A memorial service was held in the prison’s chapel on Friday 10 March. Both
staff and prisoners were invited to attend.
The woman’s family wrote to the Governor on 11 March, thanking her for her
letter. They were grateful for the information given about their adopted
daughter’s condition and circumstances, as they had not heard from her in the
last nine years. They said they would like to attend the funeral and were grateful
for the prison’s offer to make and pay for the arrangements.
20
Findings and conclusions
Clinical
The clinical review was written in two stages. The initial report submitted by the
clinical review team was based on a review of the woman’s medical records,
interviews with staff at Foston Hall and the two post mortem reports. My
investigator asked the team to elaborate on the issues highlighted in the first
draft, and a more in-depth follow-up paper was produced to support their findings
and recommendations. The review has been summarised below. Both papers
can be found in full at annexes 4 and 5.
History of Events
The woman had a long history of Crohn’s disease and had had previous
abdominal surgery for this. There was mention of previous positive results for
HIV although her HIV status in this last stay at Foston Hall was unclear.
From the drug chart provided, the woman was on the following medication:
 Paracetamol as required
 Alendronate 70mg once a week (for prevention of osteoporosis which is
common in diseases such as Crohn’s that cause malnourishment)
 Tramadol 100mg 4 times a day as required (a strong analgesic)
 Mebeverine 135 mg three times a day (an antispasmodic commonly used
in bowel disorders)
 Prednisolone 15 mg every day (a steroid to treat Crohn’s disease)
 Rabeprazole 20mg every day (a drug to reduce stomach acid)
 Codeine phosphate 60mg 4 times a day (to reduce diarrhoea)
 Ibuprofen 400mg 3 times a day (an anti-inflammatory painkiller) which
appears to have been stopped on 9 January 2006.
On 3 November 2005, whilst at HMP Brockhill, the prison’s Medical Officer wrote
to the woman’s specialist at Queen Elizabeth Hospital, Birmingham requesting
an urgent review because of her deteriorating Crohn’s disease. An outpatient
appointment was scheduled for 21 December 2005, by which time the woman
was at Foston Hall. Apparently, she refused to go.
The appointment was rescheduled and the woman was eventually seen at
Queen Elizabeth Hospital on 16 January 2006. Blood tests taken on that day
showed her to be very anaemic (Hb 5.5, normally > 11). Because of this, and her
generally poor state, the woman was admitted to hospital.
Whilst in hospital, the woman refused the treatments suggested. She became
increasingly unwell and died following a laparotomy for small bowel obstruction.
Subsequent post mortem examinations showed the woman died of
21
bronchopneumonia secondary to a collapsed lung and small bowel obstruction,
in turn caused by her Crohn’s disease. She was very malnourished and this was
stated to have contributed to her death.
Discussion of the woman’s Care at Foston Hall
Main points:
 The woman was clearly very unwell at the time of transfer to Foston Hall,
which appears not to have been fully appreciated.
 She had a history of refusing treatments, this continued until her death.
 Any earlier medical interventions made whilst at Foston Hall were unlikely
to have altered the subsequent events.
In the opinion of the clinical review team, the medical assessment that the
woman received during her stay at Foston Hall, given her apparent ill health,
could have been more thorough than that described in her notes.
The initial medical assessment form states that she was very underweight, lists
her medications (as above) and that she had Crohn’s disease. A full medical
history would have been sent from Brockhill. The prison doctor was asked to see
the woman the day after her arrival at Foston Hall, but the record provided is brief
and only says she was unfit for work.
Foston Hall should review its standardised assessment by nursing staff for
the first screen health check. Issues identified during this assessment (e.g.
current, active disease, physical measurements outside the normal range)
should be thoroughly reviewed and documented by the prison medical
officer.
Staff who had known the woman previously recorded that she was less “bubbly”
than she had been, had a poor colour and her abdomen was distended.
Staff reported that the woman did not wish to stay in the Healthcare Centre and
remained on the wing. She initially walked over to the Centre to receive her
medication. However, during her stay the decision was made to take the woman
her medication “because she looked so weak”.
She was seen repeatedly during her stay because of her ill health, but no further
investigations, i.e. blood tests were requested. The feeling seemed to be that
she would be seen soon in outpatients. Despite her ongoing bowel problems,
the health records do not contain any records of her weight. It would seem likely
that the woman’s severe anaemia would have developed slowly and therefore
easily missed unless blood tests were requested.
22
The woman’s medications had been used appropriately for her condition and at
the correct doses. There was a concern raised by a visiting doctor on 5 January
2006 that the ibuprofen may have been aggravating her abdominal pain and that
she should not take it. This drug can cause indigestion as well as relieving pain.
However, the same record states that the woman wanted to continue it. Use of
the ibuprofen does not appear to have been a significant factor in the woman’s
death.
Should staff at Foston Hall have acted differently?
The clinical review team believe that the staff at Foston Hall could have acted
differently in their approach to the woman’s care. As stated in their review,
health care staff at Foston Hall were fully aware that the woman was more unwell
than in previous admissions and that she was awaiting a review of her Crohn’s
disease at Queen Elizabeth Hospital. This review was prompted by her
worsening health.
Despite her short stay at Foston Hall, the clinical review team were surprised that
a more thorough medical assessment is not present in her healthcare notes. As
there is little in her notes concerning any such assessment or care management
plan, it is not possible to be definite about what could, or should, have been
done. In addition, he states it is not entirely appropriate to apply the level of care
expected in the community with that in the prison environment. Prisoners as a
group are more likely to have serious illnesses, and there is a custodial element
to their care, therefore a more rigorous approach to healthcare must be used. As
the woman obviously had worsening Crohn’s disease, the clinical review team
would have expected to find:
1. A plan that the woman should have been weighed, at least monthly.
2. A dietary assessment, with consideration given to involvement of a
dietician.
3. Blood tests requested whilst awaiting the outpatient appointment.
The results of the above may have prompted staff to try and expedite the
woman’s delayed outpatient appointment.
The clinical review team comment that it is surprising that management plans for
the ongoing care of prisoners is not in place. The team states that the
responsibility for the creation and implementation of such care plans lie at a
national level, although the Primary Care Trust would be happy to work with local
prison healthcare staff to achieve these recommendations.
Healthcare should produce clear care management plans for prisoners with
ongoing health needs. The medical officer should decide when this plan
should be revisited, and by whom. The management plan should be a
working document and take into account any new and emerging issues
23
during the course of care. This should be maintained by nursing staff, but
reassessed at intervals by the prison medical officer.
From reviewing the medical notes, the clinical review team’s opinion is that that
staff never really got to grips with the woman’s illness, which was clearly worse
than they appreciated - her severe anaemia was missed. This is perhaps
because it was generally thought any assessment could be left to the team that
she was due to see at Queen Elizabeth Hospital, or that she would only be
staying for a short time at Foston Hall.
The fact the woman preferred to stay on the residential wing did not materially
alter events. On speaking with healthcare staff at Foston Hall, the clinical review
team were told that the knowledge healthcare staff had of prisoners would not be
compromised by their choice of accommodation.
The woman’s refusal of treatment
Unfortunately, as the woman had a tendency not to comply with or refuse
suggested medical interventions, it is unlikely her death could have been
avoided. Despite her implied mental health problems, the clinical review team
found nothing to suggest she was not capable of making decisions surrounding
her health. Her poor compliance is, in any case, not relevant to the events
between November 2005 and January 2006, but was certainly relevant to her last
hospital admission and, the team assumes, to her illness in the months and
years prior to November 2005.
The woman’s HIV status
The notes and post mortem reports are conflicting and unclear as to whether the
woman was HIV positive or not. This is unlikely to have impacted on her care as
there is no suggestion she had an AIDS related illness.
Conclusion
The clinical review team was encouraged to hear that Foston Hall now has a
regular doctor to act as medical officer; this was not the case during the woman's
stay. This will provide better continuity of care and an opportunity to develop
new protocols. In addition, the use of information technology is set to increase at
Foston Hall, and should improve record keeping.
In conclusion, staff at Foston Hall gave the clinical review team no reason to
suggest they are anything but very caring. However, the organisation of
healthcare needs to be brought up to modern standards in line with the Primary
Care Trust.
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General
Medication at Foston Hall is dispensed from a small hatch area at the main
entrance to the healthcare unit. This is located at a central part of the
establishment and is easily accessible from all wings. There is a ramp up to the
entrance, and there are no stairs as it is all on one level. The woman had a short
walk from her wing to healthcare to collect her medicines and was happy to do
this as it meant she moved from her room. There were occasions when she was
too frail to make the journey and healthcare staff were asked to bring her
medications to the wing. Although this is not usual practice, I commend the
flexibility of healthcare staff and their willingness to accommodate the varying
needs of prisoners.
The inpatient facility at Foston Hall is small and largely used for patients with
mental health needs. Although the woman chose to reside on the wing, being
permanently based on healthcare would not have been a practical option. When
my investigator discussed with discipline staff the subject of having chronically ill
patients on the wings, it was noted that they are not briefed by healthcare about
prisoners’ conditions. Whilst I understand the issue of patient confidentiality, I do
think that it would be better practice to ensure that discipline staff have a general
overview of what to expect when housing a chronically ill prisoner. My
investigator was told that staff are not aware of any prisoner’s condition on the
wing, and that they would not know if a prisoner was diabetic or asthmatic.
Given that discipline staff are usually the first on scene during a medical
emergency, knowing these basic facts about a prisoner could result in a quicker
and more effective response.
The Head of Healthcare should consider providing basic medical
information regarding chronically ill prisoners to discipline staff who have
a duty of care to prisoners based on their wing, in accordance with the
Department of Health guidelines on sharing information.
I concur with the prison’s risk assessment regarding the use of restraints and
cuffs whilst the woman was still in full custody. She had made attempts to
escape on previous sentences and showed clear intentions of removing her
restraints under the bedwatch. The woman was fully mobile in the early stages
of her admission to hospital and was disruptive and uncooperative with both
prison and nursing staff. Equally, I agree with the prison’s later decision to grant
the woman release on temporary licence (ROTL), and then compassionate
release on temporary licence once it was clear that she was too frail and sick to
pose a threat to the public. However, I do have concerns about officers being
uniformed in an intensive care unit. I doubt this is appropriate except in the most
exceptional circumstances.
The woman’s behaviour towards staff during her stay at hospital was frequently
unacceptable and aggressive. This has been well documented within the
25
bedwatch logs. I appreciate that this must have been particularly stressful for the
escort staff who were required to remain with her at all times. My investigator
spoke with three members of staff who confirmed that it was, at times, extremely
frustrating. However, despite understanding the difficulties posed, I do not
condone some of the language used within the bedwatch logs. Some staff
comments are inappropriate and rude in describing the woman’s behaviour. I
have chosen not to use extracts within the body of the report as they did not
directly affect her care, however the logs are attached as an annex. The
Governor has reminded staff that the logs are for noting observations and not for
venting personal opinions.
Staff at Foston Hall went to great lengths to find the woman’s adoptive parents
and I commend them for their actions taken.
The Governor should commend staff for their time and effort in finding the
woman’s adoptive family.
26
Recommendations
Clinical
 Foston Hall should review its standardised assessment by nursing
staff for the first screen health check. Issues identified during this
assessment (e.g. current, active disease, physical measurements
outside the normal range) should be thoroughly reviewed and
documented by the prison medical officer.
 Healthcare should produce clear care management plans for
prisoners with ongoing health needs. The medical officer should
decide when this plan should be revisited, and by whom. The
management plan should be a working document and take into
account any new and emerging issues during the course of care.
This should be maintained by nursing staff, but reassessed at
intervals by the prison medical officer.
 The Head of Healthcare should consider providing basic medical
information regarding chronically ill prisoners to discipline staff who
have a duty of care to prisoners based on their wing, in accordance
with the Department of Health Guidelines.
General
 The Governor should commend staff for their time and effort in
finding the woman’s adoptive family.
The Governor states in her response that she has thanked the staff concerned
for their efforts.
27