Individual at Dovegate

Investigation into the death of a man at Queen’s Hospital
Burton, whilst in the custody of HMP Dovegate,
in March 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2011
This is the report of an investigation into the circumstances surrounding the death of
a man who died in hospital after several years of very poor health. In common with
far too many deaths of prisoners from natural causes, he was a relatively young
man.
The investigation was originally led by one of my investigators. One of my senior
family liaison officers contacted the man’s family and discussed their questions and
concerns about the man's death. I offer them, and all those affected by his death, my
sincere condolences. I apologise for the extreme delay in issuing my final report and
the additional distress I know this has caused to his family.
I am grateful to the two clinical reviewers from South Staffordshire Primary Care
Trust for their work in providing a clinical review of the medical care received by the
man.
This is a sad story of a man whose life and health were blighted by addictions to
heroin and crack cocaine. The man's health was further compromised when he
contracted tuberculosis in HMP Dovegate in 2005. I am disappointed to once again
read of poor record keeping and delays and cancellations of hospital appointments. I
trust that the Director of Offender Management and the Regional Offender Health
team will consider the implications of my comments. However, I am pleased to see
sensitive treatment of the man's family while he was in hospital and appropriate
judgement of when restraints are unnecessary.
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.
Thea Walton
Acting Deputy Prisons and Probation Ombudsman December 2011
2
CONTENTS
Summary
The investigation process
HMP Dovegate
The man
Key events
Issues
Conclusion
Recommendations
3
SUMMARY
The man was serving an 11 year six month sentence imposed in 2002. He was a
cooperative and popular prisoner with a supportive family.
The man had a history of chronic substance misuse since the age of 29 and was a
heavy smoker. He suffered from a duodenal ulcer, diagnosed in 2002, and
associated digestive problems. In 2005, he contracted tuberculosis while in HMP
Dovegate. Although he recovered, he was left with chronic respiratory damage that
reduced his mobility.
The man received treatment as an out-patient at Queen’s Hospital Burton from 2005
to 2006. In November 2008, he reported that he had been told by his consultant that
he had a life expectancy of only four or five years. I have not been able to find any
evidence of this.
In December 2008, the man became ill with a bladder infection. He remained unwell
and on 30 January 2009 was unable to attend an appointment with his prison drugs
worker because of a chest infection. On 13 February, he was found collapsed in his
cell in great pain. He was taken by ambulance to Queen’s Hospital Burton and the
next day was put on a ventilator in the intensive care unit.
The man was moved in and out of the intensive care unit for the next several weeks.
He was diagnosed as having suffered a spontaneous rupture of the oesophagus and
a torn bowel. His condition deteriorated and his death was confirmed shortly after
midnight in March.
The clinical review criticises the standard of record keeping at Dovegate. On one
occasion this resulted in the man not having his medication changed when this
should have happened. Also, on another occasion, he appears to have waited three
months for an X-ray deemed urgent by his doctor. Unfortunately these are themes
common to previous investigations in Dovegate.
Despite this criticism the review concludes that the general level of care received by
the man was consistent with that he would have received in the community. The
review also concludes that earlier diagnosis of his impending oesophageal rupture
would not have changed his prognosis or the outcome.
I conclude that, from the record I have seen, the bedwatch logs, risk assessments
and management checks were all completed appropriately. I highlight one area of
good practice in guidance to bedwatch escort staff.
I make four recommendations and endorse those made by the clinical review panel.
4
THE INVESTIGATION PROCESS
1. The Ombudsman was notified of the man's death on 30 March 2009. The
case was allocated to one of my investigators on 31 March. My Assistant
Ombudsman, contacted HMP Dovegate as my investigator was on annual
leave. As was our practice at the time the investigation was not formally
opened. The relevant paperwork was sent by post to my office.
2. My investigator spoke subsequently to the Senior Clinical Governance
Manager of South Staffordshire Primary Care Trust (SSPCT). The Senior
Clinical Governance was nominated by the Chief Executive of SSPCT to
undertake a clinical review of the man's medical care while in Dovegate. A
review group was established and led by the Quality officer for SPCT. We
received the final report of the review panel in early February 2010. The draft
report was issued in March 2010. We did not receive Dovegate’s action plan
in response to our recommendations until October 2011.
3. One of my family liaison officer visited the man's mother, sister and son at the
family solicitor’s office. The man’s family are pursuing a separate legal action
for neglect against the prison. Their main grievance concerns the man’s
contraction of tuberculosis (TB) in Dovegate in 2005. Because of the length of
time that has passed, we did not examine this in this investigation. We
acknowledge however that TB had a devastating effect on the man’s general
health. The family expressed several concerns about the level of care
provided to the man while he was in Dovegate. The man’s family said they
were only told he had been taken to hospital on the evening of the following
day. This information came from the police, rather than staff at Dovegate.
4. Following the publication of the draft report, the man’s family raised a number
of issues. They asked us to contact three prisoners who had known the man
in Dovegate. From the information provided we managed to trace the
whereabouts of only one of them. We wrote to him but received no reply. A
number of the family’s issues concerned the man’s medical care and the
clinical review. These have been addressed by South Staffordshire PCT and
sent to the family separately. We have reflected further comments made by
the family in the issues section of this report.
5
HMP DOVEGATE
5. Opened in 2001, Dovegate is a category B prison for adult male prisoners
sentenced to over four years. It is a private prison managed by Serco under
contract to the National Offender Management Service (NOMS). It currently
holds up to 1,146 prisoners. This is made up of 946 in the main prison and
200 in the Therapeutic Community (TC). Healthcare services in Dovegate are
provided by Serco Health.
6. Her Majesty’s Chief Inspector of Prisons last reported on Dovegate following
an announced inspection in October 2008. The Chief Inspector made the
following comment about healthcare:
“Primary health services were reasonable, but were compromised by
shortages of staff and accommodation, which needed a substantial
increase in funding for healthcare to move forward. Chronic disease
management was maintained despite staff shortages, but staff needed
more time to give a quality service to prisoners. Many NHS appointments
were cancelled or rearranged, and pharmacy services needed further
development.”
7. The latest Independent Monitoring Board Annual Report, for the period 2008-
09, made the following comments regarding healthcare services:
“Applications to the IMB regarding healthcare are the second highest
number being 14.01% of all applications. The complaints are about
medication, or lack of medication, long waits to see consultants and claims
they are ignored by staff.
“During the last reporting year, the healthcare centre has had a reworking
of the facility to reduce it from dormitory sized rooms to single cell
accommodation. The centre was closed in July 2009 and all in-patients
were transferred to HMP Birmingham. Recently re-opened it now has
improved facilities, including pharmacy and waiting rooms.
“A new healthcare manager, additional administrative staff, pharmacy
assistants and more nurses have been recruited. Hopefully this will bring
some much needed stability to this important facility.”
8. The Ombudsman has investigated over ten cases in Dovegate since taking on
responsibility for investigating deaths in custody in April 2004. In three of my
previous investigations I recommended that the Director and Healthcare
Manager ensure medical records are to the standard required by the General
Medical Council and Nursing and Midwifery Council.
6
THE MAN
9. The man grew up with his parents and three sisters. He described a happy
childhood. The man left school with O levels in maths and English. He
served an apprenticeship as a motor mechanic. He then worked for about
seven years doing car body repairs and working as a general mechanic. He
also worked as a labourer, a gardener and a painter and decorator. Sadly the
man's father died while he was in custody. He remained close to his mother
and had two children and two grandchildren at the time of his death.
10. The man had a long history of offending starting from the age of 17. Much of
his offending was related to motor vehicles and was committed for financial
benefit. The man said he started using heroin when he was 29 and moved
on to smoking crack cocaine aged 35. He said that he did not take drugs
while on holiday or when he was with his family. His addiction was at the root
of much of his offending behaviour and was also a contributory factor to the
various serious health problems from which he suffered.
11. In November 2002, the man was sentenced to 11 years and six months for six
offences of supplying vehicles knowing that they would be used to commit
crimes. He was transferred to HMP Dovegate in March 2004. Unfortunately,
the man was unable to rid himself of his addiction to illegal substances while
in prison. Although a polite and trusted prisoner in many regards, he
consistently failed mandatory drug tests.
12. In March 2005, the man contracted tuberculosis (TB). He spent some time in
outside hospital and was a regular patient in the prison healthcare centre until
his death. Although he recovered from TB, it had a devastating effect on his
health and left him with chronic breathing problems and reduced mobility.
13. The man made his most concerted attempt to overcome his drug use in
August 2008. He remained largely drug free for the remainder of his life. In
November 2008, it was reported that the man was told by a specialist that his
life expectancy was only four or five years. I have been unable to
independently verify this.
7
KEY EVENTS
14. The clinical review at annex 1 contains a very detailed history of the medical
interventions made in the man's case. The following is a summary of the
main events that occurred in the period leading up to his final illness and
death. Previous significant factors are that he contracted tuberculosis (TB) in
2005 and suffered from a duodenal ulcer and associated digestive problems.
He was treated as an outpatient at Queen’s Hospital Burton for both of these
conditions. After March 2006, he man stopped attending his outpatients
appointments with his respiratory consultant.
15. In November 2008, the man reported that he had received very bad news
from a consultant. Due to the damage done to his lungs from TB, drug use
and smoking, he had a life expectancy of only four or five years. Neither I nor
the clinical reviewer have been able to trace evidence of this prognosis. Also
at this time the process of writing and collating reports for the man's routine
parole review was begun.
16. Between October 2008 and February 2009, the man required five separate
courses of antibiotics and steroid treatment to cope with his breathing
difficulties and chest infections. In December 2008, he developed a bladder
infection. On 30 January 2009, he was unable to attend an appointment with
his prison drugs worker due to a chest and “water” infection.
17. On 13 February, the man was found collapsed in his cell with acute abdominal
pain. He was taken to Queen’s Hospital Burton in an ambulance at 6.00pm.
In accordance with prison regulations, the man was escorted by prison staff.
A bedwatch security assessment was completed by Officer A. He decided
that the man (as a category B prisoner) should be accompanied by two
members of staff and hand cuffed to one of them except when he was
receiving treatment. It was also decided that the man should not receive any
visits from family for the first seven days of his stay in hospital.
(Coincidentally on the same day the Parole Board rejected the man's
application for early release on parole.)
18. The man underwent emergency surgery on admission to Burton Queen's as it
was thought he had suffered a ruptured duodenal ulcer. In fact he had a
perforation in his oesophagus but surgery to repair it was deemed impossible
because of swelling. On 14 February, the man was placed on a ventilator in
the intensive care unit. On 15 February, another bedwatch risk assessment
was completed. Given the serious nature of his condition, and the fact that he
was heavily sedated, it was decided that the hand cuffs be removed.
19. On Friday 20 February, a caseworker at Partners of Prisoners and Families
Support Group (POPS) faxed a letter to the Director of Dovegate. The
caseworker said that the man was in a medically induced coma and his health
was such that he would be incapable of any concerted attempt to escape. In
the light of this, she asked the Director to extend the man's family's visiting
entitlement and allow them to spend time with him away from the escort
8
officers and without hand cuffs. The caseworker acknowledged that the
officers had been very understanding in their dealings with the family.
20. The Director of Dovegate replied on 23 February (which was the day he
received the fax). He told the caseworker that he would endeavour to
facilitate discreet, compassionate visits for the man's family. He said that the
family could visit all day, every day unless the situation changed in some way.
The Director explained that regular risk assessments were undertaken by
managers visiting the hospital and only the minimum level of restraints would
be applied to the man.
21. The man underwent further surgery four times in the next month. The
operations took place on 26 February, 2 March, 9 March and 18 March. He
was described as having multi-organ failure. He was unable to eat and had to
be fed via an intravenous feeding line. During this time he was regularly
placed on a ventilator. He was unable to move about unaided – and then only
for a few seconds before he became exhausted.
22. The bedwatch record and risk assessment for 23 March shows that the man
weighed only 28kg (about four stone). On the same day the prison’s Director
agreed to downgrade the man's security status from category B to category C.
A prisoner's security category is based on their risk to the public should they
escape. Given the man's physical condition, category C was deemed
appropriate.
23. On 24 March, the man was reported to be able to sit up in bed and take a few
steps with the aid of a zimmer frame. Two days later Dovegate’s Head of
Healthcare, wrote in the bedwatch log that the man was, “confused and
disorientated and did not recognize staff”. He was unable to walk unaided
and just about able to stand. The next day, 27 March, the man lapsed into
unconsciousness. A scan revealed an infection in his abdomen. He was
transferred to back to the intensive care unit.
24. At 5.30pm on 28 March, the Duty Director, received a telephone call from the
man’s sister at the hospital telling him that her brother’s death was imminent.
The man's family had been advised to agree to life support systems being
turned off. The Duty Director went to the hospital. Hospital staff asked him
how long the escort staff would be present, given the seriousness of the
man's condition. The Duty Director called the Assistant Director who joined
him at the hospital and removed the escort staff to another room.
25. At 8.00pm, the Assistant Director gave the day escort staff permission to
return to Dovegate. He instructed the duty officer in charge of running the
prison to prepare the night escort staff, but not to send them to the hospital.
By 10.00pm the man's condition stabilised. The night escort staff were called
to the prison but the man's heart began to fail and he died shortly before
midnight on 28 March. His family were at his bedside. His death was
officially pronounced at 12.05am on 29 March.
9
26. The Coroner's interim certificate of the fact of death gives the cause of death
as:
“1a Loculated peritonitis and pleuritis
b Perforated lower oesophagus”
10
ISSUES CONSIDERED
The clinical care afforded to the man
27. The clinical review at annex 1 contains a full discussion of the man's medical
treatment.
28. The clinical review acknowledged that there were a number of factors that
might have contributed to the man suffering a spontaneous rupture of his
oesophagus and undermined his ability to survive it. Among these were
vomiting and severe coughing. The man's on-going problems with a duodenal
ulcer meant that he was prone to vomiting. He had suffered from regular
chest infections since he contracted TB in 2005, but continued to smoke
cigarettes and heroin. The steroid treatment for his breathing problems and
the Subutex prescribed in October and November 2008 for heroin withdrawal
may also have compromised his ability to heal naturally. The symptoms from
the man's various health problems may have masked any warning signs of
impending oesophageal rupture.
29. Whilst a serving prisoner, the man missed a number of hospital appointments
from 2006 onwards. This was due to a combination of the hospital and prison
cancelling them and his own refusal to attend. The reasons for his non-
attendance are not always documented. The review criticises poor record
keeping at Dovegate more generally. Many entries in the man's file are
illegible or wrongly ordered. In one instance the absence of a record of the
outcome of a hospital appointment led to a delay in a change of medication.
30. I am aware that staffing levels often mean that prisons are unable to fulfil
hospital appointments. Her Majesty’s Chief Inspector comments on this and
is referred to in the background section of this report. Difficulties are also
caused because of the nature of some appointments, for example those that
rely on a space becoming available on a hospital waiting list. This can make
the production of a prisoner at a particular time a complicated logistical
juggling act. The prisoner too must bear some responsibility for willingly
attending his or her appointments. Nevertheless, it is of the highest
importance that prisoners are taken to outside hospital if they need treatment
and I therefore recommend:
In the next three months, the Head of Healthcare should audit hospital
appointments, both fulfilled and unfulfilled, for all prisoners in Dovegate
between April 2009 and March 2010. The information should be
analysed and used to plan a strategy for minimising the number of
unfulfilled appointments. Included in this strategy should be a traffic
light system for prioritising prisoners with the most serious health
needs.
31. Of equal concern is the fact that in 2006 the man waited for three months for
an X-ray that his doctor considered urgent. The reasons for the delay appear
to be entirely administrative. This is an unacceptable reason for any delay,
especially for an urgent matter. I am disappointed to see, once again,
11
criticism of medical record keeping at Dovegate. This is the fourth case in
which I find myself making a similar recommendation.
The Head of Healthcare should remind staff of the importance of record
keeping and the requirement to adhere to national standards. Regular
audits of medical records should take place in an effort to drive up
standards.
32. These criticisms notwithstanding, the clinical review concludes that the
healthcare given to the man while in Dovegate and at Queen’s Hospital
Burton (during his final illness) was appropriate. There was no indication that
he was experiencing acute abdominal pain prior to collapsing on 13 February.
It was only after surgery involving an incision through his abdominal wall that
the full extent of his illness became clear. In respect of his general healthcare
while he was in Dovegate, the review concludes that it was equitable with that
he would have received in the community.
33. I note that the Parole Refusal Notification issued to the man on 13 February
2009 complains that the panel required a detailed medical report about his
severe health problems. Only a very brief and “unhelpful” one was provided
by the prison. Clearly a prisoner’s health has an impact on the level of risk to
the public they are judged to pose and this in turn has an impact on whether
the Parole Board are minded to recommend early release. It is important that
the Parole Board are in possession of the most accurate and up to date
information on prisoners. The man’s health had been fragile for some time
and his breathing difficulties had a great impact on his mobility. This is
exactly the kind of information that the Parole Board needs to know. Had a
fuller report been supplied, it is likely that parole would have been granted and
his death would not have occurred whilst he was a serving prisoner. It is
disappointing that this opportunity was missed, especially as he presented no
risk to the public and need not have been in custody when he died.
The Director should remind staff of their obligation to provide up to date
and comprehensive reports on prisoners when required to do so by the
Parole Board.
34. The clinical review makes a number of recommendations which I endorse and
have listed in the final section of this report.
The use of restraints and bedwatch assessments
35. I have not seen a bedwatch risk assessment for the period between 15
February and 20 March. It appears from the records that I have seen that
restraints were not applied to the man when medical treatment was taking
place or when he was on a ventilator in the intensive care unit (as he was
intermittently throughout his stay). A bedwatch security assessment
completed by the Assistant Director on 20 March refers to the man “remaining
uncuffed”.
12
36. I have seen a complete bedwatch record and risk assessments for the period
between 23 and 28 March. All the records, management checks and risk
assessments were appropriately completed. Members of the senior
management team and the head of healthcare were regular visitors to the
man during his time in hospital.
37. At the front of the bedwatch pack is a handwritten note from the Head of
Healthcare at Dovegate, entitled 'Additional instructions for staff'. Her note
advises staff on the procedure for taking breaks and refreshments. It also
advises staff to be as discreet as possible and be mindful that they are guests
at the hospital. She advised staff to accede to requests from medical staff to
speak confidentially to the man and to move away from the bed to allow them
to do so. This is good practice.
38. The bedwatch records that I have seen indicate that regular risk assessments
and regular visits by management were made. I am pleased to confirm that
the man spent the majority of his stay in hospital without restraints.
Informing the family that the man was in hospital
39. The man’s family told the Ombudsman’s senior family liaison officer that they
were upset about not being told until the evening of the next day that he had
been admitted to hospital. I have sympathy with their point of view,
particularly as he had been poorly for a long time and was already frail. There
is no formal guidance to prisons as to when it is appropriate to inform the next
of kin that a prisoner has been taken to outside hospital.
40. Clearly the prison has a duty to be mindful of security considerations and
protecting the public. However I believe that the decent thing to do is to
inform the family as soon as possible if their relative is seriously ill. In this
case it was obvious from the first admission that the man was seriously ill. He
underwent emergency surgery at the earliest opportunity and the next day
was on a ventilator in the intensive care unit. In this case I consider that the
prison could have informed his family on the evening that he was taken ill. I
echo a recommendation made in a different case at another prison:
The Director should issue local guidance requiring healthcare staff and
security staff to identify when a prisoner's condition is sufficiently
serious to warrant the notification of their next of kin. The guidance
should identify who is responsible for notifying the next of kin.
Family comments
41. The man’s family told us that the man was seen by various different locum
GPs at Dovegate who recommended that he be taken to outside hospital due
to his condition. They told us that he was too ill to attend some appointments
and on more than one occasion there was a break in his medication and
delays in him seeing a doctor.
13
42. The man’s family have asked us to point out that they strongly disagree with
the conclusion of the clinical review that the man’s general healthcare at
Dovegate was equitable with that he would have received in the community.
14
CONCLUSION
43. The man had evidently suffered from very poor health for some time.
Although there are criticisms of record keeping, delays and missed
appointments in this report, neither I nor the clinical reviewer conclude that
they affected the outcome of what was to be his final illness. I am satisfied
that he was taken to hospital promptly when he collapsed on 13 February and
thereafter received consistently appropriate care. I am pleased to see that his
family were allowed unrestricted access to him in his last few weeks and that
the prison helped financially with the cost of their travel.
15
RECOMMENDATIONS
1. In the next three months, the Head of Healthcare should audit hospital
appointments, both fulfilled and unfulfilled, for all prisoners in Dovegate
between April 2009 and March 2010. The information should be analysed
and used to plan a strategy for minimising the number of unfulfilled
appointments. Included in this strategy should be a traffic light system for
prioritising prisoners with the most serious health needs.
This recommendation was accepted by Dovegate at draft report stage and
they responded:
“The escort and bedwatch data is analysed frequently by the local PCT and a
full review has in fact taken place in HMP Dovegate. This data is analysed
and monitored weekly in HMP Dovegate and the healthcare manager is linked
in to the local PCT to support and develop a longer term strategy aimed at
meeting the needs of those prisoners referred to secondary and acute care
services.”
2. The Head of Healthcare should remind staff of the importance of record
keeping and the requirement to adhere to national standards. Regular audits
of medical records should take place in an effort to drive up standards.
This recommendation was accepted by Dovegate at draft report stage and
they responded:
“NMC guidelines have been distributed to all staff. Electronic record systems
have now been put in place (system one) that addresses all concerns relating
to this recommendation.”
3. The Director should remind staff of their obligation to provide up to date and
comprehensive reports on prisoners when required to do so by the Parole
Board.
This recommendation was partially accepted by Dovegate at draft report
stage and they responded:
“Serco Health is not commissioned to complete parole reports or make
recommendations within reports. As recognised by central DH, these reports
require a capability not normally found within a prison healthcare setting and
are therefore separately commissioned by the service requiring the reports.
However, we do recognise that parole reports may need to be completed on
compassionate grounds to effect a speedy release and as such we will ensure
that each case is considered on its own merits.”
4. The Director should issue local guidance requiring healthcare staff and
security staff to identify when a prisoner's condition is sufficiently serious to
warrant the notification of their next of kin. The guidance should identify who
is responsible for notifying the next of kin.
16
This recommendation was accepted by Dovegate at draft report stage and
they responded:
“Local contingency plans make reference to the notification of next of kin. A
family liason officer is in post who is responsible for making contact with the
named next of kin when the prisoner’s condition is identified by a member of
the healthcare team (either internal or external) as being sufficiently serious.”
From the clinical review:
1. When a prisoner receives a positive diagnosis of tuberculosis, a full report of
any actions taken by prison staff and investigation details should be made in
their records.
This recommendation was accepted by Dovegate at draft report stage and
they responded:
“The recommendations utilises the terminology ‘prison staff’. I accept that
Nursing Staff should complete a full report. This does in fact happen and
detailed records are maintained on System One.”
2. A daily record should be maintained detailing conversations with hospital staff
when a patient is in hospital in order that a full picture of their progress is
maintained.
This recommendation was accepted by Dovegate at draft report stage and
they responded:
“All conversations with Hospitals are detailed on system one.”
A copy of the six month action plan provided by Dovegate is at annex six.
17