Individual at Manchester

Investigation into the circumstances surrounding the
death of a man, who was a prisoner
at HMP Manchester, on 26 June 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2010
This is a report into the death of a man at North Manchester General Hospital on 26
June 2009. He was 54 years old, and was a prisoner at HMP Manchester. He died
from natural causes, having been admitted to hospital two weeks before his death.
I offer my sincere condolences to the man’s family and friends.
The man had been arrested in June 2008 and was sentenced soon afterwards to 12
years imprisonment. He began his sentence in HMP Manchester before being
transferred on 27 February 2009 to HMP Full Sutton. Days after his arrival at Full
Sutton, the man was diagnosed as having small cell lung cancer and was returned to
Manchester so he could receive treatment at a specialist hospital. His health then
deteriorated during his time in custody. The Coroner has confirmed that the cause of
his death was cancer.
This investigation has been undertaken by a member of my investigation team. I
would like to thank the Governor of HMP Manchester and his staff for their co-
operation and active participation in the investigation.
The Head of Clinical Governance for NHS Manchester conducted a review of the
care the man received whilst in prison and I would like to thank her for her
contribution to the investigation.
As is often the case in investigations following a death from natural causes, I am
strongly influenced by the findings of the clinical review. In the case of this man, the
clinical review finds that he mostly received good care, although the quality of record
keeping and the palliative care offered could have been much better. My report
makes eight recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2010
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CONTENTS
Summary 4
The investigation process 6
HMP Manchester 8
Key findings 9
Issues 19
Conclusion 23
Recommendations 24
3
SUMMARY
The man was arrested for a serious offence on 13 June 2008 and held on remand at
HMP Manchester from 16 June. He was sentenced on 19 December to 12 years
imprisonment with a release date of 16 June 2014. This was not his first time in
prison.
He had a history of drug misuse which he disclosed during his reception at the
prison. He told staff that he was undergoing withdrawal treatment at the Salford
Drug Service and had been prescribed and was taking methadone. As a result, the
man was referred to undergo a detoxification programme. The following day, he was
transferred to the detoxification wing to commence a period of detoxification with
Subutex (a drug that is primarily used to treat heroin addiction). He successfully
completed the detoxification course.
During his stay at Manchester, the man was seen by various members of the
healthcare team and his general health and medications were reviewed at regular
intervals. His past medical history revealed that he was a known asthmatic and had
had a lumbar laminectomy (which involved the removal of the lamina, part of the
vertebra) in 1989 for a back injury. No concerns had been raised about the man’s
mental health.
On 27 February 2009, the man was transferred to HMP Full Sutton to continue his
sentence. Four days later (on 3 March), he was transferred to York Hospitals NHS
Foundation Trust because he was coughing up blood. The man underwent a series
of tests and examinations and was subsequently diagnosed with small cell lung
cancer, chronic obstructive pulmonary disease (COPD), asthma and ischaemic heart
disease. As his primary diagnosis was lung cancer, it was decided that he should be
returned to HMP Manchester to enable him to undergo treatment at the Christie
Hospital NHS Foundation Trust in Manchester.
The man was transferred to Manchester on 25 March 2009 and was immediately
taken to the Christie Hospital to commence chemotherapy treatment. He received
two treatment cycles (out of six to be received in total) of chemotherapy which he
appeared to tolerate well. He returned to Manchester on 1 April but, against the
advice of the prison doctor, he asked to be located on a normal residential wing
instead of the healthcare centre. Having later reflected on this decision, the man
was relocated to the healthcare inpatients centre on 3 April.
Thereafter, the man attended Christie Hospital on a number of occasions for
aftercare treatment. However, having initially refused his third treatment cycle, he
became very unwell with his condition rapidly deteriorating. He was admitted to
North Manchester General Hospital on 9 June as an emergency patient. The man’s
condition continued to deteriorate over the next couple of weeks and he passed
away in the hospital on 26 June 2009.
I find that overall the man received a standard of care whilst at Manchester that was
equivalent to that which he could have expected in the community. I also find that he
was treated with dignity and respect at all times leading up to his death. I do,
4
however, make eight recommendations in my report regarding record keeping and
the palliative care afforded to the man.
5
THE INVESTIGATION PROCESS
1. The investigation into the man’s death was conducted by one of my
investigator’s, Notices of the investigation and terms of reference were sent to
the prison, inviting anyone with any information to contact the investigator.
2. My investigator was provided with a copy of the man’s prison records and later
met the Governor. My investigator also met the Head of Healthcare,
representatives of the Prison Officers’ Association, and a member of the
Independent Monitoring Board. He visited all parts of the prison, in particular
the wing where the man had lived, and met the prison’s liaison officer. .
3. A clinical review of the man’s medical care was commissioned from NHS
Manchester. I am grateful to the Head of Clinical Governance, for her review.
As part of her review, the Head of Clinical Governance jointly conducted
interviews with my investigator. The Head of Clinical Governance also
separately interviewed other prison staff and external specialists. I am grateful
to HMP Manchester staff who have contributed to this investigation. They were
open and professional throughout.
4. One of my Family Liaison Officers contacted the man’s mother to inform her of
the investigation and to give her the opportunity to raise any questions or
concerns about the care he received. At the time of writing this report, the
man’s family has not raised any specific issues.
5. I am pleased to report that the man’s mother spoke very positively about the
care he received prior to his death and also the help and support her family had
received from the prison following her son‘s death. They welcomed the
opportunity to visit the prison to meet with the Governor, and with other prison
and healthcare staff, and appreciated the level of contact that the prison had
maintained throughout this difficult time.
6. I hope this reports provides the man’s family with a better understanding of the
events leading to his death.
6
HMP MANCHESTER
7. HMP Manchester is a large prison, Victorian in external appearance but greatly
refurbished internally. Cells have televisions, electric sockets and sanitary
facilities. Manchester holds both unconvicted and sentenced prisoners, as well
as a small number of high security (category A) prisoners. For this latter
reason, the jail is part of the Prison Service’s high security estate and physical
and other security within the prison reflects this.
8. At the time of the investigation, the prison served magistrates’ and Crown
Courts in the Greater Manchester area, holding up to 1,269 male adult
prisoners. The prison is divided into two main blocks. The upper prison
contains four wings (G-K) which include the First Night Centre and the induction
wing. The lower prison has five wings (A-E).
9. Healthcare at Manchester is commissioned by the Manchester Primary Care
Trust. The healthcare centre provides 24-hour nursing care and medical cover,
and has beds for up to 38 patients.
Independent Monitoring Board
10. Each prison has an Independent Monitoring Board (IMB). IMB members are
independent and unpaid members of the local community. They monitor day-
to-day life in their prison and ensure that proper standards of care and decency
are maintained. Each IMB produces an annual report. In their report on
Manchester for the period 1 March 2007 to 29 February 2008, the IMB said:
“Manchester is a well-run prison which is meeting most of its Key
Performance Targets … The Board has witnessed many occasions when
staff have demonstrated sensitivity to prisoners’ needs, e.g. in Reception
on arrival at prison, officers giving information on what was happening
and answering any questions … “
Her Majesty’s Chief Inspector of Prisons
11. The most recent inspection by Her Majesty’s Chief Inspector of Prisons, was an
announced full inspection in July 2009. Published in December 2009, her
comments in relation to healthcare services at Manchester included:
“…There was evidence of strong support from the primary care trust.
Primary care services had improved and there was access to a range of
in-house and visiting specialist clinics. Vulnerable prisoners expressed
concern about safety in waiting rooms. The introduction of telemedicine
had significantly reduced the number of prisoners going out of the prison
for NHS assessment. The healthcare application system was not
sufficiently robust, and the absence of prisoner focus groups meant that
prisoners were unaware of significant changes in healthcare delivery.
The management of external NHS appointments was efficient, and
inpatient health provision satisfactory.”
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Prison Service Orders (PSOs)
12. Prison Service Orders are long-term mandatory instructions. They were
introduced to replace Standing Orders, Advice to Governors and Instructions to
Governors.
Previous deaths at Manchester
13. The man’s death was the 28th to have occurred at Manchester since April 2004
when the Ombudsman’s office began investigating all deaths in prison custody
in England and Wales. Eight of the previous 27 deaths were due to natural
causes. There have subsequently been a further two deaths at Manchester,
both due to natural causes. The man’s case is not comparable to any of the
others, but two of my previous reports included recommendations about record
keeping and palliative care.
8
KEY FINDINGS
14. The man was arrested and remanded into HMP Manchester on 16 June 2008
from Salford Magistrates’ Court for the offences of attempted murder and
threats to kill. He arrived at Manchester around 3.00pm and went through the
normal reception screening process. The Prisoner Escort Record (PER) that
accompanied him from court noted that he had angina, asthma, misused drugs
and had a previous history of offending.
15. Prison reception staff went through the first night in custody and assessment
booklet with the man to assess any concerns or immediate needs he might
have. He was allowed to contact his mother, whom he listed as his next of kin.
The man told staff that he had angina, asthma and a spinal injury, for all of
which he was currently taking medication and had in his possession. It was
noted the man had no history or current thoughts of harming himself. His cell
sharing risk assessment (which decides whether a prisoner is a risk to others
he may share a cell with) noted that he was a “Low” risk.
16. As part of his assessment, the man was interviewed by a registered general
nurse from the healthcare team. The man said he was currently taking 80mg of
methadone daily as a result of his spinal injury and was a client of the Salford
Drug Team in the community. He said that, had he not been arrested, it was
his intention to attend a detoxification clinic and that he had already completed
the referral application for this.
17. The man did not wish to be examined immediately by the prison doctor and so
a referral was made for further consultations with both the doctor and the Drug
Service for the following day. He also asked to be referred to the Counselling,
Assessment, Referral, Advice and Throughcare Services (CARATS) team as
he wished to receive support for his drug problem. All new prisoners with
asthma are entered onto an asthma register in reception at Manchester. They
are then assessed and offered asthma monitoring to manage their condition so
that it has minimal impact on their quality of life. The man was placed on this
register.
18. After being initially admitted to G wing (Induction Wing), the man received his
first night assessment and induction into the prison. He had been risk
assessed due to his drug misuse and G wing was deemed appropriate by the
medical staff as he had taken his methadone medication whilst in police
custody before his admission to Manchester.
19. The following day (17 June), the man’s induction continued. Having declared
that he wanted to address his drug misuse problem, he was examined and
assessed by a detoxification doctor The man reiterated that he was being
treated by the Salford Drug Service for his drug misuse. He also disclosed that
he had had a lumbar laminectomy (spine operation) in 1989, asthma, chronic
obstructive pulmonary disease (COPD) and angina. No mental health
problems were recorded.
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20. The detoxification doctor discussed detoxification through the use of Subutex
which would assist in reducing his dependency on drugs. The man agreed to
this and was moved to the detoxification wing (I wing) to commence the stage
one detoxification programme on 18 June. He signed the wing compact to
enter the Drug Testing Unit (DTU) and agreed to comply with regular drug tests.
He was given further information about the prison, and staff noted no concerns.
21. Despite the fact that the man provided the details of his doctor in the community
there was no written indication on his prison medical records to show that she
was contacted. Furthermore, there was no record that Salford Drug Service
had been contacted about the man’s previous treatment. At interview with the
investigator and the Clinical Reviewer, the Head of Healthcare said that she
would expect all correspondence to be documented but could not comment on
why this had not been carried out.
22. The man was approached by healthcare and gave permission on 23 June for
the Salford Drug Service to be contacted).
23. On 18 June, the man commenced the Subutex detoxification programme. His
induction continued and later in the day he was interviewed by the prison
chaplain. The chaplain recorded in the man’s wing history sheet that he (the
man) was not feeling too well, due to the effects of detoxing. Nonetheless, he
was in good spirits during their conversation.
24. As part of the induction process, all new prisoners should be offered a
secondary health assessment within the week following their first reception.
This assessment is equivalent to a primary care assessment when registering
with a doctor in the community. It provides an opportunity for gathering further
health information, health education and promotion. Importantly, it also checks
how a prisoner is settling into the prison routine.
25. The man received his secondary health assessment by the Detoxification
Manager on 17 June. The Detoxification Manager carried out general
observations including drug tests and noted the man’s medical record
accordingly. The following day (18 June), he was seen by the prison doctor
where it was recorded that he had complained of experiencing pain from an “old
back injury”. At interview with the Clinical Reviewer a nurse added that this
entry, which was recorded on EMIS (the prison medical computer), would have
been the secondary screening.
26. On 24 June, the man received a comprehensive substance misuse assessment
by a prison CARATS worker. He said that he had been using illicit drugs since
the age of 14. He had then gone on to misuse heroin after his doctor had
stopped his morphine prescription which he had been taking for his spinal
injury. He had been in and out of drug treatment for the past two years and had
intended to go to a rehabilitation centre but was arrested for his current offence.
27. A care plan was drawn up which included the man agreeing that the Salford
Drugs team could be contacted to obtain further information about his treatment
10
with them. The CARATS team offered the man support in respect of his drug
problem and agreed that he would be seen every three weeks.
28. On 26 June, the man attended the doctor’s clinic complaining of back pain. He
was examined and referred to see the physiotherapist.
29. The man successfully completed stage 1 of his detoxification programme on 7
July. He was duly located onto H wing so that he could participate on stage 2
of the detoxification programme. H wing facilitates a 10 day group work
programme including education regarding HIV and AIDS, safe injection
practice, first aid, healthy eating, personal hygiene and testicular cancer.
30. Although the man was referred to the asthma clinic for monitoring, he refused to
attend an appointment made for him on 17 July. No concerns had been raised
about the man by staff.
31. During August, the man was seen by the prison doctor as he had complained of
experiencing abdomen pain. Omeprazole capsules (used to treat ulcers, and
other conditions involving excessive stomach acid production) were prescribed
and blood tests were taken to conduct various tests, including a helicobacter
pylori status. (Helicobacter pylori is a bacteria that causes an inflammation of
the stomach lining and is strongly linked to gastric ulcers and stomach cancer.)
Two weeks later, his results were received. It was confirmed that he had tested
positive for helicobacter pylori and was prescribed appropriate medication.
32. On 22 September, the man complained of shortness of breath. He was seen
by a prison doctor who examined him and conducted a series of investigations
including an electro-cardiogram (a test that measures the electrical activity of
the heart). The doctor suspected that the man had experienced an inferior
myocardial infarction (heart attack) and so he was immediately taken to the
accident and emergency unit of the North Manchester General Hospital
(NMGH) for assessment. He was subsequently diagnosed with an
exacerbation of his asthma. However, before hospital staff could conduct a
chest x-ray, the man discharged himself from their care. The hospital were
however able to prescribe him some medication, augmentin (an antibiotic) and
prednisone (a steroid) on discharge.
33. It was noted on EMIS that the man returned to Manchester without a discharge
letter being completed by NMGH. This had to be requested by healthcare staff
to enable further treatment to be carried out. At interview, several members of
nursing staff including the Head of Healthcare indicated that this was a common
problem for the Prison Service.
34. Three days later (on 25 September 2008), when staff unlocked the man he
complained of having a chesty cough. Healthcare staff spoke to him in his cell
and he was later taken to the healthcare centre and examined by the doctor.
He was prescribed a Salbutamol inhaler and it was documented in his medical
record that this treatment would be reviewed in two weeks time if the man felt it
necessary. Healthcare staff told the wing staff that the man was generally
okay, and that he would have to allow time for the antibiotics that had been
11
prescribed by the hospital to work. The man had no further contact with the
healthcare centre about this ailment.
35. An appointment was made for him to attend the asthma monitoring clinic on 12
November, but he again refused to attend.
36. From 28 October, the man became a wing cleaner. In November, following his
application under the Incentives and Earned Privileges Scheme (IEP), he was
granted enhanced status. (The IEP scheme rewards and promotes prisoners’
good behaviour. Enhanced is the highest of the three regimes (basic, standard,
and enhanced).)
37. The following month, on 26 November, he appeared before Manchester Crown
Court and was convicted of wounding with intent, threatening to kill and
aggravated burglary. He would return to court at a later date to be sentenced.
38. On 30 November, staff on H wing contacted the healthcare centre and reported
that the man felt unwell. He had complained of having respiratory problems,
was coughing up phlegm and was suffering from aches and pains. He was
examined by a doctor and prescribed antibiotics, a Salbutamol inhaler and
prednisone (a steroid). The man’s wing history sheet noted that he had an
infection in his lungs, and rest and medication were to be taken until further
notice. The man did not contact the healthcare centre again regarding this
problem.
39. It was recorded on the man’s medical record that he again refused to attend a
asthma monitoring check on 1 December. Immediately after this entry, the
words “Booked for respiratory nurse clinic 4/11/08” were written. It is unclear if
this was a missed appointment or just an incorrectly dated entry.
40. On 19 December, the man attended court and was sentenced to 12 years
imprisonment. On his return to prison, he was seen by a mental healthcare
nurse in reception. When interviewed, the head of healthcare said that this
would suggest that the man was screened for any potential healthcare or
suicide/self-harm issues following his court appearance. Wing staff also spoke
to the man who told them that he was happy as he had expected a longer
sentence. No further problems were raised by him or staff.
The Man’s transfer to HMP Full Sutton
41. Following his sentencing, in line with normal sentence progression within the
prison system, on 23 February the man was assessed by healthcare staff as fit
for transfer. He subsequently moved to HMP Full Sutton on 26 February 2009.
When he arrived, he again underwent the standard health screening process
and first night risk assessment.
42. Four days later (on 3 March), he attended the prison clinic and said that he had
been coughing up blood and was short of breath. He was examined by the
prison doctor and was subsequently transferred to the local hospital. He was
admitted for further tests and investigations under the care of the hospital chest
12
physician, and remained in the hospital for a number of weeks. During this time
(on 17 March), he was diagnosed with small cell lung cancer, chronic
obstructive pulmonary disease (COPD)/asthma and ischaemic heart disease.
43. After a full consultation between the Head of Healthcare at Full Sutton, York
Hospital medical staff, and the Deputy Governor at Manchester, it was agreed
that the man should be transferred back to HMP Manchester. This would
enable him to receive chemotherapy treatment at the Christie Hospital in
Manchester and, at the same time, make it easier for him to maintain contact
with his family.
44. Whilst arrangements were being put in place for the man’s return to
Manchester, he remained on a pain control regime (morphine sulphate tablets
(MST) and Oramorph) at York Hospital. (Oramorph is the brand name of a
preparation of oral morphine liquid.)
45. When the man left York Hospital on 25 March, arrangements had been made
for him to be immediately taken to the Christie Hospital in Manchester to
commence his first cycle of chemotherapy. A copy of his Full Sutton medical
records and his medication also accompanied him. The man remained at the
Christie Hospital for approximately eight days. During this time he received his
first course of chemotherapy. His prison medical records show that healthcare
staff from Manchester remained in regular contact throughout his stay at the
Christie Hospital to check on his progress.
The Man’s transfer back to HMP Manchester
46. Following the man’s first cycle of chemotherapy treatment (two out of a total of
six he would eventually receive) he was transferred back to HMP Manchester
on 1 April. On discharge, he was prescribed morphine sulphate tablets 110mg
twice a day, together with Oramorph 40mg (as necessary) for breakthrough
pain. A discharge letter was prepared by the Christie Hospital but was
incorrectly addressed to Full Sutton. It did, however, come with the man on his
return to Manchester. The letter gave detailed instructions for his treatment,
date of next cycle of chemotherapy, possible complications to be mindful of
between treatments, and details of medication he had been prescribed.
47. Comprehensive information sheets were also included (for patients) which
specifically indicated an individual’s vulnerability to infections that could become
life threatening if untreated. It also described other possible side effects. The
discharge letter included ‘urgent advice’ for doctors, namely the relevant
treatment needed if a patient felt unwell or had pyrexia (a high temperature).
All sets of instructions and advice sheets emphasised the importance of
detecting symptoms of infection at a very early stage.
48. When the man arrived at Manchester, he was seen by the prison doctor who
prescribed his medication. The man said that he did not want to be located in
the healthcare centre, against the advice of the healthcare staff. The doctor
advised the man that if he were to be located on an ordinary wing, it would not
be possible for him to have access to his pain relief medication, Oramorph.
13
This was because of the control restraint placed on this drug in the prison
environment. At interview with the Clinical Reviewer, the doctor said that the
man accepted this but still wanted to be located on an ordinary wing. The
doctor said that he would usually adjust the dose of morphine sulphate tablets
according to the patient’s reported pain until minimal Oramorph was needed.
49. The man was located on I wing as he had requested. At interview a prison
nurse told my investigator that she had a lot of contact with the man. He was
fully aware of his illness and frequently asked her questions about it. The nurse
said that the man did not want to be located in the healthcare centre. This was
also despite her advice that the healthcare centre was the best place for him
given that he had just completed a course of chemotherapy. The nurse
reiterated that the level of nursing care that would be available to the man on
the prison wing would be less than in the healthcare centre. One of the
concerns the nurse said she raised in their discussion was the difficulty in
ensuring the man’s temperature was checked regularly, as an increase could
have serious health implications.
50. The following day (2 April 2009) at around 9.50pm, wing staff contacted the
healthcare centre and spoke with a healthcare nurse. Aware of the implications
of having a high temperature, the man had voiced his concern that his
temperature had not been monitored as yet. The healthcare nurse was told
that the man was “feeling fine” and she told the man (via the wing staff) to
attend the healthcare centre the following day to have his temperature checked.
At interview with the Clinical Reviewer, the healthcare nurse indicated that on
the information given to her she felt that it was not urgent to take the man’s
temperature at that time. In addition, numerous and lengthy safety and security
measures would have had to have been undertaken to open his cell, as all
prisoners were locked in their cells at that time of the night.
51. The man’s temperature was taken the next morning, and recorded as 35.5
Celsius. (The Clinical Reviewer noted that this is a low reading and possible
cause for concern.) No comment was made about this reading in the man’s
medical record. At approximately 5.45pm, the man was seen by a nurse on the
wing who reported that he was “hot to touch” and felt unwell. The nurse again
suggested that the man should be located in the healthcare centre and he
agreed to be admitted as soon as possible.
52. An hour later, the man was given his mediation on the wing and his
temperature was again taken and recorded as 37.5 Celsius. (According to
guidelines provided by the Christie Hospital, this temperature is a possible
cause for concern). However, the reading was described as being within
normal parameters by nursing staff. The man said he was feeling increasingly
hot and had vomited. He was immediately transferred to the healthcare centre.
He subsequently told staff that he had made a mistake in wanting to be located
on ordinary location and soon became very tearful and reflective.
53. Two care plans had been created for the man, both dated 3 April 2009. One
related to pain control and the other to his chemotherapy treatment. Neither
care plan referred to any psychological or emotional support the man might
14
have required. In regard to assessing pain, the Clinical Reviewer notes that
there was no evidence of any pain assessment plans or protocols being used at
HMP Manchester. At interview, a nurse said that Manchester did not often use
pain charts. She said the man was very open in conversation regarding the
levels of pain he felt and wanted to remain in control. The nurse said his care
plans and pain charts were therefore kept to a minimum.
54. The same nurse told my investigator that she had previously worked in
hospices and had also completed palliative care training. She therefore offered
the man palliative care and talked to him a lot about his treatment and how he
was feeling. The man wanted the nurse to be honest with him as he was aware
that the type of cancer he had was quite progressive and he would not survive
it. The nurse said the man was also offered the services of McMillan Nurses (a
cancer care and support charity). However, he refused this, saying he was
happy with the level of support he was receiving from the staff in the healthcare
centre.
55. From around 22 April, there were several days of confusion regarding the date
of admission for the man’s second cycle of chemotherapy. He was aware that
his treatment should have taken place at this time, but nursing staff within the
healthcare centre were not aware of any dates. This was despite it being
detailed in the man’s hospital discharge letter of 31 March. This letter outlined
the follow up dates for his second cycle of chemotherapy. Over the next few
days, staff attempted to contact the Christie Hospital to secure a date for the
man's return.
56. He was eventually escorted to the Christie Hospital on 30 April for his second
phase of chemotherapy treatment. When he returned to HMP Manchester later
that day, no concerns were raised. There was also no evidence on his medical
records to suggest a review of his care plans was carried out.
57. On 5 May, the man asked once again to be located on an ordinary wing as he
wanted to participate in some kind of prison work. His medical record was
documented that he did not require any nursing input at this time, other than
being given Oramorph three times a day. However, this medication was not
available on the prison wing, something the man was already aware of.
58. Following his request, it was arranged for him to transfer to an ordinary prison
wing on the morning of 8 May. On that day, however, he told the nurse on duty
that he was feeling breathless and did not want to go. He also said that the
previous day he had experienced a lot of pain but had withheld this information
from staff. His move to the prison wing was cancelled and he was examined by
the doctor that afternoon. It is documented that the Oramorph was to be
restarted. The Clinical Reviewer assumes that his medication was stopped in
preparation for his return to the prison wing, although neither this nor evidence
of further care planning is documented.
59. The prison doctor examined the man on the morning of 25 May as his legs had
swollen up overnight. The next day, whilst walking to his cell, the man lost his
balance and fell. He told the nurse on duty that he was okay. He was
15
examined and it was noted he had sustained no injuries. Staff were to monitor
and observe him.
60. On 27 May, the man was due to attend the Christie Hospital for his third cycle
of chemotherapy. On this occasion, however, he refused to go and said that
the hospital had continually changed his appointments and it was “stressing him
out”. Healthcare staff tried to persuade him of the importance of attending his
appointment but he continually refused. There was nothing in his medical
records relating to problems occurring with his appointments other than that
mentioned already on 22 April (his second therapy treatment).
61. Whilst staff were trying to persuade the man to attend the Christie Hospital, he
became distressed. The nurse said that she offered the man any necessary
psychological support during this time and answered any questions. The
Clinical Reviewer has found no evidence of any care plans relating to the
emotional and psychological support that the man may have received or
required.
62. The man also said he wanted to have a central line inserted (a method used to
take blood) due to the difficulties experienced by staff at the Christie Hospital
when taking his blood. The nurse said that should a central line be necessary
on any patient, nursing staff at Manchester were fully trained in the procedure.
(It later transpired that it was not necessary for him to receive a central line.)
63. Staff monitored the man and he was given his medication as normal for the
remainder of the day. The next day, his mood had improved and at his request
staff contacted the Christie Hospital in an attempt to restart his chemotherapy
treatment as soon as possible.
64. The nurse told my investigator that, although aware that he was very ill, the
man wanted to live as normal a life as possible. She spoke with him frequently,
offering him support, and it was for this reason he had fewer care plans than
would have been expected for someone with his condition. The man did not
want staff to be “mothering him all the time” and often preferred to talk about his
family rather than his illness. The nurse also said that, although the man
received a lot of psychological support from her, this was not recorded in his
care plans.
65. Late in the evening on 3 June, the man’s condition deteriorated. He said he felt
unwell and requested his pain relief. He was examined by the nurse on duty,
given some pain relief, and an appointment was made for him to see the doctor
in the morning. The nurse also noted that the man should be moved to an
observation cell so that staff could more easily and constantly monitor him.
66. The following morning, the nurse on duty reviewed the man’s care plan. It was
noted in his medical record that he continued to be “independently caring for his
own washing and dressing needs”, and his existing care plans should continue
until he was reviewed by the prison doctor.
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67. The man met with the doctor shortly after and they spoke at length about his
refusal to attend his chemotherapy appointment at the Christie Hospital. The
man said that he had felt frustrated and angry, but now regretted his actions
and wanted to proceed with his treatment. The doctor told him that the Christie
Hospital had been contacted and arrangements would be made for him to
resume his chemotherapy treatment as soon as possible.
68. On 5 June, the man was moved to a more comfortable observation cell. He
was happy with his new cell and, despite looking tired and in pain, told staff that
he was okay. Staff continued to monitor him and when appropriate provided
him with his pain relief.
69. On the morning of 7 June, the man was described by a nurse as cheerful. He
had been up in his cell early and had gone outside for exercise in the yard.
70. The next day, two extra care plans were created. Although both lacked detail,
the first related to the man’s breathing and other to his personal hygiene. Later
in the day, the man’s condition began to significantly deteriorate. His appetite
was poor and he slept for long periods of time. He was given pain relief as
necessary and closely observed by healthcare staff throughout the night.
71. At around 4.30am on 9 June, the man told staff he was feeling a little better.
Three hours later when nursing staff checked him to give him his medication,
the man could not be roused at first and was in a very poor physical condition.
When staff managed to wake him up, he was disorientated, confused and very
pale. He was also having difficulties breathing and experiencing pains in his
back.
72. The man was thoroughly assessed by nursing and medical staff and taken via
ambulance to North Manchester General Hospital (NMGH) where he was
admitted with a suspected pulmonary embolus (blood clot on the lung). The
prison contacted the man’s next of kin to inform them that he had been
admitted into hospital. The prison chaplain was also told of the man’s
deteriorating condition, and he subsequently contacted the man’s next of kin to
offer support.
73. The man was accompanied under escort to hospital by three prison officers. A
bed watch log was opened and staff regularly monitored him along with any
visitors he received. The hospital consultant informed the bed watch officers
that the man’s condition was deteriorating. The prison was informed and,
following a risk assessment, all escort chains were removed. In addition, the
searching of visiting relatives stopped until further notice. The escorting staff
number was also reduced to two.
Events leading up to The Man’s death
74. The man remained in NMGH and received treatment for a blood clot on the
lungs and his pain relief medication. Prison healthcare staff contacted the
hospital on a daily basis for updates on his condition. Family members visited
him each day.
17
75. On 19 June, the prison nurse visited the man. His condition was reported as
stable but, because of his prognosis, the hospital had allowed open visits for
the family. The man told the nurse that he had been seen by the McMillan
Nursing team and was informed that it was unlikely that he would return to
prison. His family were aware of this as they had visited him regularly since he
had been admitted into hospital. He was later moved to a private room.
76. On 22 June, for reasons of decency and dignity, a prison Governor authorised
that staff were to remain outside of the man’s room whilst his family visited him.
The bed watch staff continually maintained the bed watch log and repeatedly
commented on the polite manner of the man’s family during this difficult time.
As his condition continued to deteriorate, hospital staff began seeing whether
there was a possibility of transferring him to a hospice. The prison nurse kept
in regular contact with the man’s mother, offering support and keeping her
abreast of the situation regarding the hospice. The man continued to receive
palliative care during this time from hospital staff and the visiting McMillan
Nurses.
77. The prison chaplain visited the man on 24 June. He was still poorly but asked
the chaplain to pass on a letter of thanks he had written to staff and prisoners at
Manchester.
78. The next day (25 June), the prison nurse visited the man and his family in the
hospital. The man had been seen on the doctors ward round that morning and
the decision was taken that he would not be transferred to a hospice but nursed
on the ward due to his deteriorating condition. The man’s family were aware of
and content with this decision.
79. On 26 June, around 3.50am, nursing staff at the hospital contacted the man’s
family and informed them that his condition had further deteriorated. The family
immediately attended the hospital arriving at around 4.15am. They asked for
the prison chaplain to attend, and he arrived at 5.10am and offered support to
the man’s family. At 6.25am, hospital nursing staff confirmed that the man had
died.
After confirmation of The Man’s death
80. The prison was immediately informed of the man’s death and invoked their
death in custody contingency plans. This ensured that all the necessary
agencies were notified of his death. The Head of Healthcare and the prison
nurse were appointed as the prison liaison officers. The Head of Healthcare
told my investigator that she continually updated and offered support to the staff
in the healthcare centre following notification of the man’s death.
81. The prison nurse and the Head of Healthcare visited the man’s family at their
home following his death to offer support and to give the family as much
information as they could. Financial assistance was offered towards the funeral
expenses. The family visited the prison on 29 June to see the cell that the man
had spent his time in, and spoke to some of other prisoners who had known
18
him. The Head of Healthcare said the family were comforted by this visit. The
prison chaplain conducted the man’s funeral at his family’s request. The prison
nurse attended the funeral where she read out a poem for the man that had
been written by another prisoner.
19
ISSUES
Clinical Review
82. The clinical review conducted by the clinical reviewer was thorough and
detailed. Overall, she notes that the level of care that the man received was
appropriate and delivered with dignity and compassion. The clinical reviewer
concludes that the man’s medical problems were identified and acted upon in a
timely manner, and he was treated and offered palliative care at the Christie
Hospital. The clinical review makes seven recommendations and I refer to
those which are most pertinent in my investigation.
83. When the man arrived at Manchester, he provided the details of his past drug
misuse, his doctor in the community, and the Salford Drug Service where he
had received treatment. In spite of this, it took over a week for his permission
to be sought to contact them to gain details of his previous medical history.
This delay meant that staff were not fully aware of the man’s medical history
and, as such, any medical assessments at this time could not have been
comprehensive.
84. It is important when a new prisoner arrives in reception that healthcare staff
elicit as much information as possible to assist with decisions about their
immediate and secondary health needs. The quicker this is done, the more
appropriate and timely the level of treatment that can be given.
The Head of Healthcare should remind staff of the importance of
requesting timely medical information from community agencies with
which a prisoner has had contact.
85. In September 2008, the man attended hospital as his asthma had got worse.
He left hospital without a discharge letter being completed by NMGH. The
clinical reviewer comments that not receiving clear and concise discharge
instructions from an Acute Trust following any admission, and in particular
following an emergency referral, is poor practice and inevitably delays
treatment for the patient. The following recommendation was made in respect
of this failing:
The Head of Healthcare and NHS Manchester should work together with
local Acute Trusts to improve systems regarding the transfer of medical
and nursing information. In particular, that discharge detail is transferred
or shared in a timely fashion.
86. On 19 December, the man attended court and was sentenced to 12 years
imprisonment. Within PSO 3050 (Significant Events Affecting Prisoners’
Health), it states that:
“Events that require a prisoner to leave the prison and pass back through
prison reception can have a significant impact on the health of a prisoner.
Examples include Court appearance, sentencing in court.”
20
On his return to prison, the man was seen by a mental healthcare nurse in
reception. However, there was no documented evidence to suggest that the
man had been screened for any potential healthcare, or suicide or self-harm,
issues following his court appearance. It is important that such assessments
are clearly detailed and documented. I make the following recommendation:
The Head of Healthcare should ensure that prisoners’ healthcare is
assessed at reception and recorded in their medical record. In particular,
this should include screening for self-harm and suicidal tendencies
following a return from a court visit.
The man’s transfer back to HMP Manchester
87. Having transferred to Full Sutton, the man was soon diagnosed with cancer and
admitted to York Hospital. He was subsequently transferred back to
Manchester, although he was taken directly to the Christie Hospital. No
problems were encountered with his transfer to the Christie Hospital for
treatment, and there was excellent communication between the hospitals and
the Prison Service. Hospital follow up visits by the Head of Healthcare and the
prison nurse also demonstrated continuation of care and a compassionate
attitude towards the family. The transfer of the man to Manchester in light of his
prognosis made it easier for him to maintain contact with his family. I consider
this move wholly appropriate, compassionate, and in the best interests of the
man.
The Governor should commend all staff involved in arranging the man’s
swift transfer between York and the Christie Hospital.
88. After the man’s first cycle of chemotherapy, the Christie Hospital documented
and provided Manchester with dates for his second cycle chemotherapy
treatment. However, this was not documented in his medical record and
resulted in the man’s appointment being delayed by around one week.
89. The prison nurse had a lot of contact with the man and demonstrated a wealth
of nursing experience, especially in palliative care. The prison nurse said that
the man was offered a Macmillan Nurse but he declined the offer. She felt that
he had enough support from healthcare staff, including herself, in the prison
and that he was a ‘private man’ who did not wish to discuss his difficulties any
further. While I do not doubt that the man received good care, the evidence of
this is lacking in his prison records. It is important that palliative care patients
receive individualised care with ongoing assessments. References to the
McMillan Nurse were not detailed on the man’s care plans.
The Head of Healthcare should ensure that staff are made aware of the
importance of record keeping, in particular that appropriate information is
of a high quality and documented in a timely fashion on EMIS.
90. Prisons are necessarily a difficult environment in which to provide palliative
care, and I am pleased to note that the Christie Hospital provided detailed
information to both the prison and the man about managing his illness. One of
the concerns raised, however, was the monitoring of his temperature.
21
91. However, it was more difficult for nursing staff to check and monitor the man’s
temperature whilst he was located on an ordinary prison wing, especially during
the patrol state (when all prisoners are locked in cells). On one occasion, the
man’s temperature was not taken for this reason and this caused him some
concern. The man was aware of the consequences of being located on an
ordinary prison wing. However, it is right that staff should try to persuade
prisoners who have undergone chemotherapy of the difficulties that will be
encountered if they are not located in the healthcare centre.
92. The Clinical Reviewer notes that on two occasions when the man’s temperature
was taken the readings were abnormal in relation to the guidance provided by
the Christie Hospital and National Institute for Health and Clinical Excellence
(NICE) guidelines. However, nursing staff had described the readings as being
within normal parameters. The Clinical Reviewer confirms that staff should
have been concerned, and queries their up-to-date knowledge regarding cancer
treatment. Staff should be reminded that there are a number of useful
documents available on the Prison Health website.
93. The man returned for his second phase of chemotherapy treatment at the
Christie Hospital on 30 April. When he returned to Manchester later that day,
no concerns were raised. There was also no evidence on his medical records
to suggest a review of his care plans was carried out after his second
chemotherapy treatment.
94. Furthermore, of the two care plans that were created for the man in April 2009,
the Clinical Reviewer has found no evidence of them including any reference to
the emotional and psychological support that he may have required. In regard
to the assessment of his pain, the Clinical Reviewer notes that there is no
evidence of any pain assessment plans or protocols being used at HMP
Manchester. This was in spite of the fact that the man was on daily medication
to combat pain.
95. The prison nurse said that, although Manchester had pain charts (used to
assess levels of pain being experienced by a patient), they were not often used
and therefore information was not recorded. This also appeared to have been
evidenced when the man’s move to a normal wing was cancelled because he
was experiencing breathlessness and severe pain. The presumption in this
instance is that the man’s medication had been stopped in preparation for his
return to the prison wing, although as I have said earlier neither this nor
evidence of further care planning was documented.
96. Again, there does not appear to have been any contact with Macmillan Nurses
who could have offered advice in pain management and palliative care. The
clinical reviewer makes a number of recommendations relating to the terminal
care for prisoners at Manchester. These include ensuring healthcare staff are
up-to-date with current practice in offering palliative and end of life care to
prisoners.
22
The Head of Healthcare should ensure that appropriate palliative care and
pain control guidance is available for all medical and nursing staff to
enable the healthcare centre to keep up to date with current best practice.
The Head of Healthcare should ensure all nursing staff are adequately
skilled and have appropriate training with regard to palliative care and
pain management.
The Head of Healthcare should ensure that all prisoners admitted to the
healthcare centre have a nursing assessment completed, appropriate care
plans formulated, and that they are reviewed and revised as necessary.
23
CONCLUSION
97. The man was sentenced to 12 years imprisonment in 2008. He arrived in
prison with several pre-existing health conditions.
98. While in the custody of HMP Full Sutton, he was diagnosed with small cell lung
cancer, and returned to HMP Manchester so that he could receive specialist
treatment at the Christie Hospital. This was in the best interests of the man
who wished to be near his family whilst he was undergoing treatment.
99. Although the man received a good standard of care at both the prison and the
hospital, improvements could be made to processes at the prison. These are
the subject of the recommendations from the clinical reviewer. In particular,
recording of information and contact with external agencies should be
improved.
24
RECOMMENDATIONS
1. The Head of Healthcare should remind staff of the importance of requesting
timely medical information from community agencies with which a prisoner has
had contact.
The Prison Service has accepted this recommendation.
2. The Head of Healthcare and NHS Manchester should work together with local
Acute Trusts to improve systems regarding the transfer of medical and nursing
information. In particular, that discharge detail is transferred or shared in a
timely fashion.
The Prison Service has accepted this recommendation.
3. The Head of Healthcare should ensure that prisoners’ healthcare is assessed at
reception and recorded in their medical record. In particular, this should include
screening for self-harm and suicidal tendencies following a return from a court
visit.
The Prison Service has accepted this recommendation.
4. The Head of Healthcare should ensure that staff are made aware of the
importance of record keeping, in particular that appropriate information is of a
high quality and documented in a timely fashion on EMIS.
The Prison Service has accepted this recommendation.
5. The Head of Healthcare should ensure that appropriate palliative care and pain
control guidance is available for all medical and nursing staff to enable the
healthcare centre to keep up to date with current best practice.
The Prison Service has accepted this recommendation.
6. The Head of Healthcare should ensure that all nursing staff are adequately
skilled and have appropriate training with regard to palliative care and pain
management.
The Prison Service has partially accepted this recommendation.
7. The Head of Healthcare should ensure that all prisoners admitted to the
healthcare centre have a nursing assessment completed, appropriate care
plans formulated, and that they are reviewed and revised as necessary.
The Prison Service has accepted this recommendation.
8. The Governor should commend all staff involved in arranging the man’s swift
transfer between York and Christie Hospital.
The Prison Service has accepted this recommendation.
25