Individual at Belmarsh

Circumstances surrounding the death of a man at hospital,
In June 2008 while in the custody of HMP Belmarsh
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2010
This is the report of the investigation into the circumstances surrounding the death of
a man in hospital, while in the custody of HMP Belmarsh. He died from natural
causes at hospital in June 2008. He was 67 years old.
One of my investigators has undertaken the investigation. I would like to thank the
Governor of Belmarsh and his staff for their participation. Particular thanks go to the
liaison officer at the prison for making all the practical arrangements and providing
the necessary documentation.
The local Primary Care Trust was commissioned to undertake a review of the man’s
clinical care. A team undertook this review.
I would like to add my condolences to those already expressed by the investigator
and the Family Liaison Officer to his family and friends. I apologise for the delay in
publishing this final report.
The man who died was placed in the healthcare wing of Belmarsh prison when he
arrived into custody and remained there throughout his sentence. In April, he began
to refuse his medication and food, which this resulted in him being taken to hospital
to be rehydrated on 9 May. On 22 May, a multidisciplinary review concluded that he
did not have the mental capacity to make decisions about his intake of food and
fluids. The following day, he was re-admitted for observations. While in the care of
the hospital, medical staff noted a problem with his left leg and, following
assessment by a surgeon, the decision was taken to amputate the leg. The
operation was carried out on 29 May. Following the amputation, his condition
deteriorated and he was located in the hospital’s high dependency unit where he
later died.
I make no recommendations in relation to prison procedures but I endorse the
recommendations made by the clinical review team relating to various aspects of his
medical care at Belmarsh and note their view that the delay in referring him to
hospital between 21 and 23 May might have contributed to the events, which led to
his death.
The man’s family were concerned not to have been told of his deteriorating health. It
was said that he was reluctant to have contact with them and it seems that the prison
did not tell them that he had been admitted to hospital because of security
considerations. I have asked the prison to consider how information is shared with
the families of those with deteriorating mental health.
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.
Jane Webb
Deputy Prisons and Probation Ombudsman March 2010
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CONTENTS
Summary
The investigation process
HMP Belmarsh
Key findings
Issues
Recommendations
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SUMMARY
The man was sentenced to 18 months imprisonment on 4 January 2008 and taken to
HMP Belmarsh. He was 66 years old and had never been in custody before.
When he arrived at Belmarsh, a nurse conducted a medical health screening.
During this assessment, the nurse identified that he had problems with walking and
had for some years had been diagnosed with mental health problems. As a result,
she recommended that he be located in the healthcare unit so that a further
assessment of his medical condition could take place. No other referrals were made
at this time.
The man remained in the healthcare unit between January and April 2008 apart from
one night on a residential wing. On that night he had a panic attack and was moved
back to healthcare. During this time, the prison’s mental health team, who had
obtained his previous treatment history, saw him regularly. He was given his
medication daily and complied with the regime. He would often move around the
unit with the aid of a Zimmer frame and talked openly with staff.
However, in mid-April, the man began to refuse his medication and also declined
food and fluids. This continued over time, in spite of frequent staff encouragement to
eat, drink and take his medication. He complained of deterioration in his physical
health, telling staff that he was constipated, unable to swallow and that his body was
shutting down. The mental health team also saw him on a regular basis and, as his
condition became worse, they referred him to an outside psychiatric hospital in an
attempt to obtain a bed for him. He continued to refuse his medication and food and
his physical health deteriorated further. It is recorded that he drank small amounts of
water or tea with the encouragement of staff but would then continue to refuse.
On 9 May, the man was taken to the hospital to be rehydrated, returning to the
prison the same day. At the hospital, he was also diagnosed with acute tonsillitis
and prescribed a course of antibiotics. However, on his return to the prison he again
refused all medication, food and fluids. The mental health team attempted to get a
bed for him under the Mental Health Act but were informed that further information
was required before anything could be offered.
Blood tests taken on 21 May indicated that, because of the man’s continued food
and fluid refusal, his renal function had become worse. The following day, a
multidisciplinary review was held and staff concluded that he did not have sufficient
mental capacity to take decisions regarding eating and drinking. On 23 May, he was
again sent to the hospital for dehydration and, after assessment by a doctor, was
admitted. The doctor told escort staff that he expected him to be in hospital for at
least a few days.
While giving the man a bed bath on 25 May, a nurse noticed that his left foot
appeared bruised and that he had no sensation in it. The duty doctor diagnosed an
acutely ischaemic (poor blood supply owing to the blockage or narrowing of the
arteries) left leg which required amputation.
While he was in hospital, the man continued to refuse food, fluids and his condition
deteriorated. He was moved to the critical care unit as his condition became worse
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and was heavily sedated. On 29 May, he underwent the operation to amputate his
left leg. Nursing staff reported that he recovered better than expected, although he
remained unconscious and sedated.
Over the next few days, the man’s condition remained stable and he was moved
from the critical care unit to the high dependency unit. On the morning of 1 June
while a nurse was attending to him, he went into cardiac arrest. An emergency team
arrived immediately and they were able to stabilise him before moving him back to
the critical care unit.
The man’s condition did not improve and he did not regain consciousness. At
8.35pm, on 2 June, the heart monitor attached to him revealed there was no output
and at 8.40pm, a nurse informed the escort that he had sadly died. A doctor
confirmed his death at 8.45pm.
The clinical review team have made eight recommendations on healthcare matters
at Belmarsh, with which I concur. In particular, they concluded that the healthcare
provided to the man at Belmarsh was not equitable to that which he might have
received in the community and that the delay in referring his to hospital might have
contributed to the events which led to his death. One of the recommendations
relates to the concerns of his family that they were not told of his deterioration in
health and subsequent admission to hospital.
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THE INVESTIGATION PROCESS
1. Notices informing both staff and prisoners of the investigation were issued on 4
June. They invited anyone who had information about the man’s death to
contact the investigator. No responses were received to the notices.
2. The investigator telephoned the prison on 10 June and arranged for the man’s
prison and medical record to be made available to him. The investigator then
reviewed all the available documentation.
3. Greenwich PCT was commissioned to conduct an independent review of the
medical care that the man received in custody at Belmarsh. This was carried
out by a team led by a clinical reviewer. She was asked to consider all the
clinical issues, including those raised by the family. She visited Belmarsh on a
number of occasions in late 2008 and early 2009 to interview healthcare staff
and managers who had been responsible for the man’s care. Although the
delay in completing the clinical review is regrettable, I would like to thank the
clinical reviewer and her team for their report, which is attached in full as an
annex.
4. The man’s wife contacted the Prison Reform Trust to ask for my office to speak
to her. After several unsuccessful attempts to get in touch by telephone and
letter, the Family Liaison Officer contacted HM Coroner, who told her that the
family had engaged a solicitor and required all correspondence to be directed
to them.
5. The Family Liaison Officer contacted the family’s solicitor, who explained that
the family wanted to meet her and the investigator and that she was happy to
facilitate this at her offices. The meeting could not be held until September
2008, but in the meantime, the Family Liaison Officer asked the solicitor to
outline the family’s concerns. These are listed below:
• The failure of the prison authorities at HMP Belmarsh to inform the man’s
next of kin and family members of his decline in health.
• The failure to inform his family members that he was in hospital until
several days after he had been admitted.
• The healthcare that he received at Belmarsh.
• The delay by the prison in taking him to hospital for treatment.
6. The investigator visited Belmarsh on 18 September and interviewed six
members of staff who had dealt with the man prior to his death. Transcripts of
these interviews are attached as annexes to this report.
7. On 7 October, the investigator along with the Family Liaison Officer and the
clinical reviewer, met with the man’s wife and son, who were assisted by their
solicitor. The purpose of the investigation and the role of the Ombudsman were
explained. In addition, the investigator and clinical reviewer explained the
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areas that they would be examining and their initial concerns. The man’s family
reiterated their previous concerns.
8. The investigator contacted HM Coroner to inform him of the nature and scope
of the investigation and request a copy of the post mortem. The post mortem
concluded that the man’s death had been as a result of bilateral pneumonia,
pulmonary oedema (swelling) and acute renal failure following amputation
above the knee of his left leg. A copy of this report will be sent to the Coroner
to assist his enquiries.
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HMP BELMARSH
9. Belmarsh is a local prison located in Thamesmead, South East London.
Opened in 1991, it is one of three local prisons managed within the high
security prison estate. Along with remand and lower risk prisoners serving
relatively short sentences, Belmarsh also holds category A prisoners.
10. HM Chief Inspector of Prisons carried out a full inspection of Belmarsh in
October 2007. Following her inspection, she said of the healthcare at
Belmarsh:
”Health services were commissioned by Greenwich Primary Care Trust
(PCT) and, in the main, provided by the Prison Service through a
prison health delivery plan. A health needs assessment had been
conducted in February 2007. Clinical leadership was poor in some
areas, infection control was inadequate and there was lack of training
in resuscitation. Documentation and record keeping were inadequate.
Most primary care services were wing based and of a good standard
but prisoners complained that getting to see a GP was difficult. Mental
health services were good with excellent clinical expertise and
leadership and prisoners with primary mental health problems were
well served by the in-reach team. Inpatients all had care plans, time
out of cell for patients was good, but was dependent on the number of
discipline staff on duty. There were too few nursing staff to provide a
full range of therapeutic interventions.”
11. The Independent Monitoring Board (IMB) at Belmarsh published their annual
report in June 2007. (The IMB are volunteers who monitor the day-to-day life in
their local prison to ensure that proper standards of care and decency are
maintained. Prisoners can make confidential complaints. The IMB members
visit the prison regularly and require responses from Governors on any points
raised by prisoners.) The Board considered the prison to be performing well
and said of healthcare:
“The healthcare improvements continue through the NHS partnership
arrangements and the determination on the part of the staff to create a
hospital environment, although there have been some serious
shortcomings on occasions due to staffing problems.”
12. Since the Ombudsman took responsibility for investigating deaths in prison
custody in 2004, there have been five previous deaths attributed to natural
causes at Belmarsh. Following these deaths, a number of recommendations
were made. One of these is repeated in this report and relates to medical
record keeping not being consistent with recognised standards.
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KEY FINDINGS
13. The man who died was sentenced to 18 months imprisonment on 4 January
2008 and taken to HMP Belmarsh. On arrival, he, who was 66 years old at the
time, was assessed by a nurse in order to complete a first reception health
screen. He told the nurse that this was his first time in custody. When asked
about outstanding medical appointments, he told the nurse that he had mental
health problems and had been seeing a doctor at the Priory Hospital, Hayes.
He also said that he had an appointment booked for 16 January. He revealed
no other medical problems but did mention that he suffered from
claustrophobia. The nurse recorded that he also appeared to have some
mobility impairment. However, the form does not state whether he had any
other concerns about his physical health.
14. The health screen went into more depth about the man’s mental health and he
confirmed that he had previously been admitted to a psychiatric hospital for
treatment in 2006. He also told the nurse that he was receiving medication for
these problems and this was also recorded. Although the nurse completing the
health screen identified his immediate needs, sections of the screening forms
were incomplete.
15. The prisoner escort form (PER) completed by court staff was given to reception
staff at Belmarsh and indicated that the man had claimed to be feeling suicidal
following his court appearance. It also showed that an Assessment, Care in
Custody and Teamwork (ACCT) document had been opened as a result.
(ACCT is a process to identify, monitor and support prisoners at risk of self-
harm or suicide.) This document was not provided to the investigator and when
he enquired with reception and nursing staff he was told that one had never
been received. During the health screen, the nurse asked him if he had ever
tried to harm himself outside of prison. He said that he had attempted suicide
in 2006 but had not since. The nurse indicated on the screening form that he
had answered yes to feeling as if he might harm himself. However, conversely,
it is then written that he had no thoughts of self-harm or suicide at that time but
was concerned about his claustrophobia. No referrals were made to any other
services as a result of the reception screening. It was also noted that the nurse
completing the health screen referred to his appearance as “mad professor”.
(Although the nurse might not have intended this to be derogatory comment, I
do not consider it to be appropriate.)
16. The man’s concerns over his claustrophobia were shared with the discipline
department at Belmarsh who informed the escort service that he would require
special transport to attend any future court appearances.
17. Following the health screen, the man was located on the healthcare wing to
allow further information to be obtained from his community general practitioner
(GP) and the Priory Hospital in relation to his health needs. He was also
referred to the prison GP for further assessment.
18. Once in the healthcare centre, the man was spoken to again by a nurse who
completed an in-patient’s admission form. (It has been impossible to identify
the nurse who completed this process as the forms were not signed.) As well
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as recording his mental health problems, the nurse recorded an assessment of
how he appeared at the time of his admission:
“… Appears low in mood, poor eye contact, states due to the shock of
being in prison especially being first time his appetite is currently poor.
Denies any self-harm or suicidal ideation. States he sleeps about four
hours a night. Describes visual and auditory hallucinations, hears
voices from his former employee who was murdered …”
19. The nurse also recorded that the man’s blood pressure was 151/94; the normal
range is 120-140/80. His physical illnesses were recorded as asthma, heart
disease, high blood pressure, high cholesterol and joint problems on his right
hip. Although not registered disabled, he had special requirements and used
walking sticks to aid his balance.
20. As part of the man’s reception onto the healthcare wing, a nurse produced a
care plan on 7 January, outlining the reasons for his admission. The plan also
set out the goals for both the nursing staff and himself and the interventions
required. They were:
Goals
• To be nursed in a safe environment.
• To reduce or prevent the risk of self-harm and or suicide.
• To carry out a holistic individual assessment and risk. Reduce anxiety
and establish rapport with him and optimise his physical and mental
health.
Intervention
• Clinical staff to establish a therapeutic relationship with him.
• Clinical staff to encourage one to one interaction with emphasis on
allowing time for him to ventilate his feelings/anxieties in a safe
environment.
• Clinical staff to offer support and adopt a non judgemental approach.
• Clinical staff to administer medication as per prescription chart, record
and observe for any side effects.
• Staff to encourage participation in constructive activities i.e.
association/exercise.
• Any violence or aggression must be dealt with as per prison service
management of violence procedures.
• Regular blood pressure checks and regular reviews by GP.
21. A psychiatrist working at Belmarsh assessed the man later that day. He
recorded that he had a history of severe depression and the first recorded
instance was in 1962. The man confirmed that he had been seeing a doctor at
the Priory Hospital privately since September 2007. He had last seen him on
21 December and was due to be seen again on 16 January. When the
psychiatrist asked about thoughts of self-harm or suicide, the man said that he
had no such current thoughts. The psychiatrist concluded that he presented as
a softly spoken elderly man who was mobile with walking sticks and a bent
posture. He complained of asthma during the assessment and also requested
earplugs as he would usually sleep for a few hours during the day. The
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psychiatrist recorded that he should remain in the healthcare centre and his
outside GP should be contacted for his previous medical notes.
22. A nurse recorded in the man’s medical notes that, during the afternoon of 7
January he appeared isolated and withdrawn, sitting separately on the ward
and not talking or interacting with other prisoners. He was eating and drinking.
Over the next few days, he continued to settle into the regime, collected his
meals and medication as required and began interacting a little more. On 9
January, he was prescribed a nasal decongestant after being diagnosed with
chronic rhinitis.
23. On 10 January, the psychiatrist received a letter from the doctor at the Priory
Hospital. The letter set out his contact with the man and provided some
background and medical history. He concluded that:
“... Diagnostically I think he probably has what would be classified as a
personality disorder with recurrent adjustment difficulties. His
presentations with the latter include quasipsychotic symptoms.
Throughout his contacts with NHS mental health services a diagnosis
of a psychotic illness has never been made ...”
24. The psychiatrist assessed the man again on 15 January. He spoke about the
spirit of an ex-colleague that had been visiting him before and after he came
into prison. He said that he found his talks with his ex-colleague both
comforting and supportive. However, he asked the psychiatrist whether he
could have his evening medication later, explaining that he slept better and the
spirit of his ex-colleague did not appear. The psychiatrist noted that he should
be assessed for a Zimmer frame to aid his mobility. He also referred to his
appearance. The man submitted a letter which said:
“... I would hereby wish to notify your presence that all my life it has
been my ambition to grow and sport a bushy beard. But unfortunately
due to a busy working life style in my herbal practices I had not been
able to do so.
Hence I am now serving at HM Belmarsh for the first time in my life
ever. I feel that I have my opportunity to fulfil my wish ...”
25. The man also asked for permission to alter his appearance. He gave the letter
to an officer who explained to him that he was at liberty to do so. He told him
that, although there are restrictions on prisoners who are subject to the higher
levels of security, they did not apply to him.
26. The Zimmer frame was provided on 18 January and the man became more
mobile with the aid of this and his walking sticks. During the remainder of
January, he raised no cause for concern amongst staff and the entries in his
medical record refer to him being stable in mood, taking his medication as
required and sleeping well. He also attended association periods (part of the
day when prisoners are unlocked and are able to make phone calls, or play
games such as pool, board games or just watch television) but it was recorded
that he kept to himself.
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27. During a review on 30 January, the man told the psychiatrist that he spent his
time reading books from the library and writing. He also said that the officer
had encouraged him to ask for categorisation. (All sentenced prisoners are
given a security category assessed on the offence and risk they pose to the
public. There are four security categories, A, B, C and D with A being those
prisoners considered to pose the greatest level of risk and D being those
suitable for open prison conditions.) He said that he hoped to move to an open
prison. However, due to outstanding court appearances, which the investigator
was told were in relation to a confiscation order, he was categorised as C and
therefore remained in closed conditions. He had submitted an application form
on the same day to support his request to be considered for open conditions.
The psychiatrist concluded that in his opinion he was suitable to be located on
a residential unit, but the GP should be consulted first regarding his fitness to
move.
28. A prison doctor saw the man on 4 February. She recorded that he had
undergone some investigations into a heart complaint at St Thomas’ Hospital,
four years earlier, but had been discharged back into the care of his own GP.
She recorded that his main problems now appeared to be anxiety and panic
and was happy for him to be monitored by the mental health team at Belmarsh.
The doctor saw no medical need for him to remain in the healthcare centre.
Following his assessment by the GP, a nurse recorded in his medical record
that he was to be discharged to a houseblock but would require a cell on the
lower level due to his mobility difficulties and either a nurse or officer to take his
medication to him.
29. The man moved to a houseblock on 5 February. However, during the early
evening on 6 February, wing staff became concerned as he appeared to be
experiencing a panic attack. A nurse went to the wing and assessed him in his
cell. She recorded that she was unhappy for him to remain on the wing and
explained this to the prison doctor. As a result, he moved back to the
healthcare centre for overnight observations.
30. The following day, a second psychiatrist reviewed the man. He told the
psychiatrist that he had had a panic attack in the houseblock the previous night.
He described how his cell mate had gone out and he had felt very anxious. He
said that everything had gone dark, he was gasping for air and could feel his
heart racing. He added that he had also had the same symptoms the previous
night (5 February) but with less intensity and that he had slept very little while
on the houseblock and found it difficult to breathe. The psychiatrist spoke at
length with him about the visual apparitions he had experienced. He told the
psychiatrist that he wished to be in the healthcare centre if possible but he did
not want to come across as someone who was not “compliant” with authority.
31. The psychiatrist explained that admittance to the healthcare centre was for
prisoners who were severely unwell, or had a mental illness. He told the man
that the first psychiatrist would be asked to review him but he would remain in
the healthcare centre for the time being.
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32. Over the next month, the man’s mental state was recorded as settled and he
complied with his medication regime. The GP prescribed a course of antibiotics
in mid-February for an infected toe but no other issues were recorded. At the
end of February, he reported that he had had a migraine for three days. His
symptoms were recorded as throbbing temples and nausea but he said that he
had no visual symptoms. He told the nurse that he regularly suffered from
migraine particularly when stressed, and he had been feeling stressed since
being on the houseblock. He went on to say that he felt better on the
healthcare centre. Paracetomol and diazepam were prescribed for the next two
days. His headaches improved and, apart from being prescribed some cream
for dry skin, no further problems were reported by him during February.
33. The second psychiatrist conducted a further assessment at the end of
February. He recorded that the man had said that he had been experiencing
anxiety symptoms such as sweating, butterflies in his stomach and his heart
was racing. He said that he had not had any further panic attacks since
returning from the houseblock. He told the psychiatrist that before he came into
prison he had been prescribed paroxetine (an anti-depressant drug) but was
now receiving fluroxetine (another anti-depressant) that did not agree with him.
He agreed with the psychiatrist that he would only take diazepam at night for
seven nights and the psychiatrist arranged for a course of paroxetine to be
started. He also recorded that the man should be encouraged to go to the day
centre to increase his interaction with others.
34. In March, the man was reviewed by the psychiatrist but apart from continued
concern about being located onto a houseblock no other issues were raised.
He told the psychiatrist that he was hoping to be released on Home Detention
Curfew (HDC) in May. (HDC allows prisoners serving between three months
and under four years early release from prison to serve a maximum of 90 days
in the community, subject to a curfew, wearing an electronic tag.) Although he
did not go to the day centre, he regularly attended association and interacted
with fellow prisoners.
35. On 17 March, the man submitted an application for the foreign national co-
ordinator at Belmarsh to visit him. He said that he required advice on his
immigration status and residence in the UK. The application form notes that he
was seen on 18 March, but does not indicate by whom or what advice was
provided. When the investigator asked the discipline department at Belmarsh
about immigration issues, he was told that nothing had been recorded. He had
not at this time had any correspondence from the UK Border Agency (UKBA).
36. At the end of March, the man was seen by a nurse after reporting further
headaches for which he was prescribed paracetomol. He also saw a nurse in
relation to passing blood for two or three days. He told the nurse that he had
been diagnosed with haemorrhoids in the past and was taking lactulose (an
oral medication used for treating constipation). He said that he had been
constipated over the last few days but was no longer so. The nurse advised
him to continue with the lactulose and referred him to the doctor the following
day. However, there is nothing to indicate that the follow up appointment took
place.
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37. On 2 April, the man asked to see the doctor as he had abdominal pain. The
nurse recorded that he had asked for Gaviscon (indigestion treatment) and
lactulose recently. He told the nurse that he had previously been taking
omeprazole (used to treat heartburn and other gastric problems). He was seen
the same day by the GP who gave instructions for omeprazole to be added to
his medication.
38. The first psychiatrist also saw the man on 2 April for a further psychiatric
review. He recorded that he was coping well on the ward but still felt anxious at
times and had difficulty sleeping. He told the psychiatrist that he had been
seen by a probation officer who was working on his HDC and that he would be
eligible on 22 May or sooner. He asked the psychiatrist if he could continue to
take diazepam and the other medication until his release and they discussed
the risk of becoming dependent. The psychiatrist concluded that he should
remain in the healthcare centre as he was unlikely to cope on the houseblock.
39. For the next few days, the man was recorded as being settled and taking his
meals and medication as required. On 5 April, he refused his aspirin and asked
the nurse to check his cholesterol levels. The nurse advised him to discuss his
medication with the doctor. On 7 April, the prison doctor explained the risks
and benefits of taking aspirin and omeprazole and he agreed to resume taking
it. Over the next couple of days, it was recorded that he had been asleep in the
evening when his medication was due; therefore it was given to him by the day
staff to avoid him missing his dose.
40. The discipline department at Belmarsh received a letter on 10 April from UKBA
who asked for a form to be passed to the man to provide information on his
immigration status. Staff passed the letter to him the same day. He completed
it as required and added a detailed, six page letter setting out his reasons for
coming to the UK and why he considered he should be given leave to remain.
He explained that his permanent home had been in the UK since November
1960. Also, he was likely to face persecution if returned to Iran and he had no
family living there. His response was faxed to UKBA on 11 April.
41. On 11 April, the man asked to speak to the psychiatrist as he felt as if he was
having panic attacks at night. He also asked for medication to relieve irritable
bowel syndrome (IBS). The first psychiatrist saw him the same day and
recorded that he was complaining of claustrophobia at night. He told the
psychiatrist that when he was at home he would often go to his garden to
relieve these symptoms. He asked to continue taking diazepam and the
psychiatrist agreed.
42. The man’s abdominal discomfort continued and the prison doctor examined him
on 16 April. The doctor recorded that he was experiencing bloating and pain
especially after eating anything apart from potatoes and bread. He told the
doctor that this was a recurring problem and he did not feel that the medication
was effective although his bowels were working properly. Over the next few
days, he continued to take his meals and medication but spent resting on his
bed. On 20 April, a nurse recorded that he did not appear very alert. His blood
pressure and pulse were taken and he was advised to drink fluids. The nurse
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discussed his condition with the doctor who advised that he should be seen at
the surgery the following day.
43. A doctor saw the man the next day. He said that he had not felt well for around
two weeks and had a poor appetite. The doctor recorded that he had “very
retarded and slow speech”, looked depressed and was experiencing other
symptoms such as headaches and anxiety episodes. The doctor advised that
his weight should be checked weekly, prescribed medication for his bowel
problems and noted that the outcome of blood tests was awaited. He also
commissioned a review of the severity of his depressive illness.
44. A nurse recorded that the man was feeling ill on 22 April. He told her that he
felt rather low, isolated and lonely since he was not receiving visits from home.
The nurse reassured him and made him comfortable. The following day a
Senior Nurse recorded that he had refused his treatment and was offered
medication to relieve his constipation but he replied that no treatment was
effective for him.
45. Later that afternoon, another nurse found the man kneeling on the floor. At
first, he would not speak. Eventually, he said that he felt unwell but said little
else. He told the nurse that his “tongue had dropped” but the nurse recorded
that his tongue appeared normal and he was able to speak. He refused to
allow the nurse to check his blood pressure, saying that he was not well
enough. The nurse offered to help him onto his bed but he declined any help.
The nurse recorded that he did not complain of any other pains but had been
refusing his medication. A message was left for the doctor.
46. The doctor assessed the man later that day, noting that he was sitting on the
floor and refusing to move. He told the doctor that he could not swallow and his
bowels were still not moving. The doctor recorded that he was depressed and
believed that he was dying. His throat was red and he had not taken any
medication (including that provided to relieve his constipation) for the previous
two days. The doctor wondered whether he was dehydrated and if he had
been taking fluids. He therefore instructed that his fluid intake be monitored
over the next few days; blood tests carried out and referred him to a
psychiatrist.
47. Later that evening, the man told nursing staff that he had a diazepam tablet in
his possession. He was asked to find it and, after checking through his
property, he produced eight tablets which were disposed of. It was recorded
that he should be given diazepam in liquid form in future. His medical notes
indicate that he would occasionally make a noise to gain the attention of staff
and asked for diazepam and paracetomol. These requests were refused.
48. The psychiatrist saw the man the following day. He told the psychiatrist that he
had been storing his medication so he could take it when he needed to help
him sleep. He also said that he needed six milk drinks a day and the
psychiatrist suggested that he should eat normal food. The psychiatrist
recorded that he appeared rather confused and slow during the assessment.
15
49. The same evening, nursing staff recorded that he appeared confused and was
not responding to verbal discussion. He was given his evening medication.
During the night he was observed sitting on his toilet for long periods and
hanging his head over his sink. It was recorded that he was very unsettled,
unable to sleep and looked very distressed.
50. The following morning, 25 April, a nurse recorded that the man seemed
confused and slow when being spoken to. He appeared distant and unable to
comprehend what was being said. Nursing staff attempted to take a blood
sample but he would not allow them to do so. They continued to encourage
him to allow the test to be done. He eventually agreed, but in spite of attempts
the nurse was unable to take any blood. He declined his medication during the
morning despite nursing staff encouraging him to do so. The doctor was
informed. A urine analysis was also carried out that indicated no glucose in his
urine and a trace of ketones (when fat is broken down by the body, for example
if there are no carbohydrates or the individual has been fasting).
51. A nurse spoke with a doctor later that afternoon and gave him the results of the
urine analysis and the observations taken earlier. The doctor told the nurse
that he would prescribe some lactulose as the man had said he had been
constipated for about a week. It was recorded that his blood pressure should
be monitored over the weekend and he should be reviewed on Monday 28 April
at the surgery. An enema was prescribed later that day.
52. On Saturday 26 April, a doctor assessed the man and recorded that treatment
with the enema should continue for the next two days. The next day, the GP
was able to persuade him to have his third prescribed enema and he also took
his medication. Despite this, his medical notes show that he was still confused
and not eating or drinking adequately. At 5.00pm, a nurse recorded that he
seemed very confused, repeatedly banging on his door and taking out bits of
food from his bin to feed imaginary birds. The nurse also recorded that some of
the other prisoners on the ward tried to help him into bed. Nursing staff were
able to persuade him to take his medication and he had two cups of water. The
night staff noted that he did not sleep at all that night, became increasingly
agitated and confused and should be seen by the doctor first thing on Monday
morning.
53. The following morning the man was reportedly very lethargic and unable to
move without assistance. The doctor saw him later in the day and recorded
that he was confused. With encouragement, he took his medication as
prescribed on that and the following day.
54. During the course of the investigation, the investigator interviewed a number of
staff who had known the man, including a HCO. The investigator asked the
HCO about the decline in the man’s health during April and whether it was
apparent. She replied that the decline had been “very rapid” and there were
occasions when staff were able to encourage him to take his medication.
However, this was not easy and she and other staff would also spend time
trying to persuade him to sip water. She said that when he first came onto the
unit he would attend the chapel regularly, but he suddenly stopped and he
16
seemed to take to his bed. He would not talk to anybody, take his medication
or care for himself.
55. Another Healthcare Officer (HCO) recorded that on 30 April, despite persistent
offers of help and persuasion, the man continued to refuse his medication. In
view of this, as well as his refusal of food and drink and his continuing
confusion, a care plan was put in place to minimise the risk of dehydration. The
interventions planned were for staff to monitor his dietary intake, using a fluid
and diet chart, for him to be encouraged to eat and drink and for the
seriousness of poor diet to be explained to him.
56. The food and fluid chart indicates that over the next two days the man
continued to refuse all meals and medication, spending the majority of his time
lying on his bed. He told staff that his organs were shutting down and that he
could not swallow. He was assessed by a doctor on 2 May. He told the doctor
that “my organs have wrapped around my spine, everything has shut down.”
The doctor assessed that he was not dehydrated, his throat was alright and
blood samples taken appeared normal. He concluded that he was suffering
from a depressive illness.
57. A visiting consultant forensic psychiatrist reviewed the man later that day,
during which he told the psychiatrist that he was “severely depressed”, his
muscles had seized up, he had painful kidneys, acid in his stomach and was
unable to talk. He told the psychiatrist that the psychiatric medication was
making him worse. He also told the psychiatrist that he was “shocked about my
life” and “about my sentencing”. He said that “I got 99 years for something as I
am a foreign national” and mentioned that he was to be deported. (It is not
clear what he had based his views on, but I have found no evidence that he
had received any further correspondence from UKBA other than the initial letter
mentioned earlier.)
58. The psychiatrist concluded her assessment by recording in the man’s medical
notes:
”... the man appears to be depressed. An organic cause has been
excluded by the GPs but in view of his age I am concerned that there
may be an organic component to his presentation. He is unwilling to
have psychotropic medication at present but is willing for physical
monitoring and energy drinks in the meantime ...”
59. Later that afternoon, the man drank 200mls of water but continued to decline all
food and medication. On 4 May, a nurse recorded that he continued to refuse
his medication despite encouragement from staff. The nurse said that he was
offered a nutrition drink but said he was unable to swallow it. She noted that
she was very concerned about his appearance and presentation and would ask
the GP to see him. The GP assessed him during the afternoon and had a
discussion about his reasons for not eating or drinking. He is recorded as
replying”what’s the point”. The GP explained that because he was unable to
provide a urine sample to check his renal function, a blood sample was needed.
Again he replied “what’s the use”. The GP asked him to consider allowing a
17
blood test. Over the following few days, he continued to refuse both food and
medication in spite of encouragement.
60. On 7 May, the man was continuing to refuse his medication, food and fluids and
he was assessed by the first psychiatrist. He told the psychiatrist that he had
not eaten for three weeks and was only drinking water. He said that the
medication gave him stomach cramps. He told the doctor that he was worried
about moving to a houseblock. He had recently been advised that he was
ineligible for Home Detention Curfew (HDC) and was therefore likely to remain
in prison for more than 18 months. (Without HDC, his release date would have
been October 2008.) He also discussed his concern that he was likely to be
deported, although no such decision had been made. He was encouraged to
drink fluids, which he agreed to, and the chart shows that he drank 750mls over
the remainder of the day.
61. The following day, 8 May, a healthcare management review took place,
attended by a number of doctors and nursing staff. The man was not present.
The review recorded that his thoughts about deportation had had a detrimental
effect on his mental health. It seems that the prison made no attempts to clarify
his immigration status. Information supplied to the investigator shows that the
UKBA had proposed on 22 April that he should not be deported, taking account
of the grounds submitted by him in his earlier supporting letter. This
recommendation had not been communicated to him.
62. The man agreed to allow nursing staff to take blood samples and they were
sent for analysis on 9 May. He was also seen by the GP who recorded that,
due to his continued refusal of food and almost all fluids, he required
rehydration. He was therefore taken later that afternoon to the emergency
department at hospital where he was given one litre of saline over a two hour
period. He was also diagnosed with acute tonsillitis and prescribed a course of
penicillin before being discharged back to the prison.
63. The food and fluid chart is not completed for 10 May but it shows that the man
ate some ice cream on 11 May and also accepted 500mls of water. There are
also no entries on the chart for 12 and 13 May. However, the medical record
states that he had refused meals and medication. He was seen drinking water
from his sink. On 13 May, staff managed to encourage him to have porridge
and also his morning medication. The psychiatrist spoke with him later in the
morning after a visit with his solicitor. He told the psychiatrist that his solicitor
had said his case was difficult with reference to deportation, but he did not
clarify what he meant. When the psychiatrist asked about his refusal to eat or
drink he replied,”it doesn’t matter” and that food got stuck in his throat.
64. The following day, the psychiatrist wrote to the ward manager at Chelsham
House, Bethlem Royal Hospital. He explained about the man’s past mental
health problems and his more recent behaviour. He expressed his concern
about the man’s mental health and asked the hospital to assess him with a view
to admission to the local mental health inpatient unit.
65. The man continued to refuse food but did tell nursing staff that he was drinking
and was observed doing so. He also continued to refuse his prescribed
18
medication. Although spending much of the time lying on his bed, he was also
seen walking around the ward and standing for long periods. On 16 May, he
told a nurse that he had chest pains. The nurse examined him and recorded
that the smell of his breath indicated that he had not been drinking enough.
(When someone has not been eating or drinking enough, ketones produced by
the body can be smelt on the breath.) The nurse contacted the doctor, who
had seen him at lunchtime and would review him again the following day. The
visiting consultant forensic psychiatrist also attempted to review him later that
afternoon but he refused to be seen. The psychiatrist recorded that there were
ongoing concerns regarding his physical state, particularly his level of
hydration.
66. On the morning of 17 May, the man refused to go to a family visit and also
refused food and medication. When the doctor reviewed him later, he recorded
that he remained convinced that his “body is not working”. The doctor recorded
that he was becoming dehydrated again following his rehydration at hospital
eight days earlier. Over the next three days the pattern of refusing fluids, food
and medication continued. The doctor also continued to liaise with Adult Social
Services in the community to try and have him assessed.
67. A nurse assessed the man on 20 May. She recorded that, despite
encouragement, he continued to refuse all efforts to get him to eat or drink. He
agreed to have his blood pressure taken, but he declined to have his weight
checked. The nurse advised him to think about having intravenous fluids
administered in the healthcare unit. He replied that he would refuse to agree to
this.
68. The nurse and doctor discussed the blood results sent back from hospital. The
doctor said that she was not satisfied with the sodium levels and had spoken to
a specialist at hospital. The doctor asked for a further blood test as a matter of
urgency the following day and said that, if the sodium levels did not improve,
the man would need to return to hospital. The nurse explained to him that he
would have to make the effort to drink fluids. He is recorded as taking 150mls
of water that evening, but continued to refuse food and medication.
69. During the early morning of 21 May the man was observed urinating on the
floor of the ward. Staff gave him a bath and changed his clothing. Blood
samples were also taken and sent to hospital as instructed by the doctor. The
nurse recorded that staff should follow up the results as soon as possible and
report them to the doctor.
70. The psychiatrist received a message on 21 May stating that the man had not
been allocated to a named hospital consultant as there were discrepancies with
his address. The doctor spoke with him that afternoon and confirmed his
address details.
71. At 7.45am on 22 May, the man was found on the floor in a sitting position.
Nursing staff recorded that he had no apparent injuries and did not complain of
any pain. He walked to his bed with assistance. (There are no incident reports
relating to this event in his medical record.) The psychiatrist was informed later
that morning that his referral for him had been forwarded to Gresham
19
Psychiatric Intensive Care Unit. A multidisciplinary meeting between the
mental health team and the doctors took place later that day. They concluded
that the man did not have the mental capacity to make decisions about food
and fluids. They also recorded that “matters are in hand to transfer him under
the Mental Health Act as soon as possible”. Any psychiatric treatment provided
was likely to require him to be in a good physical condition and therefore his
physical health would be their initial priority.
72. At 2.00am on 23 May, night staff saw the man lying on the floor near his bed.
The staff member acting as Oscar 1 was notified and the ward was opened to
allow access. (During the night, Oscar 1 is the radio call sign assigned to the
person in sole charge of the prison, who carries keys and has access to all
areas of the prison.) Staff went into the ward and helped him back onto his
bed. They recorded that there was a strong smell of ketones and they tried to
engage him in conversation, but he did not respond although he was
conscious. He was checked for any injuries but nothing was observed. (Again,
there are no incident reports or injury report forms relating to this incident.)
73. Later that day, the man was taken to hospital again to be rehydrated. He was
initially seen in the emergency department where it was confirmed that he had
acute renal failure secondary to dehydration. He was admitted for observation.
As with his previous admittance to hospital, he was escorted by two members
of staff and “double cuffed”. (Double cuffing refers to two sets of handcuffs
being used. One set is applied to the prisoner’s wrists and one cuff of the
second set is attached to the prisoner and the other to one of the escorting
officers.)
Treatment at hospital from 23 May until 2 June 2008
74. After the man’s admission to hospital, a doctor told the escort staff that he was
likely to remain in hospital until at least Monday 26 May. He was moved to a
ward at 11.10pm and had a settled night. Restraints remained in place
although they were reduced to an escort chain. (An escort chain is used when
a prisoner is confined to bed or if they require the use of a toilet while on escort.
A single handcuff is attached to the prisoner and a length of chain connects this
to another worn by an officer. The escort chain allows more freedom of
movement for the prisoner and makes it easier for nursing staff to administer
treatment.)
75. The following day, the man continued to refuse food. He would not respond to
questions form doctors, nursing staff or the escort officers. The consultant
treating him confirmed to the escort staff that he thought it likely that he would
remain in hospital for three or four days.
76. During the morning of 25 May, the man continued to ignore the escort officers’
questions as to whether he wished to have any water or food. At 10.40am
while a nurse was giving him a bed bath, she noticed that his left foot was
swollen and appeared bruised. She told the escort staff that it felt cold and that
he had no sensation in it. The nurse brought this to the attention of the senior
nurse on duty who said that she would notify the doctor. The escort staff
recorded that during the bed bath the man was very resistant to the efforts of
20
the nurses and told them to leave him alone. During the afternoon, a doctor
examined his foot and told the escort staff that he might have a blood clot. He
did not cooperate during the examination. A blood sample was also taken.
77. The investigator interviewed an officer who had been part of the escort on 25
May. The officer said that the doctor had asked the escort staff how long the
man’s foot had been in that condition. The officer told the doctor that they were
unaware of any problem until the nurse had examined him. The officer told the
investigator that the man had not mentioned any problems with his foot prior to
the nurse examining him. He said that he had continuously encouraged him to
eat and drink but he did not respond to his requests. During the night, he
remained settled and staff recorded no concerns.
78. The following day, the officer was on duty again and continued to encourage
the man to take food and fluids. He explained the consequences of refusal but
he still had nothing to eat or drink. The second officer recorded on the
bedwatch log that both bedwatch officers spoke to the nurse to express their
concerns for the man. When the investigator asked the first officer about their
concerns, he said that both officers felt that staff were not being proactive in
deciding what was going to happen to him. He told the investigator that nursing
staff had mentioned the possibility of amputating his leg. However, when they
asked about it, the nurses said that the decision would be made by a doctor
and that, due to the bank holiday weekend, only locum doctors were on duty.
79. During the afternoon, a duty doctor examined the man and told the escort staff
that no decision about the amputation or a mental health admission would be
made until at least the following day. He remained settled during the day but
continued to refuse food and fluid.
80. On 27 May at 10.00am, a nurse was again giving the man a bed bath. She told
the escort staff that she was concerned about his left foot which appeared to
have changed colour from the previous day. The nurse reported her concerns
to the senior nurse. A doctor assessed his foot and diagnosed acute ischemia
of his leg. Escort staff were told that his leg would require amputation above
the knee as soon as possible. The operation could not be carried out until he
was assessed by the intensive care doctor and anaesthetist to ensure that he
was fit enough. The escort staff reported to the prison that they had been
asked whether his next of kin would be able to attend the hospital to sign the
consent forms.
81. One of the escorting officers, a Senior Officer (SO), recorded that medical staff
had been with the man for most of the morning carrying out various tests to
prepare him for the operation, although there was still no indication when it
would take place. At 12.45pm, the duty governor at Belmarsh took the decision
that all restraints were to be removed from him. The investigator asked the SO
why the restraints were removed at this point. The SO explained that when he
arrived on duty the man was still attached to the escort chain and he felt that it
was hindering the nurses in their attempts to administer treatment. The SO
contacted the prison to obtain permission for the restraints to be removed.
21
82. At 5.40pm, nursing staff told the SO that a woman was outside the ward and
asking to speak with prison staff. The SO went to the visitors’ room and was
introduced to the woman, who showed identification that she was the man’s
wife. The investigator asked the SO to give details of their meeting. The SO
said that he explained that she would be allowed to see her husband. He
wanted to make her aware that his appearance might have changed from when
she last saw him. The SO said that she was very upset. He told the
investigator that she explained that she had attempted to see her husband
three times while he was at Belmarsh, but he had refused to have visits, which
was why he felt it was important to tell her that his appearance might have
changed. He asked her to place all the items in her pockets into her handbag
and accompanied her to the ward.
83. The SO told the investigator that as the man’s wife entered the ward she
shouted something like “that’s not my husband”. She fell backwards, but he
caught her and nearby nursing staff gave assistance. They sat her on a chair
next to her husband’s bed and gave her some water.
84. The SO also told the investigator that the man’s wife took his hand but he tried
to pull his arm away and get out of bed. The SO told him to stay in bed but he
continued to become more agitated. He explained that after about six minutes
he asked the man’s wife if she would leave the room while they spoke to her
husband, which she agreed to do. He and the other officer then asked him if he
was happy for his wife to be present. The SO told him to signal to them if he
could not speak. He indicated that he did not wish his wife to stay. (The
investigator asked how he was to signal and the SO told him that he moved his
hands once for ‘yes’ and twice for ‘no’.
85. Once the man had indicated that he did not wish his wife to remain in the room,
the SO went outside and told her that they felt she might be causing her
husband distress. He asked if she wished to return to the visitors’ room and
offered to ask the surgeon to come and speak with her. The surgeon, in the
presence of the SO, told her that her husband’s leg would have to be
amputated. The SO said that he had not given her this information as he did
not feel it was his place to do so.
86. The man’s wife then left the hospital. The SO told the investigator that when he
returned to the ward, the man was still attempting to get out of bed. Nurses
were asked if any medication could be provided to calm him down but they said
that there was nothing they could give him. The SO said that he decided to
place the handcuffs back on him to prevent him from hurting himself in his
attempts to leave his bed. He said that they remained on for around one and a
half hours until the night staff came on duty and he was placed on an escort
chain. At 10.45pm, he was moved to the critical care unit where he was
assessed by a doctor in order for a central line to be inserted into his neck.
(The line enables medication and fluids to be administered.) Following this
procedure he had a settled night.
87. When the escort staff changed the following morning, 28 May, the restraints
were not reapplied to the man because of his location in the critical care unit
22
and his poor condition. During the morning, a nurse passed a message to him
from his wife who had telephoned the ward.
88. Prison staff told the UKBA on 28 May that the man was seriously ill and had
been admitted to hospital. The UKBA senior caseworker began to work on a
proposal to support the earlier recommendation not to deport him whilst waiting
for further medical information to strengthen the case.
89. A doctor told the escort staff that the man would be taken to the operating
theatre as soon as the clot in his leg had cleared. The doctor asked the officers
whether details of his previous medical history and any current medication
could be provided. The escort staff telephoned the prison and a little later, a
Senior Nurse went to the hospital and spoke with medical staff in the critical
care unit about his previous history.
90. At 10.25am, the Governor told the escort staff that, following a request from the
nursing staff, they could leave the man’s bedside. They went to a side room
where they were still able to see him. At around 1.00pm, a nurse told the
officers that he had opened his eyes but appeared to be unaware of his
surroundings. Shortly afterwards the staff asked the nurses to attend as he had
become aggressive and had to be restrained to prevent harm to himself. A
doctor administered medication to calm him down. He was visited by his wife
and son later in the afternoon and the son discussed his father’s prognosis with
nursing staff.
91. On 29 May, the escort staff were told that it was hoped that the man would be
taken to theatre for his operation before lunch. He remained unconscious and
heavily sedated. He was initially taken to the theatre at 11.40am but returned
to the ward as the medical team were not ready. He went back to the theatre at
1.50pm, had the operation and returned to the critical care unit at 4.00pm.
Nursing staff told the officers that he was doing better than they had expected,
although he remained on a ventilator and unconscious. His wife telephoned the
hospital during the evening and was reassured by a nurse that her husband
was doing well.
92. It is recorded on the bedwatch log that the man had a settled night after his
operation. His condition remained the same the following morning and at
4.40pm he was moved from the critical care unit to the high dependency unit.
He remained unconscious and nursing staff provided constant monitoring. The
escort staff remained away from the bedside but were still able to see him. At
7.48pm, the escort staff moved back to the side of the bed at the request of the
nursing staff.
93. Over the next couple of days, the man’s condition remained stable. His family
telephoned the hospital on a number of occasions for updates on his condition
and he continued to receive constant care from nursing staff. On 1 June, a
ventilator was attached to help remove carbon dioxide from his body. It
remained in place for around two hours during which time he woke up briefly.
In the afternoon, the doctor placed him back on the ventilator and he remained
unconscious.
23
94. During the evening, the ventilator remained in place and nursing staff monitored
the man constantly. The ventilator was removed at 11.30pm and a doctor
attended but was unable to gain any response from him. The ventilator was re-
applied at 2.00am. At 7.24am, he went into cardiac arrest while being attended
by a nurse. An emergency team and doctor arrived and they were able to
stabilise him at 7.38am.
95. At 8.40am on 2 June, the man’s son came to visit along with his wife and
daughter-in-law, but his father remained unconscious. He was moved back to
the critical care unit at 12.20pm and again attached to a ventilator. A nurse told
the escort staff at 6.44pm that his condition had not improved since his cardiac
arrest earlier in the day and that he might die soon. The nurse contacted his
family at 7.50pm to tell them that he had been placed on dialysis as his kidneys
had stopped functioning properly.
96. The escort staff changed shift at 8.00pm and at 8.35pm, the officer recorded
that the heart monitor attached to the man showed no electrical activity in the
heart. At 8.40pm, a nurse informed the escort that he had died. A doctor
confirmed his death at 8.45pm.
Events following the man’s death
97. Nursing staff telephoned the man’s wife to break the news of his death. She
arrived at the hospital, along with her son and daughter-in-law, within 30
minutes.
98. The man’s wife had written to the prison on 31 May when it became clear that
her husband was going to have his leg amputated. She asked what care the
prison would be able to provide for her husband following his operation and
asked about the treatment he had received at Belmarsh.
99. The Head of Healthcare at Belmarsh received the letter on 3 June, the day after
the man’s death. He responded in writing offering his condolences. He
indicated that it would be inappropriate to respond to her questions as a review
of her husband’s medical care would now take place.
100. The Governor also responded to the letter on 5 June. He again expressed his
condolences and reiterated the points in the earlier response from the Head of
Healthcare. The Governor advised the man’s wife that the prison would be
able to assist with financial support for funeral costs if she wished, and provided
contact details.
101. The man’s son contacted a governor at Belmarsh, who had been appointed as
the prison family liaison officer, to discuss financial support. The governor
reaffirmed that the prison would like to contribute and thanked the man’s son
for providing the costs from the funeral directors. He explained that it was
normal practice for the prison to contact the funeral directors to confirm the
costs before payment could be made. The man’s son told the governor that it
was his family’s wish that the prison did not contact the funeral directors as the
family did not want them to know that his father had been in custody. He said
that if the prison had to confirm the costs with the funeral directors, then he
24
would rather the prison did not contribute. The governor said that he
understood their concerns and agreed that the prison would therefore not
provide any financial assistance. The governor told the man’s son to contact
him if they changed their mind.
102. The family told the investigator of their discussion with the prison regarding
financial assistance. He spoke with the Governor who explained the situation
regarding costs but agreed that the prison would be willing to contribute without
the need to contact the funeral directors. The Governor asked the investigator
to pass on this offer to the family which he did during his meeting with them on
7 October 2008. Following the issue of my draft report I was informed by the
prison that a payment was made to the man’s family on 31 October towards the
funeral costs.
25
ISSUES
Clinical care
103. A review of the man’s medical care was undertaken by a team led by a clinical
reviewer, of the local PCT and a comprehensive report produced. I have
summarised the team’s findings below and endorse the recommendations,
which have been slightly recast.
Reception screening
104. The clinical review found that the medical screening process had been
inadequate and ineffective in establishing the man’s past and existing physical
and mental health problems.
105. Large parts of the First Reception Health Screen form were incomplete,
including the disability questionnaire. The inpatients admission form was
unsigned and undated. The clinical reviewer says in her report that this raises
particular concerns about the section of the form that the patient is supposed to
sign to give their consent to treatment. She also highlighted the inappropriate
description of the man during his screening process and considered it could be
viewed as derogatory.
The Prison Service in partnership with Department of Health should
review the First Reception Health Screen form and amend it as necessary
to make it more precise.
Offender Health should introduce a single assessment process for older
people following the guidance in ‘A pathway to care for Older Offenders’
(Tool kit for Good Practice).
In response to my draft report, the Prison Service highlighted that the First
Reception Health Screen is a national document in use across the service. In
response, I have recast the recommendation as an issue to be dealt with
nationally.
Mental health
106. The man had a long history of mental health problems. The psychiatrist
obtained a summary of his previous history and treatment and made a referral
to Bethlem Royal Hospital to admit the man under the Mental Health Act.
107. The clinical review confirms that the man was reviewed by the mental health
team at Belmarsh on a weekly basis and that the assessments were thorough.
I endorse the following recommendation in relation to mental health referrals:
The Prison Service and Department of Health should review the process
for transferring a patient to a secure mental health unit. At present, an
outside assessment is required which might delay the process
considerably.
26
In response to my draft report, the Prison Service said that it was not clear what
concerns had led to the above recommendation being made. The
recommendation was made as a result of the clinical review and the team’s full
report was attached to my draft report. In addition, the Prison Service said that
the problems with transferring under the Mental Health Act are a national one. I
acknowledge this and have recast the recommendation as an issue to be dealt
with nationally.
Physical health
108. Thamesmead Medical Associates provide the primary and general medical
care at Belmarsh. The clinical review found that there was no clear evidence
that an adequate and effective physical history had been obtained. It also
established that while the man’s food and fluid intake was being monitored, the
charts were not completed in full every day.
109. The clinical review team interviewed the Head of Healthcare, who explained the
difficulties in monitoring such aspects of health care. He told them that “health
care staff could not always gain direct access to a prisoner over the 24 hour
period”.
110. In relation to the man’s moves to hospital, there was no evidence of any delays
on either occasion. However, although the blood tests taken on 21 May were
reported back later that day and indicated that his renal function was
worsening, he was not referred to hospital until two days later on 23 May. The
clinical review team concluded that the delay referring him might have
contributed to the sequence of events that followed, resulting in his death in
June. This is clearly a matter of great concern and the Governor and Head of
Healthcare will wish to ensure that no other prisoners suffer as a result of
delayed responses to medical tests.
The Head of Healthcare should review the procedures for receiving and
acting on urgent medical test results.
111. The review team said that there is evidence that healthcare staff assisted the
man with his personal hygiene, yet they did not report anything unusual about
his physical or mental health while they were assisting him.
Equitable care
112. The clinical review team did not comment on the care provided to the man
while at hospital as this was outside the remit of the investigation.
113. The team found no evidence of any appointments being cancelled by either the
prison or external care providers. However, given the inadequacy of the initial
screening as well as the subsequent monitoring of his food and fluid intake; and
the delay in sending him to hospital following the deterioration in his renal
function, they concluded that some of the care that the man received in the
prison was less equitable than that which he might have expected in the
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community. (Recommendations on these matters have been made within the
report.)
Documentation/standards of record keeping
114. The clinical records presented to the clinical review team did not appear to
consistently meet recognised standards and they were concerned to read
inappropriate comments entered on the First Reception Medical Screening
form.
The Governor and Head of Healthcare should introduce a computer based
record keeping system to ensure that information is available to all
relevant staff, can be easily read, and that the person entering the records
can be identified.
Communication
115. The clinical review team found that the standard of record keeping was
insufficient to ensure that effective communication took place between the
different parts of the prison or the multidisciplinary team. The team were
unsure whether appropriate information was passed between relevant
professionals and this might hamper the work of the multidisciplinary team.
The Governor and Head of Healthcare should implement a review and
update of multidisciplinary working practices and procedures where
necessary.
In response to my draft report, the Prison Service asked for clarification on
which multi disciplinary team and professionals are being referred to in the
previous paragraph. It is my understanding from reading the clinical review that
the team were referring to all staff that were responsible for the man’s care
when they refer to ‘multidisciplinary’. In relation to ‘professionals’ I believe this
to refer primarily to those doctors both inside and outside of the prison sharing
information. The review refers to information from health care professionals
outside of the prison not being acted upon thus hampering the work of the
multidisciplinary team and leading to delays in treatment.
Physical environment
116. The man was 66 years old when he first arrived at Belmarsh. Both discipline
and healthcare staff interviewed by the clinical review team expressed their
concerns and described his vulnerability in terms of mobility, physical and
mental health and how these factors contributed to the impact of his
imprisonment.
117. The doctors working at the prison reported a lack of resources in terms of
equipment and appropriate clinical environments to conduct medical
examinations.
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The Head of Healthcare should review the equipment and facilities for
primary care and where necessary update them in line with ‘Good Medical
Practice for Doctors providing Primary Care Services in Prison.’
In response to my draft report, the Prison Service asked how the physical
environment might have contributed to the man’s death. While I acknowledge
that, it is not possible to draw, a direct link between the two it is significant that
the clinical review team concluded that his care was not equitable to that which
he may have received in the wider community.
Family concerns
118. The man’s family were concerned that the prison had not notified them of the
decline in his health and his transfer to outside hospital. During the course of
the investigation, the investigator was told by staff that he had said that he did
not wish his family to be told, but there is no documentary evidence to support
this. The clinical review team also reported that during their interviews with
staff there appeared to be a widely held belief that he did not wish to have
contact with his family or for them to be informed of his deteriorating health.
119. When the clinical review team interviewed the Head of Healthcare, he said that
the decision to inform family members of a hospital stay lies with the security
department due to security risks. He also said that healthcare staff are not
allowed to make direct contact with prisoners’ families. While I accept that the
need for security is paramount, I would consider it unlikely that passing on
information relating to a prisoner’s health, with their consent, would pose a
security risk.
The Head of Healthcare should review the policies and procedures for
sharing information with families of prisoners with deteriorating mental
health.
Liaison with the UK Border Agency
120. The correspondence sent to the man by the UKBA was passed to him quickly
and he was able to respond accordingly. However, as his condition
deteriorated during April and May, it was recorded during medical reviews that
the possibility of deportation was having a detrimental effect. It was also noted
on his care plan that this issue should be clarified. Despite this, there is no
indication or evidence to suggest that Belmarsh contacted UKBA for an update
on his case.
121. While I acknowledge that he had a number of other issues, I believe that
clarification or at least an update on his immigration status would have provided
reassurance. The information supplied to the investigator clearly shows that a
proposal not to deport the man was made as early as 22 April. Equally, this
proposal was not reported to Belmarsh by UKBA.
122. The prison updated UKBA on 28 May, reporting that the man was seriously ill
and had been admitted to hospital. Unfortunately, Belmarsh did not inform
UKBA of his death and they only found out in September when they contacted
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the prison regarding progress on his case. I am aware that the prison has
procedures in place for dealing with immigration issues and make no formal
recommendation on this. However, the Governor might wish to remind staff
that all relevant information should be sought from and shared with the UKBA.
Escort arrangements at hospital
123. The use of restraints when escorting sick or dying prisoners is an issue that the
Ombudsman has commented on many times during investigations. The man
was escorted to hospital twice. On both occasions, he was escorted by two
members of staff and handcuffed to an officer. A risk assessment had been
carried out which indicated that as a category C prisoner, restraints would need
to be used and there were no medical objections to this. The level of restraint
on the first visit to hospital seems to have been appropriate and on the second
visit, the level was initially the same. When it was apparent that he was to be
admitted, the escort staff reduced the level of restraint to an escort chain.
124. The escort chain remained in place until 27 May when the decision was made
to remove all restraints from the man. However, after a short period they were
reapplied as he became confused and attempted to get out of bed. On 28 May,
the escort staff were advised that they need not remain at his bedside. They
positioned themselves away from the bed, yet able to maintain security,
allowing medical staff easier access and provide him with more dignity. A
manager from the prison reviewed the risk assessment and staffing
arrangements regularly while he was in hospital.
125. The man’s family expressed some concern to the investigator about the
presence of prison staff at the hospital and their conduct. I have looked at the
documentation relating to the bedwatch and it appears that staff were efficient
in recording all events. It is also evident from both the documents and
interviews with staff that they routinely tried to engage with him, encouraging
him to eat and drink and had expressed concern to the nurses about his care.
From the interviews and documents available, there is no evidence to suggest
that staff acted inappropriately at any time during their bedwatch duties.
Payment of funeral expenses
126. The policy regarding contribution to prisoners’ funeral expenses is set out in
Prison Service Order 2710. In line with requirements of the PSO, the prison
offered to contribute to the costs, but this was refused as the family did not
want the funeral directors to know that the deceased had been a prisoner.
Given the family’s reluctance for this information to be disclosed, the Governor
might wish to consider whether prison staff could have been more flexible in the
arrangements for payment in order to be consistent with the spirit of the PSO
guidance. I am pleased that, following the investigator’s interventions, the
Governor agreed to take a more flexible approach.
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CONCLUSION
127. The man was an older man who had been diagnosed for many years with
mental health problems. It was his first time in custody and, as mentioned in
the clinical review, his age and health issues made him particularly vulnerable.
Although initial medical documentation was not fully completed, he was placed
in the healthcare unit for a period of assessment.
128. The decline in both the man’s mental and physical health appeared to be quite
dramatic in mid-April 2008. While it is clear that efforts were being made to
attend to his mental health and to transfer him to a suitable hospital, the clinical
review team considered that his physical needs were not adequately
addressed. Although there were no delays in taking him to hospital, there were
delays in actually deciding to do so.
129. The healthcare provided to prisoners should always be equitable to that which
they would have received in the wider community. The clinical review team
concluded that the man’s care did not meet this standard and, on the evidence
provided, I concur with their view.
130. In response to the draft report, the man’s family said that they were happy with
the investigation process, and were keen for the inquest to take place. The
family added that they still felt, the actions of staff on the bed watch and the
levels of restraints used on him were of concern to them. The family
acknowledged that the investigation had raised these issues but would like
these matters considered during the inquest process.
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RECOMMENDATIONS
1. The Prison Service in partnership with Department of Health should review
the First Reception Health Screen form and amend it as necessary to make it
more precise. (National recommendation)
2. Offender Health should introduce a single assessment process for older
people following the guidance in ‘A pathway to care for Older Offenders’ (Tool
kit for Good Practice).
3. The Prison Service and Department of Health should review the process for
transferring a patient to a secure mental health unit. At present, an outside
assessment is required, which might delay the process considerably.
(National recommendation)
4. The Head of Healthcare should review the procedures for receiving and acting
on urgent medical test results.
5. The Governor and Head of Healthcare should introduce a computer based
record keeping system to ensure that information is available to all relevant
staff, can be easily read, and that the person entering the records can be
identified.
6. The Governor and Head of Healthcare should implement a review and update
of multidisciplinary working practices and procedures where necessary.
7. The Head of Healthcare should review the equipment and facilities for primary
care and where necessary update them in line with ‘Good Medical Practice for
Doctors providing Primary Care Services in Prison.’
8. The Head of Healthcare should review the policies and procedures for
sharing information with families of prisoners with deteriorating mental health.
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