Individual at Doncaster

Investigation into the circumstances surrounding the
death of a man a prisoner at
HMP Doncaster, in June 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2009
Final Report: Date: March 2009
1
This is a report into the death of a man at Doncaster Royal Infirmary on 16
June 2008. The man, a prisoner at HMP Doncaster, died from natural
causes. He was 49 years old.
I offer my sincere condolences to the man’s family and friends for their loss.
My Senior Family Liaison Officer, liaised with the man’s sisters during the
investigation.
I must thank Doncaster PCT for the appointment of the two clinical reviewers.
I am also grateful to the Director and staff of HMP Doncaster, especially one
male, whose assistance was a great support to my investigator.
As the man died from natural causes, the findings of the clinical review play a
critical part in my report. The review shows that the man received generally
good care whilst in Doncaster, although there were some shortcomings that
should be addressed.
I make five recommendations concerning record keeping, care plans,
communication with the local hospital, and to commend two members of staff.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2009
Final Report: Date: March 2009
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CONTENTS
Summary 4
The Investigation Process 6
HMP Doncaster 7
Key Findings 9
Issues 16
Recommendations 19
Final Report: Date: March 2009
3
SUMMARY
At the time of his death, the man was 49 years old and serving a 56 day
sentence at HMP Doncaster. He had arrived at Doncaster on remand on 13
May 2008. On arrival he was assessed as having pain in the head and back
of the left ear, and was taking paracetamol and ear drops. He had been seen
by the Ear, Nose and Throat (ENT) department at Doncaster Royal Infirmary.
Medical records were requested from the hospital by the doctor, the prison’s
General Practitioner.
The man was initially allocated on a general houseblock, but on 19 May
officers expressed concern that he was not coming out of his cell for meals,
and about his general feeling of being unwell. The next day the man was
assessed by the doctor who immediately referred him to hospital. The man
was returned to Doncaster the same day having had x-rays and blood tests,
both showing normal results. On his return the man was allocated a cell on
the healthcare unit where he remained until transferring to hospital on 16
June.
During his time on the Upper Healthcare unit, the man had daily medical
intervention. This involved assessing the man, seeking to address his
unwillingness to take food or fluids, and encouraging and assisting in his
personal hygiene. The man always took his medication, specifically ear drops
and antibiotics.
There were several occasions where the man had nose bleeds. On 31 May,
the man was again referred to hospital as a result of two nose bleeds, but
returned the same day following assessment. He had an appointment for an
ENT assessment scheduled for 7 July.
The man was released from Doncaster on 9 June but returned the next day
as a result of a conviction with an eight week sentence. He was screened by
reception and taken to Healthcare. Over the next five days the man remained
in his cell, and staff had continually to encourage him to eat and drink and
attend to his personal hygiene.
At 7.10pm on 16 June 2008, Prison Custody Officer (PCO) one, first checked
on the man and found him on the floor. PCO one called the first Nurse who
immediately responded. She found the man to be conscious but not
responding, and he was incontinent. She called for further assistance to
assess the man, and the third Nurse came from Middle Healthcare. It was
decided that that the man required urgent hospital treatment and a 999
ambulance call was made.
The ambulance arrived at 7.31pm, and the paramedics made an initial
assessment that the man had suffered a stroke. The ambulance left the prison
at 7.51pm, and the man was taken to Doncaster Royal Infirmary. He was
escorted by the second PCO and the third PCO. The man was single cuffed
(one cuff was attached to him and the other to an officer), but this was
removed immediately once at hospital in line with instructions. The man was
Final Report: Date: March 2009
4
placed on a life support machine following a Computed Tomography (CT)
scan (three dimensional x-ray) which showed that he was suffering from a
brain abscess.
At 9.30pm, doctors at the hospital confirmed that the man was brain dead. At
11.15pm, the life support was switched off.
The man had not informed Doncaster that he had any next of kin. However,
the hospital had found details of a relative in his medical record, and they
were contacted by hospital staff at 11.20pm. The man’s two sisters were with
him at his bedside when he died at 5.25am on 17 June.
Following the man’s death, Doncaster acted in accordance with Prison
Service Order 2710. A Family Liaison Officer was appointed who assisted the
family with arranging the funeral and returning the man’s property.
This report includes five recommendations. They mainly derive from the
clinical review and concern record keeping, care plans, and communication
between HMP Doncaster and the local hospital. Reflecting the views of the
man’s sisters, I have also commended the actions of two members of staff.
Final Report: Date: March 2009
5
THE INVESTIGATION PROCESS
1. My investigator visited Doncaster and spoke to staff who had had contact
with the man. The investigator interviewed six members of staff. Notices
were also posted to staff and prisoners about the investigation, inviting
contributions. No prisoners came forward as a result. In addition, the
investigator studied all relevant prison records relating to the man. These
included his main prison record, medical records and statements made by
staff. My investigator also visited his cell.
2. Doncaster Primary Care Trust asked two clinical reviewers to carry out a
review of the man’s clinical care. The investigator and the clinical
reviewers jointly discussed aspects of the man’s treatment with the
healthcare staff at Doncaster.
3. My Senior Family Liaison Officer contacted the man’s sisters about the
investigation. The man’s sisters had no specific matters they wished to be
considered by my investigator. However, while they had not seen the man
for quite some time, they did express concern over the amount of weight
he had lost.
Final Report: Date: March 2009
6
HMP DONCASTER
4. HMP Doncaster opened in 1994 and is a purpose-built category B male
prison, privately managed under contract by Serco Home Affairs. The
prison is made up of three houseblocks, each with four wings and has a
maximum capacity of 1,145 prisoners. Its principal function is as a local
prison serving the local courts in Merseyside and North Wales.
5. The provision of healthcare within Doncaster is the responsibility of Serco
Healthcare. The prison has a healthcare unit with provision for up to 29 in-
patients located on the second floor. The lower level is dedicated to the
delivery of primary care services. Resuscitation equipment, including the
defibrillator, is kept in the pharmacy room. A local doctor provides on site
cover 21 hours a week, and the prison employs two other part-time
doctors to provide a 24-hour service. Prisoners with more serious
conditions or clinical needs are referred to the local hospital. The mental
health in-reach team is from the Doncaster and South Humber Mental
Health Trust. It provides a service to a cluster of prisons in the area.
There are also three Registered Mental Health Nurses and a support
worker based in Doncaster. A clinical psychiatrist and a forensic
psychiatrist also attend the prison for regular sessions.
6. An unannounced inspection of HMP Doncaster took place in February
2008. Her Majesty’s Chief Inspector of Prisons, found that Doncaster
“had generally improved since our last inspection.” The report made the
following comments about healthcare provision:
“… we had significant concerns about healthcare: there was no needs
analysis, governance was weak, access to a GP and the dentist was
poor, and medicines management and inpatient services were
inadequate.
“Responsibility for the provision of health services had recently been
transferred to Serco Health. Many of the recommendations in the area
of healthcare had not been achieved, and there had been no progress
since the previous inspection. Nursing staff were seen by prisoners
and observed by inspectors to be helpful, and there were many good
entries in clinical records.”
7. The report made the following relevant recommendations:
“All health services staff, including allied health professionals, should
have annual resuscitation training, including the use of an automated
resuscitation defibrillator.
“All entries in clinical records should be written contemporaneously,
timed, dated and signed.”
8. The prison’s Independent Monitoring Board last produced a report in
September 2007. The report made the following relevant comments:
Final Report: Date: March 2009
7
“Although all services are not commissioned by the Local Primary Care
Trust, a close liaison is maintained with Partnership Boards and
Clinical Governance arrangements/support is in place, which is on
going.
“All allied services and consultants have access to dedicated
consultation rooms within the Healthcare Centre, and wherever
possible services are in place to assess and treat within Healthcare
Services. If referrals are requiring NHS facilities, prisoners are
assessed and referred by the Medical Officer to the appropriate service
and an appointment is facilitated upon receipt.
“Services are constantly being reviewed and client need is an essential
part of healthcare delivery.”
9. There have been five deaths from apparently natural causes at Doncaster
since May 2007. My investigation reports have included recommendations
concerning the standard of medical record keeping, and communication
with external services.
Final Report: Date: March 2009
8
KEY FINDINGS
10. The man was born in November 1958. He was single and declared to
prison staff that he had no family. In fact, he had a son and two sisters.
He was homeless but lived in and around the Doncaster area. The man
had a medical history of headaches and impetigo (skin sores).
11. The man was remanded into HMP Hull on 24 March 2008. Upon his
arrival he underwent a reception health screen (a routine health
assessment for all new arrivals into prison). At this assessment the man
said that he did smoke but did not use drugs or alcohol and had no
allergies. The man also said that he was not taking any medication, but
his throat became swollen on occasions when he was breathless. In
addition, he said he sometimes had ear wax and deafness but otherwise
was physically fit. He was not registered with a General Practitioner.
12. The next day the man was sentenced to 28 days in prison and was
transferred to HMP Doncaster following his court appearance. Another
first reception health screen was undertaken where no health issues were
identified. The man said he had no fixed abode, and no next of kin.
13. On 4 April, the man was released from prison, but returned to Doncaster
on remand less than a week later. Again a first reception health screen
was undertaken. The man repeated that had no fixed abode. He said that
he occasionally experienced chest pain. There were no other issues
raised as a result of the assessment, and no referral was made to the
prison doctor. The man signed the consent for medical information form
(authorisation from patient giving permission for outside medical
information to be provided to the prison).
14. Three days later the man had a Wellman screening (a check on his current
state of health and advice on reducing the risk of future illness). He told
the nurse he was a smoker, but had no alcohol or drug issues. He was
not taking any medication and had no known allergies. He again said he
had no next of kin.
15. The man was sentenced to another 28 days in custody on 24 April.
However, he was immediately released, presumably due to the time that
he had already served on remand.
16. On 13 May, the man was remanded to Doncaster once more. Again a first
reception health screen assessment was undertaken. The man said that
he had recently been seen at the Doncaster Royal Infirmary for pain to the
back of his head and left ear. As a result he had been prescribed ear
drops and paracetamol.
17. The next day the man was assessed by the prison doctor, who found that
the man had a pus discharge from his left ear. The Doctor identified no
other physical or mental health problems. He prescribed Otomise spray
Final Report: Date: March 2009
9
(for pain relief of outer ear infections) for the man’s ear, and Amoxicillin (an
antibiotic) and paracetamol.
18. Five days later the man was seen on his houseblock during medication
rounds. Officers had expressed concern about him not coming out of his
cell for meals. When asked why, he said that he did not feel like eating
and that he was unwell. He was referred to be seen by the prison doctor.
19. On 20 May, the man was seen by another prison doctor. The doctor’s
examination highlighted that the man was apathetic and dehydrated. The
man was sent to the Emergency Department at Doncaster Royal Infirmary
at 12.15pm with a letter from the other prison doctor stating his presenting
symptoms and current medication. The man returned from hospital at
3.30pm the same day and was admitted to healthcare. The results of the
x-rays and blood tests conducted at the hospital were normal.
20. The man began a three day assessment. The initial assessment,
conducted by a Nurse, recorded that the man was difficult to communicate
with and remained in bed all of the time. He needed encouragement to
eat, drink and attend to his personal hygiene.
21. The next day the man was reviewed by the doctor at 8.40am. The man
complained of a headache and sore right eye. The doctor assessed the
man as having an infection in his right upper eye lid and impetigo (skin
sores) on his lower lip and chin, with his chest being clear. The doctor
placed the man on antibiotics to include Fluclox (for treatment of impetigo).
He requested that the man be reviewed every six hours and for staff to
ensure intake of fluids, specifically Fortisip (a nutritional drink).
22. At 11.20am the man was seen by the Nurse during the medication round.
When asked why he had not eaten the man said that he could not
swallow. He was offered drinks which he accepted. He was asked to
provide a urine sample but said that he could not. A Nurse recorded that
the prison custody officers had been asked to complete the fluid input and
output chart and to encourage the man to take fluids. The Nurse took and
recorded the man’s blood pressure as 120/82 and temperature as 36.7C,
and gave him Fluclox and Fortisip in accordance with the doctor’s
instructions. The Nurse recorded that the man looked generally unwell
and was not getting out of bed.
23. During the afternoon the man was seen again by the Nurse. He was still
unable to give a urine sample and refused to eat food and the Fortisip
drink. He did take his medication with 100ml of water, and his blood
pressure was recorded as 117/82 and his temperature as 37C. The Nurse
encouraged him to eat and drink, and ordered soup from the main kitchen
for the man.
24. At some point during 21 May, the man was seen by another Nurse from
the Mental Health Team. The exact time was not recorded and a
retrospective entry was made in the man’s medical record which noted
Final Report: Date: March 2009
10
that he was reluctant to engage and simply wanted to sleep. He was
evasive and had pieces of paper in his ears. When questioned why, the
man would not respond.
25. Later that evening the man was seen by the Nurse. The man had taken
his medication with 150ml of water. He refused more water but did have
the Fortisip drink and some yoghurt. The Nurse took the man’s blood
pressure and temperature which were both within normal range.
26. The following day an overall summary of the man’s three day assessment
was completed by a Nurse. It recorded that the man was accepting no
food and little fluid, had no motivation and was low in mood. The first
nurse recommended that the man should be admitted to Upper Healthcare
for a longer period of assessment and to have a psychiatric assessment.
In addition, the monitoring of the man’s food and fluid intake, and of his
weight, was recommended. The man was the sole occupant of a cell with
twin beds, which was within a very short distance of all facilities.
27. At 4.35pm on 23 May, the man was reviewed by a third Doctor at the
request of the first doctor. The third doctor recorded that the man still had
discharge from his left ear and that he was in pain. The third doctor
prescribed Sofradex ear drops (for outer ear infection). In addition, the
third doctor noted that the man was eating very little and requested that his
weight be monitored.
28. Later the same afternoon a Nurse contacted Doncaster Royal Infirmary.
This was to obtain a faxed report of the blood tests and x-rays taken on
the man’s admission to the Emergency Department on 20 May. During
the same evening, in accordance with the fourth doctor’s instructions, the
sixth nurse recorded the man’s weight as 65kg.
29. On the morning of Saturday 24 May, the first main doctor conducted a
review of the man’s care in his cell on Upper Healthcare. The doctor
found him curled up in a ball, clutching his left ear which was discharging.
The doctor noted that the man’s condition had deteriorated and that he
had not taken fluids for 24 hours. The doctor referred the man to
Doncaster Royal Infirmary for assessment. He sent a handwritten letter
with the man to the hospital detailing his condition and fluid intake.
30. At 12.00 noon, the man was transferred by ambulance to Doncaster Royal
Infirmary. At 3.45pm the man returned to Doncaster from hospital. He
had been prescribed Sofradex ear drops and Amoxicillin antibiotics for his
ear infection.
31. The following morning at 9.15am, the doctor conducted a review of the
man’s care. The doctor again found him lying on his bed curled up with
his hand over his left ear and temple. The doctor observed that discharge
was still apparent from his ear. As well as continuing with the Sofradex
and Amoxicillin, the doctor prescribed paracetamol and Tramadol (for
treatment of moderate to severe pain).
Final Report: Date: March 2009
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32. The next day at 9.40am, the doctor saw the man again. He noted that the
man was a little better. The doctor was of the opinion that the man might
require an Ear, Nose and Throat Outpatients appointment. Later the same
afternoon the sixth Nurse saw the man and recorded that he had slept all
day, had to be encouraged to take fluids, and continued to decline food.
However, he did take his medication.
33. During the following day the sixth nurse made two entries in the man’s
records. The first, an un-timed entry, says that the man’s weight was 65kg
(the same as 23 May). The second, at 3.30pm, says that the man still had
to be encouraged to take fluids, and that he was still refusing food.
34. During Wednesday 28 May, the man was seen by another nurse from the
Mental Health Team. It was noted that he was reluctant to get up or open
his eyes, and was evasive when questioned.
35. Later the same day a seventh Nurse was called to Upper Healthcare to
attend to the man who appeared to have had a nosebleed. His nose had
by then stopped bleeding. His blood pressure was taken and he was
helped by staff to shower.
36. At 6.40pm an entry by the first Nurse noted that the man had remained in
his bed all day. He had had a nose bleed in the morning and another at
lunchtime (no other details were given) and had been assisted in having a
shower and changing his clothes. The man had pressure areas on each
side of his hip. He continued to refuse to eat and only drank fluids when
encouraged.
37. On Thursday 29 May, the man was due to attend Doncaster Magistrates
Court but was assessed as unfit to attend. It was arranged that he could
appear at court via video link, but the second Nurse noted that the man
only attended the video link following encouragement. During the hearing
he appeared uninterested and gave little acknowledgment when
addressed by the court. On being sentenced to 56 days custody the man
said, “At least I’ll have a roof over my head.” Following his court hearing
the man returned to his cell on Upper Healthcare.
38. The next day the man attended a hospital appointment (the nature of the
appointment is not in the record). The second nurse made an un-timed
entry in the record that the man was to continue with the ear drops for a
further week, and that staff were to ensure that his ear remained dry with
no use of water. The man was also to be discouraged from poking his
ears. A further appointment at the hospital was to be made in two weeks
time.
39. On Saturday 31 May at 5.45am, a nurse examined the man as he had a
nose bleed. There was blood on the floor and around the room, as well as
on the man’s face and hands. The man told a nurse that he had always
suffered from nose bleeds. He was assisted with his personal hygiene
Final Report: Date: March 2009
12
and his blood pressure was taken and recorded as 137/99. He was also
given clean bedding.
40. At 9.10am, another doctor examined the man who was again found lying
in his bed in a pool of blood. The doctor found him to be conscious but not
responsive. The man had no signs of discharge from his ears and there
were no obvious signs of head injury. The man’s blood pressure was
taken and recorded as 120/79. The doctor referred the man to the
Doncaster Royal Infirmary and wrote outlining his recent medical history.
41. During the same afternoon a nurse contacted Doncaster Royal Infirmary
for an update on the man. The hospital reported that there had been no
active bleeding from his nose and the man was being discharged with a
referral for an Ear, Nose, and Throat clinic appointment. At 2.00pm the
man arrived back at Doncaster from hospital.
42. On Sunday 1 June, the man was seen in his cell by another doctor. He
was responsive and the man said that he had drunk a cup of tea earlier
and would eat something later. That doctor requested that his food and
fluid intake be monitored. Later the same evening the sixth nurse
recorded that the man had to share a cell and he was not happy about
that.
43. The next day the first nurse recorded an entry at 6.30pm. This stated that
the man had minimal dietary intake and remained lying on his bed for the
biggest part of the day. The man was also seen by the local authority
housing officer regarding accommodation after his release, but he refused
to speak with her.
44. The man had another nose bleed the next morning. He was assisted in
having a shower. It was noted that his ear was improving and that he had
eaten all his lunch. The man was found to have two pressure sores on his
hips and these were dressed
45. In the evening of the following day, the first nurse recorded that the man
was feeling much better and that his ear had improved. He had taken
more food but needed to be encouraged to attend to his personal hygiene.
46. On Thursday 5 June, the man was seen by a visiting psychiatrist. The
psychiatrist recorded that he had seen the man in his cell and that he
seemed disoriented as to where he was but not as to the time. It was
noted that he was due for release in the immediate future and that a
referral to Social Services was required. The man was seen later in the
day by the sixth nurse who recorded there was no evidence of pressure
sores. The man had eaten a small amount of food but had remained in his
bed all day.
47. The next day the sixth nurse recorded that the man had to be prompted to
attend to his personal hygiene. He had eaten and drunk sufficient
Final Report: Date: March 2009
13
amounts throughout the day. However, he still remained in bed for most of
the time.
48. On 7 June, the first nurse recorded that the man ate and drank throughout
the day and his ear infection had improved. He told the first nurse that he
felt much better. The following evening the man was more settled and his
ear infection had cleared.
49. The man was released from Doncaster on Monday 9 June 2008.
However, on Tuesday 10 June he was sentenced to eight weeks in
custody by Doncaster Magistrates and returned to the prison. Following
initial assessment in reception the man was taken to Upper Healthcare.
The sixth nurse saw the man and referred him to be seen by the doctor the
following day.
50. The next morning the man was seen by the doctor. The doctor’s
assessment of the man was that his presenting condition did not
necessitate location in Healthcare. However, the first nurse was aware
that if the man was sent to a normal houseblock he would quickly be
returned to Healthcare. Therefore the decision was taken to allow the man
to remain on Upper Healthcare for a short period to allow him to be fit
enough for allocation to a normal houseblock.
51. Over the next four days the man remained in his cell all day. He had no
interaction with other prisoners. He refused food and drink despite
persistent encouragement from staff. He also needed to be encouraged to
fulfil all his basic personal hygiene needs.
52. On Monday 16 June, the man was seen in the morning by the local
authority housing officer but again he refused to engage. The first nurse
recorded this along with the detail that the man had only taken fluids. The
first nurse referred the man for a review with the doctor the next day.
53. At approximately 7.10pm, the first Prison Custody Officer (PCO) was
escorting the nurse dispensing medication on Upper Healthcare when he
went into the man’s cell. The first PCO found the man on the floor and
there was a strong odour emanating from within the cell. The PCO called
for assistance from the first nurse who was very close by. The first nurse
was able to assess that the man was conscious but incontinent of faeces.
The second nurse also arrived to provide assistance. The first nurse
requested the assistance of a Registered General Nurse from Middle
Healthcare to assist with the man’s assessment. This was done by
telephoning Middle Healthcare. The third nurse quickly arrived and, due to
the man’s position in the cell, it was decided to move him so that a full
assessment could take place. The two nurses along with the PCO moved
the man from the floor to a chair. After assessing the man, the decision
was taken to make a 999 call for an ambulance. The first nurse contacted
the gatehouse to make the 999 call. She then informed the on call doctor,
in line with prison policy.
Final Report: Date: March 2009
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54. At 7.31pm the ambulance arrived at Doncaster. The paramedics
suggested that the man might have suffered a stroke. The man was
escorted to hospital by two PCO’s. The order was given for him to be
restrained using a single restraint, to be removed as required by hospital
staff. The ambulance left Doncaster at 7.51pm.
55. On arrival at Doncaster Royal Infirmary, the man was taken straight to
resuscitation area and the restraint was removed by the second PCO at
approximately 8.00pm. At approximately 8.15pm, the man was taken for a
Computed Tomography (CT) scan (three dimensional x-ray). It was
discovered that the man had either a tumour or abscess on the brain. At
approximately 8.30pm, the man was placed on a life support machine.
The escort officers remained in regular contact at 30 minute intervals with
Doncaster providing updates on the man’s condition. The hospital doctors
made the assessment after two hours that the man was brain dead. At
around 11.15pm, hospital doctors turned off the life support machine to
allow the man to pass away naturally.
56. By 11.20pm, the hospital staff had located details of the man’s next of kin
from old records and contacted them to inform them of his condition. The
man had consistently said to staff at Doncaster that he had no next of kin.
At approximately 12.35am on 17 June, the man’s two sisters arrived at the
hospital. They told the escorting officer that they had not seen their
brother for several years. At approximately 1.50am, the man was moved
to a side room. The escorting officers showed great sensitivity by allowing
the man’s sisters to be at his bedside alone. They remained outside the
room with a member of the hospital nursing staff. At approximately
5.25am, hospital staff confirmed the man’s death.
57. During the day of 17 June, and in line with standard procedure, a debrief
was undertaken by senior management at HMP Doncaster. All staff who
had been directly involved with the man had support made available to
them. The man’s fellow prisoners on Upper Healthcare were told of the
man’s death by nursing staff.
58. Doncaster acted in accordance with Prison Service Order 2710. A Family
Liaison Officer was appointed who assisted the family with arranging the
funeral and returning the man’s property.
Final Report: Date: March 2009
15
ISSUES
Record keeping
59. Whilst at HMP Doncaster the doctors recommended that the man’s fluid
and dietary intake, weight, and blood pressure be checked and recorded.
60. There was no evidence found within the medical records that a food and
fluid intake chart was maintained, and other checks were not consistently
recorded.
61. Some of the records do not contain times of actions taken or have illegible
signatures. There are specific guidelines for doctors and nurses to
complete medical records. It is essential that all contact is recorded
accurately and chronologically to ensure there is an accurate and
continuous history of a prisoner’s needs and treatments.
The Head of Healthcare should ensure all healthcare staff are trained
and kept updated in the requirements of accurate and
contemporaneous recordkeeping in accordance with the required
standards of the General Medical Council and the Nursing and
Midwifery Council.
The Head of Healthcare should ensure that, when medical
interventions are requested or suggested, they are duly undertaken
and recorded in the individual’s medical record.
Relations with Doncaster Royal Infirmary
62. There were occasions following the man’s admission to hospital for
assessment when prison healthcare staff did not receive results or the
assessments undertaken. This was despite healthcare staff attempting to
obtain feedback from Doncaster Royal Infirmary. One reply was received
by Doncaster the day after the man’s death.
63. Follow up of treatment has been recognised by the prison doctors as an
area of concern. Health professionals at Doncaster are presently
considering the best method of addressing the problem. This issue was
also identified as part of the clinical review.
The Head of Healthcare, in conjunction with the PCT, should engage
with the hospital trust to put into place a robust communication
strategy in order that HMP Doncaster receives timely hospital
assessment information.
Clinical care
64. The first clinical reviewer, has highlighted a number of issues, in addition
to those of record keeping and interface between the prison and
Doncaster Royal Infirmary. He writes as follows:
Final Report: Date: March 2009
16
“Despite the man continuing to experience ongoing problems and
appearing not to respond to the treatment, the same antibiotic
continued to be used.
“No Swab results from hospital appointments were available within the
prison records.
“The man was prescribed ear drops that appear to have been given for
longer than was originally prescribed. Communication around this,
following hospital appointments was not clear.
“There is one recorded blood test that was conducted at Doncaster
Royal Infirmary but no other blood tests appear to have been
requested in relation to the man’s health needs.
“The man appeared to have significant nursing needs but there are
very few documents relating to the assessment of these needs and
minimal appropriate plans of care.”
65. In relation to the issue of equivalence of care (that is, that prisoner-patients
are entitled to the same treatment as someone in the community), the
clinical reviewer makes the following comment:
“This gentleman does not appear to have received a standard of care
that would have been equitable with that he would have received within
a normal primary care setting when care was being provided by a
General Practitioner supported by appropriate colleagues within the
hospital. Despite regular contact with healthcare professionals, the
man continued to experience problems that for a long time did not
seem to be responding to the treatments that were provided. The lack
of appropriate response to treatment did not prompt changes in the
therapeutic approach.”
66. I therefore endorse the following recommendation made by the clinical
reviewer:
It is recommended that healthcare staff review their care planning
process and documentation to ensure that all patients receive a full
assessment with adequately documented plan of care to meet all
their needs.
Actions taken by escorting officers
67. In their conversations with my Senior Family Liaison Officer, the man’s
family complimented the two escort officers for their professionalism and
sensitivity at such a difficult time.
The Director of HMP Doncaster should recognise the two PCOs for their
professionalism and sensitivity whilst escorting the man.
Final Report: Date: March 2009
17
RECOMMENDATIONS
1. The Head of Healthcare should ensure all healthcare staff are trained
and kept updated in the requirements of accurate and
contemporaneous recordkeeping in accordance with the required
standards of the General Medical Council and the Nursing and
Midwifery Council.
2. The Head of Healthcare should ensure that, when medical
interventions are requested or suggested, they are duly undertaken and
recorded in the individual’s medical record.
3. The Head of Healthcare, in conjunction with the PCT, should engage
with the hospital trust to put into place a robust communication strategy
in order that HMP Doncaster receives timeous hospital assessment
information.
4. It is recommended that healthcare staff review their care planning
process and documentation to ensure that all patients receive a full
assessment with adequately documented plan of care to meet all their
needs.
5. The Director of HMP Doncaster should recognise the two PCOs for
their professional and sensitive manner whilst escorting the man.
Final Report: Date: March 2009
18