Individual at Exeter

Investigation into the death of a man,
in January 2010, at Axminster Hospital
whilst in the custody of HMP & YOI Exeter
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2012
This is the report of an investigation into the death of a prisoner of HMP Exeter. He
died in January 2010. He died of cancer of the throat.
One of my family liaison officers contacted the man’s wife to explain the purpose of
my investigation. I would like to repeat the family liaison officer’s condolences to his
family. I hope my report addresses the questions the family may have.
The investigation was undertaken by one of my senior investigators. I would like to
thank the Governor of Exeter and his staff for their participation in the investigation.
A clinical reviewer was asked to undertake a review of the man’s clinical care. I
appreciate his assistance throughout the investigation process and his final report.
He found that the man’s care whilst in Exeter was good. He highlights some areas
around healthcare procedures in HMP Erlestoke that might be improved.
The clinical reviewer also comments on the circumstances of the man’s transfer
between Erlestoke and Exeter. I agree that the transfer could have been better
managed, although fortunately it does not seem to have had an impact on the man’s
ongoing treatment. I make three recommendations: two to Erlestoke about
explaining the procedures for compassionate release and urgent hospital referrals,
and one to Exeter ensuring that medical incidents during transfer are noted on the
records.
Both prisons sought specialist advice about the man’s care and made thoughtful
arrangements for his treatment. Compassionate release was considered, but
thought inappropriate, and I am pleased to see that minimal use was made of
restraints.
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.
Nigel Newcomen CBE
Prisons and Probation Ombudsman October 2012
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CONTENTS
Summary
The investigation process
The man
HMP & YOI Exeter
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was serving a life sentence, and had been in prison for some 20 years. In
June 2009, whilst in Erlestoke, he was diagnosed with cancer of the throat
(oesophageal). He developed pain in his foot in August and was referred to hospital
but, by the time he was admitted, his leg had to be amputated below the knee.
Staff at Erlestoke realised that the man and his family would require support, and
made some changes to his care. They began the process for applying for
compassionate release. It is not apparent, though, how clearly this was explained to
the man.
By September, the man needed to be in a prison which provided 24 hour healthcare.
Exeter was identified as being the most convenient for his partner (whom he went on
to marry whilst a hospital patient in Exeter) to visit, and the governors of the two
prisons spoke about the transfer and agreed it in principle. However, it seems that
there was a misunderstanding over the timing of the transfer. The man arrived at
Exeter on 17 September, only to find that the prison was not expecting him so
quickly. After urgent discussion with his staff, the Governor agreed that the man
could remain. No arrangements had been made for continuity of the man’s cancer
care with the local hospital, but fortunately they were able to continue with little
disruption to his treatment.
The man was initially allocated to a normal prison wing. But by mid-November his
health had deteriorated and he had to move to the healthcare centre. Staff worked
closely with specialists to ensure that he received the treatment he required. Special
arrangements were made for the man’s family to visit him in the healthcare centre.
In December, the man developed fluid in his abdomen and was admitted to hospital.
His condition deteriorated further and, by the end of December, he was extremely
unwell. He moved to the hospice in the Axminster Hospital for end of life care.
Arrangements were made so that the prison officers accompanying him did not wear
prison uniform. Medical staff at the prison remained in ongoing contact with the
hospital to monitor his condition until the man died.
I have found that the care the man received was equitable to what he would have
received in the community and some excellent individualised arrangements were
made at both prisons. I make two recommendations to Erlestoke, about explaining
compassionate release procedures to terminally ill prisoners, and urgent hospital
referrals. I also make one recommendation to Exeter about recording medical
incidents during escorts. Although I do not make a recommendation, the Governors
of both prisons will wish to ensure that any future transfers of prisoners with medical
needs are clearly arranged.
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THE INVESTIGATION PROCESS
1. My investigator was given full access to all the relevant records relating to the
man, including his prison and medical files. During the investigation he
visited Exeter and spoke to staff who had cared for the man. He interviewed
four members of staff, and these interviews were recorded.
2. The investigator also spoke to the Governor of Exeter. A note of the
conversation, which has been agreed by the Governor was also attached.
The investigator made himself available to the Prison Officers Association,
the Independent Monitoring Board and the chaplaincy had they wished to
speak to him. The investigator also corresponded with the Governor of HMP
Erlestoke concerning the circumstances of the man’s transfer from Erlestoke
to Exeter.
3. Notices were posted to staff and prisoners about my investigation, inviting
contributions but none were received. The investigator had access to
statements made by the staff after the man died.
4. The clinical reviewer was asked to carry out a review of the man’s clinical
care. I am grateful to him for undertaking this review. My investigator
discussed aspects of the man’s treatment both with healthcare staff at Exeter
and with the reviewer.
5. My investigator contacted Her Majesty’s Coroner to inform her of the nature
and scope of my investigation and request a copy of the post mortem report.
Upon completion, my report will be sent to the Coroner to assist her enquiries
into the man’s death.
6. One of my family liaison officers (FLOs) contacted the man’s wife. She told
her of my investigation and invited her and the man’s family to ask any
questions or raise any issues for consideration. The man’s wife said that, in
her opinion, her husband received excellent care at HMP Exeter. She asked
if my investigation could consider the care that the man had received at HMP
Erlestoke prior to his transfer to Exeter. She also asked if I would consider
the preparations for her husband’s transfer, and the application process for
compassionate release. I hope my report addresses the matters which the
man’s wife is concerned about.
5
THE MAN
7. The first conviction recorded for the man was in 1973. He had a number of
convictions, largely for stealing offences, although he had one conviction for
assault in 1981. He was sentenced to life imprisonment in 1989 and was
serving this sentence when he died.
8. The man formed several serious relationships with women who corresponded
with him during his prison sentence. Following the breakdown of one
relationship, his former partner complained that he had threatened her.
Security reports suggested that he had arranged for her to be assaulted.
9. The man married towards the end of his life. Having been due to marry in
prison, his admission to hospital caused a change of plan, and the wedding
took place in the hospital chapel.
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HMP & YOI EXETER
10. HMP Exeter was originally built in the 1850s as Devon County Jail. It has an
operational capacity of 537 and accepts adults and young offenders from
courts in Cornwall, Devon and West Somerset.
11. It has four residential wings, which are in a traditional Victorian layout,
emanating from a centre area. A and C wings hold normal prisoners mainly
in shared cells, while B wing is the first night accommodation and integrated
drug treatment system facility. D wing is a brick built, three-storey building,
physically separate from the main prison building, for vulnerable prisoners.
12. Facilities include an outdoor exercise yard, a gym and weights room, a
chapel, a library and a large workshop that has recently been partitioned into
smaller units for delivering training courses. The visitors’ reception centre is
just outside the prison walls.
13. The Devon Partnership Trust provides healthcare in the prison in the
separate healthcare unit. The unit has 15 beds for in-patients, and serves the
three prisons in Devon (HMP Dartmoor, HMP Channings Wood, and Exeter
itself). Two cells are suitable for disabled prisoners, with adapted shower and
toilet facilities. Doctors are on duty in the prison during working hours, and
nurses are on duty 24 hours a day. Outside the normal working day, doctors
are available through the standard out-of-hours service in Devon.
Compassionate release
14. When a prisoner is diagnosed with a terminal illness, an application can be
made for release on compassionate grounds. Procedures for applying for
compassionate release for prisoners serving indeterminate sentences are
contained in Prison Service Order (PSO) 4700. The criteria are as follows:
• “the prisoner is suffering from a terminal illness and death is likely to
occur very shortly (although there are no set time limits three months
may be considered to be an appropriate period for an application to be
made to Lifer Review & Recall Section), or the lifer is bedridden or
similarly incapacitated, for example, those paralysed or suffering from a
severe stoke; and
• the risk of re-offending (particularly of a sexual or violent nature) is
minimal; and
• further imprisonment would reduce the prisoner’s life expectancy; and
• there are adequate arrangements for the prisoner’s care and treatment
outside prison; and
• early release will bring some significant benefit to the prisoner or
his/her family.”
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Previous deaths at Exeter
15. The man was the eleventh prisoner to die at Exeter since 2004, when my
office became responsible for investigating deaths in custody. There has
since been a further death. There is nothing in any of my previous
investigations which is relevant to the circumstances of the man’s death.
Her Majesty’s Chief Inspector of Prisons
16. The latest report on Exeter by Her Majesty’s then Chief Inspector of Prisons,
was an announced inspection in October 2009. Although she made some
comments about the policies for disabled prisoners, there are no issues in the
report which are relevant to the care that the man received.
Independent Monitoring Board (IMB)
17. Each prison in England and Wales has an Independent Monitoring Board
responsible for monitoring day-to-day life in the prison and to ensure that
proper standards of care and decency are maintained. The report published
for Exeter for the year 2008-09 does not raise any issues which are relevant
to the man.
8
KEY FINDINGS
18. The man was sentenced to life imprisonment in 1989 for a domestic murder.
He moved through the prison system, and in doing so completed a number of
offender courses including anger management, victim awareness, coping
skills and a relationship course.
19. Security reports were compiled at various times during the earlier part of the
man’s sentence that he had threatened staff and prisoners. He also
threatened to damage prison property, go on hunger strike, and climb on the
roof to make protests. The comment was made that he could “try to
manipulate staff to his own advantage”.
20. On four occasions, the man was placed on the prison’s special measures to
support prisoners thought to be at risk of harming themselves. The measures
were still in place when he transferred to HMP Erlestoke in May 2008, but
were removed the following day and not needed again. The man seemed to
settle well at Erlestoke, working in a trusted position as head of quality control
within the workshop.
21. After suffering pain in his abdomen, the man saw the prison doctor on 1
December. The doctor examined him and, unable to find any obvious cause,
prescribed medication to counteract acid in the stomach. The man needed to
see the doctor again on 9 January, and was additionally prescribed
painkillers. The abdominal pains did not improve and, on 16 March, he
underwent blood tests. The results were normal but by 23 March the man
was prescribed a stronger painkiller to take at night, when the pain was
worse. On 2 March, he was referred for an ultrasound scan (to provide an
image of the internal organs), and prescribed further medication for the pain.
22. By 17 April, the man complained that the pain had become considerably
worse. The prison doctor examined him and found a swelling on his right
side. He referred him to the hospital, with a comment in the referral letter that
the swelling was probably in the muscle. In the meantime, the doctor
increased the dosage on the man’s painkillers. The papers do not indicate
when or if the hospital appointment took place.
23. The man saw a prison doctor on 23 April. More blood tests were carried out,
all of which were normal. The out-of-hours doctor had to be called to see the
man on 3 May. He was prescribed further pain medication.
24. The Parole Board considered the man’s case on 12 May. They noted that,
despite concerns from staff, he did not accept that he was at risk of harming
his partner (who later became his wife), nor that he had a problem controlling
his temper. The Board recommended that he should undertake further
offence-related work, including the Controlling Anger and Learning to Manage
it (CALM) course, and the Healthy Relationships Programme (HRP). The
man’s case was to be reviewed again in November 2010.
9
25. On 21 May, the man told the doctor that he was having difficulty digesting his
food and had been losing weight. He was not suffering from any pain, so his
medication was adjusted accordingly. The doctor made an urgent referral to
Salisbury District Hospital for him to have an endoscopy (a procedure to
examine the body internally). However, despite the doctor having adjusted
his prescription, he seemed to continue to receive the old dosage.
26. The hospital appointment took place on 17 June. The endoscopy revealed a
growth that was narrowing the man’s stomach. He was told that the growth
was cancerous.
27. The man had an appointment with a consultant orthopaedic surgeon at the
hospital on 19 June. The doctor wanted to assess whether the man’s back
pain was due to the cancer spreading to his spine. He requested an urgent
magnetic resource imaging scan (MRI – a scan using radio waves to give a
detailed image of the inside of the body). An appointment was made, but
subsequently cancelled by the hospital. The records do not show if the scan
was rescheduled.
28. As part of the response to his cancer diagnosis, prison and hospital staff
liaised over any amendments that ought to be made to the man’s diet. A
number of changes were made in view of his changing metabolism.
29. In view of the man’s prognosis, staff at Erlestoke considered whether he
should be given compassionate release. The process was set in motion, and
reports from staff who knew and worked with the man were collated. A
number of reports recommended against release. Agreeing with the recent
Parole Board decision, some staff had concerns about the risk the man might
present to his partner.
30. On 15 August, the man complained that his left foot was numb. The out-of-
hours doctor attended, and noted that the foot was cold and pale. The doctor
prescribed painkillers. The man saw the prison doctor on 17 August, who
noted that he had a pulse in his ankle, but not in his foot. The doctor referred
the man to the blood clinic, and an appointment was made for 27 August.
31. The man said that he was still in a lot of pain. He spoke to his partner, who
contacted the hospital and spoke to the oncology (cancer) team. Notes on
the man’s prison medical file indicate that the medical team in Erlestoke also
spoke to a nurse from the oncology team. According to the notes, the
hospital nurse said that she had told the man’s partner that the pain in his
foot was not a symptom of his cancer treatment, and they were unable to
help. She advised that he should contact the doctor where he was (either the
prison doctor or the out-of-hours service). The man’s partner, however, said
that hospital staff advised her that if he was in such pain he should be in
hospital. The man felt that this was the case.
32. The following morning the man’s foot had gone darker in colour, and a
request was put to the hospital for an urgent appointment. This was made for
9.00am the following morning, 19 August.
10
33. A case conference was held in Erlestoke on 18 August. Attendees included
the Governor, healthcare practice manager, chaplain, the man’s personal
officer, the head of resettlement, the man’s probation officer, and a
representative from the security team. They agreed that the man and his
partner would need a good deal of support in the coming months, and a
number of measures were put in place. The man would only be escorted by
a single officer when in hospital, and would not be subject to any physical
restraints. While he was in hospital for chemotherapy sessions,
arrangements were made for his partner and her children to have extended
visits with him. The conference also held preliminary discussions as to where
he could transfer when his illness progressed and he needed a higher level of
care. HMP Winchester could provide continuity of medical treatment but
Exeter gave greater proximity to his partner. The papers do not show
whether any contact was made with either prison at this stage. A family
liaison officer was appointed to provide support and a first point of contact for
the man’s partner.
34. The following morning, the man attended his hospital appointment. On
seeing the man, the hospital admitted him as an in-patient. He had to go into
surgery, which resulted in the amputation of his left leg below the knee.
35. On 20 August, the Governor of Erlestoke wrote to the man about the outcome
of the case conference. Amongst other issues, he wrote that in view of the
man’s illness, he had submitted an application for compassionate release.
He also wrote to staff in Erlestoke, outlining the man’s health problems and
explaining the special arrangements that he had put in place. He noted that
the man had initially seemed to take the news of his cancer well, but
struggled more recently. He did not always speak consistently about his
treatment, sometimes seeming to be content, and other times not. He
advised that staff needed to be aware of this.
36. Medical records show that, on 11 September, the man was discharged from
the hospital back to prison. He was able to move around using a wheelchair,
and was waiting for an appointment to have a prosthetic leg fitted. His
chemotherapy was placed on hold. The disability officer in the prison
considered any issues relating to the man being in a wheelchair, such as
access to toilets and showers. The notes indicate that it was now considered
to be an appropriate time for the man to move to a prison with 24 hour
medical cover.
37. On 16 September, the Governor of Erlestoke telephoned the Governor at
Exeter. The Governor of Erlestoke explained that the man had terminal
cancer, and had reached the stage where he would need to be in a prison
with 24 hour medical cover. Exeter has such cover, and was the most
convenient available location for the man’s partner, who did not drive, to visit.
The Governor of Erlestoke asked whether the Governor of Exeter would be
willing, in principle, to accept the man. The Governor of Exeter told the
investigator that he replied that he would accept the man in principle, and
would speak to the Governor of Erlestoke again about the arrangements.
11
Exeter had looked after prisoners with cancer in the past, and he was
confident that they would be able to do the same for the man. The Governor
of Exeter spoke to the Head of Healthcare and she contacted the healthcare
centre at Erlestoke to gain an understanding of the level of the man’s illness
and the extent of the care he required. The Head of Healthcare wanted to
ensure continuity of care for the man although, at this stage, she did not know
when this might be.
38. However, there was some breakdown in communication between the two
establishments about the timing of the transfer. The following day, Erlestoke
put into place arrangements for the man to transfer to Exeter. He left
Erlestoke at 9.30am in an escort vehicle. The escort papers show that 15
minutes later the car had to return to Erlestoke as the man had passed out.
Back in the prison, he was seen by nurses and, having taken some painkillers
and a drink, the vehicle left Erlestoke for a second time at 10.15am. The
man’s medical notes do not contain any reference to this incident. It might be
that his papers were packed away to go with him to Exeter but, nevertheless,
this should have been entered on the medical record.
39. The vehicle arrived at HMP Exeter at 12.25pm. This was during the lunch
period, when staffing levels are reduced and the prison is in a state of
lockdown. Staff on the gate and in the reception area were not expecting the
man, and he remained in the car in the secure area between the gate and the
building while staff tried to clarify what should happen. After some urgent
discussion with his staff, the Governor of Exeter agreed that Exeter would
accept the man.
40. Prisoners arriving in Exeter will, as routine, go through a reception health
screening. As the man arrived in exceptional circumstances and with specific
health needs, he did not go to the reception area in the normal way. Instead,
he went to the healthcare centre, and one of the prison doctors, Dr A,
conducted the reception screening and a medical assessment in a single
consultation. The man said that he wanted to remain on a normal wing while
he could, and he and the doctor agreed that he did not need to be in the
healthcare centre at that stage.
41. In line with normal reception procedures, a cell sharing risk assessment was
made (to decide whether there is any potential threat to a cellmate if the
prisoner was allocated a double cell). As a lifer, the man had been allocated
a single cell for a number of years. It was agreed that this was even more
important because of his medical needs. As well, there was considered to be
a high risk that he might assault a cellmate.
42. The man was allocated to B wing, which has an ordinary level exit to allow
wheelchair users to leave the wing when required, or in an emergency. It is,
however, a flight of stairs above the servery (from where meals are collected)
and the medical hatch (where medication is given out). The Governor of
Exeter explained to the man that he was not happy with a wheelchair user
being separated from these facilities by a staircase. He intended to arrange
for him to be relocated. However, the man said that he was satisfied where
12
he was. A “buddy” was collecting his meals and nursing staff brought his
medication to him. He did not want to move because of his disability and was
happy on B wing. Satisfied that his safety was not compromised, his care
was not disadvantaged, and his quality of life was not reduced, the Governor
of Exeter agreed that the man could remain on B wing.
43. Being a cancer patient, the man’s ongoing medical care had to be transferred
to the local hospital. This was the Royal Devon and Exeter Hospital (RD&E).
An entry on the man’s medical file on 17 September indicates that the RD&E
had no details of the man’s care. A nurse from the medical team at Erlestoke
had contacted the oncology team to say that she would fax the relevant
information but none were received.
44. It was during a stay in hospital in September that the man married his fiancée
in the hospital chapel.
45. The medical team at Exeter liaised with the RD&E and arranged an
appointment to plan the man’s ongoing care. However, on the day, he felt
too weak to attend and the appointment was rearranged for 5 October. The
prison made arrangements to manage the man’s security whilst he was
attending hospital. He had previously been subject to the standard security
procedures when outside the prison, consisting of two members of staff, plus
handcuffs. But at this stage, the arrangements were changed, and the man
was no longer subject to physical restraints whilst in hospital.
46. After a short period on B wing, the man transferred to A wing. His cell was on
the ground floor, opposite the servery and near the staff office.
47. The man went to the outpatients department of the RD&E as planned on 5
October. His treatment was reviewed, and arrangements made to
commence his fourth cycle of chemotherapy. On 10 October, he went into
hospital to begin this treatment. Having had problems swallowing, a stent (an
artificial tube) was inserted into his oesophagus to help him swallow.
However, it was removed because of a problem. Further changes were
made to his diet, and the man said that swallowing had become easier. He
remained in hospital until 22 October. After he had left hospital, the staff
contacted the prison to tell them that a scan had shown that the man had a
blood clot on his lung. Healthcare staff in the prison provided the appropriate
treatment.
48. The man’s wife wrote to the Director General of the National Offender
Management Service (NOMS) on 15 October about compassionate release
for her husband. She said that they had been led to believe that the
application had been approved at the first stage, and they were awaiting
further news. The papers do not make clear when the Director General of
NOMS replied, but the response set out the procedures for compassionate
release and explained that his situation remained under review.
49. As the man’s pain got worse, staff worked to keep it under control. He
developed metastasis (secondary cancer deposits in the bone) and it was
13
judged necessary for him to move to the healthcare centre on 11 November.
Staff in the prison kept in contact with the hospital’s hospice care team, which
looks after cancer patients. The team regularly visited the prison and
provided support, both to staff in their duties of care, and to the man himself.
Additionally, the community matron went to the healthcare centre to provide
advice and assistance to obtain equipment for the man’s care.
50. The man was allocated a double cell, which had been adapted to a single cell
for use by disabled prisoners. A hospital bed was obtained. Healthcare staff
arranged an open door policy so that they could go in freely at any time day
or night, without needing permission to unlock the door. The man was unable
to reach the emergency call bell from his bed and a monitor was provided to
allow him to be heard in the office.
51. The application for compassionate release remained under consideration.
The Public Protection Casework Section (PPCS) of NOMS was responsible
for processing the application, and they consulted the Directorate of Health
Care. They advised that the man did not yet meet the medical criteria for
early release.
52. The regime for prisoners in healthcare differs slightly from that in the main
prison. There is no evening association (free time out of their cells for the
prisoners to mix and socialise), and smoking is not allowed. The staff did
their best to allow the man to maintain some of the things he was missing by
not being on normal location. They would escort him back to A wing for
evening association, to allow him some social activity, and take him outside
for a cigarette. With the agreement of the Governor, special arrangements
were put in place to allow the man’s wife to visit him in the healthcare centre,
without the normal visiting procedures or the normal restrictions on visiting
hours. Visits were arranged through the chaplaincy, and held in the interview
room in healthcare.
53. Through November, the man suffered from increasing levels of pain, and his
medication was adjusted accordingly. Medical records show that on 1
December, staff suspected that he might have fluid on his lung. An x-ray was
arranged for the following day, when this was confirmed. The man was
admitted to hospital to have the fluid drained and returned to prison on 9
December.
54. The PPCS continued to liaise with Exeter about whether the man met the
criteria for compassionate release. There were concerns about releasing the
man to any address other than a hospice. However, Axminster Hospital’s
end of life care section had indicated that they would not be willing to accept
the man without support from the prison. The prison could only provide
support if the man remained a prisoner, and so he was not released at this
stage. This information was passed to the man’s solicitors on 2 December.
55. By 19 December, the man was suffering from increased pain in his stomach.
He saw Dr A who diagnosed that, as the cancer was spreading, it was
causing a build up of fluid in the man’s abdomen. He referred him to hospital
14
to have the fluid drained, and the man went that afternoon. The prison
reviewed the security arrangements, and the man was not subject to any
physical restraints, and was accompanied by only one prison officer.
56. Whilst the man was in hospital, healthcare staff remained in regular contact
with hospital staff. This served to check on his wellbeing, and assess when
he was likely to return to prison and whether additional equipment would be
required. It became apparent that the man’s cancer was spreading, and
doctors concluded that surgery was no longer an option. The decision was
taken that the only treatment was to alleviate his symptoms and make him as
comfortable as possible.
57. A discussion was held on 22 December between prison staff, hospital staff,
and the man and his wife about where he would be best placed as his illness
progressed. It was agreed that Axminster Hospital was the preferred option
because of it was more accessible for the man’s wife.
58. The PPCS had continued to keep the man’s application for compassionate
release under review. On 24 December, the prison were told that approval
had been given for him to be released on compassionate grounds when he
was no longer considered to pose a risk to others. This information was
passed to the prison.
59. The man was taken to Axminster Hospital on 30 December for end of life
care. In his notes he was described as comfortable on arrival. A syringe
driver (a portable battery-operated pump to administer medicines steadily)
was introduced to help control his pain. The application for compassionate
release remained under consideration because of the change in the man’s
circumstances, but approval was not given at this stage. The prison reviewed
the security arrangements again, and agreed that the officer accompanying
the man should wear civilian clothing. This would give greater privacy and
dignity to the man and his family.
60. The duty Governor visited the man in hospital on 30 December, and again on
1 January. He spoke to hospital staff, who gave no indication that the man’s
condition had deteriorated significantly.
61. Officer A was escorting the man (known as bedwatch duty) on the night shift
on 1 to 2 January 2010. He arrived at approximately 9.45pm on 1 January to
take over from a colleague, and it was immediately apparent to him that the
man was in a poor condition. He did not respond to attempts at conversation,
had difficulty breathing, and was grey in colour. Through Officer A’s shift, the
man did not respond to anything, apart from appearing to find it painful when
nurses moved him. At approximately 5.50am, the officer thought that the
man had stopped breathing. He summoned nursing staff, and they confirmed
that he had died. The officer contacted the prison, while nursing staff
contacted the man’s wife. She arrived shortly afterwards with her two
children, and at 8.00am the officer left the hospital.
15
62. Notices were posted to staff and to prisoners informing them of the man’s
death, and reminding them where support was available if required.
63. The man’s wife said that her husband’s property was returned to her without
delay. The prison offered financial assistance with the costs of the funeral,
and were represented on the day.
16
ISSUES
HMP Erlestoke
64. The man was diagnosed with cancer whilst at Erlestoke. Staff held a case
conference to discuss his ongoing care, recognising that there were issues
that needed to be addressed. The Governor wrote to staff, and separately to
the man, explaining the measures to be put into place. The man was subject
to less intrusive security during hospital visits, special arrangements were
made for extended family visits, and consideration was given to ensuring that
he was best placed when his condition became such that he could no longer
remain at Erlestoke. Such a sympathetic and proactive approach is to be
commended. The clinical reviewer notes that when the man was recorded as
losing weight, staff at the prison liaised well with the hospital to effect any
necessary changes to the man’s diet with his changing condition. I do note,
however, that the man’s partner mentioned problems with some dietary
changes, specifically providing extra full fat milk.
65. More broadly, while the clinical reviewer commends the use of computerised
medical notes by staff at Erlestoke, he comments on the general brevity of
entries to the record. He recommends that medical notes at Erlestoke should
be more clearly documented, using a “Subjective, Objective, Assessment,
Plan” format. I draw this to the attention of the Head of Healthcare.
66. When the man was diagnosed with cancer, staff at Erlestoke compiled the
papers required for an application for compassionate release. This included
reports from the relevant departments with whom he had contact, and who
could contribute to the consideration. Some of the report-writers expressed
concern at the potential risk to the man’s wife and her children. It was noted
that the man had been convicted of a domestic murder, and that his current
relationship had not been tested outside a prison setting. There was also
concern at the man’s failure to fully address his thinking and behaviours
within relationships, and the triggers that led to his offence. This echoed
concerns expressed by the Parole Board at their last consideration of his
case, and the man had not undertaken any work on these areas since then.
The man’s declining health meant that he would be likely to be increasingly
dependent on his wife, which would be likely to increase the pressures.
67. But the man and his wife were confused about the process for applying for
compassionate release, and as a consequence were not clear how far the
application had progressed. It is not clear from the files whether this was a
misunderstanding or whether the process was not clearly explained to them.
But the man’s wife felt it necessary to write to the Director General of the
NOMS for clarification. In order to ensure the same confusion does not
happen in similar circumstances, I make the following recommendation.
The Governor at HMP Erlestoke should consider how compassionate
release procedures can be explained to terminally ill prisoners and their
families.
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68. Whilst still a prisoner at Erlestoke, after his cancer diagnosis, the man
developed problems with his left leg which resulted in a below-knee
amputation. The clinical reviewer comments that, prior to the amputation, the
man’s medical notes do not contain an assessment of his pain. Nor was any
working diagnosis recorded. The clinical reviewer observes that he would
normally expect an urgent referral to hospital in such circumstances. I
similarly would have expected more urgency in dealing with this condition. I
note the clinical reviewer’s opinion that there is nothing to suggest that the
outcome would have been different had things been handled any differently.
Nevertheless, I suggest that the Head of Healthcare at Erlestoke considers
what happened in this case, to be satisfied that referrals for urgent hospital
treatment are made promptly and there are no delays for prisoners requiring
treatment.
The Head of Healthcare at HMP Erlestoke should ensure that there is an
efficient process for making urgent hospital referrals.
Transfer from HMP Erlestoke to HMP Exeter
69. When the man left Erlestoke to transfer to Exeter, the escort vehicle had to
return to Erlestoke when he became unwell. This is recorded on the escort
records, but no note is in the medical record. All the records should be
complete so that staff at the receiving prison are fully informed.
The Head of Healthcare at Exeter should ensure that any medical
incidents during prisoners’ transfers are subsequently recorded in the
medical file.
70. Erlestoke and Exeter have different views about the circumstances of the
man’s transfer between the two prisons. Staff at Exeter say that they were
taken by surprise at the speed of the man’s arrival. My investigator wrote to
the Governor at Erlestoke who replied that, from his point of view, there had
been prior notice. He considered that the circumstances of the transfer were
appropriate and were communicated, although he did not provide any
supporting documentation.
71. Whatever the agreement between the Governors, it is clear that the man was
not expected at Exeter on the day that he arrived. I am pleased that the
Governor there acted swiftly and humanely to avoid unnecessary discomfort
and distress for the man and his family. I hope that the confusion on this
occasion was unusual and so do not make a recommendation. I am sure
that, in future, both Governors will ensure that detailed transfer arrangements
are in place before a prisoner is moved.
72. The man’s serious condition meant that there should have been a plan to
ensure continuity of his cancer care but unfortunately, this was not the case.
A member of Erlestoke’s healthcare team did contact the RD&E hospital and
give advance notice that she would fax some information through. The
communication, however, broke down after this. It is not clear where the fault
lay, but I would have hoped that, realising the importance of the transaction,
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each side would have ensured that the information was exchanged
satisfactorily. One of the prison doctors at Exeter did comment in interview
that the RD&E continued the man’s treatment without any disadvantage.
73. This may well have been the case, and it is fortunate that they were able to
do so. But the communications should have been better and the transfer of
care should have relied less on good fortune and more on good planning.
The clinical reviewer recommends that, bearing in mind the need for a
comprehensive care plan, good communications should be maintained
between prisons when transferring prisoners for healthcare reasons. I agree,
and would hope that the confusion in this case is not repeated.
HMP Exeter
74. One of the prison doctors described oesophageal cancer as an aggressive
form of the illness. The man was diagnosed in June, transferred to Exeter in
September, required full-time healthcare in November, was hospitalised in
December, and died in January. This is within the boundaries of what could
be expected for such an aggressive form of cancer.
75. The investigator asked whether the man’s care followed an end-of-life
pathway (a specific level of care devised for those who are terminally ill). The
doctor said that the prison has an end of life policy, which follows recognised
care pathways and they work closely with specialists in palliative care.
76. The clinical reviewer concludes that the standard of care the man received at
Exeter was equivalent to that which he could have expected in the
community. Good contact was maintained with specialist agencies,
appropriate equipment was provided and records were well-kept .
77. I too believe that the care the man received at Exeter was good. There are
many examples of thoughtful and imaginative arrangements which improved
his comfort and treatment. When he was unable to reach the emergency call
bell in his cell in the healthcare centre, staff provided a monitor which could
be heard in the office. I applaud the way that the staff identified the problem
and introduced a solution.
78. Staff were willing to engage with him to make him as comfortable as
possible. Any expertise required was brought in via the nurses from the
hospice care team (which I understand is equivalent to the Macmillan
Nurses), and the community matron was engaged to assist in providing any
equipment (and further advice) which was needed.
79. After the man transferred to the healthcare centre on 11 November, he was
given a large room which could accommodate a hospital bed, which was
brought in especially for him.
80. Another example of consideration to the man’s wishes was when staff took
him back to the wing at association time so that he could spend some
“normal” time with other prisoners, and enjoy a cigarette.
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81. An open-door policy was put in place so that the staff could go into the man’s
cell during the night (when under normal circumstances it would be locked), if
he needed urgent attention. Family visits were arranged on the healthcare
wing.
82. I am also pleased to see the sensitive use of physical restraints and escort
officers whilst the man was in hospital. The safety of the public is paramount,
and must be the primary consideration. But it seems to me that both prisons
sensibly assessed the risk the man could pose and balanced that against his
comfort and dignity.
83. I agree with the clinical reviewer that the man received care for his cancer in
prison which was equivalent to what he would have received in the wider
community.
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CONCLUSION
84. The man had been in prison for a long time. During his sentence, he had
formed a relationship with the woman who became his wife.
85. In the summer of 2009, whilst in Erlestoke, he was diagnosed as suffering
from oesophageal cancer. Erlestoke recognised that the man and his family
would need a higher level of support over the coming months, and put some
changes into place. They also put into motion the process for applying for
compassionate release. The man and his family, however, did not seem to be
clear on how the process worked and this caused them a degree of confusion.
86. In August, the man developed problems with pain in his foot. He complained
to medical staff in the prison, and was referred to hospital. It was four days
before he was seen in the hospital, and ultimately he had to have his left leg
amputated below the knee. However, the clinical reviewer judges that the
delay is unlikely to have meant that the outcome would have been any
different.
87. By September, the man needed to be in a prison which had 24 hour medical
care, and Exeter was identified as the easiest place for his wife to visit. The
Governor at Erlestoke spoke to the Governor at Exeter and they agreed the
transfer in principle. However, there was a misunderstanding over the timing
of the transfer, and the man arrived unexpectedly the next day. I am pleased
that the Governor at Exeter acted swiftly and agreed to accept him. His
medical care was transferred to the local hospital.
88. After initially being on a normal prison wing, the man had eventually to move
to the healthcare centre. Staff brought in specialist expertise and equipment
as required, and the man was in a specially adapted cell. Staff helped him to
continue to live as normally as possible, and special arrangements were
made for his wife to visit him.
89. In December, the man went to hospital for treatment but his condition did not
improve and, by the end of the month, he was transferred to an end-of-life unit
in Axminster Hospital. Compassionate release remained under consideration,
but concerns about the risk the man could present to his family meant that it
was not granted.
90. Whilst the man received good care at both prisons, I comment on the
arrangements at HMP Erlestoke regarding information about compassionate
release for prisoners and their families and swift referrals for hospital
treatment, and recording events during prison transfers at Exeter.
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RECOMMENDATIONS
1. The Governor at HMP Erlestoke should consider how compassionate release
procedures can be explained to terminally ill prisoners and their families.
2. The Head of Healthcare at HMP Erlestoke should ensure that there is an
efficient process for making urgent hospital referrals.
3. The Head of Healthcare at HMP Exeter should ensure that any medical
incidents during prisoners’ transfers are subsequently recorded in the medical
file.
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