Individual at Norwich

Investigation into the death of a man
whilst in the custody of HMP & YOI Norwich,
in June 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2011
This is the report of an investigation into the death of a man at HMP & YOI
Norwich. The man died at the Priscilla Bacon Lodge. He was 60 years old.
The cause of his death was metastatic small cell carcinoma (lung cancer).
I offer my sincere sympathy and condolences to his family, and to all who
have been affected by his loss. I apologise for the delay in issuing this report
and any additional distress this may have caused.
The investigation was carried out by my investigator. A review of the man’s
medical care was led by the clinical reviewer on behalf of NHS Norfolk. I am
grateful to the clinical reviewer for her assistance. I would also like to thank
the Deputy Safety Custody Manager, for his work liaising with the investigator.
My report finds that the man received an equivalent level of care to that he
could have expected in the community. I do however make five
recommendations in respect of areas where improvements are needed.
These relate to the clinical care for prisoners on L wing at Norwich and escort
arrangements.
This version of my report, published on my website, has been amended to
remove the names of the man who died and those of staff and prisoners
involved in my investigation.
Thea Walton
Acting Deputy Ombudsman November 2011
2
CONTENTS
Summary
The investigation process
The man
HMP & YOI Norwich
Key events
Issues
Conclusion
Recommendations
3
SUMMARY
1. The man was given an indeterminate public protection sentence with a
four year tariff on 9 December 2005 and arrived at HMP Gartree in July
2006. Whilst at Gartree the man re-established contact with his two
brothers. In June 2009 he spent a period of time in HMP Durham on
accumulated visits to enable him to receive visits from his family.
2. On 10 December 2009 the results of a chest x-ray showed an upper lobe
mass on the man’s right lung. The man was moved to the prison’s
healthcare wing on 15 December.
3. The man was given a diagnosis of small cell carcinoma of the lung1 on 6
January 2010. The following week he had his first session of
chemotherapy2 treatment. On 27 January he was re-categorised from
category B to category C 3due to his deteriorating health. It was also
decided that he would be moved to a suitable category C prison that
could support his healthcare needs. On 5 March the man decided that
he did not wish to continue with the chemotherapy treatment.
4. The man was moved to HMP and YOI Norwich on 6 March for end of life
care. He was located in L wing which is the dedicated elderly prisoners
unit. On 18 May the man was referred to the palliative care team.
Following a comprehensive assessment by a palliative care consultant
the man was placed on the waiting list for the Priscilla Bacon Lodge, a
local facility which provides specialist palliative care4 and support for
patients with advanced diseases.
5. On 3 June the man was moved to the Priscilla Bacon Lodge. He was
placed in a single cuff restraint and escorted by two officers. The escort
risk assessment remained in place until 7 June when the man’s
restraints were removed.
6. This report contains five recommendations. These relate to the use of
locum doctors at Norwich, End of Life Care pathways and the support
offered to prisoners receiving palliative care. I also criticise the lack of a
formal assessment of the man’ mental capacity to refuse treatment and
make a recommendation regarding risk assessments for escort
arrangements.
1Small cell carcinoma (sometimes rendered as "small-cell carcinoma") is a type of highly
malignant cancer that most commonly arises within the lung.
2 Chemotherapy is the use of anti-cancer drugs to destroy cancer cells. There are different
groups of anti-cancer drugs that can be used.
3 There are four security categories for adult male prisoners. Prisoners who are categorised
as Category C cannot be trusted in open conditions but do not have the resources or will to
make a determined escape attempt.
4 Palliative care is a specialised area of healthcare that focuses on relieving and preventing
the suffering of patients.
4
THE INVESTIGATION PROCESS
7. The investigation was opened on 14 June 2010 by my investigator. She
was met by the prison’s liaison officer and reviewed the man’s prison and
medical files. Copies of documents from those files were given to the
investigator. My investigator met with the Chair of the Independent
Monitoring Board (IMB) and a representative from the Prison Officers
Association. She also spoke the Head of Healthcare at the time of the
man’s death.
8. NHS Norfolk commissioned the clinical reviewer to undertake a clinical
review into the man’ medical care prior to his death. The clinical review
panel met on 10 September 2010. This meeting was attended by the
investigator and the clinical reviewer. Following this meeting a clinical
review report was written, which I include with this report as Annex 1. The
review was received on 10 December 2010.
9. My investigator visited the prison on 20 September and interviewed three
members of prison staff and the head of healthcare. The interview with
the Head of Healthcare was also attended by the clinical reviewer.
10. The Ombudsman’s family liaison officer wrote to the man’s brother on
6 July to inform him of the investigation and determine whether he had any
issues he wished it to address. The man’s brother did not raise any
issues. The Ombudsman’s family liaison officer wrote to the man’s brother
again on 18 April 2011 to inform him that the Ombudsman’s family liaison
officer had been changed to another one. I hope that the findings of my
report help to clarify the circumstances of the man’ death for his family.
11. The second Ombudsman’s family liaison officer wrote to the man’s brother
on 28 July to inform him that the draft report was ready and to ask if he
wished to receive a copy. The man’s brother did not respond to her letter.
The draft report was issued to the National Offender Management Service
(NOMS). NOMS’ responses to my recommendations are included at the
end of this report.
5
THE MAN
12. The man was born in January 1950 and was the youngest of three
brothers. After leaving school he enrolled in the Army in 1970 but left
two years later with a dishonourable discharge. The man gained a City
and Guilds qualification in catering which he used to gain employment as
a chef for Butlins. He married twice but did not have any children.
13. The man had an extensive history of offending behaviour which dated
back to the 1960s. He received his first custodial sentence aged 19
when he spent three months in a detention centre. On 9 December 2005
the man was convicted of a serious offence and received an
indeterminate public protection sentence with a four year tariff.5
14. The man started his sentence at HMP Blakenhurst before being
transferred to HMP Gartree in July 2006. During his time at Gartree he
completed several offending behaviour programmes and was
participating well in the regime of the prison. He also re-established
contact with his two brothers which resulted in him being transferred in
June 2009 to HMP Durham for accumulated visits.6
5 Indeterminate public protection sentences were introduced by the Criminal Justice Act 2003.
The purpose of these sentences is to detain in prison people who pose a significant risk to
members of the public until their risk is reduced. In sentencing the courts will impose a
minimum term that the prisoner must serve before they can be considered for release by the
Parole Board.
6
If a prisoner is in a prison a long way from home and family they can save up their visiting
time. This enables the prisoner to be transferred on a temporary basis to undertake the visits
at a prison closer to their family.
6
HMP & YOI NORWICH
15. Norwich is a large prison built on a site close to the city centre. The
original buildings date back to the Victorian era. The prison holds a
maximum of 767 men, both adults and young offenders. Some men
have been convicted and some are being held on remand. The prison
largely receives men from courts in Norfolk and Suffolk. The site is
geographically split and the prison has to deliver a number of different
functions.
Healthcare
16. The healthcare provision at Norwich changed in October 2010. NHS
Norfolk now commissions a private company, Serco Health, to provide
the healthcare at Norwich and two other nearby prisons. However,
although Serco Health is the provider, they deliver the care in association
with a number of partners, including Norfolk Community Health and Care
NHS Trust (NCH&C). The three managers overseeing healthcare at
Norwich (one on behalf of Serco, two for NCH&C) were appointed late
last year.
17. The man was transferred from Gartree to Norwich on 6 April 2010 and
went to L wing. This is a dedicated older prisoners unit. L wing is on the
ground floor of the healthcare centre at Norwich. It used to be referred to
as the Nelson Unit. Staff on L wing often work closely with colleagues at
Priscilla Bacon Lodge, an NHS facility nearby in Norwich which
specialises in palliative care.
Her Majesty’s Inspectorate of Prisons
18. The former Her Majesty’s Chief Inspector of Prisons completed an
unannounced inspection of Norwich in February 2010. She judged that
Norwich was an improved and safer prison since her last inspection.
She found that the provision of healthcare was improving, but that the
facilities offered to those prisoners staying in the healthcare centre were
‘insufficient’. With regard to L wing, Her Majesty’s Chief Inspector of
Prisons commented:
‘Many of the patients required full nursing care and staff were hard
pushed to provide the required level of care despite their best efforts ...
‘The unit had excellent links with outside agencies, including the local
palliative care team.’
7
Independent Monitoring Board
19. The most recent annual report published by the Independent Monitoring
Board (IMB)7 at Norwich covers the year from March 2009 until February
2010. The Board identified difficulties with the provision of healthcare.
They were critical of staff shortages and a lack of care plans for the
chronically ill.
Previous deaths at Norwich
20. Norwich has specialised in recent years in caring for older prisoners
whose lives may well end lives whilst still serving a prison sentence. The
prison has established links with a palliative care provider in the local
community. L wing is a dedicated unit for older prisoners with chronic or
terminal illnesses. Since assuming responsibility for investigating deaths
in custody in 2004, I have investigated a significant number of deaths at
Norwich resulting from illness, primarily diseases such as cancer.
7 The IMB at each prison is made up of members of the public who are both independent and
unpaid. They monitor the day-to-day life in their local prison and ensure that proper
standards of care and decency are maintained.
8
KEY EVENTS
21. The man was convicted of a violent offence on 9 December 2005 and
received an indeterminate public protection sentence with a four year
tariff. He spent most of his sentence at HMP Gartree before being
moved to HMP Norwich in April 2010 on the grounds of his deteriorating
health.
22. The man arrived at Gartree on 27 July 2006 and received the
appropriate medical assessments. His medical records showed a history
of asthma and dermatitis for which he was prescribed the appropriate
medication. The man had also made use of the prison’s primary
healthcare facilities including general practice, practice nursing, podiatry
8and dentistry.
23. On 21 September 2009 the man was seen at Gartree by Dr A. He
complained of experiencing occasional hot flushes with cold hands and
feet. The prison doctor referred the man for blood and urine tests. The
test results were received on 25 September and were within normal
ranges.
24. On 9 October the man complained of feeling anxious when he
participated in the cognitive self change programme (CSCP).9 Dr B
suggested that the man should be referred to the mental health team and
prescribed propranolol.10
25. The man was seen by Dr C on 19 October to discuss his anxiety. He
said he had not taken the propranolol because he was worried the
medication could have an adverse effect on his asthma. The following
day he was admitted to healthcare for overnight observation while
starting propranolol. The man was discharged back to the wing on the
following day.
26. A mental health assessment took place on 7 November. The
assessment concluded that there was no evidence of physical or mental
signs of anxiety. The man told Nurse A at Gartree that his problems
related to his attendance on the CSCP.
27. On 12 November the man complained of feeling breathless and was
seen on the wing by Nurse B. He complained that he had been
8 Podiatry is a branch of medicine devoted to the study, diagnosis, and treatment of disorders
of the foot, ankle, and lower leg.
9
The cognitive self change programme is an offending behaviour course which targets high
risk violent offenders. It equips prisoners with skills to help them control their violence and
avoid reconviction. It is aimed at offenders with a history of violent behaviour and is suitable
for those whose violence is reactive and/or instrumental.
10Propranolol is a beta blocker mainly used in the treatment of hypertension (high blood
pressure).
9
coughing up green phlegm for the past few days. He was reviewed
again on 15 November by Nurse C. The man said he was experiencing
a shortness of breath after little exertion. He was advised to ask for help
from prisoners or staff on the wing.
28. On 23 November 2009 the man was seen in healthcare by Dr C. He
complained of a persistent cough and said he was worried that he had
lost weight over the past few months. The doctor referred the man for a
chest x-ray. The appointment took place on 8 December at Market
Harborough Hospital.
29. The results of the chest x-ray were sent to Dr C by fax on 10 December.
The results showed an abnormality on the man’s right lung. This was
identified as a right upper lobe lung mass. The hospital advised that the
man should be referred to Leicester Royal Infirmary department of
Oncology11 for further investigation into possible lung cancer. The
referral form was completed by Dr D, on 10 December. The doctor said
that the man had been told that the x-ray had shown a shadow on his
lung.
30. On 15 December the man was seen on the wing by Nurse C. The man
was very upset about the deterioration in his physical health and weight
loss. In view of the chest x-ray results the man agreed to be moved to
the healthcare wing at Gartree. This would allow healthcare staff to offer
him support and to facilitate his visits to hospital for treatment.
31. Nurse C noted on the man’ medical record that the man ‘had been hinted
that there were some abnormalities on his last chest x-ray’. It is not clear
if the man was told that he had been referred to the Oncology
Department for further investigation into possible lung cancer.
32. On 19 December the man was referred to the mental health team at the
prison because he was feeling depressed and anxious about his health.
33. On 22 December the man attended the Respiratory Clinic12 at Glenfield
Hospital. On his return to Gartree he was seen by Nurse D, a mental
health nurse. The nurse noted in his medical records that the man told
her he believed he had lung cancer. The nurse reassured the man that
he would be offered support by healthcare staff. The man said he was
very anxious because he had experienced a ‘funny turn’ that morning
and fallen to the floor. He told the nurse that the clinic doctor had told
him he would need a brain scan to see if the cancer had spread.
34. A consultant respiratory physician wrote to Dr D on 23 December. He
said it was likely that the man had lung cancer. The consultant
respiratory physician said he had explained to the man that more
information was required before his condition could be confirmed. For
11 Oncology is the field of medicine that deals with the diagnosis and treatment of cancer.
12 Respiratory clinics see patients who are suffering from common chest illnesses.
10
this reason the man would be given an ultrasound13 of his neck lymph
nodes.14 A further discussion of his case would take place on 24
December.
35. On 24 December a nurse, a lung clinical nurse specialist from the
Oncology Department at Leicester Royal Infirmary, contacted the prison
healthcare department to discuss the man’ diagnosis and treatment. The
nurse said they had been given a diagnosis of small cell carcinoma of
the lung. The man would be offered chemotherapy.
36. The same day the man was seen in his cell by Nurse F and Nurse D.
They told the man he would be going out to hospital the following week
to discuss his diagnosis and treatment options. Nurse D noted in the
man’s medical records that he appeared to be convinced that he was
suffering from a virus that was affecting his lung and perhaps his brain.
Nurse D wrote that she needed to confirm with the man how much the
man knew about his condition. She decided that it would be more
sensitive not to tell the man any further information about his condition
on Christmas Eve.
37. On 31 December the man was seen by Nurse D. He expressed concern
about his weight loss and asked about the possibility of having some
build up drinks. Nurse D said it was clear that the man was very worried
about his health and anxious about the appointment to discuss his
diagnosis and treatment options.
38. Nurse D saw the man again on 4 January 2010. She agreed to
accompany him to his appointment at the Oncology Department on 6
January. The man said he was looking forward to finding out what was
wrong so he could ‘get back to normal’. Nurse D noted that she believed
that the man was aware that he was seriously ill.
39. On 6 January 2010 the man was seen at Leicester Royal Infirmary by a
doctor, a consultant oncologist. He was accompanied to the
appointment by Nurse D. During the appointment the man was told that
he had been diagnosed with lung cancer. His treatment plan was
outlined. The man was extremely upset by his diagnosis, in particular
the effect that it would have on his seventy year old brother.
40. The man had his first session of chemotherapy treatment on 15 January.
On 22 January a MacMillan nurse, contacted healthcare and said she
had received the man’s referral and was happy to be contacted for
guidance and advice.
41. A sentence planning board was held on 27 January to discuss the man’s
security categorisation. The Board noted that whilst the man needed to
13 An ultrasound scan is a painless test that uses sound waves to create images of organs
and structures inside the body.
14 A lymph node is a small ball or an oval-shaped organ of the immune system.
11
reduce his risk of re-offending, he would need to complete further
offending behaviour programmes and this would not be possible due to
the seriousness of his illness. For this reason a long term objective was
made that the man should be transferred to a suitable category C prison
that could support his healthcare needs. A recommendation was made
that the man should be re-categorised from category B to category C due
to his deteriorating health.
42. The man had his second chemotherapy session on 5 February. On 10
February healthcare staff observed the man lying on his bed. He told
staff that he was feeling dizzy.
43. On 25 February the man told Nurse C, that he had been told by the
consultant that the results of one of the scans had indicated that the
cancer was spreading to his liver. Nurse C noted that he believed the
man had not been fully informed of his prognosis.
44. The same day the man was seen in his cell by Dr B and Nurse C. Dr B
noted that the man was aware of his diagnosis, in particular that he was
unlikely to be cured of his condition. The man had not wished to discuss
his specific prognosis with the consultant.
45. Nurse D saw the man again on 5 March. He expressed concern about
having his next session of chemotherapy treatment. He said the
treatment was making him feel physically very ill. The man was also
expressing depressive thoughts and feelings. The man said he had
decided to stop having his treatment and asked for his decision to be
noted in his medical notes. He asked healthcare staff to respect his
wishes in wanting to discontinue the treatment. The nurse asked the
man if he would consider talking to the doctor and taking an
antidepressant. The man said he that he did not wish to do so.
46. On 8 March the man discussed his decision to stop having treatment
with Nurse C. The man said he was finding his decision difficult to cope
with. He was pleased to have been recategorised to category C and
said he would prefer to be moved to a prison with similar healthcare
facilities to Gartree.
47. The next day the man was seen by the Head of Healthcare and Nurse
F, the nurse manager. The man was told that a referral had been made
to the healthcare department at Norwich.
48. The man completed a treatment disclaimer form on 12 March 2010. This
said he had refused chemotherapy at Leicester General Infirmary and he
recognised that the refusal was against medical advice.
49. A nurse from the chemotherapy suite at Leicester General Infirmary
contacted Gartree on 18 March to ask if the man would be attending for
his chemotherapy. The man said he did not wish to receive his
treatment. On the same day a consultant in clinical oncology, wrote to
12
healthcare regarding the man’ decision to refuse chemotherapy
treatment. The consultant said the man had a chemo-sensitive tumour
and following several cycles of chemotherapy could have a remission
which sometimes lasted over a year. The consultant went on to say that
the man needed to come and have a discussion about his situation
without committing to any treatment.
50. Nurse D reviewed the man on 25 March. He said he felt much better
than when he was having chemotherapy treatment. The man was also
regularly in contact with his brothers by telephone.
51. On 29 March the man was seen by a healthcare practise manager in
order to complete a treatment disclaimer form. The man confirmed that
he did not wish to attend an out patients appointment to discuss his
treatment options with the consultant. There is no evidence that a formal
assessment of the man’s mental capacity to refuse treatment was carried
out at this time.
52. The man was accepted by Norwich on 30 March. On 5 April he was
reviewed by Nurse D and discharged from her care. Nurse D noted in
the man’s care plan that they had discussed his expectations and
anxieties. On 6 April the man moved to Norwich for end of life care.
53. On arrival at Norwich the man underwent a first reception health screen.
The man felt unable to discuss his ‘do not resuscitate’ (DNR) status with
the doctor. However, he was aware that his suitability for this policy was
being discussed with the palliative care team. 15
54. On 10 May the man was seen by Nurse A at Norwich. The man
complained of feeling short of breath when he walked around and said
that he felt like he was experiencing flu-like symptoms. Later the same
day the man was reviewed by Dr A at Norwich. He was prescribed
amoxicillin16 for a suspected chest infection. The following day the man
refused to take his medication because he believed he did not have a
chest infection. The man asked for a doctor’s appointment to discuss his
constipation.
55. Dr A at Norwich saw the man again on 14 May. He noted that the man
was aware that his cancer was growing rapidly. The doctor described
the man as being anxious with a ‘demanding demeanour’. He reviewed
the man again on 18 May. The man complained that he was
experiencing indigestion and hot flushes and was also tearful.
56. On 18 May the man was referred to the palliative care team.
15 A DNR order on a patient's file means that a doctor is not required to resuscitate a patient if
their heart stops and is designed to prevent unnecessary suffering.
16Amoxicillin is an antibiotic medication used to treat infections.
13
57. Nurse A at Norwich reviewed the man on 21 May. She said the man
was experiencing some nausea and vomiting. Whilst the man denied
that he was anxious regarding his prognosis he asked for a mental
health assessment. The following day the man was seen by Nurse B at
Norwich. He said he felt agitated and asked to be taken to hospital.
58. On 23 May the man said he was feeling increasingly agitated and felt
that staff were not taking him seriously. Nurse A at Norwich described
the man as being confrontational and very restless. However, she felt
that this could be attributed to an increase in the dosage of morphine
sulphate.
59. The man was assessed by a palliative care consultant, on 25 May. The
palliative care consultant noted that the man had been feeling more
unwell over recent days. It was recorded in the assessment that the man
was aware that his condition was incurable and he was comfortable with
his decision not to pursue any more treatment. The palliative care
consultant went on to say that the man agreed with the decision to
complete a DNR order. Once completed the DNR order would be
considered by healthcare.
60. The palliative care consultant completed the DNR later that day. The
reasons for the order were because the man’s condition had indicated
that CPR was not likely to be successful in event of him experiencing a
cardiac arrest. The man had also made it known that he did not wish to
be resuscitated. The DNR order said the man was judged to be mentally
competent of making this decision. The order was countersigned by
Nurse A and Dr A at Norwich.
61. On 27 May a drug error is recorded in the man’s medical record. On
investigation the clinical reviewer found that the error appeared to have
been made because the locum doctor did not know how to prescribe
medication using the electronic medical information system.
62. The palliative care consultant undertook a further review of the man’s
condition on 1 June. During this review the man acknowledged that he
was feeling less well. The palliative care consultant said that she
considered that the man’s condition was deteriorating. The suggested
plan of action was to place the man on the waiting list for the Priscilla
Bacon Lodge.17
63. On the same day the man’s medical record shows that the Head of
Healthcare at the time, contacted the man’s brother by telephone.
During her interview with the investigator, she said she had first
contacted the man’s brother by telephone when it was clear his condition
was deteriorating. During their conversation she told the man’s brother
about his move to the Priscilla Bacon Lodge. The Head of Healthcare at
17 The Priscilla Bacon Lodge provides specialist palliative care advice and support for patients
with advanced diseases, and for those close to them. The centre incorporates an inpatient
unit and day centre.
14
the time said the man had asked her to keep his brother informed. She
had agreed with the man’s brother that she would contact him if there
were any other changes.
64. An outpatient escort log dated 1 June was completed by Senior Officer
(SO) A. A risk assessment is carried out for all prisoners who are
leaving the prison for any reason. The assessment takes account of the
risk the prisoner poses to the public and therefore what arrangements
should be in place to manage these risks. The man was placed in a
single cuff restraint and escorted by two prison officers. 18 The escort risk
assessment noted that the man’s condition was life threatening and he
was possibly not returning to Norwich. The acting Deputy Governor at
the time authorised the risk assessment but said it should be reviewed
for appropriateness if the man remained at the Priscilla Bacon Lodge.
The man was moved to the Priscilla Bacon lodge two days later on 3
June.
65. The head of healthcare at the time contacted the acting Governor at the
time, to express her concern that the man would be placed in a single
cuff restraint. In her opinion the man was far too ill to be a risk and she
asked for consideration to be given to the man being placed on an escort
chain (a long chain with a single cuff at each end. One end is attached
to the prisoner’s wrist and the other the member of staff). In response,
the acting governor at the time, asked the acting Governor at the time
asked Governor A and Governor B to review the man’s risk assessment.
66. On 4 June Governor A reviewed the man’ risk assessment as requested
by the acting governor at the time. He decided that the risk assessment
should remain unchanged. During his interview with the investigator
Governor A said as part of the risk assessment process he had visited
the man at the Priscilla Bacon Lodge. He recalled that the man looked
relatively fit and should therefore remain in single cuffs.
67. My investigator also spoke to Governor B who said he had visited the
man on 5 June. Governor B said at this point the man was still able to
walk around the Priscilla Bacon Lodge and he considered that the risk
assessment in place was appropriate.
68. On 6 June the head of healthcare at the time contacted Governor C in
the security department to express her concern that the man remained
single cuffed. She described the man as ‘a very frail, terminally ill man’,
with an extremely poor prognosis. She said for the purpose of dignity
the man should be uncuffed with a discreet support officer. The following
day the man’s restraints were removed. During her interview with the
investigator the head of healthcare at the time said that it was clear that
18 Each time that a prisoner is escorted outside the prison to hospital, a risk assessment
considers the risk to the public, potential for escape and likelihood of outside assistance. The
assessment informs the decision about the number of escorting officers and the type of
restraint to be used. In this case the man was escorted in a single cuff restraint and escorted
by two prison officers.
15
the man was very unwell and his physical condition was such that he
would be unable to present a risk of escaping.
69. The man died on 10 June. The same day the head of healthcare at the
time was asked by the acting governor at the time to telephone the
man’s brother to let him know. He was also contacted by the prison’s
family liaison officer, Governor D. The man’s funeral took place on
2 July in Newcastle. My investigator found that the prison’s offered a
contribution to the funeral costs in accordance with Prison Service Order
(PSO) 2710.19
19 PSO 2710 provides instructions on the action to be taken following a death in custody.
16
ISSUES
Clinical Care
The man’s clinical care at HMP Gartree
70. Following his conviction, the man spent the first 14 months of his
sentence at HMP Blakenhurst. He was moved to Gartree on 27 July
2006. On arrival at Gartree he underwent the appropriate health
assessments. The man’s medical record shows he was prescribed
seretide for asthma.20 He had reduced his cigarette intake from forty a
day to between seven and ten. Between July 2006 and September 2009
the man received regular appointments with the dentist and chiropodist
and was prescribed the appropriate medication.
71. The clinical reviewer described the End of Life Care Pathway Model
(2009) that was in use at Gartree as ‘comprehensive and developed in
conjunction with local healthcare organisations’. She comments
“The information in the clinical record for the man demonstrates that
there was robust communication between the secondary care oncology
multi-disciplinary team at Leicester Royal Infirmary and HMP Gartree
healthcare department following the man’s diagnosis. A referral was
made in January 2010 to the McMillan nursing team in Market
Harborough who agreed they would provide the healthcare team
guidance and advice as required while caring for the man.
72. In December 2009 the man was moved to the healthcare department for
observation and support. The clinical reviewer comments that the
Primary Care Manager at Gartree was clear that there was no formal
protocol for admission to the beds in healthcare and the man was
originally admitted to facilitate his visits to hospital for chemotherapy and
to allow him some peace and quiet which was not possible on the wing
73. The clinical reviewer has questioned the appropriateness of the man’s
move to Norwich when a comprehensive End of Life Pathway model was
in place at Gartree. The man spent a period of time in HMP Durham on
accumulated visits. The clinical reviewer has commented that
consideration should have been given to moving the man to a prison
closer to his family. I do not consider that the man’s move to Norwich
contributed to his death and for this reason I make no recommendation.
74. In early March the man took the decision to stop chemotherapy. There is
no evidence that a formal assessment was undertaken to confirm that he
had sufficient mental capacity to make this decision. This is a surprising
omission, given that the treatment may have potentially prolonged the
man’s life. I discuss this issue further later in my report.
20 Seretide is a combination inhaler prescribed to control the symptoms of asthma.
17
The man’s clinical care at HMP Norwich
75. The man arrived at Norwich on 6 April and underwent a first reception
health screen. Arrangements were made for the man to see a doctor the
following day to re-write his medications. It was noted that he required
assistance with cleaning his cell and bed making. The health screen
says that there were no concerns about the man’s psychological state, in
particular his thinking, feelings or behaviour.
76. On 7 April the man was seen in his cell by Dr A at Norwich. He
expressed concern about his move to Norwich and was described as
being ‘evasive about whether his chemotherapy would have been
curative or not’.
77. The man had received support from the mental health team at Gartree to
help him deal with his diagnosis. However, he did not receive a mental
health assessment during his time at Norwich nor was he offered any
support from the mental health team, despite his worsening condition.
During her interview with my investigator the head of healthcare at the
time said if there had been any concerns about the man’s mental health
he would have been referred to the mental health team.
78. The clinical reviewer found that mental health services for older prisoners
at Norwich were not well developed. She comments that there is no
evidence in the clinical record to suggest that any mental health
assessment was undertaken. I consider that Norwich should have
undertaken an assessment of the man’s mental health. Despite
receiving support from the mental health team at Gartree, I am
concerned that no such assessment took place. I make the following
recommendation:
Prisoners on L wing who are receiving palliative care should be
offered support from the mental health team at the prison.
79. The man was supported by a specialist outreach team from the Priscilla
Bacon Lodge. The clinical reviewer has commented that there is not an
agreed end of life care pathway in place at Norwich which clarifies the
roles and responsibilities across healthcare and local health services.
She writes that given the number of prisoners at Norwich that are
receiving end of life care it is important that staff are fully aware of their
responsibilities to ensure that prisoners experience a dignified and
comfortable death. The clinical reviewer makes the following
recommendation:
HMP Norwich should have an agreed End of Life Care pathway
which reflects the care available in the wider community.
18
80. During the man’s time at Norwich he was seen by several doctors, all of
who were locums. 21 The clinical reviewer considers that a reliance on
locum doctors at Norwich has resulted in a lack of continuity and may
have put pressure on local specialist services, such as palliative care. In
addition she found no evidence of an induction plan for locum doctors
which would include clinical pathways for specialist care in the outside
community. The clinical reviewer has also referred to a drug error in the
man’s medical record that was made by a locum doctor. Although on
investigation the error was found to have been made due to the doctor
trying to prescribe a drug electronically, the clinical reviewer considers
this illustrates the lack of a robust induction for locum doctors. I repeat
the clinical reviewer’s recommendation here:
A locum and new doctors’ induction pack should be developed to
provide information about the complex health needs of the
prisoners in HMP Norwich.
81. The man suffered from asthma for many years. The clinical reviewer is
critical of Norwich’s approach to chronic disease management. She
considers that their approach did not mirror what is available in the wider
community. As it is not directly related to the man’s death I make no
recommendation in this regard. However, the Governor and Head of
Healthcare will wish to carefully consider the contents of the clinical
review, which includes the following:
“Although HMP Norwich chronic disease management is provided on
an in reach basis by nurse practioners to the general prison population
there is no evidence to suggest that the man’ asthma was assessed by
a nurse practitioner. It is unclear how prisoners on L wing access the
full range of primary care services.”
Communicating the man’s diagnosis
82. Dr C at Gartree received information regarding the man’s diagnosis on
10 December. On 15 December the man told Nurse C at Gartree that he
was aware the chest x-ray results had shown some abnormalities and he
would undergo further scans and tests in the forthcoming weeks.
83. On 22 December the man told Nurse D at Gartree that he thought he
had lung cancer. Nurse D offered him reassurance that he could
discuss his condition with staff at any time. The man’s medical record
shows on 24 December healthcare staff were told that he was suffering
from small cell carcinoma of the lung. During his meeting with Nurse D
and Nurse F at Gartree, the man told them he believed he was suffering
from a virus that was affecting his lung and perhaps brain.
21 A locum doctor is not employed on a permanent basis by the PCT and will undertake duties
on a contract basis.
19
84. Nurse D at Gartree concluded that Nurse The manon, a lung clinical
nurse specialist from the Oncology Department at Leicester Royal
Infirmary, should be asked how much the man knew about his diagnosis
and that staff had decided it would be cruel to give him any further
information on Christmas Eve. In the circumstances I consider this to be
appropriate.
85. The man’s medical record shows that Nurse D at Gartree contacted
Nurse The manon on 30 December about the man’s appointment to
discuss his treatment plan. However, it is not clear if Nurse The manon
was told of Nurse D’s decision not to inform the man about his diagnosis
because it was Christmas Eve.
86. Nurse D at Gartered accompanied the man to the Oncology Unit at
Leicester Royal Infirmary on 6 January for an appointment with the
consultant oncologist. During the appointment the consultant oncologist
outlined the man’s treatment plan. In his medical records Nurse D has
noted that the consultant oncologist did not check how much the man
had been told about his condition by the Glenfield Hospital. The doctor
opened the appointment by telling the man he was there to discuss his
treatment for lung cancer. The man was understandably shocked and
burst into tears. It is very unfortunate that the man found out about his
diagnosis in this way. I would urge the Head of Healthcare to consider if
more could have been done to liaise with the Oncology Department to
avoid this. However, the decision of Nurse D to accompany the man to
the appointment was compassionate and allowed her to offer him
support. I commend Nurse D for her actions.
The man’s refusal of treatment
87. Following his diagnosis the man had his first chemotherapy session on
15 January 2010. This was followed by a second session on 5 February.
The man discussed his diagnosis with Nurse D at Gartree on 21
February. He told Nurse D that he had decided to stop his
chemotherapy treatment because it was making him physically ill. Nurse
D noted that the man appeared to be very stressed about going out to
the hospital for his treatment.
88. Nurse at Gartree met with the man again on 5 March to discuss his
decision to stop the chemotherapy treatment. The man told the nurse
that he was aware of his condition but felt that the treatment was worse
than the disease. He said he felt as if ‘the whole world was crashing
down on his shoulders’. The nurse tried to persuade the man to discuss
his decision with the doctor and to consider taking an anti-depressant.
However, the man was adamant that he did not wish to do so. The man
asked that the staff respected his wishes to discontinue the treatment.
89. On 8 March the man told Nurse C at Gartree that he was finding his
decision to stop the treatment difficult to cope with. He advised the man
to raise any concerns with healthcare staff. On 12 March the man
20
signed a treatment disclaimer form. The form said he recognised that his
refusal was against medical advice.
90. In his letter to Gartree of 18 March, the consultant in clinical oncology
explained that the man had a chemo-sensitive tumour and following
several cycles of chemotherapy could have a remission which
sometimes lasted over a year. The consultant in clinical oncology went
on to say that the man needed to come and have a discussion about his
situation without committing to any treatment. Nurse D discussed the
consultant in clinical oncology’s letter with the man on 25 March. The
man said he was feeling much better than when he was having the
treatment and did not wish to discuss his decision with the consultant in
clinical oncology.
91. On arrival at Norwich on 6 April the man told the doctor he felt unable to
discuss his ‘do not resuscitate’ (DNR) status. Following his referral to
the palliative care team on 18 May the man underwent a comprehensive
assessment with the palliative consultant. During this assessment the
palliative consultant noted that the man was aware that his condition was
incurable and he was comfortable with his decision not to have any
further treatment.
92. The man’s capacity to refuse treatment was not formally assessed at
either Gartree or Norwich. Whilst at Gartree he discussed his decision
with Nurse D on several occasions. He also spoke to a doctor at
Norwich, who was confident that he understood and was comfortable
with the decision he was making. Whilst I do not doubt that staff at both
prisons considered the man’s mental capacity to refuse treatment (and
were satisfied that his capacity was intact) it is concerning that this is not
documented.
The Governors and Heads of Healthcare at both Gartree and
Norwich should remind staff of the importance of assessing and
recording mental capacity assessments where a prisoner is
refusing treatment.
Use of restraints at the Priscilla Bacon Lodge
93. The man was moved to the Priscilla Bacon Lodge for symptom control
and a blood transfusion. It was initially hoped that he would be able to
return to Norwich once his condition had been stabilised. On admission
to the hospice he was escorted by two officers and cuffed to one of them
by means of an escort chain. The Head of Healthcare at the time, told
the investigator that whilst the man was able to move independently
albeit with assistance, he was a very unwell man. In her opinion the
man’s condition meant that he was too ill to be able to escape from
custody. The Head of Healthcare at the time emailed the acting
Governor to ask him to consider the use of an escort chain only.
21
94. At the time of his admission to the Priscilla Bacon Lodge the man’s
condition had deteriorated and he was described by the palliative
consultant as ‘weak and breathless’. The risk assessment completed on
1 June described the man’s medical condition as life threatening and he
would probably not be returning to Norwich.
95. The man’s risk assessment was reviewed on 4 June by Governor A.
The risk assessment remained unchanged. Governor B visited the man
on 5 June. He told my investigator that the man was still able to walk
around the Priscilla Bacon Lodge and he considered that the risk
assessment in place was appropriate.
96. The following day the Head of Healthcare expressed her concern about
the risk assessment to Governor C in the security department. In her
opinion the man was a very frail and terminally ill man with an extremely
poor prognosis. The Head of Healthcare told Governor C that the man’s
cuffs should be removed and he should be supported by a discreet
officer. She considered that the man’s poor physical condition would
prevent him from escaping. The man’s restraints were removed on
7 June.
97. The decision on whether to restraint a prisoner in a hospice is a difficult
one. The balance between decency and security can be hard to judge.
As I have previously mentioned the man was initially moved to the
Priscilla Bacon Lodge to stabilise his condition. I therefore consider the
level of restraints used appropriate. However, once it was established
that he would not be returning to Norwich I judge that the restraints
should have been removed and the presence of the bedwatch officers
would have provided adequate security at this time.
The Governor should remind senior managers to seek advice from
Healthcare colleagues on the medical condition and mobility levels
of seriously ill prisoners when determining the cuffing levels for
outside escorts
Breaking the news of the man’s death to his next of kin
98. The Head of Healthcare at the time told my Investigator that she had
contacted the man’ brother on 1 June. During their conversation she told
the man’ brother about his move to the Priscilla Bacon Lodge. She said
the man had asked her to keep his brother informed. She had agreed
with the man’s brother that she would contact him if there were any other
changes.
99. During her interview the Head of Healthcare at the time told my
investigator that she had visited the man at the Priscilla Bacon Lodge on
either the 6 or 7 June. She was aware that the man was in regular
telephone contact with his brother at that time. Following the man’s
22
death the Head of Healthcare at the time was asked by the acting
Governor to contact his brother to break the news of his death. She said
the role of informing the next of kin was usually undertaken by a trained
family liaison officer but that she undertook it on this occasion as she had
been in contact with the family previously.
100. The acting Governor confirmed to my investigator that, as the Head of
Healthcare at the time was in regular telephone contact with the man’s
brother, he considered her to be the most appropriate person to contact.
101. There is specific guidance in Prison Service Order (PSO) 2710 (Follow
up to Death in Custody) on how the news of a prisoner’s death should be
passed on to their next of kin. The PSO says that Governors must:
“Arrange notification to the next of kin and any other person reasonably
nominated by the prisoner as soon as possible in a suitable manner,
giving an accurate factual account of what has happened.”
The accompanying Family Liaison Officer (FLO) guidance
recommends that:
“The family should be informed face to face as soon as possible after
the death. Wherever possible this should be done by a dedicated
Family Liaison Officer working alongside the Chaplain, or Governor or
most senior individual available together with the Chaplain.
“If distance from the prison presents a problem, a dedicated Family
Liaison Officer or chaplain based in the area nearest the family home
could inform the family face to face.
“The prison should demonstrate its duty of care and show that it is
taking the death seriously by making a personal visit.”
102. The man’s brothers live in Newcastle so it would not have been
unreasonable to have contacted a prison nearer to there to ask them to
break the news in person. However, the Head of Healthcare at the time
had already established a relationship with the man’s brothers and they
were already aware that he was terminally ill. In addition, it had also
been agreed with the brothers that they were to receive updates to the
man’s condition over the telephone.
103. Governor D, a trained Family Liaison Officer, also made contact with the
man’s brothers and this was entirely appropriate under the
circumstances. Although the guidance in PSO 2710 was not followed I
do not consider that the way in which the news was broken to the man’
family was unreasonable under the circumstances.
23
CONCLUSION
1. The man was diagnosed with small cell carcinoma of the lung whilst at
HMP Gartree. He began a course of palliative chemotherapy in order to
achieve a period of remission. Unfortunately he found the treatment too
physically demanding and he decided not to continue. On 6 April 2010
he was moved to HMP &YOI Norwich on the grounds of his deteriorating
health.
2. The man was referred to the palliative care team and following a
comprehensive assessment, he was moved to the Priscilla Bacon Lodge
for symptom control and a blood transfusion on 3 June. However his
condition further deteriorated and he sadly died on 10 June.
3. The clinical reviewer finds that the man that his overall medical
management was satisfactory and his death could not have been
prevented. Nevertheless there are some areas that could have been
improved, most notably carrying out a formal assessment of the man’s
capacity to refuse treatment. The man received regular support from the
mental health team. This support was not continued at Norwich and no
mental health assessment was undertaken.
4. Despite his deteriorating physical condition the man’s restraints were not
removed until three days before his death.
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RECOMMENDATIONS
1. Prisoners on L wing who are receiving palliative care should be offered
support from the mental health team at the prison.
Accepted- An assessment is carried out by the Nurse in Charge on all
palliative care patients and should they require a mental health
assessment this will be actioned.
2. HMP Norwich should have an agreed End of Life Care pathway which
reflects the care available in the wider community.
Accepted- End of Life Care Pathway will be developed in conjunction
with the Prison and Healthcare.
3. A locum and new doctors’ induction pack should be developed to provide
information about the complex health needs of the prisoners in HMP
Norwich.
Accepted- This has been added to the newly developed Doctors
induction pack.
4. The Governors and Heads of Healthcare at both Gartree and Norwich
should remind staff of the importance of assessing and recording mental
capacity assessments where a prisoner is refusing treatment.
Not accepted- The Mental Capacity Act makes it clear that a person
must be assumed to have capacity unless it is established that he or she
lacks capacity. The report states that the man spoke to a doctor at
Norwich who was confident that he understood that he understood and
was comfortable with the decision he was making.
5. The Governor should remind senior managers to seek advice from
Healthcare colleagues on the medical condition and mobility levels of
seriously ill prisoners when determining the cuffing levels for outside
escorts.
Accepted- This will be included in the End of Life Care Pathway, and
communicated to Prison Managers. The External Escort Risk
Assessment booklets require that medical information is provided – in
particular, whether the prisoner has any medical condition to influence
the application of cuffs or considerations of any medical factors in
respect of the escort (to influence cuffing arrangements or staffing
levels). A reminder will be issued to all operational Duty Managers of the
need to ensure this information is obtained, entered within the booklet
and taken into consideration when making their assessment.
25