Individual at Isle of Wight

Investigation into the circumstances surrounding the
death of a man
at HMP Isle of Wight in March 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2011
The man was a prisoner at HMP Isle of Wight (Albany site) when he died of
disseminated adenocarcinoma of the stomach (stomach cancer) in March 2010. He
was 52 years old when he died.
I would like to extend my condolences to the man’s family and friends and all those
affected by his death. I apologise for the delay in issuing this report and for any
distress this has caused.
My colleague was appointed to investigate the circumstances of the man’s death. A
clinical review was commissioned from Isle of Wight Primary Care Trust and led by a
clinical reviewer. I am grateful for his contribution to this investigation, and to the
members of the panel convened to assist the review.
I am also grateful to the Governor of HMP Isle of Wight and his staff for their help
and co-operation during this investigation. In particular I would like to thank the
individuals who acted as liaison for the investigation.
The clinical review carried out by the clinical reviewer and his panel found that the
man had received appropriate treatment after being diagnosed with cancer in 2009.
However, they were concerned that an attempt was made to resuscitate the man
when healthcare staff clearly thought that he had died. The man’s family also had
concerns about the manner in which they were informed of his death. I am satisfied
that although staff acted according to the instruction of the relevant Prison Service
Order, news of the man’s death reached the family by other means before officers
had left the island to break the news. In my opinion, this could have been avoided.
I make three recommendations as a result of this investigation. One relates to family
liaison, and another the compassionate release process. I also make a
recommendation about resuscitation.
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 Prisons and Probation Ombudsman September 2011
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CONTENTS
Summary
The investigation process
HMP Isle of Wight – Albany site
Key events
Issues
Conclusion
Recommendations
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SUMMARY
1. The man was convicted in 2004 of serious sexual offences. He arrived at
Albany at the end of that year. He had little contact with healthcare during the
first five years of his sentence, other than receiving painkillers for an old hip
injury and medication to help him lose weight.
2. In the summer of 2009, the man reported having difficulty swallowing and mild
stomach pain. He was prescribed medication and a follow-up appointment
was made. However, he missed that appointment and it was over two months
after he first reported symptoms before he was sent to hospital for an urgent
endoscopy (a surgical procedure in which a camera is inserted into the
oesophagus).
3. Shortly afterwards, the man was diagnosed with stomach cancer. Over the
next few months, he had chemotherapy treatment and was seen regularly by
specialists in palliative care.
4. In February 2010, the Parole Board rejected an application for his release, as
they thought that he still needed to address his offending behaviour. His
health began to deteriorate at the start of March and he agreed to move from
the wing to the healthcare centre.
5. However, on the day of his proposed move, he was found unresponsive in his
cell. Although most staff thought that he had died, they tried unsuccessfully to
resuscitate him. Although family liaison officers left the prison soon after the
man’s death was confirmed, his family learnt of his death after another
prisoner telephoned them.
6. I make three recommendations as a result of this investigation. One
recommendation relates to family liaison, and another to the compassionate
release process. I also make a recommendation about resuscitation.
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THE INVESTIGATION PROCESS
7. Following notification of the man’s death, one of my investigators was
appointed to conduct the investigation. HMP Isle of Wight provided a copy of
his prison records, including his medical records. Notices were issued to
prisoners and staff inviting anyone who had information regarding the man’s
death to make themselves known to the investigator. No other witnesses
came forward.
8. My investigator visited HMP Isle of Wight on 5 May 2010 to carry out recorded
interviews with seven members of staff.
9. One of the Ombudsman’s Family Liaison Officers contacted the man’s family
to explain the role of the Ombudsman and to offer the opportunity to
participate in the investigation. They asked for the following concerns to be
addressed.
10. The man’s Parole Board hearing was in November 2009 and his consultant
submitted a letter requesting that he should be moved nearer to his family due
to his short life expectancy. The family were concerned that this was not
granted and caused them difficulty in visiting him. They said they did not
know when they could visit because of the man’s hospital appointments and
said they felt as if they were constantly asking the prison to try to arrange
visits. The man’s family said the prison did not seem to facilitate the visits
and, given the gravity of his illness, they found this unacceptable. They
believed a better system for visiting terminally ill prisoners should be in place
that causes less stress and upset for families. The man’s family said that he
had been well cared for in prison, but felt that the problems were due to
security issues.
11. The man’s family contacted the prison at 12.30pm on the day of his death and
were told that the Governor would telephone them back. They were then told
by another family member that the man had died. They contacted the prison
again and were once again told that someone would call them back, but again
nobody telephoned. The Governor eventually telephoned at 4.00pm and
explained that he could not discuss the man over the telephone and was
sending two staff members to their home. The family expressed concern that
another family member had already been telephoned by a prisoner and told
that the man had died. They were concerned about the prisoner’s offences
and wondered how he had obtained the telephone number and been allowed
to speak to the family member and her children. The family confirmed that the
man’s property had been returned to them, apart from a couple of
photographs and that the prison had assisted with the cost of funeral
expenses.
12. Isle of Wight Primary Care Trust were commissioned to conduct a clinical
review. They appointed a clinical reviewer to conduct the review. The clinical
reviewer also carried out some joint interviews with my investigator. A review
panel meeting was held in June 2010, and the minutes of this meeting
forwarded to my investigator late in August.
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13. Both the prison and the man’s family were given the opportunity to comment
on the draft report. The prison responded on 4 May and my family liaison
officer spoke to members of the man’s family who gave their response in
September 2011. Both the prison and the man’s family give different
accounts of the issue regarding family visits. This is covered in detail in the
issues section of this report.
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HMP ISLE OF WIGHT – ALBANY SITE
14. HMP Isle of Wight was inaugurated on 1 April 2009. It is the amalgamation of
the former Albany, Camp Hill and Parkhurst prisons. HMP Isle of Wight holds
approximately 1,700 prisoners across the three sites. Each site has its own
Director who reports to the Governor of HMP Isle of Wight.
15. Albany is a category B training prison. It opened in 1967 on the site of a
former military barracks. It offers a varied regime with education and several
offending behaviour programmes.
16. There are five wings that have single cells and access to electronic night
sanitation (this is when the cell door unlocks for a limited time to allow the
prisoner to go to the toilet). There are three small areas on each landing with
communal recesses containing showers, toilets and wash basins.
17. Health services at HMP Isle of Wight are commissioned and provided by Isle
of Wight Primary Care Trust (PCT). A new in-patient healthcare unit (IHU)
was opened in October 2009 and situated at Albany. It has 12 beds and
provides for prisoners with a wide range of health needs who require a
hospital type in-patient care within a prison setting.
18. Doctors from a local community practice attend Albany for four three hour
sessions each week. Evenings and weekends are covered by on-call doctors
from the same practice. Prisoners with more serious conditions or clinical
needs are referred to the local hospital.
19. A risk assessment must be completed when prisoners attend hospital in-
patient and out-patient appointments. This is to determine the level of escort
and restraints (handcuffs) required to ensure the safe custody of the prisoner.
Restraints are applied if the risk assessment states they are necessary. If a
prisoner is admitted to outside hospital, prison staff will carry out a bedwatch
duty. This means the staff will stay with the prisoner at all times and maintain
a log of all activity. Visits may be allowed from the prisoner’s family, but these
will be closely monitored to ensure they do not interfere with security.
Independent Monitoring Board
20. Each prison has an Independent Monitoring Board (IMB). IMB members are
independent and unpaid. They monitor day-to-day life in their prison and
ensure that proper standards of care and decency are maintained. Each IMB
produces an annual report. The latest available report for Albany, for the year
2007/08, drew attention to limitations in the healthcare services at Albany.
However, since this report was issued, the new healthcare centre has been
completed.
Her Majesty’s Chief Inspector of Prisons
21. The last inspection report covering Albany was published following a full,
announced inspection conducted between 12 and 16 November 2007. In her
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foreword, the then Chief Inspector of Prisons noted that five of the wings at
Albany lacked internal sanitation, a practice that she called “unacceptable in a
21st century prison”. However, she described Albany overall as having an
“important, difficult and specialist role” and that it delivered “well-run and
effective [offender] treatment programmes”.
22. Inspectors also found that access to primary medical services was good,
although staffing more generally was a problem across the Isle of Wight
cluster. Secondary healthcare was provided by hospitals on the island and
mainland, but appointments were often cancelled because of a lack of
escorts.
Previous deaths in custody at Albany
23. Since the Ombudsman took responsibility for investigating deaths in custody
in April 2004, there have been 23 deaths at Albany, of which 19 occurred
before that of the man who is the subject of this report. All but two of these
deaths have been because of natural causes. Although several of these
deaths were due to cancer, there are few similarities in the circumstances
between those and this man’s death. I have, however, made a
recommendation in the past about visiting orders for the families of terminally
ill prisoners.
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KEY EVENTS
24. The man arrived at HMP Isle of Wight from HMP Exeter on 12 November
2004. He had been convicted of several sexual offences at a crown court
and, on 26 October 2004, was sentenced to ten years in custody. He was
due for a parole review in December 2009. This was his first prison sentence.
25. As is usual on reception, the man was seen by healthcare staff when first
remanded in custody at Exeter. He reported that following a motor cycle
accident when he was 20, he had arthritis in his hips and was waiting for a hip
replacement operation. (He later agreed that the operation should be left until
after his release.) At both Exeter and Albany, the man was accommodated in
suitable locations to help him cope with his lack of mobility.
26. After he arrived at Albany in November 2004, the man was given a cell on C
wing and worked as a cleaner on the wing for a short while, until starting work
at the wood mill. He remained working at the wood mill until shortly before his
death. The man also completed several treatment programmes. In an
assessment for a parole application in 2009, an officer wrote that the man had
completed the Sex Offender Treatment Programme and the Enhanced
Thinking Skills programme with “good reviews”. The officer said that the man
“appears to have benefited considerably [and] understands his offending
behaviour”.
27. The man was seen by healthcare staff on a number of occasions between his
reception into Isle of Wight and 2009, although none of these appointments
appear to have been significant. On several occasions, the man reported
having pain in his hip. In addition to being given painkillers, he was advised to
try and lose some weight. He was also prescribed orlistat, a medication which
assists weight loss, in December 2008. Over the next four months, the man’s
weight was monitored, and it was noted that he was “responding to orlistat”.
28. However, on 23 June 2009, the man reported a short history of weight loss
(although he had been on a diet), difficulty in swallowing and mild abdominal
discomfort. He was prescribed a 28 day course of omeprazole (a drug which
inhibits the production of stomach acid) and a nasal spray. The next entry in
the medical records shows that the man was prescribed a further 28 day
course of omeprazole on 21 July. Six days later, he was issued with
paracetomol (a pain killer) and Gaviscon tablets (also for stomach acid
problems).
29. The man failed to attend a doctor’s appointment arranged for 31 July. He did
not go to healthcare again until 18 August, when another course of
omeprazole was prescribed.
30. On 7 September, the man attended healthcare as he was again having
difficulty swallowing. He said that solid food kept getting stuck in his throat.
He was referred to outside hospital for an urgent gastroscopy (a procedure in
which a camera is used to view the upper alimentary canal). This took place
three days later.
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31. Just over a week later, the man was seen by a doctor at Albany who had
received a letter from a consultant at outside hospital. The letter confirmed
that the man had a malignant neoplasm (cancer) of the pyloric canal (the
pyloric canal is the opening between the stomach and the small intestine).
The doctor at Albany discussed the diagnosis with the man, and prescribed
two antibiotic drugs, clarithromycin and amoxicillin, and Lansoprazole, to help
combat stomach acid.
32. The next day, the man had a further CT scan (computerised tomography, an
imaging method that uses x-rays to produce a cross sectional view of the
body). On 29 September, the hospital tests confirmed that the man had
adenocarcinoma (a form of cancer) of the stomach and oesophagus with
extensive metastatic deposits in his liver and lymph nodes (which means that
the cancer had spread from its initial location). At first, the man appeared to
be in shock when he was given the news, and was tearful and low for a
number of weeks. An officer on the man’s wing said that after a while he
appeared to come to terms with his diagnosis and began to put his affairs in
order.
33. The man spoke to an officer on his wing about his parole application. He
asked the officer whether he thought he might be eligible for compassionate
release. The officer suggested that he should speak to his offender
supervisor in the first instance.
34. On 13 October, the man began chemotherapy treatment after seeing an
oncologist the week before. He discussed his diagnosis with a consultant in
palliative care at outside hospital, and he was told that his cancer was
inoperable but that palliative chemotherapy was an option. A senior staff
nurse at Albany also discussed the man’s care with the consultant in palliative
care. They discussed the possibility of bacterial infection while the man was
undergoing chemotherapy, and the consultant in palliative care stressed the
importance of monitoring the man’s temperature. The senior staff nurse
arranged for a thermometer to help the man monitor his own temperature.
35. By late October, staff at Albany began collating evidence for a parole
application. The man confirmed to healthcare staff that he was happy for
details of his illness to be shared with prison and probation staff.
36. The man saw a doctor at Albany on 29 October. He reported having several
side effects, including diarrhoea and insomnia, for which he was prescribed
Immodium and zopiclone respectively. The next day, the man was seen by
healthcare for a flu vaccination. His temperature was recorded as 37.4C, and
he was taken to outside hospital as a precaution. He returned to Albany on
the same day, and eventually had the vaccination on 20 November.
37. From paperwork held on the man’s file, it is clear that by January 2010 staff at
Albany had started to prepare an application for compassionate release. A
woman from the Offender Management Unit at Albany explained the process
for applying for parole to my investigator. She explained that the man had
10
completed the application for parole which had been forwarded to her
department. As there is a considerable amount of paperwork, including
reports, which need to be compiled, the process can take three or four
months. The woman from the Offender Management Unit at Albany recalled
that an officer told her around this time that the man was unwell and asked
her to look into raising an application for early release. She explained that as
he was going through the normal parole process anyway, it would be ideal to
send all the paperwork to the Parole Board so they could consider the man’s
release under normal procedures and also under compassionate release.
38. The woman from the Offender Management Unit at Albany also explained that
her department were still awaiting an internal probation report, a governor’s
report and a healthcare report for the man. She eventually received two of
these reports, but the governor’s report remained outstanding. While the
medical case for release was made, the prison probation officer thought that
the application was “premature”, as the man continued to be “quite active”.
The prison probation officer noted though that he hoped that a future
application would be expedited if the man’s condition deteriorated
39. The woman from the Offender Management Unit at Albany sent the
paperwork she had to the Parole Board, for the man to be considered for
release under normal parole conditions, as they did not have the governor’s
report to submit for consideration for compassionate release. (My investigator
also interviewed the governor who the woman from the Offender Management
Unit at Albany said she requested the governor’s report from. The governor
told my investigator that he did not recall seeing any paperwork for the man,
and in any case, was not the governor responsible for parole. The governor
presumed that if such paperwork had been sent to him, he would have
forwarded it to the Governor or Deputy Governor of the Isle of Wight site.)
40. For the next three months, the man continued to receive chemotherapy at
regular intervals. In a letter to his solicitors on 29 January, the consultant in
palliative care reported that the man had responded well to chemotherapy,
although he had started to deteriorate. However, he was also being treated
for a pain in his right side, which the consultant in palliative care thought might
represent a sign that his cancer had started to progress. The man also had a
low blood count. (Blood counts count the number of cells in the blood. A low
blood count is often a side effect of chemotherapy.)
41. The Parole Board met on 9 February to discuss the man’s parole application.
The Board decided that the risk he presented was such that he could not be
safely managed in the community, and they refused the application. In
refusing the application, they noted that he pleaded guilty at court and had
completed a number of courses to address his offending behaviour. They
also noted his illness and the likely prognosis. They found, however, that
further offender treatment work was necessary, and also took into account
that both the man’s offender manager and senior probation officer had
recommended that the application be refused.
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42. In the meantime, the consultant in palliative care wrote to the prison
suggesting that they considered compassionate release. A doctor at Albany
saw the man and passed him fit to work in his old workshop.
43. A consultant of palliative medicine saw the man in his cell at Albany on 26
February. The consultant of palliative medicine later wrote to the consultant in
palliative care describing the man as being “in good spirits” and being able to
swallow comfortably. They discussed the possibility of the man being
released and returning to the south-west of England to be near his family.
The consultant of palliative medicine agreed to meet the man a month later.
44. On 4 March, the man attended a support group with a nurse. The nurse
noted that he looked pale, and asked the man if he wished to speak to her
alone. He told her that he was starting to find it hard on the wing, with some
insensitive comments from other prisoners. The nurse suggested that he
move to the impatient unit for a few days for some respite, and the man
agreed to consider this.
45. Two days later, the nurse saw the man again. He asked if he could be moved
to a lower level of the wing as he was getting breathless walking up the stairs.
Staff agreed to consider this. The man also said that he would see a doctor
the following week to review his pain control medication. The nurse recorded
that the man was being “positive” about his condition, although he was
concerned about telling his partner, a prisoner on another wing, about how
bad his condition was.
46. The man was seen in healthcare by a senior staff nurse on 8 March. The
senior staff nurse noted his severe weight loss and telephoned the consultant
in palliative care for advice. The consultant in palliative care asked how the
application for compassionate release was progressing, and the senior staff
nurse told her that the paperwork was still being prepared. The next day, the
consultant in palliative care advised that the review with the consultant of
palliative medicine should be brought forward in light of the man’s
deterioration and increasing pain. At the same time, an officer asked him if he
would be prepared to move to healthcare.
47. The next day, the same officer unlocked the man at approximately 9.30am.
The man confirmed that he would like to move to healthcare. The officer
arranged for some other prisoners to help the man pack his belongings and,
while they were doing so, the man went to speak to a prisoner in another cell.
Shortly afterwards, the man said he felt unwell and was seen by a senior staff
nurse who noted that he looked “sallow and waxy and … ill at ease with his
various aches and pains”. A further nurse checked on him at about 10.45am.
By this time, the man was back in his own cell. His belongings were packed
and he was ready to move.
48. An officer was on duty that day and was responsible for locking prisoners
back in their cells for lunch on the man’s landing. At approximately 12.15pm,
he went to the man’s cell and found the door closed but unlocked. He opened
the observation panel on the door and thought that the man was sleeping as
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he was lying on the bed. As he was about to lock the door, the officer
remembered that the man was ill and instead went into the cell to check on
him. However, he could not get a response from the man, and noted that his
lips were blue and “his skin did not look natural”. As he did not have a radio
(not all officers on the wing are allocated a radio when they begin their shift),
the officer locked the cell and went to get help. He saw an officer further
along the landing and asked him to come to the cell.
49. The officer who came to help his colleague confirmed to the investigator that
he thought the man had died, and called for urgent medical help on his radio.
(Unlike other prisons, Albany does not use a code system to describe the type
of emergency.) Two nurses went to the cell with an emergency bag and
checked for signs of life, but were unable to find any. The officer who had first
found the man in his cell was asked to contact the control room and
paramedics were called. They were joined shortly afterwards by a senior staff
nurse and another colleague who was also a nurse.
50. The senior staff nurse assessed the man and found that he had no pulse, was
not breathing and had fixed pupils. When interviewed by my investigator, the
senior staff nurse told her that he thought that the man was dead and that he
had died peacefully. He believed that the most dignified course of action
would have been to leave the man, but he was also aware that other
members of staff were questioning whether they should attempt to resuscitate
him. As a result, the senior staff nurse decided that they should attempt to
resuscitate the man and, with another nurse, he started chest compressions.
He also used the emergency defibrillator (a machine which detects electrical
activity in the heart and advises on what action to take) but was advised by
the defibrillator not to administer any shocks.
51. Shortly afterwards, at 12.35pm, paramedics arrived and took over the
resuscitation, moving the man to the corridor (other prisoners had been
locked in their cells by officers shortly after the man had been found). They
continued until a doctor arrived from the Parkhurst site after being asked to
attend. At 12.55pm, the doctor confirmed that the man had died.
52. Following the man’s death, two family liaison officers were appointed. After
making some checks, arranging a hire car and collecting some overnight
clothes, they left the prison at 3.30pm to visit the man’s family in Devon.
53. However, before they had left the island, the SOs were told that the family had
already been informed of the man’s death by a prisoner at Albany. They
continued the journey, but agreed to visit the family the following day rather
than the same evening.
54. Other prisoners on the man’s wing were told of his death by the Head of Safer
Custody. The Head of Safer Custody asked them to speak to staff if they
were upset, and they were also offered the opportunity to speak to a Listener
(Listeners are prisoners who are trained by the Samaritans to offer support to
other prisoners). All prisoners who were receiving support under ACCT
procedures (which aim to protect prisoners at risk of self harm or suicide). He
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also confirmed to them that the man’s partner, who was on a different wing,
was being supported.
55. A briefing for staff was held, in which they discussed any concerns and were
offered support. Notices were issued to prisoners and staff by the Director of
Albany informing them that the man had died and explaining the support
available to them.
56. The man’s funeral was held on 25 March. One of the family liaison officers
went to the funeral on behalf of Albany, accompanied by a Governor, and the
prison contributed to the cost of the funeral. The family liaison officer met the
man’s sister the day before the funeral and returned his property.
14
ISSUES
Clinical care
57. A review of the clinical care provided to the man was conducted by a clinical
reviewer. A panel review meeting was held on 29 June 2010.
Diagnosis of the man’s illness
58. The first issue the panel reviewed was whether the man’s cancer was
diagnosed appropriately. He had initially complained of having difficulty
swallowing on 23 June 2009 and was seen by a doctor. He was prescribed
medication and a follow up appointment arranged. However, the man did not
keep the appointment for 31 July, although it is not clear why. When he next
saw the doctor, on 18 August, he was given further medication and was then
seen again on 7 September. At this point, the man was referred to outside
hospital for an urgent endoscopy.
59. The review panel noted that a prison doctor at Albany had arranged a follow
up appointment for the man, but that he had not attended. The doctor from
the Parkhurst site, who was a member of the clinical review panel, thought
that the man did not meet the criteria for an urgent referral when he first saw
the prison doctor and noted that a further follow up appointment was made for
him.
Attempt to resuscitate the man
60. When the man was found in his cell on the day of his death, both officers who
first attended to him thought that he was dead. The officer who had
responded to the call for help from the original officer who had found the man
confirmed when interviewed by the investigator that he thought the man had
been dead for at least 20 minutes. He called for assistance, saying that there
was a medical emergency, but did not give any further details as there were
other prisoners on the landing.
61. It is clear that staff responded quickly to the officer’s call. Two nurses arrived
with appropriate medical equipment, and further help arrived shortly
afterwards. A senior staff nurse told my investigator that, when he arrived, the
nurses were checking for signs of life and that they believed that he had died.
62. The senior staff nurse also checked the man and believed that he had been
dead for some time. Given his knowledge of the man’s illness, he felt that it
would be inappropriate to attempt to resuscitate him. However, while he was
making his assessment, he became aware that other members of staff were
suggesting that an attempt should be made and that they were becoming
anxious. The senior staff nurse then decided to attempt to resuscitate the
man. The doctor from the Parkhurst site noted at the panel review that, when
she arrived, a resuscitation attempt was ongoing, which surprised her.
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63. I am satisfied that the man was, in all likelihood, already dead when the first
officer found him, and that he had died some time before. Given that he was
terminally ill, I also agree with the senior staff nurse that resuscitation was not
the most appropriate cause of action. The clinical review panel also found
that the attempt to resuscitate the man was not respectful. I make a
recommendation about this issue. This is to ensure that staff are aware
whether terminally ill prisoners wish to be resuscitated when they die. (I
accept that, when he died, the man was not on the healthcare unit and, even
if this had been discussed with him, not all the staff on the wing would have
been aware, given confidentiality issues.)
The Governor and Head of Healthcare should ensure that a Do Not
Resuscitate (DNR) policy is in place for terminally ill prisoners and that
the relevant staff are aware of the policy.
64. The review panel made a further recommendation about healthcare having
the right to decide whether a resuscitation attempt should be made. They
refer to PSO 2700 (a Prison Service Order which relates to suicide and self
harm attempts) in their recommendation. I do not make a recommendation of
my own, but would urge the Governor and Head of Healthcare to make sure
that this issue is discussed openly at Albany, and that officers and healthcare
staff feel able to make decisions in the best interests of terminally ill prisoners.
65. Overall, the panel found that the man received the equivalent standard of care
to that of a patient in the community.
Refusal of parole
66. The man’s family have asked me to look at the decision of the Parole Board in
November 2009, when his application for parole was refused. Decisions of
the Parole Board do not fall within my terms of reference and I am unable to
comment on the decision itself. However, I have given a copy of the Parole
Board’s refusal to his family, and I hope this will help them understand the
decision.
The delay in submitting documents for compassionate release
67. There seemed to be some confusion about who the man’s application for
release on compassionate grounds was forwarded to. The Executive Officer
in charge of the Offender Management Unit said that she forwarded the
governor’s report to the Director of Albany but had not received a completed
copy. She said that without this report, the man could not be considered for
compassionate release, but only for parole under normal conditions. It is
unclear how much effort was made to chase up the outstanding report. It
appears that it took the intervention of a senior officer, who asked about the
man’s parole decision, to alert staff to the outstanding report. This was only a
short time before the man died. In any case, it appears that the paperwork
was not sent to the correct governor, and was mislaid.
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The Governor should ensure that staff are aware of the roles and
responsibilities of staff in compassionate release applications, and that
there is a system in place to ensure the appropriate actions are taken in
a timely manner.
Family visits
68. The man’s family have also said that they found it difficult to visit him, partly
because of his medical treatment. My investigator has not found any record
that the man had any difficulty arranging visit orders and, indeed, an officer
said at interview that the man did not mention having any difficulties. I am
also aware that one of the man’s sisters spoke to outside hospital and knew
when his appointments were, as this was recorded in his file. There was no
mention there that his prison visits should be curtailed. It is clear, however,
that the man’s family feel that it was very difficult to visit him, which distressed
them especially given the nature of his illness. I have previously made a
recommendation in another case about visiting orders for terminally ill
prisoners at Albany. While I do not repeat the recommendation here, I
suggest that the Governor assures himself that the visit process for those with
terminal illnesses is as straightforward as possible.
69. The man’s family were given the opportunity to comment on the draft report.
They had felt extremely distressed and upset by the report and gave their
comments to my family liaison officer on 6 September. In their response they
told my family liaison officer that their most significant concern was their
inability to see the man towards the end of his life. They said they found the
prison unhelpful and felt that due to the man’s terminal condition, special
consideration should have been given to the family when arranging visits.
The man’s family lived 150 miles from the prison and when they contacted the
prison to arrange a visit for that or the following day, they report that the
prison refused to tell them if the man was there or not. The man’s family feel
that concessions should have been made when he became seriously ill and
the facilitation of visits made a little easier.
70. However, the prison’s response on 4 May on this matter differs from the
family’s account. They reported as follows:
“[The man’s] sister and brother-in-law…. (nominated NOK), stated to
establishment FLO's that the reason that they had not been able to visit [the
man] recently was because he had instructed them not to come to the Island
as he was undergoing lots of tests and treatment at hospital and he did not
want them to have a wasted journey if on the day of a visit he was taken to
hospital for an appointment. He told them to wait until he had a better idea of
what was happening and then to arrange visits. Unfortunately [the man] died
several weeks before the doctors predicted that he would and obviously
before his family had visited.
During my conversations with them they expressed sadness that they had not
seen [the man] before he died but did appreciate that he had put off their
visits himself with their best interest at heart.
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This is contrary to the Ombudsman's investigator's draft report which seems
to indicate that they were refused or stalled in their attempts to visit by the
prison. It is the establishment’s practice to be extremely flexible with family
visits for terminally ill prisoners but if the prisoner restricts the family that is his
decision. I feel that this is not accurate and that the report should be
amended to reflect my comments above.”
Informing the man’s family of his death
71. Prison Service Order (PSO) 2710 (Follow up to deaths in custody) provides
guidance for prison staff on the best and preferred ways to inform families of a
death. The recommended option is that “the family should be informed face
to face as soon as possible after the death”. It is clear to me that staff at
Albany were trying to comply with this, the recommended, option. However,
the PSO also lists other options, and in particular mentions that they might be
used when the next of kin live at some distance from the prison. The location
of the prison on the Isle of Wight is clearly a factor which should be taken into
account in deciding what might be the best way to break such bad news. I
believe that the Governor should make sure that family liaison officers are
aware that they should use the appropriate option according to individual
circumstances.
The Governor should ensure that family liaison officers choose the most
appropriate method to inform a family of a death in custody.
72. The PSO also states that “Using the telephone is too impersonal to use in
delivering news of a death to the family and should be used only as a last
resort”. It is unfortunate that the man’s family telephoned the prison on the
day that he died but staff did not feel that they were able to tell them about his
death. However, a senior staff nurse, in particular, commented that he had
spoken previously to the man’s family and would have been comfortable
about breaking the news to them.
73. The man’s family have also asked how another prisoner was able to
telephone them with news of his death. On 24 November 2008, the man’s
partner asked to be allowed to include the telephone number of one of the
man’s sisters on his agreed list (prisoners are only allowed to make calls to
numbers on the list). On a security report for this date, an officer recorded
that he spoke to the man’s sister and she agreed to the request as her brother
was expecting to be transferred and wanted his partner to let his family know
where he was. This explains why the prisoner had the man’s sister’s number
and, as it was on his agreed list (known as a PIN list), why he was able to call
her. I hope that this explanation answers the family’s concerns.
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CONCLUSION
74. The man was serving a long prison sentence when he was diagnosed with
stomach cancer in 2009. An application for parole was refused and, after his
health began to decline, he was about to move to the healthcare unit when he
died suddenly.
75. While, overall, the man was well cared for at Albany, I have found that there
are three areas for improvement. These include that a do not resuscitate
policy is put in place, and that consideration is given to changes in how
families are informed of deaths in custody.
76. The prison and the man’s nominated next of kin have different accounts of
their experience of facilitating family visits. Both forwarded their comments to
the Ombudsman’s office after the draft report was issued. It is not for the
Ombudsman to judge which account is most accurate, but it is important to
record that these differences exist.
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RECOMMENDATIONS
1. The Governor and Head of Healthcare should ensure that a Do Not
Resuscitate (DNR) policy is in place for terminally ill prisoners and that the
relevant staff are aware of the policy.
Accepted by the prison. They responded as follows:
“Staff will use the UNIFIED DO NOT ATTEMPT
CARDIOPULMONARY RESUSCITATION (DNACPR) ADULT POLICY which is
available on the Trust website a copy has been sent to all Nursing Leads for
dissemination to all Prison Healthcare staff.”
2. The Governor should ensure that staff are aware of the roles and
responsibilities of staff in compassionate release applications, and that there
is a system in place to ensure the appropriate actions are taken in a timely
manner.
Partially accepted by the prison. They responded as follows:
“The system for Compassionate Release has historically been
appropriate – at the time of [the man’s] death the establishment was going
through major changes with respect to ‘Clustering’ of three sites. This did
cause confusion over overall responsibility for Compassionate Release
Applications at the senior level. However, [the man’s] case and poor
prognosis was taken into consideration by the Parole Board and early release
was declined. A system is in place to monitor and manage the remaining time
for terminally ill prisoners at HM Prison Isle of Wight. When the establishment
is made aware of a prisoner’s poor prognosis, the Death in Custody Lead
meets regularly with the prisoners on a personal basis to discuss their wishes
(this includes Compassionate Release) and to help smooth the way for family
contact. Due to Medical in Confidence policies, the establishment will not
always be aware of an accurate prognosis of a terminally ill prisoner and often
relies upon the prisoner informing the staff of his prognosis.”
3. The Governor should ensure that Family Liaison Officers choose the most
appropriate method of informing a family of a death in custody.
Not accepted by the prison. They responded as follows:
“This issue arose due to [the man’s] family dynamics; the
establishment carried out the Family Liaison role appropriately with the
nominated next of kin. [The man’s] two sisters held differing views on the fact
that [the man] had been in a long term relationship with another prisoner.
[The man’s] ‘partner’ had authorised telephone contact with one of [the
man’s] sisters who was accepting of the relationship, but no contact with the
sister who was nominated Next of Kin. When [the man] died, the
establishment deployed FLO’s to visit the nominated Next of Kin. This was to
conduct the face to face breaking of the news of the death of [the man]. [The
man’s ‘partner’ contacted one of [the man’s] sisters and broke the news of the
death of [the man] whilst the FLOs were travelling to the nominated Next of
Kin. This situation could not have been avoided if the establishment had
chosen other options to inform the Next of Kin.’
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