Individual at Usk and Prescoed

Investigation into the circumstances surrounding the
death of a man at Neville Hall Hospital
In October 2008, while in the custody of HMP Usk
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2009
This is the report of an investigation into the death of a 70 year old man at Neville
Hall Hospital, Abergavenny, on 27 October 2008. The man, a prisoner at HMP Usk,
had been suffering from chronic illness for some considerable time before his death.
I would like to offer my condolences to the man’s family for their loss.
The inquest into his death took place on 17 January 2009. HM Coroner concluded
that his death was as a result of natural causes.
One of my investigators conducted the investigation on my behalf. I also
commissioned the Healthcare Inspectorate for Wales to conduct a clinical review into
the standard of healthcare the man received while in custody. I would like to thank
the Governor of Usk, and his staff for their co-operation and assistance.
Owing to the man’s poor health, he had been admitted to Neville Hall Hospital on two
occasions in the weeks before he died. At the time of his death, Usk was in the
process of arranging to transfer for him to a prison with 24-hour healthcare cover in
recognition of the gravity of his medical needs. I am satisfied that he received the
highest standard of care possible at Usk and staff did all they could to manage his
illnesses. My report also reflects on the professional way in which the prison
supported the man’s family after his death.
I have endorsed four recommendations as a result of the clinical review. I have also
commented, not for the first time, on the importance of ensuring a balance between
public protection and the compassionate management of seriously ill or dying
prisoners.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2009
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CONTENTS
Summary 4
The investigation process 6
HMP Usk 8
Key findings 9
Issues 15
3
SUMMARY
The man was remanded to HMP Swansea in October 2005. He was 67 years old
and had not been in prison before. During a reception assessment, he told the nurse
that he had suffered a heart attack in 2003 and regularly took medication for
hypertension (high blood pressure).
Given the nature of his alleged offences, the man was considered a vulnerable
prisoner. After three weeks, he transferred to HMP Parc.
The following week, a nurse examined him in his cell as he was experiencing chest
pain. Although his blood pressure was slightly high, the nurse did not consider that
he needed to be sent to outside hospital. On 11 November, the man collapsed at
court with a suspected heart attack and was taken to the local hospital. However,
tests showed that he had not had a heart attack so he returned to Parc the same
day. He continued to attend court without further problems. On 24 November 2005,
he was convicted and sentenced to ten years imprisonment.
The man transferred to HMP Usk as a sentenced prisoner on 30 January 2006. As
part of his reception health screen, he was referred to the hypertension clinic. His
blood pressure was monitored regularly and checks were made to ensure that he
was taking his medication correctly. In March 2006, staff became concerned that he
was not taking his medication as prescribed and that this was causing his blood
pressure to rise. However, it was brought under control when his medication was
supervised.
On 17 July 2006, the man was taken to outside hospital after experiencing pins and
needles down the right side of his body. Tests showed nothing of concern and he
returned to Usk later that day. In September that year, he experienced the same
symptoms and told the nurse that he had blacked out. After examining him, the
nurse concluded that the man was suffering from anxiety due to domestic problems.
In order to support him, he was referred to the Mental Health In Reach Team
(MHIRT) and seen the same day. The nurse from the MHIRT concluded that his
mental health was good and there was no history of mental illness.
In April 2008, the man was seen by a nurse after complaining of feeling generally
unwell. He had not been able to collect his medication while he was at outside
hospital and had not taken it for around three days. The nurse consulted the doctor
who prescribed a course of antibiotics and said that he should begin to feel well
again once he resumed his regular medication. It was also recorded in the man’s
medical records that he was showing early signs of congestive heart failure. As a
result, he was started on a course of medication.
In mid-April, he attended Neville Hall Hospital to be assessed prior to having a hip
replacement operation. Following this appointment, the hospital contacted prison
healthcare at Usk and informed them that the operation was to be postponed, as the
anaesthetic team did not consider him well enough to be operated on.
In September, the man’s breathing problems began to get worse and he was
admitted to Neville Hall Hospital where he stayed for nine days. During this time, he
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was treated for pneumonia and had a catheter fitted due to a blockage in his bladder.
Following his discharge, he spent a week in the healthcare wing of HMP Cardiff
before returning to Usk.
Over the next two weeks, the man was taken to outside hospital on two further
occasions due to continuing problems related to his urinary tract infection and
breathing. On 17 October, during a routine appointment in the healthcare
department, staff noticed that the swelling in his legs and his breathlessness had
become worse. The nurse contacted the on call doctor who immediately arranged
for him to be admitted again to Neville Hall the same day.
The man’s condition was considered by the consultant at Neville Hall to be due to
extensive emphysema and pulmonary fibrosis, which were untreatable. Nursing staff
kept him comfortable but he died on 27 October.
I judge that he was well cared for in prison, and after his death, the prison provided a
high standard of family liaison. I make no formal recommendations but endorse four
made by the clinical reviewer.
5
THE INVESTIGATION PROCESS
1. My investigator opened the investigation on 3 November 2008 when he
contacted Usk to arrange for documentation to be provided. Notices were
issued to staff and prisoners informing them of the investigation process and
inviting anyone who had relevant information to come forward. The investigator
received no responses to the notices.
2. The investigator was unable to begin the investigation process until January
2009 as there was a delay in providing the necessary documents including the
man’s medical records. The Governor is aware of the impact this delay has
had on the timeliness of this investigation.
3. In accordance with my terms of reference, I commissioned the Healthcare
Inspectorate for Wales to conduct a clinical review into the care and treatment
of the man at Usk. An appointed clinician conducted the review and makes
four recommendations relating to record keeping and issuing of medication. A
copy of the clinical review is attached as an annex.
4. One of my Family Liaison Officers (FLOs), telephoned the man’s sister on 24
November. My FLO explained the role of my office in relation to the
investigation and offered to visit the family with the investigator if they wished.
His sister thanked the FLO for her offer but said that her brother’s death was
closure for the family and they did not want a visit.
5. The investigator wrote to HM Coroner to inform him of the nature and scope of
the investigation. The Coroner told him that he would be holding the inquest
into the man’s death on 27 January. The inquest concluded that his death was
due to natural causes resulting from bronchial pneumonia, pulmonary fibrosis,
emphysema and coronary artery disease. A copy of my report has been sent
to the Coroner for his records.
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MP USK
6. HMP Usk is in Monmouthshire. It is a male category C prison holding up to 250
prisoners serving sentences for predominantly sexual offences.
7. HM Chief Inspector of Prisons, Dame Anne Owers, carried out a follow up
inspection of HMP Usk/Prescoed in March 2008. In her report, Dame Anne
highlights that only five of her ten earlier recommendations in relation to the
provision of healthcare had been addressed. One that had not been
implemented was the provision of new healthcare facilities. However, my
investigator was informed during his visit that a new building was due to open in
March 2009.
8. The Independent Monitoring Board (IMB) at Usk published their most recent
annual report in April 2008. In relation to healthcare the IMB said:
“The Board receives a minimum of applications about Healthcare. All
prisoners have access to a doctor and dentist within reasonable time.”
9. Since my office took responsibility in 2004 for investigating all deaths in prison
custody, there have been three other deaths from natural causes at Usk.
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KEY FINDINGS
10. The man was remanded into custody on 7 October 2005 and taken to HMP
Swansea. He was 67 years old and it was his first time in custody. On his
arrival at Swansea, a registered nurse in reception conducted a health screen.
It became apparent that he was not in the best of health. He disclosed that he
had suffered a myocardial infarction (heart attack) in 2003, and listed the
medication that he was taking daily to treat his heart condition (hypertension).
11. The man remained at Swansea for around three weeks before being
transferred to HMP Parc on 26 October. As he had been charged with sexual
offences, he was considered a vulnerable prisoner. (My investigator was told
that Swansea is not able to provide a full regime for vulnerable prisoners. As a
result, any prisoner considered vulnerable by the nature of their offence is
transferred to either Parc or HMP Cardiff.)
12. As at Swansea, the man was seen on reception at Parc by a member of the
healthcare team, and a health screen completed. Again, his previous heart
problems were recorded along with his blood pressure, which was considered
high. The nurse also recorded that he had previously had hip replacement
surgery and was a smoker. (This information had not been noted on his initial
health screen at Swansea.) Following the reception process, the man was
located in the segregation unit as there was no space on the vulnerable
prisoner unit. (A segregation unit is an area where prisoners can be located
when their behaviour is considered inappropriate. It can also be used
temporarily to house prisoners who are considered to be at risk, due to the
nature of their charge or offence, while a space on an appropriate residential
wing is awaited.) In his case, a space in the vulnerable prisoner unit became
available after a few days and he was moved.
13. On 5 November 2005, at the request of an officer, a nurse went to see him in
his cell as he had been complaining of chest pains since the early hours of the
morning. The nurse checked his blood pressure, which was slightly raised, but
observed that he was able to hold a conversation, have a cigarette and drink
tea. The nurse prescribed 150mg of aspirin and arranged to review him later in
the day and discuss his condition with the doctor. The man was given an
electro cardiogram (ECG) later in the morning and further pain relieving
medication. He told the nurse that he was not happy and wanted to see the
doctor, but he was assured that his blood pressure had lowered and the ECG
was normal.
14. While at court on 11 November 2005, the man collapsed with a suspected heart
attack and was taken to Prince Charles Hospital in Merthyr Tydfil. However,
after five hours he was discharged and returned to the prison following another
normal ECG. He continued to attend court daily for his trial without any further
problems. On 24 November, he was convicted and sentenced to ten years
imprisonment.
15. As a sentenced prisoner, he transferred to HMP Usk on 30 January 2006. A
health screening was completed along with a further assessment as he was an
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elderly prisoner. This highlighted hypertension and previous heart problems
(ischaemic heart disease). The man was placed on the hypertension clinic
pathway. This ensured that a full assessment of his physical health and diet
was completed, and advice provided accordingly. He was also seen regularly
to have his blood pressure monitored. In addition, it was recorded that he had
undergone a right knee and hip replacement operation and was awaiting
surgery on his left hip.
16. To help address his offending behaviour, the man was seen in March by a
trainee psychologist at Usk. He said that he wanted to complete the Sex
Offender Treatment Programme (SOTP) but intended to appeal against the
length of his sentence. The man was still waiting for his appeal to be heard at
the time of his death.
17. His blood pressure was checked regularly but it remained high. Nursing staff
were concerned about it and on a number of occasions referred him to the
doctor. In March 2006, nursing staff became concerned that he was not
complying with his medication regime and that this was causing his blood
pressure to rise. Although this was not considered intentional, the man was
placed on supervised medication (where medication is provided and has to be
taken in sight of a nurse.) This seemed to work and further tests showed his
blood pressure had lowered. A nurse advised Mr Welch about the importance
of taking his medication as prescribed, and told him that if he did not it could
result in a stroke.
18. On 17 July 2006, he complained of pins and needles down his right side. He
was given an ECG and taken to outside hospital. However, following tests, he
returned to the prison and no further problems were recorded. The man
complained of having the same symptoms again in September and told the
nurse that he had ‘blacked out’ on his bed. When the nurse assessed him, she
recorded that he was presenting symptoms of anxiety. He told the nurse that
he had received a letter from his wife’s solicitor indicating that she wished to
divorce him and sell the family home. It is apparent from the man’s documents
that the breakdown of his relationship had caused him a lot of worry. However,
the nursing staff at Usk supported him during this time and a nurse from the
Mental Health In Reach Team (MHIRT) saw him to assess whether he required
additional support. The nurse confirmed that he was not suffering from any
mental illness.
19. During the remainder of 2006, he became more compliant with his medication
and it was recorded in his medical record that this was evident in his general
condition. He was also advised that, if he wished, arrangements could be
made for him to transfer to a prison that could provide 24-hour healthcare.
However, the man said that he was fully able to manage all aspects of daily
living at Usk. His divorce was finalised in November 2006.
20. Apart from being diagnosed with viral labyrinthitis (inflammation of the labyrinth
in the inner ear) in July 2007, he had very little recorded contact with the
healthcare team during that year.
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21. The man complained of feeling generally unwell in April 2008 and of having
palpitations (an abnormal awareness of the beating of the heart, whether too
slow or too fast.) He was seen by a member of the healthcare team who
recorded on his medical notes that he had not taken his regular medication for
three days. He had been unable to collect it before the weekend as he had
been at a hospital appointment. After a discussion with the doctor, the man
was prescribed a course of amoxicillin (an antibiotic used to treat a variety of
bacterial infections). It was concluded that the palpitations should settle once
he had resumed taking his regular medication again.
22. Over the next two weeks, it was also recorded in his medical record that he was
showing signs of early congestive heart failure (CHF) and he was started on a
course of medication (furosemide). (CHF is a condition in which the heart's
function as a pump to deliver oxygen-rich blood to the body is inadequate to
meet the body's needs.)
23. As mentioned earlier, the man was awaiting surgery on his left hip. On 29 April,
a nursing sister at Neville Hall Hospital contacted the nursing staff at Usk. The
nurse was concerned about the man’s general health following an appointment
earlier in the week with the anaesthetic team who would be responsible for his
care during the procedure. She said that they did not consider him sufficiently
fit to undergo the operation and, as a result, it would be postponed until his
general condition improved.
24. Over the following six weeks, he continued to have his blood pressure checked
by nursing staff. They also recorded that his dyspnoea (shortness of breath)
was improving. On 19 June, the workshop manager, informed healthcare staff
that the man had complained of having chest pain and that he had advised him
to report to healthcare. However, he had failed to attend so the nurse went to
see him in his cell. The man denied having any chest pain. He said that he
had suffered a panic attack and had gone to bed. He refused to attend
healthcare for a check up, and the nurse instructed him to either press his cell
bell or go to healthcare if he felt unwell again.
25. His shortness of breath got worse and on September 9 he was admitted to
Neville Hall Hospital, Abergavenny, where he remained for nine days. He was
escorted by two members of prison staff and remained handcuffed throughout.
This arrangement for restraints to be used remained the same on all
subsequent visits to outside hospital. During this time, investigations took place
to rule out a pulmonary embolism (a blockage in the blood vessels supplying
the lungs), the results of which were negative. He was treated for pneumonia
and an abnormal renal function was noted for which an indwelling catheter was
fitted. (This is when a catheter is fitted to drain the bladder and left in
continuously.) The man also showed signs of hydronephrosis (swelling of the
kidneys due to an obstruction of urine) with a mass in his bladder.
26. Following treatment, he was discharged on 18 September 2008. However, due
to the indwelling catheter and the continued need for regular medical care, he
was temporarily transferred to HMP Cardiff, which is able to provide 24-hour
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healthcare. This was considered to be of benefit to him. He remained at
Cardiff until 23 September when he was assessed as well enough to return to
Usk.
27. My investigator asked nursing staff at Usk whether they had concerns about
being able to provide for the man’s increasing medical needs. He was told that,
although he was adamant that he wished to remain at Usk, efforts were being
made by the healthcare governor for him to be transferred to a prison such as
Cardiff that could provide 24-hour care on a permanent basis. However, the
nurses were keen to stress that, despite only providing part-time healthcare,
they operate an on call system out of hours. This means that, should a
problem arise, the prison is able at any time to contact a nurse who will attend
the prison if necessary. This arrangement was to apply to the man should he
be taken ill during the evening.
28. On his return to Usk on 23 September, a care plan was started to ensure that
the effectiveness of the catheter was monitored and for the purposes of
infection control. As part of the care plan, nursing staff at Usk taught the man
to care for himself in terms of personal hygiene, and advice was given on how
to minimise the risk of infection.
29. On 1 October, the man went to the Accident & Emergency Department at Royal
Gwent Hospital as a result of swellings. He was seen and prescribed treatment
for a urinary tract infection and returned to Usk the same day.
30. His health continued to deteriorate. His breathing became increasingly difficult
and he was once again admitted to Neville Hall Hospital on 8 October. He
remained there for a week and was discharged on 15 October with antibiotics
for both pneumonia and his urinary tract infection.
31. In addition to his physical problems, the prison had concerns about the man’s
mental wellbeing due to an ongoing domestic problem. As a result of these
concerns, nursing staff referred him to the community psychiatric nurse (CPN)
on 15 October. The CPN diagnosed reactive depression, but prescribed no
medication.
32. On 17 October, he had a review with a nurse in the healthcare unit. The nurse
recorded that the swelling in his legs had reached his thighs and he was
breathless. The man was also finding it difficult to sit down due to the catheter
and the increased swelling in his legs. Given her concern about the
deterioration in his condition, the nurse contacted the prison GP. In turn, the
GP arranged for the man to be admitted to the Medical Assessment Unit (MAU)
at Neville Hall Hospital.
33. Two members of staff escorted him to Neville Hall Hospital that afternoon.
Despite his ill health and frailty, restraints were still used in the form of an
escort chain. (This is attached to the prisoner’s wrist by a single ratchet
handcuff with the other end attached to an officer in the same way. The length
of chain in the middle allows for more freedom of movement. In most cases,
escort chains are used to allow escorted prisoners access to toilets while
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ensuring that they are still kept secure. However, they are commonly used
when a prisoner is confined to bed in outside hospital.)
34. Over the next few days, the nursing staff at the prison contacted Neville Hall
regularly for updates on the man’s condition. On 20 October, during a routine
call the hospital asked whether the prison had notified his next of kin as his
congestive heart failure had deteriorated and he was coughing up blood
(haemostasis). The nurse at Usk who had made the call contacted the duty
governor who confirmed that the man’s brother had been notified of his
condition at the weekend. The nurse also informed the prison chaplain, who
had visited the man earlier in the week.
35. The consultant physician who was treating the man, concluded that he had
extensive emphysema in addition to pulmonary fibrosis. Due to the advanced
nature of the illnesses, little could be provided in the way of medication.
Nursing staff managed his condition over the next few days and kept him
comfortable. However, on 27 October at 3.55pm, the man died.
After the man’s death
36. Following the man’s death, the prison appointed an officer as their Family
Liaison Officer (FLO). Owing to the distance between the prison and her home,
the man’s sister was notified by telephone by the prison chaplain on 27
October. The chaplain broke the news of her brother’s death and arranged to
call her back within the hour to allow her time to gather her thoughts. The
prison’s FLO made the follow up call, told the man’s sister of her role, and gave
contact details. The FLO arranged to call again the following day to allow the
man’s sister time to tell other members of the family.
37. The following day, the prison FLO contacted the man’s probation officer to seek
help in notifying his former wife and children of his death. Later that day, the
prison FLO telephoned the man’s sister again to tell her that the post mortem
would take place the next day and that there would be an inquest as he had
died in prison custody. On behalf of the prison, the FLO offered to meet the
costs of the funeral, and the family were very grateful for this. The family were
informed of the post mortem results the next day.
38. On 3 November, the prison FLO along with the chaplain, visited the man’s
sister at her home. Also present were the man’s two other sisters, his brother,
and his brother in law. The prison FLO returned his property including his
money. The family confirmed that the funeral would take place on 10
November in Poole and requested the help of the prison in tracing his
daughters. On her return to Usk, the prison FLO passed the details of the
man’s daughters to the prison’s police liaison officer (PLO) to see if he could
help to trace them.
39. During a call to the man’s sister on 6 November, the prison FLO was told that
one of his daughters had been in touch with the family but had not left any
contact details. The prison FLO attended the man’s funeral, which was
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officiated by the prison chaplain at the family’s request. After the funeral, the
prison FLO told the family that she would let them know the date of the inquest.
40. The prison FLO contacted the man’s sister again on 20 January 2009 and
informed her that the inquest would take place the following week. His sister
confirmed that no family members wished to attend so the prison FLO agreed
to let them know the outcome. She telephoned the family on 27 January as
arranged and told them the verdict of natural causes. The family thanked her
for the assistance the prison had provided following the man’s death and said
that they felt there was no need for further contact.
13
ISSUES
Escort to Neville Hall Hospital
41. The man was taken to Neville Hall Hospital on three occasions in less than a
month. On each occasion, his condition had deteriorated. However, this
deterioration does not seem to have been considered when assessing the need
for him to be restrained. My investigator spoke about the decision to restrain
the man with the Governor of HMP Usk. The Governor said that the decision
had reflected the seriousness of the offence for which the man had been
imprisoned.
42. I appreciate that such risk assessments are a matter of fine judgement and
properly place an emphasis upon public protection. However, he was 70 years
old and it seems extremely unlikely that he would have had the inclination or
capability to escape from custody given his advanced illness. It is part of a
prison’s duty to ensure a balance between public protection and the
compassionate management of seriously ill or dying prisoners. The Governor
will wish to consider with his senior colleagues whether that balance was
achieved on this occasion.
Family Liaison
43. The prison appointed a trained FLO immediately after the man’s death, and the
chaplain made initial contact by telephone due to the distance the family live
from Usk. It is good practice for news of a death in custody to be broken in
person but I understand that this is not always possible. There is no question
that the sad news was conveyed to his family in a sensitive fashion.
44. The prison FLO maintained regular contact with the family. She was attentive
to their needs, providing advice and guidance on a process that must have
seemed very confusing to them. I am sure that the professional approach
taken by the FLO in her role was of benefit to the family at a very distressing
time.
45. The prison FLO and Chaplain should be proud of the kindness, professionalism
and sensitivity they displayed. I would be grateful if the Governor shared my
view with them and with the FLO’s manager.
Clinical Review
46. The clinical reviewer said following her review of the man’s medical care that
staff at Usk were conscientious about caring for him and acted appropriately to
his medical and nursing needs.
47. In relation to medical record keeping, she said that the man’s records were
generally in good order but some entries were illegible and not dated.
Assessment forms were not always dated either and where there were more
than one page the page, numbers were missing. The reviewer also said that
despite the man being admitted to hospital on a number of occasions there
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were no medical notes relating to these events. The reviewer makes the
following three recommendations in relation to recording information and record
keeping which I endorse:
Healthcare medical and nursing staff should ensure that entries they
make in medical records are legible.
Assessment forms should be dated and if there are more than one page
then page number, patient identifier and common title/heading should be
included.
All dates of admission to hospital and attendance at clinics should be
recorded including the reason for admission/clinic.
48. On 4 April 2008, the man attended a hospital appointment, on his return to Usk
had missed the opportunity to collect his medication, and subsequently became
ill on the Sunday. The reviewer makes the following recommendation in
relation to this which I endorse:
If medication is prescribed on a daily r more frequent basis a procedure
must be developed to allow arrangements to be made to ensure that the
prisoner/patients receive their medication as prescribed.
Conclusion
49. The man was an elderly man who had entered prison with serious and ongoing
illnesses for which there was no cure and which ultimately led to his death. I
judge that he was well looked after, and appropriately referred to outside
hospital on a number of occasions when his condition deteriorated and gave
cause for concern. Steps were taken to arrange a transfer to prison better able
to provide round the clock care. My investigation identified no shortcomings in
his treatment and, after his death, staff were very professional in their contact
with his family. I have not had the benefit of the opinion of the clinical reviewer,
but as a layperson, I am entirely satisfied with the care and support provided for
him.
50. I entirely understand the current climate of risk aversion when it comes to
decisions about the use of restraints. Both public protection and the reputation
of the Prison Service rely upon the Service’s admirable achievements in recent
years in reducing the number of escapes and absconds. As I have said above,
risk assessment is a matter of fine judgement, and it is an inexact science at
the best of times. However, this is far from being the first report when I have
observed that in a less risk adverse climate very different decisions about the
use of restraints might reasonably have been made.
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