Individual at Pentonville

Investigation into the circumstances surrounding the
death of a prisoner at HMP Pentonville on 2 October
2005
Report by the Prisons and Probation Ombudsman for
England and Wales
June 2006
This is the report of an investigation into the death of a prisoner who died in
the Healthcare Centre at HMP Pentonville on 2 October 2005. The man had
been diagnosed with terminal lung cancer earlier in the year. In September,
he had returned from hospital to Pentonville, where his condition rapidly
deteriorated.
The man was 54 years old when he died. In January 2006, an inquest into his
death found that his death was due to natural causes.
I would like to extend my condolences to the prisoner’s family and friends for
their loss.
One of my Investigators conducted this investigation. I am grateful to the
Islington Primary Care Trust for undertaking a clinical review into the man’s
care and treatment. I would also like to thank the Governor of Pentonville,
and his staff, for their help and co-operation during this investigation.
I would like here publicly to commend those members of Pentonville staff who
were involved in the care of the prisoner. They demonstrated sensitivity,
flexibility, and compassion both to the prisoner and his family in what were
difficult and emotional circumstances. However, as the clinical review
highlights, there are also some lessons to be learned in caring for those who
are terminally ill in prison.
Stephen Shaw
Prisons and Probation Ombudsman June 2006
2
CONTENTS
Summary
The investigation process
The prisoner
HMP Pentonville
Events prior to the prisoner’s death
Events after the prisoner’s death
Clinical review and post mortem
Findings and conclusions
Recommendations and good practice
Annexes:
A. Clinical review by the Islington Primary Care Trust
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Summary
At approximately 9.55am on 2 October, the prisoner was provisionally
pronounced dead by healthcare staff in the Healthcare Centre at HMP
Pentonville. He was 54 years old when he died and had been suffering with
terminal lung cancer. A post mortem was not carried out on the direction of
HM Coroner, as the man’s condition was known and the outcome anticipated.
The prisoner had been remanded in custody in December 2004. In February
2005, he was sentenced by Crown Court to two years imprisonment.
In early May 2005, the prisoner was referred to the hospital having
complained of severe pain across his shoulders and neck. He had also
coughed up blood. It was suspected at the time that he might have
contracted tuberculosis and he was subsequently allocated to the prison’s
Healthcare Centre, and special nursing procedures were implemented, whilst
clinical investigations continued. Further investigation at the hospital
determined that in fact the prisoner had lung cancer.
Following his diagnosis, the man received radiotherapy and chemotherapy
treatment as an inpatient in hospital. On 26 June, he was told that the cancer
therapy was not effective and that the cancer had spread. He was advised he
only had a few months to live. In view of this prognosis, the prison prepared a
report on the prisoner that would be sent as a submission the Secretary of
State in the final stages of his life asking for consideration to be given to the
man’s release on compassionate grounds. However, the request was not
submitted by the prison because the prisoner’s condition deteriorated so
rapidly that there was no time to submit the report or to arrange for his release
before his death.
In early September, the prisoner was discharged from hospital back to the
prison. Arrangements were made between the prison and the hospital for him
to receive palliative care in the Healthcare Centre. Preliminary arrangements
were also in hand to transfer the prisoner to a local hospice with support from
officers in civilian clothes. However, the man’s rapid deterioration was of such
concern to medical staff that this was not considered to be in his best
interests. Indeed, it was the prisoner’s wish to die in the Healthcare Centre.
As the prisoner continued to deteriorate, the prison arranged for members of
his family to visit and stay with him at his bedside. His brother, who was also
his next of kin, was present when he died. The family were very grateful for
the way in which Pentonville afforded the prisoner compassion, care and
dignity in the last days of his life.
The clinical review by the Islington Primary Care Trust has highlighted a
number of administrative deficiencies in respect of maintaining clear, concise
and continuous medical records. However, the review has also confirmed
that the prisoner was given a level of care equal to, if not better than, he
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would have received in the wider community. I hope this finding, which
coincides with what the family themselves told my investigator and with my
own layman’s judgement, offers comfort and reassurance to the man’s friends
and relatives.
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The investigation process
1. The investigation was opened at HMP Pentonville on 6 October 2005
when my investigator attended the prison. Notices were issued to staff
and prisoners informing them about the investigation and giving them the
opportunity to speak with the investigator. No responses were received.
2. The Governor and his staff produced the prisoner’s core record, his
Medical Record and a number of other documents for examination.
3. Islington Primary Care Trust was contacted so that they could conduct a
clinical review into the care and treatment that the prisoner received in the
prison. The review is attached to this report as an annex.
4. One of my Family Liaison Officers, contacted the prisoner’s family by
telephone on 26 October. He offered the family an opportunity to meet
with him and the investigator to discuss the purpose of the investigation,
and to raise any concerns or questions that the family would like explored
and addressed. The family were very appreciative of the care and
treatment afforded to the prisoner.
5. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and the scope of my investigation. In early January 2006, the
inquest took place into the man’s death and established that he died of
natural causes. Upon completion, my final report will be sent to the
Coroner for his information.
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The prisoner
6. The man was born in 1951. At the age of 14, he left school with no
qualifications and came to the United Kingdom in search of work. He was
employed as a builder, but had to give up work about ten years ago
because of failing health. The prisoner came from a large family and
remained in contact with them. The family is described as very close knit.
7. The prisoner was a single man at the time of his sentence but according to
prison records had two grown up children. Although some contact was
maintained with his children, they were not aware of the nature of his
offences.
8. The man had been a heavy drinker and this problem escalated following
the death of his brother. At the time of his arrest in December 2004, the
prisoner was voluntarily undergoing alcohol detoxification in East London.
9. This was not the prisoner’s first experience of prison. He had a criminal
history going back to 1968 for a variety of offences that included crimes of
violence.
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HMP Pentonville
10. Pentonville is a Victorian prison. Its primary function is to serve the courts
of north London. The prison holds prisoners on remand for all Magistrates’
Courts and Crown Courts within the area, as well as prisoners who have
been convicted and sentenced. The establishment has an operational
capacity (maximum crowded capacity) of 1,175 prisoners.
11. An inspection report for 2005 from HM Chief Inspector of Prisons said that,
although there was a new and impressive Healthcare facility at
Pentonville, primary care was limited and some prisoners did not have
confidence in the system. The report found that Nursing Plans were poor,
as was health promotion.
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Events prior to the prisoner’s death
12. The prisoner was remanded into custody at Pentonville in December 2004.
It was established during the routine health screen that day that he had a
history of ischemic heart disease and had suffered three heart attacks. It
was also established that in 1995 he had been treated for a brain tumour.
The man also had diabetes that was controlled by diet, and was a heavy
smoker. At the time of his reception, he was described as in reasonably
good health.
13. In February 2005, the prisoner received a two year sentence. Having
spent a considerable time on remand, he was due to be released from
prison in December 2005. Whilst at Pentonville, he was not considered to
be a discipline problem and had not been subject to any adjudication
(disciplinary hearings) in respect of his conduct.
14. On 14 March, the clinical record indicates that the prisoner complained of
pains in the right side of his neck and left shoulder.
15. On 20 April, the prisoner was seen again by Healthcare, complaining of
pain in his neck and across his shoulders. He found it hard to move. At
the time, it was believed that the problem was muscoskeletal in nature and
involved trapped nerves. The prisoner was prescribed analgesics and
referred for blood tests and an x-ray.
16. On 28 April, he stated that he was ‘coughing blood’. He continued to
suffer with pain across his shoulders and his spine. An x-ray was
arranged in order to eliminate tuberculosis (TB). The x-ray indicated a
shadow on the left side of his chest which could have been indicative of
TB. For that reason, the prisoner was moved to an isolation cell in the
Healthcare Centre. In light of his suspected condition, Pentonville also
implemented barrier nursing procedures and nursing staff wore gloves and
masks when dealing with the prisoner.
17. On 4 May, he attended the hospital for tests under prison escort and
restraint. He returned to his isolation cell at Pentonville that same day.
18. On 13 May, he attended the Chest Clinic at hospital where he was told by
the consultant that he had cancer of the lung. He returned to Pentonville
and remained in Healthcare, receiving painkillers for the pain in his neck,
shoulders and spine. In the meantime, arrangements were made for him
to attend the local hospital in order to receive treatment for his cancer.
19. On 26 May, he was admitted to hospital. In compliance with the prison’s
security procedures, he was subject to constant bed watch by prison staff.
While he remained mobile and in light of his offence, it was vital to retain
public confidence in the criminal justice system and balance security
needs against those of the individual. Throughout his stay in hospital, the
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prisoner was not considered and did not present a discipline problem to
the staff.
20. On 8 June, in a letter from the hospital to Pentonville, it was stated that the
man’s cancer had spread. A scan had detected secondary cancer in the
cervical, thoracic and lumber spine regions. In light of this development,
he required urgent radiotherapy in order to prevent spinal compression
and early neurological damage. The prisoner was given approximately six
months to live at this stage. The consultant treating him was concerned
that, in light of this prognosis, he should receive appropriate palliative care.
The consultant spoke to the Governor at Pentonville, asking him to
consider early release for the prisoner on compassionate grounds.
21. Throughout June and July, he was still an inpatient at the hospital where
he had been receiving radiotherapy and chemotherapy. However, by late
August, the treatment was deemed to be ineffective and unlikely to prolong
his life. The prisoner was given about three months to live. His mobility
was greatly reduced and he was mainly confined to a wheelchair. He was
also given special permission by the medical staff to smoke in the hospital
grounds.
22. The deputy governor confirmed that Release on Temporary Licence
(ROTL) was not considered appropriate because of the nature of the
prisoner’s offence and the fact that he still had some mobility. The man’s
consultant advised the deputy governor and the Head of Healthcare that
he was not ill enough at this stage to transfer to a hospice.
23. The deputy governor asked the prison’s operations manager to prepare a
report to the Secretary of State, asking him to consider compassionate
early release of the prisoner on medical grounds (under section 30 of the
Crime (Sentences) Act 1977). The report was completed on 23 August, in
anticipation of the man’s discharge from hospital. However, the deputy
governor believed that release could only be considered when the prisoner
entered the final stages of his life. When this was known, the report would
have been submitted for the Secretary of State’s consideration. The
deputy governor stated that this was difficult to determine in the prisoner’s
case - even in late August as he was still mobile. Indeed, there was a
view that the man might well live to his release date. The deputy governor
was mindful of the fine balance between the prisoner’s needs and the
public interest in not interfering with the intentions of the sentencing court.
24. Meanwhile, on 12 September, th e prisoner was discharged from the
hospital back to the Healthcare Centre at Pentonville. A letter written by a
Palliative Care Consultant records that his condition was deteriorating and
that he was fully aware of this. Whilst in hospital, he had been receiving
regular visits from the prison chaplain as well as from his family. The
prisoner derived much comfort from these visits. It was the prisoner’s wish
to go back to Ireland to be close to his family, but he recognised that this
was unlikely to happen.
1 0
25. On 13 September, the prisoner was seen at Pentonville by an
Occupational Therapist from the hospital. Following the visit, an elevated
bed was ordered that would allow for better comfort and assistance with
breathing. More pillows were provided to support the prisoner. It was
noted in the medical record that he was able to use a wheelchair and that
he was able to breath unaided. The man continued to suffer pain in his
shoulders and neck and this pain was adequately controlled with
appropriate medication. The prisoner also continued to enjoy smoking.
26. On 15 September, the medical record indicates that he was experiencing
some shortness of breath and a lot of pain in his neck and shoulders. A
soft collar was given to him for psychological and physiological support.
He was also taking Ensure protein drinks to supplement his diet.
27. By 16 September, the prisoner’s condition had significantly deteriorated,
so much so that moving him was considered to be against his best
interests. Consequently, the report asking for release on compassionate
grounds was never forwarded for consideration. The prisoner had also
stated that he wanted to remain in the prison’s Healthcare Centre until his
death.
28. On 16 September, a spinal chair was ordered for the man by the
Healthcare Centre. At this time, initial enquiries were made for him to
transfer to a hospice. A placement in the hospice would have allowed
greater access for his family in his final days. However, as a serving
prisoner, he would have been initially subject to bed watch by prison
officers until such time that a request for his compassionate release had
been granted. The family felt that the prisoner’s presence at the hospice
would bring unwanted and unwelcome attention. Because of these
sensitivities, this option was eventually discounted.
29. On 16 September, he was moved to a room in the Healthcare Centre
where an elevated, electrical bed had been placed. Initially, the bed did
not work properly because of electrical problems, but he was made
comfortable. The following week, the prisoner was to be formally reviewed
by the palliative care team from the hospital. In the meantime, healthcare
staff at Pentonville were encouraged to contact the palliative care team if
they were not sure how to manage the prisoner. A pain chart was started
for him.
30. On 17 September, the medical record indicates that the prisoner was
reasonably comfortable and was pleased to learn that his sister would be
visiting him shortly. He was comfortable in talking to staff about his illness
and prison life. The medical record indicates that he was in good spirits all
things considered.
31. On 18 September, the medical record shows that healthcare staff were
concerned about the prisoner’s habit of chain smoking and his proximity to
the oxygen cylinder in his cell. He was encouraged to smoke outside his
cell as he had the use of a wheelchair.
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32. On 20 September, some members of his family visited him in Pentonville.
The visit was described as emotional and tearful, with family members
acknowledging his condition and coming to terms with the fact that he had
only a short time to live. During the day, and in consultation with the
prisoner, a form was signed by the Palliative Care Consultant and a nurse
indicating that, in the event of losing consciousness, no efforts were to be
made to resuscitate him. The visit by the Palliative Care Consultant that
day indicated that the prisoner had been managing reasonably well since
being discharged from hospital. However, he had been experiencing
increasing pains in his neck and shoulders and increasing weakness in his
limbs. The man was also beginning to experience some difficulty in
passing urine and required nursing care primarily in bed.
33. On 21 September, the medical record indicates that during the morning,
the man had been coughing up fresh blood. During the afternoon, he was
told by the Governor that attempts were being made to transfer him to a
hospice although because of the restrictions placed on him, he would need
to be escorted at all times by two prison officers in compliance with
standing security procedures. The prisoner stated that he was receiving
good care and attention in the Healthcare Centre. It was also noted in the
medical record that he did not want to have a shower as this process could
cause respiratory distress. He appeared to be paler in complexion and
had developed an audible wheeze. The man was given the use of a
nebuliser in the early evening to assist his breathing. He also had the use
of oxygen in his cell. It was also noted by healthcare staff that he was
smoking less.
34. On 22 September, the man’s skin on his lower chest looked mottled. His
physical condition continued to deteriorate and he was beginning to lose
the strength in his limbs. In consultation with his next of kin, it was
decided that in the circumstances it was not in his interests or safety to
move him to a hospice.
35. On 23 September, the medical record indicates that he was displaying
signs of cyanosis (a bluish colouration of the skin, due to a lack of oxygen)
and also suffering bouts of apnea (cessation of breathing). A memo dated
the same day was signed by the prison Governor, the prison’s lead GP
and acting head of healthcare. It stated that, in agreement and with the
advice of the nursing staff assigned to the prisoner and the Palliative Care
Consultant, in the event of a significant bleed from his lungs, a single
injection of Morphine Sulphate and Midazolam could be given to him. This
would ease any pain or distress suffered by him associated with a major
inter-thoracic bleed. This procedure was agreed with the prisoner.
36. On 24 September, the man’s respiratory levels were recorded at 14-16
breaths per minute. He was described as very weak, but still orientated in
his thought. During the afternoon, it was noted that his breathing pattern
had changed and that no air was entering his left lung. He was also
struggling to get air into his right lung and the man felt as though his lungs
1 2
were stiffening. In light of his extreme difficulty in breathing, the prisoner
was asked if he would like to see a priest. He declined the offer. The duty
governor was made aware of his deteriorating condition. He was made as
comfortable as possible by Healthcare staff. Later on in the day, the
prisoner received a visitor and was able to have a cigarette. He later told
staff that he was glad to have the chance to speak openly with his visitor
and to make his peace.
37. On 25 September, the medical record notes that the man’s oxygen
saturation level was 92% on room air with 18-20 breaths per minute
recorded. His pain was under control, although he was experiencing
episodes of apnea, as well as confusion. It was also noted that the
prisoner was sleeping for long periods of time. He had developed
pressure sores which necessitated him being turned regularly in bed by
the nursing staff. By this time, he was finding it very difficult to eat solid
foods and in view of this, pureed and soft foods were offered. He was also
given Ensure Plus drinks. He developed a liking for the vanilla flavoured
variety.
38. In the early evening of 26 September, a prayer service was arranged in
the Healthcare Centre for him and other prisoners.
39. On 27 September, the medical record indicates that the prisoner took
some breakfast and three cups of fluid. He was also able to have a
cigarette. He was still complaining of pain across his shoulders and had
developed a pressure sore on his neck that was treated.
40. On 28 September, the man was visited by his family. His respirations
were recorded at 14-20 breaths per minute and he was using oxygen
through nasal prongs. He was able to tolerate fluids with assistance and
was washed in bed by nursing staff. Because of the pain he was
experiencing in his shoulders, he was given a strong analgesic. The
prisoner stated that he was comfortable.
41. At about 4am on 29 September, the man woke up and experienced a
severe episode of shortness of breath. He appeared to be in a confused
and disorientated state of mind. However, despite his breathing
difficulties, the medical record indicates that he was insistent on being able
to smoke.
42. At 4pm that day, the medical record indicates that the prisoner was
commenced on a syringe driver containing 200mg of Morphine and 5mg of
Midazolam. He was visited by the palliative care team during the day. He
did not raise any concerns about his care or treatment. The medical
record also notes that he was drinking good amounts of water but was
passing little urine. He was not able or willing to eat any meals.
43. At 7.50pm on 29 September, the Healthcare Centre received a telephone
call from the man’s daughter, stating that she would like to visit her father.
She also stated that some members of the family would also like to visit
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him in order to pay their last respects to him. The prison made the
necessary arrangements. The medical record indicates that the prisoner
had an unsettled night. He was still showing signs of confusion and
disorientation, however his pain was controlled and he was reasonably
comfortable.
44. In the meantime, the prison had been in contact with the Coroner’s Office
seeking advice on what action to take when the man passed away. The
prison was advised that his death should be treated as a death in custody
and that the prison’s contingency plan for such events should be followed
accordingly.
45. At about 9.10am on 30 September, the Healthcare Centre asked for the
prisoner’s nominated next of kin, to be contacted. The prisoner’s vital
signs had deteriorated overnight and he was again showing signs of
cyanosis. A member of the Prison Chaplaincy team, also attended the
man’s cell and spoke with him. The Chaplain’s visit appeared to give the
prisoner some comfort and solace. The Chaplain spent a significant
proportion of the day at the man’s bedside. The medical record states that
the prisoner was not able to smoke and declined oxygen.
46. At about 6.35pm on 30 September, the man’s daughter and partner visited
him. He was asleep for most of the time and, although his daughter was
very tearful, she appeared to become more settled after visiting her father.
The medical record indicates that at 9pm the prisoner still had visitors at
his bedside. He was not in any sign of distress and his oxygen levels were
recorded at 88%. Photographs of his family were left at his bedside by his
visitors.
47. On 1 October, the man was still showing signs of cyanosis. Although
unable to drink, he was taking fluid from foam swabs. It was noted that his
heart rate was weaker and that his complexion had paled. He was
reacting to voice commands but unable to co-ordinate his responses with
his eyes. At 8.30am, his brother was present at his bedside. By 11.30am,
his pulse was described as weak. A fan was placed in his cell to keep him
cool. With the consent of the prison, a member of his family took
possession of his watch, ring, radio and glasses for safe keeping. By
8.20pm, the medical record indicates that the man was experiencing
severe breathing difficulties. The prison made prompt and sensitive
arrangements to enable the prisoner’s brother and sister to remain with
him throughout the night. His fluid intake was very poor by this point, and
his lips were extremely dry so they were being moistened regularly by
staff.
48. At about 6.30am on 2 October, the man’s breathing was described as very
laboured, his pulse was irregular and he had a slightly raised temperature.
49. By 8am, the prisoner’s breathing was described as very shallow. His
brother was advised by Healthcare staff to remain at his brother’s bedside,
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as it was felt that the prisoner’s breathing pattern would not be sustained
for much longer.
50. At 9.55am on 2 October, the man was provisionally pronounced dead by
Healthcare staff. No attempts were made to resuscitate him in compliance
with the order signed on 21 September. At about 10.20am, he was
officially pronounced dead by a doctor.
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Events after the prisoner’s death
51. Following his death, and with the consent of the duty governor, the
prisoner’s brother took legal possession of his brother’s personal affects.
These included a box of photographs that that had been left at the man’s
bedside and a crucifix that belonged to the prison Chaplain. The Chaplain
had given permission for the prisoner to be buried with it. A set of prison-
issued rosary beads was also taken. Permission had been granted for the
prisoner’s brother to stay with the body until the police and undertakers
had arrived.
52. The man’s funeral took place in October 2005. According to the family,
the prison had offered financial support towards the cost of the funeral but
this was declined by the family. The Prison Service was not represented
at the funeral.
53. In a telephone conversation with my Family Liaison Officer, the prisoner’s
family were full of praise for the efforts of the Healthcare staff at
Pentonville. A member of the family who works in a hospice has said that
the man received compassionate care and attention whilst he was in the
final stages of his life.
54. On 22 November, my investigator received a copy of a letter from the
Coroner’s Office. The letter, dated 8 November, and signed by members
of the prisoner’s family, said that he received an excellent level of care
whilst at Pentonville with one to one nursing. Indeed, the family are
convinced that he received a better level of care compared to that he
would have received in the wider community.
55. In January 2006, the Coroner’s inquest took place and it was recorded that
the prisoner died of natural causes. The family have not raised any
concerns in regard to his care or treatment.
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Clinical review and post mortem
56. The Coroner’s Office confirmed that they were made aware of the
prisoner’s condition by the prison. Because the outcome had been
anticipated, a post mortem was not carried out.
57. The clinical review into the care and treatment provided to the prisoner has
highlighted a number of issues in regard to the maintenance of medical
notes and care plans with a view to ensuring that they are legible, clear,
concise, consistent, continuous, appropriate and robust. The review has
also highlighted the need to ensure that palliative care staff are given quick
and easy access to a prisoner, particularly in circumstances where such
visits are unannounced. The review has also established that, where
specific medication is required for the purpose of pain control, Healthcare
should make adequate arrangements for it to be stored on site for use by
the palliative care team.
58. The clinical review concludes that the diagnosis of the man’s cancer was
appropriate and timely. The review also suggests that the care provided to
him by the prison healthcare team and the palliative care team in the
Healthcare Centre was reasonable, appropriate and exceeded the
expected level of care that would be available to the wider community.
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Findings and conclusions
59. The was initially suspected of having contracted tuberculosis. The prison
implemented a barrier nursing policy and kept the prisoner in isolation
pending further investigation. Following x-rays and scans, it was soon
discovered that he had cancer of the lungs and secondary cancers that
required urgent treatment in hospital.
60. Despite radiotherapy and chemotherapy, the treatment was not deemed to
be prolonging the prisoner’s life and he was discharged from hospital back
to the Healthcare Centre for palliative care in September. Although
terminally ill, he was not considered ill enough to be transferred to a
hospice at that stage. In August, he was given approximately three
months to live. The man’s health continued to deteriorate rapidly and
would have done so in any environment.
61. In anticipation of the prisoner’s death, the prison prepared a report dated
23 August that was to be submitted to the Secretary of State seeking
permission to release him on compassionate grounds. The report was to
be forwarded for consideration in the final stages of his life. The timing of
the submission to the Secretary of State took into account the needs of the
prisoner and the wider public interest in the integrity of sentencing
decisions. However, the deputy governor who requested the report stated
that it was very difficult to establish exactly how long the prisoner had to
live at the time that the report was compiled. Unfortunately, from 16
September, the prisoner’s condition deteriorated with such rapidity that
there was little time to submit the report and to obtain the Secretary of
State’s authority to release him. In any event, his condition was
considered to be so grave after 16 September that moving him was
considered to be against his interests. It was also the prisoner’s wish to
remain in the Healthcare Centre. I make no criticism of the prison, in that
decisions relating to compassionate release are necessarily inexact.
However, consideration might have been given in submitting the report
prior to the man’s discharge from hospital, particularly when it was known
that he had only months to live. In response to my draft report the Prison
Service has stated that the prisoner’s condition deteriorated rapidly, an
unforeseen development that rendered prison management unable to
continue with the process of early release.
62. Some attempts had been made in September to transfer the man to a
hospice where he would be close to his family. Although this would have
afforded better access to him, the family felt that he might attract unwanted
attention as the man would initially have been subject to bedwatch by
prison officers (until such time as authority had been received from the
Secretary of State for him to be released on compassionate grounds). A
Release on Temporary Licence (ROTL) was not considered appropriate
because of the nature of the prisoner’s offence.
63. On discharge from hospital on 12 September, the prisoner’s care was
taken up by the prison healthcare team who were supported by the
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hospital’s Palliative Care Consultant and specialist nursing team. The
man was moved to a large cell that was equipped with a special bed and
oxygen cylinder. He was reviewed regularly by the prison doctor as well
as the Palliative Care Consultant.
64. As the prisoner’s condition deteriorated, provision was made by the prison
for his immediate family to visit him in the Healthcare Centre. These visits
were arranged outside of normal visiting hours and gave family members a
high degree of space, quality time and dignity to say their goodbyes.
There is no doubt that the man derived a great deal of inner peace,
comfort and solace from such visits. He died with his brother at his
bedside. The family were full of praise for the way in which the Prison
Service in conjunction with the hospital managed his condition. His family
are convinced that he received a good level of care and treatment that was
at least equal to, if not better, than that in the wider community. I share
these views. Staff at Pentonville are to be commended for their sensitivity,
compassion and flexibility. I am sure the Governor will wish to share my
comments with the staff concerned and with the wider prison community.
65. The prisoner received an appropriate level of care and treatment whilst in
prison. Indeed, the clinical review notes that the treatment afforded to him
was that which might have been expected in society at large. However,
the clinical review has highlighted a number of issues that should be
addressed, including ensuring that record keeping is in compliance with
the Nursing and Midwifery Council’s standards. The Prison Service has
subsequently accepted most of the recommendations that I have made.
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Recommendations
(cid:131) Operational
In line with the prison’s security procedures, consideration should be given to
developing a local policy to ensure quick and easy access to a prisoner by
palliative care staff, particularly when visits are unannounced or arranged at
short notice.
This recommendation has been accepted by the Prison Service.
In the event that larger than normal quantities of pain relief medication are
required for a prisoner with palliative care needs, the Healthcare Manager
should ensure that adequate stocks are available and secured on the
premises.
This recommendation has been accepted by the Prison Service.
Where specific medication is required for the purpose of pain control, the
prison should make arrangements for these to be stored on site for use by the
palliative care team.
This recommendation has been accepted for review by the Prison Service.
The Healthcare Manager should ensure that record keeping complies with the
Nursing and Midwifery Council’s standards for record keeping in order to
maintain consistent, continuous and legible records with a view to providing a
concise and accurate overview of a patient’s care in compliance with the
Nursing and Midwifery Council’s standards for record keeping.
This recommendation has been accepted by the Prison Service.
(cid:131) Recommendations from the clinical review
Whilst the panel acknowledge the delivery of care given to the prisoner,
exceeded that which he could have expected to have received in the wider
community, speedier and timelier planning for the place of care could have
been more effectively managed so that the man could have received palliative
care in a hospice.
Not accepted – the Prison Service acknowledges that the delivery of care was
‘reasonable, appropriate and equitable to that of the wider community’.
Further, the prisoner’s condition deteriorated rapidly, an unforeseen
development that rendered prison management unable to continue with the
due processes that are in place to enable full review of healthcare options.
The prison healthcare team need to review and agree a standardised set of
healthcare records that can be used for every prisoner. Particular attention
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needs to be given to developing a continuous record that can be used for in-
patients in the healthcare unit that includes robustly and regularly reviewing
nursing care plans.
This recommendation has been accepted by the Prison Service.
Standards of record keeping need to be reviewed as part of the appraisal
process for all healthcare staff including GPs.
This recommendation has been accepted by the Prison Service.
Record keeping audits are considered to be good practice and the panel
strongly recommend that all healthcare staff participate in a record keeping
audit at least once a year.
This recommendation has been accepted by the Prison Service
The panel remain concerned that the prisoner remained shackled for the
duration of his treatment and care whilst an in-patient at hospital. It is
suggested that the procedure for restraining individuals that are known to
have a terminal illness is reviewed.
Not accepted – Shackles is an emotive term. The handcuffs were removed
from the prisoner while he was at the hospital. While he remained mobile and
in the light of his offence, it was vital to retain public confidence in the Criminal
Justice System and balance security needs against those of the individual.
The wishes of the prisoner’s family for a prison family liaison officer and a
family room to be available for similar future situations to be given some
consideration.
This recommendation has been accepted for review by the Prison Service.
Good practice
Staff at Pentonville should be commended for the flexibility, care and
compassion shown to the prisoner and his family in what were sensitive and
difficult circumstances.
This recommendation has been accepted by the Prison Service.
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