Individual at Preston

Investigation into the circumstances surrounding the
death of a man, who was a prisoner at HMP Preston,
in hospital in May 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
October 2006
This is the report of an investigation into the death of a man. The man died
from apparent natural causes on 13 May 2006 in hospital. He was a prisoner
at HMP Preston and had a significant history of chronic diseases including
hypertension, angina, diabetes and spondylosis. The man was 69 years old.
I would like to add my personal condolences to those already expressed by
one of my Family Liaison Officers on behalf of this office.
This investigation has been undertaken by one of my colleagues. I would like
to thank the Governor and staff of HMP Wymott (where the man spent most of
his time in custody until the final stages of his illness) for their ready
assistance with this investigation.
A doctor was asked by Chorley and South Ribble Primary Care Trust to
undertake a review of the man’s clinical care, and I also appreciate her
assistance.
As is the case in many of my investigations following a death from natural
causes, I am much influenced by the findings of the clinical review. In the
case of the man, the review raises concerns to which both HMP Preston and
HMP Wymott and their healthcare provider will need to give careful
consideration.
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.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2006
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CONTENTS
Summary 3
The investigation process 4
HMP Wymott 5
Key events 6
Clinical review 8
Conclusion 9
Recommendations 10
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SUMMARY
The man was born in March 1937. He was 69 years old when he died on 13
May 2006.
The man had been received into custody on 9 June 2005 after being
sentenced to five years imprisonment. He was initially held at HMP Preston
and transferred to HMP Wymott on 27 June 2005. During his first reception
health screen at Wymott, it was noted that the man had hypertension (high
blood pressure), angina, diabetes and spondylosis (arthritis) of the spine.
On 10 February 2006, the man was taken into hospital. He was then
transferred to another hospital where he underwent an operation on his bowel
and a liver biopsy on 6 March. He was diagnosed with incurable cancer. The
man was discharged from hospital on 27 March and transferred to the hospital
wing at HMP Preston. He did not return to Wymott.
On 5 May 2006, the man was again taken to hospital. Whilst he was an in
patient at the hospital, a bedwatch was carried out by prison officers.
Around 2:40am on 13 May, an officer noticed that the man did not appear to
be breathing. The officer asked the Ward Sister to check and she confirmed
that the man appeared to have died while he was asleep. The man was
pronounced dead at 3:10am.
The clinical review concludes that the man’s clinical care was, overall, of an
appropriate standard. The review makes two recommendations which I
endorse.
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THE INVESTIGATION PROCESS
1. My investigator studied all relevant prison records relating to the man.
These included his main prison record, his medical records and
statements made by prison staff.
2. The Chorley and South Ribble Primary Care Trust asked a doctor to carry
out a review of the man’s clinical care. I am grateful for her review and for
the fact it was undertaken in a most timely manner.
3. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of my investigation and to request a copy of the Post
Mortem report. Upon completion, this report will be sent to the Coroner to
assist him in his enquiries into the man’s death.
4. One of my Family Liaison Officers contacted the man’s family. This was to
give them the opportunity to meet with the investigator to discuss the
purpose of the investigation, and to raise any concerns or questions that
they would like explored and addressed. In the event, the family raised no
specific concerns about the man’s care and treatment whilst he was in
custody.
5. My investigator discussed aspects of the man’s treatment with both staff at
Wymott and the clinical reviewer.
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HMP WYMOTT
6. Wymott is a Category C training prison for adult male prisoners. Over half
of the population are vulnerable prisoners, approximately half of whom are
sex offenders. The prison is located on the outskirts of Leyland in
Lancashire. The maximum number of prisoners who can be held at
Wymott is currently 1,046.
7. Provision of healthcare within the prison is the responsibility of the Chorley
and South Ribble Primary Care Trust. The healthcare centre has a doctor
available every weekday. Overnight and weekend cover is provided by
local GPs, who are on call. There is also a qualified member of healthcare
staff on duty at these times. There is no in patient care facility at Wymott
and prisoners who require this care are referred either to HMP Preston or
to local hospitals.
8. Medication is administered on a weekly and/or monthly basis to those
prisoners who have been assessed as capable of holding it in their own
possession. It is administered on a daily basis to other prisoners, when
they are considered to be at risk or the medication is unsuitable to be held
in their possession.
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KEY EVENTS
9. The man arrived at Wymott on 27 June 2005. On his arrival, it was
decided that he should be given Vulnerable Prisoner status due to the
nature of his offences. During his health screen it was noted that he had
hypertension (high blood pressure), angina, diabetes and spondylosis
(arthritis) of the spine.
10. On 10 February 2006, the man was taken into hospital. He was then
transferred to another hospital where he underwent an operation on his
bowel and a liver biopsy on 6 March. The man was discharged from
hospital on 27 March and transferred to the hospital wing at Preston
prison. He did not return again to Wymott.
11. A letter on the file from a Consultant, dated 4 April, reports on his
consultation with the man. The Consultant stated that the man had been
diagnosed with incurable cancer and confirmed that he had discussed the
poor prognosis with him. The Consultant also pointed out in his
correspondence that he had discussed chemotherapy and the impact
treatment would have on how long the man had to live.
12. On 5 May 2006, when his condition deteriorated, the man was again taken
to hospital. Whilst he was an in patient at the hospital, a bedwatch was
carried out by prison officers. The security risk assessment identified that
a closeting (escort) chain was used. The restraints were removed on 9
May after a further risk assessment and after the man’s health had
deteriorated.
13. Around 2:40am on 13 May, an officer noticed that the man did not appear
to be breathing. The officer asked the Ward Sister to check and she
confirmed that the man appeared to have passed away in his sleep. The
man was pronounced dead at 3:10am.
14. The Ward Sister contacted the man’s family to inform them of his death.
The prison also contacted the man’s family to offer condolences and
support. The prison maintained contact with the family and made
arrangements for the funeral. The prison provided financial assistance for
the funeral costs.
15. The post mortem report records the cause of death as due to natural
causes as a consequence of carcinomatosis (the spread of cancer from
the original site of growth to other tissues in the body) which was caused
by carcinoma (cancer) of the colon (first part of the large intestine).
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16. When contacted by my family liaison officer, the man’s family said they
were very happy with the way in which the man had been treated by
Wymott and the hospital. The family felt that after the man’s diagnosis of
cancer, and when his health deteriorated, the prison did the best they
could under the circumstances. The family also drew attention to some of
the positive practices employed by the prison. These included handing
back the man’s belongings in a timely manner and assisting with the costs
for the man’s funeral.
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THE CLINICAL REVIEW
17. As noted, the clinical review was undertaken by a doctor on behalf of
Chorley and South Ribble. She found that the man had suffered from
significant long-term chronic diseases (diabetes, hypertention and angina)
and had been diagnosed with incurable cancer shortly before his death.
18. The medical records for the man included a report prepared for his
solicitors in May 2005 by a Consultant Physician. The report noted that
the man had an enlarged and tender liver, abnormal liver function tests
and some shadowing on his lung. The report discussed the possibility of
a malignant cause of the man’s liver problems, which could not be
clarified until the results of scans were available.
19. There does not appear to be any record of these investigations into the
man’s liver pathology being followed up. The first reception health
screens at both Wymott and Preston make no reference to the report by
the Consultant Physician, and my investigator has been unable to
establish whether the report was available to prison staff at the time of
either healthscreen. If the report was available, it is regrettable that no
mention is made in the healthscreens of the need to chase up the
proposed liver scan and blood tests. It is also regrettable that the
abnormal liver function tests were not repeated on a regular basis.
20. The reviewer recommended that at each Reception Health Screening
health care staff should note any outstanding investigations, out-patient
visits etc and ensure that these take place and that the outcomes are
reviewed. The reviewer also recommended that, when medical
information is received by healthcare at a later date, the date of receipt
should be clearly recorded - and again any outstanding investigations or
issues should be noted and dealt with promptly.
At each Reception Health Screening, healthcare staff should note
any outstanding investigations, out-patient visits etc and ensure that
these take place and that the outcomes are reviewed.
If medical information is received by healthcare at a later date, the
date of receipt should be clearly recorded and again any outstanding
investigations or issues should be noted and dealt with promptly.
21. The reviewer judged that, when the man became very ill, the treatment
that he received was appropriate and equivalent to that which would have
been available to anyone else in the wider community.
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Conclusion
22. The man was received into prison in June 2005. He died from carcinoma
(cancer) in May 2006. The man had arrived in prison with a number of
heath problems. He had a history of heart related disorders, diabetes and
spondylosis of the spine. In March 2006, the man was diagnosed with
cancer which was widespread and incurable.
23. In reviewing the bedwatch log, it is clear that the staff involved with the
man’s care behaved with sensitivity. The security arrangements at the
hospital seem to have been appropriate, and struck a good balance
between public protection and sensitivity to the man’s circumstances.
24. In light of the findings of the Clinical Review, and my own investigation, I
conclude that while the man’s medical care was satisfactory, it is possible
that there was a failure to act upon information about his condition and the
need for further exploration. I cannot say if earlier action would have
affected the outcome of the man’s illness. I have endorsed the two
recommendations from the clinical review to be addressed by Chorley and
South Ribble Primary Care Trust in partnership with the Governors of
Preston and Wymott.
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RECOMMENDATIONS
Medical
At each Reception Health Screening, healthcare staff should note any
outstanding investigations, out-patient visits etc and ensure that these take
place and that the outcomes are reviewed.
Accepted by the Prison Service.
If medical information is received by healthcare at a later date, the date of
receipt should be clearly recorded and again any outstanding investigations or
issues should be noted and dealt with promptly.
Accepted by the Prison Service.
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