Individual at Ranby

The death of a man
in custody at HMP Ranby in November 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2005
This is the report of an investigation into the circumstances of the death in
November 2004 of the man at hospital, whilst temporarily released from HMP
Ranby.
The man’s death was caused by lung cancer.
One of my investigators carried out the investigation and a clinician also from
my office carried out the clinical review.
My colleagues and I would like to extend our condolences to the man’s family
for their loss. I would also like to thank the Deputy Governor of Ranby, who
forwarded all relevant information to my investigator.
The clinical review questions whether Ranby was an appropriate location for
the man. I share that view. However, I should also like to draw attention to
the compassionate way the man and his son were repeatedly co-located.
This showed a level of individualised care that reflects extremely well on the
individual prisons and the Prison Service as a whole.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2005
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Contents
Contents ..........................................................................................................3
Summary .........................................................................................................4
Background......................................................................................................5
HMP Ranby...........................................................................................5
Investigation process.......................................................................................6
Events leading up to the man’s death..............................................................7
Post Incident Response...................................................................................8
Level of Compliance ........................................................................................8
Findings and Conclusions................................................................................9
Recommendations.........................................................................................10
Good Practice................................................................................................10
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Summary
The man died at the age of 77, in hospital, having been admitted ten days
earlier. His death was not connected to the fact that he was in prison or to the
level of care that he received there.
This was the man’s first time in prison. He spent most of his custody located
in the prison Healthcare Unit. The prison describes him as a polite man, with
positive custodial behaviour.
The man died of natural causes as a result of lung cancer.
The report makes three recommendations.
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Background
HMP Ranby
Ranby is a category C male adult training prison, near Retford in
Nottinghamshire. It was converted in the early 1970’s from its original use as
an Army camp. While some old billets remain, purpose built accommodation
has since been added.
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Investigation process
All the indications were that this was a death from natural causes. The
Ombudsman’s Terms of Reference allow in these circumstances for a clinical
review to be carried out by an independent health care professional, rather
than conducting a full investigation.
My approach in cases of apparent natural cause deaths has been to conduct
an initial review to determine if a full investigation is justified. In the man’s
case, I decided that the circumstances did not require a full investigation. I did
so after my investigator contacted Ranby Prison, reviewed the documentation
and had a very helpful discussion with the Deputy Governor.
My investigator wrote to the Chairman of the local Prison Officers’ Association
(POA), and the Chair of the Independent Monitoring Board (IMB). Neither the
POA nor the IMB had any issues they wished to draw to my investigator’s
attention.
My investigator was given access to all the man’s prison records, including his
medical records, and was given copies of everything that was required.
Following a telephone call, my investigator sent a letter to the man’s next of
kin, his younger son, inviting him to get in touch, if he wished, to make any
comments or ask questions. The man’s younger son wrote to my investigator
and provided a very useful chronology of events and background information.
Information supplied has been considered in this investigation.
One of my clinicians carried out the clinical review.
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Events leading up to the man’s death
Following sentence in 2004, the man was taken to the local prison. He was
subsequently transferred to HMP Ranby on 16 July 2004. This was despite the fact
that Ranby does not have 24-hour Healthcare Centre cover.
Following a recurrent and deteriorating complaint of shortness of breath, in October
2004 the man was admitted to hospital for assessment and an ECG. His family was
not formally told that this had happened. However, they found out that evening in a
telephone conversation from his son.
The family saw the specialist in charge of the man’s case on 27 October. The family
was told that the man had cancer of the lung that was quite well advanced. A junior
doctor indicated that he might have only weeks to live.
On 28 October, the family contacted the prison and spoke to the Governor. They
discussed the possible early release of the man from custody due to his condition. A
meeting was arranged for 2 November to discuss this further.
The hospital discharged the man to Ranby on 28 October. He was taken to hospital
again on 30 October for pain relief but was not kept in.
At the scheduled meeting on 2 November, the family was relieved to find that the
Governor was working towards releasing the man. Following the meeting, the prison
regularly contacted the family and kept them informed of progress.
The medical facilities at Ranby were judged as not adequate for the man’s needs.
On 4 November, he was transferred to the healthcare centre at HMP Lincoln that has
24-hour inpatient facilities consistent with his needs. His son was transferred with
him. Shortly after his arrival, the man was admitted to hospital. Lincoln released him
on a compassionate temporary release licence.
On 9 November 2004, the prison doctor, from Ranby wrote to the Home Office, in
support of an application for the man’s early release, on compassionate grounds.
On that day, the man was transferred to hospital where a further complication of
pneumonia was diagnosed. The prison considered the man’s condition had
deteriorated to such an extent that he posed no risk of escape and released him from
custody, on a compassionate temporary licence.
Responsibility for the man was transferred back from Lincoln to Ranby, who
maintained regular contact with the hospital and the family.
The man died in hospital later that month.
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Post Incident Response
All the necessary information was gathered together for the purposes of this
investigation.
Level of Compliance
Standards of healthcare in prison are intended to mirror those available in the
outside community. The man’s prison records indicate that he was being
given an appropriate level of care, and his medical and social needs were
recognised and adequately dealt with. The medical aspects of his care are
described in the independent clinical review. The clinical reviewer also
concludes that appropriate care was given to the man.
I note, however, that while entries in medical records were fairly good, some were
difficult to read and they were not always signed.
Prison Service Order 2710 sets out what action prisons must take following a
death in custody. Ranby fully complied with this order.
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Findings and Conclusions
The man had a number of medical problems. Prior to his being given a prison
sentence, he was found to have a shadow on one of his lungs. The man died
of natural causes as a result of lung cancer.
Apart from the initial notification, when the prison neglected to tell the family
the man had been admitted to hospital, the family liaison arrangements
appear to have been effective.
Most of the man’s health problems whilst in prison were attributed to the lung cancer.
The medical and nursing staff in the various establishments cared for the man’s
needs and his treatment and care appeared to be appropriate. However, I consider
that the man would have benefited from an earlier transfer to a prison with 24-hour
inpatient facilities.
A request was sent to the Home Office in an effort to obtain an early release on
compassionate grounds. Regrettably, the man died before any further action could
be taken. I make no formal recommendation on this point, as I have not investigated
it further. However it is manifest that any consideration of release on compassionate
grounds needs to be conducted urgently.
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Recommendations
I make the following recommendations: -
(cid:190) Healthcare staff should be reminded that entries in medical records should be
signed and legible.
(cid:190) Patients requiring 24-hour medical and nursing assessment and care should be
located to establishments, which have a 24-hour inpatient facility.
Good Practice
It was very good practice that the man and his son were repeatedly co-located. This
demonstrated kindness and sensitivity in the best tradition of public service.
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