Individual at Send

Investigation into the death of a woman whilst in the
custody of HMP Send in May 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2009
This is the report of an investigation into the circumstances surrounding the death of
the woman in May 2009. The woman was a prisoner at HMP Send. A post mortem
recorded the cause of death as cancer.
I offer my sincere sympathy and condolences to the woman’s family for their loss, as
I do to all of her friends and acquaintances who have been touched by her passing.
One of my family liaison officers was in contact with the woman’s family at the start
of the investigation process.
The investigation was led by one of my investigator. I must thank the local PCT for
the appointment of a clinical reviewer. I am also grateful to the Governor and staff of
Send, especially to the Governor, whose assistance was a great benefit to the
investigator.
As the woman died from natural causes, the findings of the clinical review play a
pivotal role in my report. The review of the woman’s clinical care shows that she
received equitable treatment at Send to that expected in the community.
I make one recommendation concerning the follow up procedures for external
medical treatments by healthcare at Holloway. I also recognise two areas of good
practice that is the risk assessments carried out in respect of the use of restraints
and the excellent family liaison.
The version of my report, published on my website, has been amended to remove
the names of the woman who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman December 2009
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CONTENTS
Summary
The Investigation Process
HMP Send
Key Findings
Issues
Conclusion
Recommendations
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SUMMARY
The woman was born in the London area. She had a history of depression and
epilepsy. She was remanded into custody she was convicted of murder and
sentenced to life imprisonment.
The woman spent a number of years at HMP Holloway. During this period she was
treated by forensic psychiatrists and prescribed antidepressant medication. She was
also treated from prison doctors for several urinary tract infections.
The woman had hip replacement surgery. Arrangements were made on her to
prison to have physiotherapy. The woman had two reviews at the hospital after the
hip operation and, after being x-rayed, it was recommended that she had a
Computed Tomography (CT) Scan. This was arranged but on the day the woman
refused to go to hospital despite encouragement from staff.
The woman transferred to Send where she had a full health check which confirmed
her recent medical history and medication. Her weight was recorded as 73kg. She
saw a nurse because she was concerned that her weight had fallen to 64.7kg.
Five months later a nurse saw the woman at the request of the wing staff as she felt
unwell. The nurse recorded that she looked very pale and her weight had fallen
further to 59kg, which was a loss of 5.5kg from two weeks previously. An
emergency appointment was made to see the doctor. However the next day she
was taken by ambulance to the Royal Surrey County Hospital as her condition had
deteriorated. .
Healthcare staff kept in regular contact with the hospital to check on the woman’s
progress. She consented to the prison contacting her family but preferred them not
to visit. The hospital contacted the prison to confirm that the woman had wide
spread cancer and only had days to live and that ward staff had informed her family.
Later that afternoon she died.
Following the woman’s death Send maintained contact with her family and offered
emotional support as well as financial assistance towards the cost of funeral
expenses.
I find that the woman received a good standard of care whilst at Send and was
treated with dignity and respect in her final days. There were significant and
unacceptable delays in her receiving hip replacement surgery whilst at Holloway.
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THE INVESTIGATION PROCESS
1. My investigator visited Send and collected all the relevant records including the
woman’s main prison record and medical records. Notices were posted to staff
and prisoners about the investigation inviting contributions. One prisoner came
forward as a result and was interviewed by my investigator.
2. The local PCT asked a medical practitioner to carry out a review of the woman’s
clinical care. I am grateful to her for undertaking this review.
3. The investigator contacted HM Coroner to inform him of the nature and scope of
my investigation and to request a copy of the post mortem report. Upon
completion, my report will be sent to the Coroner to assist his enquiries into the
woman’s death.
4. One of my Family Liaison officers contacted the woman’s family at the beginning
of the investigation and asked if they had any questions or concerns to raise
about the care she received. The woman’s family did not have any issues that
they wished the investigator to consider. They said that they had not been told
at first that the woman was in hospital. This was at the woman’s request as she
did not want them to be worried. The prison staff had then persuaded her to tell
them when her illness became more serious. The family were very impressed
that someone from the prison rang every morning to give an update on the
woman’s progress and they found this very comforting. The family could not
speak more highly of the prison family liaison officer. They were offered financial
support towards the costs of funeral expenses. A copy of my report will be
provided to the family.
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HMP SEND
5. HMP Send was re-rolled in 1998 and rebuilt by 1999. It currently operates as a
closed female training prison and incorporates a 20 bed addictive treatment unit,
an 80 bed resettlement unit and a therapeutic community with a capacity of 40.
As of 1 May 2009 Send has an operational capacity of 282 prisoners.
6. The wings include single cells with integral sanitation and individual showers. A-
Wing is the therapeutic community and E & F wings make up the resettlement
unit. D Wing, the addictive treatment unit is a 20 women unit with double rooms
and communal showers.
7. The latest report produced by HM Chief Inspector of Prisons was published in
October 2008. The report, in its introduction, stated:
“Send has gone through a very unsettled period, with an expansion of its
population and an increase in short-term prisoners, but without sufficient
investment in the regime. The pervasive impact of the inability to recruit and
retain staff had resulted in shortages, an influx of inexperienced staff and
difficulty in maintaining an appropriate gender balance. On top of this, there
had been an excessive turnover of governors – three in less than two years
– and further uncertainty created by a new clustering arrangement with a
women’s prison in Sutton. The outcome had been slippage in some
important areas since our previous inspection, including a worrying
deterioration in aspects of safety.”
8. Regarding health services at Send, the report said that prisoners were
dissatisfied with healthcare and went on to say:
“Healthcare services were under strain due to problems recruiting
permanent nursing staff. The healthcare department provided cover
between 7.30am and 6.30pm seven days a week. There were four
healthcare staff on the early and late shifts. There were 11 agency nurses
regularly on duty, which led to problems such as a lack of continuity of care
and unfamiliarity with healthcare procedures. On some occasions,
healthcare was staffed exclusively by agency staff. Lack of regular staff
affected every discipline in healthcare.”
In addition the report made the recommendation that prisoners with disabilities
should have care plans in place.
9. The latest Independent Monitoring Board (IMB) annual report was produced for
the period ending March 2008. In the report the IMB specifically commented on
healthcare as follows:
“In the 2007/08 Report, significant concern was expressed by the Board
about the shortage of nursing staff at HMP Send. It is with much regret that
we report that the situation has deteriorated further and this has started to
have an adverse effect on the service provided to prisoners.”
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“Despite numerous attempts, recruitment of new staff to meet the required
complement has met with little success. As a result, the quality of applicants
has often been below the required standard. The shortage of suitably
qualified staff has been mitigated by the use of agency staff who have the
required professional expertise but often lack the experience of working in a
prison.”
“With effect from 1st April 2008, the Surrey Primary Care Trust has taken on
full responsibility for staff employment within Healthcare at HMP Send.”
10. There have been four previous investigations into deaths that have occurred at
Send since 2004. There are no similarities between those deaths and that of the
woman.
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KEY FINDINGS
11. The woman was born in the London area. She had a history of depression,
epilepsy and alcohol dependency. The woman was remanded into custody at
HMP Holloway. She was convicted of murder and sentenced to life
imprisonment. The woman had been prescribed Fluoxetine (antidepressant and
mood stabilising medication) by her general practitioner before coming into
prison and the prescription continued when she was in prison.
12. The woman was assessed by a consultant forensic psychiatrist, who conducted
a review of her Fluoxetine as the dose had been increased from 20mg to 40mg a
day. The woman told the consultant forensic psychiatrist that since the increase
in medication she felt much better and less emotional.
13. The woman’s next contact with healthcare was when the first nurse saw her on
the wing because she was complaining about pain in her lower back and
kidneys. She told the nurse that she was passing urine frequently and blood
was present. She was referred to the prison doctor the next day who prescribed
a course of Trimethprin (antibiotic).
14. Six days later wing staff were concerned about the woman’s health and the first
nurse came back to see her on the wing. The nurse recorded that the woman
said she had not eaten for three days as trying to eat made her feel sick. The
nurse suggested to the woman that she should move to the healthcare centre for
a period of observation, but she refused. The nurse encouraged her to drink as
much fluid as possible. Urine samples were taken which showed raised blood,
protein and sugar levels. These tests were repeated with the same results and
samples were sent to the local hospital for analysis.
15. The woman saw the prison doctor. (It has not been possible to identify who the
doctor was from the handwritten notes.) The doctor recorded that the woman
felt tired, was off her food and vomited the previous day. The doctor noted that
the woman was tender in the kidney area, but that her urine was clear. The
results from the hospital were followed up and she might require a further course
of antibiotics. (There is no record in the medical record of these results being
received.)
16. A second forensic psychiatrist saw the woman. The doctor prescribed a change
in her medication from Fluoxetine to Citalopram (another antidepressant)
because of her history of renal problems and also prescribed Sodium Valproate
(a mood stabiliser). The forensic psychiatrist was concerned about the woman’s
memory function and asked for further investigations to be made. (There is no
evidence available in the medical records to show that these investigations were
undertaken.)
17. The woman had a medical review conducted by the first prison doctor, and a
second nurse. She was prescribed Citalopram, Sodium Valproate, Ferrous
Sulphate (iron dietary supplement) and Diclofenac (non steroid anti-inflammatory
medication for treatment of arthritis). She was a smoker, but usually no more
than nine cigarettes a day.
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18. Two weeks later the woman saw the first prison doctor as she had suffered from
a chesty cough for a week that produced green phlegm. The doctor recorded
that the woman was not experiencing any chest pain or shortness of breath.
The doctor prescribed Erythromycin (antibiotic for treatment of respiratory tract
infections). The woman also told the doctor that she had experienced a spinning
sensation, felt sick and light headed. The doctor recorded that there was no
drowsiness, weakness of limbs or hearing loss and prescribed Prochlorperazine
Maleate (for treatment of nausea and vertigo).
19. The woman was seen by a second prison doctor, as she had been referred by
nursing staff for a possible urinary tract infection and haematuria (presence of
red blood cells in the urine). The doctor recorded that the woman had
pyelonephritis (a urinary tract infection that has reached the kidneys) in the past
and suffered from obvious pain on moving her right hip. The doctor prescribed
Ciprofloxacin (to treat urinary tract infections) and Tramadol Hydrochloride (an
analgesic used to treat moderate to severe pain) and requested investigation of
the woman’s hip.
20. The woman next saw the second prison doctor because she had pain in the
bladder area. The doctor recorded that blood and urine samples had been taken
and advised that the woman did not take the Diclofenac until she felt better. The
doctor prescribed another course of Ciprofloxacin as well as Hyoscine
Butylbromide (used to treat pain caused by abdominal cramps and other
spasmodic activity in the digestive system) and paracetemol. The test results
were received six days later and the doctor recorded that all the results were
normal.
21. The second prison doctor saw the woman as she had been depressed, felt very
low, weepy and slept all day following the recent death of a cousin. She told the
doctor that she had no thoughts of self harm. The doctor increased the
prescribed Citalopram from 10mg to 40mg a day.
22. The second prison doctor next saw the woman two months later as she had
fallen in the laundry a few days earlier. The doctor noted that the woman had
not had an x-ray on her hip, even though one was requested and that she was
able to move but with a pronounced limp and in obvious discomfort.
Arrangements were made for x-rays to be carried out three days later.
23. The x-rays were taken at the hospital and the results showed that there were no
fractures of the right hip. However there was complete loss of the joint space
and the joint had degenerated. The second prison doctor wrote to the hospital
to ask for an orthopaedic surgeon to consider the woman for hip replacement
surgery.
24. The woman was then seen by a third forensic psychiatrist, as no follow up had
taken place since the second forensic psychiatrist had raised concerns about her
memory. As a result of these sessions, the third forensic psychiatrist believed
that there was little short term memory loss. However the woman agreed with
the forensic psychiatrist’s suggestion of a referral for neuropsychological tests.
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25. A third prison doctor saw the woman as she had a cough and sore throat for
about four weeks. She also told the doctor that she experienced pain in the loin
area. The doctor prescribed Amoxicillin (antibiotic for treatment of bacterial
infections) and asked for urine sample tests. The tests were completed the
same day and the results were normal.
26. All of the woman’s medication was removed from her possession two days later
as it was reported that she was trading her Tramadol with fellow prisoners. She
saw the first prison doctor and he reinstated the possession medication as he
accepted her word that she had not been trading her medication.
27. The woman had four neuropsychological assessments with a psychologist. The
psychologist recorded that the woman was happy to undergo formal cognitive
testing and on each session was in a good mood and engaged well.
28. The second prison doctor wrote again to the local hospital to refer the woman to
the orthopaedic surgeon for consideration of hip replacement surgery. In this
letter the doctor stated that a referral was first made but appeared not to have
been followed up.
29. As a result of the second prison doctor’s letter, the woman had an appointment
at the hospital. She was seen by a consultant orthopaedic surgeon, who
confirmed that hip replacement surgery would be beneficial and a date was set.
As the woman was informed directly of this date, for security reasons it was
cancelled and rescheduled.
30. The woman had the hip replacement surgery and was kept in hospital for seven
days. When she returned to prison arrangements were made for her to have
physiotherapy sessions. The wound was checked by healthcare staff in
accordance with the orthopaedic surgeon’s instructions.
31. A fourth prison doctor saw the woman and said that she felt tired all the time,
was sleeping most of the day and was feeling anxious. The doctor noted that
the woman had a history of renal problems which would contribute to her
tiredness. The doctor discussed the benefits of counselling and she was happy
for a referral to be made. The doctor saw her a week later. He recorded that
she was much better, was able to walk with crutches, sleeping less and was
brighter in mood.
32. The woman had two reviews at the hospital regarding her hip replacement. The
reports show that she had made good progress and used crutches less.
However, as a result of having the x-rays, concerns were raised about the
woman’s chest. A Computed Tomography (CT) Scan (a computerised view of
the whole body) was recommended. This was arranged but on the day Ms King
refused to go to the hospital despite encouragement from prison staff.
33. The woman transferred to HMP Send. The third nurse conducted a new patient
health check. The nurse recorded that she had a long standing history of
depression, epilepsy, chronic pyelonephritis and recurrent urinary tract
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infections. The nurse also recorded that the woman was still recovering from hip
replacement surgery and used crutches to aid her mobility. Her weight was
recorded as 73kg. The third nurse referred the woman for a full assessment with
a doctor. (There is no record that this took place)
34. The next contact the woman had with healthcare was 13 days later when she
was seen by a fourth nurse. They discussed the woman having her medication
in the afternoon rather than at night time which she accepted.
35. A search was conducted of the woman cell and a Tramadol tablet had been
found. A fifth nurse referred the woman for a review with the doctor. The
woman was seen by a fifth prison doctor to review her medication and
recommended that the pain relief was still required.
36. The woman was seen by a sixth prison doctor as she was experiencing pain
when passing urine. The doctor prescribed Amoxicillin and asked for urine
samples. The results of these tests showed that there were increased protein
levels and traces of blood.
37. A seventh nurse saw the woman because she was worried about her weight.
The nurse recorded the woman’s weight as 64.7kg, which is a loss of some nine
kg since she arrived at Send five months earlier. She told the nurse that she
was sleeping throughout the day as well as all through the night.
38. The fourth nurse saw the woman at the request of the wing staff. She was taken
in a wheelchair to healthcare by a fellow prisoner. The woman told the nurse
that she had felt unwell for the past few months, never felt hungry and felt sick at
the thought of food. The nurse recorded that the woman looked very pale and
her weight was 59kg, which was a loss of five and a half kg from when she was
weighed two weeks previously. An emergency appointment was made for the
woman to see the doctor. The nurse also noted that there had been no
assessment for the woman to use a wheelchair and it did not have foot rests.
Due to the health and safety concerns, the wheelchair was kept in healthcare as
an assessment would be required to allow the woman to use one.
39. The next day the third nurse responded to a call for assistance as the woman
had collapsed on the landing. The nurse found the woman sitting on a chair on
the landing. She was moved to a bed in the cell next to where she was sitting.
The nurse gave her oxygen as the woman was having difficulty in breathing.
40. The third nurse called for an emergency ambulance and she observed that the
woman was coughing and appeared to be trying to vomit but nothing was
produced. She felt cold and clammy to the touch and had been incontinent. The
woman was taken by ambulance to the hospital. A formal bedwatch risk
assessment was completed and the woman was escorted by two officers with
the use of a long escort chain (a long chain with a single cuff at either end, one
cuff attached to the prisoner the other to an officer), which was to be removed
when treatment was given.
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41. Healthcare staff kept in regular contact with the hospital to check on the
woman’s progress. There were daily risk assessments made of the level of
restraint to be used. The Governor gave the order that no restraints were to be
used but two officers should remain with her.
42. Two days later the woman was visited in hospital by a seventh nurse. The
woman was in pain and had been given morphine pain relief. After she had
been in hospital for two weeks, the woman finally consented to the prison
contacting her family to inform them of her illness but did not want them to visit.
The seventh nurse encouraged her to think about allowing them to visit. Once
the family had been informed, a member of healthcare staff contacted them each
day to update them on her condition.
43. The hospital contacted the seventh nurse to confirm that the woman had wide
spread cancer and only days to live. An End of Life care plan was put in place.
The hospital ward staff informed the woman’s family of her rapid deterioration.
Later that afternoon at 4.00pm she died and her death was confirmed by a
doctor at 4.13pm.
44. Following the woman’s death the prison family liaison officer, maintained contact
with the family, assisted with the funeral arrangements, liaised with the coroner’s
office and made arrangements for a visit to be made to Send so that the family
could meet the woman’s friends and collect her personal belongings. In addition
financial assistance was offered towards the cost of the funeral expenses.
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ISSUES
The woman’s final illness
45. The clinical review highlights that whilst the woman was at HMP Holloway it was
recommended that she had a CT scan following abnormal chest x-rays at the the
hospital. Arrangements were made for the scan however, despite healthcare
advice and encouragement, the woman refused to attend.
46. The woman was responsible for her own health and should have undergone the
proposed medical assessment. Following medical advice might have aided the
early identification of her health condition and facilitated proactive treatment, it is
recognised that she had the right to refuse treatment.
47. The review also highlights that the woman had lost nine kg in weight by 27 but
her Body Mass Index was within normal limits. The report states:
“Anaemia and weight loss are listed in the referral criteria for investigation of
colorectal cancer. It should be remembered that loss of appetite and lethargy
may indicate physical disease as well as being signs of depression.”
48. In addition the review commented that mortality rates for individuals with a
similar condition to the woman who are admitted to hospital as emergencies, are
higher than for those having planned surgery.
49. In conclusion the review makes the following comments regarding the woman’s
clinical care:
“Despite the lack of follow-up of the abnormal chest X-ray and the anaemia
and weight loss I do not feel that the eventual outcome would have been
different. If the colorectal cancer had metastasised to the lungs this would
have been an indication of advanced disease and bowel obstruction is also an
indication of advanced disease. Following her collapse with bowel obstruction
the woman followed a path similar to that for someone living outside prison.”
Hip replacement surgery
50. The clinical review focused on the care the woman received. However the
investigator highlights an area of concern regarding the delay in the woman
receiving her hip replacement surgery.
51. The second prison doctor first recorded that investigations were required into the
woman’s hip condition. The same doctor saw the woman on three separate
occasions before x-rays were requested these were taken three days later. This
is an unacceptable delay of seven months.
52. A referral letter to the orthopaedic consultant at the hospital sent by the second
doctor. The same doctor sent a further letter. There is no evidence in the
medical records that any follow up action took place in the intervening period.
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53. As a result of the second letter the woman was seen by the hospital consultant
in four weeks and she had her hip replacement surgery 12 weeks from the date
of being seen by the consultant. Had appropriate follow up action been taken by
healthcare at Holloway. The woman may well have had her operation at a much
earlier date which would have reduced the pain and discomfort she had to
endure.
I recommend that the Head of Healthcare at Holloway review the procedure
for following up referrals to outside health services to ensure that
prisoners receive timely medical treatment.
Use of restraints
54. Unfortunately there have been too many reports where I have critical of the use
of restraints when prisoners are under escort in outside hospital. It is pleasing
therefore to recognise the good practice adopted by Send to ensure that the
woman was treated with dignity and respect during her final weeks in hospital.
Family Liaison
55. Send appropriately followed the guidance given in PSO 2710, “Follow up to
death in custody”. The woman’s family told my family liaison officer, that they
were very impressed with the after care service offered by the prison and I
recognise the best practice followed by the prison family liaison officer.
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CONCLUSION
56. I’m disappointed in the delays faced by the woman, whilst at Holloway, in
receiving her hip replacement surgery. Prompt follow up action should have
been taken by healthcare staff which would have reduced the amount of time the
woman suffered from pain and discomfort. The amount of time that elapsed
from the initial assessment by the prison doctor to a letter of referral to the
hospital being sent is, in my view, unacceptable.
57. This investigation shows that whilst at Send the woman received equitable care
to that she could have expected in the community. Send also demonstrated
best practice in the use of restraints, when the woman was sent to outside
hospital, and family liaison.
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RECOMMENDATIONS
1. I recommend that the Head of Healthcare at Holloway review the procedure for
following up referrals to outside health services to ensure that prisoners receive
timely medical treatment.
The Recommendation is accepted. The Head of Healthcare has been
instructed to review the current procedures for following up referrals to outside
health services by the end of December 2009. Holloway aims to provide a
GP/Primary Care service that is equivalent to that provided in the community.
That also includes encouraging patients to take responsibility for managing their
own health, and seeking appropriate help as patients would do in the
community. The Head of Healthcare believes procedures at Holloway reflect
those in the local community and has agreed to formally review their systems to
see if there is anything that requires improvement.
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