Individual at Shepton Mallet

Circumstances surrounding the death of a life sentence prisoner
from HMP Shepton Mallet
at the Royal United Hospital, Bath, on 26 May 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2005
CONTENTS
Part One : 1. Introduction
2. Summary
3. Investigation methodology
4. The deceased
5. HMP Shepton Mallet
6. Events prior to the prisoner’s death
7. Consideration of emergent issues
8. Conclusions
9. Recommendations
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This is the report of an investigation into the circumstances surrounding the
death of a life sentenced prisoner, at the Royal United Hospital in Bath on 26
May 2004.
Although a post mortem report has not been made available to my
investigator, it is understood that the prisoner died from peritonitis caused by
the perforation of a duodenal ulcer.
The investigation was conducted on my behalf by my colleague.
I commissioned an independent clinical review of the management of the
prisoner’s health needs during his time at Shepton Mallet. This was carried
out by a representative of the North Dorset Primary Care Trust in June 2004.
I am most grateful to the PCT for their work.
I would like to thank the Governor and staff at Shepton Mallet prison for their
ready help and co-operation during the investigation.
This published version of the report does not contain any of the original
annexes.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2005
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2. Summary
At the time of his death, the prisoner was 62 years old and was serving a life
sentence at Shepton Mallet prison in Somerset. He had suffered from asthma
and back problems and was overweight. In 2003, he was admitted to hospital
after suffering a heart attack. During the evening of 22 May 2004, he was
admitted to the Royal United Hospital in Bath with severe abdominal pains.
On 23 May he was given an emergency operation after which he was
admitted to the intensive therapy unit where he died on 26 May.
A post mortem examination was carried out on 27 May 2004. Although the
report of that examination has not been made available to my investigator, I
understand that the prisoner died of peritonitis caused by the perforation of his
duodenal ulcer.
Two prisoners, who were associates of the deceased at Shepton Mallet,
submitted statements to my investigator in which they expressed their
concerns about the way the prisoner had been treated by healthcare staff.
The prisoner’s son wanted to know whether his father:
• had been seen by medical staff in the week preceding his death;
• had been prescribed a drug for his heart condition which, he thought,
carried the risk of causing ulcers if taken without food;
• whether his father might have survived if his condition had been diagnosed
earlier.
He also complained to the prison that he had been told of his father’s
admission to hospital by another prisoner’s mother rather than by a prison
official.
These concerns were examined during the investigation. Although the
majority of the claims made by the two prisoners are judged to be unfounded,
some of their criticisms are justified. That said, I have nevertheless drawn the
conclusion that the prisoner was given appropriate care at Shepton Mallet.
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3. Investigation Methodology
The investigation was opened on 2 June 2004. My investigator issued notices
to staff and to prisoners at Shepton Mallet, detailing the terms of reference,
and inviting those who wished to submit information to make themselves
known to the investigating team.
On 14 June, one of my Family Liaison Officers made contact with the
prisoner’s son to explain the nature of the investigation and to allow him an
opportunity to express any concerns about his father’s death.
An independent clinical review of the management of the prisoner’s health
needs was carried out by a representative of the North Dorset Primary Care
Trust during the latter half of June.
My investigator received statements from two prisoners at Shepton Mallet in
which they expressed their concerns about the prisoner’s treatment by the
healthcare staff. Those staff were interviewed in the prison in December
2004.
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4. The deceased
The prisoner was born an only child in Handsworth, Birmingham, on 13
January 1942. He received a Grammar school education, leaving at the age
of 16 with six ‘O’ levels. He was employed mainly in the retail trade until 1960
when he joined the Dunlop Rubber Company as a production manager. He
married in 1964 and went on to have three sons.
In 1988, the prisoner was convicted of the contract killing of a businessman
and sentenced to life imprisonment with a tariff of 25 years. He had no
previous convictions. He had been at Shepton Mallet since July 2002.
His case was due to be reviewed by the Parole Board for the first time in June
2004.
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5. Shepton Mallet
The establishment operates as a small closed prison for life sentenced
prisoners and is located in the town of Shepton Mallet in Somerset. It can
hold up to 224 prisoners.
Her Majesty’s Chief Inspector of Prisons carried out a short unannounced
inspection of Shepton Mallet in November 2003. No recommendations were
made in respect of healthcare.
Since 2002, two other prisoners have died at Shepton Mallet: one from natural
causes and one by suicide.
Healthcare is provided by the West Dorset and Mendip Primary Care Trusts.
The prison has a very small healthcare centre with no in-patient facilities. At
the time of the investigation the healthcare staff complement comprised:
• A healthcare manager
• A registered general nurse
• A registered mental nurse
• Two doctors.
The centre is open from 7:30am until 5:30pm seven days a week and the
nursing staff remain on call to the prison outside working hours.
The establishment’s role as an all-lifer prison is relatively new. However, my
investigator saw evidence of good staff/prisoner relationships and a positive
regime.
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6. Events prior to the prisoner’s death
The prisoner was transferred from Kingston prison in Portsmouth to Shepton
Mallet in July 2002. He had suffered from asthma, back and knee problems.
He was also overweight. At the beginning of 2003 he developed chest pains
and in April of that year he suffered a heart attack. He was admitted to the
Royal United Hospital in Bath on 14 April 2003 and returned to Shepton Mallet
at the end of the month. Whilst in the Royal United he threatened to
discharge himself but withdrew the threat after being moved to a single room.
He suffered further chest pains in September 2003 and was readmitted to the
same hospital, this time for one night.
On 18 May 2004, the prisoner complained of abdominal pains for the first
time. He was seen on his wing by a staff nurse who found him to be clammy,
sweating and pale. The nurse took him back to his cell and examined him.
His blood pressure was 130/70, his temperature was 36.1 and his pain score
was 2/10. The prisoner told the nurse that he thought his pain was due to
constipation. He was therefore advised to take more fluids. The nurse also
carried out an ECG examination during which the prisoner’s pain subsided.
The ECG results were reviewed by a doctor who advised that a further ECG
should be carried out in the healthcare centre as the chest leads had not
registered on the ECG print out. No entry was made in the Inmate Medical
Record (IMR) to show whether a further ECG was carried out or what results
were obtained.
On 19 May, the prisoner again complained of abdominal pains and was seen
by a doctor who made the following unsigned entry in the IMR:
“ Abdominal pain. (No cardiac signs)
................... (illegible entry)
Been constipated recently
....................(illegible entry
Re Lactulose- suggest stop diclofenac”
The IMR records that, on 21 May, the prisoner again complained of abdominal
pains. The letters “BNO” are included in the entry made on that date. I
understand that these initials stand for “Bowels not open”. There is no
indication in the IMR as to what treatment the prisoner received on that
occasion.
During the evening of 22 May, a nurse, who was off duty, was called to the
prison to see the prisoner as he had once again complained of severe
abdominal pains. The nurse examined him and made the following note in the
IMR:
“ Called to the prison by evening staff. Prisoner c/o (complains of) severe
abdo (abdominal) pain, from groin upwards. Very clammy sweating
++.Unable to lie/sit down comfortably. Pulse difficult to find. Doctor contacted
at 19:45 (approx) advised diclofenac 75mg and co-prox T. Same given with
no effect. Temp 35.5. No sickness or problems with bowels noted today.
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Pain started when passing urine-sudden onset. But no burning or other
associated pain when urinating. Doctor contacted again at 20:30 (approx)
decision made to contact ambulance and send to A+E dept as pain travelling
around from stomach to back/shoulder.
21:00 (approx) ambulance technicians + 1 more crew and paramedic
attended. Gone to RUH (Royal United Hospital) (2200).”
The next day, the prisoner was admitted to the intensive therapy unit and, on
23 May, underwent an operation. A perforated duodenal ulcer was found and
the prisoner was assessed as having less than a 40% chance of survival. A
comment written in his IMR records that his relatives were at his bedside after
the operation. The prisoner remained critically ill throughout 24, 25 and 26
May. He died at 11:30am on 26 May.
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7. Consideration of emergent issues
7.1 Family concerns
One of my family liaison officers spoke to the prisoner’s son by telephone on
14 June 2004 to ascertain whether the family had any concerns that the
investigation should take into account. He said that he wanted to know
whether his father:
- had been seen by medical staff in the week preceding his death;
- had been prescribed a drug for his heart condition which, he thought,
carried the risk of causing ulcers if taken without food;
- whether his father might have survived if his condition had been
diagnosed earlier?
One family member also told the then Head of Lifer Services at Shepton
Mallet, that the family had not been informed immediately of the prisoner’s
emergency admission to hospital on 22 May 2004.
Consideration
The investigation has shown that in the days prior to his admission to the
Royal United Hospital, the prisoner complained of abdominal pains. His
medical record shows that he was seen by nursing or medical staff on 18, 19
and 21 May.
It is a fact that the prisoner had been prescribed diclofenac, which does carry
the risk of causing ulcers if taken on an empty stomach.
In the clinical review, the comment is made that it was most unfortunate that
the true nature of the prisoner’s symptoms was not apparent earlier. It was
though that this was due to the variable nature of the disease rather than to
any shortcomings by medical staff at the prison.
The report also says:
“ I believe that the prisoner received appropriate medical attention whilst at
Shepton Mallet Prison and that there was little in his history or examination to
lead a doctor to believe that he was developing a peptic ulcer prior to its
perforation but that this perforation was related to his use of Diclofenac which
he preferred more than other, less effective, medication.
I think it is probable that had the prisoner been taken ill outside prison his first
contact with the medical system would have been on the evening he was
admitted to hospital. We know he had been reluctant to take medical advice
in the past and I understand that he had to be encouraged to do so by other
inmates.’’
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7.2 Concerns expressed by prisoners
In response to the Notice to Prisoners published at Shepton Mallet
announcing the Ombudsman’s investigation, my investigator received
statements from two prisoners.
Both prisoners make similar complaints against three members of the
healthcare staff: a male doctor, a female doctor and the Healthcare Manager.
My investigator interviewed all three staff. The issues arising from the
allegations and from the subsequent interviews with staff are considered
below.
• The management of the prisoner’s knee problems
One of the complainants alleges that the deceased prisoner received
inadequate treatment from healthcare staff after injuring his knee in his cell.
The other complainant alleges that in May 2003 he found the prisoner on the
floor of his cell after his knee had given out on him. He says that the prisoner
was told by a female doctor to continue to take diclofenac and was given a
cold pack for his knee.
Consideration
It is clear that the healthcare team at Shepton Mallet were aware from the
outset that the prisoner had pains in his knees. On 3 July 2002, very shortly
after his arrival at the prison, the male doctor noted on the opening page of
the Shepton Mallet chapter of the prisoner’s IMR that he had a previous
medical history of arthritis in both knees. On the same day, that doctor
reviewed the prisoner’s medication and wrote in the continuous medical
record,
“.......Knees- diclofenac....does make a bit wheezy....”
The female doctor confirmed at interview that she knew that the prisoner had
wear and tear arthritis in several joints and that his knees gave him problems.
She also confirmed that the prisoner saw her “a couple of times” about his
joints. Although the doctor had no recollection of the prisoner falling in his
cell, she made an entry in the IMR on 18 October 2002 to record that he had
fallen “and banged his back on the bed-rail” the day before. She wrote:
“ o/e (on examination) localised tender over T6
musc spasm
n ( normal) breathing
add ....sal oint (ointment)’’
There are no other entries in the IMR relating to the prisoner’s knee
problems. In the clinical review, no mention is made of this aspect of the
prisoner’s medical history. It is known that he was extremely overweight and
that this added to the difficulties he experienced with his joints.
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Finding: There is no evidence to support the suggestion that the
prisoner received inadequate treatment for his knee problems.
• The prescription of diclofenac and lactulose
One of the complainants alleges that, on 23 May 2004, the male doctor
questioned why the prisoner was on diclofenac when he had obviously been
having trouble eating and why he had been on the medication for so long.
The complainant also claims that the doctor felt that the prisoner could be
constipated and therefore prescribed him 150mg of lactulose. The
complainant says in his statement that the prisoner felt that this was a little
odd because he had not eaten for some time due to the considerable pain he
had experienced. However, on the doctor’s advice, he took the medication.
The complainant claims that the lactulose seemed to aggravate the prisoner’s
condition and so he and his friend reported this to healthcare staff.
The other complainant alleges that diclofenac will cause stomach burning
when taken with no food; that the prisoner continued to take diclofenac tablets
as advised by the female doctor despite experiencing breathing difficulties;
and that, on 19 May 2004, the male doctor advised the prisoner to stop taking
diclofenac and, because he thought the prisoner might be suffering from
constipation, prescribed lactulose. The complainant claims that this caused
the prisoner further discomfort.
Consideration
Diclofenac
Diclofenac is an effective non-steroid painkiller. The prisoner was prescribed
the drug to ease the arthritic pain in his knees and other joints.
The prisoner had already been prescribed diclofenac before he arrived at
Shepton Mallet. On 3 July 2002, shortly after his arrival, the male doctor
reviewed his medication and wrote in the IMR,
“..........Knees: diclofenac as necessary ......does make a bit wheezy”
The female doctor also confirmed that she had prescribed diclofenac for the
prisoner’s joint pains after he had told her that the previous prescription of
paracetamol and codeine was not working. There is a note to this effect in the
IMR, dated 19.1.04. The doctor told my investigator that diclofenac came in a
modified release form which worked over a period of 24 hours. She therefore
thought that it was ideal in the prisoner’s case as he was in long term pain
which intensified overnight. The doctor said that the prisoner was suspected
by the nursing staff of hoarding his prescribed drugs in his cell and might, on
occasions, have taken a greater dosage than that prescribed.
The doctor confirmed that diclofenac can cause side effects, such as ulcers, if
taken on an empty stomach, and asthma. She said that, before prescribing
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the drug, she would always ask the patient whether he or she was asthmatic
or suffered from indigestion. She said that part of her standard procedure was
to point out to her patients the need to take diclofenac with food, or not on an
empty stomach, and to stop taking the drug and report back to her if they
began to get indigestion. She said that she would also ask her patients if they
were asthmatic because she knew that the drug could bring on asthma in
people who are susceptible.
The doctor admitted that the prisoner had suffered from indigestion in the
past. She said that, although she could not recall the detail of her
consultations with him, she could remember saying to him words to the effect,
“ Well, you’re not getting relief from the other tablets so it’s worth a try but
come back to me if you have problems.” There is no evidence in the
prisoner’s IMR that he complained to anyone of having indigestion after being
prescribed diclofenac at Shepton Mallet, but there were episodes when he felt
asthmatic. Entries made in the IMR on 14 August 2002 by the male doctor,
and on 31 March 2003 by the female doctor suggest that, in spite of the fact
that the prisoner had experienced some asthmatic symptoms, he agreed to
continue to take diclofenac.
On 5 September 2003, shortly after the prisoner had returned from outside
hospital to Shepton Mallet, the female doctor wrote:
“….also wondering whether to change him from diclofenac to cocod. 30/500-
had these previously…”
The IMR does not make clear whether diclofenac was not prescribed following
this comment.
Although the prisoner had complained of central chest pains on occasions, it
was not until 18 May 2004 that he complained of having pains in his
abdomen. He was seen first by a staff nurse and, the next day, by the male
doctor who advised him to stop taking taking diclofenac. Between 18 and 22
May, The prisoner was therefore not prescribed diclofenac.
At 7:45pm on 22 May, the male doctor was contacted by a nurse after she
had examined the prisoner. She told the doctor that the prisoner was in
severe abdominal pain. Despite the fact that the doctor had advised him to
stop taking diclofenac four days earlier, he decided to prescribe 75mg of the
drug, together with coproxamol, in view of his condition. Later that evening,
the prisoner was admitted to hospital.
It was not until the prisoner underwent surgery at the Royal United Hospital on
23 May that he was diagnosed as having a duodenal ulcer. By this time, the
ulcer had perforated.
In the clinical review, the following comment is made:
“ When the prisoner became seriously ill on the Saturday evening, his
symptoms began when he was passing urine. Renal colic is one of the
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severest pains imaginable but it is swiftly and miraculously relieved by
diclofenac. Given the history and the fact that at no stage was the prisoner
recorded as having symptoms suggestive of indigestion, it was reasonable for
the doctor to suggest that a dose of 75mg to be given to him. I do not know
but I imagine by this stage in fact he had already developed a perforation, but
two other important conditions give pain in the back as well as abdominal
pain: a leaking aortic aneurism and renal colic. If the perforation had in fact
already occurred, administration of diclofenac at this stage would not worsen
the condition.’’
Finding:
There is no evidence to suggest that the prescription of diclofenac to the
prisoner was inappropriate.
Lactulose
It is clear from the entries made in the IMR and from the evidence gained from
interviews with both doctors that lactulose was prescribed for the prisoner
because he occasionally thought he was constipated and because he showed
symptoms suggestive of constipation.
The author of the clinical review writes:
“The male doctor and the nurse told me that up until the evening of his
admission, the prisoner was up and about and, although complaining of pain,
this was not severe, was not characteristic of indigestion pain and could easily
be explained by constipation, for which he was given appropriate treatment.”
Finding:
The prescription of Lactulose was justified given the symptoms the prisoner
manifested.
• The prisoner’s inability to collect his medication
One of the complainants alleges that the prisoner could not collect his
medication from the healthcare centre because of his bad back and breathing
difficulties. He claims that some staff would help by collecting the medication
for him and others would not. The complainant alleges that this caused the
prisoner to go without medication for a number of days.
Consideration
My investigator was told by the nursing staff at Shepton Mallet that, in general
terms, the prisoner’s poor health would not have prevented him from
collecting his medication. The female doctor reported that the prisoner was
not always content to take the medication he was prescribed and that the
nursing staff thought he might sometimes have hoarded tablets in his cell to
take when it pleased him to do so. The prescription charts made available to
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my investigator show that, for the most part, the medication prescribed for the
prisoner was to be retained in his possession. This was certainly the case
where diclofenac and lactulose were concerned. This regime carried with it
the guarantee that the prisoner could decide whether and when he took the
drugs.
The prescription charts should provide an accurate record of:
• the medication prescribed and the reasons for the prescription;
• the exact date - day/month/year - on which the prescription was made;
• the dates on which the medication was collected and how it was
administered;
• the reasons for any failure to dispense or to collect the medication.
The standard of record keeping in the prisoner’s case is so poor that it was
not possible to ascertain the frequency of any failure on his part to collect his
medication. One example of poor record keeping can be found in a
prescription chart which records that a doctor prescribed lactulose 20mg for
28 days on a date shown only as 19/5. No record was made of whether the
drug was collected, or whether it was intended for retention in the prisoner’s
possession. Another chart refers to the prescription of diclofenac 50mg on 3/7
for 28 days. Once again, the chart does not show whether the drug was
collected.
Finding:
Although the nursing and medical staff have offered circumstantial evidence
that suggests that the prisoner probably chose not to collect his medication on
occasions, the prescription charts cannot be relied upon either to substantiate
that evidence or to discredit the complainant’s allegations.
• The prisoner’s relationship with the female doctor
One of the complainants alleges that the female doctor aggrieved the prisoner
in the way she spoke to him and treated him, and that the prisoner was so
upset with her that he refused to see her ever again. The complainant also
alleges that he and his friend advised the prisoner to see the male doctor
rather than the female doctor and that as a result the prisoner saw the former
on Wednesday 23 May 2004.
The other complainant alleges that in April 2003, the female doctor rushed the
prisoner into hospital two days after telling him that there was nothing wrong
with him. The complainant also claims that the prisoner stayed away from the
healthcare centre because of the problems he encountered in April and May
2003. He alleges that the prisoner preferred to see the male, rather than the
female doctor.
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Consideration
It is clear from the prisoner’s IMR that he was seen on a number of occasions
during his time at Shepton Mallet by both doctors as well as by the nursing
staff. The IMR also shows that, contrary to the complainant’s claim that the
prisoner refused to see the female doctor after his heart attack in April 2003,
he in fact saw her in August and September of that year and again in January
2004.
There are further entries in the IMR to show that, contrary to the complainant’s
claim that the prisoner stayed away from the healthcare centre in April and
May 2003, he was seen by the female doctor on 2 May, following his
discharge from the Royal United Hospital, and by a nurse on 27 May.
The female doctor told my investigator that she thought she had seen the
prisoner more frequently than had her male colleague. However, as each
doctor attended the prison on specific days it was possible for prisoners to
choose which doctor they saw. Neither was aware of any preference by the
prisoner to see a particular doctor. The male doctor confirmed at interview
that he saw the prisoner on 19 May 2004, and not on 23 May as the
complainant claims.
The female doctor also told my investigator that she remembered seeing the
prisoner two days before he was admitted to hospital in April 2003. At the
time, the prisoner was reluctant to be admitted to hospital because he wanted
to continue with his Open University studies. The doctor considered that there
was no particular reason for the prisoner to go to hospital at that point. He
was not acutely ill, but she nevertheless took the view that the prisoner should
be admitted to hospital if there were any further concerns on his part or on the
part of the nursing and medical staff. She thought that she might have said to
the prisoner words to the effect, “ Surely it’s worth submitting a few days from
your Open University to go in? “
Finding:
There is no evidence to substantiate the claims by either complainant that the
female doctor’s approach to the management of the prisoner’s health needs
was inappropriate.
• The prisoner’s relationship with the Healthcare Manager, and 24 hour
medical cover at Shepton Mallet
One complainant alleges that, on 21 May 2004, he and his friend were so
concerned about the prisoner’s condition that one of them immediately went to
the healthcare centre and demanded the attendance of a nurse. The
complainant claims that, after the Healthcare Manager had seen the prisoner,
she showed little interest and was more minded upon leaving for the evening.
He claims that she walked away with a smirk on her face. He admits that the
nurse said that she would keep an eye on the prisoner but questions how she
could do that as there was no 24 hour medical cover.
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The complainant alleges that the Healthcare Manager had been told by the
prisoner that he did not need her help. He felt that this was odd because the
prisoner had asked him to arrange for a nurse to see him. The complainant
also alleges that, when the Healthcare Manager saw the prisoner in his cell on
21 May 2004, she attended with annoyance and could not wait to get away.
He claims that she just smirked and walked away saying no more than that
she would keep an eye on him. Both complainants questioned how she could
do this given that that 24 hour nursing care was not available at Shepton
Mallet.
Consideration
At interview, the Healthcare Manager told my investigator that she
remembered going to see the prisoner in his cell at about 5pm on Friday 21
May 2004. She said that the prisoner greeted her with the words, “ What are
you doing here, princess? I don’t want to see you. I don’t really want
anything.”’ The Healthcare Manager said that this was how the prisoner
normally spoke to her. She also explained that, although her period of duty
normally ended at 5:30pm, she was used to working later, sometimes until
6pm. She emphasised that she was not prepared to divulge confidential
medical information about the prisoner to either of the complainants. She
remembers writing a note in the IMR about her consultation with the prisoner
and that she had remarked that the nurse who was on duty the following day,
would “keep an eye on” the prisoner. The Healthcare Manager told my
investigator that, had there been any more pressing concerns, she would
have taken steps to arrange for the prisoner’s admission to hospital sooner.
She confirmed that no such concerns were expressed the following day, either
by staff or by the prisoner himself, until 7pm when the nurse was recalled to
the prison and, in consultation with the male doctor, immediately arranged for
the prisoner to be admitted to hospital.
Findings:
There is no evidence to support the claims made by either complainant that
the Healthcare Manager behaved inappropriately towards the prisoner.
Whilst it is true that Shepton Mallet does not have a 24 hour inpatient facility,
a member of the nursing staff and a doctor are on call to the prison every
night. On more than one occasion, the on-call staff were asked to attend the
prison to see the prisoner and did so promptly.
• Keeping the prisoner’s relatives informed of his condition
One of the complainants alleges that the prisoner’s family were not kept
informed of his condition when he was admitted to hospital and that the
bedwatch staff were told not to inform them. He claims that the prisoner was
in the process of complaining about this when he died.
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Consideration
This allegation tallies with the complaint made to the Head of Lifer Services at
Shepton Mallet by the prisoner’s son.
The Deputy Governor told my investigator that the establishment was
concerned to ensure that any information given to the family about the
prisoner’s admission to hospital was well informed and accurate. However,
the prisoner’s son told my investigator that he was told of his father’s
admission to hospital over the telephone by the mother of one of the
complainants two days after it had happened. He had received no notification
from Shepton Mallet. The prisoner’s son also said that the family had not
been informed of his father’s earlier admission to hospital in April 2003. As a
result of this call, members of the family made arrangements to travel to the
hospital to see the prisoner. Some were at his bedside when he died.
As soon as the prisoner was admitted to hospital on 22 May, a ‘bedwatch’
(Prison Officer escort ) was established. In the log of events recorded by the
escorting staff, there is an entry made by a Prison Officer shortly after the
prisoner’s death on 26 May. It reads:
“ .......A doctor has asked me to refrain from informing the prison of the death
as the family have requested to speak to the prisoner’s personal officer. I
have agreed to do this but I have urged the family to do this as the prison
need to be informed.’’
There are no other references to any instructions to escorting staff with regard
to the notification to any persons of the prisoner’s condition.
The Deputy Governor checked the Request and Complaints register at
Shepton Mallet to ascertain whether the prisoner had lodged a complaint
about this matter at any time. He told my investigator that, although the
prisoner had made complaints about other matters, he had not done so in
relation to his admission to hospital at any time whilst at Shepton Mallet.
Findings:
It appears that staff at Shepton Mallet did not inform the prisoner’s family of
his admission to hospital on 22 May 2004.
There is no evidence in the Request and Complaints Register of any
complaint made by the prisoner about his earlier admissions to hospital.
• The communication of the news of the prisoner’s death
One of the complainants alleges that neither he nor his friend were told of the
prisoner’s death until two and a half hours had elapsed.
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Consideration
The Deputy Governor told my investigator that the news of the prisoner’s
death was announced to staff and to prisoners as soon as was possible
during the afternoon of 26 May. He took the view that it was correct to tell all
prisoners of the death through the medium of a formal written Notice to
Prisoners rather than making a verbal announcement to a select few.
Finding
It is clear that both complainants were close friends of the prisoner. Their
frustration at not being told of his death sooner is understandable. However, I
am satisfied that the timing and method of announcing the death to the prison
community was appropriate in the circumstances.
• The complainant’s placement in the segregation unit shortly after
being told of the prisoner’s death
One of the complainants states that he was placed in the segregation unit at
2:05pm on 26 May 2004 and that it was not until 5.25pm that day that he was
told of the reasons for his segregation.
Consideration
The Deputy Govenor told my investigator that this complainant reacted badly
when he was told of the prisoner’s death and that he was placed in the
segregation unit because of his behaviour. The Deputy Governor also
confirmed that this matter had been the subject of an internal investigation.
Finding:
Since the complainant’s placement in the segregation unit has been the
subject of an internal investigation by the Governor at Shepton Mallet it would
be inappropriate for me to comment on his complaint about this matter.
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8. Conclusions
The investigation has shown that the prisoner had limited interest in his own
health while he was at Shepton Mallet. The female doctor argued that he
tended to “play down” his condition and would, on occasions, fail to appear at
the healthcare centre when she was expecting to see him. Perhaps the most
obvious evidence of the prisoner’s attitude to his own healthcare can be found
in the entries made in his IMR in April 2003 after he had complained of chest
pains. On 7 April he was told that he needed to be admitted to hospital but he
refused admission. On 11 April he experienced further chest pains and still
refused to go to hospital, against medical advice. He finally agreed to be
admitted on 14 April.
This investigation also finds that any risks created by the diclofenac he was
prescribed for his arthritis were clearly and responsibly explained to him by
each of the doctors who saw him. There is no evidence to support the
suggestion by both complainants that diclofenac was wrongly prescribed. The
decision to prescribe lactulose for the symptoms the prisoner presented on 19
May is also judged as appropriate.
Neither is there any evidence to support the suggestion by each complainant
that the female doctor and the Healthcare Manager were uncaring of the
prisoner. It became clear during their interviews with my investigator that,
despite the prisoner’s reluctance to avail himself of the healthcare services
available in and beyond the prison, they went out of their way to monitor his
condition by visiting him in his cell. At interview, the female doctor confirmed
that she was aware of the prisoner’s knee problems, but acknowledged that
she was not aware of all the occasions when he might have fallen over in his
cell. There is no evidence to support the suggestion that the prisoner had
refused to continue to see her.
The claim that there were times when the prisoner went without his
medication because he could not get to the treatment hatch to collect it is not
supported by any evidence. The prisoner’s general reluctance to avail himself
of treatment, together with his apparent tendency to hoard drugs in his cell are
more likely to explain any failure on his part to collect his medication. The fact
that most of the drugs prescribed for him were to be kept in his possession
allowed him autonomy in the way he took them.
The family should have been informed promptly of the prisoner’s admission to
hospital on 22 May 2004.
The communication to the prison community of his death was handled
appropriately.
The prisoner’s family have, understandably, been keen to discover whether he
might have survived if his condition had been diagnosed earlier. The author
of the clinical review has concluded that, although it was most unfortunate that
the true nature of the prisoner’s symptoms was not apparent earlier, this was
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due to the variable nature of his disease rather than to any shortcomings by
medical staff at Shepton Mallet.
There is evidence in the prisoner’s IMR of poor record keeping. Some entries
are unsigned. There are incomplete entries in some of his prescription charts.
The prescription charts used at Shepton Mallet are not standard Prison
Service charts. Following an examination of the prisoner on 18 May 2004, no
record was made to show whether a follow up ECG was administered. On 21
May, no record was made to show what treatment the prisoner received after
he complained of abdominal pains and it was discovered that his bowels were
not open.
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9. Recommendations
I make the following recommendations:
Local recommendation 1:
• The Governor should remind medical staff that all entries made in Inmate
Medical Records should be legible and signed.
Local recommendation 2:
• The Governor should remind medical staff that an entry should be made
in the Inmate Medical Record on every occasion when:
- a prisoner is seen by a member of the Healthcare staff
- a diagnosis is made
- a course of treatment is decided upon or prescribed
- any other event occurs that relates to the management of a prisoner’s
health needs.
Local recommendation 3:
• Standard prescription charts should be used at Shepton Mallet. The
Governor should remind medical staff that all entries should be clearly
written. Entries should show:
- the name of any medication prescribed
- the dosage prescribed
- the diagnosis for which the medication was prescribed
- the name and signature of the prescriber
- whether the drug can be retained in the prisoner’s possession
- whether and when the drug has been collected
- the reasons for any failure to dispense of collect the drug
Local recommendation 4:
• The Governor should remind staff of the need to ensure that proper steps
are taken to inform prisoners’ relatives promptly whenever a prisoner is
admitted to hospital. Local contingency plans should make clear what
arrangements are in place to ensure that this is done.
Stephen Shaw CBE
Prisons and Probation Ombudsman for England and Wales
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