Individual at Shrewsbury

Investigation into the circumstances surrounding
the death of a man in May 2010
whilst in the custody of HMP Shrewsbury
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2011
The man was 53 years old when he died in a nursing home in Shrewsbury in May
2010. He had been diagnosed with cancer a few weeks earlier. The Coroner
recorded the cause of death as carcinomatosis (meaning that the cancer had spread
widely throughout his body).
The man previously complained of some pain at HMP Hewell between December
2009 and February 2010. He underwent tests which gave no indication of what
might be wrong. Within a week or two of his arrival at HMP Shrewsbury at the start
of March 2010, healthcare staff ordered more tests because he was not looking at all
well and was complaining of severe pain. He died less than three months later.
When the cancer was diagnosed, it had already spread to his bones and his
prognosis was very poor. He accepted that he did not have long to live and his
treatment in his last few weeks focussed on pain relief to ease his discomfort.
The man is survived by a number of family members. I would like to take this
opportunity to express my sincere condolences to them for their loss.
The investigation was completed by my colleague. He visited both Shrewsbury and
Hewell, speaking to both discipline and healthcare staff. One of my Family Liaison
Officers contacted the family to tell them about the investigation. She continued to
liaise with the family after the draft report was published.
A clinical review of the treatment which the man received in prison was undertaken
by a panel led by a clinical reviewer appointed by the local Primary Care Trust
(PCT). The panel judged that the care he received in custody was comparable to
that he would have been offered in the community. I am grateful to the panel for
their assistance.
I would like to express my thanks to the Governor and the staff and prisoners at
Shrewsbury for their full cooperation whilst the investigation was completed.
The investigation has found that the man was offered a good level of care at
Shrewsbury. Staff made considerable efforts to speed his diagnosis and to look after
him as his health rapidly deteriorated. The joint efforts of the prison staff and the
hospital meant that he was able to end his life in the more comfortable and humane
surroundings of a nursing home. Consideration was given to releasing him on
compassionate grounds, but events unfolded very rapidly and I support the
Governor’s view that he benefited from the presence of a prison officer as a
bedwatch escort. I make one recommendation and endorse four others made by the
clinical review panel.
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.
Jane Webb
Prisons and Probation Ombudsman April 2011
2
CONTENTS
Summary
The investigation process
HMP Shrewsbury
Key findings
Issues
Conclusion
The family’s response to the draft report
Recommendations
3
SUMMARY
The man arrived at HMP Hewell from court on 4 December 2009. He said that he
had recently had pneumonia but did not report any potentially life threatening
physical health problems such as cancer. During his first month in Hewell, he was
given several warnings for attempting to conceal rather than swallow his medication
in order to repay a drugs debt that he owed to another prisoner.
Over the new year, the man reported pain in his kidneys and back on several
occasions. A urine test and x-ray gave no indication as to the cause of the pain. He
spoke to a doctor about his discomfort in mid-February. The doctor prescribed pain
relief. Whilst at Hewell, his mental health was regularly assessed because he had
previously experienced drug induced psychosis.
On 1 March, the man transferred to HMP Shrewsbury. He did not report any chronic
health problems during his initial health screen. However, over the next few days, he
began reporting pains in his hip and staff initially gave him paracetamol. Once
again, a community psychiatric nurse regularly reviewed his mental health. On 11
March, a nurse referred him to the doctor for his hip pain and because he looked
frail. He had suddenly lost a lot of weight and the doctor ordered tests. Staff noticed
that he had visibly aged since his arrival at Shrewsbury.
Over the next few weeks, the man underwent a number of tests at hospital. Staff at
the prison tried to hurry along the tests because they were concerned about him. He
was admitted to the hospital between 27 and 28 March when his health declined,
and again between 8 and 13 April. He discharged himself from the hospital on 13
April against medical advice. When he returned to the prison, staff drew up a care
plan because he could no longer look after himself independently.
A couple of days later, the man made a written complaint to the Governor about the
pain relief he was receiving. Staff responded and he does not seem to have
expressed any further dissatisfaction with his treatment during the weeks that
followed. Healthcare staff arranged for him to be taken to hospital on 17 April, after
he became more unwell. He underwent further tests and was diagnosed with an
aggressive form of cancer which had spread to his bones.
The man was too unwell to return to Shrewsbury, which has no inpatient facilities.
Staff tried to locate a bed in a prison with better healthcare facilities, but none was
available. He was told by the hospital consultant that his prognosis was very poor
and that he would only live for another few weeks. Hospital staff found him a place
in a nursing home and he moved there on 10 May after receiving radiotherapy
treatment to try to slow the progress of the cancer.
From the time the man received his diagnosis, he was not handcuffed to his
escorting officers. From 14 May, only one officer was required to stay with him at the
nursing home. Although his release on compassionate grounds was considered,
and assessments were completed, events unfolded quickly and he seemed to
benefit from the company and assistance that an officer provided. He died in the
nursing home.
4
THE INVESTIGATION PROCESS
1. The investigator was formally notified of the man’s death on 28 May 2010.
Notices were subsequently issued to both staff and prisoners at HMP
Shrewsbury, informing them of the investigation process and giving them the
opportunity to contact the investigator with any relevant information.
2. The investigator liaised with the Deputy Governor at Shrewsbury throughout
the investigation. He visited Shrewsbury on 7 June and was provided with all
the documents relating to the man’s time in custody. Whilst there, he spoke
to several staff about his care.
3. The investigator wrote to the local Coroner’s office to inform them of the
nature and scope of the investigation. HM Coroner will be provided with a
copy of the report of the Ombudsman’s investigation.
4. The investigator also contacted the local PCT and asked that a review be
carried out with regard to the clinical treatment which the man received at
Hewell and Shrewsbury. The purpose of the review is to establish whether
the care that he was offered in prison was comparable with that he would
have received in the community. A panel completed the review. The clinical
reviewer and the investigator visited Hewell to interview two members of the
healthcare staff on 7 July.
5. One of my Family Liaison Officers contacted the man’s brother to discuss the
investigation and to find out if the family had any concerns about the
treatment he received. His brother did not have any specific concerns he
wished the investigator to address. He spoke very positively about the
compassionate way that prison escort staff had treated his brother at the
nursing home. However, he said that he had yet to receive his brother’s
property from Shrewsbury. The investigator contacted the liaison officer who
agreed to send his belongings to his brother immediately.
6. After the draft report was published, the man’s siblings contacted the Family
Liaison Officer to ask for a meeting with her and the investigator to give their
feedback. The meeting took place on 14 January 2011. I have added a
section to the final report to reflect the family’s opinions, beginning on page
31.
5
HMP SHREWSBURY
7. Whereas Shrewsbury used to accept prisoners on remand from the nearby
courts, recently this function was largely reallocated to HMP Dovegate. The
prison will now receive mostly longer term sentenced prisoners. Shrewsbury
accommodates a maximum population of 340 men.
Healthcare
8. The healthcare department at Shrewsbury does not have any inpatient
facilities. There is 24 hour nursing cover. Throughout the night a nurse and a
healthcare assistant remain on duty. Doctors’ surgeries are held every
afternoon from Monday to Saturday. Until the man fell ill, the prison had not
previously had to address the issue of palliative care (when a patient will not
get better and the priority is to make him as comfortable as possible as his
health declines). The healthcare staff are presently drawing up a palliative
care policy and examining the needs of older prisoners in general. This has
become a salient issue since the prison changed functions and the average
age of prisoners consequently increased.
Her Majesty’s Inspectorate of Prisons
9. HM Chief Inspector of Prisons completed an inspection of Shrewsbury in June
2006. She found that Shrewsbury was a ‘reasonably safe and relaxed’ prison,
in spite of its ageing infrastructure and continued overcrowding. However,
she noted that the opportunities available to prisoners to keep themselves
constructively occupied were ‘severely restricted’. Some cells were unfit for
purpose. Despite the limited resources available, she wrote that the
healthcare department provided ‘a good service’.
10. HM Chief Inspector of Prisons completed a short, unannounced follow-up
inspection in February 2010. She described Shrewsbury as a ‘singularly poor
choice’ for a training prison but noted that the provision of healthcare was
‘much improved’.
Independent Monitoring Board
11. The most recent annual report published by the Independent Monitoring
Board (IMB) at Shrewsbury covers the year from May 2008 to April 2009.
(The IMB at each prison is made up of members of the public who are both
independent and unpaid. They monitor the day-to-day life in their local prison
and ensure that proper standards of care and decency are maintained.) The
IMB noted ‘severe staff shortages’ in the healthcare department and called for
closer cooperation between the prison and the local Primary Care Trust in
order to explore staff retention.
Previous deaths at Shrewsbury
12. The Ombudsman assumed responsibility for investigating deaths in custody in
2004. Since that time, I have investigated nine previous deaths of which eight
6
were self inflicted and one was the result of natural causes. There are no
significant similarities between the circumstances of the man’s death and
those of the other prisoners.
Performance
13. The most recent prison quarterly ratings published by the Ministry of Justice
show that Shrewsbury scored 3 overall, indicating a good performance. The
prison achieved the same score in the previous quarter. The minimum score
is 1 (serious concerns) and the maximum is 4 (exceptional performance). The
rating takes into account 34 different aspects of the way the prison is currently
operating.
7
KEY FINDINGS
14. Having received a prison sentence of three and a half years for domestic
burglary, the man arrived at HMP Hewell on 4 December 2009 from Crown
Court. He had been discharged from prison nine weeks earlier and did not
have a permanent address.
15. Upon arrival, the man underwent a routine initial health screening. Although
he had a long history of drug and alcohol misuse, he said that he had not
taken drugs for two years. He was not therefore referred to a substance
misuse worker. Nurse A wrote that he looked physically well. The nurse
recorded that he had been hospitalised with pneumonia five weeks earlier but
did not have any concerns about his physical health.
16. The man was prescribed an inhaler for his asthma, medication for his epilepsy
and anti psychotic medication for mental health problems. He had been
admitted on several occasions to psychiatric care over the years as a result of
drug induced psychoses. He had displayed symptoms of schizophrenia in the
past and told the nurse that he had gone to an appointment with his
psychiatrist in the community three weeks before.
17. During the assessment, the nurse did not think the man seemed depressed or
showed any signs of serious mental illness or psychosis. He presented as
stable and good humoured. Nonetheless, he referred him to the In-Reach
team (who treat prisoners with severe mental health problems). He reported
that he had been under the care of another In-Reach Team until his recent
release from custody.
18. The man was located in a single cell because he said that he found it difficult
to share with others. Staff completed a Cell Sharing Risk Assessment,
(CSRA) and assessed him as presenting a low risk to other prisoners. He
completed an application for vulnerable prisoner status (otherwise known in
prison as asking for ‘rule 45’). It is not clear from the paperwork why he made
this request.
19. Prison Doctor A assessed the man the following day, 5 December. He was
allowed to keep his anti psychotic medication and inhalers ‘in possession’
instead of the nurses giving it to him at set intervals. The doctor thought that
he looked well but noted a history of chronic obstructive lung disease. Nurse
A completed a full secondary assessment of his health the same day.
20. On 8 December, the man was classified as a category C prisoner. (Category
A and B prisoners are considered to represent a higher risk if they escape,
whilst category D prisoners are trusted to live in open conditions.)
21. The man was assessed by Community Psychiatric Nurse (CPN) A on 11
December. (She had previously met him when he was held at Hewell in the
summer.) She went to speak to him in his cell and found no signs of
significant mental health problems. However, the assessment was cut short
8
because he said that he was experiencing pains around his kidneys in the
lower back area.
22. Prison Doctor B assessed the man the same day. He said that, when he
urinated, he passed blood and experienced a burning sensation. The doctor
sent a urine sample to be tested and ordered x-rays to find out more about the
pain in his kidneys. He thought he might be suffering from kidney stones.
The doctor prescribed cephalexin (a treatment for urinary tract infections) and
diclofenac (an anti-inflammatory drug).
23. Prison Doctor A reviewed the results of the urine test on 13 December and
advised that no further action be taken because the results were normal.
24. On 15 December, the man’s in possession medication for his urinary infection
was removed after he tried to ‘palm’ it (meaning that he would pretend to
swallow it, but actually conceal it in order to sell it on to other prisoners). He
was told to collect his medication from the hatch instead. He was cautioned
under the Incentives and Earned Privileges (IEP) Scheme. (The IEP scheme
is intended to encourage and reward good behaviour. Additional entitlements
can be gained in return for good behaviour. However, those entitlements can
be lost if the prisoner’s behaviour deteriorates. Prisoners can be placed on
either a basic, standard or enhanced regime.)
25. The next day, 16 December, the man was supposed to attend hospital for an
x-ray, but no staff were available to escort him and so he could not go. On 18
December, he went to another appointment with the CPN. Again, she had no
significant concerns about his mental health. His state of mind seemed to be
much improved in comparison to previous periods in custody. He said that his
mood had improved because his kidney pain had decreased.
26. The man’s rescheduled x-ray appointment took place on 23 December. The
CPN assessed him again on 24 December. She noted a family history of
mental health problems and alcohol misuse. She recorded that he had
become institutionalised after numerous custodial sentences and that he
coped well in prison. He told her that he had used ‘every drug in the world’ at
various times in his life.
27. On 28 December, the man was placed on report for again trying to ‘palm’ his
medication. On 29 December, he was given another warning under the IEP
Scheme for the same reason.
28. A Security Information Report (SIR) dated 5 January 2010 stated:
‘He has asked staff to keep his canteen back on Friday 08.01.10 as he
has to pay back his drug debt. Apparently his canteen sheet was taken
off him and someone else filled it out and handed it in.’
29. Staff thought that the man might be assaulted by a fellow prisoner if he did not
pay back his drug debt. Illegally obtained subutex (a heroin substitute) seems
9
to have been circulating amongst several prisoners on the wing, prompting
him to palm his medication.
30. The man was due to go to an appointment with the CPN on 5 January, but
she was unavailable and the assessment did not take place. Prison Doctor B
reviewed his x-ray on 7 January and recorded that no kidney stones were
apparent.
31. On 8 January, the man (and some other prisoners) told staff that they were
being bullied for their medication by another man. The following day, he was
asked to confirm in writing that he felt safe associating with the other
prisoners on the wing. He did not attend a scheduled mental health
assessment on 13 January.
32. During an assessment on 15 January, the man asked the CPN if he could talk
to a psychiatrist. He wanted to request stronger mental health medication
because he did not feel that his current prescription was having the intended
effect. He mentioned that he had used alcohol and cannabis whilst in custody
over the Christmas period. She thought his mood was bright and that he
presented as ‘mentally stable’, but booked an appointment with the doctor for
25 January (although the appointment eventually took place on 4 February).
33. On 18 January, the man was given another warning under the IEP scheme for
failing to attend work. On 28 January, he was given a further warning for the
same reason and moved from the standard to the basic regime (meaning that
he lost some privileges). Towards the end of January, he was repeatedly
prescribed doses of paracetamol.
34. At the start of February, the man complained to staff again of pain in his
kidneys and blood in his urine. He provided a urine sample, which staff
concluded looked normal. On 3 February, he met the CPN and said that the
pain in his kidneys was affecting his mood and ability to sleep. He also told
her that he had recently refused to go to work (and consequently been placed
on report) because of the pain he was experiencing.
35. The next day, 4 February, the man was assessed by a psychiatrist. The
psychiatrist noted that he had complained of ongoing kidney pain for the past
seven weeks and that it became worse when he urinated. He wrote that his
urine sample was normal and that the recent x-ray showed ‘no abnormalities
detected’. He said that the pain was stopping him sleeping. He asked for
pain relief and was given paracetamol over the next few days. The
psychiatrist referred him to the general practitioner.
36. The man was assessed by Prison Doctor C on 12 February. He asked for
pain killers for the ‘crippling’ pain in his back. The doctor wrote that he
claimed to have passed blood in his urine and was ‘drug seeking’. He
prescribed naproxen (a non steroidal anti-inflammatory drug used to reduce
pain).
10
37. On 13 February, the man received a further IEP warning for having a
television (something not permitted under the basic regime).
38. The CPN assessed the man again on 16 February. He said that he was still
experiencing some pain despite his new medication. He showed no sign of
mental health problems. Nurse B assessed him on 19 February. He
complained of tightness in his chest. He had not been using his inhalers and
said that they had run out. The nurse provided him with new inhalers.
39. The man went to healthcare staff as an emergency on 25 February and asked
Nurse C for two paracetamol tablets. She issued them as a one-off
immediate prescription.
40. On 1 March 2010, the man was assessed by healthcare staff as ‘fit to transfer’
before moving to HMP Shrewsbury. The move was not unusual, as he was a
long term sentenced prisoner. Hewell functions predominantly as a local
prison accepting men on remand from nearby courts and needs to progress
sentenced prisoners to other nearby prisons. Shrewsbury has recently
changed its function and now accepts mostly sentenced prisoners.
41. During the man’s initial health screening in the reception area, he told Nurse
D that he had epilepsy, short term memory loss (the result of a head injury 25
years previously) and asthma (for which he was given an inhaler). He again
reported mental health problems related to his long standing drug misuse and
was referred to the In-Reach Team.
42. Staff completed a CSRA and decided that the man presented a low risk to
other prisoners. He was assessed by Prison Doctor D and his prescriptions
were continued. There does not seem to have been any discussion of the
pain he had been reporting recently at Hewell, although the details were
contained in the clinical record that arrived with him.
43. The man underwent a second health screening on 3 March. He confirmed
that he had suffered from fits since having a brain haemorrhage in 1985. His
fitting was the only issue identified under the section of the form marked
‘Chronic health concerns’. Officer A interviewed him the same day. He was
placed on the standard regime under the IEP scheme.
44. Because staff thought the man looked frail, he was located in a cell near the
wing office. He was given paracetamol for hip pain on 5, 7, 8 and 9 March.
45. On 10 March, the man was assessed by CPN B from the In-Reach team).
They discussed his history of drug induced psychosis, something he told her
no longer affected him. During the interview, he was ‘bright, chatty and
cooperative’. He told her that his mood was only affected by the pain in his
hip. She referred him to a psychiatrist to review his medication. She also
drew up a care plan for his mental health treatment with his help.
46. The next day (11 March), the man was assessed by Nurse D and they
discussed the severe pain in his right hip which he had been experiencing for
11
the previous two weeks. The nurse noted that he looked frail and pale and
that there was no relevant history in his clinical record. She referred him to
Prison Doctor D. Later that day, he told the doctor that he had lost weight
(half a stone in the space of a week). The doctor noted that he was anaemic,
prescribed co-codamol (a painkiller) and ordered full blood tests and a chest
x-ray.
47. Shortly before 6.00am on 13 March, the night officer on the wing found the
man and another prisoner smoking cannabis. No disciplinary action was
taken. On 15 March, he was escorted to hospital for x-rays. The results were
expected within seven to ten days.
48. Prison Doctor E looked at the results of the first blood test on 17 March and
ordered an immediate follow-up blood test because the results were
concerning and inconclusive.
49. A second, urgent blood sample was taken on 18 March and sent to the
hospital by taxi for testing. The doctor compared the man’s appearance with
his photograph taken at reception on 1 March and wrote that ‘he appears to
have aged 30 years in 17 days’. He observed that he could still walk, could
talk coherently and looked ‘pale but not ghastly’. He noted that his main
complaint was the pain in his hip and prescribed tramadol (a pain killer). The
doctor wrote:
‘…I think he’s got a chronic process gradually deteriorating, rather than
anything acute…’
50. The results of the second blood test were telephoned through from the
hospital on the same day. The doctor noted that the results were still ‘awry’.
Healthcare staff called the hospital on behalf of the doctor to obtain the man’s
x-rays but were told that they were not yet ready. The doctor thought he had
an ‘acute [chest infection] on [top of] chronic [ill health]’. His asthma and
blood pressure were checked by a nurse.
51. The same day, the man attended a smoking cessation clinic. He was given
advice on how to stop smoking and provided with nicotine patches. CPN B
also assessed him again on 18 March and did not identify any mental health
problems.
52. On 24 March, the man received further advice about stopping smoking. On
the same day, Prison Doctor E wrote that the blood tests taken on 18 March
gave further cause for concern. (The hospital had not yet returned the results
of the chest and hip x-rays taken on 15 March.)
53. A nurse assessed the man on 25 March. She noted his ongoing hip pain and
wrote that his pain relief (tramadol) was not helping sufficiently. More blood
tests were carried out on 26 March. On the same day, he underwent a
‘Health and Social Care Assessment for Prisoners Aged 50 and Over’. It was
noted that he had a cyst behind his left ear that had been getting bigger over
12
the previous six months. His breathlessness and hip pain were also recorded,
as was his weight loss of half a stone in the previous three months.
54. Following an assessment on Saturday 27 March, another nurse became
concerned and consulted a doctor on duty at a nearby prison, HMYOI Stoke
Heath by telephone for further advice about the man’s symptoms. The doctor
thought that he should be admitted to hospital the same day.
55. The man was taken to hospital where he stayed overnight, returning the
following day, 28 March. It was thought that he had had an internal bleed and
he was given a blood transfusion, although this was not completed because
his temperature rose during the procedure. The consultant surgeon decided
that his ill health required further investigation.
56. On 29 March, the man went to the hospital again to undergo a scheduled
endoscopy and colonoscopy (a procedure which allows a doctor to look at the
inside of a patient’s digestive system using a tiny camera that is fed through
on the end of a tube). However, the hospital had no record of the
appointment and he was brought back to the prison without the procedure
taking place. A member of healthcare staff contacted the ward where he had
just been staying. The ward staff agreed to speak to their colleagues about
the delayed procedure. The same day, Nurse E noted that his temperature
was raised and gave him a paracetamol to lower it.
57. The next day, 30 March, Nurse D called the hospital to check if a new
appointment had been arranged for the man’s endoscopy. She was told that
the new referral from the ward had not yet reached the relevant department
but would do so later that day. His temperature remained raised and Prison
Doctor E continued to prescribe paracetamol to keep it down.
58. On 31 March, the man went back to the smoking cessation clinic. The same
day, he complained to a senior member of healthcare staff that he felt ‘lousy’.
He was checked by Prison Doctor E.
59. The next day, 1 April, the senior member of healthcare confirmed with hospital
staff that the man’s endoscopy and colonoscopy had been rescheduled for 16
April. She also telephoned the hospital laboratory, who advised her that tests
to rule out tuberculosis could take up to ten weeks.
60. A nurse was asked to assess the man in his cell on 2 April. He was feeling
faint, looked very pale and his hands were shaking. During the next few days,
he continued to smoke, but told staff that he felt a little better.
61. On 6 April, the man went to a psychiatric assessment with a consultant
psychiatrist. She had organised the assessment because she thought that his
medication for his mental health problems (the result of his long term drug
misuse) needed to be reviewed. He was being prescribed risperidone and
chlorpromazine (both antipsychotic drugs). He said that he was not
experiencing psychotic symptoms and she ended his risperidone prescription,
13
instead prescribing mirtazapine for depression. He said that he was having
trouble sleeping due to the pain in his hip.
62. A nurse went to assess the man in his cell on 7 April after officers on the wing
expressed concern about him. He had not eaten for a couple of days and felt
shaky and lethargic. His temperature was fluctuating. The same day, Prison
Doctor E enquired with the hospital whether his colonoscopy could be
scheduled any earlier in order to hurry a diagnosis along.
63. A nurse reviewed the man in his cell early on 8 April. He was no longer
shaking but complained of the pain in his hip. A short while later, the nurse
was called back to the cell to find him lying on the floor. He had been unable
to reach the toilet and felt so weak that he lay down and could not get back
up. He was awake and uninjured. However, the nurse noted that he was
very frail and his health was deteriorating. Staff helped him back to his bed
and the nurse gave him paracetamol to lower his temperature. The nurse
noted that his colonoscopy had not been brought forward, despite Prison
Doctor E’s request. He returned to check on him a little later on.
64. Another nurse assessed the man shortly afterwards. She noted that his
condition had deteriorated within 24 hours. He had stopped eating solid food
and looked frail. She referred him to Prison Doctor E because she thought he
should be taken to hospital. The doctor agreed and he was admitted to the
hospital’s accident and emergency department at 10.30am.
65. The man stayed in hospital between 8 and 13 April because he was too
unwell to return to the prison. On 9 April, the senior member of healthcare
and Prison Doctor D advised discipline and healthcare colleagues that he
should not return to the prison until his condition had stabilised. On the same
day, he underwent an endoscopy. His stomach, windpipe and small intestine
were checked but no serious concerns were identified. He received blood
transfusions but his temperature remained raised.
66. On 13 April, the man discharged himself from hospital against medical advice
and returned to the prison. He wanted to attend any tests and appointments
as an outpatient. Although hospital staff told him that his decision might delay
his treatment, he insisted. His discharge summary detailed the medication he
needed to take. He could no longer walk any significant distance without
collapsing.
67. Healthcare staff drew up a care plan on 13 April. It was agreed that staff
would help the man to maintain his personal hygiene (because he was unable
to do this independently) and ensure that he took all of his prescribed
medication. Staff also arranged to give him a sedative to help him sleep at
night (if the doctor thought this appropriate) and administer pain relief when
needed because of the trouble his hip was giving him. A nursing assessment
noted that he had been reporting constant kidney and back pain.
68. The man’s temperature and other clinical observations were checked each
day. The Clinical Nurse Manager assessed him in his cell on the morning of
14
15 April. His right leg and hip caused him constant pain and he could only eat
tiny amounts of food because otherwise he tended to be sick. His discomfort
was getting worse and he asked for increased pain relief. A CPN checked
him the same day and noted how much his health had deteriorated and
mobility reduced in recent weeks. He said that he was depressed because he
was in constant pain.
69. On 15 April, the man made a formal complaint to the Governor. He wrote:
‘Sir, I am in chronic pain in right hip and I am now suffering in chronic
pain and not getting any pain relief from medical staff. As you know
discrimination of a disabled person is unlawful and this prison is clearly
discriminating against me as a very very ill prisoner. I wish you to
know I have asked solicitor to have a public enquiry in the event of my
death in custody. I wish to be moved into a prison with medical help.
‘I want to go into a prison who can control my chronic pain, as med
care is not helping me or I know you will have a death on your hands
very soon. I have asked the Ombudsman to also investigate the
treatment I am receiving here.’
(The Prisons and Probation Ombudsman investigates complaints from
prisoners but did not receive a complaint from him. He did complain to
the Parliamentary and Health Service Ombudsman (PHSO) in April.
However, the PHSO have been unable to disclose to my investigator
either the details of the complaint or the outcome.)
70. The next day (16 April), the man was escorted to hospital for a colonoscopy.
At 7.00pm that day, a Healthcare Assistant checked him in his cell. He had
not eaten or drunk much at all and was sweating a great deal.
71. On the afternoon of 17 April, a nurse consulted Prison Doctor F. They were
very concerned about the man and arranged for him to be taken to the
hospital at 4.30pm. However, at 6.15pm he was still waiting in an ambulance
outside the hospital as no bed was available. He was admitted later in the
evening and was made comfortable.
72. Following a risk assessment, the man was initially handcuffed at all times to
one of the two escorting officers using an escort chain. (An escort chain
consists of a length of chain with handcuffs at both ends. It allows a prison
officer to remain a few feet from the prisoner and permits hospital staff to take
care of the patient without the officer getting in the way.)
73. A senior member of healthcare visited the man in hospital at 2.00pm on 19
April. He had received a diagnosis of secondary cancer in his bones. (There
was concern that his bones were so fragile as a result of his condition that he
could easily fracture them.) The primary source of the cancer was unknown.
He was located on the oncology ward, told his diagnosis and given adequate
pain relief.
15
74. A further risk assessment on 19 April approved the removal of restraints
because the man’s condition had deteriorated. He was no longer handcuffed
to an officer and would not be again before he died. The two escorting
officers remained with him for the time being.
75. The senior member of healthcare discussed possible treatment options with
the ward staff. She explained to them that the prison healthcare team did not
have the facilities and resources to care for the man in Shrewsbury. They
discussed the possibility of release on licence (if a prisoner is terminally ill
then they may be released from custody for compassionate reasons), but
concluded that this might not be an appropriate option because he had no
permanent address when he arrived in prison. They agreed that it was not yet
appropriate to move him to a hospice, which only happens at the end of the
patient’s life.
76. The man’s condition was reviewed by a consultant during ward rounds on 20
April. The consultant noted that he had been in pain for six weeks and that
the primary cause of the cancer in his bones had not yet been determined, in
spite of an endoscopy, a bone scan and x rays. The consultant noted that his
chest, pelvis and abdomen would need to be examined to discover where the
cancer had begun. The escorting officers told him that his daughter had been
trying to get in touch with him.
77. The Head of Reducing Reoffending responded to the man’s complaint on 20
April. She wrote:
‘He was interviewed by a governor whilst at the hospital doing
management checks. He stated that … he did not have an issue with
the PCT but he had with the doctor which he is taking further outside of
this complaints procedure.
‘Healthcare staff locally were advised of the situation. His condition is
serious but not yet fully diagnosed.’
78. The next day, the senior member of healthcare also responded to the man’s
complaint. She wrote:
‘Thank you for bringing this to my attention. I am sorry to hear that you
are still in pain, but you have been receiving strong pain relief (ie.
tramadol) since 29.3.10.
‘You have been seen by the doctor and the nursing staff on a regular
basis, have had extensive investigations and have been admitted to
the hospital on several occasions.
‘In future please inform your landing staff of any concerns and a
member of the healthcare staff will come and see you.
‘Please also contact me again if you have further problems. This
complaint was not received by healthcare until 21.4.10.’
16
79. Scans of the man’s abdomen did not reveal the primary cause of his cancer.
He underwent a colonoscopy on the morning of 21 April. Whilst his colon was
not affected (the bowel was ‘normal’), the test revealed a mass on his right
side ‘going into his spine’ and a biopsy was scheduled. It was noted that his
cancer had spread to the bones in his arm and leg. The primary source of the
cancer was still not determined. The same day, the senior member of
healthcare tried to establish whether he had any accommodation to which he
could be released.
80. The next day, the senior member of healthcare confirmed with the man’s most
recent probation officer that he had been homeless when he arrived in prison.
She recorded that the likelihood of him being offered any other
accommodation (where he might be released on licence) was now
‘unrealistic’, given his history of offences of theft and his fragile condition.
81. The man underwent a biopsy (the removal of cells for further examination) of
the lesion on his right hip on 23 April. By the following day, he could no
longer walk and was confined to a wheelchair. He asked the escorting
officers to contact his brother on his behalf.
82. On 26 April, hospital staff confirmed to the senior member of healthcare that
the man would not be able to cope if he was released to a private address
and they agreed that he would need to be admitted to either a nursing home,
a hospice or a prison with proper inpatient facilities. His morphine dosage
was increased. Staff again telephoned his brother on his behalf on the
evening of 27 April. (He had also been in touch with his brother personally.)
83. The day afterwards, the senior member of healthcare was advised by the
hospital staff that the man could expect to live for about another four weeks.
He was told by the consultant that afternoon (28 April) that the cancer was
‘extensive and difficult to treat’. His pain relief was increased.
84. The need to find a suitable facility to which the man could be discharged was
pressing. The senior member of healthcare spoke to staff at HMP Dovegate,
HMP Norwich, HMP Birmingham and Hewell, all providing inpatient
healthcare, but none had an available bed. She discussed the situation with
Deputy Governor, who suggested that he might be released on temporary
licence once he became bed-bound.
85. The next day, 29 April, the senior member of healthcare was told by hospital
staff that a bed had been found for the man at a nursing home. The manager
of the home agreed to accept him on the condition that the escorting officers
did not wear a prison uniform. She also indicated that she would continue to
accommodate him if he was released on compassionate grounds (and was
therefore no longer escorted by prison staff), providing that he did not present
a risk to others. The senior member of healthcare noted in the clinical record
that his pain was being controlled and he was able to walk slowly using a
Zimmer frame.
17
86. The same day, the man was assessed by an oncologist. The oncologist
wrote that the cancer which had spread through his bones had probably
begun in his lungs. He was located in a side room at the hospital with two
escorting officers. The oncologist told him that his condition was treatable but
not curable because the cancer had spread. He understood that his
prognosis was not good and agreed to accept radiotherapy. (The oncologist
considered that he was too poorly to undergo chemotherapy.) He was told
not to try to walk but instead to use his wheelchair. Staff telephoned his
brother again that evening to update him.
87. Also on 29 April, a seconded probation officer in Shrewsbury completed part
of a report about the man’s possible early release on compassionate grounds.
She assessed that there was a high likelihood of him committing further
offences of theft and noted that he did not have any family or friends who
would be willing to look after him.
88. She wrote that the man had a history of misusing substances and then
reoffending very soon after release. He was registered as a prolific offender
and had previously breached licence conditions. She commented that he had
become institutionalised and usually returned to prison very rapidly after
release into the community. She expressed concern that he would not attend
his hospital appointments if he was released and no longer had prison officers
to escort him. She noted that release to a hostel would be ‘wholly unsuitable’.
89. The senior member of healthcare visited the man at the hospital the following
day, 30 April. She was told that he would undergo radiotherapy and then be
discharged to the nursing home within seven to ten days. She spoke with him
about his diagnosis and he expressed his pleasure that his brother would be
visiting him. He was supposed to undergo an MRI scan (which provides an
internal image of a patient’s body) the same day, but this could not happen
because he had a piece of metal in his head from a previous operation. He
was told that he had developed a fracture in his arm because the cancer had
weakened the bone so much. Hospital and prison staff had to take great care
when moving him.
90. On the same day, at the request of the governor, Prison Doctor D completed
a ‘Compassionate medical condition report’ to assess the man’s application
for early release on compassionate grounds. He wrote on the form that he
had terminal lung cancer which had spread to his bones. He noted that his
prognosis was ‘extremely poor’ and that he had less than four weeks to live.
The doctor strongly recommended early release on compassionate grounds.
91. At the start of May, the security department decided that the man would be
allowed as much tobacco as he needed because he was dying and it gave
him some pleasure and relief. The escorting officers were asked to escort
him from his bed to a designated outside smoking area when he wanted to
smoke. He could no longer either get out of bed or use his wheelchair
because of the fragile state of his bones and his swollen feet.
18
92. On 2 May, the man spoke to his brother on the telephone. He started his
course of radiotherapy two days later on 4 May. His bones were so fragile
that he broke his arm again whilst turning over in bed and it was put in a
plaster cast.
93. The man refused radiotherapy on 7 and 8 May. A nurse rang the hospital on
8 May on behalf of the healthcare department (after the escorting officers
expressed concern) but was told that he was currently consenting to
treatment. His relatives visited him on 8 May.
94. On 10 May, the man again declined his radiotherapy session and expressed
his wish to simply move to the nursing home. He transferred to the nursing
home the same day and attended further radiotherapy sessions as an
outpatient at the hospital on 11, 12 and 13 May. Healthcare staff provided
him with nicotine patches because the nursing home would not allow smoking
inside the building. However, escorting officers would still take him to smoke
in the garden.
95. A member of staff at the nursing home telephoned Prison Doctor D on 11 May
to suggest that the man be registered as a patient at a nearby doctor’s
surgery. Healthcare staff faxed a copy of his clinical record through to the
new surgery. The prison doctor spoke to a doctor at the surgery to provide a
handover about his condition.
96. The man was given a palliative care Macmillan nurse whom the senior
member of healthcare spoke to on 12 May. Two days later, on 14 May, the
senior member of healthcare visited him in the nursing home. She noted that
he was comfortable and well looked after. He acknowledged that he was
dying and asked for the Anglican chaplain to visit him. Following a visit by the
duty governor and a further risk assessment the same day, only one officer
was required to escort him in the nursing home from the evening of 14 May
onwards.
97. The man’s sister visited him on 15 May, and he went to an appointment at the
hospital shortly afterwards to have his plaster cast changed. The senior
member of healthcare visited him on 17 May. He had very little mobility and
used a Zimmer frame to move to the bathroom with a member of staff present
in case he got into any difficulties. His pain relief medication was increased.
The next day, he returned to the hospital to have his plaster cast changed
again because the wound underneath the cast was weeping.
98. On 20 May, the man’s offender supervisor wrote a report concerning his
possible early release. He referred to his numerous previous convictions for
domestic burglaries and the fact that he had previously stolen from relatives.
Previous risk assessments also recorded that he enjoyed the ‘buzz’
associated with stealing and was unlikely to stop. The officer supervisor
expressed reservations about him being left on his own in the nursing home
without an escorting officer because of the likelihood of further offending. The
same day, he went back to hospital to have his plaster cast checked.
19
99. The next day (21 May), the oncologist at the hospital wrote to the healthcare
team to tell them that the man had completed his course of radiotherapy. On
the same day, healthcare staff renewed their efforts to find an inpatient bed
for him in another prison. The clinical nurse manager and a governor visited
him the same day. The governor visited again on 24 May and organised for
him to be given more tobacco.
100. The man spoke to one of his brothers on the telephone on the evening of 26
May. Just after midnight, a doctor came to check him and increased his pain
medication. The clinical nurse manager and the prison chaplain both visited
him in the nursing home on 27 May. She noted that his condition had
deteriorated markedly in the last day or two. His legs were very swollen and
he was in more pain. He was eating very little but managed to speak to his
family on the telephone.
101. Officer B stayed with the man on the night of 27 May. He began his shift at
the nursing home at about 8.00pm. He told my investigator that the nurses
checked him every two hours during the night, at 1.30am, 3.30am and so on.
He was asleep most of the night and his breathing became more laboured.
102. As the night wore on a nurse advised the officer that the man’s condition had
worsened and he would not regain consciousness. Nursing home staff
contacted the next of kin to let them know. The officer was relieved by Officer
C at about 7.20am on 28 May and left the nursing home. On the advice of the
nursing home staff, Officer C telephoned the man’s sister to tell her that the
end of her brother’s life was near. He died shortly afterwards, in the presence
of Officer C and a carer at 7.50am.
103. The prison chaplain visited the nursing home later that day and a doctor from
the local surgery confirmed death. The man’s relatives also visited the home
the same day. The prison paid for his funeral, which was held in Nuneaton on
14 June.
20
ISSUES
Mental health
104. Although the man’s mental health was a significant concern during previous
custodial sentences, his mood remained stable in both Hewell and
Shrewsbury from December 2009 until his death in May 2010. Staff remarked
on his good humour and “being something of a character”. Whilst his physical
health declined rapidly, his mental health actually seemed to stabilise. The
escorting officers at the hospital noted that he was polite and respectful and
got on well with the nursing staff.
105. I would like to commend the work done by the CPN A at Hewell and the CPN
B at Shrewsbury to regularly review the man’s mental health. As the clinical
review panel note, all of the record keeping was of a high standard and the
CPN at Hewell seemed to have a particularly good relationship with him,
something she had developed over different custodial sentences.
106. The man discussed the pain he was experiencing with other healthcare staff
at Hewell, most notably CPN A (a mental health nurse). Because physical
pain is not her area of expertise, she told the investigator that, after each of
her meetings with him to discuss his state of mind, she confirmed that he was
scheduled to be assessed by a doctor in the near future. She had met him
when he was previously held at Hewell in the summer of 2009. She told the
investigator that she did not observe any obvious deterioration in his
presentation when she met him again in early 2010.
107. The investigator and the clinical reviewer interviewed the CPN. The man
reported physical pain symptoms to her. However, as a mental health nurse,
she said that she does not have a regular opportunity to liaise with her
colleagues who care for prisoners’ physical health. I endorse the clinical
review panel’s recommendation:
The Head of Healthcare at HMP Hewell should consider whether to hold
multi-disciplinary team meetings involving primary care and in-reach
staff relating to both general issues and specific prisoners.
Complaint made by the man
108. In mid-April, the man made a formal complaint to the Governor. He was
unhappy that he was in pain and he said that he would contact ‘the
Ombudsman’. He received full responses to his complaint from a governor
and also from the senior member of healthcare. He did not make any further
complaints to the Governor and there are no entries in any other records to
suggest that he continued to be unhappy with the treatment he received from
healthcare staff.
109. The team who respond to prisoners’ complaints in my office have confirmed
that they did not receive a complaint from the man in April or May 2010. I
understand that the Parliamentary and Health Service Ombudsman (PHSO)
21
did receive a complaint from him in April. However, the PHSO have been
unable to release details of the complaint (or any response they might have
made) to my investigator.
110. With regard to the complaint the man made to the Governor, he was
undoubtedly in a great deal of pain at the time. It would very soon become
clear that he was actually dying and within a couple of days he was
hospitalised. I consider that the healthcare team did their best to give him
appropriate pain relief, although I recognise that this was the first time that
they were required to help a man whose prognosis was so poor. Shrewsbury
does not have inpatient facilities and is not able to offer the sort of pain relief
that patients at the end of their lives might receive elsewhere.
111. The senior member of healthcare in particular responded to the man’s
complaint thoughtfully and fully. I am satisfied that he, whilst unhappy when
he wrote the complaint, seems to have responded well to the care he received
in the weeks that followed. There is not a pattern of complaints over several
weeks which would give serious cause for concern.
The man’s diagnosis
112. The man originally came into custody on 4 December 2009. He remained at
Hewell for the next three months. His cancer was not diagnosed during this
period although he complained of hip, back and kidney pain several times.
He reported passing blood in his urine and tests were completed but no
problems of this nature were diagnosed. The clinical review panel have
concluded that his own account was ‘inaccurate’. Kidney stones were
suspected and an x-ray was taken, but did not show any stones.
113. Prison Doctor C assessed the man on 12 February and thought that he was
complaining of pain as a means of seeking drugs. He had a long history of
drug misuse. He received warnings at Hewell for concealing his prescribed
medication and then trading it in order to obtain subutex. However, the doctor
told my investigator that he had not been aware of this behaviour.
114. The doctor said that he would normally read through his colleagues’ previous
entries in the clinical record before he assessed a patient, but could not recall
if he had done so on this occasion. There is no mention of the man’s
attempts to ‘palm’ medication in his clinical record. It does not appear that
nursing staff working with him were told about this pattern of behaviour. I
consider that healthcare staff need to know this kind of information because it
affects their assessment of whether to trust the prisoner with ‘in possession’
medication and whether to continue their prescription. I therefore make the
following recommendation:
The Governor and the Head of Healthcare at Hewell should ensure that
discipline and healthcare staff communicate effectively if a prisoner
tries to supply their medication to others. Attempts to ‘palm’ medication
should be noted in the prisoner’s clinical record.
22
115. When he spoke to the investigator and clinical reviewer, the doctor explained
that he had never met the man before the examination on 12 February. He
doubted how genuine his complaint of pain was and initially decided to
prescribe pain killers. The doctor thought that he wanted the medication more
for its own sake rather than for its pain relieving properties. He referred to the
World Health Organisation’s guidelines and planned to check how well the
pain relief worked.
116. The doctor explained that his intention was to consider further exploratory
procedures if the man continued to report pain after taking naproxen. The
doctor accepted during interview that he had not made the intended plan of
action clear to other colleagues in the clinical record.
117. The doctor commented that he did not consider the possibility of an ‘occult
malignancy’ (cancer) causing the back pain. He agreed that his presentation
of pain, age and history of smoking may have indicated that such a diagnosis
was a possibility. However, I am satisfied that the doctor planned to make a
follow-up assessment if the man continued to report pain.
118. The doctor anticipated that the nurses handing out the prescribed pain
medication would monitor the man’s presentation and refer him back to a
doctor if his pain did not reduce. This approach seems comparable with that
which a general practitioner in the community might take. A patient who
reported pain would not necessarily be sent immediately for cancer tests.
119. Further checks at the time might have revealed that the man had developed
cancer. However, the clinical review panel stress that the pain the man
originally reported cannot with any certainty be directly linked to his cancer.
120. The man arrived in Shrewsbury on 1 March. The senior member of
healthcare told my investigator that the healthcare staff soon noticed that he
looked unwell and anaemic. Within weeks he was in hospital and received a
terminal diagnosis. He died less than three months later.
121. It seems to have been coincidental that the man’s cancer was only diagnosed
once he arrived at Shrewsbury. Although he reported pain at Hewell, there do
not seem to have been any other associated symptoms such as weight loss.
Within three weeks at Shrewsbury, his appearance had altered dramatically
and staff remarked on how he had visibly aged since his arrival.
122. At the time the man transferred from Hewell, he had no diagnosis of cancer
(only reports of pain) and there were no outstanding hospital appointments.
In the circumstances, I believe that healthcare staff acted appropriately in
allowing him to transfer. There was nothing remarkable about his transfer,
which represented a logical progression within his sentence. He moved from
Hewell (a local prison where many of the prisoners are new arrivals from
court) to Shrewsbury (a training prison intended for longer term prisoners).
123. The clinical review panel stress that transferring a prisoner can interrupt the
investigation of illness and subsequent diagnosis. I consider that his
23
continuity of care was not interrupted. A ‘medical hold’ (which prevents a
prisoner who has forthcoming treatment scheduled from transferring) was not
necessary or stipulated in this instance. The man was not undergoing
treatment for a serious illness when he moved prisons.
124. Although, as the panel highlights, a prisoner’s healthcare needs to be taken
into account if a transfer is planned, there was nothing in the clinical record to
indicate that a transfer might be inappropriate. A urine test and an x-ray had
been carried out and the results were normal. Although the doctor intended to
follow up on the man’s assessment in mid-February, he did not write this in
the notes.
125. I would encourage the Head of Healthcare at Hewell to think about the clinical
review panel’s recommendation about improving the handover between
prison healthcare departments when a prisoner transfers. The panel suggest
that a summary of ongoing treatment and health issues is prepared for the
receiving prison.
126. The doctor acknowledged that he might have been more proactive in
considering the possibility of cancer and taking the man’s complaints of pain
more seriously. However, I am satisfied that a diagnosis perhaps three weeks
earlier would almost certainly not have made a difference to the man’s life
expectancy, given how far, how quickly and how aggressively the cancer had
spread by the time it was discovered.
127. In January, discipline staff placed the man on report and took away his
privileges when he refused to go to work because he said he was in too much
pain. It is likely that he was indeed in some genuine distress (given how
advanced the cancer was once it was diagnosed in April). However, without a
diagnosis from the healthcare team, it is hard to see how discipline staff could
have confidently known at the time about the extent of his pain.
Access to palliative care
128. Until recently most of the men at Shrewsbury were serving short sentences or
on remand. Now that the prison has switched functions, it will predominantly
hold sentenced prisoners and the average age of the men is likely to increase.
This may well present problems, as the prison has no inpatient facilities and
no ability to offer around the clock nursing care of the kind required by
patients like him. I endorse the clinical review panel’s recommendation:
The Head of Healthcare at Shrewsbury should review the facilities for
intensive nursing and work with the Primary Care Trust to improve them
where possible.
129. When the man died, the healthcare department did not have a palliative care
policy in place. The senior member of healthcare told my investigator that he
was the first example (that she knew about) of a prisoner at Shrewsbury who
had required care until the end of his life. On this occasion, the speed of his
24
illness meant that he moved rapidly to outside hospital and then to a nursing
home.
Escorts and restraints
130. The Governor was concerned that the man had only a very short time to live
and should not be alone. He was also aware of his numerous previous
convictions for stealing. Although he was very unwell, he was still sufficiently
mobile to cause a little concern in this regard.
131. The man had no permanent address to which he could be released. His
family members were unable to accommodate him. The Governor only
allocated one officer to the escort, which seems a proportionate and sensible
decision. Equally reasonably, the escorting officers did not wear a uniform in
the nursing home and he was not handcuffed once his terminal diagnosis was
known.
132. After some consideration, I am also pleased that the prison management
team took the decision to keep an escorting officer with the man until he died.
He was, by all accounts, grateful to the officers who sat with him. They
provided him with company and were able to take him out to the garden to
smoke cigarettes.
Compassionate release
133. The prison management team began the process of applying to the Ministry of
Justice to have the man released on compassionate grounds. Some
members of staff (the offender supervisor, the seconded probation officer and
a doctor) completed assessments to move the process forward.
134. In the end, the man remained under escort and was not released from
custody on compassionate grounds. The seconded probation officer had
advised against release. She noted that he could not have coped on his own
and would not have been able to go to all his appointments without the help of
the escorting officers.
135. I am pleased that the hospital was able to locate a suitable nursing home and
that the man was able to spend his last weeks in a comfortable and suitable
environment. The staff who spent time with him in the home all spoke very
highly of the standard of care offered there and the accommodation provided.
The senior member of healthcare praised the team at the home and also
thought that he was offered very good care. The clinical review panel
consider that all of his palliative care needs were met by the nursing home.
136. The clinical review panel judges that the man’s poor health in the last few
weeks of his life meant that he presented little risk of either re-offending or
harming others. They believe that release on compassionate grounds should
have been given more thought. They highlight the significant cost of keeping
an escort with him. They argue that the money had to be taken from the
prison’s healthcare budget, potentially impacting on the regime and services
25
offered during the financial year to other prisoners. Given the changing
nature of Shrewsbury’s population, the panel foresee further similar instances
of this nature.
137. Although I consider that the man benefited from the presence of the escort
officer in that it was both wise (because he had a very long history of
offending) and humane (because the officer could help him to move around)
to provide an escort, I endorse the clinical review panel’s recommendations
regarding release on compassionate grounds. Other prisoners in similar
situations in the future may have family they can be released to or will have a
different offending history. Given the changing population of the prison, the
financial impact of ongoing escorts could well also be significant.
When a prisoner is receiving palliative care, all the relevant departments
at Shrewsbury should give careful consideration within a multi
disciplinary framework to early release on compassionate grounds.
The Governor and the Head of Healthcare at Shrewsbury should review
the effects of potential rising bedwatch costs with a view to minimising
any effect on the delivery of prison healthcare in general.
138. The change in the prison’s function means that, sadly, it is likely that the
healthcare team will treat other prisoners who require palliative care. To this
end, I gather that the clinical nurse manager have been tasked with focussing
on the care of older prisoners. Following the creditable example of the man’s
care, I am pleased to hear that the healthcare team is currently drafting a
palliative care policy.
139. The senior member of healthcare spoke to my investigator about her
experiences of trying to find the man somewhere appropriate to stay during
his final weeks (until the nursing home accepted him). She expressed her
frustration that the allocation of inpatient beds across the prison estate is not
organised centrally. Instead, she found herself telephoning colleagues in a
number of prisons with appropriate 24 hour healthcare facilities as far away as
Norwich seeking a bed for him, to no avail. She chose the prisons on the
recommendation of colleagues.
140. Until she helped the man, she had assumed that one centrally located team
had overall responsibility for coordinating the allocation of inpatient beds
across the entire prison estate. She thought that such an arrangement would
have been an enormous help in the circumstances. Shrewsbury is not
equipped to treat inpatients, and it is fortunate that the local authority made
the unusually swift and thoughtful decision to locate him in a nursing home.
141. Offender Health has advised my investigator that, if a similar situation arises
in the future, healthcare staff at Shrewsbury should, in the first instance,
consult the regional offender health manager (ROHM) in the West Midlands.
The ROHM is ultimately responsible for securing inpatient healthcare beds for
prisoners such as the man. With a remit covering a large region and a
26
number of prisons, they are better placed to have an overview of availability
and organise a transfer.
142. Although I do not make a formal recommendation, I have considered the
usefulness of a central register of available inpatient beds. I appreciate that
such a measure would have cost implications, as it would need to be staffed
and updated each day. Nonetheless, the NOMS Population Management
Unit already keeps track of each prisoner across the estate using computer
systems. It may be that its function could be extended to keep Offender
Health updated about the availability of healthcare beds. The increasing
number of elderly prisoners requiring a high level of care means that such an
innovation would no doubt be welcomed by staff such as the senior member
of healthcare.
Clinical record keeping
143. The man’s death was caused by cancer which had spread through his body
and into his bones. The origin of the cancer was hard to determine but was
thought to have begun in his lungs. I have been impressed by the standard of
clinical record keeping at Shrewsbury. The progress of his treatment and the
actions taken by all those involved are clearly documented. I am satisfied that
any member of staff caring for him would have been able to consult the
clinical record and understand the progress of his treatment. I make a point of
highlighting the thorough and well written entries because, all too often, I have
not found record keeping at other prisons to be of a similar standard.
144. I commend the implementation of a formal nursing care plan on 13 April. This
is an expected and highly desirable step forward when a patient requires
significant assistance and is facing a poor prognosis. However, it is not
always the case that such action is completed promptly and documented
accurately, and I am therefore keen to highlight good practice. Staff took the
action in response to the man’s discharge from hospital.
27
CONCLUSION
145. The man arrived in custody in December 2009, having only been released
from prison a matter of weeks previously. He reported pain during the next
three months at Hewell, but initial tests showed nothing concerning. After he
arrived at Shrewsbury at the start of March 2010, his health failed rapidly and
staff referred him to the local hospital. After a number of tests and admissions
as an inpatient, he received a very poor prognosis. His cancer had
progressed very quickly. He died less than three months after staff first
became concerned about him at Shrewsbury.
146. I consider that healthcare staff at Shrewsbury cared very well for the man,
particularly since they did not have previous experience of caring for
terminally ill prisoners and had no inpatient facilities. The clinical review panel
commend the care and concern shown by the healthcare team at
Shrewsbury. The cooperation between the hospital and the prison healthcare
team seems to have worked well and he was able to end his life in a nursing
home where members of his family could spend time with him. I hope that the
healthcare team will gain confidence from the way they helped him and use
this experience going forward. Now that Shrewsbury has a larger number of
older prisoners, this will probably not be the last time that they have to care for
a man who faces the prospect of dying in custody.
28
The family’s response to the draft
After the draft report of the investigation was published, the man’s relatives
contacted my family liaison officer. They asked to meet both her and the
investigator. The meeting took place in the home of one of his brothers on 14
January 2011. Four of his siblings attended. They expressed their unhappiness
about what they had learned from the draft report. In order to properly reflect their
feedback, I have reproduced below the summary of the meeting which the family
liaison officer sent to the family afterwards.
Summary of discussion
1. The family liaison officer began by explaining that the purpose of the visit was
to help explain any aspect of the report the family were unclear about and to
consider any feedback the family may have before the Ombudsman’s report is
made final.
Coroner’s Inquest
2. The family were concerned the coroner’s inquest may have already taken
place. The investigator said he was not aware that it had and would seek to
clarify this with the Coroner’s office.
Subsequent to the meeting, the Shropshire Coroner’s office confirmed the
inquest had not taken place and that a date had yet to be scheduled for this.
The family liaison officer confirmed this in a letter to the man’s brother dated
17 January 2011, along with contact details for the Coroner’s office and
further information about the inquest process.
Inadequate healthcare
3. The family feels strongly that the Prison Service, specifically HMP Hewell,
failed in its duty of care to him and that the healthcare he received while in
custody was not equivalent to that he would have received in the community.
4. Having considered the findings of the Ombudsman’s investigation the family
are deeply concerned by the lack of healthcare intervention during the three
months he was at HMP Hewell. He told staff repeatedly during this period
that he was experiencing pain however this does not appear to have been
acted upon. Given that they think it likely he was suffering from cancer at this
time, the family are upset that he was not given any stronger medication to
manage this pain.
5. The family questioned the availability of doctors at Hewell, given that he
appeared to have very limited interaction with the prison GPs despite his
ongoing pain and discomfort. His family were highly critical that a period of
about six weeks elapsed without him being seen by a doctor.
6. The family also feels strongly that the tests and referrals made were
inadequate, and are concerned that healthcare staff did not explore matters
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further despite his complaints of pain and discomfort. They questioned the
willingness of local prisons to invest in prisoner health given they are
considered a temporary location for the majority of prisoners.
Prison Doctor C
7. The family found the doctor’s assessment of him a serious matter of concern.
The family thinks that his crippling back pain was not taken seriously and that
it was perceived by the doctor that he was merely drug seeking. Given his
rapid decline in health just a few weeks later, the family believe he would have
been experiencing considerable pain at this time and are angry that his
symptoms were dismissed. The family commented on how isolating and
frightening it would have felt for him not to be believed particularly in the
restraints of a prison environment.
Refusal to attend work
8. The family believes that Hewell further failed in their duty of care by choosing
to punish him for not attending work rather than investigate the cause of his
refusal. He told his family he felt so unwell that he was unable to get out of
bed some days, the pain he was experiencing prevented him from sleeping
and he lacked the energy to attend work. The family said that, had staff
explored his reluctance to work further, they would have realised that this was
unusual behaviour (he had never previously shirked from prison work). In any
event they believe his lack of willingness to work, coupled with his ongoing
complaints of health problems should, at the very least, have prompted further
referrals to healthcare.
Palming medication
9. The family questioned why he was not made to take his medication in front of
nursing staff if there was an ongoing issue with palming medication.
Information sharing
10. The family were concerned that he told his Community Psychiatric Nurse on
several occasions about the pain he was experiencing, yet she failed to inform
other nursing staff.
The investigator agreed information sharing between healthcare professionals
could be improved. The Ombudsman has made a recommendation to
improve practice in this area.
Missed hospital appointment
11. The family are concerned he was unable to attend a scheduled hospital
appointment on 16 December due to a shortage of escort staff.
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The investigator explained, although by no means ideal, this is not uncommon
within the prison estate. On this occasion, his appointment was rescheduled
and took place the following week on 23 December.
Transfer to HMP Shrewsbury
12. The family is struggling to understand why HMP Hewell did not pick up on his
declining health yet he was sent for urgent tests within days of transferring to
HMP Shrewsbury.
13. They are also concerned there was a delay in transferring his medical
records.
The investigator has looked into this matter and is unable to find any evidence
of a delay in transferring his medical record. Paragraph 45 of the report
confirms that his clinical record arrived with him when he transferred to HMP
Shrewsbury.
14. For the most part, the family spoke positively about the care he received at
HMP Shrewsbury, although they are concerned the Prison Service only acted
when faced with no other option and questioned why the same care and
attention was not afforded to him from the start.
15. The family spoke very positively about the care home and their interaction
with escorting prison staff during this period.
Medical Records
16. The family asked for copies of his prison medical record.
A copy of the man’s prison medical record was sent to the family.
Internal investigation
17. The family also asked whether the Prison Service has carried out an internal
investigation into the care he received and whether they could receive a copy
of this.
The Prison Service accepted the findings of the Ombudsman’s independent
investigation into the care he received in prison custody and, as far as we
have been able to establish, is not carrying out internal investigations in
individual establishments.
Lessons learned
18. The family said they felt he was denied dignity in the way he was treated,
specifically at HMP Hewell. They feel it was inhumane for someone to
experience such chronic pain and discomfort for three months, made worse
by disbelieving healthcare professionals and inadequate and delayed
treatment. The family said it is important to them to ensure lessons are
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learned and that the same things are prevented from happening to another
prisoner and their family.
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RECOMMENDATIONS
For HMP Hewell:
1. The Head of Healthcare at HMP Hewell should consider whether to hold
multi-disciplinary team meetings involving primary care and in-reach staff
relating to both general issues and specific prisoners.
The prison accepted the recommendation.
2. The Governor and the Head of Healthcare at Hewell should ensure that
discipline and healthcare staff communicate effectively if a prisoner tries to
supply their medication to others. Attempts to ‘palm’ medication should be
noted in the prisoner’s clinical record.
The prison accepted the recommendation.
For HMP Shrewsbury:
3. The Head of Healthcare at Shrewsbury should review the facilities for
intensive nursing and work with the Primary Care Trust to improve them
where possible.
The prison accepted the recommendation.
4. When a prisoner is receiving palliative care, all the relevant departments at
Shrewsbury should give careful consideration within a multi disciplinary
framework to early release on compassionate grounds.
The prison accepted the recommendation.
5. The Governor and the Head of Healthcare at Shrewsbury should review the
effects of potential rising bedwatch costs with a view to minimising any effect
this may have on the delivery of prison healthcare in general.
The prison accepted the recommendation.
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