Individual at Stafford

The death of a prisoner on 7 August 2004 while in the custody of HMP
Stafford.
Report by the Prisons and Probation Ombudsman for England and
Wales
May 2005
CONTENTS
1. Introduction by the Ombudsman
2. Summary
3. The prisoner
4. Investigative process
5. The prisoner's health prior to arriving at HMP Stafford
6. The care given to the prisoner whilst at Stafford
7. Events leading up to the death of the prisoner
8. Issues considered during the investigation
9. Conclusion
10. Annexes
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This is the report of an investigation into the circumstances surrounding the
death of a prisoner who died in a hospital on 7 August 2004. At the time of
his death, the man was serving a four-year prison sentence at HMP Stafford.
The cause of death was myelofibrosis (an impairment of the bone marrow's
ability to produce blood cells). A post-mortem was not performed as his
death was predicted.
Since 1 April 2004, the Prison and Probation Ombudsman's office (PPO) has
been responsible for investigating all deaths in custody, including those due to
natural causes. The investigation was conducted on my behalf by one of my
colleagues. A clinical review of the prisoner's health care whilst in prison was
carried out by a doctor of the South Western Staffordshire Primary Care Trust
(PCT).
I offer my sincere condolences to the prisoner's family, friends and others
touched by his death. Losing a loved one who is in custody is a painful
experience, all the more so when they have been suffering from a terminal
illness.
I would like to thank the Governor of HMP Stafford, and her staff for their help
and openness during this investigation. The prisoner was clearly well liked by
staff and prisoners and remembered with affection. I was particularly
impressed with the holistic approach from staff in all departments to caring for
the prisoner with compassion and for the dedication of the Health Care
department who ensured that the prisoner was treated in accordance with his
wishes.
In sad circumstances, this is a report that reflects very well upon Stafford and
the Prison Service as a whole. I draw attention in particular to what I have
been pleased to write in the Conclusions section of this report.
Stephen Shaw CBE
Prisons and Probation Ombudsman
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Summary
The prisoner was 65 years old when he died on 7 August 2004 in hospital,
while in custody at HMP Stafford. In January 2003 he had been sentenced to
four years imprisonment. At the time he was suffering from myelofibrosis.
After being sentenced, the prisoner was first sent to HMP Blakenhurst, and in
June 2003 spent a very brief period in HMP Wymott. In July 2003, he was
transferred to Stafford. Stafford has no inpatient facilities.
During his period in prison, the prisoner continued to attend regular hospital
appointments to manage his condition. By August 2003, he had begun to feel
unwell. In January 2004, his prognosis was described as poor and he was
given three to five months to live.
Stafford continued to care for the prisoner but, despite regular blood
transfusions and medication, his health steadily deteriorated. In April, the
prisoner said that he wished to stay at Stafford where he had friends and had
been treated well.
In July, Stafford arranged for the prisoner to be released on temporary licence
to attend his hospital appointments. He attended hospital appointments in
early August, but his condition worsened and he died in hospital on 7 August.
This report commends Stafford for the way they assessed and met the
prisoner’s needs, and involved him in the process. The care provided was
comparable to what he would have received in the wider community, and staff
are praised for the quality of care they provided. It identifies several areas of
good practice in relation to the multi-disciplinary approach used at Stafford to
meet the prisoner's health care needs.
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The Prisoner
He had one sister, and worked as a manager in the engineering sector until
his retirement in 2001. He was married, had four children. He and his wife
separated after he was arrested.
The prisoner was diagnosed with myelofibrosis in 1998 and had been
receiving treatment on a regular basis including a blood transfusion every
three weeks. He was sentenced to four years imprisonment for sex offences
on 31 January 2003. He had no previous convictions and it was his first time
in prison.
His prison records described him as quiet, polite, respectful and cheerful
despite his illness.
Investigative Process
In cases of apparent death from natural causes, my practice has been to
conduct an initial review to determine the extent of the investigation required.
My investigator visited HMP Stafford on 13 August 2004 and spoke informally
to a number of staff in different areas of the prison including the prisoner's
residential unit, the Catering Department, Chaplaincy and Health Care. Staff
described their day-to-day contact with the prisoner, his treatment at Stafford
and in hospital. My investigator was given access to the prisoner's records,
including his medical record.
My investigator spoke to the Branch Chairman of the Prison Officers'
Association (POA), and a representative from the Independent Monitoring
Board (IMB). Neither had any issues which they wished to draw to the PPO's
attention.
Notices to staff and prisoners about the investigation into the prisoner's death
were distributed and displayed around the prison. No responses were
received.
The prisoner's son, was contacted by my investigator. He said that he had no
concerns at all about the way his father had been treated at Stafford. He
accepted that his father was an elderly man suffering from a terminal illness.
He expressed his thanks for the exceptional care the staff had provided and
the professionalism they had displayed.
The prisoner's sister wrote to the Governor, to thank staff for the compassion
and care her brother was shown. She said that she found this comforting,
even in the midst of a distressing and painful situation.
A representative from South Western Staffordshire PCT conducted a clinical
review.
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The prisoner's health prior to arriving at HMP Stafford
On 31 January 2003, the prisoner was sentenced to a total of four years
imprisonment. He was sent to HMP Blakenhurst in Redditch. He was seen
on reception by a Health Care Worker and stated that he was suffering from
myelofibrosis. He said that he was taking long term treatment in the form of
aspirin, anagrelide, folic acid, phenoxymenypenicillin and glucosamine. His
spleen had been removed 18 months previously. He described himself as a
social drinker and a pipe smoker. He was described as generally well.
A note dated 3 February 2003 in the prisoner’s medical record said that the
prison was awaiting confirmation of his medication from his General
Practitioner as some of it was not licensed for use. Blakenhurst's Senior
Medical Officer (SMO) wrote to the Consultant Haematologist who was
treating the prisoner when he was in the community, to say that he did not feel
competent to prescribe anagrelide as it was an unlicensed treatment for
myelofibrosis, as was glucosamine. He asked for the consultant
haematologist to remain the responsible prescriber for the prisoner. The
senior medical officer maintained contact to seek advice concerning the
prisoner's continuing treatment until the prisoner was transferred to HMP
Wymott on 17 June 2003.
An entry in his medical record on 17 June said that the prisoner felt he needed
to go to Wymott as he wanted to be in a more settled environment and he was
happy to be referred to a local hospital there. Once at Wymott, however, his
Record of Events (a record of occurrences completed by staff on each
prisoner) states on 20 June that he was too far away to receive visits and he
was hoping to be nearer to his family.
The prisoner was transferred back to Blakenhurst on 23 June 2003 due to
concerns expressed at Wymott about prescribing Agrylin (anagrelide) and the
fact that they did not have an SMO and used locum doctors as medical cover.
The prisoner was feeling under stress, having travelled to and from Wymott in
a short space of time. A hospital appointment had been arranged for the next
day but it was too short notice for the prison to arrange for him to attend, so it
was rescheduled for 27 June. The prisoner was seen at the prison's Well-
Man clinic on 26 June.
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The care given to the prisoner while at Stafford
The prisoner was transferred to Stafford on 25 July 2003. It is a category C
(medium security) prison for adult males. It was described in its last
inspection report by Her Majesty's Chief Inspector of Prisons (21-23 May
2003) as a safe and calm prison whose Health Care department "was well-
integrated into all departments of the prison". There is a no in-patient facility
so prisoners requiring such care may be transferred to other prisons. There is
also no medical cover after 8.45pm but staff can contact the Senior Medical
Officer if necessary.
The prisoner was prescribed a 28 day supply of his usual medications on 29
July 2003. On 25 August, the IMR states that he was "feeling rough". Two
more entries that day detail the concerns of his residential unit staff i that he
appeared to be very unwell and exhausted following minimal effort. As a
result, the duty doctor was contacted for advice. The duty doctor saw the
prisoner that day, and arranged for him to be admitted to hospital the next
day. Following a blood transfusion, he returned to the prison. His medical
record contains regular detailed entries about his health and medical checks.
It also records contact with the prisoner's son concerning his father's health.
On 8 January 2004, the prisoner was told by his consultant that his life
expectancy was limited as the prognosis for his condition was poor. He
understood that he would only have between three to five months left. His
health declined steadily over the next three months and he suffered from
internal bleeding, and a grossly enlarged liver. According to his records, he
remained in an optimistic mood despite realising that his illness was becoming
more aggressive. He continued to keep weekly appointments with the
hospital for transfusions and other scheduled appointments with his
consultant. On 6 February, a Macmillan nurse was contacted to take part in
the prisoner's case review.
On 15 April, the prisoner met with a Nurse from Stafford's Health Care Centre
as part of regular support sessions. She talked through pain relief issues with
him and asked the prison kitchen to alter his diet accordingly. The nurse felt
that a case meeting should be convened to create an action plan for
supporting the prisoner whilst in Stafford. Together, they discussed which
staff should attend the meeting, including the Disabilities Liaison Officer, Wing
Manager, Head of Health Care and his personal officer.
The case meeting took place on 26 April. The prisoner said that he wished to
stay at Stafford on a residential unit rather than be moved to a prison hospital
as he felt he had been treated well by staff and he had friends at Stafford.
The Head of Health Care agreed to contact Macmillan nurses to arrange
palliative care. It would also be ensured that contact was kept with his family
by the staff responsible for the prisoner's care, that he would be provided with
appropriate pain relief and that a wheelchair or any other equipment would be
available when he felt it was needed. In addition, the nurse was to draw up a
staff protocol so staff would know what to do when the prisoner's condition
deteriorated. The Deputy Governor was to consult the Home Office Sentence
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Enforcement Unit to find out their position on possible early release. The
Security department was to arrange for his visits to take place in the multi-faith
room or his residential wing should he be unable to access the visits room due
to ill-health. Similarly, the Chaplaincy was to be asked to make arrangements
for pastoral support should he be unable to attend church services.
Other arrangements involved ensuring that the prisoner did not suffer a loss in
pay simply because he was ill. The Kitchen agreed to adjust his meals as
required and his wing manager agreed to discuss with the Governor the
possibility of him being given a personal alarm if he was unable to reach his
cell call bell, and for a portable stereo system with relaxation tapes or compact
discs to be provided. In addition, it was agreed that a Critical Incident Debrief
would be held for staff and prisoners after the prisoner's death and
bereavement counselling would be available to anyone who desired it.
On 13 May, the Head of Health Care met with the prisoner to discuss his
health and his "will-of-life". The prisoner chose to move to G Wing as he
could have his own room with an en-suite shower. A Macmillan nurse visited
him on 18 June for assessment, and she asked for a special supporting
mattress and chair cushion to be provided.
On 12 July, the prisoner discussed pain relief with a member of Health Care
staff. He said that he had been resistant to taking it as he felt that he was
"giving in" to his illness. As a result of the discussion, however, he accepted
that analgesia was there to improve his quality of life and was not a
weakness.
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Events leading up to the prisoner's death
On 14 July, Stafford began the process to risk assess the prisoner for Release
on Temporary Licence (ROTL) due to his terminal illness. A Board was held
that day to consider whether it was appropriate to grant ROTL. As the
prisoner had been convicted of sexual offences, it was important that his risk
to the public be considered. The Board noted that he had no history of violent
response to confrontation and had no previous convictions. The risk
assessment form also noted that he had expressed regret and remorse for his
offences. The Board recommended that he should be released on temporary
licence to attend his hospital appointments (provided he was accompanied by
an officer) as he was extremely poorly, was at low risk of re-offending, had
received good reports from staff and had complied with prison discipline.
The prisoner attended hospital accompanied by one prison officer on 3, 4, and
5 August as part of his regular treatment. He was not handcuffed. On 6
August, he went to the hospital for a blood transfusion which started at
11.45am. At 4.30pm the hospital decided to keep him overnight for
observation. At 9.50am on 7 August, he was told by a doctor that he would be
remaining there for a few days.
At 7.50pm the prisoner was given oxygen. At 8.20pm, the escorting officer
contacted Stafford to say that the prisoner's condition was deteriorating
rapidly. Health Care staff contacted the prisoner' s son, who set out for the
hospital but his father died peacefully at 9.30pm.
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Issues considered during the investigation
My investigator obtained the prisoner's records and spoke to a number of staff
informally at Stafford. She also visited the last residential wing where the
prisoner had lived with a view to assessing whether the prison had met the
prisoner's needs and wishes before his death.
The prisoner had moved to G wing when it opened and benefited from being
in a cell by himself with his own shower. As noted, he had a special
supportive mattress and use of a wheelchair when he wanted one. Wing staff
spoke to my investigator about taking him outside in his wheelchair when he
was unable to walk and being familiar with his condition both through working
on his wing and also from having accompanied him on hospital appointments.
The prisoner had been provided with a small fridge to keep his protein health
drinks. Staff appeared to be responsive to his needs and spoke
knowledgeably about his life at Stafford.
Staff from other non-residential areas of the prison commented favourably on
the quality of care that officers showed the prisoner. This was evidenced by
his records which indicated that the departments whose work had an impact
on him were pro-active and adaptable in tailoring their work as appropriate,
without compromising on aspects of security or quality.
Catering department records showed that the prisoner had been treated as an
individual. Staff had discussed with the prisoner what foods he was able to
eat and in what quantity. He was given packed lunches rather than a hot
meal at a set time so that he could eat at a time that was convenient for him,
bearing in mind his frequent appointments out of the prison and his physical
discomfort. For example, he was given small meals and more digestible items
like packet soups and soft fruit.
As the prisoner had chosen to remain at Stafford, it is understandable that the
prison did not pursue the issue of release on compassionate grounds.
However, they did consider and grant ROTL when it became clear that the
prisoner was approaching the end of his life. This showed appropriate and
well-balanced judgement.
A clinical review was commissioned from South Western Staffordshire PCT
which concluded that the prisoner appeared to have received medical care
equivalent to that found in the wider community and that prison staff should be
commended for the quality of care they provided.
The prisoner's medical record was informative and updated regularly to an
excellent standard. The quality and frequency of the entries, particularly by
the Nurse and Head of Health Care were high and reflected care and
compassion in their dealings with the prisoner. Residential unit staff had
forged effective links with Health Care, who in turn consulted other
departments so that decisions affecting the prisoner were not made in
isolation. The prisoner himself was actively involved in decisions affecting his
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own health care. This no doubt made him feel valued and that staff were
considerate of his wishes.
Conclusions
The prisoner's family are in no doubt that he was treated with sensitivity and
that Stafford did all they could for him bearing in mind that he was suffering
from a terminal illness. I concur with their views. It is clear that Stafford's
care for the prisoner embraced the spirit of treating prisoners and their
families with respect, dignity and, above all, with humanity as individuals.
Staff demonstrated a true multi-disciplinary approach which did not depend on
financial resources but, rather, a willingness to work effectively. They have
provided a model example of the care terminally ill prisoners should be able to
expect no matter the type of prison they are in, or the offence they have
committed. These are facts of which the Governor and her staff can be proud.
I hope the knowledge that he could not have received more considerate care
will bring comfort to the prisoner's family as they come to terms with his death.
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Examples of Good Practice at Stafford
The prisoner was able to contribute towards the agenda of care meetings and
suggest which staff he wanted to attend. He was also able to become
involved in planning his own care when he was physically able to rather than
being a passive recipient. Moreover, staff respected and acted on his
decisions where appropriate.
Health Care staff maintained regular contact with his son so that he was
aware of developments in his father's condition.
Staff in all departments liaised to provide a comprehensive and holistic
approach to the prisoner's care and this was reflected in the quality of
information recorded about the prisoner and items he was allowed to have to
improve his quality of life.
Contingency plans were in place so that staff would know what to do should
the prisoner's condition deteriorate, especially when there was no night
medical cover.
The Disability Liaison Officer was involved in meetings concerning the
prisoner.
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