Individual at Stocken

Investigation into the circumstances surrounding the death
of a man in March 2008 at
Melton Mowbray Hospital while a prisoner at HMP Stocken
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2009
This is the report of an investigation into the circumstances surrounding the death from
cancer of a man, a life sentenced prisoner at HMP Stocken, in March 2008. He died in
Melton Mowbray Hospital. He had been ill for a little over six months before his death,
having first reported sick and complained of a sore throat on 3 September 2007. He
was treated regularly throughout the autumn months, both at Stocken and through
hospital outpatient appointments. The man was not always a compliant patient. He
often refused medical treatment at the prison, declined to attend outpatient
appointments and on more than one occasion threatened to discharge himself from
hospital if he was not returned to prison.
In January 2008, the man was admitted for three days to Leicester Royal Infirmary. I
have found it difficult to piece together precise details relating to subsequent spells in
hospital. Prison records show that he was transferred to hospital on several further
occasions and continuously from 9 February until he died. Details of transfers between
Leicester Royal Infirmary and Melton Mowbray Hospital are not clear. Prison records
refer to both hospitals and identify specific events in each, but not the dates of transfers
between hospitals.
The man was admitted to Melton Mowbray Hospital for the last time on in March and he
died peacefully there. He was 47 years old.
A doctor at Melton Mowbray Hospital issued a death certificate on 20 March, identifying
the cause of the man’s death as carcinoma of the larynx. There was no post mortem
examination.
An investigator carried out the investigation on my behalf. As part of his investigation
he commissioned a review of the man’s clinical management. I am grateful to the
clinical reviewer who carried out the review on behalf of the local NHS Trust. I
appreciate also the willing cooperation of the Governor and all staff at Stocken, notably
the Governor who acted as liaison officer. The clinical reviewer has found that doctors
and nurses in the prison did their best to help the man, notwithstanding his reluctance or
refusal to cooperate in his own treatment.
The man had no known family. He gave several different versions of his upbringing and
family connections. When asked about his family, although his explanations differed, he
said consistently that all contact had long since been lost and he did not want to try to
trace anyone who might know him. The visitors and correspondents he had in prison
were limited to those who dealt with his case as a life sentenced prisoner. To all intents
and purposes, prison staff were his only associates. Many staff from Stocken attended
his funeral.
Two prison officers were particularly concerned about the man. They told my
investigator that they were his only family and that they felt a need, over and above
official and pastoral care, to see that he was treated well, particularly in respect of his
deteriorating health. These officers were critical of nursing services at Stocken. They
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felt that the man should have been an in-patient at the prison at a much earlier stage in
his illness.
I conclude that the care given to the man , both inside and outside Stocken, was
appropriate and compassionate, consistent with his worsening illness and his reluctance
to allow medical staff to treat him. To all intents and purposes staff and prisoners at
Stocken were his only family. As this report makes clear, there was a real sense of loss
at his passing.
I make no recommendations.
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.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2009
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CONTENTS
Summary
The investigation
HMP Stocken
Events in the last six months before the man’s death
Issues considered
Conclusions
SUMMARY
The man was sentenced in July 1991 to life imprisonment for the murder of a man he
had met at an alcoholics recovery project centre. The judge set the minimum period
that he should serve in prison (known as the ‘tariff’) at 13 years. Although that period
had expired, the Parole Board assessed in 2007 (their fourth review of the man’s case)
that he should address areas of risk and complete further offending behaviour work
before they could recommend a transfer to an open prison with a date for release from
custody. The man had been at HMP Stocken since 2002.
My report shows that prison staff and prisoners were aware of the man’s general
problems. Although not difficult to manage, he could be stubborn, particularly in respect
of personal hygiene, medical treatment and compliance with voluntary drug testing or
offence related work. Refusal was often assessed as stubbornness because, when the
man complied with requirements, he was capable of producing good results. For
example, on the occasions he took drug tests, the results were always negative. His
main reason for refusing medical treatment centred on the fact that, if he were to be
admitted to a healthcare centre in prison, or a hospital outside, he would not be allowed
to smoke cigarettes.
The clinical reviewer’s clinical review shows that the quality of care and clinical records
at Stocken and Leicester Hospitals were of a high standard. He expresses surprise,
however, that a post mortem examination was not conducted.
Between reporting sick in September 2007 and his death from cancer in March 2008,
the man received in-patient treatment at Leicester Royal Infirmary and Melton Mowbray
Hospital. From early February 2008 he was in hospital continuously. Never an easy
patient and sometimes an acutely disruptive one, he did not make caring for him a
straightforward task. Prison healthcare staff and their discipline officer colleagues are to
be commended for their patience and kindness during this time. It could not have been
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easy for the man either, but staff never lost their sense of compassion or their
determination to do their best to care for him.
Notwithstanding the genuine and heartfelt comments of two officers who felt that
medical care for the man was poor, having examined the circumstances from all
perspectives, I conclude that care was appropriate during his relatively short terminal
illness.
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THE INVESTIGATION
1. My investigation opened in April 2008 when my investigator visited HMP
Stocken. He met the Governor and other senior staff and visited the area of the
prison where he had lived. He talked to staff and prisoners who had known him.
Two prison officers, both on sick leave, asked to see my investigator and he
visited them at their homes. They said that the standard of care given to the man
was poor; although they added that he would not help himself and usually
refused medical treatment.
2. Having regard to the comments made by the two officers, my investigator
examined in detail the standard of care the man received from the healthcare
centre, together with the level of communication between healthcare staff and
those on B wing, where he lived.
3. My investigator examined all documents which shed light on the man’s clinical
condition, his treatment and the degree to which he cooperated with it. He also
scrutinised other more general information relating to the man’s demeanour and
conditions on the prison wing where he lived.
4. My investigator considered the clinical reviewer’s clinical review. This documents
not only the difficulty doctors had in diagnosing the man’s illness, but also his
enduring refusal to engage in treatment. My investigator considered whether or
not, given the nature of the man’s illness, it would have been possible to have
located him in a prison healthcare centre, either in Stocken or at a prison with full
time in-patient facilities.
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HMP STOCKEN
5. Stocken opened in 1985 as a young offender establishment, converting later to
adult accommodation which holds medium to long-term prisoners, including
those serving a life sentence. The prison holds over 800 prisoners and at the
time of my investigation was undergoing its fifth stage of expansion.
6. Nurses provide healthcare in the prison between 7.30am and 5.30pm Monday to
Friday, and between 8.00am and 5.00pm at weekends. Doctors are available for
three hours each day from Monday to Friday.
7. The most recent report published by the Stocken Independent Monitoring Board
(IMB) said that healthcare in the prison continued to raise concern. The IMB
were particularly worried that a difficulty in finding staff for escort duties meant
prisoners were being denied access to the NHS.
8. Two days before the death of the man, another prisoner at Stocken died. There
had been three previous deaths at Stocken since I was given responsibility for
investigating all deaths in prison custody in 2004. All the deaths at Stocken have
been from natural causes. In three of my investigation reports I have praised the
prison’s sensitive approach to the question of applying restraints to terminally ill
prisoners.
9. HM Chief Inspector of Prisons noted in her report of an inspection in 2008 that
the prison had been undergoing continuous expansion for a number of years and
that the ‘extensive building work continued to blight the environment’. She
concluded, nevertheless, that there had been significant improvements since her
last visit. Stocken remained a safe prison which had made good progress,
particularly in the quality and quantity of purposeful activity for prisoners.
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EVENTS IN THE LAST SIX MONTHS BEFORE THE MAN’S DEATH
Healthcare records
10. The man had been continuously in prison for some 18 years before his death and
there is a wealth of information in the files relating to his health. I have examined
in depth the last six months of his life and I mention earlier events only where
necessary to provide context to my report.
11. The man first reported sick with a sore throat on 3 September 2007 and was
prescribed painkillers. A surgery doctor saw him just over two weeks later (19
September) when he complained of a migraine. This consultation did not
mention his sore throat.
12. On 12 October, the man had a cold which he said had lasted a few weeks. He
said also that his appetite was poor and he had lost weight. He did not go to his
next consultation with the surgery doctor on 17 October, but did attend another
appointment on 7 November. The surgery doctor recorded a sore throat,
difficulty in swallowing and blood stained mucus. He noted that the man had a
red and swollen throat. He prescribed erythromycin suspension as the man
reported difficulty swallowing. He advised a further review if his condition did not
improve.
13. A Nurse recorded weight loss, vomiting and a continuing sore throat on 23
November. She organised a number of blood tests and a review by the doctor.
The blood tests revealed normal haemoglobin and acceptable values for renal
and liver function. A second surgery doctor, who saw the man the same day,
also reported haematuria (blood in urine). The second surgery doctor expressed
concern at the spectrum of symptoms, particularly his weight loss.
14. A review by the surgery doctor on 30 November revealed worsening symptoms
including cachexia, fetor (smelly breath) and dehydration. He advised
emergency admission to an acute hospital. There are separate records
recording the man’s refusal to go to hospital. The prison’s mental health in-reach
team became involved to monitor and support him during this episode. A review
a week later by a third surgery doctor documented a discussion with the man
during which the doctor told him that he should have agreed to go to hospital. An
x-ray and sputum sample was sent off.
15. The third surgery doctor reviewed the man’s case on 10 December. His chest x-
ray was clear and ‘watchful waiting’ was advised. The in-reach team continued
to review his condition. On 21 December, the man was assessed by a fourth
surgery doctor who noted poor air entry to the lungs and referred him on a ‘two
week wait’ to chest physicians with a view to a scan and sputum tests.
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16. On 2 January 2008, a worker from the in-reach team recorded worsening
personal hygiene and reports from wing staff that the man was giving his food
away. He had stopped going to work. Between 3 and 17 January, his physical
deterioration was documented including on-going sore throat, altered voice,
clinical dehydration and malaise. The in-reach team worker also documented the
concerns raised by other prisoners about his physical condition. A review on 24
January by the surgery doctor revealed significant deterioration and he too
advised hospital admission. The man initially refused and discussions took place
to try and arrange transfer to a prison with 24 hour healthcare facilities, but
eventually he consented to go to hospital.
17. The man was admitted to Ward 23 of Leicester Royal Infirmary on 25 January.
The only recorded positive finding was H. pylori infection of the stomach. He was
started on triple therapy and an Ear Nose and Throat (ENT) referral was advised.
From 25 to 27 January, a hospital nurse recorded several conversations with
doctors and nurses involved with the man’s care. She documented her opinion
that his return to Stocken was not appropriate. However, HMP Leicester had
refused to take on his care so he had returned to Stocken. Further deterioration
was recorded from 27 January to 6 February. During this time, the in-reach team
worker recorded several entries about attempts to arrange alternative prison
healthcare.
18. There were several medical record entries on 8 February. The man’s weight had
decreased to 59.4 kg (a loss of 10 kg in seven days). He was unable to swallow
and he collapsed later that day. The forensic psychiatrist assessed the extent
that his mental state was affecting his physical health and recorded his
worsening condition. She sent an email to the local Primary Care Trust urgently
seeking care elsewhere. The man again initially refused to go to hospital and
said that this was because he would be ‘unable to smoke’. He maintained that
he would commit suicide if he was forced to go to hospital. However, he
eventually consented and was admitted to Leicester Royal Infirmary’s Acute
Medical Unit via the Accident and Emergency Department.
19. During admission the man was treated with antibiotics for a working diagnosis of
tuberculosis. Two quantiferon tests were positive. His refusal to accept
intravenous antibiotics and tests including videofluoroscopy (a test which looks
closely at a person’s swallowing process) and nasopharyngolaryngoscopy (a test
examining the person’s airways) were recorded. Staff also recorded that his
behaviour was disruptive, including urinating next to his bed and spitting onto it
bed. He threatened to discharge himself on two occasions.
20. Ongoing dialogue between Stocken, the hospital and other prisons was recorded
between 16 and 20 February outlining the fact that healthcare at Stocken thought
that his return there was not appropriate. Discussions continued to find suitable
accommodation for the man and the prison liaison officer visited him in hospital.
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He agreed to move, following discharge from hospital, to HMP Leicester’s
healthcare centre.
21. The man left Leicester Royal Infirmary on 21 February but, after a night in the
healthcare centre at HMP Gartree en route to Leicester prison, he was again
admitted to an NHS hospital, this time at Melton Mowbray. Although prison
officers were present throughout, he was not handcuffed or placed under any
other restraint. A senior manager from Stocken, usually a governor or nursing
grade, visited each day, sometimes more than once.
22. Following support and persuasion by the Clinical Manager at Stocken, a flexible
laryngoscopy was finally performed at Melton Mowbray Hospital on 27 February
2008. This revealed a ‘large’ laryngeal tumour, a terminal diagnosis. The man
was transferred to Leicester Royal Infirmary on 4 March for a PEG (percutaneous
endoscopic gastrostomy) feed, a surgical procedure for inserting a feeding tube
without having to perform an open laparotomy (operation on the abdomen).
23. On 17 March, a doctor from the Health Protection Agency confirmed from the
sputum specimen that the man had non-infectious tuberculosis. He continued to
be disruptive. He spat and urinated inappropriately on the wards and, on one
occasion, removed the PEG feed. The ENT specialist, considered that active
treatment was no longer possible.
24. Following limited success with his toleration of the PEG feed, he was transferred
from Leicester Royal Infirmary to Melton Mowbray Hospital on 18 March. Over
the course of the next three days his overall health continued to deteriorate, and
he died peacefully from the effects of his cancer in March.
Wing records and information from staff
25. Wing records show that on 17 October 2007 staff thought that the man was
giving away his food in exchange for cigarettes. An officer sent a report to a
worker at the healthcare centre expressing her concerns. On 4 December, wing
staff again noted their concerns and said that the man should not stay on an
ordinary residential wing. On 19 January 2008, the officer yet again recorded her
worries about him. She said that he was being cared for by wing staff and other
prisoners. The wing records also document the man’s refusal to go to hospital
and the difficulty persuading him to accept medical treatment.
26. Two officers told my investigator in interview that they were dismayed at what
they perceived to be the poor treatment given to the man by healthcare staff at
Stocken. They were concerned and distressed at his deteriorating condition, not
only for his own sake but also for that of staff who had to manage him and for
other prisoners with whom he shared communal eating and hygiene
arrangements. It is clear that those two officers thought that not enough was
being done for him.
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27. However, wing records also show that healthcare staff arranged many
consultations and clinical tests. Staff tried to persuade him to go to an outside
hospital and actively sought a transfer, as an alternative, to a prison hospital with
appropriate facilities. The B wing occurrence book shows that healthcare centre
staff were doing their best in the face of the man’s refusal to go to hospital. They
also communicated well with the wing staff. A note made on 23 November 2007
in the occurrence book reads, ‘Healthcare Centre would like us to continue to
monitor the man as we have been. They appreciate the input from the wing and
agree that he seems to have deteriorated. He will see the doctor again this
week.’
28. Other notes from the occurrence book and from the man’s wing file record his
‘point blank’ refusals to go to hospital, and the many attempts made by prison
officers and healthcare staff to get him to change his mind. Entries also show
that healthcare and wing staff worked together to try to arrange the best possible
care. An entry on 5 December shows that ‘a care plan has been put in place’.
On 11 December, an entry shows that healthcare staff arranged extra food for
him. A further entry on 24 January 2008 shows that the man was too ill to attend
his healthcare appointment. A doctor came to see him on B wing but ‘he told her
he would not go to outside hospital’ and swore at her.
Events following the man’s death
29. The man died peacefully in March. Following his death, the Governor published
notices for the information of staff and prisoners. He also made the funeral
arrangements and paid the costs. In the absence of any family, the Governor,
Head of Residence, Family Liaison Officer, Head of Healthcare and members of
staff from the wings attended the funeral, held at Gilrose Crematorium in
Leicester. At the same time as the funeral service, the prison chaplain held a
service at the prison which was attended by both prisoners and staff. Those who
had attended the funeral brought the flowers, paid for by prisoners and staff, from
the service and arranged them in Stocken’s chapel. The chaplain later held a
memorial service at the prison.
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ISSUES CONSIDERED
Clinical care
30. The clinical reviewer conducted a clinical review of the man’s treatment in
Stocken and in outside NHS facilities. The clinical reviewer has wide experience
as a general practitioner and as a prison medical officer. His review appears in
full as Annex 1 to my report.
31. In brief, the clinical reviewer’s comments particularly concern the availability of
prison healthcare units and wing staff assessments of whether they are able to
care for seriously ill prisoners. He believes that wing staff could influence the
transfer of prisoners from a prison which is unable to provide care to one which
has better facilities. He says, however, that in this case ‘access to healthcare
was made by appropriate clinicians. For this reason I do not feel there are any
issues relating to the process of heath care at HMP Stocken.’
32. The clinical reviewer emphasises the importance of communication between
healthcare professionals and their prison officer colleagues. He considers that it
would have been beneficial for a decision about the man’s mental capacity to
have been clearly communicated to the prison officers on the wing. Having said
that, the clinical reviewer is satisfied that the man was capable of refusing active
consent to medical intervention, however unwise his decisions may have been.
33. The clinical reviewer concludes that the quality of medical care and record
keeping was consistent with the standards provided within a typical doctor’s
surgery. He also judges that earlier investigation of the man’s illness did not
occur because of his refusal to consent to treatment and does not reflect on the
level of care provided at Stocken.
Compassionate release
34. HMP Stocken did not consider recommending that the man be released from
custody on compassionate grounds during the later stage of his illness. I think
that this was appropriate. The terminal diagnosis was only made in February
and he was in hospital until his death, some 22 days later. He had nowhere to
go outside prison and I am satisfied that the care given to him by both NHS and
prison staff was what he needed in the circumstances.
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CONCLUSIONS
35. In the six months between the onset of the man’s illness and his death, prison
wing staff, healthcare staff and professionals in the wider NHS did all that they
could to get him to cooperate fully with his treatment. He usually refused and, on
the occasions he accepted treatment, did so on his own terms, making it difficult
for those administering care to do so comprehensively. He often disrupted the
process or made threats to harm himself if he could not have his own way.
36. I cannot say whether, by the time symptoms of his illness were manifest, earlier
admission to hospital, together with his full cooperation, would have prolonged or
even saved the man’s life. No doubt he had his reasons, and those who treated
his condition had to do the best with how he presented as a patient.
37. This investigation draws attention to the extent to which prison staff and fellow
prisoners become a surrogate family for those prisoners who have lost touch with
any blood relatives. Aside from this sad but revealing insight, I have no other
conclusions or recommendations to make.
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