Individual at Swaleside

Investigation into the circumstances surrounding the
death of a man
at HMP Swaleside in December 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2011
1
This is the report of an investigation into the circumstances of the death of a
man on in December 2009 at HMP Swaleside. He was 59 years old when he
died and had been ill for some time before his death.
I would like to offer my condolences to his family and to all those touched by
his death. I apologise for the delay in the production of this report, and for any
additional distress this might have caused. I would also like to thank his
family for their contribution to the investigation under the most distressing of
circumstances and their patience in waiting for my report.
The investigation was undertaken by my colleague. Both he and I would like
to thank the management and staff at HMP Swaleside. In particular, I thank
the Governor of Swaleside and the Senior Officer, who acted as liaison
officer, for their cooperation during the course of my enquiries. I am also
grateful to the clinical reviewer who was commissioned by the local Primary
Care Trust (PCT) to review his medical care whilst he was in prison.
He was found dead in his cell in the morning in December 2009. He had
been treated for pancreatic cancer since February 2008 and, in August 2008,
had his pancreas and spleen removed following the discovery of a tumour.
He remained very independent, taking responsibility for administering his own
medication as far as possible and choosing not to move to healthcare but to
remain on the wing. In the days before his death, staff on his wing noticed
that he seemed to be deteriorating, but he refused a medical assessment.
When he was found unresponsive in his cell, staff and paramedics attempted
to resuscitate him but were unsuccessful.
I make two recommendations as a result of this investigation. They relate to
sharing concerns about prisoners and going into cells at night.
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.
Thea Walton
Acting Deputy Prisons and Probation Ombudsman
October 2011
2
CONTENTS
Summary
The investigation process
HMP Swaleside
Key events
Issues
Conclusion
Family response to the report
Recommendations
3
SUMMARY
The man was found dead in his cell at HMP Swaleside in December 2009.
He had been diagnosed with chronic pancreatitis in March 2008 and his
pancreas and spleen were removed in August 2008 after a tumour was found.
The removal of his spleen meant that he became diabetic and totally
dependant on insulin and penicillin therapy.
In August 2009, he attended hospital for a scan. Something showed on his
scan, and he was told that it was likely that the cancer had returned. He was
both upset and angry that he had been given conflicting information about his
life expectancy. He was originally told that he had up to two years to live but,
in late August, he was told by doctors that his life expectancy was now only
six months.
In December 2009, staff noticed that his condition had started to deteriorate.
As prison staff were checking prisoners prior to unlocking cells, he was found
lying on the floor of his cell. There was a delay before staff went into the cell,
but when they did so, they did not find any signs of life and started to
resuscitate him. The paramedics arrived shortly afterwards and declared that
he had died.
I make two recommendations as a result of this investigation. These relate to
sharing concerns about prisoners and going into cells at night.
4
THE INVESTIGATION PROCESS
1. This office was notified of his death on 20 December 2009. An
investigator was appointed to lead the investigation. Notices were issued
to staff and prisoners at Swaleside informing them that an investigation
would be taking place and inviting those who wished to see the
investigator to make themselves known. No prisoners came forward to
speak to the investigator.
2. He opened the investigation on 5 January 2009. He spoke with various
members of staff, and asked for copies of the man’s full prison records
including medical records, wing sheets, security information, hospital bed
watch logs and the family liaison log. (A bed watch log is a history,
recorded by escort officers, of events while a prisoner is an in patient at
hospital outside the prison.) A Senior Officer was appointed as the
investigator’s liaison officer. He visited Swaleside again on 30 March and
28 June. On 22 July, he returned to interview an officer who had been off
work following the man’s death.
3. The investigator also contacted HM Coroner for Mid Kent to advise him of
the nature and scope of the investigation and to ask for a copy of the post
mortem report.
4. An independent clinical review of the care provided for the man was
commissioned from the local PCT. They appointed a clinical reviewer to
conduct a review. The investigator received the review in June 2010.
5. One of the Ombudsman’s family liaison officers contacted several
members of the man’s family to explain the purpose of my investigation
and invite them to raise any questions or concerns to be considered. The
investigator and, in the first family liaison officer’s absence, another of my
family liaison officers met with members of the family on 16 March 2010.
The family have raised the following matters of concern:
.
(cid:127) They wanted to know more detail about the night he died, and in
particular whether he was found on the floor of his cell or on his
bed.
(cid:127) The family had been told that he had fallen over a number of
times on the wing.
(cid:127) The family wanted to know whether healthcare staff had regular
liaison with wing staff concerning the management of his illness.
(cid:127) They wondered whether wing staff could have spotted his
deterioration.
(cid:127) The family are worried that he was too weak to press his cell
bell.
5
(cid:127) The family wanted to know why he was not checked overnight
more often.
(cid:127) The family wanted to speak to other prisoners at his memorial
service but the prisoners were taken back to Swaleside before
they had the opportunity to do so.
(cid:127) The family expressed concern whether his in possession
medication was monitored effectively to ensure that he was
taking it.
(cid:127) The family also wanted information about his pain management
plan, and asked whether he was capable of making his own
decisions and how much he understood about his illness.
(cid:127) They also asked whether his illness could have been managed
better at home or hospital?
(cid:127) The family were concerned that they did not have access to a
letter of 7 September 2009 from a doctor, and why were they not
consulted about his treatment plan.
(cid:127) Could the family have be offered more visiting time?
(cid:127) Why, when he was in hospital, was he handcuffed in public
areas but not handcuffed in his own room?
(cid:127) The family have been told that there was a possibility that he
could be released on compassionate grounds, given his terminal
illness, and be provided a place in a hospice. This did not
happen and they question what consideration was given to
releasing him on compassionate grounds.
I hope that the findings of my investigation address the family issues
and help them to better understand the circumstances of his death.
Family response to the draft report
6. The family received a copy of my draft report as part of the consultation
process. Their comments in response to the investigation findings are
reflected on page 24.
6
HMP SWALESIDE
7. HMP Swaleside opened in 1988 and is one of three prisons on the Isle of
Sheppey which, along with HMP Elmley and HMP Stanford Hill, are known
as the Sheppey cluster. The cluster is managed by a chief executive.
8. HMP Swaleside is a category B prison holding convicted men aged 21 and
over. Prisoners are categorised A, B, C and D according to the
seriousness of their offence and the risk posed to the public should they
escape. Category A prisons hold the most dangerous prisoners with
category D being the least secure and generally known as open prisons.
The man was assessed as a category B prisoner which means that the
potential for him to escape must be made very difficult.
9. Swaleside has the capacity to hold 951 prisoners. All the prisoners are
serving four or more years with around half the population serving life
sentences.
10. The local Primary Care Trust is responsible for commissioning healthcare
services at Swaleside. The prison has a healthcare unit with 18 beds and
provides a general practitioner service every weekday between 8.00am
and 5.00pm, with out of hours service cover provided by the local NHS.
The prison healthcare unit provides clinics for diabetes, cardiac conditions,
physiotherapy, dental health and hepatitis C.
11. In the most recent Ministry of Justice quarterly ratings for prison
performance, the Sheppey cluster of prisons was assessed as “good
performing”.
Independent Monitoring Board
12. All prisons in England and Wales have an Independent Monitoring Board
(IMB). The IMB is made up of local people who volunteer to visit the
prison and deal with a range of issues including prisoner complaints,
commenting on the prison regime, the standard of healthcare and issues
that affect security. IMB members have full access to the prison and
prisoners. Each IMB is required to publish an annual report.
13. The latest published report for the IMB at Swaleside covered the period
between May 2008 and April 2009. They reported that the refurbishment
of the healthcare centre was complete. Plans for telemedicine were at an
advanced stage, which would allow for speedier consultations via the
internet and reduce the need for bedwatch escorts and the use of
restraints. The IMB also noted that prisoners were represented on a
consultative committee, which had improved communication between the
wings and healthcare.
HM Inspectorate of Prisons
7
14. The prison is also subject to inspection by HM Inspectorate of Prisons.
Following the last inspection in 2008, inspectors made the following
judgement on the healthcare services provided at Swaleside:
“Health services offered prisoners access to a broad range of
clinical specialisms in the prison and through external NHS
sources. The management of long-term illnesses was good, as
was the GP service. Dental services did not meet the needs of
prisoners, and the lengthy waiting lists would grow with the increase
in prisoner numbers. Relationships with the primary care trust were
developing well, and the healthcare team benefited from the strong
support of the governor. Despite the positive aspects, prisoners
were extremely dissatisfied with perceived poor attitudes by
healthcare staff, who they claimed denied them access to some
services.”
15. In her foreword, the then Chief Inspector also noted that staff-prisoner
relationships were “a particular strength”.
Previous deaths in custody
16. There have been 19 deaths at Swaleside since 2004 when the
Ombudsman was given responsibility for investigating all deaths in prison
custody. Of these, there are none with similar circumstances to those in
this investigation.
8
KEY EVENTS
2006- 2008
17. The man appeared at Crown Court in February 2006 and was sentenced
to life imprisonment under the terms of Imprisonment for Public Protection
(IPP) legislation. (IPP means that offenders can be sentenced to life but
must have a minimum period of imprisonment specified at the time of
sentence, which is known as the tariff. Prisoners can be considered for
release once the tariff period has been served. His tariff was three years
and six months.) He served the early stages of his sentence at HMP
Parkhurst and transferred to HMP Swaleside in July 2006.
18. At reception into Swaleside, he was seen by healthcare staff and
considered to be to be fit for normal location and work within the prison.
Apart from an eye check and a prescription for lenses, he had very little
contact with healthcare in the early stages of his sentence at Swaleside.
19. On 1 February 2008, he was seen by healthcare staff. He complained of
having yellowness to the skin, clubbing of the fingers (this deformity of the
fingers is often associated with cancer) and weight loss.
20. He was immediately referred to hospital and admitted with a diagnosis of
obstructive jaundice (usually caused by an interruption to the draining of
bile). On 12 February, his symptoms were discussed at a multi
disciplinary conference which noted that there was an abnormality to the
head of the pancreas. A decision was made to investigate further. The
procedure was booked for 15 February, but this did not take place. The
clinical reviewer notes in her clinical review that the medical record does
not explain why the procedure did not take place, although it is recorded
that he had a stent (an artificial tube) inserted temporarily to relieve an
obstruction in the bile duct to relieve the jaundice.
21. On 19 February, following a medical conference, he was referred to liver
and pancreatic specialists at the hospital. A week later, on 26 February,
the hospital reported that his symptoms were consistent with chronic
pancreatitis. This diagnosis was accepted and he was given an outpatient
appointment to be reviewed in May.
22. He met Nurse A at Swaleside, on 4 March. Her role was to lead his
palliative care (a form of medical care used to reduce the severity of a
patients symptoms) in the prison. She was interviewed by the investigator
and clinical reviewer and she said that he understood the possibility of
cancer and did not seem unduly anxious. She also commented that he did
not appear to have any pain at that stage apart from occasional mild
discomfort.
23. On the same day, Prison Doctor A wrote in his medical record that he had
received a telephone call from a doctor at the hospital. The hospital doctor
told him that the results had come back from the man’s biopsy which
9
showed that he had chronic pancreatitis (long standing inflammation of the
pancreas) and not cancer.
24. He was taken to hospital on 29 March with increased abdominal pain. His
chest and abdomen were x rayed and blood tests taken, after which he
was returned to prison with further pain relief medication. The consultant
who saw him became suspicious that his symptoms could be the result of
cancer and he was referred back to hospital. He was admitted to hospital
again on 30 April with a recurrence of jaundice and once more medical
staff discussed transferring him to hospital for surgery to relieve the
obstruction.
25. On 7 June, he was admitted to hospital. He stayed for 24 hours and had a
range of tests done. The next day, 25 June, he was readmitted for a
diagnostic laparoscopy (an operation using a camera to inspect or
diagnose a condition) and biopsy (a medical test where cell or tissue are
removed for examination). A tumour on the head of the pancreas was
detected and he was booked for surgery on 6 August to remove the
tumour and perform a total pancreatectomy (the surgical removal of the
pancreas).
26. His operation went ahead on 6 August and during the operation his spleen
was also removed. The removal of his pancreas meant that he became
diabetic and totally dependant on insulin maintenance. He received a
number of immunisations to protect him from infection, which is normal
procedure for patients without a spleen. He was advised that he should
have life long penicillin therapy to help avoid infection. He was referred to
the oncology department for consideration for chemotherapy.
27. He returned to prison on 20 August. Whilst in transit to Swaleside, he told
escort staff that he did not want to be admitted to healthcare. On arrival at
prison reception, he signed a disclaimer refusing admission to healthcare.
Healthcare staff assessed him and decided that they had no concerns
about him and that he could return to his wing.
28. While he was still in hospital, he had been given instructions about self
administration of his insulin and how to test his blood glucose levels. He
was prescribed a variety of medication and nutritional supplements to
assist his recovery. Nurse A assessed him once on the wing and advised
him how to manage any discomfort such as changing his position regularly
when he was seated or lying down. She also spoke to the prison kitchens
to ensure that he was given a supply of custard, which he felt he could eat
as his diet was limited at that time.
29. On 8 September, he was referred to a specialist diabetic nurse, as his
blood sugar level was high. He was visited by a dietician who arranged for
his milk allowance to be increased and for glucose and Hypostop (a
formula to address low glucose levels) to be available on the wing. The
nurse again asked him if he would consider moving to healthcare, but he
refused.
10
30. She introduced him to Nurse B, a specialist palliative care nurse, on 9
September. She had more specialist knowledge to advise and assist him
to manage his condition. Nurse A was also concerned to offer emotional
and psychological support and referred him to the specialist diabetic
nurse, who saw him the next day and altered his insulin regime.
31. Later that month, he experienced breakthrough pain and at this time his
medication was increased by Nurse B. He was visited by the diabetic
specialist nurse on 19 September and his insulin was adjusted.
32. An appointment was made for him to see a consultant oncologist (cancer
specialist) on 24 September. He was given a course of chemotherapy.
Medical records from this time show that staff saw him regularly, noting his
appointments with the oncologist and also monitoring his temperature.
33. Wing records from this time show uniform staff making regular entries in
the wing observation book about him. The entries highlight positive
interaction between him and wing staff. He is also recorded as mixing well
with other prisoners as well as working on the wing.
2009
34. On 26 January, he expressed his displeasure to Nurse A about the
frequency with which his hospital appointments were rearranged, which he
said was often at short notice. (The clinical reviewer, in her clinical review,
notes that this was usually because the hospital had rearranged the
appointment although this, in turn, caused difficulty for the prison in
arranging escorts.) The nurse offered him counselling, which he refused.
35. Further positive entries by wing staff show a good level of continued
interaction with him. For instance, on 22 February, Officer A wrote:
“The man went to outside hospital this week. He is coping well and
has received many positive comments from staff he has interacted
with.“
36. Officer B introduced herself as his new personal officer on 4 April. They
developed a good relationship and she wrote in his personal record that he
was starting to open up and talk to her.
37. On 1 June, wing staff asked healthcare staff to review him as he had not
come out of his cell that morning. He was seen later that day by Nurse A.
He denied having any new problems and said that he was not a “morning
person”. However, it was noted that he was becoming less willing to
engage with staff, and would sometimes refuse to have his temperature
taken.
11
38. Wing observations of him over this period remained positive. He
continued to work in the prison laundry and as a cleaner and comments
made about him describe his general cooperation and politeness.
39. In August, he attended hospital for a scan. He was told that something
was shown on his scan and the assumption was that his cancer had
returned. (The clinical reviewer could not find a letter confirming this in his
medical records.)
40. On 9 August, Officer C wrote in his personal record that he had received
some medical news which he had not expected. He noted that he had
decided to delay making a parole application for three months until he
received his results from the hospital.
41. He attended hospital on 28 August. He was told that his life expectancy
was now six months, despite being told at a previous hospital that his life
expectancy was about two years. He discussed this with Officer C on a
number of occasions over the following weeks. On 20 September, she
wrote in his personal record that his parole application had been rejected.
He decided to write to his home area probation officer with the new
information about his life expectancy to see if he could appeal against the
Parole Board’s decision.
42. In September, he also started another course of chemotherapy which
involved a regime of taking tablets and weekly hospital visits. He took his
medication regularly and, although the medication was prescribed to be
taken twice a day, he preferred to take all of his medication in the morning.
He also attended hospital as required.
43. On 7 September, he attended healthcare for blood tests and was seen by
Senior Healthcare Officer (SHO) A. The SHO said in interview that it was
not possible to take blood as his veins “had all been used in previous
blood tests”. However, he did have a conversation with him which he
recorded in his medical record, noting that he said that he did not want to
die in prison and hoped that he could apply for “compassionate discharge
grounds”.
44. His pain continued to be well managed, although on 19 October he did not
receive all of his pain relief medication at the usual time as there had been
a delay delivering medication to the prison. Staff responded by arranging
for a delivery in the evening. This delay caused him some discomfort and
upset his management of his pain. His prescription was written up as a
dose twice daily and staff delivering the medication would not have known
about his preference to take his daily medication in the morning.
45. On 17 October, Officer C wrote in his personal record that she had spoken
to a representative of the Parole Board on his behalf. She was told that
his letter concerning parole appeal had been received and he would
receive a written response within two weeks. No response had been
received by 31 October and she emailed the Parole Board for a reply. He
12
sought the help of his solicitor in December because he was unhappy at
the lack of a response.
46. On 10 December, he reported that he was experiencing dizziness. He
was seen by both nurses, who asked wing staff to observe him. They also
advised him to monitor his blood glucose levels more closely. On 13
December, wing staff noticed that he had not come out of his cell and was
not eating much. When checked, he told the staff that he wanted to be left
alone. He was offered admission to the healthcare centre but again
refused and instead he was checked regularly over the next three days by
wing staff.
47. Later that week, on 17 December, wing staff noticed that he had not
washed or shaved and he remained in bed in his single cell. Nurse A
came to the wing and wrote in his medical record that he looked a little
grey and was unwilling to engage with her. She visited later that day with
a doctor, but he refused to be seen by the doctor and so a medical
assessment could not be undertaken.
48. On the same day, Officer C wrote in his record that he now spent most of
his time in bed and other prisoners collected his meals for him. She also
wrote that she believed he was deteriorating fast and spending too much
time on his own. She completed her entry by noting that “we are still
waiting for a decision from the Parole Board”.
19 December
49. On 19 December, Nurse C went to his cell to deliver his medication. He
noted that he did not want to engage in conversation. Later that day,
Officer D wrote in his note book that, while he was helping to lock up the
wing, he went into his cell and saw that he was in bed. He wrote that he
noted nothing out of the ordinary during his check.
50. The same day, Officer B wrote in her note book that she spoke to him
when she unlocked his cell. She also allowed a prisoner who was friendly
with him into his cell at 5.00pm to deliver some food to him. At 5.10pm,
she checked him again and wrote in her notebook that he was in bed, lying
on his back with his duvet over him.
20 December
51. On 20 December at 6.20am, Officer Support Grade (OSG) A was
undertaking checks on prisoners as he was coming to the end of his shift.
(OSGs are prison staff who do not have direct face to face supervisory
contact with prisoners. They are used in a support capacity to escort
prison visitors, contractors and to carry out patrols when prisoners are
locked in their cells.) He went to the man’s cell and opened the
observation flap which allows staff to look inside. He looked into the cell
and saw him on the floor. He put the cell lights on and banged the flap
window with his torch to make a noise. He thought that he saw him move
13
in response to the disturbance. He then carried on with his checks and
prepared to handover to the day shift.
52. At 7.00am, Officer E, who had just come on duty, started his routine roll
checks. He went to the man’s cell and opened the flap to look inside. He
saw him lying naked on the floor. The officer started to knock on the cell
door, then kicked it and shouted to him. There was no response. He
returned to the office and asked the OSG to return to the cell and continue
to try to get a response from him. He then called Operations (the
communications control for the prison) and Oscar 1 (the person
responsible for running the prison at that time) who was the Acting Senior
Officer (ASO) to alert him to the man’s condition. The ASO had just
escorted the night staff from the prison and was making his way back to
the main prison. A number of other officers were also instructed to make
their way to the cell.
53. The ASO instructed Officer F to go to the healthcare wing to collect the
duty nurse. He then made his way to the man’s wing. He made notes
later that morning and he recorded the time that he arrived at the cell
between 7.15am and 7.18am, when he opened the cell door with two
officers. Officer G, who arrived at the same time, went into the cell to
check him for signs of life. He described him as lying naked on the cell
floor. He tried to find a pulse, but did not have any success. He then
covered the lower half of his body.
54. At 7.20am, Nurse C arrived at the cell with a defibrillator (a defibrillator is
machine which can detect electrical activity in the heart and uses electric
shocks to restore an abnormal rhythm) and attempted to administer CPR
(cardio pulmonary resuscitation). The nurse could not deliver effective
breaths because the man’s mouth was tightly shut. He then set up the
defibrillator, which advised that no shock should be delivered to stimulate
his heart but that chest compressions should continue. The nurse
continued to do so until the paramedics arrived at 7.44am. The
paramedics went into the cell and, after conducting a number of checks,
they declared that he had died.
55. Staff who attended when the man was discovered, and during the
emergency response which followed, were invited to attend a hot debrief
meeting. (The purpose of a hot debrief is to clarify what happened,
support those involved and identify immediate issues and learning.) Some
staff did not take part in the debrief as they had completed their shift and
left the prison. All the staff who were interviewed commented that they
were aware of who they could approach in the prison should they need
assistance.
56. The man’s sister was contacted by the prison’s family liaison officer by
telephone to inform her that he had passed away. He rang her a second
time later that morning. She told him that she would take responsibility for
informing the rest of the family.
14
57. Prisoners at HMP Swaleside were informed of the death through notices
placed on the wings. Staff were also informed by way of a notice, and
some staff received telephone calls to their home or to their prison
location.
58. The post-mortem into the death was opened on 29 December 2009. The
initial findings are that he died from natural causes caused by
carcinomatosis (cancer) of the Pancreas.
59. His funeral was held on 21 January and I understand that the prison
contributed to the costs of the funeral.
15
ISSUES
Clinical care
60. The clinical reviewer, in her clinical review, has included several
comments on the standard of care provided for the man at Swaleside.
She notes that his cancer was diagnosed at a very early stage, which
enabled a surgical intervention to take place. This is not a common
outcome for someone diagnosed with pancreatic cancer, which is often
detected at a late stage.
61. He seems to have been determined to keep his independence for as long
as possible. He managed to control his insulin levels by injecting himself,
and his insulin was kept in a fridge on the wing. Healthcare staff visited
him every day to ensure that he received his pain relief medication. This
arrangement only appears to have broken down on one occasion, on 19
October 2009. He also complained once that he was running out of insulin
needles. I believe that these were exceptions, and that the standard of
care provided to him was generally good.
62. I am also pleased to note that, while staff respected his wish to remain on
the wing or move as an inpatient to healthcare, he was regularly asked
whether he wanted to change his mind. His answers suggest that he was
happy with the way he was cared for on the wing and that he felt that this
was the best place for him.
63. She notes that there were, on occasions, problems with his attendance at
hospital appointments (indeed, he complained to Nurse A about this on 29
January 2009). She comments that “this required good liaison with the
appointments system in the hospital and good planning on the part of the
prison”. She attributes the breakdown of planned appointments to the
hospital changing them at short notice. I accept this, and therefore do not
make a recommendation on this subject, but suggest that the Head of
Healthcare may wish to raise this subject with colleagues at the hospital to
see how a repeat of events might be avoided. In not making a
recommendation, I also note that Swaleside are planning to make greater
use of teleconferencing for medical appointments, which will also help to
address this issue.
Liaison between wing staff and healthcare
64. In her clinical review, she comments that he was “fiercely independent and
determined to manage his own health within his own terms”. She has also
commented in her report that he mastered the skills of self administering
insulin and remained in control of his own medication throughout his
illness. He was capable of making decisions for himself and there were no
grounds for healthcare staff or others to override his wishes.
16
65. The family have also asked my investigator to ascertain whether he had a
number of falls on his wing. There is no evidence that he suffered any
falls whilst at Swaleside.
66. Having considered the content of my interviews with medical and wing
staff, I am satisfied that there is good evidence of consistent and helpful
liaison between both groups of staff. Medical matters are confidential
between the patient and their healthcare professionals, such as doctors
and nurses. Wing staff, who are not healthcare professionals, do not
routinely have access to medical records or any other medical matter such
as a diagnosis or treatment. However, in practice, wing staff often learn a
great deal about a prisoner’s condition, for example, by providing the
escort to hospital appointments. I have found that several staff working on
his wing took account of his poor health and his personal officer in
particular showed great compassion in her dealings with him.
Overnight checks
67. The family have asked whether he should have been checked more often
during the night. In the course of the night, and in between routine roll
checks, wing staff only check prisoners who are at risk of haring
themselves or escaping. He did not come into either category and so
there was no reason to check him any more than other prisoners are
checked. Had he become an inpatient in healthcare, he may well have
been checked more often by nursing staff. However, he chose to remain
on the wing which is not a hospital environment.
68. As well as checking specific prisoners, night staff are required to patrol the
wings which would include listening for any untoward behaviour such as
loud music or other disturbances. There is no evidence that the OSG
responded to any such events during the night of 19/ 20 December or that
he called for assistance.
69. I have no reason to doubt that all the appropriate checks were made
during the night. Although officers had noted that he was deteriorating, he
remained on the wing and spent most of his time in bed. Given this, I am
satisfied that further checks were not required at that time. I do, however,
note that the OSG on duty on the night of his death was not aware of his
illness, and I address this more fully in the following section of the report.
Discovering the man in December
70. The OSG said at interview that he is only allocated to work in a specific
location when he reports to the prison. He does not know in advance
where in the prison he will be working and so he does not get to know the
prisoners on the wing which he is to supervise overnight.
71. On the evening of 19 December, he OSG was allocated D wing, the wing
where the man lived. The OSG had not worked on D wing before and so
he did not know him. He said that he checked with the staff going off duty
17
whether or not there was anyone who he particularly needed to check on.
He told my investigator that he was told there were no prisoners who
required regular checks overnight. As I say, it is usually prisoners who are
vulnerable to self harm and suicide who will be checked during the night.
72. He then waited for the officer going off shift to complete the last roll check
of D wing before he assumed responsibility for his own checks. He
described carrying out his own evening checks on the prisoners and said
that, whilst doing this, he spoke to him, asking him if he wanted his cell
light turned off. He asked for it to be turned off later and he returned at
10.00pm, and asked him if he was alright. He replied that he was. He told
my investigator that he saw him sitting on his bed as he turned the cell
lights off.
73. The next morning, at 6.20am, he was undertaking cell checks on D wing
when he went to the cell. He told my investigator that he opened the cell
observation panel, put the light on and saw him lying on the cell floor. He
said that he hit the observation window with his torch and saw him move
his head in what he believed to be a nodding movement.
74. He said that at the same time a prisoner in an adjacent cell shouted for
quiet as it was early in the morning. The OSG said in interview that he
may have been put off looking further into the situation by the other
prisoner shouting. At interview, he said that he did not believe he was in
distress, so he decided to carry on with his cell checks.
75. My investigator asked him if he knew what to do in the event of an
emergency. He replied that if he thought a prisoner was in distress he
would call for “comms”, that is the communications control for the prison,
to call for assistance.
76. It appears that he acted appropriately in the circumstances, given that he
was not aware of the man or his illness, and thought that he had received
a response when he knocked on the observation panel. However, staff on
the wing had noticed that his health had deteriorated in the previous few
days. This information was not given to him and he therefore did not know
that a further check on him might have been appropriate. I do not
apportion blame to any member of staff, but I do think that such
information should have been passed between staff more effectively.
The Governor should ensure that, when staff have concerns about a
prisoner, this information is shared appropriately with colleagues on
all shifts.
77. After the OSG made his final check at 6.20am, the next check was made
by Officer E shortly after 7.00am. The officer immediately recognised that
something was wrong with the man and called for help from his
colleagues. Given the timings given by the ASO and the officer, it seems
that help only arrived some ten minutes later.
18
78. I believe that, in the circumstances, staff should have gone into the man’s
cell much earlier. He was in a single cell and was known to be ill. The
OSG was outside the cell with the officer and therefore could have
assisted him if he decided to go into the cell. The officer told my
investigator that, for reasons of personal safety, he preferred to go into
prisoner’s cells only when accompanied by another officer. The ASO
confirmed that both the OSG and the officer both had the authority and the
keys to go into the cell.
79. While accepting that staff have to assess the risk at the time and without
the benefit of hindsight, I think that on this occasion they should have gone
into the cell at the earliest opportunity. I appreciate that in such
circumstances staff have to consider whether there is a risk of assault from
the prisoner. It is easy with hindsight but I believe that the staff, one of
whom knew the man well, could have reached a different view and gone
into the cell straightaway. Although it is unlikely that the outcome for him
would have been any different, in other circumstances a life might be
saved.
The Governor should remind staff of the procedures for going into a
cell during an emergency.
Whether the man was too weak to press his cell bell?
80. Nurse C told my investigator that he spoke with the man on 19 December
when he delivered his medication to him in his cell. He told the nurse, who
had noticed he was jaundiced and had asked him if he was alright, that he
was fine.
81. In interview with the investigator, the nurse said that she checked him
twice on 19 December, the last time being at 5.10pm when he was in bed
with his duvet over him. She said that he was breathing and looked as
though he was watching television. The OSG in his interview said that
when he saw him at 10.00pm he was sitting up on his bed. The OSG also
said that he did not hear anything untoward from his cell for the remainder
of his shift as he went about his wing patrol.
82. The clinical reviewer wrote in her review that his death was sudden and
unexpected with no record of him calling for help. Staff statements show
that when staff checked on him he was able to communicate appropriately.
83. It may be that he was trying to get to the cell bell when he died and this
may explain why he was found on the floor of his cell.
Release on compassionate grounds
84. The family have asked whether his illness could have been managed
better at home or at hospital. As noted above, the clinical reviewer has
found that his care at Swaleside was good and he generally received the
medication and appointments which he required. No formal application
19
was made for him to be released on compassionate grounds. In the
period leading up to his death, he was mobile and functioning
appropriately on the wing with both staff and other prisoners.
Compassionate release can only be considered for prisoners who can no
longer care for themselves and do not present any risk to the public. He
was serving a life sentence and, despite his serious health condition, I do
not think that there were grounds for applying for compassionate release.
Consultation with the man’s family about his treatment
85. The family have also asked why they were not consulted about his
treatment and specifically about a letter from a consultant dated 7
September. The clinical reviewer commented that he was in control of his
medication and able to represent himself with medical staff when
discussing his treatment. Patient confidentiality would have meant that it
was his own decision about who to share information with regarding his
medical treatment. Had he asked for his family to be involved, I would like
to think that his request would have been considered sympathetically.
Availability of extra visiting time
86. He was entitled to two weekend visits or four weekday visits every month.
I have seen no evidence to suggest that he applied for any extra visits
from his family. While it is possible for the prison to offer extra visits, this
is usually only done when a prisoner is clearly very ill. Although he was
terminally ill, he was independently caring for himself. Had he wished to
do so, he was able to apply for extra visits until shortly before his death. In
the circumstances, I do not consider that Swaleside should have offered
extra visits.
Use of restraints
87. The family have asked why restraints were used while he was in public
areas of the hospital, but not in his own room. Every time that a prisoner
such as the man leaves prison to attend hospital, a risk assessment is
completed, concerning areas such as likelihood of escape and risk to the
public. Each assessment is checked by healthcare and prison
management at different stages during the visit. It probable that when he
was in a private room, prison managers approved the removal of restraints
to make him more comfortable.
Informing the family of his death
88. After he died, his family were informed by telephone by a prison FLO.
Prison Service Order 2710, entitled “Follow Up to deaths in Custody”,
contains an annex giving guidance to FLOs on how to break such news.
The preferred option is that news is given in person, and the option to use
the telephone is described as being “the last resort”.
20
89. My investigator asked the FLO why he had telephoned the family instead
of visiting. He replied that, following two previous deaths in custody, other
prisoners had informed the family by using illicit mobile telephones before
he had arrived at their home to break the news in person. He was keen
that this did not happen on this occasion.
90. While I understand the reasons for his actions on this occasion, the
guidance in the PSO is clear in giving a best option, which should be
followed when possible. I do not make a recommendation on this
occasion, given that the family did not raise this as an issue, and I
understand why the FLO reached his decision. However, the Governor
might want to consider this issue further and thus I bring it to his attention.
The memorial service
91. The family asked my investigator to look into the prison’s management of
the memorial service for him. I am pleased that the family were invited to
the service and that they were able to accept. Not every family wishes to
attend and it is important that they are consulted.
92. In interview with the investigator, the FLO, who chaperoned the family
during their attendance at the memorial service, said that he thought the
period of time after the service, when the family talked to other prisoners,
had seemed to come to a natural conclusion. The prison can allow a
certain length of time for memorial services before prisoners and staff
have to return to the main prison. I am sorry that the family felt that they
were unable to spend time talking to his friends and suggest that they
could have been asked if they were ready to leave the service.
21
CONCLUSION
93. The man died in his cell in December 2009, whilst being treated for cancer
of the pancreas. Staff at Swaleside noted that his condition had started to
deteriorate earlier that month and he was visited regularly in his cell by
other prisoners, wing staff and healthcare staff.
94. Prison healthcare staff and some wing staff including his personal officer
were aware that he had received a revised estimate about his life
expectancy and that the prognosis was poor. However, he died
unexpectedly and, whilst I make two recommendations including ensuring
that when staff have concerns about a prisoner this should be shared
appropriately, I conclude that staff at Swaleside could not have prevented
his death. His family have raised several issues about his treatment and I
hope that they are reassured by my findings. I repeat my apology for the
delay issuing my report and understand that this cannot have helped to
alleviate their concerns.
22
Feedback from the family
The family made the following observations having considered the
investigation findings as part of the consultation process.
(cid:127) The family told my family liaison officer that they were angered and
saddened by the findings and hurt by the prison’s failure to
acknowledge any responsibility for the events on the night the man
died. They are concerned about the inexperience of the officer on duty
and do not agree that he acted appropriately in the circumstances.
They feel strongly that a prisoner lying naked on the floor of his cell in
the middle of December should in itself be enough to prompt further
investigation by staff.
(cid:127) They were concerned by the lack of intervention, towards the end of his
life, by his personal officer. Although she identified a decline in his
health, noting in his file just two days earlier that he was deteriorating
fast and spending too much time on his own, there is no evidence that
she took these concerns any further. The family questioned whether
personal officers have the appropriate autonomy to bring matters to the
attention of others, if they have significant concerns about an
individual.
(cid:127) They also spoke of their frustration that no attempts were made to
engage with them with regard to his illness and treatment. They accept
the issue of patient confidentiality but feel it is often the case that the
individual is too fragile and unwell to initiate contact themselves,
particularly when faced with a terminal prognosis. The family feel they
were deprived of the chance to care for him in the final stages of his
life.
(cid:127) The family feel that the lack of information sharing between wing staff
and night staff about his illness, particularly given this had deteriorated
in the days prior to his death, was a significant failing and compromised
the care he received. They acknowledge the Ombudsman’s
recommendation regarding this and hope practise will be improved for
the benefit of other prisoners.
(cid:127) The family accept it was his decision not to move to the healthcare unit,
however, given it was noted by wing staff that his condition appeared to
be deteriorating, they believe formal checks should have been put in
place as a means of monitoring him throughout the night.
23
RECOMMENDATIONS
NOMs have accepted all of the recommendations. The response to each
recommendation is set out below in italics.
1. The Governor should ensure that, when staff have concerns about a
prisoner, this information is shared appropriately with colleagues on all
shifts.
The most recent Safer Custody Audit conducted in May 2011 highlighted
that there are no concerns in this area. Improvements have clearly been
made and all staff make full use of the observation book and Cnomis. The
Auditor also made comment that communication between Healthcare and
the Residential Units is very good.
2. The Governor should remind staff of the procedures for going into a
cell during an emergency.
All Staff will be addressed at the full staff meeting on 8th June 2011. A
notice to staff will also be published the same day outlining the correct
procedures
24