Individual at Usk and Prescoed

Investigation into the circumstances surrounding the
death of a man at Nevill Hall Hospital in June 2009, while a
prisoner at HMP Usk and Prescoed
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2010
This is the report of the investigation into the death of a man at Nevill Hall Hospital
on 8 June. The man was a serving prisoner at HMP Usk and Prescoed (referred to
as Usk for the remainder of the report) at the time of his death. The post mortem
revealed that he died of cancer.
I offer my sincere condolences to the man’s family and friends, and all those touched
by his loss.
The investigation was carried out by an investigator from my office. Healthcare
Inspectorate Wales commissioned a doctor to undertake a review of the clinical care
the man received at Usk. The review was completed by her colleague. I am grateful
for their assistance. I would also like to thank the Governor and his staff for their co-
operation. I am particularly grateful to the establishment’s investigation liaison
officer.
The man first arrived in custody in June 2006. He had a history of ill health and was
being prescribed a number of medications. However, I am satisfied that his
conditions were managed well and he enjoyed reasonable health.
In January 2009, the man complained of a cough, pains in his chest and feeling
generally unwell. The doctor diagnosed pleurisy and prescribed antibiotics. After
three courses of antibiotics, healthcare staff were satisfied that the problem had
been resolved. However, in May staff and friends noticed that the man had lost a lot
of weight. On 27 May, a chest x-ray revealed a large mass on his chest and he was
told he most probably had cancer. The man’s health rapidly deteriorated and he was
admitted to hospital on 3 June. Doctors there confirmed he had cancer and that he
would not be well enough to return to prison. He died in hospital on 8 June.
The short amount of time between the diagnosis and the man’s death caused his
family considerable concern. The clinical reviewer and I have considered their
concerns carefully and are satisfied that healthcare staff treated the man’s symptoms
appropriately and that he received a suitable level of care. I make two
recommendations: one concerns recording when prisoners do not collect prescribed
medication and the other issuing guidelines to staff carrying out hospital bedwatch
duties.
The man’s family gave careful consideration to the content of this report at the draft
stage. I am grateful for their participation in what is, undoubtedly, a very difficult
process.
This is the fifth natural causes death to occur at HMP Usk and Prescoed since the
Ombudsman began investigating all deaths in custody in 2004. I have found no
particular similarities between the circumstances of the deaths.
Jane Webb
Acting Prison and Probation Ombudsman January 2010
2
CONTENTS
Summary 4
The investigation process 6
HMP Usk and Prescoed 7
Key events 8
Issues 19
Conclusion 23
Recommendations 24
3
SUMMARY
The man was remanded into custody on 8 June 2006. In September that year he
received an Indeterminate Public Protection sentence, with a minimum tariff of three
years. He spent the first 21 months at HMP Cardiff and HMP Parc, before
transferring to HMP Usk on 19 March 2008.
On arrival at Usk, the man told healthcare staff that he had a number of existing
health problems including asthma, hypertension and angina. He had suffered a
heart attack 15 years previously, had his gallbladder removed and had received
treatment for hernias. He had been a smoker but successfully gave up in 2007. He
was being prescribed a number of medications.
In January 2009, the man was examined by the prison doctor complaining of a
cough, pain on the left side of his chest and feeling generally unwell. The doctor
thought the man might have pleurisy and prescribed a course of strong antibiotics.
The man returned to see the doctor a week later, with the same symptoms, and was
prescribed a second course of antibiotics. He failed to attend an appointment with
the doctor in February and also did not turn up for a chronic disease clinic that
month. As a result, staff thought he must be feeling better.
On 13 March, the doctor examined the man again. He recorded that the man had
another chest infection and prescribed antibiotics for the third time. Following this, it
seemed the infection had been successfully treated.
The man was found guilty of six additional offences on 22 April 2009 and received a
further seven years on his sentence. Prison staff and the man’s friends knew he was
upset by this. In early May, a nurse recorded that the man looked very pale, was
sleepy and had lost weight. She referred him to the doctor and to the community
psychiatric nurse, in case these were symptoms of depression or stress following his
court appearance.
The doctor examined the man on 11 May (after the man missed an earlier
appointment) and, having noted his obvious weight loss, referred him for a chest x-
ray and blood tests. The man’s friends in the prison and staff working on the wing
also noticed that he had lost a lot of weight and began to be concerned about him.
These concerns were raised with healthcare.
On 20 May, the man went to the local hospital and had a chest x-ray. The results
arrived a week later and showed a large mass on his chest. The man was told that
he probably had cancer. It seems that he chose not to share this news with his
family or friends.
The man’s health continued to deteriorate, but he made it clear to healthcare staff
that he did not want to be transferred to another prison with more appropriate
healthcare facilities. He denied being in any pain and appeared to remain positive
about his condition. His cellmate provided support and helped with practical tasks
such as showering. Staff on the wing knew that the man was not well, but did not
know the cause of his worsening health.
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On 2 June, a nurse visited the man and found him to be dehydrated, dizzy and
breathless. The man said he was unable to leave his cell. The doctor examined him
the following day and agreed that he was suffering with malnutrition and dehydration.
The doctor decided that the man should be admitted to hospital to enable a proper
diagnosis and prognosis, and to treat his dehydration.
The man was admitted to hospital as an inpatient on 3 June. The doctors there
confirmed that he had cancer and told him it was unlikely he would be able to return
to prison. He died in hospital on 8 June.
I make two recommendations as a result of this investigation, one concerning
recording when a prisoner does not collect prescribed medication and the other
issuing guidelines to staff undertaking hospital bedwatch duties. I conclude,
however, that the man received an equitable level of care at Usk to that he would
have in the community and that neither recommendation would have impacted on
the final outcome.
5
THE INVESTIGATION PROCESS
1. The Ombudsman’s office was informed of the death of the man on 8 June 2009.
The investigation was allocated to an investigator that day. The investigator
issued notices inviting staff and prisoners to contact her with any information they
felt might be relevant to the investigation. Three prisoners made contact and they
were interviewed as part of the investigation. I am grateful for their cooperation.
2. The Healthcare Inspectorate Wales appointed a clinical reviewer to undertake a
review of the clinical care the man received at Usk. The investigator and the
clinical reviewer were supplied with copies of the man’s medical records and other
relevant documentation. They conducted a number of joint interviews with prison
healthcare staff in September. The review was completed by the clinical
reviewer’s colleague. Prisoners are entitled to receive care equitable to what they
would receive in the community and part of the purpose of the clinical review is to
judge whether that was the case.
3. One of the Ombudsman’s Family Liaison Officers, made contact with members of
the man’s family to invite them to be involved in the investigation. They raised
concerns about the standard of medical care the man received. In particular, they
wanted to know whether:
(cid:127) The cause of the man’s weight loss was properly investigated.
(cid:127) The diagnosis of pleurisy was, in the circumstances, appropriate.
(cid:127) The man should have been diagnosed with lung cancer earlier than he
was.
(cid:127) Had an earlier diagnosis of lung cancer been made, whether there was
any treatment that the man could have received.
(cid:127) The man received a lower standard of clinical care as a result of him
being in prison.
(cid:127) Discipline staff looking after the man on the wing were aware of raised
concerns about his sudden weight loss.
(cid:127) The prison responded adequately to the man’s family’s concerns about
him.
The man’s family also raised concerns about the actions of some staff undertaking
bedwatch duties. I hope that this report addresses their concerns.
6
HMP USK AND PRESCOED
4. HMP Usk and Prescoed are jointly managed prisons in Monmouthshire, Wales.
Usk is a closed training prison housing up to 250 adult male prisoners, most of
whom are convicted sex offenders. In March 2008, 39 per cent of the population
was aged over 50.
5. Every prison in England and Wales is subject to performance monitoring by the
National Offender Management Service (NOMS). The performance of each
prison is assessed against an agreed framework and awarded one of four ratings:
exceptional performance, good performance, requiring development or serious
concerns. Usk/Prescoed is currently rated as ‘good’.
6. The prisons last underwent an unannounced short follow up inspection by HM
Chief Inspector of Prisons (HMCIP) in March 2008, following a full announced
inspection in April 2005. Staff-prisoner relationships were described as “relaxed”,
with prisoners finding staff to be “friendly and helpful”. However, there was “little
evidence” that the personal officer scheme in place had “any impact”.
Furthermore, HMCIP found that the “personal officer plus work that the prison
aspired to, and that sought personal officer engagement with families, was also
not working”.
7. Healthcare services at Usk/Prescoed are run along the lines of a doctors’ surgery
in the community. Healthcare staff are based in the prison between 7.30am and
4.30pm on weekdays. Outside these hours, staff are available by telephone and
on an ‘on-call’ basis. There are no inpatient facilities at either prison. HMCIP
found healthcare facilities at Usk to be “small [and] cramped”. In 2005, the Chief
Inspector recommended that a new healthcare facility be provided at Usk.
Building work was due to start in September 2008, but had not been completed at
the time of this investigation.
8. Each prison in England and Wales is also monitored by an Independent
Monitoring Board (IMB), formed of volunteers from the local community. IMB
members have full access to each part of the prison and every prisoner held
there. The Boards produce annual reports, with the most recent available report
for Usk/Prescoed covering April 2007 – April 2008.
9. The IMB noted that the healthcare centre at Usk is inappropriate, and that neither
Usk nor Prescoed have any inpatient bed spaces. However, the Board praised
the “majority of staff” who “continue to impress with their dedication and
professionalism under often extremely difficult conditions”.
Personal officers
10. Personal officer schemes operate in most prisons across England and Wales.
Each prisoner is allocated a named officer (or officers) who acts as their first port
of call if they need help or advice. Usually, a prisoner’s personal officer is
expected to see the prisoner and make entries in their file at least once a fortnight.
7
KEY EVENTS
11. On 8 June 2006, the man was convicted of sexual offences and was remanded
into the custody of HMP Cardiff to await sentencing. It was his first time in prison.
On arrival, he underwent the first reception healthscreen with a nurse. (This is
designed to identify any immediate mental or physical health concerns requiring
referral to the doctor or a specialist service.) He told the nurse that he had a
history of angina, had suffered a heart attack in the past and had received
treatment for hernias. He said he was asthmatic and allergic to penicillin. The
man said that he smoked, drank socially but did not use drugs. He said he had no
mental health concerns.
12. Five days later, on 13 June, the man was transferred to HMP Parc. On 22
September 2006, he received an Indeterminate Public Protection (IPP) sentence,
with a minimum tariff of three years. (IPP sentences apply to those who commit
certain serious violent or sexual offences and who are deemed to pose a
“significant risk of serious harm in the future”. The sentencing court sets a
minimum period of imprisonment required, but the individual will only be released
after that point if the Parole Board is satisfied that the risk to the public is
reduced.)
13. Whilst at Parc, the man completed two offending behaviour programmes: the
Enhanced Thinking Skills Programme and the Rolling Sex Offenders Treatment
Programme. He also undertook a number of education and training related
courses and had various jobs in the prison.
14. The man’s health problems were monitored by healthcare staff whilst he was at
Parc. In July 2006, the prison doctor referred the man to the Bro Morgannwg
Hospital because he complained of severe abdominal pain caused by a recurring
hernia. The man was examined by a consultant general surgeon at the hospital in
January 2007. The consultant told the man that to repair the hernia would be a
“major undertaking” with “no guarantee” of a cure. The man and the consultant
agreed that the hernia should be “left well alone”. The man was offered an
abdominal support to wear when exercising but did not attend his appointment to
have the support fitted.
15. In 2007, the man attended smoking cessation sessions and succeeded in giving
up smoking. He was also referred to the prison gym, specifically to improve his
health. As a result, he reported improvements in his breathing and asthma.
However, in February 2008, he was treated by healthcare staff when he again
complained of abdominal pain at the site of his hernia operation scar.
16. On 19 March 2008, the man transferred to Usk. On arrival, he underwent a
transferred prisoners’ reception healthscreen with a nurse. The nurse recorded
that the man had a history of asthma and possibly hypertension. She noted that
he had been diagnosed with angina and suffered a heart attack 15 years ago, and
had his gallbladder removed ten years earlier. She recorded that he was currently
prescribed a number of medicines for his various conditions, and was receiving
pain relief medication. The man weighed 87.8 kilograms.
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17. A couple of weeks after transferring to Usk, the man complained that his hernia
scar was leaking fluid. Healthcare staff dressed the wound on 28 March, and
continued to do so until it burst on 2 September. On 8 September, the man was
referred to the wound specialist at Nevill Hall Hospital in Abergavenny. The
specialist did not assess him in person, but gave healthcare staff advice on how
best to treat the wound. She also advised that the man be referred to a consultant
at the Royal Gwent Hospital for further assessment. Healthcare staff at Usk
interviewed for this investigation said that the man did not seem troubled by the
problems with his scar and did not complain of being in pain.
18. The man’s hernia wound was not healing and on 24 September, the nurse who
dressed it referred the man to the prison doctor. The nurse recorded that surgical
thread and mesh used during the original hernia operation were now visible in the
wound. On 8 October, the prison doctor recorded that the man was “seeing [the]
hospital specialist” and wrote a letter to the Royal Gwent Hospital seeking a
consultant surgical opinion.
19. On 17 October, the man was charged with six further sexual offences. A wing
officer made an entry in the man’s wing history file noting that he might be facing a
long sentence as a result. The officer wrote that the man was “aware of this and
appears to be dealing with it ok”, but that staff should, nevertheless, monitor him.
The personal officer spoke to the man on 29 October and recorded that he was
“obviously very concerned” about the further charges. The personal officer was
interviewed as part of the investigation. He said that the man was “devastated” by
the additional charges and “felt very worried”. The man appeared at a local
magistrates’ court on 12 and 20 November and was remanded into custody.
20. The man was taken to the Royal Gwent Hospital on 24 November and his hernia
wound was assessed by a consultant surgeon there. The consultant decided that
the man should return to have the wound treated under local anaesthetic. A
further appointment was made for 18 December.
21. A nurse saw the man on 10 December to change the dressing on his wound. She
recorded that he felt anxious because of the further charges he was facing. She
noted that they discussed “thought distraction” (techniques which encourage the
individual to think about something calming and positive) and that the man was
“happy to liaise with staff” if he felt more anxious. The nurse wrote that the man
had no thoughts of harming himself or anyone else.
22. As arranged, the man was taken to the Royal Gwent Hospital on 18 December
and received treatment for his hernia wound, returning to the prison later that day.
The consultant directed that the man needed no further follow up treatment.
Healthcare staff continued to change the wound dressing frequently. (In fact, they
continued to do so until 13 February, when an entry in the man’s medical record
notes that no more dressings were required.)
23. On 19 January 2009, the man was examined by the doctor. The doctor made few
notes about the appointment in the medical record but wrote that the man was
suffering with a chest infection and might have pleurisy (when the lining of the
pleural cavity, which surrounds the lungs, becomes inflamed). The doctor
9
prescribed a course of antibiotics. In interview, the doctor was asked about the
symptoms the man presented with. He remembered the man complaining of a
cough, a pain in the left side of his chest and “just feeling generally unwell”. The
doctor said he prescribed a strong antibiotic because the man had previously
been a smoker.
24. The man returned to see the doctor on 26 January. Although the reason for the
appointment was not recorded, in interview the doctor said that the man continued
to complain of chest problems. He prescribed another course of antibiotics.
Entries in the man’s medical record note that he failed to attend an appointment
with the doctor on 11 February, and the chronic disease management clinic on 27
February. No reasons for missing these appointments were recorded, but as in
the community, prisoners are responsible for attending (or not) their medical
appointments. Generally, healthcare staff will not follow up missed appointments.
Healthcare staff interviewed said that, because the man missed his appointments,
they assumed he was feeling better.
25. The doctor examined the man on 13 March and recorded that he had a “chest
infection again”. Once more, no symptoms were recorded, but the doctor noted
that he had prescribed antibiotics for a third time. The doctor said that after the
third dose of antibiotics he thought the man’s chest infection had been
successfully treated. On 1 April, the doctor recorded that the man’s asthma
inhaler was being changed. A nurse showed the man how to use the new inhaler.
26. The nurse that carried out the man’s initial reception screening weighed him on 22
April (the reason for her doing so is not recorded) and noted that he weighed 76.9
kilograms. Two days later, he appeared at a local crown court and was convicted
of several sexual offences. He was sentenced to a further seven years in prison.
The man’s personal officer explained that he kept a close eye on any prisoners
who received additional years on their sentence. He said he would look for any
changes in their attitude or lifestyle. Again, the man told his personal officer that
he was “devastated” by the outcome of the court case. One of the man’s friends
at Usk, described the man as “knackered” following the case.
27. On 5 May (a Tuesday), the nurse that carried out the man’s initial reception
screening made an entry in the man’s medical records, noting that he weighed
71.8 kilograms, and that he looked “very pale” and said he was sleepy. She
recorded that he should be examined by the doctor and undergo blood tests. The
man told the nurse that he was eating and drinking very little. She noted that he
had lost 17 kilograms since March 2008 and that his weight should be monitored
each week. She also referred the man to the community psychiatric nurse (CPN).
28. The nurse was interviewed during the investigation. She explained that it was not
normal practice to refer a prisoner to the CPN for weight loss, however she knew
that the man had been facing new charges and was back in court. She said she
“had a few concerns about him” and that he seemed “quite stressed and … not his
usual self”.
29. The doctor examined the man seven days later on 11 May. The nurse explained
that she had made an appointment for the man to see the doctor on Wednesday 6
10
May but he did not attend. She went to the wing to find him and was told that he
had gone to his education class instead. The doctor is normally available at Usk
on Mondays, Wednesdays and Fridays, but that week was not in the prison on the
Friday. As a result, the next opportunity for the man to be examined was the
following Monday.
30. In interview, the doctor said that the man’s weight loss was “obvious” and so he
referred him to Nevill Hall Hospital for a chest x-ray and blood tests. On 13 May,
the man attended the asthma clinic. The nurse running the clinic recorded that
the man was grey in colour and his chest “was rattley”. The man was asked to
provide a sputum sample “as soon as possible”.
31. The next day, the CPN, assessed the man following the nurse’s referral. The
CPN recorded that the man had not been eating, had suffered with flu twice and
with “several chest infections”. The man denied having any mental health
problems or any thoughts of harming himself but said that his mood had been low.
He told the CPN that his low mood and lack of appetite were caused by his recent
ill health. The CPN asked the man to write down what he ate over the following
week and arranged to see him again on 22 May.
32. On 15 May, the officer that previously mentioned in his record that he should be
monitored as his sentence had been extended made an entry in the man’s wing
history sheet. He wrote that the man’s cellmate, had approached him with
concerns about the man’s physical and mental health. The officer told the man’s
cellmate that he would inform healthcare, and did so that day by telephone. The
nurse that previously dressed the man’s scar, recorded the officer’s concerns in
the man’s medical record, but did not record whether any action needed to be
taken as a result. There is no indication that healthcare staff visited the man or
talked to him following the officer’s call.
33. The man attended for hypertension screening on 18 May, and his blood pressure
was found to be “quite high”. The nurse recorded that it should be monitored.
That same day, the man’s personal officer spoke to him about his new sentence.
He noted that the man was not in good health and that he had “had pleurisy and
… lost four stone in weight”. The personal officer recorded that staff were aware
of this.
34. The CPN saw the man again on 22 May. As instructed, he had kept a diary of
what he had eaten in the past week, which the nurse found “quite satisfactory”.
The CPN told the man that she would show the nurse that carried out the man’s
initial reception screening his diary. The man said he was feeling a little stronger,
but was hoping for his test results in the next few days. The CPN recorded that
the nurse would review the man the following week, but concluded that there did
not appear to be “any serious mental health issues at this time”. She gave him a
further appointment for 29 May and told him to contact healthcare if he had any
problems.
35. Following the doctor’s referral, the man went to Nevill Hall Hospital for chest x-
rays on 20 May. In interview, the man’s cellmate, raised concerns about the way
the man had been treated by staff who escorted him. (Whenever a prisoner is
11
taken out of the prison, a risk assessment is carried out to decide how many staff
should escort the prisoner. The assessment also informs decisions about the
extent to which the prisoner needs to be restrained, by handcuffs, for example.)
The man’s cellmate said he was working in the brick shop and saw the man being
escorted from the prison. He said the man was handcuffed to an officer. From
what he heard and saw, he thought the man had been treated unnecessarily
roughly by the officer. The man’s cellmate told the investigator that, on his return
from hospital, the man said he had been “dragged around” by the officer he was
handcuffed to that day. The man’s cellmate said the second officer escorting the
man told the cellmate that he had tried to make sure the man was handcuffed to
him instead, but had not been able to arrange this.
36. Since the draft version of this report was issued, Usk have provided the
investigator with a copy of the Prisoner Escort Record (PER) and risk
assessments relating to the hospital visit. This indicates that the second officer
escorting the man and the officer that was handcuffed to the man were
responsible for escorting the man to hospital that day. The investigator spoke to
the second officer escorting the man by telephone. He was certain that the man
had not been mistreated while being escorted. He said that he would challenge
any colleague he felt was treating a prisoner inappropriately.
37. Seven days later, on 27 May, the x-ray results arrived. The doctor recorded that
they showed a “large bronchial mass – needing urgent chest referral”. He
discussed the results with the man that day. In interview, the doctor explained
that without a tissue biopsy it is not possible to give a definite diagnosis of cancer.
However, he said that the x-ray revealed a “growth on the lung … and with a
picture like that and with weight loss you have to consider a cancerous growth”.
The doctor confirmed that this was the first time that the man was told he might
have cancer. He said, however, that he thought the man already understood he
was “in a pretty poor condition … and knew things weren’t right”. The doctor
prescribed Fortisips (a high energy food supplement) to help combat the man’s
weight loss and requested further blood tests. He wrote an urgent referral letter to
the consultant chest physician at Nevill Hall Hospital, which was faxed to the
hospital that day.
38. The nurse that previously dressed the man’s scar made a further entry in his
medical records that day. She recorded that the man had been given time to talk
about how he felt and had been offered support and advice by nursing staff. She
noted that he was due to undergo further blood tests the following day. The nurse
recorded that the man and his cellmate were now located in a ground floor cell
and noted that he should be checked by nursing staff every week day. She wrote
that the man knew that, should he find it difficult to look after himself or his
condition worsen, he should contact healthcare staff. The nurse also noted that
she had talked to the prison catering staff, who had agreed to provide the man
with a “light, nutritious” diet. The man was told to contact catering staff if his
needs changed. The nurse contacted a palliative care nurse at the St David’s
Foundation (a hospice), and arranged to speak to her again once the man had
been assessed by the hospital specialist.
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39. The nurse drew up a care plan for the man, which outlined how his weight loss
and mobility problems would be addressed. She wrote that the man would be
encouraged to eat and drink, and would be provided with food supplement drinks.
Catering staff would continue to provide the man with suitable food, and the man
would be asked to complete a chart to record his food and fluid intake. The nurse
wrote that the man would be provided with a soft chair and the furniture in his cell
would be arranged to allow him to move more easily. The care plan also recorded
that the man was to be seen by healthcare staff every day, and notes made in his
medical record.
40. At 2.20pm, the nurse that carried out the man’s initial reception screening checked
him and noted that he was still “shell shocked”. In interview, she said that while
the man had been shocked by the likely diagnosis, he remained very positive and
forward-looking. She reiterated that he should contact healthcare if he needed
anything and that she would check him again before the end of her shift. Later
that evening, at 7.10pm, the man’s cellmate spoke to the second officer
responsible for escorting the man to hospital on 20 May as he was concerned
about the man’s health. The officer informed a senior officer (SO), who spoke to
the man. The senior officer made an entry in the wing observation book writing
that the man “should be referred to healthcare for an up date on his wellbeing”.
The SO recorded that he too was concerned about the man’s “deterioration”.
(Information relating to prisoners’ health is regarded as “medical in confidence”.
Healthcare staff do not routinely share such information with discipline staff.
Discipline staff might be told that a prisoner is unwell but would not normally be
informed of a diagnosis. A prisoner might however choose to share information
about his health with any member of staff or other prisoners. Staff responsible for
the man on the wing were not aware that he had been told the seriousness of his
condition.)
41. Ten minutes later, the senior officer contacted healthcare to inform them that the
man had soiled himself. The duty nurse agreed to come and see the man and
arrived on the wing at 8.15pm. She provided him with incontinence pads, and
talked to him about how he felt. The nurse told the man to contact staff if he felt
unwell. She recorded that she had informed the doctor of her assessment.
42. The nurse that carried out the man’s initial reception screening visited him at
9.45am the following day and found him to be lethargic and grey in colour. She
was unable to take a blood sample from him and wrote that she would try again
the following day. She returned to see the man at 2.00pm and he told her he had
only been able to eat a very small amount of his lunch. The nurse encouraged
him to eat and told him she would visit again later. She did so at 4.00pm and
noted that the man had now been given a comfortable chair. The nurse asked
him if he was in any pain, and he replied that he was not.
43. On 29 May, the same nurse and the CPN visited the man. The man told them
that he knew he was physically ill but that it was not affecting his mental health.
The CPN noted that she would continue to monitor the man as he had not yet
received the test results or a confirmed diagnosis. The nurse recorded that he
seemed lethargic again. He told the her that he felt very tired but was trying not to
sleep. He said he was not in any pain, but was told that he could ask for pain
13
relief if he needed any. The nurse returned at 2.00pm, when the man was asleep,
and again at 4.00pm. She checked he had enough Fortisips drinks to last the
weekend and reiterated that he should tell staff if he was in any pain. The nurse
also made an entry in the man’s wing history sheet, confirming her visit. (In
interview, the nurse said that healthcare staff often asked the man if he was in any
pain and he always said he was not. She explained that they told him they could
provide him with pain relief if he needed it, but he continued to insist that he did
not.)
44. The following day, a Saturday, the second officer responsible for escorting the
man to hospital on 20 May noted that the man had showered, with the help of his
cellmate. (Healthcare and discipline staff alike spoke very highly of his cellmate
and the care he showed to the man while he was ill.) The officer noted that the
man was eating “very [little] if any food at the moment”. The nurse that carried
out the man’s initial reception screening visited again on Monday 1 June, and
found the man to be very tired. He said he had managed to eat a little over the
weekend but the nurse described him as looking “gaunt”. The man maintained
that he was not in any pain. Later that morning, the nurse left a message for the
hospital specialist about the man’s appointment. She visited the man again
shortly afterwards and gave him a food chart to complete (to record how much he
ate and drank). The man was also asked to provide a urine sample. Later that
day, the nurse recorded that the hospital consultant’s secretary had returned her
call and had explained that the consultant was on leave. She agreed to ask
another consultant to review the man’s chest x-rays with a view to arranging an
appointment.
45. On 2 June, the nurse that previously dressed his scar visited the man in his cell.
She described him as “grey, face drawn, skin showing signs of dehydration”. She
recorded that he was only able to walk a very short distance before feeling dizzy
and breathless. She thought that he might be suffering with malnutrition and
dehydration and wrote that he was “not really able to tolerate” the Fortisips drinks.
Analysis of his urine showed the presence of ketones and protein. (Ketones are
produced when the body breaks down fat for energy. Their presence might
indicate that the individual has not eaten for some time.) The nurse wrote that the
man had showered the previous day and “felt exhausted”. He told the nurse that
he was not leaving his cell, and was having his food brought to him. He said that
other prisoners were visiting him, but the nurse recorded that he could not really
remember who had visited. The nurse arranged for a jug of water to be placed in
the man’s cell so staff could monitor how much he drank. She also arranged for
the Fortisips drinks to be replaced with high energy yoghurts. She was able to
take a sample of the man’s blood to be tested.
46. Later that day, the nurse rang the doctor to discuss the man’s deteriorating health.
She told the doctor that the man appeared malnourished and dehydrated and that
he was unable to walk very far. The doctor agreed to examine the man the
following morning, with a view to arranging for him to be transferred to a prison
with an inpatient healthcare facility.
14
47. As arranged, the doctor examined the man on the morning of 3 June. He found
him to be very weak and unable to look after himself “as much as he would like
to”. The man told the doctor that he was drinking enough but the doctor recorded
that his tongue showed signs of thrush and dehydration. The man said he was
not in any pain. They discussed whether the man should transfer to another
prison with better healthcare facilities, but the man said he was happy to stay at
Usk. The doctor recorded that he would speak to the prison head of healthcare
about whether the man should be admitted to hospital. He wrote that this would
enable a proper diagnosis and prognosis to be made, help rehydrate the man and
allow for consideration of whether he should transfer to another prison.
48. The nurse that carried out the man’s initial reception screening and the nurse that
had previously dressed his scar visited the man at 9.30am that morning to tell him
he was going to hospital. The nurses washed the man and found a sore area at
the base of his spine. He told the nurses that it hurt to be touched. He also said
that he had not been taking any of his medication because he was “unable to
tolerate them”. (The man was prescribed most of his medication on a monthly
basis, meaning he kept a month’s supply in his cell and was responsible for taking
the correct dose.) His urine was tested again and traces of blood, protein and
ketones were present. He now weighed 63.2 kilograms. In interview, the nurse
said that this was the first time that he admitted to being in pain. However, she
also said that when told that he would be going to hospital, the man was “begging
us not to send him in because he didn’t want to go”. The nurse thought that he
realised that if he left Usk, it was unlikely that he would return – either because he
would be staying in hospital or because he would be transferred to a prison with
24 hour healthcare, better suited to address his needs. The nurse said the man
had previously “refused point blank” to consider transferring to another prison.
49. Because the man was being transferred to hospital, a risk assessment was
carried out. The nurse that carried out the man’s initial reception screening noted
that there were no medical objections to the use of restraints (for example,
handcuffs) but that the man was unable to walk. A member of staff from the
security department recorded that the man did not pose a risk to hospital staff and
had no history of violence, or drug or alcohol use. They noted that there was no
indication that he might try to escape or that the man himself might be at risk. A
Governor completed the assessment and agreed that no cuffs be applied, due to
the seriousness of the man’s condition. It was decided that two members of staff
should escort him to the hospital, but that only one would be necessary once he
had settled there and necessary security assessments had taken place. At
10.15am, the man was taken to Nevill Hall Hospital by the nurse, a SO and a
officer.
50. An officer recorded in the man’s wing history sheet that he had left a message for
the man’s ex-wife on her mobile telephone, and had also spoken to one of the
man’s sisters-in-law to let them know he had been admitted to hospital. He gave
both the prison telephone number so they could contact staff for further
information. Later, the officer made a further entry recording that one of the man’s
brothers had telephoned and been told which hospital ward the man was in.
15
51. After the man left for the hospital, the nurse that previously dressed his scar
telephoned the healthcare centre at HMP Parc to ask if they could accommodate
the man if he was discharged from hospital, explaining that he would need an
inpatient bed. Staff at Parc agreed to discuss the matter with the Governor, but
thought it unlikely they would be able to assist due to staff shortages.
52. Later that afternoon, hospital staff telephoned the prison to make sure that the
man’s family had been told that he was seriously ill. One of the man’s brothers
visited him that evening. The nurse that carried out the man’s initial reception
screening telephoned the hospital for an update and was told that he had
undergone a scan, and was being given an intravenous drip with potassium. The
nurse agreed to call again the following day for further updates.
53. The following day, the nurse telephoned the hospital again and was told that the
man was undergoing further investigations. The nurse told hospital staff that the
prison would need “as much notice as possible” if the man was to be discharged
as they still needed to find another prison that could accommodate him. The
hospital agreed to liaise with prison staff if the man was well enough to be
discharged.
54. On 5 June, an officer who was conducting the bedwatch (when officers remain
with a prisoner while in hospital), called the prison and told a senior officer that a
hospital doctor had confirmed that the man had cancer, and that it had spread.
The officer recorded in the bedwatch notes that the man also had a problem with
his stomach, which would require examination by a surgeon. The senior officer
wrote in the man’s wing history sheet that the man’s condition was terminal and
he was also being treated for diabetes. Hospital staff had told the man that he
would probably not leave the hospital. The senior officer passed on the
information to the nurse that carried out the man’s initial reception screening and
the Duty Governor (who is the Head of Release and Reoffending). Later that
evening, two of the man’s brothers visited him. The officer recorded that hospital
staff had given the family permission to visit at any time.
55. The Duty Governor was interviewed during the investigation. He was asked
whether consideration had been given to releasing the man on temporary licence
(ROTL) or on compassionate grounds. He explained that ROTL was rarely
available for prisoners at Usk due to the nature of their offences, the length of their
sentences and the perceived risk to others. Prison Service Order (PSO) 6300
provides guidelines on the use of temporary release or release on compassionate
grounds. It directs that prisoners serving IPP sentences should be classed as life
sentenced prisoners. Prisoners serving life sentences are normally only eligible
for temporary release if they are held in open, or semi-open conditions. Usk is a
closed prison and so the man was not suitable for ROTL or compassionate
release.
56. The man’s daughter telephoned the prison on 6 June, asking for permission for
her mother (the man’s ex-wife) to visit the man in hospital. As she was not listed
as an ‘approved visitor’ (someone who has been cleared by the security
department to visit the prisoner in prison), the Prison Family Liaison Officer
16
contacted the Duty Governor. He gave permission for them to visit. The man’s
daughter asked why her mother had not been informed that the man was in
hospital and was told that a message had been left on her mother’s mobile
telephone on 3 June.
57. The Duty Governor explained that he was aware that there were some “family
tensions” and that, for the man’s own safety, the escort should be increased to
two officers. He told the investigator that doing so meant an officer would always
be present to make sure no unauthorised visitors arrived and that the man was
supported at all times. The Duty Governor said he visited the hospital and spoke
to the man, who was not concerned about the new escort arrangements. He was
not sure whether the man’s brothers had been told but thought that the escorting
staff on duty at their next visit would explain the situation. The Duty Governor said
he told the staff nurse on the ward about the decision.
58. The following day, the man’s ex-wife, and later his brothers, visited him. At
8.25pm, one of the escorting officers noted that the man was “not looking well at
all”. During the night, the officer noted that the man was breathing very heavily.
59. Another officer took over bedwatch duties at 7.45am on 8 June. At 8.05am, she
recorded that the man had died, which was confirmed by a hospital doctor at
9.45am. The ward sister contacted one of the man’s brothers to tell him of his
death.
60. The post mortem concluded the cause of the man’s death to be:
1a. Dissemintated malignancy (widespread cancer)
1b. Small Cell Anaplastic Carcinoma of the lung (lung cancer)
Contact with the man’s family
61. When the seriousness of the man’s condition became clear, a senior officer was
appointed as the family liaison officer. Following the man’s death, she contacted
the man’s brother, his appointed next of kin, and the man’s ex-wife and visited
them both on 8 June. The family liaison officer provided the family with
information and helped to arrange the funeral. The Prison Service offered
financial assistance towards the cost of the funeral.
62. A member of the prison’s chaplaincy team led the funeral service and the family
liaison officer and the Duty Governor attended. Members of the man’s family told
the Ombudsman’s family liaison officer that the prison family liaison officer had
been “absolutely marvellous”, and that they had appreciated her kindness and
support.
Support for other prisoners
63. The man’s friends at Usk found out he had died by a variety of means including
through individual members of wing staff and a member of the chaplaincy team.
In addition, the Governor issued a notice informing all prisoners of his death. The
man’s cellmate said he was not offered any specific support following the man’s
death, but that he did not think he had needed any. The member of the
17
Chaplaincy team arranged a memorial service in the prison chapel. However, two
of the man’s friends said that, due to confusion about the arrangements, the
service did not take place as scheduled and that they were not told that a new
time had been arranged. As a result they both missed the service and were upset
and angry.
Support for staff
64. All staff interviewed said that they had been well supported by colleagues and
managers after the man’s death. The Prison’s family liaison officer told the
investigator that officers conducting bedwatch duties who were present when a
prisoner died were usually offered support. However, she said that this did not
normally apply to other officers who had carried out bedwatch duties.
18
ISSUES IDENTIFIED DURING THE INVESTIGATION
Clinical care
65. Healthcare Inspectorate Wales commissioned a review of the clinical care the
man received at Usk. The review was completed by the original reviewer’s
colleague.
66. The clinical reviewer concludes that, on the available evidence, he doctor’s
diagnosis of pleurisy was appropriate. The man complained of a cough, pain in
the left side of his chest and feeling generally unwell – all indicative of pleurisy.
The doctor prescribed a course of strong antibiotics. In total, the man was
prescribed three courses of antibiotics. The man did not return to see the doctor
following the third course and, in fact, failed to attend two appointments with
healthcare staff. On that basis, they were satisfied that the man felt better.
67. The man’s rapid weight loss (a possible symptom of cancer) was noted in May
2009, and the doctor promptly referred him for a chest x-ray. On 27 May, the man
was told that he most probably had cancer. Lung cancer is very aggressive, with
an average survival from diagnosis to death in the United Kingdom of six months.
The doctor confirmed that he had anticipated the man receiving a course of
radiotherapy, which might have given him an additional month or two.
68. The length of time between the man receiving the probable diagnosis of cancer
and being admitted to hospital was only a week, and I have no doubt that the
speed at which his health appeared to decline caused a great deal of concern to
his family. For whatever reason, it seems the man chose not to tell his family that
he was unwell, or that he probably had cancer, and that must also be difficult to
accept. However, both the clinical reviewer and I are satisfied that the man
received the appropriate assessment and treatment at Usk, and that this was
equitable to what he would have received in the community.
69. The man’s family were concerned that the man’s diagnosis and possible treatment
were delayed by the fact that he was a serving prisoner. The investigation has
found no evidence of this. The family told the Ombudsman’s family liaison officer
that the man had been in pain for “some time”. The nurse that carried out the
man’s initial reception screening who visited the man daily when he became ill,
said that she and her colleagues frequently asked him if he was in any pain and
offered pain relief if he was. She said the man denied being in any pain until 3
June, when he was admitted to hospital. The man’s friends at Usk agreed that he
had never mentioned being in pain.
70. The clinical review identifies that the man did not collect his prescribed medication
at the beginning of May. There is no documented reason for this, although the
reviewer notes that it appears to coincide with the man’s deteriorating health. It is,
clearly, not possible to know whether the man failed to collect his medication
because he felt unwell or for any other reason. However, had staff recorded that
the man had not collected his medication, it might have prompted an investigation,
which might have identified his declining health earlier.
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The Head of Healthcare should ensure that staff make an entry on the
medication chart and/or clinical record whenever medication has not been
collected as required, in line with the Nursing and Midwifery Council
standards.
How discipline staff responded to the man’s ill health
71. The man first complained of chest problems in January 2009 and his health began
to significantly decline in May. Entries in his wing history file indicate that
discipline staff noticed his ill health (and were further alerted to this by his
cellmate, the man’s cellmate) on 15 May. By this point, healthcare staff were also
concerned about his rapid and noticeable weight loss and general ill health.
72. During the course of the investigation, the man’s personal officer was interviewed.
He said that he spoke to the man each day that he was on duty and “built up a
good rapport” with him. The personal officer explained that he had noticed that
the man had lost some weight, but realised how much when he returned from a
period of leave. He described the man’s weight loss as “drastic” and said he had
planned to speak to him about this. In the meantime, a member of the healthcare
department asked the personal officer to discuss the weight loss with the man.
He did so and the man told him he had lost four stone, but that this was due to
having pleurisy. He reassured the personal officer that this had been “sorted out”.
The second officer escorting the man to hospital on 20 May spoke to healthcare
on 27 May, having become concerned about the man’s ill health. Earlier that day,
the man had been told he probably had cancer.
73. All those who knew the man described his weight loss as rapid and startling.
However, he had been charged with additional offences and, in April, was
sentenced to a further seven years in prison. Staff knew he was very upset by
this. The nurse that carried out the man’s initial reception screening was
concerned that his ill health was a result of stress. Both discipline and healthcare
staff told the investigator that information about prisoners’ health remains “medical
in confidence”. Staff looking after the man on the wing would not have been told
that he had suffered with chest infections, been diagnosed with pleurisy or
prescribed antibiotics over the preceding months – until or unless the man chose
to tell them himself. On these grounds, I think that it is reasonable that discipline
staff were not concerned about the man’s health until his weight loss became
worryingly evident in May. At this point, they raised their concerns with
healthcare, which was entirely appropriate. I do not believe they could be
expected to have done more or acted sooner.
74. It is worth noting that many of the Ombudsman’s investigations find that personal
officer schemes are not used to the full. I am pleased to note that on this
occasion the man seems to have had a good relationship with his personal officer,
who took a close interest in his welfare.
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Hospital visit on 20 May
75. The man’s cellmate told the investigator that he had seen the man being roughly
treated by a member of prison staff responsible for escorting him to hospital on 20
May. He said that the man told him he had been “dragged around” the hospital.
The cellmate believed the officer that treated him badly to be the officer
handcuffed to him. The investigator spoke to the second officer escorting the
man. She also requested the PER relating to the visit from the prison, which was
provided after the draft version of the report had been issued. The PER confirmed
the identities of the two officers responsible for escorting the man to hospital that
day. The second officer escorting the man could not remember who he had been
on escort duty with but was certain that the man had not been mistreated that day.
He said he would have challenged any officer he felt to be treating a prisoner
inappropriately.
76. Given the two varying accounts from the man’s cellmate and the second officer
escorting the man, I am unable to reach a definite conclusion about the
allegations that the man was roughly treated during the escort.
Contact with the man’s family
77. The man’s family thought that the prison should have been more pro-active in
letting them know that the man was unwell. The man had not sent any Visiting
Orders to his family or written to them for several months and his brother said this
was unusual. He telephoned the prison to check he was alright but said he
received an “unhelpful” response from the prison officer whom he spoke to.
78. During the investigation, the investigator spoke to the prison family liaison officer.
She explained that she is usually told promptly when a prisoner is seriously ill and
likes to make contact with the prisoner’s family as soon as possible. She said,
however, that it is a finely balanced decision and requires a great deal of
sensitivity. She explained that she normally listens to the prisoner’s recent
telephone calls to see who they have been in contact with and whether they have
discussed their illness. (All prisoners’ telephone calls are recorded and can be
monitored if necessary.) On listening to the man’s telephone calls, she
understood that he had not told his family he was unwell. She explained that it is
for a prisoner to decide what to tell friends and family, and that staff would never
force them into a decision, or contact family without their consent. She said that
staff would, in most circumstances, contact a prisoner’s next of kin if the prisoner
is admitted to hospital. In doing so, however, they would not reveal details about
the nature of the prisoner’s illness.
79. The prison family liaison officer was also asked how prison staff are expected to
respond to family members telephoning with concerns about prisoners. She was
surprised to learn that the man’s family had not found the officer’s response
helpful and said that she would expect the majority of staff to take action on
receiving such a call. In this case, the SO said she would have expected the
officer to tell the man that his family were worried, and perhaps suggest that he
sent them a Visiting Order, or telephone them to reassure them. She said that
staff could not send out Visiting Orders on behalf of a prisoner, unless the prisoner
21
asked them to do so. The prison family liaison officer said that, ideally, a note of
the family’s concerns should be made in the prisoner’s file, although she accepted
that this did not always happen. (There was no mention of the man’s family
having telephoned the prison in his prison file.)
80. The man’s personal officer explained that, due to shift patterns, staff often do not
know whether a prisoner is receiving visits. However, he said that in his role as a
personal officer he would try to ask prisoners if they were receiving visits and
keeping in touch with friends and family. The man did not mention any problems
with either. The personal officer was clear that, if there had been problems, he
would have tried to discuss these with the man but that he would not have
contacted friends and family unless the man had asked him to.
81. There is no doubt that having a family member who is ill and in prison is extremely
worrying. Lack of information and contact can only make the experience more
stressful for those on the outside. However, it is clearly for individual prisoners
(who have the capacity to make such decisions) to decide what and when to tell
their family. The man was told he most probably had cancer on 27 May. By all
accounts he remained lucid and fully aware of the seriousness of his condition
throughout. Staff at Usk respected his choices and were clear that they could not
have contacted his family without his express permission. I appreciate that this
will be of little comfort to the man’s family, but I agree it must be the case.
The actions of bedwatch staff
82. The man’s family raised concerns about the actions of some individual officers
conducting bedwatch duties while the man was in hospital. They said that most
had acted sensitively and left the room during their visits, however, some staff
stayed throughout the visit and they thought this was unnecessary and intrusive.
83. The Duty Governor told the investigator that there are no specific instructions for
bedwatch, beyond whether the prisoner must be restrained and that staff are
encouraged to use their judgement in other matters. On 6 June, the Duty
Governor decided to increase the level of escort from one to two officers, for the
man’s own safety. He thought it possible that staff on duty after that time might
have believed they needed to stay in the room in the light of that decision.
84. The investigator was provided with the bedwatch logs covering the man’s time in
hospital and found no evidence of purposeful insensitivity. However, staff
undertaking such duties at what is likely to be a highly distressing time for the
prisoner and his family, might benefit from some additional guidance.
The Governor should consider issuing formal guidelines to staff
undertaking bedwatch duties.
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CONCLUSION
85. The man arrived in prison in 2006 with a number of existing health problems. His
health was monitored and he received appropriate treatment when necessary. In
January 2009, the man’s health began to deteriorate. The doctor diagnosed
pleurisy and chest infections and prescribed three courses of antibiotics. After the
third course, the symptoms appeared to clear.
86. In May 2009, healthcare and discipline staff noticed that the man had lost a lot of
weight in a short space of time. The doctor referred the man for chest x-rays at
the local hospital and on 27 May told the man that he probably had cancer. The
man’s health quickly deteriorated. On 3 June, he was taken to hospital, where he
died five days later.
87. The length of time between the man being diagnosed with cancer and his death
was very short and, undoubtedly, shocking for his family. However, this
investigation has found that the care provided to him at Usk was appropriate and
equitable to that he would have received in the community. I make two
recommendations, but do not believe that either would have changed the outcome
for the man.
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RECOMMENDATIONS
1. The Head of Healthcare should ensure that staff make an entry on the medication
chart and/or clinical record whenever medication has not been collected as
required, in line with the Nursing and Midwifery Council standards.
The Prison Service has accepted this recommendation. Nurses will be reminded
to note when a patient fails to collect repeat prescriptions.
2. The Governor should consider issuing formal guidelines to staff undertaking
bedwatch duties.
The Prison Service has accepted this recommendation. Existing instructions will
be amended to ensure future risk assessments/ care plans contain necessary
guidance to staff, which will reflect the sensitivities of each particular prisoner
being managed.
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