Individual at Wakefield

Investigation into the circumstances surrounding the
death of a prisoner from HMP Wakefield,
at Pinderfields Hospital in September 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2008
This is the report of an investigation into the death of a man who died in
September 2007 in hospital while in the custody of HMP Wakefield. He was
61 years old. I extend my sincere condolences to the man’s partner, family
and friends.
A post mortem was held at the request of HM Coroner for West Yorkshire
(Eastern District). The man’s death was from natural causes resulting from
metastatic malignant melanoma, an extremely aggressive form of cancer.
The man had been admitted to hospital on 11 September 2007 after a short
period of being unwell. He had been diagnosed with skin cancer in 2004 and
had had surgery in August of that year. He then attended regular outpatient
appointments. Sadly, his cancer recurred and he died soon after it was
diagnosed.
The investigation was undertaken by one of my investigators. I would like to
thank the then Governor of Wakefield and his staff for their help and
assistance. I am especially grateful to two senior managers.
A review of the man’s medical care at Wakefield was commissioned from
Wakefield and District Primary Care Trust. I acknowledge the contributions
from a senior nurse advisor and the Director of Patient Expereince/ Chief
Nurse Mid Yorkshire Hospital NHS Trust. A panel of clinicians carried out the
review and their report was then further reviewed by a General Practitioner. I
am most grateful to all the clinicians for their assistance. However, However,
the clinical review into the man’s death was not received in my office until late
April 2008 and this has resulted in the delay in my issuing this report, for
which I must apologise.
I make three recommendations for the attention of Wakefield and District
Primary Care Trust, and one recommendation for the Governor at Wakefield
in relation to visiting arrangements for relations of terminally ill prisoners. I
also comment on two areas of good practice.
In this final report I acknowledge the PCT’s request to delete a paragraph
from the investigation process in relation for the Independent Monitoring
Board’s report. The PCT have responded to the recommendations and action
has already been taken to address those issues highlighted.
The man’s partner and sister have also responded to the draft report. Their
responses have been added into the report under Family Issues
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2008
CONTENTS
Summary
The investigation process
HMP Wakefield
Key findings
Issues
Recommendations and Good Practice
SUMMARY
The man was remanded to HMP Leeds in August 2004. This was his first
time in prison. In September 2004, he was sentenced to seven years and
nine months imprisonment for serious offences. After his conviction, he
remained in Leeds for five weeks and then transferred to HMP Wakefield on 8
October.
Shortly before the man’s conviction, he had been diagnosed with a malignant
melanoma on his back for which he underwent surgery in August 2004. (This
is an extremely malignant form of cancer spread by lesions or via the
lymphatics or blood stream which can invade any organ of the body,
especially the lungs, liver, brain, skin and bones.) During his time in both
Leeds and Wakefield, the man attended outpatient clinics with a dermatologist
and plastic surgeon. In November 2004, he had further surgery on his back,
and thereafter there was no sign of any residual melanoma. The man was
prescribed medication for high blood pressure, high cholesterol and heart
related disease. He continued to have regular outpatient appointments for the
next few years.
On 3 July 2007, the man was seen at the first contact clinic with a swollen left
leg, knee and ankle. On 10 July, the prison doctor prescribed medication and
advised him to rest his leg on two pillows. Three weeks later, the man visited
healthcare complaining of chest pain, shortness of breath and sweating. His
observations were taken and an electrocardiogram (ECG) was performed to
trace his heart functions. The man was then taken to the local Accident and
Emergency Department at a hospital and discharged later that day.
On 6 August, the man attended healthcare again as he was having dental
problems with some numbness on the side of his face. Painkillers were
prescribed, he was advised to see the doctor if the symptoms persisted, and
an urgent appointment was made for him to see the dentist. The man was
seen on two further occasions by nurses as the symptoms persisted. Both
nurses prescribed painkillers but did not refer him to the doctor.
Just over a month later, whilst in the prison library on 7 September, the man
became unwell with chest pain. An ECG was performed that indicated that,
since the previous ECG, there had been changes to his heart rate. As a
result, he was taken to hospital by emergency ambulance. He was
discharged the following day having been diagnosed with a chest infection for
which he was prescribed antibiotics and painkillers.
On 11 September 2007, a nurse was called to see the man in his cell as he
was complaining of pain in his lower left lung and his right leg was noticeably
swollen. The nurse referred him to the doctor who noted that the man had
been diagnosed with a chest infection four days earlier, and thought the
swelling in his leg might have indicated a deep vein thrombosis (DVT). The
man was again taken to hospital, under escort, and admitted to the High
Dependency Unit. During his stay, the prison kept in regular contact with the
hospital.
The man was told by doctors on 20 September that he probably had cancer
and the diagnosis was confirmed eight days later. His condition deteriorated
rapidly and he was told that his life expectancy was only a few days.
The prison contacted the man’s relatives to inform them of the situation and
advised that, in view of his decline, they might wish to visit him sooner than
their planned visit in two days. When the man’s relatives arrived at the
hospital they were initially refused access to his room as there was no female
officer available to search them. After 45 minutes, no female officer had
arrived at the hospital so the bedwatch officer allowed the visitors to stand by
the man’s bedside until the officer arrived. The searching procedures were
then carried out.
The man’s condition continued to deteriorate and, on 30 September, medical
staff requested that his restraints be removed. The duty governor authorised
their removal at 10.00am. At 2.25pm, his family visited again and stayed for
three and half hours. Staff said that if the man’s situation became critical they
would contact them. At 9.00pm, medical staff informed the bedwatch officers
that the man’s condition was critical. His family was contacted and advised to
return to the hospital. However, he died shortly before they arrived. The
man’s death was confirmed at 11.10pm.
After the man’s death, the prison chaplain provided support for the family.
The chaplain also officiated at his funeral and conducted a memorial service
in the prison chapel.
I have made four recommendations and identified two areas of good practice.
THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened on 4 October
2007 when my investigator visited HMP Wakefield. She met the
then the Governor and a senior manager. My investigator handed
over notices and the Ombudsman’s terms of reference. Members of
the Independent Monitoring Board (IMB) and the Prison Officers’
Association (POA) did not wish to meet my investigator. During the
visit, she went to C wing and spoke to a friend of the man. She also
spoke to the chaplain.
2. My investigator and one of my family liaison officers, visited the
man’s sister and partner on 12 November at his sister’s home. Both
family members praised the support of the chaplaincy and members
of prison staff for their help and assistance whilst the man was in
hospital and following his death. Nevertheless, they raised the
following points in relation to the man’s medical care and his time in
hospital:
(cid:127) Can the clinical review comment on the speed of the deterioration
in the man’s health?
(cid:127) Why was the recurrence of cancer not picked up by the six monthly
checks?
(cid:127) Was the fact he was restrained for most of his stay in hospital
reasonable?
(cid:127) Why were the family dealt with so rudely when they arrived at the
hospital just before the man’s death?
3. I have addressed these concerns later in this report. Although
issues relating to the care by the hospital fall outside the remit of my
report, I will address matters in respect of the prison’s medical care.
4. My investigator returned to Wakefield on 19 November 2007 to
carry out interviews with staff and prisoners. The following day, she
was joined by one of the clinical review panel members, and
together they interviewed members of healthcare staff.
HMP WAKEFIELD
5. HMP Wakefield holds male prisoners serving four years or over,
including life sentence prisoners. The prison is part of the high
security estate, taking those prisoners who potentially pose the
greatest risk to the public. It specialises in the treatment of serious
sex offenders.
6. The prison provides workshops and an education department
offering both full and part-time education. The programmes
department offers a range of offending behaviour courses including
FOCUS (a drug programme), the Sex Offender Treatment
Programme (SOTP), and the Enhanced Thinking Skills (ETS)
programme.
7. The most recent report by HM Chief Inspector of Prisons was
published in April 2005 after an unannounced follow-up inspection.
The report said of healthcare:
“There had been little change in healthcare facilities since the
last report. Wakefield provided 24 hour care for prisoners and
had a 20 bed inpatient facility. Staff were enthusiastic and
committed to improving services but there appeared to be a lack
of strong clinical leadership particularly in primary care area.”
8. This is the ninth death my office has investigated at Wakefield since
2004 and the second death by natural causes investigated by my
investigator. The previous death investigated by her was in entirely
different circumstances to that of the man.
KEY FINDINGS
9. The man was received into HMP Leeds, on remand, in August
2004. On reception, he told staff of a history of skin cancer on his
back and that he had recently undergone an operation for the
removal of a malignant melanoma (growth), with four stitches
remaining in place. He also said he had problems with his blood
pressure, chest pain, and a family history of coronary heart disease.
The man had an outstanding dermatology outpatient appointment at
a hospital in Bradford on 1 September. This appointment was
subsequently re-arranged for 20 September. The man attended
and was referred to a plastic surgeon.
10. Four days later, a consultant dermatologist at the hospital faxed to
Leeds a confidential report dated 6 September. The fax explained
the seriousness of the illness and also requested that the
information not be disclosed to him. The man continued to receive
medical care at Leeds. In September 2004, he was sentenced to
seven years and nine months imprisonment.
11. The man transferred to Wakefield on 8 October. His reception
health screen document noted his previous medical history,
including the removal of the melanoma. The prison medical officer
wrote to a consultant plastic surgeon at a hospital referring the man
for an urgent appointment as he had been unable to attend a
previously booked appointment. He also referred the man to a
consultant dermatologist. The man continued with his prescribed
medication of atenolol, simvastatin, doxazosin and aspirin, for high
blood pressure, high cholesterol and heart related disease.
12. Two weeks later, the man was seen by a plastic surgeon at a
hospital who listed him for further surgery on his back. This took
place on 4 November at hospital. A diagnosis was given that that
there was no residual melanoma and he returned to Wakefield the
following day. He attended an outpatient appointment a month later
to have his dressing checked.
13. The man was seen regularly in healthcare for medication reviews
between November 2004 and June 2007. Whilst his medical notes
record some back pain, there are no significant entries. There was
no record in the man’s wing file with reference to his medical
condition.
14. The consultant dermatologist at hospital wrote to the prison medical
officer on 16 February 2005 to confirm that there had been no
recurrence of the skin cancer, no lymphadenopathy (swelling of the
lymph nodes), and nothing else of concern following the surgery in
November. The man attended an outpatient appointment the
following day at the plastic surgery clinic.
15. Following further reviews with the man, the consultant dermatologist
subsequently wrote to Wakefield in June and October 2005 to
confirm that there had been no recurrence of the melanoma or
lymphadenopathy. In June 2006, the consultant saw the man again
and noted, in a letter to the medical officer, that there were no
problems regarding the melanoma on his back. The naevus (a
small dark spot of skin) was unchanged and there were no worrying
features when he was examined through a dermatoscope (a hand
held optical device for examination of the skin). The man was to be
seen again in four months time.
16. On 20 June 2007, following another outpatient appointment, the
consultant dermatologist informed the prison medical officer that
there were no continuing problems and the man would be
discharged from the clinic after his six-month review.
17. The man went to the first contact clinic in the prison’s healthcare on
3 July. His left leg was swollen between his ankle and knee. An
urgent referral was made and, a week later, he was seen by the
doctor who prescribed medication and advised the man to raise his
leg on two pillows at night.
18. Healthcare staff saw the man again on 24 July when he reported
chest pain, shortness of breath and sweating. He was given an
electrocardiogram (ECG) to trace his heart functions. His
observations were also noted and showed blood pressure of 176/95
with a pulse rate of 40. The man was taken, under escort, to the
Accident and Emergency Department of the local hospital. There is
no other information in his medical notes as to the outcome of this
referral, but the clinical reviewer points out that this is apparently
normal practice for prisoners attending Accident and Emergency.
19. The man’s medical record shows that on 6 August he failed to
attend a doctor’s appointment at the healthcare unit. On 23 August,
the man was seen by the nurse. He was complaining of dental pain,
some numbness on the left side of his face and a foul taste in his
mouth. He was already using paracetamol for pain control and a
mouthwash. The nurse noted there was no drooping or swelling of
his face. The man was advised to make an appointment with the
doctor if the sensation returned.
20. The man had ongoing dental problems with dental caries. On 6
September 2007, he was seen again in healthcare by a nurse who
noted in his medical file that he needed to see a dentist urgently and
to carry on with the pain control and mouthwash. Unlike the
previous nurse who saw him in August, this nurse did not refer him
to the doctor.
21. The following day, the man became unwell whilst in the prison
library. A code blue alert was made (a communication radio call to
healthcare staff to attend as a matter of urgency) and healthcare
staff went to the library. On arrival, the nurse noted that the man
was sweating, clammy to touch, short of breath and complaining of
central chest pain radiating to the right shoulder. An ECG was
carried out that indicated some changes from his previous ECG two
months before. The man was escorted to hospital by emergency
ambulance.
22. The man was discharged from hospital the following day and
returned to his wing on normal location. The discharge information
form noted that he had been diagnosed with a chest infection. The
man was prescribed antibiotics and pain control. He was also
advised to stop smoking, to take exercise and to continue with his
regular prescribed medication. By this time the man was having
difficulty sitting up in bed and was eating very little. Other prisoners
from his wing assisted the man by collecting his food and helping
him maintain his personal hygiene.
23. At 8.30am on 11 September, a nurse was called to see the man on
the wing. He was complaining of pain in the lower left lung, and his
right leg was swollen and noticeably larger than his left. The nurse
referred the man to the doctor, who examined him at 10.10am. The
doctor noted that the man had been diagnosed with a chest
infection the previous week whilst in hospital, and there was gross
swelling in his right leg with a very tense calf. The doctor requested
an emergency ambulance to take the man to the hospital’s Accident
and Emergency Department to rule out the possibility of a deep vein
thrombosis (DVT). The man was escorted to hospital by two
officers under a double handcuff restraint.
24. On arrival at hospital, doctors examined the man and moved him to
the High Dependency Unit (HDU) for observation and treatment.
On the advice of medical staff, the man’s restraints were removed
and a single escort chain was used. On 16 September, the man
was moved from HDU to a general ward. His partner and sister
arranged, through the prison’s visitors centre, to visit him that
afternoon and during the evening two days later. The man’s
condition was gradually deteriorating.
25. On 20 September, the man was seen by a hospital doctor who
informed him that he probably had cancer. Three days later, he
received another visit from his partner and sister, and his two sisters
visited him on 26 September. At that point, the man was eating very
little and a drip had been inserted to increase his fluid intake.
26. The man was told by a doctor on 28 September that the cancer had
spread to his kidneys and his life expectancy was only a few days.
The bedwatch officer, informed the control room of the situation and
suggested that the man’s visitors arrange a visit sooner than the
one booked for 30 September. The control room then contacted the
man’s partner. It is unclear what the staff member told her, but it
seems they did not make it clear that the re-scheduled visit had to
be booked in the usual way. As a result, a formal visit was not
arranged.
27. The man’s partner and sister arrived at the hospital at 1.45pm on 28
September. However, a governor informed them that they would
not be allowed to see the man until a female officer had arrived from
the prison to search them. At 2.30pm, as the officer had not arrived,
the bedwatch officer decided to permit the visitors to see the man,
but without any physical contact until they could be searched. The
officer arrived at 2.40pm and conducted the search procedure. The
visitors left at 5.15pm and were advised to contact the visitors
centre to book a time to return the following day. The next day, the
man’s visitors arrived at the hospital at 2.10pm. The bedwatch
officer telephoned the visitors centre to arrange further visits for the
family.
28. At 6.00am on 30 September, nursing staff informed the bedwatch
escort that the man’s condition was deteriorating rapidly and
medical staff might shortly request all restraints to be removed. At
10.00am, a governor gave permission for the restraints to be
released. The man’s partner and sister visited at 2.25pm. At
5.20pm, the bedwatch escort notified the prison that the man’s
visitors had been allowed to remain by his bedside as his condition
continued to deteriorate. The visitors left at 5.50pm, having been
informed that if the man’s condition became critical they would be
contacted immediately.
29. At 9.00pm, medical staff informed the bedwatch escort that the man
was close to death. The escort contacted the prison who, in turn,
telephoned his relatives to advise them to return to the hospital.
Unfortunately, he died at 10.44pm and his death was confirmed at
11.10pm. Five minutes later, at 11.15pm, the man’s relatives
arrived at the hospital and were met by a governor who told them
the sad news.
30. The chaplain visited friends of the man’s in HMP Wakefield to tell
them of his death. The bedwatch notes indicate that officers were
supported by senior managers during the man’s time in hospital.
31. The chaplain provided support for the family. He also conducted the
funeral service and a memorial service, attended by the man’s
family, was held in the prison’s chapel. While they were at the
prison, his family was given to the opportunity to meet his friends.
The prison offered the family financial assistance towards the costs
of the man’s funeral.
ISSUES
Key findings from the clinical review
32. An interim report on the man’s medical care was carried out by a
panel of clinicians from Wakefield and District Primary Care Trust
(PCT). A GP was then commissioned by the PCT to complete the
clinical review. The review was based on the man’s post mortem
report, medical record, interviews with medical staff and copies of
his outpatient letters.
33. The GP has noted:
“…The man had been diagnosed with a malignant melanoma in
2004. The melanoma was treated with surgery in November
2004 with no obvious recurrence. In September 2007, the man
was admitted to hospital with chest pain, and a possible deep
vein thrombosis (DVT) or pulmonary embolus. He was also
found to have a widespread and incurable metastatic malignant
melanoma. The man died shortly after the diagnosis.”
34. Following the initial surgery, it is normal practice to have further
surgery for a much wider excision of the mole. However, the clinical
review finds there was a delay in referring the man to the plastic
surgeon, so this second surgical procedure did not take place until 4
November. Some of his outpatient appointments had been
cancelled for security reasons, though there is no documentation to
evidence this other than a handwritten note on the appointment
letter by the security governor.
35. Following the second surgical procedure, the man was referred to
the dermatologists for reviews of his medical condition and he
attended outpatients for six monthly reviews. At the first review, a
consultant dermatologist said he would have wished to refer the
man for trial therapy to treat the deep melanoma found during the
first surgery in July 2004. This did not take place as the referral
should have been made within eight weeks of the surgery.
36. It was considered that the man was at risk of developing coronary
heart disease, but it is difficult to ascertain from his written medical
record the overall assessment of this risk and any steps taken to
prevent it. The man had multiple blood pressure readings and was
treated with atenolol and doxazosin, which are anti-hypertension
medications. In addition, he took simvastatin, a cholesterol reducing
drug, but the dosage was altered at times and it seems the man
took this medication intermittently. The drug prescribing record is
also inadequate.
37. The man suffered chest pain on 24 July 2007, thought to be
coronary, and was treated with aspirin and oxygen. He was
admitted to hospital but returned the same day. There is no
discharge letter in the man’s medical records so it is not possible to
know how the hospital viewed his presentation or investigations.
There is no record of any advice given or any medication dispensed
at the discharge. Neither is there evidence of any assessment on
the man’s return to prison.
38. On 7 September 2007, the man had further possible cardiac chest
pain and he was again taken to hospital by emergency ambulance.
He remained in hospital overnight and blood tests were carried out.
Later that day, he returned to Wakefield with a diagnosis of a chest
infection and a prescription of amoxicillin, an antibiotic. No follow up
was arranged and the man was returned to his cell.
39. Three days later, the man presented with further chest pain and a
swollen right leg, thought to be a deep vein thrombosis (DVT). An
emergency ambulance was called and the man was taken to
hospital. On 21 September, it was determined that he had cancer
and he was referred to the cancer services. As noted earlier, the
man died at 10.44pm on 30 September.
Issues arising from the key findings
40. The man’s medical records show a significant variation in the
legibility of information recorded and ownership of many of the
entries. It significantly impeded an assessment of his hypertensive
care. A new computerised system was introduced to Wakefield on
1 August 2007 that led to a substantial improvement with legible
entries and accurate dating. The doctors have passwords to enter
the system with meaningful and specific entries in their name. The
clinical reviewer notes that:
“The doctors had a good understanding of the need to record
accurately with sufficient detail to allow the team caring for
prisoners to be sufficiently informed as to make important
decisions if needed.”
41. Prior to the man’s imprisonment, he had undergone a localised
excision of a melanoma of two millimetres or more in depth. This
carried with it a 25 per cent risk of microscopic spread. It is not
known whether the delay in referring him for a wider excision
increased the risk of metastatic disease, but the delay did exclude
the man from the entry criteria for trial medication. Standard
General Practice would aim for a two week period between initial
presentation of a suspicious lesion and its excision. The
expectation would be for wider excision to be carried out within a
short period of time. This timescale was clearly not provided for in
the man’s case. The GP says he understood that the appointments
made for the man whilst he was at Leeds were stopped on security
grounds, but there was no evidence of any discussion with medical
staff as to the need for the outpatient appointments or indeed a
timescale for them.
42. The man’s medical record included a letter from his solicitor dated
26 August 2004. The letter requested that the man attend his
outpatient appointment on 1 September. A security governor at
Leeds had made a handwritten note on the letter that the man could
not attend the appointment because the fact he was aware of the
date and time made him a high security risk. Another appointment
was booked for 8 November. My investigator contacted the security
department at Leeds but they held no records for the man.
43. Although this cancelled appointment occurred at Leeds, it would
appear that within the primary healthcare setting in Wakefield there
is no clinical lead for cancer patients, no register of cancer patients,
and no system for auditing the decision making processes around
appointment planning. At interview, the doctors did not consider it
was their role to interfere in the appointment planning process.
44. I endorse the following recommendations taken from the clinical
review:
The Primary Care Trust should appoint a lead clinician.
Clinical leads should be identified to provide leadership and
governance on important clinical areas such as cancer care
and chronic disease management. This should be supported
by the development of the Primary Care Team and
management changes to support these developments.
A reassessment of referral arrangements should be carried
out. An up to date list of referrals with auditing to ensure
attendance, transport and escorts are all in place. Cancellation
of arrangements made within a prison should be flagged up
and assessed against the clinical needs of the patient. A
clinical lead may be necessary to ensure that medical factors
are sufficiently weighed by all parties when making
arrangements regarding hospital attendance.
45. The management of the man’s hypertension was generally effective,
in that multiple blood pressure results showed that he was largely
kept within the normal range. The introduction of the computer
medical record system should allow for better documentation, both
in issuing medication and the registration of risk factors, blood
pressure, cholesterol, weight and smoking. The system should
allow for the pro-active making of appointments as well as auditing
patients who do not return for routine screening.
46. The management of the man’s acute admissions seems to have
been relatively smooth with admissions to Accident and Emergency
being justified. However, The GP raises concerns about the man’s
rapid return to prison having being referred with a potentially
significant illness and it seems he was not reassessed on his return
to Wakefield. There did not seem to be any regular system of
reassessment, or any prior discussion with hospital staff before a
patient was discharged, to ensure the hospital understood the
prison’s requirements. There was no assessment of the man’s
placement in the prison on his return. Without such an assessment,
there is a risk of patients returning to a cell area whilst unfit to be
there, particularly at nights and weekends. There appeared to be
only one discharge note received following his two attendances at
the hospital.
47. The GP questions whether the man’s discharge on 8 September
was appropriate, given his relatively rapid re-admission. He also
wonders whether at that time the man had a chest infection or a
pulmonary embolism, based on his ECG change and the post
mortem findings. The GP considers that the whole area of
communication around the discharge of potentially significantly ill
prisoners needs to be assessed.
48. I endorse the following recommendation taken from the clinical
review:
I recommend that the arrangements for the return of a prisoner
from hospital allow for a proper assessment of the prisoner’s
continuing needs. This would include a proper assessment of
continuing symptoms, the need for appropriate medication and
a suitable location within the prison. This should be available
both out of hours and during normal working hours.
Family issues
49. On 12 November 2007, my investigator and one of my family liaison
officers visited the man’s sister and his partner. Both said that the
prison had supported them following his death, and they were
grateful to the chaplain for his assistance in helping to arrange and
officiate at the man’s funeral. The issues they raised about the
deterioration in his health and the recurrence of his cancer have
been discussed within the clinical review and the main body of this
report. The remaining questions about the man being restrained in
hospital and the handling of his family are dealt with below.
Restraints
50. The man was a category B prisoner held at a high security prison. He had
been convicted of serious offences but had not been able to participate in
any relevant offending behaviour programmes as he had denied his
offences. Moreover, as the man was formerly a locksmith by trade, this
raised significant security issues. Wakefield has a local security instruction
manual. The instruction regarding restraints for prisoners in outside
hospital says: “The prisoner must in normal circumstances be secured to
one of the officers by means of mechanical restraints. The risk
assessment will indicate whether this will by double handcuffing or escort
chain only.” The man’s risk assessment before he was admitted to
hospital on 11 September noted that he had previously been on the E-list
(escape list) due to his previous occupation as a government locksmith.
The man’s restraint was an escort chain.
51. At the request of medical staff, and duly authorised by a governor, the
escort chain was removed at 10.00am on the day the man died. His
condition was deteriorating rapidly and any further use of restraint was
clearly inappropriate. Whilst I entirely understand the family’s distress that
restraints were used until twelve hours before the man died, staff were
following the prison’s security manual on the use of restraints for category
B prisoners and the prison regarded him as being at increased risk in view
of his former occupation. I think these were not unreasonable judgements
in the circumstances.
52. I frequently comment on the difficulty facing prisons in balancing the
need for public protection and the compassionate management of
seriously ill or dying prisoners. In several recent reports, I have
been critical about the lack of flexibility in local policies on
bedwatches. The Prison Service accepted my recommendation in a
previous report about the need for explicit instructions on how to
manage gravely ill or dying prisoners in outside clinical
environments. In addition, a review of the use of restraints during
hospital escorts and bedwatches has been undertaken following the
case of G in the High Court in November 2007. The policies within
the Prison Service’s National Security Framework (NSF) have been
amended to take account of prisoners who are seriously or
terminally ill and the need to balance their changing physical
condition against the need to provide the public with adequate
protection. In view of this, I make no further recommendation.
Events on 28 September 2007
53. Both the man’s sister and partner were unhappy with the reception
they received on arrival at hospital in the early afternoon of 28
September. They both felt that a member of prison staff spoke
rudely to them when they arrived to see the man, following
information that he was very ill. The member of staff has been
identified as a governor who was carrying out a management and
security check at the hospital. The governor was unaware that the
man’s relatives had arrived at the hospital and there was no female
officer to carry out searching procedures on the visitors.
54. The bedwatch officers made contact with the prison and requested a
female officer to attend the hospital as soon as possible to search the
man’s visitors. Unfortunately, this was over lunchtime and it took
some time to identify an officer and dispatch her to the hospital. Both
the man’s relatives had to remain outside the ward to wait for the
officer to arrive. The relatives became anxious and they felt the
governor was unsympathetic, rude and failed to recognise their
distress.
55. The governor responded to my enquiry to give his version of the
incident. He told me that he was not aware that the man’s family had
been contacted by the prison to inform them of the man’s
deteriorating condition. A female officer had not been told to attend
the hospital and, when he became aware of the situation, he made
sure the prison was sending someone as soon as possible. The
governor thought that one of the relatives became angry at having to
wait for security searching, but said that he apologised to them and
expressed his sympathy concerning the man’s medical condition.
56. The local security instructions for bedwatches say:
“Visits to prisoners will be booked in the usual way by phoning
the prison visits booking number. (Visits booking staff will tell the
prisoners visitors that no money, property or food will be taken for
the prisoner.) This will allow the Security Department to ensure
that the correct staff are available for searching purposes i.e. a
female officer to search female visitors etc.”
57. It was understandable that the man’s relatives were upset when they
arrived at the hospital and told they could not see him as there was
no officer to carry out searching procedures. They had been
telephoned by the prison and had been told he was very ill. They
were asked to arrange to come and see him before the next visiting
time, booked for Sunday 30 September. All visits to Wakefield
prisoners in hospital are arranged through the visitors centre and are
in accordance with usual visiting patterns for a prisoner. I
understand that the governor had not been alerted to the situation
and was therefore surprised to see the man’s relatives at the hospital
ward. However, this was a sensitive situation and, whatever exactly
passed between them, communication between the prison and the
man’s relatives was unsatisfactory. I therefore recommend that the
Governor ensures that, where a prisoner is on bedwatch at an
outside hospital, and becomes very ill, a family liaison officer is asked
to make visiting arrangements on their behalf.
The Governor should ensure that the local security instruction
manual is amended to include guidelines for informing relatives
of prisoners who become terminally ill at outside hospital, and
arrange for a family liaison officer to make suitable visiting
arrangements on their behalf.
Family response to draft report
58. The man’s partner responded to the draft report and noted that the
man did not see a dentist even though an urgent appointment was
requested for him to see a dentist. She further noted that the man
did not seem to have a full medical assessment when he returned to
the prison following an emergency admission to hospital.
59. The man’s partner felt the legibility of the medical records were poor
and concluded her response by noting that in her view her partner
would have received better treatment in the community for his
condition.
60. The man’s sister also responded to the draft report. She noted the
poor standard of written medical notes. The man’s sister questioned
the time her brother waited to see the doctor on the 11 September,
after being seen by the nurse. To clarify this point, the doctor saw
her brother as soon as practicable after he arrived for his duty at the
prison that morning.
61. A second point raised by the man’s sister referred to her brother
saying he was on the wrong medication as noted in an annexe. I am
unable to comment on this point other than it may have been the
man’s own opinion on to what he was being prescribed. All his
prescribed medications were correct for the symptoms he was
presenting at the time.
62. The final point the man’s sister wished to comment upon was the
event on 28 September 2007, when she arrived at the hospital with
the man’s partner following the telephone call from the prison. The
man’s sister did not agree with the governor’s memory of the meeting
outside the hospital ward. She felt that his demeanour was rude and
insensitive. The man’s sister and partner were confused and upset
at the news that he was very ill and the governor did not help the
situation by his inappropriate behaviour towards them. This was in
complete contrast to everyone else they met, hospital or prison staff.
63. The man’s sister thought the recommendation for a family liaison
officer to be appointed for seriously ill prisoners was a good way
forward nevertheless, her experience that day was less than
satisfactory.
64. Finally, the man’s sister said how comforted they had felt by the
impression that he had been very well liked and respected by both
prisoners and staff. They were apparently told this many times when
they visited the prison.
Bedwatch
65. With the exception of the incident on 28 September, The man’s
family were very grateful for the support offered and for the sensitive
manner in which the escorting officers carried out their duties whilst
at the hospital.
66. The bedwatch notes detail all relevant information whilst the man
was an in-patient and were kept in a clear and concise manner. The
notes were informative and accurately recorded all the interventions
in relation to the man’s care.
I note the sensitive way in which the bedwatch officers cared
for the man and his family, and the well-recorded bedwatch
notes.
Family support
67. The man’s family expressed their gratitude to Wakefield’s chaplain,
for his help and assistance following the man’s death. The family
was also appreciative of the support from two senior managers for
their sensitive approach.
I commend Wakefield’s continuity of care following the death of
a prisoner, and in this particular case the actions of two senior
managers and the chaplain.
RECOMMENDATIONS
For Wakefield Primary Care Trust
1. The Primary Care Trust should appoint a lead clinician. Clinical leads
should be identified to provide leadership and governance on important
clinical areas such as cancer care and chronic disease management.
This should be supported by the development of the Primary Care
Team and management changes to support these developments.
Accepted – This is being processed through the strategic outline plan
08/09 (primary care project); currently recruiting a lead clinician; new
operational and clinical management arrangements are being
processed.
2. A reassessment of referral arrangements should be carried out. An up
to date list of referrals with auditing to ensure attendance, transport and
escorts are all in place. Cancellation of arrangements made within a
prison should be flagged up and assessed against the clinical needs of
the patient. A clinical lead may be necessary to ensure that medical
factors are sufficiently weighed by all parties when making
arrangements regarding hospital attendance.
Accepted – An Escorts and Bedwatches (E&BW) project manager is in
post. Medical lead to be appointed to carry out clinical audits.
3. I recommend that the arrangements for the return of a prisoner from
hospital allow for a proper assessment of the prisoner’s continuing
needs. This would include a proper assessment of continuing
symptoms, the need for appropriate medication and a suitable location
within the prison. This should be available both out of hours and during
normal working hours.
Accepted – E&BW project manager in post; lead nurse in post;
medical lead to be appointed to carry out clinical audits.
For the Governor of HMP Wakefield
4. The Governor should ensure that the local security instruction manual is
amended to include guidelines for informing relatives of prisoners who
become terminally ill at outside hospital, and arrange for a family liaison
officer to make suitable visiting arrangements on their behalf.
Accepted - LSS (2.21) to be amended to identify when a prisoner is
terminally ill, the Family Liaison Officer (FLO) is contacted to arrange future
visits.
GOOD PRACTICE
5. I note the sensitive way in which the bedwatch officers cared for the man and
his family, and the well-recorded bedwatch notes.
Accepted
6. I commend Wakefield’s continuity of care following the death of a prisoner,
and in this particular case the actions of two senior managers and the
chaplain.
Accepted