Individual at Wakefield

Investigation into the circumstances surrounding the death
of a prisoner at Pinderfields Hospital, while in the custody of
HMP Wakefield in April 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 48 year old man, who died at
Pinderfields Hospital on 1 April 2007. The man was serving a life sentence and was
in the custody of HMP Wakefield. I would like to offer my sincere condolences to his
family and friends for their sad loss.
One of my investigators, conducted the investigation. Wakefield Primary Care Trust
(PCT), commissioned a review of the man’s clinical care and treatment in custody.
I am grateful to the Governor of Wakefield, for his cooperation with the investigation.
I am particularly indebted to the governor who was the appointed liaison officer, they
have been very helpful to both my investigator and to the man’s family.
On 30 March 2007, the man who died was taken to Clayton Hospital to have a follow
up x-ray for an ongoing chest infection. When the x-rays were examined, he was
immediately taken to Pinderfields Hospital where he was admitted for further
observations. The man was told that he had fluid on his chest that needed to be
drained, and that he was expected to be at Pinderfields for approximately four days.
However, on 1 April, he died unexpectedly. A post mortem concluded that the cause
of death was tuberculosis.
I apologise for the delay in issuing this report. The results of medical tests and the
outcome of the post mortem were not notified until seven months after the death.
Consequently, this delayed the clinical review which in turn meant I could not
complete this report.
It seems clear that the man received a good standard of care at HMP Wakefield. I
have made one recommendation regarding record keeping and highlighted one area
of good practice in health promotion.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2008
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CONTENTS
Summary 4
The investigation process 5
HMP Wakefield 6
Key findings 7
Issues 12
Recommendation and good practice 16
3
SUMMARY
The man was sentenced to life imprisonment in February 1995. In May of that year
he transferred to HMP Whitemoor - where he remained until 1999 when he
transferred to HMP Full Sutton. His final transfer was to HMP Wakefield in
December 2003. The only major medical concern during this period was a heart
attack suffered at Whitemoor in August 1996.
In November 2006, after feeling unwell for some time, he was diagnosed as diabetic.
He attended a first contact clinic in January 2007 for conditions mostly associated
with his diabetes, but also complained of a cough and weight loss. As a result, he
was referred for a chest x-ray at Pinderfields Hospital which took place on 16
February. The x-ray confirmed that he had a chest infection for which he was given
a course of antibiotics. A follow-up x-ray was arranged. During the following weeks,
the man continued to lose weight and the healthcare team at the prison prescribed
Ensure as a nutritional supplement.
In March 2007, he was again seen by the prison doctor. Although he felt that he had
improved, the doctor explained that he would still need to have another x-ray in April.
Around two weeks later, the man was seen by nursing staff and his cough had
returned. Samples of sputum were taken and sent for analysis. The results were
negative indicating no serious infection.
The man attended Clayton Hospital on 31 March. After the x-ray, he was sent
urgently to Pinderfields Hospital. A consultant at Pinderfields explained that his
chest would have to be drained because of a build-up of fluid. He was admitted and
treatment began. The escort staff said that the man was settled and spent most of
the first night in hospital awake and talking with them.
On 1 April 2007 at around 2.30am, the man appeared to be having a panic attack.
Nurses attended to calm him down and he appeared to relax. However, at 4.10am,
escort staff again alerted the nurses as the man’s breathing had become very
shallow and he appeared to be in distress. The nursing staff administered oxygen
therapy. At 5.12am, he removed his oxygen mask and appeared to go to sleep. The
escort staff were concerned by this and, on checking him, discovered he was not
breathing. They immediately called for medical assistance. Medical staff entered
the room at 5.15am and attempted to resuscitate him, but at 5.30am a doctor
pronounced that he had died.
The provisional findings of the post-mortem suggested the man had died from
natural causes. After a considerable period, further tests on a sample taken from
him prior to his death confirmed the presence of tuberculosis. In light of this
information, the prison and local PCT put in place an action plan to minimise the
potential risk to those who had been in contact with the man and to provide support.
This report reflects well upon the care offered to the man by HMP Wakefield. The
report makes one recommendation relating to medical record keeping which has
been accepted by the Prison Service. It also highlights one area of good practice
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THE INVESTIGATION PROCESS
1. My investigator opened the investigation at HMP Wakefield on 2 April 2007.
Notices were issued to staff and prisoners inviting anyone with any information to
come forward. The investigator visited Wakefield on 12 April and collected
background documents.
2. Having reviewed the documents, three members of staff were identified for
interview and the investigator attended the prison on 12 June, with a colleague,
to conduct these interviews. Whilst at the prison, he also interviewed a prisoner
who had responded to the notices. The prisoner had known the man and had
contacted the investigator with concerns about the medical care.
3. During the interview with the prisoner, my investigator was made aware of three
other prisoners that had the same concerns about the man’s medical care. He
spoke to these prisoners and asked them to put in writing their concerns so that
he may follow them up. On receipt of these letters, the investigator passed on
the concerns to the clinical reviewer so that they could be looked into in more
detail.
4. Wakefield Primary Care Trust carried out an independent clinical review of the
man’s healthcare at Wakefield.
5. One of my family liaison officers contacted the man’s family. Although they
declined the offer of a home visit, they raised some issues for further
investigation and clarification. They were mainly concerned about the medical
care, in particular whether he had been diagnosed with pneumonia and why he
had not been admitted to hospital sooner. I hope I have been able to answer
their questions in this report.
6. I should record here, however, that the family were very pleased with the support
and assistance they had received from the prison following the man’s death.
They singled out the prison’s family liaison officer, for particular praise.
7. HM Coroner provided a copy of the post mortem for the investigator. It
concluded that death was due to natural causes and that the man had
succumbed to severe infection within the lungs comprising an empyema (the
collection of pus within a body cavity), lobar pneumonia and pulmonary
tuberculosis.
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HMP WAKEFIELD
8. HMP Wakefield is a prison for male prisoners serving four years or over,
including life sentence prisoners. It is part of the high security estate, housing
prisoners who potentially pose the greatest risk to the public or state.
9. The prison’s healthcare centre is separate from the main residential areas. All
the cells have integral sanitation and the prison has recently undergone
refurbishment.
10. The most recent report by HM Chief Inspector of Prisons, Ms Anne Owers, was
published in 2005 and followed an unannounced follow-up inspection. The report
concludes:
“Overall, Wakefield was clearly a prison on the move. But there was a great
deal of movement still required in order to make it a fully effective prison, able
to engage properly with the serious and difficult offenders that it holds.”
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.”
11. A report by the prison’s Independent Monitoring Board (IMB) in 2006 praised the
healthcare department, which was said to do good work under difficult
circumstances due to the lack of engagement by the PCT. The IMB also
commented that staff morale was at an extreme low. However, the Board
congratulated healthcare staff for the provision of palliative care to a number of
terminally ill prisoners.
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KEY FINDINGS
Events leading up to the man’s death
12. The man who is the subject of this report was convicted on 18 January 1995 and
sentenced on 22 February 1995 to life imprisonment. On 2 May 1995, the man
transferred to HMP Whitemoor. He had no significant health concerns at
Whitemoor until August 1996 when he complained of chest pains. A prison
doctor admitted him to Peterborough District Hospital where he was diagnosed
as having had a myocardial infarction (heart attack). Healthcare staff saw him on
his return and began a programme to lower his weight and cholesterol. He was
seen as an outpatient at Peterborough District Hospital and advised to continue
with the programme of weight reduction. The man had no further serious chest
problems while at Whitemoor.
13. The man transferred to HMP Full Sutton on 18 May 1999. During his time at Full
Sutton, he was seen in the chronic disease clinic to assess his cholesterol and
weight. His cholesterol levels were monitored regularly and the man was offered
annual flu vaccinations. However, his medical notes indicate that he declined
these (no reasons are recorded). Apart from the continuous monitoring of his
cholesterol, he had no other contact with healthcare during this time.
14. He transferred to HMP Wakefield on 17 December 2003. For three years
between his arrival and November 2006, the man only attended healthcare for
minor ailments, including optician’s appointments and dental referrals. On 21
November, he attended the treatment surgery and asked to speak to the
Registered General Nurse (RGN). He told the RGN that he was experiencing
symptoms of diabetes. He also said that he had been feeling unwell for
approximately seven weeks but had not told anyone. (He gave no further
explanation for his silence.) During the same afternoon, the RGN saw him for a
full assessment at the diabetes clinic. She told him that if his blood sugar levels
remained high he would be admitted to the healthcare centre and possibly begin
insulin therapy.
15. His blood sugar levels did remain high. Consequently, the RGN admitted him to
the healthcare centre the following day and he started insulin therapy. During his
stay in the healthcare centre, he was given advice on managing his diabetes.
Nursing staff observed him checking his own glucose levels and administering his
insulin. It was recorded that staff found him to be very capable and confident in
both procedures. The RGN attributed his motivation to the fact he disliked being
located in healthcare and wished to return to the wing as soon as possible. He
continued to be monitored at the morning surgeries and the diabetes clinic. His
insulin levels were adjusted as necessary.
16. The man attended a first contact clinic on 26 January 2007 with multiple
complaints. These included painful feet, legs and ribs, and insomnia. He also
complained of feeling lethargic (a common symptom of diabetes). Further
symptoms were a sore throat and hacking cough, which he had had for
approximately four weeks. His weight was recorded as having dropped by 7kg in
one month. He was prescribed a course of antibiotics and given simple cough
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17. On 30 January, a doctor referred him for a chest x-ray at Pinderfields Hospital
which was carried out on 16 February. The report of the x-ray recorded, “Ill
defined air space opacification noted in the right mid zone with air bronchograms.
Also linear opacity possibly suggestive of mild fibrosis noted in the left para
cardiac region.” It was suggested that the man attend for a follow up x-ray in
eight weeks after a course of antibiotics had been administered.
18. The man was seen by the prison doctor in healthcare on 23 February. He said
he felt the antibiotics prescribed were not working and that he still had a
productive cough. The doctor extended the course of antibiotics for a further
seven days and advised him to rest in his cell and not to go to work for one week.
19. During this period, he continued to lose weight and, as a result, he was
prescribed Ensure, a nutritional supplement. However, there appears to have
been some confusion as to the reasons for his weight loss. The man spoke at
length to his wing officer, who mentioned that his weight loss was noticeable. he
told the officer that, since being diagnosed as a diabetic, he had been careful
about what he ate and had been trying to lose weight. The officer also recorded
that since January there had been a change in him. He was associating less on
the wing and spending more time in his cell. When the officer spoke with him
about his health, he “appeared to accept he was recovering from pneumonia”
although there was some confusion as to whether this diagnosis had ever been
given. His fellow prisoners had also noticed his weight loss and had asked him
about his health. He told them that he was being treated for an illness but did not
say what this was. When interviewed, prisoners also mentioned that the man
had expressed concerns about his medication. He had told them he was only
receiving paracetomol from the healthcare staff (at the time, it is likely he was
also actually receiving a course of antibiotic treatment).
20. The prison doctor saw the man again on 8 March. He said that he felt generally
better but was still having night sweats. His weight was stable at this time. The
doctor explained that despite this improvement he should have a follow-up chest
x-ray later in April.
21. During his next consultation with the doctor on 20 March, the man was coughing
excessively. He told the doctor that he was coughing up “gunge” and was keen
to provide a sample of sputum. The doctor explained that the samples needed to
be taken at various times of the day. She arranged the test and sent the samples
away. The doctor also had concerns that the dust in the textile shop where the
man was working might have been the cause of his problems, and advised him to
cease work there until he was well again. He followed this advice.
22. His next contact with the doctor was on 26 March when he attended the clinic to
enquire about his sputum results. The doctor explained that it could take up to
three weeks for results to be returned. However, the man told her that his
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23. The following day, he attended the treatment centre where he was seen by the
RGN who had dealt with him originally. He said that he had a sore mouth which
had developed overnight. In interview for this investigation, the RGN recalled
thinking that the man looked ‘shocking’ due to his weight loss. During the
appointment, she noticed that the man was due to go to the Clayton Hospital later
that morning for his follow-up chest x-ray. She saw him again that day when he
was taken to the treatment room to be assessed as fit to travel. He was in a
wheelchair as he was experiencing breathlessness. He told the RGN that the
two officers who had escorted him had advised that it would be better to
postpone the appointment given his shortness of breath. The RGN reassured the
man that the decision rested with her and, in her opinion, it was important for him
to attend. Before he left, he spoke with the RGN again and asked to be located
in healthcare on his return from the appointment. This came as a surprise to her
given his aversion to being located there in the past.
24. The RGN spoke to both the inpatient manager and the doctor to inform them of
her concerns about the man. They agreed that on his return from the
appointment he would be placed in the healthcare department for observations.
25. At 10.50am on 30 March, escorted by three officers, he went to Clayton Hospital,
a short drive from the prison. After the x-rays were taken, the medical team told
the escorting staff that the man needed to be taken immediately to Pinderfields
Hospital. They arrived within 15 minutes and he was seen by a consultant who
admitted him as an in-patient. The consultant told the man that he had fluid on
his chest which had to be drained, and then further x rays would be taken. Staff
informed the prison of his condition and that he had been admitted to
Pinderfields.
26. At this time, the man was handcuffed to an officer as is normal practice with most
prisoners when outside of prison. It is understood that, once he was in bed, staff
applied the escort chain which enables more movement. It also allowed medical
staff better access to him in order to administer treatment.
27. At 8.00pm, a doctor checked on his progress. He was sitting up in bed and in
good spirits. The doctor informed the escort staff that the man was expected to
remain in hospital until Monday 2 April. There was nothing to suggest that his
family needed to be contacted at this time. The man was awake for most of the
night talking to the escort staff, and told them he needed very little sleep. The
escort staff said that he had given no cause for concern.
28. The following afternoon, a member of the prison’s chaplaincy team, visited the
man and spent a short while talking with him. Later that day, he had further x-
rays to monitor his progress. He ate his evening meal and was given his
medication at 10.25pm. At that time he was relaxed and lying on his bed. Over
the next few hours, he appeared settled.
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29. However, at 2.30am on 1 April 2007, the man began to have what appeared to
be a panic attack. The prison officers alerted nursing staff who attended and
calmed him down. Following this episode, he remained settled until 4.10am
when the officers noticed that his breathing appeared very shallow and rapid.
They immediately notified the nursing staff who attended. The man’s breathing
became worse and he began sweating. Nursing staff asked for the restraints to
be removed to enable treatment to be administered to him, and this was done.
He was then given oxygen and appeared to settle. A doctor examined him at
4.58am, taking his pulse and temperature, before informing the escort staff that
he was happy for the restraints to be reapplied.
30. The man appeared comfortable breathing with the aid of oxygen, but at 5.12am
he removed the mask and appeared to go to sleep. The escort staff felt that
something was wrong, and when they checked it was clear that he was not
breathing. They immediately alerted nursing staff. The resuscitation team
entered the room at 5.15am and attempted to revive him. At 5.25am, the hospital
suggested the man’s next of kin be notified of his condition and this was passed
to the control room at the prison. Efforts to revive him continued but sadly, at
5.30am, his death was confirmed.
Events following the man’s death
31. Following the man’s death, the duty governor, was contacted. He ensured that
the prison’s contingency plans were followed with all relevant departments being
notified. The Governor published notices informing both staff and other prisoners
of the death and of the services available to those who felt particularly affected by
it.
32. A Principal Officer was appointed as the prison’s Family Liaison Officer after the
man’s death, but this role was later taken over by a Governor. The Principal
Officer telephoned the one of the man’s brothers. He told her that their other
brother would deal with all the necessary arrangements, but he was currently out
of the country and expected back on 2 April.
33. A post mortem was carried out at midday on 1 April given initial concerns that he
might have been suffering from tuberculosis. An infectious disease of this kind
would have required precautionary measures to be taken at HMP Wakefield.
However, the post mortem initially ruled out tuberculosis and this was relayed to
the prison.
34. The prison family liaison, along with staff from the prison chaplaincy team,
attended the man’s funeral. The prison offered to meet the funeral costs.
35. On 26 April, a sputum sample taken from the man on his admission to
Pinderfields Hospital that had originally shown as negative was reported to be
positive for mycobacterium (TB) after being cultured.
36. It was mentioned in documentation that there was national press coverage of the
case. However, my investigator was unable to find evidence of this during his
investigation. To prevent anxiety within the prison population and wider
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11
ISSUES
Staff Conduct
37. My investigation found that Wakefield cared for the man extremely well. His
personal officer, and the nursing staff, particularly the RGN, showed compassion
in all their dealings with him. This care continued when he was admitted to
hospital, a fact which is evident from the bed watch log. The Governor may wish
to consider if he should formally recognise the professional way in which
members of his staff conducted their duties.
Clinical Care
38. The doctor, who conducted the clinical review concludes that the medical
interventions that the man received while in custody were timely and appropriate
given his symptoms. The fact of his imprisonment was not a barrier to him
receiving a good quality of healthcare.
39. The prison referred him appropriately and all appointments were attended as
scheduled. The prison also initiated tests and acted correctly on receiving the
results. However, the routine investigations failed to identify the TB. In summary,
the clinical reviewer notes the following:
“In my opinion, the single most significant contributory factor would appear to
be that our routine investigations (chest x-ray, sputum culture, routine
haematology tests) are still not sufficiently sensitive enough to pick up and
confirm the diagnosis of TB. All of these investigations were however carried
out.”
40. The clinical review makes no recommendations. In light of the overall finding of
the clinical review that I have quoted above, I judge that the prison health team
cannot in any way be held responsible for the fact that the initial tests did not
highlight the man’s tuberculosis.
Recording of medical information
41. During my investigation, it was often difficult to find specific details relating to the
man’s care in his medical record, such as results from x-rays and other tests that
had been carried out. It was also difficult to decipher some of the written entries
and the identity of their authors.
The Governor and Head of Healthcare should remind all clinical staff of
their obligations to comply with the rules regarding record keeping set out
in the relevant Nursing and Midwifery Council Guidelines.
The Prison Service accepted this recommendation and in response said,
All healthcare staff to be issued with current Guidance on Records and record
keeping in line with NMC (National Medical Council) Guidelines.
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Actions taken following confirmation of tuberculosis
42. Following the results from toxicology tests the action plan developed by
Wakefield PCT and the prison’s healthcare team sought to prevent anxiety within
the prison population and wider community in relation to tuberculosis. It also
gave prisoners access to information and the opportunity to be tested.
I am pleased to see that Wakefield PCT and the prison healthcare team had
the foresight to introduce a joint protocol to increase awareness of
tuberculosis. This information was circulated beyond the prison gates and
should be recognised as good health promotion practice.
Family
43. The man’s family were concerned that he might not have been promptly
diagnosed and treated for TB. However, during the investigation it was apparent
that medical staff at the prison had treated him for the symptoms presented at the
time. The doctor and nursing staff who had been treating him regularly were
clearly shocked and saddened by his death, given that they had performed all the
necessary tests and believed his illness to be under control. As indicated by the
clinical reviewer, there does appear to be a national problem regarding the
effectiveness of the screening process for TB. The final results of tests support
the family’s initial concerns. However, I hope this report reassures them that the
care he received while in custody was of a high standard and the ineffectiveness
of the screening process was beyond their control.
44. The appointed governor acted as both liaison with my office and as the prison’s
family liaison officer. She performed her duties to a very high standard, ensuring
that the man’s next of kin were dealt with appropriately and compassionately.
Despite her core work commitments, she provided regular assistance throughout,
and the family greatly appreciated this.
Family’s response to draft report
45. Following the issuing of my draft report, the man’s family responded with a
number of concerns that I have attempted to address.
The lack of statements from other prisoners who knew the man better than
the prisoner interviewed. Why no other prisoners were asked about their
opinion of events.
When the original notice went out only one response was received. It was not
until my investigator arrived at the prison to conduct the interviews that he was
informed that there were in fact about four other prisoners that would like to
speak with him. The interviewed prisoner informed the investigator of this. Due
to time constraints, he was only able to speak briefly with these individuals and
arranged for them to put in writing their concerns. This they did and all had
concerns regarding the healthcare afforded to the man. In view of this, the
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investigator passed on their concerns to the clinical reviewer. These letters did
not contain anything that had not been previously mentioned by the prisoner
interviewed. They were not annexed to the report because permission was not
granted by the letter writers.
Concern that the man was portrayed as being a loner, which is not how the
family remembers him.
My investigator was informed that the man was clearly a popular individual on
his wing and I make mention of his involvement in the band. But I also make
equal reference to his choice to spend more time in cell as his health issues
continued.
Prison Officer not addressing the man’s weight loss.
The wing history documents clearly showed the amount of interaction that the
officer had with the man. When my investigator interviewed her she was very
genuine in her regret that he had died. It was clear that she had conversed with
him regularly and given his explanation for his weight loss she had no reason to
question it further. She was also fully aware that he was, as he had stated,
recovering from pneumonia. The transcript of the officer’s interview makes this
clear and, given that she had no medical training, it is in my opinion fair that she
would have no reason to question the man’s account for losing weight.
Concerns regarding nursing care.
The man’s family said that he had complained to them that he did not have a
good relationship with the RGN, feeling that she had not been helpful when he
reported symptoms to her and that she obstructed his attempts to see a doctor.
The medical record clearly shows the input that the RGN had with the man. It
was very often her that he would be seen by when attending the treatment area.
There is no evidence of him being dissatisfied with the care that he received
from her and he made no mention of any concerns to any other officer or
prisoner. He did however mention to others on the wing that he was not happy
with the treatment he was receiving but would tell officers that he was.
Poor Medical records.
Unfortunately this is an ongoing concern in many cases. In relation to the man’s
medical record the entries made from 26/01/07 onwards are very legible except
for those by the doctor but these were clarified with her during her interview with
my investigator. I have however made a recommendation in relation to record
keeping that should address this concern.
Disappointment at no one being held to account for the failure to diagnose
TB and concern over the Clinical review.
The purpose of my investigation is to ensure that individuals who become unwell
while in prison custody are afforded the same standard of treatment as those in
the wider community. During my investigation, it was apparent from the
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documentary evidence provided that the Healthcare team at the prison had
cared for the man very well. The relevant tests were conducted as his illness
continued but the results to these proved negative. As a result, the medical
team continued to treat him for a chest infection. Tuberculosis was only
confirmed after his death following a very lengthy and in-depth toxicology
examination. The clinical review blames the failure of the screening procedures
nationally and supports the findings that the prison did every thing they could to
identify the cause of the ongoing illness. I fully appreciate the familys concerns
in this area but feel that my investigation has taken account of all the available
information in reaching its conclusion. However, I have passed on the family’s
concerns to HM Coroner who may wish to investigate the medical findings in
more depth prior to the inquest.
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RECOMMENDATION AND GOOD PRACTICE
The Governor and Head of Healthcare should remind all clinical staff of their
obligations to comply with the rules regarding record keeping set out in the
relevant Nursing and Midwifery Council Guidelines.
I am pleased to see that Wakefield PCT and the prison healthcare team had the
foresight to introduce a joint protocol to increase awareness of tuberculosis.
This information was circulated beyond the prison gates and should be
recognised as good health promotion practice.
16