Individual at Wandsworth

Investigation into the circumstances surrounding the
death of a prisoner at HMP Wandsworth, who died at a
hospice, in March 2007
Report by the Prisons and Probation Ombudsman for
England and Wales
October 2007
This is a report into the death of a 48 year old prisoner at HMP Wandsworth. He
died of lung cancer at a hospice, in March 2007.
I would like to offer my sincere condolences to the man’s family and friends for their
sad loss.
My colleague conducted the investigation. I am grateful to the Governor of
Wandsworth, and the prison’s liaison officer, for their assistance and co-operation. I
am also grateful to Wandsworth Primary Care Trust, for providing the clinical review
into the man’s care and treatment whilst in custody.
On 1 August 2005, the man had a routine chest x-ray conducted by St George’s
Hospital to screen for tuberculosis. A shadow was discovered on his lung. This was
initially thought to be tuberculosis, but this was ruled out following a series of tests.
On the advice of specialists at St George’s, the man underwent a biopsy of his lung
and squamous cell carcinoma (lung cancer) was diagnosed. He received palliative
care at Wandsworth, but in the later stages of his illness, he was transferred to the
hospice.
I make three recommendations. I was particularly disappointed by some aspects of
the prisons family liaison following the death. However, I have also identified two
areas of good practice, notably the prompt action of staff in facilitating a visit by his
brother just before he died.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2007
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CONTENTS
Summary 4
The investigation process 5
HMP Wandsworth 7
Key findings 8
Clinical review 10
Issues 11
Recommendations and good practice 13
Annexes
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SUMMARY
The man was remanded into custody in 1999. Apart from a brief stay at HMP
Elmley, he served his subsequent sentence at HMP Wandsworth located in the
Onslow Centre, a unit for vulnerable prisoners. Prior to 2005, his only medical
concern was migraine, which was treated by the prison healthcare team.
In August 2005, he attended a routine chest x-ray at a mobile clinic from St George’s
Hospital, stationed within the prison. The results indicated a shadow on his lung.
However, these findings were not immediately made available to the prison
healthcare team and this led to a slight delay in the start of his initial treatment.
He was first treated for suspected tuberculosis (TB). This included a brief spell in the
healthcare centre. Following further x-rays carried out at St George’s Hospital, a
referral was made to a specialist. Due to an administrative error, there was a delay
in arranging this appointment. Further tests, including a bronchoscopy, confirmed
that he in fact had squamous cell carcinoma (lung cancer).
The man underwent chemotherapy in an attempt to reduce the cancer and make it
operable. This failed, so he then had a course of radiotherapy to slow down the
progress of the disease. When he had completed radiotherapy and began to be
treated symptomatically, a comprehensive care plan was put in place. The
healthcare team in conjunction with hospice staff managed this.
On 10 February 2007, he was transferred to the hospice. During this time, he was
escorted by two officers but no restraints were used. The man’s family visited daily
and he had access to the day room and grounds to spend time with them.
The man’s brother, arrived at Wandsworth three weeks before he was admitted to
the hospice. His brother is a prisoner at HMP Albany. He had applied for
accumulated visits to enable a temporary move to be closer to his brother and the
rest of his family. At the request of the man’s family, the prison arranged for the
brother to visit under escort the day before his death. This meant a great deal to the
family.
My investigation found that the prison was not at fault for the delays that had
occurred in the man’s treatment. However, there is a need for better procedures to
monitor outstanding test results from external healthcare providers.
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THE INVESTIGATION PROCESS
One of my investigators conducted the investigation on my behalf. After the man’s
death, he spoke to the appointed liaison officer at Wandsworth. The Governor and
the appointed liaison officer produced the man’s prison records, including his
medical, for examination. Notices were issued to staff and prisoners to inform them
of the investigation process and to give them the opportunity to speak with my
investigator. No responses were received.
I commissioned Wandsworth Primary Care Trust to conduct a clinical review into the
care and treatment of the man whilst at Wandsworth in accordance with any Terms
of Reference. An appointed doctor conducted the review, which is attached in full to
this report as an annex.
One of my Family Liaison Officers contacted the man’s sister. The family declined
the offer of a meeting. However, they raised a number of concerns which I have
attempted to address in my report. They also mentioned aspects of the man’s care
that they considered very good.
The investigator wrote to Her Majesty’s Coroner to inform them of the nature and
scope of the investigation. A copy of the report will be sent to the Coroner to assist
with their enquiries.
Following comments by the Prison Service on the first draft of this report, I have
made a number of amendments to correct factual inaccuracies and to reflect further
information about the man’s care and treatment.
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HMP WANDSWORTH
Wandsworth is a large category B local and remand prison in South West London,
built in 1851. With an operational capacity for 1,416 prisoners, it is the largest
prison in the United Kingdom and one of the largest in Western Europe. Although
the residential areas remain in the original buildings, there has been extensive
refurbishment and modernisation of the wings.
Her Majesty’s Chief Inspector of Prisons, Ms Anne Owers, conducted a follow-up
inspection of Wandsworth in 2006. She noted that it was an improving prison, but
with a significant way to go. The man was a resident in the Onslow Centre, a unit of
three wings that holds about 321 vulnerable prisoners. (Vulnerable prisoners are
those identified as needing protection from mainstream prisoners. This is often due
to the nature of their offence or their risk of being bullied.) During the inspection, the
Centre was found to have good staff-prisoner relationships, with 75 per cent of
prisoners in the unit saying that most staff treated them with respect.
The local area Primary Care Trust (PCT) took responsibility for the provision
of healthcare at Wandsworth from April 2005. All staff working in Wandsworth
healthcare are clinically qualified. A full-time doctor is available each weekday and
cover is provided during the evening and weekends by two General Practitioners
commissioned by the PCT. Prisoners submit an application form to see a doctor,
and the waiting time varies between two to ten days, dependent on the urgency of
the request.
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KEY FINDINGS
Events leading up to the man’s death.
The man entered prison in November 1999, when he was remanded into custody
and sent to HMP Belmarsh. During the initial health screen, it was noted that he
suffered from migraines and theses were treated appropriately with medication. The
man was sentenced to 12 years imprisonment later that month. Following his
conviction, he was transferred to HMP Wandsworth, where he remained apart from a
brief period at HMP Elmley. He lived in the Onslow Centre. The centre houses
prisoners that are considered to be vulnerable. This can be due to the nature of a
prisoner’s offence, or because they find it difficult to cope with the normal prison
environment. He remained there until his transfer to a hospice in February 2007.
During the first week of August 2005, the man attended a mobile chest-screening
clinic. This was conducted by tuberculosis (TB) nurses from St George’s Hospital,
London, as part of a pan-London screening initiative organised by University College
Hospitals, in association with London prisons. The screen highlighted a shadow on
the man’s lung, but this was not communicated to the prison until September 2005.
On receipt of the initial x-ray results, the man underwent a further series of x-rays.
On the advice of St George’s Hospital, he spent a period in the healthcare centre
from 7 October as a precautionary measure in the event of TB. He returned to the
Onslow Centre on 3 November.
A referral was made to a specialist at St George’s Hospital for further tests. Owing
to an administrative error, there was a delay of a week in arranging the appointment.
He was finally seen at St George’s on 26 October. The x-rays confirmed the shadow
on his lung and further tests were carried out to eliminate TB. A bronchoscopy
confirmed the presence of squamous cell carcinoma (lung cancer).
In December 2005, the man began a course of chemotherapy in an attempt to
reduce the size of the tumour and make it operable. After four cycles of treatment
that finished on 27 February 2006, it was found that the treatment had been
unsuccessful in reducing the disease. On 3 April, he was prescribed twelve cycles of
high-dose palliative radiotherapy in a further attempt to slow down the disease.
While undergoing his treatment, he remained on the Onslow Centre at his own
request. He was reassured by staff that he would not be moved to the healthcare
centre against his wishes. Staff supported him and he had daily access to his
medication without the need to leave the unit.
On 26 January 2007, the man was seen by a Consultant Medical Oncologist who
confirmed that all chemotherapy treatment would cease and that he would be treated
“symptomatically”. (This meant that his symptoms, rather than the disease itself,
would be treated.) The prison healthcare team, staff from the hospice and Onslow
Centre staff put in place a comprehensive care plan to ensure that his needs would
be fully met on the unit. The care plan covered all areas, including monitoring his
ability to attend to his personal hygiene, as well as his intake of food. By this stage,
a nutritional supplement had been prescribed as he was experiencing a lack of
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appetite. The care plan also monitored the man’s medication and staff would be
alerted if he failed to collect it.
A doctor from the A hospice visited the man at the beginning of February to review
his situation and level of care. It was noted in the care plan that he was content with
the existing arrangements with his medication and was sleeping well. During this
period, the man remained mobile with the use of a wheelchair, which had been
supplied by his family. He also had use of a walking stick and a “Zimmer” frame. He
was sleeping well with the use of sedation. Staff noted in the care plan that the man
remained mobile and where necessary was pushed in his wheelchair by other
prisoners or his brother. They also recorded that his levels of personal hygiene
remained good.
In February, the man’s brother arrived at Wandsworth. The brother is a serving
prisoner at another prison. The man had asked to see his brother and the Offender
Management Unit at Wandsworth completed the relevant administrative steps to
secure his temporary transfer. Upon his arrival at Wandsworth, the man’s brother
also lived in the Onslow Centre.
On a particular day in February, he asked staff to contact a doctor as he was
experiencing increased pain and discomfort. The following day, he was transferred
from Wandsworth to the hospice.
The man’s family were notified of his transfer. Throughout his stay they visited daily,
usually for between four to six hours. At no time were restraints used, and he and
his family had access to all areas of the hospice including the grounds. This
afforded the man a degree of dignity, despite being escorted by two officers.
The man continued to receive daily visits and remained mobile, which enabled him to
visit the grounds and day room with his visitors. He also conversed with the
escorting staff. While staying at the hospice, he received a telephone call from his
brother and spent some time speaking with him. During his period at the hospice,
the man attended a number of hospital appointments for ultrasound and these were
also facilitated without the use of restraints.
In March, the man became increasingly agitated and doctors told the escorting staff
that this was due to the deterioration in his condition. Nursing staff were concerned
that he would become violent in his current state and enquired as to the remit of the
escorting staff if this became the case. Prison managers informed escorting officers
that under no circumstances should they restrain him. His immediate family were
contacted by other family members to inform them of the deterioration in his
condition.
The next day, the man’s sister and daughter asked that his brother be allowed to visit
before he died. That afternoon, his brother was escorted to the hospice. The man’s
family expressed their gratitude to the prison for arranging this visit.
On the day the man died, the escort staff were told by a nurse that he had passed
away in his sleep at approximately 2.40am. Escorting staff reported this to the
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prison and the nursing sister at the hospice contacted his family to let them know of
his death.
CLINICAL REVIEW
The clinical review conducted by the appointed doctor concluded that the man had a
cancer, which, on diagnosis, had already spread widely. As a consequence, active
treatment was unlikely to have been successful.
The doctor found nothing in the medical records of particular concern. There may
have been some delay in the initial stages when the man had his screening x-rays.
However, this appeared to have been the responsibility of the screening service
rather than the prison health partnership.
The doctor judged that the man’s case was adequately managed, and his
subsequent care was appropriate to meet his needs.
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ISSUES CONSIDERED
Care at Wandsworth and delay in treatment
It emerged from the investigation that there had been a gap in the period between
the man’s initial chest screening on 5 August 2005, Wandsworth being notified of the
results and the commencement of any follow up treatment. He was concerned about
this delay and instructed his solicitors to look into the reasons. The Clinical
Reviewer, also looked into this. He found that there may have been some delay in
the initial stages which seemed to be attributable to the screening service, rather
than to the prison healthcare team. Nevertheless, the investigator was told that the
Prison Service had acknowledged the concerns that the man had raised and settled
out of court. These delays are clearly of concern.
In order to assist external healthcare providers to make timely clinical
interventions and provide continuity of care, Wandsworth should consider
introducing procedures to check the progress of overdue test results.
When the man’s treatment became symptomatic, the Prison and the hospice
formulated a comprehensive care plan that ensured he was cared for and systems
were in place to monitor his well-being. I consider this partnership working to be an
example of good practice.
The comprehensive care plan that was drawn up by all the relevant parties
involved in the man’s care should be highlighted as good practice.
Transfer and collaborative care with the hospice
When the man was transferred to the hospice, he was escorted by two officers. I am
pleased that at no time were restraints used. He was allowed to have access to all
areas of the hospice, including the garden, and this gave him a degree of dignity.
Family
The transfer of the man’s brother from his prison to Wandsworth was entirely
appropriate and compassionate. Similarly, following the family’s request for him to
be allowed to visit the hospice, Wandsworth arranged for an escort the same day.
This quick action enabled him to say goodbye and spend time with his brother in the
final stages of his life. The prison also offered the man’s brother the opportunity to
attend the funeral but he declined this offer.
The Governor and his staff should be acknowledged for their sensitive and
quick response in facilitating the visit by the man’s brother. Other aspects of
family liaison were managed less well.
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Following the man’s death, Wandsworth dealt primarily with his brother who
remained resident in Wandsworth. It seems they expected him to pass on
information to the remainder of the family. As a consequence, the other members of
the family had little contact with the prison and felt forgotten. Wandsworth was fully
aware that the man’s sister was the contact point, but explained that they had found
difficulty in contacting her as she had failed to respond to telephone messages. No
attempt was made to contact her by correspondence.
The man’s property was returned sometime during the week beginning 2 April. His
family subsequently expressed concern that all his property had not been returned,
but there are insufficient records to resolve this point. Again, the confusion may
have arisen as a result of Wandsworth dealing with the man’s brother, rather than
the other members of his family.
The family does not seem to have been made aware of a named prison Family
Liaison Officer (FLO) as required under Prison Service Order (PSO) 2710.
The family was not offered any financial assistance for funeral expenses. Once
more, this is a requirement of PSO 2710 and both of these matters could have been
explained by letter.
Following a death in custody, Wandsworth should ensure, where appropriate,
that regular contact is made with the nominated family contact and they are
informed of the named FLO. In the event that telephone contact is fruitless,
essential information should be communicated by correspondence, which
should be documented and recorded.
When a prisoner is transferred to a hospice due to a terminal illness.
Wandsworth may want to consider appointing an FLO at an early stage. This
would enable the family to discuss any concerns and avoid later confusion.
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RECOMMENDATIONS
1. In order to assist external healthcare providers to make timely clinical
interventions and provide continuity of care, Wandsworth should
consider introducing procedures to check the progress of overdue test
results.
2. Following a death in custody, Wandsworth should ensure, where
appropriate, that regular contact is made with the nominated family
contact and they are informed of the named FLO. In the event that
telephone contact is fruitless, essential information should be
communicated by correspondence, which should be documented and
recorded.
3. When a prisoner is transferred to a hospice due to a terminal illness,
Wandsworth may want to consider appointing an FLO at an early stage.
This would enable the family to discuss any concerns and avoid later
confusion.
GOOD PRACTICE
1. The comprehensive care plan that was drawn up by all the relevant
parties involved in the man’s care should be highlighted as good
practice.
2. The Governor and his staff should be acknowledged for their sensitive
and quick response in facilitating the visit by the man’s brother.
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