Individual at Wellingborough

Investigation into the circumstances surrounding the
death of a man whilst in the custody of
HMP Wellingborough in March 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2011
This is the report of an investigation into the death from natural causes of a
man, who was a prisoner at HMP Wellingborough, who died in hospital in
March 2010. He was 74 years old. He came into custody in 1985.
I offer my sympathy to all those touched by the man’s death. I apologise for
any further distress caused by the delay in the production of this report.
The investigation was carried out on my behalf by my colleague. An
independent review of the man’s medical care in prison was conducted by a
clinical reviewer on behalf of the local Primary Care Trust. I am most grateful
to him for his assistance.
He concludes that the man’s clinical care at Wellingborough was at least to
the standard he would have received in the community and that he was
treated with compassion and care. I agree. Unusually I also highlight the
decision not to apply for compassionate release towards the end of his life. I
have in the past criticised decisions not to apply for compassionate release.
On this occasion he wanted to stay in prison and the decision was made
wholly in his interests, despite the demands it placed on the prison. The
compassion shown towards him was, I believe, an example of good practice.
This report recognises the good quality care which all staff provided to him. I
would be grateful if the Governor would share this report with staff and pass
on my thanks for their actions. I make no recommendations.
This version of my report, published on my website, has been amended to
remove the names of the man who died and those of staff and prisoners
involved in my investigation.
Jane Webb
Acting Prisons and Probation Ombudsman May 2011
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CONTENTS
Summary
The investigation process
HMP Wellingborough
Key findings
Issues
Conclusion
Good practice
Response from National Offender Management Service
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SUMMARY
The man had an unsettled childhood, and lived in a number of different
children’s homes. He committed his first offence at 18 years of age, for which
he received a term of imprisonment. This was followed by a number of further
periods in prison. In 1985 he was convicted of the murder of his long term
partner.
In 1999, he was admitted to hospital having experienced severe chest pains.
He was diagnosed as having suffered a heart attack. He refused to have
surgery until he suffered a further bout of severe chest pain in 2001. He was
placed on the waiting list for a heart bypass, which he had in 2002.
His health remained generally settled until mid 2008 when he suffered a
severe attack of angina (spasmodic intense chest pain) and was diagnosed
with an irregular heart rhythm. In September 2008, he was fitted with a heart
pacemaker. Two months later, he was found to have excess fluid in the
abdomen and disease of the liver. He delayed having treatment until
December 2008 when he had an operation to drain the excess fluid.
He remained stable until 4 March 2010, when he was admitted to hospital
suffering from a swollen abdomen, chest pains and difficulty breathing. He
discharged himself the same day, but was readmitted the following day.
Excess fluid was drained from his abdomen and he was found to be suffering
from multi organ failure including kidney failure.
On 12 March, the consultant treating him told staff that he was not responding
to treatment and was terminally ill. The consultant instructed that, in the event
of heart failure, he was not to be resuscitated. He said that he should not be
moved from hospital and should spend his last days there. The end of life
pathway procedure was commenced on 13 March (designed to give a high
quality of care for people approaching the end of life). Over the next days
prison healthcare staff and a representative of the chaplaincy visited. He died
several days later. The coroner’s office told the prison that he had died of
natural causes.
The clinical reviewer said that he had been given a standard of care at least
equivalent to that he would have received in the community. I too do not have
any concerns.
I have been struck particularly by the way the Governor and staff at
Wellingborough gave timely consideration to issues such as the
compassionate release and ensuring that appropriate end of life and palliative
care was in place. The consultant spoke compassionately about his
relationship with him and a number of staff visited him in hospital. In
particular, I believe that the decision not to grant compassionate release
solely in order that he would have company during his final days was an
example of good practice.
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THE INVESTIGATION PROCESS
1. This investigation was undertaken by one of the investigators from this
office. He first visited HMP Wellingborough on 23 March 2010 when he
met the Governor and family liaison officer. He was given access to the
man’s prison records and to all the relevant staff. Notices were issued
inviting staff and prisoners to contribute to this investigation. In the
event, no one came forward with any further information.
2. The local Primary Care Trust (PCT) was commissioned to review his
clinical care and treatment at Wellingborough. The PCT appointed a
clinical reviewer.
3. The clinical reviewer was asked by my investigator to establish the
circumstances surrounding the man’s death and to comment on the care
provided to him. The doctor made two visits to Wellingborough. The
initial visit was to establish the facts and to familiarise himself with the
medical environment. The clinical reviewer examined the medical
records, including those on the computerised system. He also reviewed
the notes made by the hospital and correspondence between the
hospital and Wellingborough relating to his out-patient appointments.
On his second visit he was accompanied by my investigator and,
together, they interviewed a number of staff.
4. The man had declined to give Wellingborough any details of his next of
kin and instructed that they should not be contacted whilst he was alive.
Despite exhaustive attempts by the prison’s family liaison officer to trace
his next of kin she has been unable to locate any family members to
inform them of his death. I too have no contact details for any members
of his family. A copy of this report will be retained by my office should
any of his relatives make contact in the future.
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HMP WELLINGBOROUGH
5. HMP Wellingborough currently holds 635 adult male offenders. It first
opened in 1963 as a borstal and held young offenders until 1990.
Following a temporary closure whilst essential repairs were carried out,
Wellingborough re-opened as a category C training prison for adult men.
(Category C prisoners are seen as presenting a medium risk of
offending and escape. Training prisons provide courses to help
prisoners address their offending behaviour.)
6. Commissioning healthcare in the prison is the responsibility of the local
Primary Care Trust, which in turn, commissions Care UK to provide
primary care services. The healthcare centre employs a part-time doctor
and operates an out of hours GP service. There are a number of out-
patient clinics on site, including dentist, optician and psychiatrist. There
are no in-patient beds.
HM Chief Inspector of Prisons’ report
7. The most recent full inspection of Wellingborough by the then Chief
Inspector of Prisons dated December 2008, describes Wellingborough’s
healthcare as largely satisfactory. The Chief Inspector said that it was
insufficiently integrated into the rest of the prison, and did not have a
lead person who was responsible for older prisoners. I note that the
clinical reviewer reports that there is now a lead nurse for older patients,
who coordinates care and is the nursing link for medication. He says
that “[the nurse] had lots of input into the care of the man over the time
he was at Wellingborough and particularly in the build up to his hospital
admissions”.
Independent Monitoring Board
8. Every prison in England and Wales has an Independent Monitoring
Board (IMB). IMB members are volunteers who monitor day-to-day life
in the prison to help ensure proper standards of care and decency are
maintained. The Board’s report for the year from 2008 to 2009 does not
contain any issue that should be considered here.
9. Since my office took over responsibility in 2004 for investigating all
deaths in prison custody, there have been two deaths attributed to
natural causes at Wellingborough, including the man’s death. No issues
arising from the other case are directly relevant to the circumstances
surrounding his death.
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KEY EVENTS
10. The man was born in April 1935. He was the youngest of three children
having one brother and one sister. His father died during the Second
World War and he spent his formative years in several children’s homes.
After leaving school, he did National Service before taking a variety of
jobs. He had spent a number of periods in custody before committing
the offence of murder in 1984.
11. On conviction on 12 September 1985, he was sent to HMP Wormwood
Scrubs. He moved to a number of prisons before moving to HMP
Wellingborough on 1 June 2005.
12. In 1999, he was taken to hospital suffering from acute chest pain. He
was found to have a posterior myocardial infarct (heart attack) but he
refused to have surgery. He went to hospital again in 2001 suffering
from chest pains. He was referred to a consultant cardiac surgeon who
diagnosed triple artery disease (blocking of the arteries that supply the
heart with oxygen rich blood) and moderate ventricular function (irregular
heart beat). He required coronary artery bypass graft surgery (heart
bypass) and his name was placed on the waiting list for an operation
which took place in June 2002. Following discharge from hospital, he
chose not to go to follow up appointments with a consultant cardiologist.
In February 2003, the consultant decided to discharge him from hospital
care.
13. On arrival at Wellingborough in June 2005, he had established
hypertension (high blood pressure), hypercholesterolemia (high levels of
cholesterol – one of the body’s fats – in the blood), and mild renal
impairment (which means that the kidneys do not function properly).
The clinical reviewer concluded that all these medical conditions “appear
to have been managed appropriately”.
14. On 2 June 2008, he told Nurse A at Wellingborough that he was
experiencing an ache in his left arm and shortness of breath when
walking. He was examined by Prison Doctor A, who noted that he had
“significant pitting oedema (retention of fluid) in his legs up to mid calf
level”. The doctor prescribed an increase of furosemide (a drug used to
treat excessive fluid) which the man had been prescribed for a number
of years. He examined him again on 6 and 13 June, and on each
occasion noted an improvement in the oedema.
15. When he went to collect his medication from healthcare on 18 June, he
told one of the community health service staff that he felt unwell. She
offered to speak to the doctor and an appointment was made for him to
see him on 20 June. He did not go to the appointment. When he did not
go to another appointment made for 25 June, the doctor went to the
wing and examined him there. The doctor noted that his oedema had
become slightly worse and prescribed a further increase in furosemide.
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16. He was examined by Prison Doctor B on 14 July. The doctor noted that
the oedema had spread to the knees and there was a small amount in
the tissues of his lower abdomen wall and thighs. He prescribed an
increase in captopril, a medication which had been prescribed for a
number of years. (Captopril is used to treat a number of medical
conditions including hypertension, congestive heart failure and kidney
malfunction.)
17. Nurse A saw him on the wing on 21 July and noted that his legs
remained swollen but his arms were “no longer” swollen. (There is no
earlier mention in the clinical record of him suffering from swollen arms.)
He was not in pain. She discussed the case with an unnamed doctor
who advised that medication should continue as prescribed and an
appointment made for him to have blood tests. He failed to go to a
number of appointments with healthcare staff and doctors including
those for 23 and 28 July and 1, 4 and 8 August.
18. On 9 August, he was seen by Nurse A, who was concerned because he
looked unwell. He had a sudden onset of swelling to hands and was
short of breath. She contacted the out of hours doctor service who
advised that he should be admitted to hospital by ambulance. He was
admitted to the Accident and Emergency Unit at hospital.
19. The nurse visited him in hospital on 11 August. She was told by a
hospital nurse that he had suffered a severe angina attack the previous
day and should remain in hospital for monitoring. The clinical record
noted that :
“He stated that he has contacted his sister although it is too far [for]
her to visit. He was unwilling to give prison staff any numbers for
her, which was respected.”
20. He was subsequently moved from that hospital to another, where, on 19
September, he had an operation to fit a biventricular inplantable
cardioverter defibrillator implant (heart pacemaker). He was discharged
from hospital on 26 September.
21. On 2 November, Nurse B went to his cell to give him a flu vaccine. She
thought that his physical health had deteriorated. She noted he had a
“large swollen abdomen and mild swelling to the ankles”. Staff on the
wing told her that he was no longer taking any exercise but he told her
that he felt fine.
22. He refused to keep an appointment that had been made for him to
attend hospital on 3 November for a review of his pacemaker and signed
a disclaimer to that effect. The clinical record gives the reason for his
refusal that he “cited that he does not want to be handcuffed and that is
the only reason why he won’t go”.
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23. There is a further entry in the clinical record for 3 November, by the
Healthcare Practice Manager, which states “seen by Prison Doctor A –
referred to A+E for further investigation (Patient informed)”. It is not
clear from the clinical record when he went to hospital as the next
reference to hospital is on 6 November, which states “rang hospital, he
is having a scan at 3pm”. However, there is a letter in his medical
papers from the hospital to Wellingborough’s medical officer dated 5
November which states that he went to Accident and Emergency on 5
November at 3.09pm where he was seen by a doctor and admitted to
hospital.
24. He discharged himself from hospital on 10 November, before an ultra
sound scan could confirm a diagnosis. The initial diagnosis was that he
had developed ascites (excess fluid in the abdomen) and cirrhosis
(deterioration of the liver). He told Nurse C that he had been fed up with
waiting for “things” to be done in hospital. She noted that she “stressed
to him that he was extremely unwell and that the hospital could provide
the best possible care for him at this time”.
25. On his return from hospital, staff discussed whether to open the
Assessment, Care in Custody and Teamwork procedures. (The ACCT
procedures are used to monitor and support prisoners considered to be
at risk of suicide or self harm. Once placed on an ACCT, the prisoner is
subject to regular reviews that decide the level of observations and
conversations to be carried out at intervals determined by the perceived
level of risk to the prisoner.) Staff decided not to open the ACCT
procedures and instead opened a care plan, which set out what support
was in place for him, and who would provide the support. The care plan
required wing staff to check on him every time his cell was locked or
unlocked and twice throughout the night. He was made aware of the
plan. He was asked whether he would like his next of kin contacted, but
declined.
26. He refused to accept any treatment on 11 November and told Nurse C
and the community health service staff, that he “couldn’t be bothered
and just wanted to be left alone”. Nurse C had another discussion with
several staff about opening the ACCT procedures and they decided that
they should be opened as the existing care plan was not an official
Prison Service document.
27. Nurse D tried to assess his mental state on 13 November but he refused
to cooperate. He told her that he was unhappy about being monitored
by the ACCT procedures which meant that he was being woken by
officers asking him if he was alright. He told her that he did not want to
go to hospital. She noted on that clinical review that he showed “[n]o
evidence of any mental health issues”.
28. Following a review, the ACCT procedures were closed on 13 November,
as he was not considered at risk of harming himself. Healthcare staff
continued to see him at least daily and wing staff observed him each
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time his cell was unlocked and were told to contact healthcare if they
had any concerns. Healthcare staff continued to visit him at least daily,
although he told Nurse B on 18 November that he considered that staff
were wasting their time by doing so.
29. My investigator asked the Healthcare Practice Manager further
questions about opening the ACCT monitoring. He explained, in an e-
mail of 3 November 2010, that
“an ACCT was opened on 11 November 2008 following discussions
between healthcare and residential staff … in order to observe his
well being. … The ACCT was subsequently closed on 13 November
as it was clear he wasn’t at risk of direct self harm.“
30. On 2 December, he refused to go to a pre-operation appointment at the
infirmary “... and that it is very doubtful that his [he] would attend the
actual procedure on 12 Dec[ember]”. Both appointments were cancelled
and he signed a disclaimer. There is no reference as to the purpose of
the operation. He told two nurses that he refused to go to hospital
because he did not want to die in handcuffs in hospital. (Prisoners who
are taken out of the prison for any reason, including hospital, are risk
assessed and restrained by hand cuffs or an escort chain as well as
being escorted by two or more staff.)
31. Prison Doctor A saw him on 10 December, when he continued to refuse
to go to hospital and said that he understood that the decision could
have grave consequences. On 11 December, he went to healthcare as
he felt unwell. He told staff that he had had trouble breathing in the night
and his abdomen was swollen. He was taken by ambulance to Accident
and Emergency at hospital, where he was seen by a consultant. The
doctor noted that he was suffering from abdominal pain. However, he
refused treatment and discharged himself.
32. The following day, prison medical staff and the Heart Failure Nurse
Specialist at the hospital talked to him about the options for further
treatment. As a result he agreed to return to hospital for treatment. He
also agreed to consider a transfer to HMP Norwich. (Norwich has a
specialist elderly patients unit, the Nelson Unit. The unit has been
designed and equipped to enable older and less able prisoners to be
supported and cared for within the confines of the prison environment.)
33. He was taken back to hospital on 12 December and had an operation to
drain the excess fluid from his abdomen. On 21 December, he
discharged himself against medical advice and signed another
disclaimer. Nurse A saw him on the wing on 22 December and he told
her that he felt fine and would contact healthcare if needed. A nurse
wrote to the Healthcare Practice Manager on 29 December including a
management plan for him.
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34. The clinical record shows that throughout 2009 he was regularly
reviewed by healthcare staff and his heart condition was monitored. The
Healthcare Practice Manager wrote to Norwich on 23 January 2009,
proposing that he should transfer there. On 9 February, Nurse C told
him that Wellingborough “were no longer able to give him the care which
he required and that his needs would be met in a more appropriate
manner at Norwich”. When Nurse E spoke to the Head of Healthcare at
Norwich on 26 February she was told that the referral papers had not
been received. Prison Doctor A wrote to the Head of Healthcare at
Norwich on 13 March saying that the man “would benefit greatly from a
transfer to Norwich as the holistic care we are able to give him here
[Wellingborough] is not ideal”. The medical record for 16 March by the
Healthcare Practice Manager states:
“Have been repeatedly following up on referral process for Norwich
elderly lifer unit – additional information faxed and further e-mails
sent including referral letter from Prison Doctor A and the hospital
discharge information. Will need to explore community palliative
care options as there continues to be a general deterioration in
health and ability to self care.”
35. There are no further references in the clinical record to the proposal for
the man to transfer to Norwich. My investigator asked Prison Doctor A
why he had decided he should not be transferred. He said that, after
taking some advice, he concluded that it would be better for him to
remain at Wellingborough. The doctor confirmed that he had discussed
the matter with him who had told him that “he wasn’t particularly keen to
be transferred” and was happy at Wellingborough.
36. The Parole Board had last considered his case on 2 October 2009 but
he did not cooperate with the process or attend the hearing. The Board
is responsible for releasing prisoners serving a life sentence. A case
cannot be referred to the Board until a prisoner has served the minimum
term. The Board is empowered to direct release if it is satisfied that it is
no longer necessary for the protection of the public that the individual
should remain in prison. On this occasion the Board decided not to
direct his release because they had no evidence that his risk of re-
offending was manageable in open conditions or on release. The risks
remained unaddressed because he refused to participate in
rehabilitative work.
37. In December 2009, he was examined by Prison Doctor A and found to
have a low haemoglobin (Hb) level (below average concentration of the
oxygen-carrying proteins in the blood). The doctor discussed this with
the hospital’s Medical Registrar, who agreed that he should be referred
to hospital. He was taken to hospital on 4 December, but discharged
himself despite the advice of both hospital nurses and the prison officers
who were escorting him.
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38. The following day, he told the officers on his wing that he again felt
unwell. The officers asked Staff F to visit him and he told her that he
wanted to go to hospital. Arrangements were made for him to be taken
to the hospital’s Accident and Emergency by ambulance. He had a
blood transfusion before being discharged on 8 December.
39. The entries in his clinical record covering the next few months show that
he continued to receive regular care and medication. On 5 February
2010, an appointment was made at the pacemaker department at
hospital in May, although concerns were raised that he would refuse to
go.
40. On 4 March, Officer A asked Nurse B to come to his cell on the wing.
He told the nurse that he had been experiencing chest pains and
shortness of breath. She noticed he had a swollen abdomen and
arranged for him to be admitted to Accident and Emergency at hospital.
He was examined by one of the hospital doctors but discharged himself
before the tests could be completed. The Case Note History completed
by Officer B, his personal officer, records that he “discharged himself
against medical advice”. (Every prisoner is assigned a personal officer.
Their role is to meet prisoners regularly to discuss any issues or
concerns the prisoner may have.) On return to Wellingborough, he told
Nurse B that he had discharged himself “because they were faffing
about”.
41. The next day, Prison Doctor A examined him and found that he
continued to experience chest pains and difficulty breathing. He also
noted widespread oedema. He readily agreed to the doctor’s advice that
he should go to hospital. The Governor decided that he need not be
handcuffed for the journey to hospital as a defibrillator was in place. The
machine uses electricity to re-establish a normal heart rhythm.
42. Later on 5 March, Nurse C received a telephone call from Oscar 1 that
he was refusing medical intervention and intending to discharge himself
from hospital. (Oscar 1 is the senior officer on duty who responds to any
emergency situations. The record does not show how he became aware
of his intentions, but it is likely that one of the escort staff would have
reported their concern to Oscar 1.) She passed on the information to the
Governor and also contacted the palliative care team at the hospital.
43. In the event, he did not discharge himself and remained at hospital. The
Hospital Watch Occurrence Log for 5 March records “Full briefing
received from day staff. He is uncuffed and very poorly.” (When a
prisoner is admitted to an outside hospital the escort staff maintain a
daily occurrence log recording all events that occur whilst the prisoner is
out of the prison.) The Governor also asked staff to see if they could
find another prison with 24 hour healthcare which would be prepared to
take him. Their attempts were unsuccessful.
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44. Nurse E contacted a member of the hospital ward staff on 7 March and
was told that he was suffering from a kidney infection which meant that
they did not work properly. Fluid had been drained from his abdomen.
A member of Wellingborough’s chaplaincy team visited him at the
hospital.
45. On 8 March, a Macmillan nurse from the hospital’s palliative care team,
contacted Nurse C. She confirmed that, while she was content to
assess him, the request would have to be made by a member of the
hospital staff. (Macmillan Nurses provide advice and support for people
who are thought to be near to the end of their lives.) Nurse C contacted
a nurse at the hospital to ask her to make the necessary referral to the
Macmillan nurse.
46. The Bedwatch Log for 8 March states he is “demanding to go back to
prison. We have tried to reassure him that the hospital is the best place
for him at this time”. It also records that he was asked twice whether he
would like the prison staff to contact his sister but was “adamant that we
are not to contact his next of kin or give us a number for them”. Officer
B was on bedwatch duty and noted in the Case Note History:
“Myself and an officer tried on several occasions to convince him
that contacting his next of kin, his sister, was a thing he should
consider. He became agitated and said ‘I will contact her in my own
time’.”
47. On 9 March, Nurse C visited him in hospital and also spoke to a ward
doctor and hospital nurse. They told her that he was making steady
progress and was not considered to require palliative care. They also
informed her that no discussion was necessary at that time as to
whether he would wish to be resuscitated in the event of his heart failing.
She left papers relating to the compassionate release of prisoners with
the doctor and the hospital nurse. (In certain circumstances a prisoner
will be allowed to leave prison on a temporary licence for, amongst other
reasons, compassionate grounds. In the case of the man, who was
already outside the prison, the practical applications of granting
compassionate release could include the withdrawal of the bedwatch
staff and resettlement into accommodation in the community such as a
nursing home or hospice.)
48. Also on 9 March, a multidisciplinary meeting took place at
Wellingborough. Among those present were the Governor and two
members of staff who had visited him earlier in the day. The minutes of
the meeting record that he continued to refuse to provide any details of
his sister’s whereabouts but efforts would continue to trace her. In
accordance with his wishes, if the staff did trace her, she would not be
contacted until after his death. Compassionate release (possibly to a
hospice) would also be pursued. The meeting also made arrangements
to support the welfare of the staff assigned to bedwatch duty.
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49. Another multidisciplinary meeting took place the following day. Nurse C
reported that she had been told by a consultant the previous day that his
condition had improved. Contingency plans were considered for the
possibility of his discharge from hospital and also if remained and died in
hospital. The meeting was told that bedwatch staff had talked with him
about his will, funeral arrangements and making contact with his sister.
50. On 11 March, the Consultant Gastroenterologist (a specialist in diseases
of the digestive system), told the staff who were on bedwatch that he
was suffering from multi organ failure and could not be moved from
hospital. One of the officers on bedwatch updated the Senior Officer.
51. The following day, the Consultant told the bedwatch staff that he was not
responding to treatment and, if that remained the position for the next 24
hours, treatment would be stopped. The bedwatch log completed by
one of the officers states:
“[i]nstructions have been given by the Consultant that if his [the man’s]
heart fails he should not be resuscitated. ... I have discussed
compassionate release with the consultant and he would be content for
him to be released to the hospital”. (The decision not to resuscitate
means that, should the patient go into heart failure, no attempt would be
made to restart the heart.)
The bedwatch log notes confirm that the Consultant had completed the
application for compassionate release. The record also noted that no
restraints (handcuffs) were in use.
52. A further multidisciplinary meeting was held on 12 March attended by,
among others, three members of staff who had visited him earlier in the
day. They reported that the Consultant advised that he had a terminal
illness. All treatment was to be withdrawn and he would be made as
comfortable as possible. The meeting discussed compassionate release
and the Governor decided that the application should not be pursued.
The minutes of the meeting record that “removal of staff from the
bedwatch would not be beneficial to him and that it was more decent for
staff to remain with him during his last days”. The Governor asked that,
when he died, a governor should go to the hospital to ensure that the
bedwatch staff were supported.
53. The clinical record states that after the meeting of 12 March, Nurse C
went to the hospital and spent some time with him. She noted that
“… he was comfortable in bed, unable to maintain a conversation
but occasionally able to answer yes when I asked him if he was
comfortable. He is being nursed in a side room.”
54. On 13 March, Nurse B noted that the hospital doctor had withdrawn all
treatment except paracetamol. The bedwatch log for 13 March states
“Nurse states he is on palliative care and will give him medication to
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manage his pain if required”. The Liverpool end of life pathway was put
in place. It ensures that high quality care is given to people approaching
the end of life.
55. The Bedwatch Log records that over the next few days he continued to
receive regular visits from doctors and nursing staff. The bedwatch staff
reported every four hours to healthcare. On 15 March, Nurse C was told
in a telephone conversation by a hospital staff nurse that he remained
comfortable. The following day, she visited him. She recorded that “[he]
remains comfortable in bed, receiving regular analgesia (used to relieve
pain) so he is pain free and comfortable”.
56. Officer C confirmed to my investigator that he was on bedwatch duty on
the evening of 16 March. He and a colleague had taken over from the
day staff at approximately 7.45pm. The day staff had briefed them that
there was no change in the man’s condition. The officer said that:
“The man slept throughout the night with the occasional coughing
and groaning similar to the day of 14 March when I was also on
duty. The nurses attended him at regular intervals to adjust his pain
medication and his bedding with the last occasion at approximately
6.55am [on 17 March] when his medication was checked and his
arms were placed under the covers.”
57. The officer confirmed that he was relieved of duties by day staff at
approximately 7.25am on 17 March.
58. Officer D was the second officer on duty on the night of 16 March. He
told my investigator that the man did not wake up during the night and
he was checked throughout the night by nursing staff.
59. At approximately 7.35am on 17 March, whilst the officer was handing
over the bedwatch duty to Officer E, a nurse came into the room to
check on the man. The nurse told the officers that she thought he had
died. The nurse went to get a second nurse who confirmed that he was
dead.
60. When interviewed, Officer E told my investigator that, shortly after he
came on duty, a hospital staff nurse told him that she believed that the
man had died. At 7.52am, the officer contacted a Senior Officer at
Wellingborough to inform him of the death.
61. A meeting took place in the deputy governor’s office at 11.30am on 17
March. After being debriefed, the relevant staff were offered appropriate
support, including being allowed to go home for which transport was
provided.
62. The Consultant’s assistant wrote to the Coroner’s office on 17 March to
report that the man had died that day. In his letter he gave the cause of
death as follows: “1. a) Decompensated chronic liver disease, b) biliary
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tract infection and 2. Congestive heart failure, ischaemic heart disease
and chronic disease”. The death certificate identified that death was
caused by biliary tract infection (the biliary tract transports bile from the
liver to the duodenum to aid digestion). Contributing causes were
congestive cardiac failure (heart failure), ischaemic heart disease and
chronic kidney disease.
63. HMP Wellingborough arranged and met the full costs of the funeral. The
man was buried with a Quaker service led by a member of the
chaplaincy at Wellingborough and was attended by the Governor.
16
ISSUES
The length of time the man served in prison
64. The man was sentenced in September 1985 and given a life sentence
with a 12 year tariff. The term to be served was reached on 1 December
1996. After that date he was eligible to have his case considered by the
Parole Board.
65. Shortly after being sentenced, he told the prison chaplain at HMP
Wormwood Scrubs that he was innocent of the offence and would rather
serve “natural life” than face society as a murderer released on licence
for an offence he did not commit. He continued to deny the offence
throughout his time in prison. He did not attend any hearings of the
Parole Board or have any involvement in the sentence planning process,
which is designed to help towards rehabilitation on release.
66. The Parole Board last looked at his case (in his absence) in October
2009. The Board considered a number of reports including one of 21
July 2009, prepared by his probation officer which states:
“... unless he receives a Free Pardon, he is quite content to remain
at Wellingborough. He otherwise does not expect to be released;
moreover, in the past he has voiced a preference to remain in
prison rather than face having to support himself in the community
in poor health in his latter years.”
67. The Parole Board decided that it was not safe to direct his release from
prison or to recommend transfer to an open prison (Wellingborough is a
closed prison). The ground for their decision was that they considered
that his risk of re-offending remained unaddressed as he had not
completed any offending behaviour work.
Clinical care and refusal of medical treatment
68. Prison Doctor A, and healthcare staff, referred him to hospital for
medical treatment on seven separate occasions between November
2008 and his death in March 2010. On five of those occasions, he
discharged himself from hospital, and on one occasion he declined to go
to an appointment that had been made for him. The clinical record
shows that healthcare staff warned him of the consequences of refusing
treatment. He signed a disclaimer on four occasions to confirm that he
understood the implications of refusing treatment. He said that he
disliked being handcuffed to prison officers, and having to wait for
treatment.
69. In the same period, the clinical record shows that on a number of
occasions he refused to see the prison doctor and did not keep
appointments with staff in the healthcare centre.
17
70. The doctor told my investigator that he was:
“… not a man who sought medical help in lots of ways really:
refused admission to hospital, then often discharged himself once
he’d been sent to hospital. Not because he was in any way
aggressive or whatever, he was a nice man, but he was almost
resigned to his fate.”
71. The clinical reviewer comments on his attitude to accepting treatment:
“His [the man’s] medical care throughout has been compromised by
his intermittent lack of co-operation with treatment, however, there
is nothing contributory either in his actions or in anyone else’s to his
ultimate deterioration and death.
“I have found the medical care to at least be of a standard he would
have received in the community and where he was treated with
compassion and care and his difficult medical conditions managed
to the very best of their ability. This is an excellent example where
the use of appropriate computerised medical records, organised
chronic disease management programmes and a well staffed and
trained medical, nursing and pharmacy team have provided good
quality care. I do not feel that there are any specific
recommendations for improvement within the service that was
provided for him.”
72. Given that he was undoubtedly a patient who frequently refused to co-
operate with medical staff, I am satisfied that staff at Wellingborough
made every effort to persuade him to accept treatment. Indeed, on
those occasions when he discharged himself and was almost
immediately taken ill again, staff invariably managed to convince him to
return to hospital the next day. I believe that the care given to him was
appropriate and empathetic to someone in his position, and I agree with
the clinical reviewer’s comments. I am particularly impressed with the
multi disciplinary meetings which meant that healthcare and discipline
staff worked together to plan the best arrangements for him.
Transfer to HMP Norwich
73. In December 2008 and early 2009, Prison Doctor A and healthcare staff
at Wellingborough actively considered his transfer to the specialist unit
for elderly patients at HMP Norwich. He was refusing medical
intervention at that time and Wellingborough staff thought that Norwich
would be better equipped to provide the care that he required. He was
receptive to the move and an application for his transfer was made in
January 2009.
74. The prison doctor decided not to pursue the application after taking
advice. He told my investigator that the man was happy to remain at
Wellingborough. It is unfortunate that the application seems to have
18
been lost. It is clear that, on reflection, the doctor considered it in his
best interests that he should remain at Wellingborough. Also he spent
his last weeks in hospital, rather than in prison, which was the right place
for him.
Consideration of compassionate release
75. I note that timely consideration was given as to whether to release the
man from prison on compassionate grounds. The Governor initially
supported the move and had the support of the hospital consultant who
was treating him.
76. However, it became apparent that he could not be moved from hospital
(for example to be transferred to a hospice) as this would have been
detrimental to his health. He had expressed his wish to return to prison
if possible, and had not discussed any plans for resettlement. The
Governor decided not to apply for compassionate release so that
bedwatch staff would remain with him. He had no visitors and rejected
the suggestion that his family should be told that he was dying.
Retaining the bedwatch officers, despite the emotional cost on them and
the demands on the prison’s budget, meant that he was not alone at this
time.
77. I often comment on cases where compassionate release has not been
considered at all, or where a decision not to apply for such a release has
been particularly risk averse. On this occasion, however, I applaud the
compassion shown by the Governor and believe that this is an example
of good practice. By keeping the bedwatch officers with him, which
could only be done as he remained a prisoner in custody albeit one who
was in hospital, the Governor ensured that he was well supported
through the final days of his life. For a man who had no next of kin and
who clearly saw the prison as his home, I think that this would have
provided great comfort.
The decision not to release the man in order that bedwatch officers
could remain with him was, on this occasion, an act of compassion
and an example of good practice.
Use of restraints
78. There were two occasions when he refused to go to hospital because he
did not want to be handcuffed and he said that he did not want to die in
handcuffs. I have no reason to doubt that the risk assessment
concluded that restraints (handcuffs) were necessary on those
occasions. However, it is not evident whether the considerations were
properly explained to him or if other options such as escorting him with
more officers and without restraints were considered.
79. However, I am pleased to report that from when he was taken to hospital
on 5 March until his death, he was not restrained in any way. This
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common sense approach is welcomed and I am pleased that
Wellingborough treated a terminally ill man so decently. In addition, my
investigator found that the bedwatch notes were detailed with full and
appropriate entries.
Contacting the man’s next of kin
80. I have referred to the efforts made to trace his next of kin by
Wellingborough’s family liaison officer. It is evident from the clinical
record that she tried several different routes and possible leads to track
down his sister. She also contacted one of my family liaison officers for
advice. My investigator noted from his prison record that he had told
staff when he was remanded in custody in 1985 that he had lost contact
with his brother and sister. Latterly, he received no visits or letters, and
it was always going to be difficult to trace the whereabouts of his next of
kin. I commend the efforts made by the family liaison officer.
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CONCLUSION
81. The man was a prisoner who, because of his continual refusal to admit
guilt or engage with offending behaviour programmes, remained in
prison long after the length of his tariff. He seemed content to stay in
prison and expressed his desire to remain there in preference to being in
hospital.
82. When he became ill, he was given care to a standard that was at the
very least equivalent to that he would have received in the community.
The clinical reviewer cites the good standard of chronic disease
management programmes and well trained staff across all parts of
healthcare as key factors to achieving this outcome.
83. In addition, I am pleased to report that staff at Wellingborough ensured
that the use of restraints were appropriate and that, in his final days, he
had the companionship of the bedwatch staff. Releasing him would
have meant that the staff could return to the prison to their other duties.
Instead, the Governor decided that it was in his best interests to keep
the bedwatch arrangements in place. I consider this to be a highly
compassionate decision.
21
GOOD PRACTICE
The decision not to release the man from custody in order that bedwatch
officers could remain with him was, on this occasion, an act of compassion
and an example of good practice.
22
Response from the National Offender Management Service Safer
Custody
“As a general comment the prison are grateful that the Ombudsman
acknowledges the good quality of care provided by all staff involved
during the man’s time at HMP Wellingborough and in particular
recognises the importance of the Governor's decision not to take forward
an application for compassionate release. We are also pleased to note
the Clinical Reviewer's very positive comments on the organisation and
delivery of clinical care.”
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