Individual at Whatton

Investigation into the circumstances surrounding the
death of a man, a prisoner at HMP Whatton, in a local
hospital at Nottingham, on 30 November 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2010
Final report
This is the report of an investigation into the circumstances surrounding the death of
a man. The man was 72 years old when he died from natural causes on 30
November 2008 at a local hospital in Nottingham. He was a prisoner in the custody
of HMP Whatton.
The man had been diagnosed with lung cancer in the spring of 2007. He managed
quite well in the months that followed, but his health declined in 2008. He was
placed under the care of a palliative care nurse because it was recognised that his
illness was terminal. The cancer began to spread to other parts of his body. He
underwent a course of chemotherapy to slow the spread of the disease, but this left
him feeling weaker. He died as a result of neutropenic sepsis (meaning that an
abnormally low number of white blood cells in his body led to him developing an
infection and then a fever). This is a recognised complication in patients receiving
chemotherapy.
I would like to offer my sincere condolences to the man’s wife and to all those
affected by his death. I understand that the man’s wife was able to spend time with
her husband during a visit on the day he went to hospital, and that she was also able
to be at his bedside when he died the next day. I hope that this has provided her
with some comfort.
I would like to apologise for the lengthy delay in issuing the final version of the report.
The investigation was completed by one of my investigators. My former Senior
Family Liaison Officer contacted the man’s wife to discuss my investigation and the
questions which she had about her husband’s death. Another of my Family Liaison
Officers has maintained contact with the man’s wife.
A clinical review of the treatment which the man received in custody was undertaken
by Dr A on behalf of NHS Nottinghamshire County. He has assessed whether the
care that the man received in custody was comparable to that he would have been
offered in the community. I am grateful to Dr A for his assistance. (A copy of his
review is annexed to my report.) I would also like to thank the Governor and her
staff and prisoners at Whatton for their full cooperation whilst my investigation took
place. I especially acknowledge Ms C, who liaised with my investigator and
organised the interviews.
The man had spent several years in custody before his illness was diagnosed.
Whilst his death was expected within weeks, my investigation has determined that
more might have been done to prevent the final infection that caused his death. Had
he been treated more proactively, he might have lived a very short while longer. In
particular, I have highlighted the vulnerability of prisoners who are receiving a course
of chemotherapy. I make one recommendation in relation to the use of restraints. I
also note the number of times that hospital appointments were cancelled because of
a shortage of prison staff to act as escorts.
Jane Webb
Acting Prisons and Probation Ombudsman December 2010
Final Report 2
CONTENTS
Summary 4
The Investigation Process 6
HMP Whatton 8
Key Findings 10
Issues 21
Conclusion 34
Recommendations 35
Annexes
Final Report 3
SUMMARY
The man arrived at HMP Nottingham on 10 January 2003. A few weeks later, on 4
February, he transferred to nearby HMP Whatton.
As a long term smoker, the man was advised to give up in 2005 when he became
increasingly short of breath. In February 2007, he started to cough up blood. The
following month, he was assessed during a stay at the local hospital in Nottingham.
On 30 March, he was told that he was likely to have lung cancer, and a two week
referral was made (the NHS promises to assess all patients suspected to have
cancer within a fortnight).
Having missed an appointment on 10 April because prison staff were unavailable to
escort him to the hospital, the man underwent further tests later that month. He was
due to attend an appointment on 1 May, but again prison staff were unable to
accommodate the hospital’s request. The man made four visits to the hospital later
that month, and following further exploratory tests was told that he might undergo an
operation to remove his diseased right lung.
With a view to surgery, further hospital appointments were organised for 11 and 21
June to allow for pre-operative tests to be carried out. However, the prison was
unable to supply the necessary staff to escort the man to hospital, and he missed
both appointments. On 22 June, a consultant wrote to the healthcare team at the
prison to say that the failure to bring the man to his appointments was jeopardising
his chances of successful treatment.
When the man attended appointments on 26 June and 2 July, it was decided that the
tumour in his lung was now inoperable because it was too close to his windpipe. It
was instead decided that he would begin a course of radiotherapy to slow the growth
of the tumour. Between 29 July and 11 August, the man stayed in hospital for
radiotherapy treatment.
Over the next year, the man became gradually frailer. It was recognised that the
cancer could not be successfully treated, and he was therefore placed on the
palliative care register. (Palliative care is treatment which seeks to reduce the
severity of the patient’s symptoms, because it is recognised that the disease cannot
be cured.) The man maintained some of his mobility, but by the summer of 2008 he
had become weaker and had to use a wheelchair more frequently.
At the end of October 2008, the man began chemotherapy treatment after it was
found that the cancer from his lung had now spread to his liver. However, the
chemotherapy weakened him further and made him feel unwell. In the middle of
November he moved to a specially equipped cell where his wife could visit him.
On Saturday 29 November, the man was visited by his wife. Afterwards, his
condition deteriorated. Nurse A consulted with the out of hours doctor, who liaised
with the Oncology Department at the local hospital. Nurse A was advised by the
doctor that the man would be admitted to hospital, and at 3.41pm an ambulance was
requested on a ‘within an hour’ basis. Later in the afternoon, the man’s temperature
had risen above normal limits.
Final Report 4
The ambulance did not reach Whatton for 90 minutes, meaning that the man
eventually arrived at hospital at 6.45pm. He was visited by his wife in the evening
and his condition deteriorated overnight. At 5.45am, the escorting officers were
asked by hospital staff to remove the restraints. The man died an hour later, with his
wife by his side. The cause of death was neutropenic sepsis (blood poisoning),
resulting from a weakened immune system caused by his chemotherapy treatment
and his ongoing lung cancer.
My investigation has raised some concerns. Prison staff failed to escort the man to
four appointments whilst he was being diagnosed in 2007. When he was eventually
brought to the hospital and tests were completed, the tumour in his lung was found
to be inoperable. I am satisfied that the new Head of Healthcare has made
substantial improvements to the appointments system.
I express concern about hand-cuffing the man in hospital until an hour before he
died. I do not consider that this was either necessary or respectful. I understand
that a previous recommendation that I had made regarding the cuffing of prisoners is
now being implemented, albeit after the man’s death. I make one recommendation
in the hope that the unnecessary use of restraints does not occur in the future.
Although my investigation is critical in some respects, I have been impressed by the
efforts being made by the Governor, wing and healthcare staff to address the needs
of the increasing numbers of chronically ill, elderly prisoners at Whatton.
Final Report 5
THE INVESTIGATION PROCESS
1. My investigator was formally notified of the man’s death on 3 December 2008.
Notices were subsequently issued to both staff and prisoners at HMP
Whatton, informing them of the investigation process and giving the
opportunity to contact my investigator if they felt that they could provide any
relevant information. No prisoners came forward, but when he visited
Whatton my investigator was able to speak informally with two of the men who
helped to care for the man.
2. My investigator made contact with Ms C, the prison’s liaison officer. She
provided him with all records relating to the man’s time in custody and
organised the interviews subsequently conducted at Whatton.
3. Having examined all of the relevant documents relating to the man’s time in
custody and the medical treatment he received, my investigator arranged to
visit Whatton on 6 February 2009. He interviewed one of the governors and
the doctor who oversaw the man’s treatment. My investigator returned to
Whatton on 23 February to complete interviews with the Head of Healthcare,
a nurse specialising in palliative care, and two prison officers. He
subsequently interviewed two other prison officers and a nurse over the
telephone.
4. My investigator wrote to the local Coroner’s office to inform them of the nature
and scope of the investigation, and to request a copy of the notes made by
the doctor on duty at the time of the man’s death. HM Coroner will be
provided with a copy of my report.
5. My investigator contacted NHS Nottinghamshire County and asked that a
clinical review be carried out with regard to the medical treatment which the
man received in custody. The purpose of this review is to establish whether
the care which the man received in prison was comparable with that he would
have been offered in the community. Dr A completed the review, which is
annexed to my report.
6. On 17 December 2008, my then Senior Family Liaison Officer wrote to the
man’s wife providing information about my investigation. She telephoned the
man’s wife on 5 January 2009 in order to discuss the questions and concerns
which she had about the circumstances surrounding her husband’s death.
7. The man’s wife wanted to know more about the reasons why her husband
was not granted early release on compassionate grounds and could not come
home to her when he was very unwell. (The interviews which my investigator
conducted reflect the fact that early release on compassionate grounds is still
very much the exception rather than the rule. This appears to be largely due
to the nature of the offences committed by the prison’s population.) She also
wondered if she could have been permitted more privacy with her husband
before he died. I endeavour to address these issues in my report, which I
hope gives the man’s wife a better understanding of what occurred.
Final Report 6
8. HMP WHATTON
9. HMP Whatton is a category C training prison which holds men who have
committed sexual offences. In recent years the prison’s population has
doubled, and its maximum operational capacity is now 841. In general,
prisoners at Whatton are much older than the prison population as a whole.
They may also have been convicted of a sexual offence many years after it
took place. This was true in the man’s case.
10. Since April 2004, I have investigated 15 deaths at Whatton. Of these, 12
were as a result of natural causes. Three of my earlier investigations raised
concerns which I return to in this report.
11. In the case of a prisoner of a similar age to the man whose death in June
2007 was also caused by lung cancer, I recommended that a palliative care
policy be implemented. I am pleased to say that my investigator observed
good progress in this regard during his visits, and I understand that the
palliative care needs of prisoners are now being met by a dedicated nurse.
The man benefited from some of these improvements during his illness.
12. When another prisoner died of lung cancer in August 2007, I addressed the
use of restraints when prisoners are escorted to hospital. I recommended that
a full risk assessment and an assessment of the use of restraints be
performed in these circumstances. I repeated my recommendation when I
investigated the death of another prisoner in July 2008. Although I am critical
of the decision made with regard to the cuffing of the man when he was taken
to hospital on 29 November, I am pleased to note that the prison’s Local
Security Strategy has been updated since he died. It now reflects the need
for a more flexible and ‘common sense’ approach to cuffing.
13. With regard to healthcare provision, nursing staff are on duty from Monday to
Friday between approximately 7.30am and 7.30pm. Amongst a variety of
tasks, they complete the reception of new prisoners, run clinics and triage
prisoners. Different nurses have specialist training in areas such as the
management of terminal illness. Doctors from local practices also hold
surgeries each weekday. During the weekend, nursing staff work from
approximately 7.30am until 2.30pm. During out of hours periods, nurses and
prison officers can contact the Nottingham Emergency Medical Services
(NEMS). (This is an out of hours service which provides medical advice and
allows nurses and prison officers to speak with a doctor to decide whether an
ambulance should be called. It is the same out of hours service that the
general public would call.)
14. HM Chief Inspector of Prisons carried out an announced inspection of
Whatton in January 2007. She acknowledged ‘a dramatic and rapid period of
change’ at Whatton. As far as a palliative care strategy was concerned, none
was in place at the time of the inspection. HM Chief Inspector of Prisons
recommended the development of such a strategy.
Final Report 7
15. Having spoken with various members of staff at Whatton, my investigator has
found that progress has been made in this regard over the last couple of
years. The management team has introduced several innovations, and there
is a recognition that the ageing population makes particular demands on staff
that other prisons may not experience.
16. The most recent annual report published by the Independent Monitoring
Board (IMB) at Whatton covers the year from June 2007 to May 2008. (The
IMB at each prison is made up of members of the public who are both
independent and unpaid. They monitor the day-to-day life in their local prison
and ensure that proper standards of care and decency are maintained.) The
IMB report indicates that the wheelchairs used at Whatton are in poor
condition and short supply. They are also not meant to be used outside,
which is problematic as most units stand alone and prisoners must be pushed
for short distances in the open air in order to reach other parts of the prison.
The IMB commends the ‘professional dedication’ of a healthcare team who
are caring for the oldest population of any prison in England and Wales.
Final Report 8
KEY FINDINGS
17. The man arrived at HMP Nottingham on 10 January 2003 having received a
ten year prison sentence at the Crown Court. He underwent an initial health
screening in the reception area and did not report any significant health
concerns. He was prescribed amitriptyline (an anti-depressant) to treat his
anxiety.
18. Just over three weeks later, on 4 February, the man was transferred to nearby
HMP Whatton and a second health screening was completed. Again, no
significant health problems were highlighted.
19. The man remained at Whatton and, in March 2004, went before an Incentives
and Earned Privileges (IEP) review board, becoming an enhanced prisoner.
(The IEP scheme seeks to encourage and reward cooperative and
constructive behaviour by prisoners. Prisoners can either gain or lose certain
privileges, depending on their actions. Enhanced is the highest of the three
levels of the scheme.)
20. Just over a year later, in July 2005, the man underwent a spirometry test
(which can help to diagnose a variety of lung conditions). The test confirmed
that the man’s lungs were working poorly. In late December 2005, as a long
term smoker the man was advised by healthcare staff to stop smoking
altogether or reduce the amount he smoked. It was noted in his clinical
record in November 2006 that he became breathless, particularly after
walking short distances. He was unable to breathe comfortably when he was
lying down. Three months later, on 5 February 2007, he told healthcare staff
that his chest felt tight and he had been coughing up dark yellow sputum.
21. The first indication that the man had a serious illness came a few weeks later
on 27 February. He attended the over-65s clinic and reported that he had
been coughing up blood in his phlegm and was experiencing more
breathlessness. It was planned that these symptoms would be assessed by a
member of the healthcare team in March. Two weeks later, on 13 March, The
man went to the healthcare centre after coughing up a lump that was ‘filled
with blood’. He provided a sample of the blood-tinged phlegm, which was
sent for tests.
22. Between 19 and 27 March, the man stayed at the local hospital in
Nottingham. During this period a chest x-ray was taken which gave cause for
concern and further investigation was recommended. On 30 March, the man
was informed by healthcare staff at the prison that his likely diagnosis was
cancer. A ‘two week wait’ urgent cancer care referral was made (this meant
that the man should be assessed by a specialist within two weeks).
23. The man was offered an appointment with a specialist on 10 April. However,
the prison was unable to provide staff to escort him to hospital on that date.
Instead, he visited the local hospital later than planned on 17 April. A
malignant tumour was suspected and further tests were arranged. Two days
later, on 19 April, the man underwent a bronchoscopy. (This is an
Final Report 9
examination of the patient’s airways using a device which is inserted through
either the nose or mouth. Ideally, a small tissue sample is taken from the lung
for analysis during this procedure.)
24. About a week later, on 25 April, a computerised tomography (CT) scan
confirmed that the man had a malignant tumour in his right lung. (This type of
scan helps medical staff to see what is happening inside a patient’s body.) It
was decided that he would undergo a positron emission tomography (PET)
scan. (The scan produces a three dimensional image of the patient’s body to
assist diagnosis.)
25. Prison officers were unavailable to escort the man to hospital on 1 May, and
he therefore missed another appointment. However, the man did go to his
hospital appointments on 9 and 16 May. During the latter visit, the PET scan
was carried out at the Combined Lung Oncology Clinic and more lung function
tests were ordered. The man was told that, as the result of this scan was
‘favourable’, he might undergo an operation to try and remove the tumour. A
couple of days later, the man spoke with healthcare staff at the prison and
expressed a wish to stop smoking.
26. Further hospital appointments followed. On 24 May, an isotope lung scan
was carried out to check on the blood and oxygen supply to the man’s lungs.
He was told on 30 May by a thoracic surgeon (a specialist in problems
associated with the lungs) that he might undergo surgery to have his right
lung removed (referred to as a right pneumonectomy) or start intensive
radiotherapy. If his condition remained untreated, the man was told that he
had a life expectancy of between six and eight months.
27. With a view to potential surgery, the man was due to undergo a pre-operative
bronchoscopy on 11 June. However, he did not attend his appointment
because officers were again unavailable to escort him to hospital. After his
case was discussed at a hospital meeting on 15 June another appointment
was offered for 21 June, but again the prison was unable to provide an escort.
28. On 22 June, Mr A (a consultant and specialist registrar in thoracic surgery at
the local hospital in Nottingham) wrote to the Head of Healthcare at Whatton
expressing his concern regarding the prison’s failure to bring the man to two
pre-operative assessments. It seems that hospital staff had just been told by
prison staff that the man could not be escorted to another appointment until
19 July. It was thought by hospital staff that such a delay was unacceptable.
In his letter, Mr A commented:
‘… if this [situation] is not resolved immediately then the man may have
lost the chance for any potentially curative surgery!’
29. I explore the reasons for the repeated failure to escort the man to his hospital
appointments in the Issues section of my report. Mr A’s letter included the
offer of another appointment. The man was taken to a pre-operative
exploratory assessment at the local hospital on 26 June. (He again made an
application to the healthcare team at the prison on the same day asking for
Final Report 10
help stopping smoking.) His case was discussed at a hospital meeting the
following day. It was thought that the man was ‘borderline for surgery’ and
should be seen by the oncologist.
30. Following receipt of the letter from Mr A, Ms D (the then Head of Healthcare at
Whatton) spoke with Governor A on 28 June. She wanted to ensure that the
man would be taken to his next appointment on 2 July, as it seems to have
been in doubt. It was agreed that he could attend the appointment. On 29
June, the man was advised that he would start a course of ferrous sulphate to
treat his anaemia (a lack of red blood cells leading to feelings of extreme
tiredness, because insufficient oxygen is circulating around the body).
31. The man went to the appointment on 2 July and underwent an oral endoscopy
(during which a tube is inserted through the mouth to examine the patient’s
internal organs) and a bronchoscopy to help the hospital staff decide how to
treat him. He was told that surgery was not the best option because the
tumour was sufficiently enlarged as to be too close to his windpipe. This
meant that removal of the tumour (an operation known as a pneumonectomy)
was impossible, as other organs were in the way and could be damaged
during an operation.
32. Dr B (consultant thoracic surgeon) referred the man to Dr C (Head of Service,
Oncology Department, Nottingham University Hospitals) on 4 July, confirming
that his cancer was advanced and inoperable. The letter suggested that the
Oncology Department should take over the man’s treatment. Following a
meeting of hospital staff the same day, radiotherapy was planned instead in
order to shrink the tumour and manage the spread of the cancer. This form of
treatment is known as Continuous Hyperfractionated Accelerated
Radiotherapy.
33. Ms D spoke with Governor A again on 5 July to ensure that the man would be
able to go to his next appointment four days later on 9 July. He did attend
and was assessed by a consultant who arranged radiotherapy.
34. On 6 July, hospital staff noted that the timeframe within which the man’s
treatment was supposed to start had passed. The delay was said to be
caused by the prison failing to escort him to his appointments. It was
recorded that the tumour was now inoperable and that radiotherapy was to be
arranged instead.
35. A further hospital visit was scheduled for 19 July, but the man did not leave
the prison that day and his clinical record indicates that the appointment had
to be cancelled. A further hospital visit took place on 23 July.
36. The man fell in the shower on his wing on 27 July. He was examined by
healthcare staff but had not sustained any injuries.
37. The man stayed in hospital between 29 July and 11 August for radiotherapy
treatment, which aimed to shrink the tumour.
Final Report 11
38. Later that month, on 15 August, staff started to blend the man’s food as he
was having trouble swallowing. However, he did not like the blended food,
and two days later asked that staff stop doing this.
39. The man became unwell on 20 August due to vomiting and diarrhoea. His
vomit contained traces of blood and it was suspected that this might be the
result of food poisoning. Staff were told that the man should be admitted to
hospital if he vomited a large amount of blood during the night. However, the
following day he felt much better.
40. During a journey to a hospital appointment on 10 September, the taxi
escorting the man was involved in an accident when the vehicle was bumped
from the rear by another car. When he arrived at the hospital, a chest x-ray
was taken and indicated some improvement in the rate of deterioration in the
man’s condition. It was felt that he had tolerated the course of radiotherapy
well and that his cough had improved.
41. A few days later, on 15 September, the man felt too unwell to see his wife in
the visits room. Prison staff called the out of hours NEMS (Nottingham
Emergency Medical Services) helpline because he complained of chest pain
and was coughing up blood. He was given antibiotics and steroids and was
visited by his wife the next day.
42. On 3 October, the man was assessed in the healthcare centre. He said that
he had started smoking again due to the stress of his upcoming parole
hearing. He was anxious after receiving a letter indicating that he could be
deported to the Republic of Ireland on his release from custody. The man told
staff that he had been experiencing a pain in the left side of his neck following
the traffic accident on 10 September.
43. The man went to further hospital appointments on 8 and 12 November. He
was told during the latter visit that, whilst the cancer was not in remission, he
should not be overly concerned about the immediate situation. He was told to
attend a check-up appointment in three months time.
44. On 15 November, the man was examined by a prison doctor. There was
concern about his medication because he had been waking up in the night
short of breath. A home oxygen cylinder was ordered to reduce his breathing
difficulties.
45. Five days later, on 20 November, the man vomited and collapsed in his cell.
He was taken by ambulance to the Accident and Emergency Department at a
second local hospital. Previously he had attended appointments at the other
main hospital in Nottingham. He was subsequently moved to the local
hospital, and returned to the prison on 3 December. At this point, whilst he
was using oxygen to assist his breathing, he was also still smoking.
46. As part of improvements made by the healthcare team, in January 2008
Nurse B was given responsibility for the treatment delivered to patients with
Final Report 12
palliative care needs. The man’s care was managed by Nurse B and Dr D,
who was familiar with the issues surrounding terminally ill patients.
47. The man was placed on the palliative care register and was treated according
to the guidelines set out in the Liverpool Care Pathway. (This is a recognised
model of caring for patients whose illness cannot be cured. The intention is
that treatment should be comparable to the type which people receive in a
hospice.) The man’s case was reviewed at monthly multi-disciplinary
meetings involving both the healthcare and prison staff.
48. On 10 January 2008, the man was told that his first parole request had been
refused. In early February, he received a final warning after repeatedly
smoking in the vicinity of his oxygen cylinder. At about the same time he
developed a chest infection.
49. The man was taken to the healthcare centre in a wheelchair just before
3.00pm on 11 February. He had woken up in the early afternoon with severe
chest pain. Paramedics transferred him in an ambulance to the Accident and
Emergency Department at the second local hospital at 5.15pm. He was given
drugs to prevent a clot from forming in his blood, although tests confirmed that
he was not experiencing a heart attack, as had been suspected. He returned
to Whatton on the following day. He attended a scheduled appointment at the
local hospital a fortnight later, on 25 February.
50. Between 3 and 6 April, the man’s condition was reviewed by the prison doctor
each day because he had another chest infection. In early May, healthcare
staff noted that the man was experiencing disorientation with regard to the
time of day, as well as confusion and memory loss. It was thought that the
lung cancer might have started to spread to his brain. On 28 May, a
physiotherapy assessment confirmed that the man remained both mobile and
independent.
51. The man continued to visit the local hospital regularly. He was escorted to his
appointments twice in June and three times in August. During this period he
became generally frailer and less mobile. He had started to use a wheelchair
to make the journey from his cell to the visits room to see his wife. He could
still walk with the aid of a stick, but managed ever shorter distances. He had
been given a special chair in his cell and needed some help from other
prisoners to carry out daily chores such as making his bed. He also continued
to lose weight as the cancer became more advanced and his health
deteriorated.
52. On 24 July, the man developed a further chest infection and was prescribed
steroids and antibiotics. Two months later, on 15 September, it was noted in
the man’s medical record that he should have been sent to the hospital the
week before for a CT scan. He eventually went to the hospital on 6 October
and the procedure was carried out.
53. A fortnight later, on 20 October, because recent blood tests showed a raised
potassium level, the man was taken into hospital and kept in overnight for
Final Report 13
observation. He returned to the prison the following day. Whilst at the
hospital’s Oncology Department, he had been told that his lung cancer had
now spread to his liver. Plans were made for him to undergo chemotherapy in
an attempt to slow down the effects of the cancer, and he was advised of the
possible complications of this treatment.
54. At the end of the month, on 30 October, the man began the course of
chemotherapy but was exhausted afterwards. The healthcare staff
established a protocol whilst the man was receiving ongoing chemotherapy,
ensuring that his blood was regularly tested and his temperature checked
daily. A note was made in the man’s medical record to indicate that, if his
temperature rose above normal limits and he became feverish, the hospital
was to be contacted.
55. From the beginning of November, Dr D (who had been overseeing the man’s
treatment) started to visit more frequently. The effects of the chemotherapy
were making the man feel unwell. Dr D told my investigator that he had
become ‘more nauseous, more breathless, probably more frail’ from this point.
He struggled to walk any significant distance.
56. On 6 November, the man was told that his second parole application had
been refused. On the same day he received his next chemotherapy treatment
in the prison. Further hospital visits for chemotherapy treatment followed on
19 and 21 November.
57. Nurse B thought that the combination of the refusal of parole and the
debilitating effects of the chemotherapy had caused the man to ‘go downhill a
bit’. In mid-November, he had moved from C1 landing (where he had been a
resident for some time) to a larger cell on A8 landing where his needs could
be more easily accommodated and he would receive assistance from his
fellow prisoners. The man was initially uneasy about moving into a cell where
the previous occupant had died.
58. Some of the prisoners volunteer to act as carers, and two of them, Mr B and
Mr C, helped the man with everyday tasks such as collecting his meal,
opening and shutting his blind, and pushing him across to the visits room in
his wheelchair.
59. On 27 November, the man felt poorly, lethargic and was short of breath. Later
in the day he was noted to be ‘looking very unwell’ and had coughed up a
small amount of blood.
60. The man’s next dose of chemotherapy was administered orally in prison on 28
November as the hospital had instructed. (The man had not eaten for two
days, but had been drinking.) Dr D visited the man in his cell the same day.
She and the other healthcare staff had observed a decline in his health and
mobility since he had begun his chemotherapy treatment, and particularly in
the previous ten days.
Final Report 14
61. Dr D had been told that morning by the nursing staff that the man ‘looked
quite unwell’ and his lips had turned blue. She told my investigator that:
‘… by the time I got there, actually he wasn’t so bad, he was short of
breath but not obviously worse, he was still speaking in sentences, his
pain was well controlled, he wasn’t particularly nauseated, he was
using his home oxygen …’
62. Dr D thought that the man’s health had declined to a point where she did not
think that he was able to get to the visits room to see his wife, even with the
use of a wheelchair. She discussed the matter with Governor Phil Aspinall
(the duty governor between Thursday 27 November and Sunday 30
November). They decided that from then on the man’s wife would be allowed
to visit her husband in his cell on the wing. (The cell was designed with a
curtain across the entrance to allow privacy whilst an officer remained in the
corridor.)
63. The man’s wife had the opportunity to visit her husband in his cell on the
morning of Saturday 29 November. Practice Nurse A came across to the
wing during her morning rounds to give the man his daily medication and
examine him. She was aware that he was receiving chemotherapy, and that
his body temperature should be checked on a daily basis. If it went above
normal limits, she knew to notify a doctor.
64. When Nurse A arrived, she found the man with his wife. She decided to delay
her assessment until after the visit, because she knew that they valued the
time together and she did not want to interrupt. Before she left, she
encouraged the man to take a tablet of Sevredol. (This is a morphine based
painkiller which he was to take at his own discretion when he experienced
pain.) Officer A sat outside the cell to monitor the visit. As the man’s wife left
the prison, Governor A told her that he would contact her if there was any
change in her husband’s condition.
65. Nurse A was concerned about the man following her visit during morning
rounds. She felt that he had not looked as well as she expected and had not
been his usual self. She had had to help him into his chair.
66. The wing was unlocked after the lunch period and Nurse A returned to the
man’s cell. She remained concerned and spoke with wing staff. She
completed her observations and made a record of her findings back in the
healthcare centre at 1.37pm. He complained of chest pain, his blood
pressure had dropped, his pulse was elevated but his temperature remained
within normal limits (35.8 degrees Celsius).
67. Nurse A rang the out of hours service to consult a doctor between 2.30pm
and 3.00pm. She left a message with the operator who told her that a doctor
would call her back. Dr E from NEMS returned her call soon afterwards and
she described her findings. She told him that the man was unwell and they
discussed the need for possible hospital admission.
Final Report 15
68. Dr E told Nurse A that he would consult staff at the Oncology Department at
the local hospital where the man had received his recent treatment. (Nurse A
told my investigator that staff working for the out of hours service are made
aware of palliative care patients who are being held in prison.) The nurse
remembered that Dr E had said that, on the basis of what she had described,
she should make preparations for the man to be admitted to hospital later that
day. Nurse A recalled in interview that she and Dr E had discussed the
chemotherapy the man had been receiving during their conversation. She
made a record of their telephone call at 3.26pm.
69. Nurse A went back to speak with the man in his cell. She asked him whether,
if things came to the worst, he had thought where he would like to be. He
replied, ‘Home’. Remembering the recent refusal of his parole application,
she reminded him that this would not be possible.
70. Dr E rang Nurse A back and confirmed that, having consulted with staff at the
Oncology Department, he had arranged for the man to be admitted to
hospital. According to the call log kept by the East Midlands Ambulance
Service (EMAS), an ambulance was requested at 3.41pm. Because it was a
planned admission, Dr E made the arrangements, rather than prison staff.
The ambulance crew were instructed that the man needed to be collected
‘within an hour’.
71. According to the call log provided by EMAS, after the ambulance service was
called at 3.41pm, a crew was asked at 4.22pm to collect the man. (This log
seems to be the most accurate record of events because it was entered onto
a computer as events took place.) The paramedics set off at 4.26pm, and
reached the prison at 5.07pm. The ambulance left Whatton at 5.44pm,
reaching the local hospital in Nottingham at 6.45pm.
72. In interview, Nurse A remembered going back and forth between the
healthcare centre and the man’s cell whilst they waited for the ambulance to
arrive. She recalled that Officer A, who knew the man quite well, stayed with
him whilst she returned to the healthcare centre. Nurse A had been due to
finish her shift at 2.30pm, but remained with the man until the ambulance
arrived.
73. When she spoke with my investigator, Nurse A recalled examining the man
once or twice more before he went in the ambulance. She made one further
entry in his medical record at 5.32pm. She noted that his temperature had
risen above 37 degrees Celsius (meaning that it was now above normal limits)
and that he was not communicating very coherently. She tried to be
supportive and encouraged him to keep drinking fluids. When she spoke to
my investigator, Nurse A remembered that the man’s temperature had
‘jumped up’ in the late afternoon.
74. The ambulance crew arrived after 90 minutes. Nurse A knew that the
paramedics were on their way, but said in interview that it seemed to take a
long time for them to arrive. She recalled that she might have made a
telephone call to find out how long they would take to reach Whatton.
Final Report 16
75. The man was escorted to hospital by Senior Officer Y and Officer A. He was
in a wheelchair and was cuffed to one of the officers by an escort chain. (This
is a chain approximately eight feet long with a cuff on each end. It allows
hospital staff to carry on treating the prisoner without the officer getting in the
way.)
76. Governor A and Senior Officer W oversaw the cuffing arrangements. Along
with Nurse A, they completed the escort risk assessment. The escorting
officers were instructed to remove the chain in the event of an emergency or
after contacting the duty governor to obtain his permission.
77. Nurse A completed her part of the Prisoner Escort Record (PER) at 4.45pm,
over an hour after the ambulance had originally been called. According to
the PER, the ambulance left Whatton at 5.55pm and arrived at the local
hospital at 6.40pm. Although these timings differ slightly from the EMAS log,
both records confirm that the man did not arrive at hospital until three hours
after the ambulance was originally called.
78. In interview, Nurse A said that the man had told her that he was ‘comfortable
and pain-free’ as he left in the ambulance. She talked to him and they shared
a joke as he was leaving. She did not recall the precise details of her
handover to the paramedics, although she photocopied the man’s prescription
chart for them.
79. After the ambulance had left Whatton, Governor A telephoned the man’s wife
to advise her that her husband had been admitted to hospital. He went home
and had no further contact with prison staff or the hospital until after the man
died. Before she went home, Nurse A called the Head of Healthcare, Ms E, to
advise her of the man’s admission to hospital.
80. The man was placed in a side room on Fraser Ward in the local hospital. Dr
E from NEMS had handed over on the telephone to the hospital staff, briefing
them as to the man’s current state of health. The man’s wife visited between
7.20pm and 9.30pm. Notes made by Dr F after the man died indicated that a
‘Do Not Resuscitate’ form was discussed with the man’s wife before she left
and signed by the registrar on duty.
81. The man was diagnosed with neutropenic sepsis. This is an infection and
fever caused by a lowered immune system. A localised fever is followed by
septicemia (the spread of bacteria in the blood stream, also known as blood
poisoning) unless the condition is successfully treated. The patient’s immune
system is compromised by an abnormally low level of white blood cells.
Neutropenic sepsis is a recognised complication which can occur after a
patient has undergone chemotherapy. Nursing staff on Fraser Ward recorded
that antibiotics were given ‘promptly’ to the man to try and fight the infection.
82. At about 7.00pm, Senior Officer V and Officer B travelled to the local hospital
and took over the bedwatch from Senior Officer Y and Officer A. In interview,
Senior Officer V recalled that the man seemed to be aware of them, was able
Final Report 17
to speak but appeared lethargic. She was a familiar face, having worked on
wing A8. She updated Officer B with regard to the man’s health, as he had
not worked on wing A8.
83. Dr F’s notes confirm that the man continued to deteriorate overnight. Officer
B was cuffed to the man. He rang the prison control room approximately
every four hours at 7.10pm, 11.05pm and 3.00am. Officer B spoke to the
night orderly officer (Senior Officer T) or an Operational Support Grade (OSG)
member of staff if she was patrolling the prison. He did not report any
significant change in the man’s condition to prison staff until shortly before he
died. In interview, Senior Officer T could not recall being told of any
noteworthy developments until she was telephoned at 5.45am. The cuffing
arrangements were not discussed until then.
84. During the night, it seems that hospital staff were very busy, and there was
little communication between them and the escorting officers. When my
investigator spoke with the escorting officers, they both said that they had not
been made aware that the man’s death was imminent until shortly
beforehand.
85. Senior Officer V noticed that the man seemed to get weaker as the night went
on. She described how he became agitated in the early hours of the morning,
but settled down after he was given morphine and became ‘very, very quiet’
after 3.00am. She said that his face seemed to lack colour. Officer B agreed
that the man became quiet after 3.00am, and said that he had thought that the
man might be dying at this stage but did not share his feeling with Senior
Officer V.
86. Officer B made his regular telephone call to the prison at 3.00am. The man
was assessed by a doctor at 3.20am. Senior Officer V told my investigator
that, at this point, she still did not realise how ill the man was or that his death
was imminent.
87. In interview, Senior Officer V was unable to specify the precise time that she
and Officer B were told that the man was dying. She commented that the
information which she had received from those working on the man had been
‘a bit sketchy’. She concluded that they had been told definitively at about
5.30am that he would die imminently and that the restraints should therefore
be removed. (Officer B similarly recalled that the hospital staff had spoken to
them at about 5.15am, and that this had been the first time that he was given
an indication of the seriousness of the situation.)
88. At 5.45am, Officer B removed the escort chain from the man at the request of
the hospital staff. He telephoned Senior Officer T at the prison to inform her
of his action. She agreed that this was appropriate in the circumstances. In
interview, Senior Officer T could not recall consulting Governor A about the
removal of restraints. She commented that this decision would normally rest
with the duty governor. Similarly, Governor A said that the first time he was
contacted by the prison that day was to be told that the man had died.
Final Report 18
89. A short while later, having been contacted by hospital staff, the man’s wife,
sister-in-law and brother-in-law arrived and spent time with him. The man
died at 6.45am with his wife at his bedside.
90. Officer B telephoned Senior Officer T and told her that the man had died. She
in turn telephoned Governor A, who made his way to the prison. Senior
Officer T started the contingency planning which takes place following a death
in custody on Governor A’s instructions, but shortly afterwards finished her
shift. Principal Officer A took over as the day orderly officer.
91. At 7.30am, Nurse A arrived at Whatton to start her shift. She was told that the
man had died, and telephoned Ms E to inform her. The man’s death was
certified at 10.45am.
92. The man’s wife visited the prison later to look around. Her husband’s
belongings were returned to her, and his funeral (which the Prison Service
paid for) was held on 16 December.
Final Report 19
ISSUES
Failure to escort the deceased man to hospital appointments
93. According to a hospital consultant, the failure of prison staff to ensure that the
man was escorted to his hospital appointments delayed his diagnosis and
treatment in 2007. He first showed signs of lung cancer at the end of
February 2007 when blood was found in his phlegm. Following a chest x-ray
at the end of March, he was told that he most likely had cancer. He was
offered an appointment on 10 April, but was not taken to hospital because too
few officers were available. This appointment was rescheduled for 17 April.
Towards the end of that month, he underwent further tests and was informed
that he had a tumour on his lung.
94. Once again, a scheduled appointment was missed on 1 May because
insufficient staff were available to escort the man to the hospital. He next
attended hospital on 9 May. Subsequent appointments were kept, and at the
end of May he visited the hospital and was told that he would either undergo
an operation or would begin radiotherapy. Prison staff then failed to ensure
that he was escorted to two consecutive pre-operative assessments on 11
and 21 June. These appointments were intended to explore the possibility of
surgery and help surgeons decide whether an operation could take place.
95. On 22 June, Mr A, a consultant from a local hospital, wrote to the Head of
Healthcare at Whatton expressing his concern regarding the prison’s failure to
bring the man to the two recent appointments. He cited the unavailability of
prison staff to escort the man as the reason. As I have quoted earlier, Mr A
used unambiguous language in his letter, writing that:
‘…if this [situation] is not resolved immediately then the man may have
lost the chance for any potentially curative surgery!’
96. The letter included the offer of another pre-operative assessment. The man
was escorted to appointments on 26 June and 2 July. He underwent an oral
endoscopy and a bronchoscopy at the latter appointment and was told that
the tumour was enlarged, and was therefore too close to the windpipe. This
meant that an operation to remove the tumour was not possible, and
radiotherapy was planned in order to shrink it instead.
97. Mr A’s letter raises concerns that the failure to produce the man from custody
on two occasions in June 2007 may have had some impact on the outcome of
his treatment. In total, four scheduled appointments were missed during the
period of initial diagnosis. Dr A, who completed the clinical review, has raised
the possibility that the man’s condition became inoperable over the month of
June because the tumour was allowed to continue growing. A bronchoscopy
(an exploratory procedure prior to surgery) should have taken place on 11
June, rather than 2 July, three weeks later. If one includes the week’s delay
in April, and another week’s delay in May (both a consequence of the prison’s
failure to escort the man to hospital), then the decision regarding surgery
might have been reached five weeks earlier.
Final Report 20
98. It is impossible to know whether, had the man undergone the bronchoscopy
on 11 June, the tumour might have still been small enough to remove. Other
factors have to be taken into account, for example the man’s refusal to stop
smoking. Nonetheless, the repeated failure to ensure the man could attend
his appointments has been acknowledged by Ms E, the new Head of
Healthcare who came into post in November 2007. (At the time of the man’s
diagnosis, Ms D was in post.)
99. Ms E told my investigator that the man was not taken to the appointments on
11 and 21 June because at the time only four prisoners could be escorted out
of Whatton each day. (These escorts were in addition to those for court
appearances and the like.) Ms E explained that on both dates the four
available medical escorts were booked for other prisoners going to scheduled
appointments or emergencies. The diary booking system operated at the time
meant that the four slots available each weekday were filled up as
appointment letters arrived from the hospital.
100. When she spoke with my investigator, Ms E accepted that there had been a
failure on the part of the prison to escort the man to hospital. There was little
flexibility built into the booking system at the time. The opportunity for
healthcare staff to exercise discretion and prioritise a patient diagnosed with
cancer seems to have been limited. Ms E agreed that what appeared to have
happened was that an appointment was booked, but on the morning itself
healthcare staff were informed by the prison that the man could not attend as
not enough escorts were available. In other words, a last minute cancellation
occurred on two consecutive occasions.
101. Ms E indicated that efforts had been made in liaison with the hospital to
reschedule the man’s appointments around the availability of escort staff.
During interview, she highlighted the complex negotiations required between
the hospital and the prison when scheduling treatment. The hospital has
limited appointments available, and the prison has to ensure that they have
enough staff available to escort the patient.
102. Ms E said that, on both occasions when the man was not taken to hospital,
her predecessor Ms D asked for an additional escort to be organised, but her
request was refused. She confirmed that, following the letter from Mr A, Ms D
spoke with Governor A on 28 June to ensure that the man would definitely be
sent to his next appointment on 2 July (which he was).
103. My investigator asked Ms E about the priorities assigned to prisoners
requiring medical treatment. She confirmed that in her opinion patients
diagnosed with cancer must, without question, be allowed to attend all
scheduled appointments. She also indicated that, since she became the
Head of Healthcare in November 2007, significant changes had been
implemented to improve the provision of escorts for prisoners requiring
medical treatment. Nurse B and Dr D both confirmed that considerable
progress has been made in the last 18 months.
Final Report 21
104. Ms E explained that, under a national agreement in place since April 2008,
the Primary Care Trust (PCT) pays for staff escorting prisoners for medical
treatment or undertaking a hospital bedwatch duty. She commented that this
change has given her greater influence over the provision of escorts and freed
the Governor from some financial considerations. Whilst the Prison Governor
still has overall control of prison staff, Ms E explained that she and the Prison
Governor have developed a positive and constructive working relationship.
105. Consequently, an occasional extra escort can be provided if too many
prisoners have appointments or emergencies arise. Ms E can obtain
authorisation from the Governor for an overtime payment, allowing extra staff
to come into work and an escort to take place. This optional escort is in
addition to the two regular medical escorts who leave Whatton each morning
during the week, and the two scheduled each afternoon. Ms E also pointed
out that the new arrangement allows her to comment on the level of security
and restraint used during hospital stays, although the Governor has the final
word in these matters.
106. Ms E said that, in addition to a fifth escort if required, some slots in the
hospital appointments diary are deliberately kept free until a late stage to build
some slack into the system and to accommodate emergencies. As well as
improving the booking system, Ms E explained that the introduction of an
electronic patient records system in February 2008 has improved the
healthcare team’s ability to coordinate prisoners’ hospital visits.
107. Dr D and Ms E both spoke about the intention to provide terminally ill
prisoners with the chance to stay in Whatton as their health deteriorates. The
healthcare team are now able to fit prisoners with syringe drivers, meaning
that they can receive pain relief as their health worsens. This relatively new
development has eased the burden on the daily escorts to hospital and
reduced the need for bedwatch staff. It allows prisoners to stay in an
environment they feel comfortable with and where they may choose to die.
108. Dr A is of the opinion that the care the man was given was generally
comparable to that which would have been delivered in the community,
although he highlights the ‘administrative delays’ which prevented the man
from accessing treatment. Although I cannot be sure to what extent the man’s
health was affected by the failures to escort him to appointments, I am very
pleased that improvements have been made in this regard in the last 18
months. In particular, Ms E has recognised that patients diagnosed with
cancer should, without fail, attend all planned hospital visits. I urge both the
Governor and the Head of Healthcare to keep a close eye on what is
happening in practice.
Response to the deterioration in the man’s health on 29 November
109. A post mortem report was not completed because the man’s death was
expected and his illness had been previously diagnosed. Dr F confirmed the
cause of death and made some notes having consulted with his colleague Dr
Final Report 22
C (Head of Service, Oncology Department, Nottingham University Hospitals
NHS Trust).
110. Dr F and Dr C agreed that the man had died of neutropenic sepsis. As I have
said, this is a recognised complication which can occur after a patient has
undergone chemotherapy. The man had been undergoing chemotherapy
treatment to slow the spread of his cancer. He had last received this
treatment the day before he was taken to hospital, 28 November. The
healthcare staff at the prison had noticed him becoming visibly more unwell in
the last ten days of his life.
111. In his notes, Dr F wrote that he had discussed the case with Dr C. They
agreed that the necessary antibiotics had been appropriately administered
when the man was brought into the local hospital on the evening of 29
November. Dr C asked Dr F to make a note for the benefit of the Coroner,
querying a possible delay in bringing the man to hospital. My investigator
spoke with Dr C on the telephone on 24 April 2009. She confirmed her belief
that the man could have been brought into the hospital sooner on 29
November. My investigator asked her to explain her concerns.
112. Dr C said that a patient in the community who had recently received
chemotherapy and then developed the symptoms of an infection (such as a
fever) is instructed to contact their hospital immediately. She would advise a
patient to come to the hospital on the assumption that neutropenic sepsis was
the likely cause of the fever.
113. According to Dr C, a patient would need to go to hospital for immediate
treatment with antibiotics, being brought in by car or ambulance. She would
expect the ambulance to be prioritised as an emergency ‘999’ call out. Dr C
said that it is ‘not that common these days’ for a patient such as the man to
die as a result of this condition. She told my investigator that ‘minutes count’,
and that the vast majority of cases can be successfully treated if the correct
antibiotics are administered within about an hour. She recognised that it was
more problematic for a prisoner to be given the antibiotics within the critical
timeframe for successful treatment if they developed neutropenic sepsis,
given the delays that can be incurred when transferring them from the prison
to the hospital.
114. In the man’s case, Dr C thought that ‘hours had been wasted’ before he
reached the hospital. She believed that an emergency ambulance should
have been called, and the man should have travelled to hospital ‘under a blue
light’. She considered that there had been an unreasonable delay in his
treatment, and that he may have died ‘unnecessarily’ of neutropenic sepsis.
Essentially, Dr C thought that, whilst the man would have died soon
afterwards as a result of cancer, his death was brought forward by an
infection that could have been prevented if dealt with more rapidly.
115. Dr C’s opinion is clearly of concern. Healthcare staff at Whatton had
established a routine when the man was receiving ongoing chemotherapy
which ensured that his blood was tested regularly and his body temperature
Final Report 23
monitored every day. A note was made in the man’s medical record to
indicate that, if his temperature rose above 38 degrees Celsius, the hospital
was to be contacted.
116. When my investigator interviewed Dr D and Ms E, both expressed the view
that the man had been expected to live for a few more weeks, perhaps until
Christmas 2008. Special equipment had been ordered to arrive on Monday 1
December to help him in the last weeks of his life. There is no indication from
the man’s medical records that, when Dr D visited him on Friday 28
November, she identified symptoms of neutropenic sepsis.
117. The delay in transferring the man to hospital on Saturday 29 November
seems to have been the result of a number of factors. I have considered the
actions of Nurse A who was on duty at Whatton over the weekend. She knew
that the man had received chemotherapy treatment the day before which
could render him more vulnerable to infection. She was aware that his
temperature should be checked daily, and that if raised she should report it to
a doctor immediately. She did not test his blood because this was not
something that was expected of her during day-to-day monitoring of the
patient. It was her role to note any changes in the patient’s condition, and to
report them to a doctor.
118. Nurse A visited the man during her morning rounds. However, he was in the
middle of his weekly visit with his wife which she did not want to interrupt.
She therefore delayed checking his temperature and completing her
assessment until after lunch. She observed that he looked more unwell, and
her concern was growing. It is possible that, had she performed a full
examination in the morning, she might have been alerted to the need to call a
doctor rather sooner than she was.
119. Having assessed the man after lunch, Nurse A decided to telephone the out
of hours Nottingham Emergency Medical Services (NEMS) about an hour
later, between 2.30pm and 3.00pm. I am concerned that approximately an
hour had passed between Nurse A visiting the man in his cell and then
making this telephone call. I note that Dr C has said that ‘minutes count’
when a patient receiving chemotherapy begins to show signs of an infection.
120. Dr E, who was employed by NEMS over the weekend, called Nurse A back
after she left a message. She informed him of the man’s symptoms, and he
consulted with the Oncology Department at the local hospital. He then called
Nurse A back and told her that the man was to be admitted to hospital, and
that an ambulance had been arranged. Another hour or so had passed, and it
was 3.41pm when the ambulance was called.
121. I am concerned that Dr E arranged for an ambulance to pick up the man
‘within an hour’ and did not request an emergency ambulance. Dr C believes
that this should have been done, given the critical timeframe involved in
treating neutropenic sepsis. Nurse A did not recall discussing neutropenic
sepsis specifically with Dr E. I presume that Dr E decided to call a non-
emergency ambulance after obtaining the man’s symptoms from Nurse A and
Final Report 24
consulting with staff at the Oncology Department. He would have been aware
that the man was receiving chemotherapy.
122. I have some reservations about the communication between the three parties
involved (Nurse A, Dr E and the Oncology Department at the local hospital)
and the advice which seems to have been passed between them.
123. Calls to the ambulance service are treated in one of three ways. There are
critical emergencies, call outs that require relatively urgent attention, and then
there is the collection of patients where time is not considered to be a critical
factor. The call out in the man’s case was of the least urgent, latter kind. This
meant that an ambulance crew would attend in due course, but it was not
considered to be a critical emergency, and other higher priority calls might
take precedence if the paramedics were needed elsewhere. Such a call out
would be expected to be completed within about 90 minutes, according to the
East Midlands Ambulance Service (EMAS).
124. The EMAS policy with regard to neutropenic sepsis states that this is not a
condition that automatically triggers the need for an emergency ambulance if
the doctor making the call does not think this is necessary. The priority given
to the ambulance call out rests with the doctor who has assessed the patient.
There are some conditions that oblige the ambulance service to override a
doctor’s decision, such as meningitis. Neutropenic sepsis is not included
amongst these in the current policy. The doctor arranging for an ambulance
would be asked if the patient’s condition is immediately life threatening. If so,
then an emergency ambulance is sent. The ambulance service was not
therefore at fault in providing the non-emergency ambulance requested by Dr
E.
125. However, although Dr E asked for an ambulance to collect the man within an
hour, the paramedics did not arrive for 90 minutes. (The ambulance was
ordered at 3.41pm, arrived at 5.07pm, left Whatton at 5.44pm and arrived at
the hospital at 6.45pm.) Although the Prisoner Escort Record (PER) shows
slightly differing times, it also confirms that the ambulance arrived at the
hospital three hours after it was requested. The EMAS log indicates that the
reason the paramedics took so long to reach the prison was because there
was ‘no vehicle [ambulance] available’.
126. It would appear that the man was taken to the local hospital because this was
where he had been receiving his chemotherapy treatment. Whatton and the
local hospital are on opposite sides of Nottingham, 14 miles apart. The
considerable distance between the prison and the hospital clearly lengthened
the journey involved, and this is something which I have raised during
previous investigations.
127. In total, five hours had passed from the time Nurse A became actively
concerned about the man (approximately 1.30pm) and the time he reached
the local hospital (6.45pm). I agree with Dr C’s assessment that ‘hours were
wasted’. There appears to have been a failure to understand the urgency
involved when a patient who develops an infection has recently had
Final Report 25
chemotherapy. When the man was taken to hospital, Governor A (the duty
governor that weekend) said that he had ‘no idea how serious his condition
was’. Nurse A does not appear to have been told by Dr E that the infection
could be serious. There seems to have been a lack of understanding that it
could be successfully treated if dealt with rapidly.
128. In light of Dr C’s comment that ‘minutes count’ when a patient has developed
neutropenic sepsis, I consider that there was an unreasonable delay in
ensuring that the man received the treatment he needed, and which might
have prolonged his life, albeit briefly. Criticisms could be levelled at Nurse A
(who did not complete her assessment of the man until the early afternoon
and did not telephone NEMS immediately), Dr E (who decided not to request
an emergency ambulance), the member of staff spoken to at the Oncology
Department (who may not have emphasised the urgency involved in treating
neutropenic sepsis), or the ambulance service (who appear to have had
insufficient resources available to ensure that paramedics reached the prison
within an hour). However, it is not my intention to apportion blame.
129. I have considered the possibility of storing the antibiotics required to treat
neutropenic sepsis in prison healthcare centres to ensure that treatment is
delivered as swiftly as possible. This raises a variety of concerns. A member
of healthcare staff should ideally not be working alone when they administer
the antibiotics. It would not be practical for them to carry out and monitor the
procedure when they may have other ill prisoners to care for in the meantime.
130. The necessary antibiotics have to be injected intravenously. Although they
can be given to patients by specially trained nurses, they have to be
prescribed by doctors (who are often not present in prisons, as was the case
at Whatton on Saturday 29 November). Dr C did advise my investigator that
nurses can sometimes be trained up to oversee the giving of antibiotics in
specific circumstances.
131. However, whether nurses would feel comfortable delivering critical antibiotics
without supervision is debatable. Whilst I make no recommendation, I am
sure that the Head of Healthcare will want to give careful consideration to the
feasibility of keeping the necessary antibiotics to treat neutropenic sepsis in
the healthcare centre.
The use of restraints
132. The Local Security Strategy in operation at Whatton at the time the man died
(effective from August 2007) instructed staff that restraints should be applied
to all prisoners at hospital at all times, other than in an emergency. If
restraints had to be removed, the duty governor was to be consulted at the
earliest opportunity.
133. The man was still cuffed to Officer B by an escort chain until about an hour
before he died. In interview, Governor A (the duty governor on the weekend
the man died) accepted that, to provide the man with a dignified death, the
escort chain should ideally have been removed sooner than it was. He
Final Report 26
emphasised that this opinion was expressed with the benefit of hindsight. He
agreed that there had been a lack of emphasis on ‘common sense decision
making’.
134. Dr D said that she ‘really did not like’ the fact that the man had still been
cuffed at such a late stage. Both members of staff, one speaking from a
Prison Service perspective, the other from a healthcare background,
highlighted the risks which have to be considered when prisoners are taken to
hospital.
135. A combination of circumstances seems to have led to the man being cuffed
until very shortly before he died. In particular, his death was not considered to
be imminent by healthcare staff at the prison. There seems to have been a
consensus that he might be expected to live for several more weeks.
136. What took place on 29 November was a critical situation (the development of
neutropenic sepsis following chemotherapy) in the context of a longer, chronic
condition (lung cancer). Whilst the man had been a palliative care patient for
quite some months, Dr D confirmed that, until a week or two before his death,
he had been managing quite well. Over the course of the 20 months he had
been diagnosed with cancer, there were long periods when his condition was
relatively stable and he coped with the demands of daily life. He had become
more and more frail, but there had not been any sudden or critical episodes
until this point.
137. The chemotherapy the man underwent weakened him considerably, and it
was only in the last ten days or so that his condition markedly deteriorated.
The rapid deterioration in his health on 29 November was not anticipated. As
I have already discussed, the development of neutropenic sepsis does not
appear to have been treated with sufficient urgency by either Nurse A, Dr E,
or the paramedics. It seems that prison staff were therefore unaware that his
death might occur within a matter of hours.
138. The man was taken to hospital late on a Saturday afternoon. The prison is
not fully staffed on a weekend and only one member of the healthcare team
was on site. Had the man become very unwell on a weekday, then a member
of the management team may well have gone to the hospital later in the day,
made a risk assessment, and authorised the removal of the chain.
139. Governor A indicated that he would have visited the hospital on Sunday 30
November to assess whether the man should continue to be cuffed. The
Local Security Strategy in place at the time indicated that a manager should
visit the prisoner and escorting officers on bedwatch within 24 hours of the
departure from prison.
140. When he spoke with my investigator, Governor A said that he had not
expected the man to deteriorate so quickly. He had felt that he could wait
until the following morning to visit and obtain a prognosis from the doctors.
Ms E also indicated that the duty governor would, in all likelihood, have visited
Final Report 27
the hospital on 30 November to complete a risk assessment. She felt that
they would probably have decided to remove the restraints from the man.
141. Finally, and most importantly, all parties involved seem to have struggled to
communicate after the man left Whatton late in the afternoon on 29
November. Hospital staff do not appear to have advised the escorting officers
(Senior Officer V and Officer B overnight from 7.00pm) that the man’s death
was imminent until perhaps an hour and a half before he actually died.
Shortly afterwards, the hospital staff requested that the escort chain be
removed. Given the imminence of death, Officer B removed the chain to
preserve the man’s dignity. He then telephoned Senior Officer T at the prison
and updated her.
142. Senior Officer V told my investigator that she and Officer B had noticed that
the man had become very quiet and seemed to be unconscious from 3.00am
onwards. Officer B confirmed much the same thing. He said that it had
crossed his mind that the man might be dying, but he did not share this with
Senior Officer V.
143. Officer B said that he had not wanted to intrude on the nurses whilst they
were doing their job. He waited for them to brief him fully, but that this had not
occurred until after 5.00am. Neither officer seems to have been told that
neutropenic sepsis could result in the man’s death in a matter of hours. From
the discussions my investigator had with both officers, it does seem that
nursing staff were very busy during the night.
144. Neither Governor A nor Senior Officer T (the night orderly officer responsible
for the running of the prison) appear to have tried to establish the man’s
prognosis. Once the man left Whatton in the ambulance, Governor A went
home, and did not speak with the prison or the hospital until after the man had
died. Whilst Senior Officer T was in regular contact with the escorting officers,
they do not seem to have discussed how ill the man was or whether the use
of restraints could be ended.
145. The combination of the unexpected and rapid decline in the man’s health, the
admission to hospital over a weekend and the failure by all parties involved to
understand and communicate the imminence of death led to the man being
handcuffed until 5.45am. He died at 6.45am.
146. I make a recommendation which may help to ensure that, in future, staff have
the information available to them to ensure that a sensible, humane and well
reasoned decision is made with regards to cuffing when a prisoner is so close
to death.
The Governor should ensure that, when a prisoner is admitted to
hospital unexpectedly, escorting officers at the hospital speak with
nursing staff regularly in order to obtain up-to-date information about
the prisoner’s condition.
Final Report 28
147. A preoccupation with the risk to the public from sex offenders may have
impinged on the use of discretion and ‘common sense decision making’ in this
instance. From the interviews my investigator conducted, it was apparent that
consideration of possible media interest if a prisoner committed a further
offence whilst at hospital had the potential to influence the cuffing of prisoners
like the man.
148. Whilst risk assessment should be thorough, and public protection is a
fundamental priority for the Prison Service, a balance should have been
struck between the risk that the man presented as an able bodied younger
man and the risk that he presented as a much older man in the final stages of
a terminal illness. There seems to have been a lack of finesse and discretion
exercised with regard to the man’s risk assessment and cuffing during the
weekend of 29 and 30 November. Staff seem to have operated under a
generalised assumption – namely that all sex offenders represent a risk all of
the time. I am bound to say that only a highly risk averse culture could lead
anyone to suppose that a terminally ill man of 72, convicted of offences
committed more than three decades earlier, represented either a credible
escape risk or any risk to public safety. He was using oxygen to assist his
breathing and, by the time he was escorted to hospital, was wheelchair-
bound. Governor A accepted in interview that the man would not, in all
likelihood, have posed a risk directly to the general public.
149. As I have said, it seems that the prison management team may have had
some concern about the man assaulting female nursing staff at the hospital.
This was of course a perfectly proper concern. However, I note that Dr D and
Nurse B had spent a great deal of time in the man’s presence in the months
before he died. To the best of my knowledge, neither complained of any
inappropriate behaviour on his part. Furthermore, there is no evidence to
suggest that the man represented a risk to adult women.
150. Governor A told my investigator that escorting and cuffing prisoners is partly
for their own benefit. As Whatton is known to accommodate sex offenders,
there is a concern that, if a prisoner is identified whilst at hospital, a member
of the public may attack them. Whilst the presence of two escorting officers is
both a necessary and wise precaution, I struggle to comprehend why the man
had to be physically restrained, given the frailty of his health.
151. Whilst I make no further recommendation, I make the broader observation
that a necessary focus on sexual offending and an acute awareness of media
interest would seem in this instance to have led to an automatic assumption of
risk at the expense of a ‘common sense’ approach.
152. Although staff indicated that they were following the Local Security Strategy
guidelines with regard to the use of restraints, many of the deaths I have
previously investigated at prisons across England and Wales have provided
examples of Governors using their discretion when prisoners are dying.
153. I made recommendations in relation to the cuffing of older prisoners during
two previous investigations at Whatton. With regard to the death of a prisoner
Final Report 29
in August 2007, I wrote in June 2008 that a full risk assessment, including an
assessment of the use of restraints should be prepared by staff and
considered by the duty governor when a prisoner who is in hospital
experiences a significant change in circumstances. I repeated my
recommendation in February 2009 (writing about the death of a prisoner in
July 2008), adding that the assessment of the use of restraints should be
reviewed every 24 hours.
154. I am pleased to report that Whatton’s Local Security Strategy has now been
revised, and new quidance has been put in place for staff. My investigator
has spoken with Governor A, who has implemented these changes. He
emphasised that staff are now encouraged to consider a prisoner’s age,
mobility and health when assessing the risk they might realistically represent
to members of the public. A new and more comprehensive risk assessment
form was introduced in spring 2009.
Parole Board decisions
155. The man had been refused parole twice, in January and November 2008.
The basis for the Parole Board’s decision seems largely to have been his
unwillingness to address his offending behaviour (he did not wish to attend an
offending behaviour programme) and his continued minimisation of guilt. The
Parole Board felt that there was no evidence of a reduction in the risk which
the man represented. The decisions of the Parole Board are not matters
within my terms of reference, but a refusal to grant release on licence on
these grounds seems both defensible and understandable. (This is
something that the man’s wife asked about.)
Visits
156. When my former Senior Family Liaison Officer spoke with the man’s wife, one
of her concerns was the lack of privacy which she was able to enjoy with her
husband until she was allowed to visit him in his cell on 29 November (the day
he went into hospital). On Friday 28 November, Dr D and Governor A had
agreed that the man’s wife could start visiting her husband in his cell.
157. Permitting family members to visit prisoners in their cells is a relatively new
and unusual development. Dr D said that this was something that never used
to happen. Very few prisons permit visits to take place in a cell. Staff at
Whatton are pioneering this initiative (which I commend), and it is not the only
innovation they have implemented in the last 18 months in relation to
prisoners with a terminal illness.
158. The new policy allows the family member a degree of privacy when they visit
the wing. The cell door is kept open, but a privacy curtain is drawn across the
entrance. A mesh observation strip forms part of the curtain, allowing the
officer on duty to maintain security. A ‘dignity line’ is also in place during visits
on the wing, indicating to other prisoners that they should not go near the cell.
Final Report 30
159. The visits room is a considerable distance from the wing where the man lived,
and the distance can be prohibitive for chronically ill prisoners. Governor A
told my investigator that it was preferable for prisoners to continue to receive
visits in the purpose-built visits room (which is accessible for wheelchair
users) for as long as is practicable. If the man was unable to go to the centre
on foot, he was pushed in a wheelchair by another prisoner.
160. Whilst visits on wings have been devised specifically in response to the
number of prisoners with palliative care needs, the implementation of this
policy would only come at a point when the prisoner was so unwell that they
were unable to make the journey from the wing to the visits room. There is an
understandable need to withhold wing visits until absolutely necessary, as
they involve maintaining the safety of the visiting relative and an officer
monitoring the visit.
161. On a practical level, very few cells have been equipped with the privacy
curtain and such like. Additionally, there is a certain stigma attached to these
cells, as prisoners are aware that moving into one means that they are
considered by healthcare staff to be dying. The man exhibited a certain
reluctance whilst he settled into his cell.
162. In the man’s case, as I have already outlined, the decline in his health was
rapid and unexpected. Whilst he had a terminal illness, his death was not
anticipated for some weeks to come. Hence, when Dr D and Governor A
organised the wing visits, they both felt that several more might take place
before the man died.
163. When Dr D decided that the man was so unwell that the time was right for his
wife to start visiting him on the wing, Governor A authorised it immediately.
Prior to 28 November, she had not taken this step as the man was not bed-
bound. As a consequence, the man’s wife was able to visit her husband on
the wing for the first time the next day.
164. My investigator has spoken with two of the prisoners who acted as helpers for
the man when he became unwell. (This scheme is another innovation that the
management team has implemented to address the growing number of ill and
frail prisoners held at Whatton.) Both prisoners said that the man had been
pleased with his life on the wing, and was grateful for the help they offered
with simple tasks like pulling up his blind and collecting his food. They would
push the man in his wheelchair across to the visits room when his wife
arrived. Both prisoners were impressed with the prison staff’s treatment of the
man, saying that all concerned had ‘gone the extra mile’.
165. Nurse B told my investigator that the man had always managed to get to the
visits room until his final few days. She remembered him being pushed
across in his wheelchair, and she could not recall him ever complaining about
this arrangement. Governor A said that the man had been ‘happy’ to make
his way to the visits room to see his wife. He too could not recall the man’s
wife complaining to him about the visiting arrangements which had been put
in place.
Final Report 31
The possibility of the man being released
166. As noted, the man made two applications to the Parole Board. He wanted to
return to live with his wife. Both applications were refused on the grounds of
the risk he represented to the public. Healthcare staff submitted an account
of the man’s diagnosis and frailty but it would appear that these concerns
were outweighed by public protection issues.
167. Similar concerns affect requests for the early release of prisoners on
compassionate grounds. The offences committed by prisoners at Whatton
mean that this is a rare occurrence. Governor A told my investigator that, in
the 14 years he has worked at Whatton, he could only remember one prisoner
who was released early on compassionate grounds into the care of his family,
five days before he died. (Such decisions have to be approved by the
Secretary of State for Justice.)
168. Ms E said that the threshold for prisoners granted release on compassionate
grounds was ‘quite high’ as a result of the nature of their offending and the
risk they were considered to present to the public.
169. Ms C, the Secretariat Manager, confirmed to my investigator that the man did
not request early release from prison on compassionate grounds. Nurse B
said that the man had expressed his satisfaction with the treatment he was
receiving at Whatton. She said that he had not complained about the care he
was receiving, and had in fact praised the staff.
170. Dr D and Ms E spoke about their intention to care for terminally ill prisoners.
They hope that prisoners with palliative care needs will be able to remain at
Whatton until their death, if that is what they prefer. This is an admirable goal,
reflecting the fact that, as I have written elsewhere, the Prison Service has
become in effect a welfare agency as well as a criminal justice one.
Final Report 32
CONCLUSION
171. My investigation has raised some serious concerns about the care the man
received. Indeed, the delay in treating the infection which caused his death
may raise questions about how appropriate it might sometimes be to give
chemotherapy to prisoners. Given that the man was in the final stages of a
terminal illness, and that chemotherapy can have potentially fatal
complications which have the potential to shorten life rather than extend it, Dr
C thinks that this is something which may require closer consideration.
Whatton lacks inpatient treatment facilities and 24 hour healthcare, and is
geographically distant from the hospital, meaning that prisoners are less likely
than a member of the public to be able to access promptly the necessary
antibiotics. I make no recommendation but draw Dr C’s observation to the
attention of Offender Health.
172. Nonetheless, progress has clearly been made at Whatton with regard to the
treatment of terminally ill prisoners. Palliative care has become a priority for
the healthcare team. I am pleased that the recommendation I made with
regard to the death of a prisoner in June 2007 and the need for a palliative
care strategy seems to have been implemented. Dr D, Ms E and Nurse B all
spoke with pride about the service they are either currently delivering to their
patients or which they are aspiring to deliver.
173. In spite of the criticisms in this report, my investigator has found grounds to be
optimistic about the treatment that elderly prisoners are receiving at Whatton.
Prisoners are being consulted and offered some choices about the way they
are looked after. I consider that the healthcare staff (with the support of both
Governor Saunders and the local branch of the Prison Officers’ Association)
are pioneering several innovations that are changing the treatment of older
prisoners who face the prospect of ending their life in Whatton. I commend
the improvements being made, but equally hope that some lessons can be
learnt from this investigation into the death of the man.
Final Report 33
RECOMMENDATION
1. The Governor should ensure that, when a prisoner is admitted to hospital
unexpectedly, escorting officers at the hospital speak with nursing staff
regularly in order to obtain up-to-date information about the prisoner’s
condition.
NOMS partially accepted the recommendation and gave the following
response:
‘Escort staff are already expected to liaise with the hospital staff about the
prisoners condition, however depending what nursing staff are on duty will
depend on what information is shared. This information is then recorded in the
bedwatch occurrence log. Managers visiting the bedwatch each day are
expected to consult with the healthcare staff and pass any information back to
the Head of Security so that any change of risk can be reflected in the
prisoners risk assessment.’
Final Report 34