Individual at Whatton

Investigation into the circumstances surrounding the
death of a man in hospital, whilst in the custody of HMP
Whatton on 15 October 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2010
This is the report of an investigation into the death of a man, a prisoner at HMP
Whatton, on 15 October 2009. The man had been diagnosed with lung cancer a
month earlier. Following his diagnosis, the man stayed on a normal wing until he
was transferred to hospital, two days before he died. He was 53 years old.
Her Majesty’s Coroner for Nottinghamshire and Nottingham City was informed of the
Ombudsman’s investigation. A post mortem was undertaken and it was noted that
the man died of natural causes resulting from cancer. I extend my sincere
condolences to his partner and family.
The investigation was undertaken by one of my colleagues. A review of the man’s
healthcare whilst in custody was commissioned from Nottinghamshire County
Teaching Primary Care Trust (PCT). Not for the first time, I am grateful to the clinical
reviewer his report. I would also like to thank the Governor of Whatton and her staff
for their help and assistance. I am especially grateful to liaison officer for her
support.
I endorse what the clinical reviewer has to say about the good practice in facilitating
in-cell visits for the man. I further note the good practice of linking the family liaison
officer role with that of the personal officer, thereby offering support both to the man
and to his family in a seamless way. I have also been pleased to note that he was
not restrained when he was admitted to hospital.
All in all, this report reflects extremely well upon HMP Whatton and HM Prison
Service as a whole. The approach to end-of-life care was admirable.
The prison service noted two minor inaccuracies which have been amended in this
final report. The Governor has written to an officer thanking him for his work with the
man and his family. His family have not raised any issues from the draft report.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2010
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CONTENTS
Summary
The investigation process
HMP Whatton
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
The man arrived at HMP Durham in May 2008 after being sentenced to five years
imprisonment for conspiring to commit sexual offences. The following day an
Assessment, Care in Custody and Teamwork (ACCT) plan was opened. (This
documents interventions, care and observations of prisoners at risk of self harm.)
The man had indicated to prison staff that he was thinking of self harm. Three
weeks later, the ACCT was closed after the man was feeling positive and less
anxious about being in prison. He moved to another wing to be apart from his co-
accused.
On 1 July, the man was transferred to HMP Whatton. His medical notes record that
he was in reasonably good health, although an asthma sufferer and smoker. An
inhaler was prescribed and the man was offered access to health promotion
facilities. He settled into the wing and worked in the recycling workshop.
In July, the man had a mental health review and was prescribed an anti-depressant,
Fluoxetine. On 4 August, he was seen in healthcare with a pain on the right side of
his chest and prescribed pain relief. At the end of September, the man had a
medication review with a doctor and agreed to discontinue his Fluoxetine as he felt
settled at Whatton.
Following a chest examination in October, the doctor examined the man and
prescribed an antibiotic. In January 2009, The man was treated for haemorrhoids
and later given Simvastatin, for high cholesterol, following a blood test.
The man saw healthcare staff with a sore throat in July. The symptoms persisted
and on 12 August the doctor referred the man to an Ear Nose and Throat (ENT)
physician at hospital under the two week rule. (This means an urgent referral for an
appointment within two weeks when a cancer is suspected.) On 2 September, the
doctor noted that results from the hospital indicated that cancer was suspected and
arrangements were being made for further medical investigations.
On 17 September, the man was admitted to hospital as an emergency following
deterioration in his health. On return to Whatton the following day, he told healthcare
staff that he had been diagnosed with lung cancer and a deep vein thrombosis
(DVT), a blood clot. He was moved to A8 wing on 29 September, where he could
have a larger cell and additional personal care. He was visited daily by healthcare
staff and allowed visits from his partner in his cell.
Following a further deterioration in his health, the man was admitted to hospital on
14 October. He was not restrained. His partner and relatives were informed and
advised to make plans to visit him in hospital. The following day, he was transferred
to the intensive care unit and his family was contacted. The man died at 8.00pm
with his family at his bedside.
I note the very good practice demonstrated by healthcare and prison staff in their
care of the man and his family.
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THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened on 2 November 2009,
when my investigator visited HMP Whatton. She was met by the liaison
officer and reviewed the man’s prison and medical files. Some copies of
those documents were taken by my investigator. The Deputy Governor also
met with my investigator.
2. Later, my investigator visited C3 wing and spoke to staff and a prisoner. The
Ombudsman’s terms of reference and notices of investigation had been sent
to the prison in advance of her visit. There was no response to the notices of
investigation from staff or prisoners.
3. Neither the prison’s Independent Monitoring Board (IMB) nor the local branch
of the Prison Officers’ Association asked to see my investigator. I assume
this reflects the fact that Whatton has significant previous experience of my
investigations following deaths of prisoners from natural causes.
4. On 4 November, my investigator spoke to an officer by telephone. The
officer had been the man’s personal officer and the family liaison officer.
5. A review of the man’s healthcare was commissioned with Nottinghamshire
County Teaching PCT.
6. One of my family liaison officers made contact with the man’s partner. His
partner simply asked if the man had already contracted cancer before he was
taken into custody. I will deal with his under the issues section of this report.
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HMP WHATTON
7. HMP Whatton is a category C training prison for prisoners convicted of a
sexual offence, or who have a sexual element in their offending history. (A
training prison is one which has offending behaviour courses and
opportunities for work in preparation for release.)
8. In response to overcrowding across the prison estate, Whatton underwent a
rapid expansion in 2006, increasing the operational capacity from around 400
prisoners to 841 by 2008. Before the expansion the prison only accepted
prisoners who were assessed as suitable for sex offender treatment
programmes and who were in denial of their offence. With the new
accommodation the admission criteria were changed. Whatton now accepts
offenders who are in denial of their offence and are assessed as being
unsuitable for undertaking specialist offending behaviour courses.
9. Healthcare is provided by Nottinghamshire County Teaching PCT. There is
no 24-hour in-patient facility at the prison and an out of hours emergency
doctor service is used during the evenings and weekends. Visiting doctors
hold daily surgeries during the week and there are qualified nurses on duty
with healthcare assistants from 8.00am to 8.00pm. A range of clinics are
held in the healthcare unit which include smoking cessation, well being, and
specialist clinics for chronic diseases and older prisoners.
10. Following an announced inspection of Whatton in 2007, HM Chief Inspector
of Prisons said many aspects of the regime at Whatton that had been
applauded in a previous inspection were still in place. HM Chief Inspector
further commented on healthcare services:
“Health services were commissioned by Nottinghamshire County
Teaching Primary Care Trust. Funding for health services, in particular
mental health services, had not kept pace with the rapid growth in size
of the establishment. The health services department was a clean and
clinical environment but its location was difficult for older prisoners to
access. There had been a health needs assessment that was used to
plan services, but prisoner delays in getting to basic services, such as
GP appointments or to see the dentist, were unacceptably long. Health
promotion activities were being developed, and there were check ups
for prisoners with lifelong conditions. The primary mental health
service and the in-reach mental health team were both under-
resourced.”
11. The Independent Monitoring Board’s most recent annual report noted:
“HMP Whatton is one of the few prisons if not the only prison in the
country with an average age in the mid forties. The general adult male
prison population has about 80% under the age of 40 whilst Whatton
will regularly house some 60% to 70% of its 845 prisoners over the age
of 40 years. Naturally, this brings a completely different dimension to
the healthcare needs of those in Whatton to almost any other prison
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establishment. It is therefore inevitable that more prisoners will die of
natural causes in Whatton with the resultant effect that the healthcare
has been required to respond to major incidents from time to time, on
the palliative care of individuals. It has done this and continues to do
so with great staff dedication and in an extremely sensitive manner.
Whilst there is a number of healthcare professionals that visit the prison
on a regular basis providing care through a doctor, dentist, chiropodist,
optician, phlebotomy and triage nurses and a psychiatrist, there are
also a number of regularly held nurse led clinics in operation, mainly
relating to the management of chronic conditions and primary
prevention in ‘at risk’ prisoner. The IMB continually monitors the
provision of healthcare provided for the prisoners as it is regarded as
an essential indicator on the wellbeing of these above average aged
prisoners in the prison system.”
12. There have been 16 natural cause deaths at Whatton since my office began
investigating all deaths in prison custody in 2004. A number of these deaths
were terminally ill prisoners who received nursing and palliative care.
13. Whatton has received funding to provide a special room for terminally ill
prisoners to be cared for in an appropriate setting, with relevant healthcare
support.
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KEY FINDINGS
14. The man was born in South Shields. He was separated from his wife and
lived with his partner in Carlisle. He was unemployed. During 2006-2007,
the man underwent medical examinations at hospitals in the North East for a
deep vein thrombosis, re-current respiratory problems, and skin rashes. His
medical notes further recorded he had suffered from irritable bowel
syndrome.
15. Whilst living in the community, the man has a chest x-ray in June 2007 and
was subsequently referred to a chest physician. Medical investigations,
including a computerised tomography (CT) scan and a bronchoscopy
indicated some chronic inflammatory changes in his lung base. (A CT scan
takes internal images of the body and a bronchoscopy is an examination of
the chest area by passing a camera down the throat). However, a CT scan
in early January 2008 showed an improvement and he was discharged from
seeing the chest physician.
16. In January 2008, the man was convicted of conspiring to commit sexual
offences. Four months later, he was sentenced to five years imprisonment
and taken to HMP Durham. This was the man’s first time in prison since
1982.
17. The following day, an ACCT was opened. The man had handed a letter to
an officer the previous evening saying he was considering taking his life. The
ACCT remained open until 17 June, when the man felt much better and had
a more positive attitude. It was further noted that the man might have been
subject of harassment from his co-accused and he was moved to another
wing. On 1 July he was transferred to HMP Whatton.
18. On the man’s reception into Whatton it was recorded in his medical notes
that he was in reasonably good health, was a smoker, and had a history of
asthma for which medication was prescribed. The man was allocated a job
in the recycling workshop.
19. The Healthcare Manager saw the man on 21 July for a mental health review.
He told the manager that he was not sleeping well, and was anxious at being
in prison. The manager prescribed Fluoxetine, an antidepressant, and
advised the man to seek help from healthcare staff if he felt he needed it.
Otherwise, they would review him in two weeks time.
20. The man was seen in the healthcare unit on 4 August, complaining of
muscular pain in his right side. He was prescribed pain relief of ibuprofen
and advised to rest for two days. The man returned to healthcare on 18
September with an infected rash on his chest. Antihistamine medication was
prescribed to relieve the itching.
21. Two weeks later, the man saw a doctor in the healthcare unit for a review of
his asthma and medication. They discussed the man’s previous low mood
and he told the doctor that he had now settled at Whatton and agreed that he
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no longer needed to take Fluoxetine. The man was advised that, should his
mood change, he should make an appointment to see the doctor.
22. The man saw a nurse on 15 October. He told the nurse that his asthma had
worsened despite using his inhaler. The nurse advised the man that he was
not using his inhaler correctly and demonstrated techniques on how to use a
different inhaler that might help control his symptoms. The nurse also gave
the man an influenza injection. The following day, he had an appointment
with a doctor. The doctor examined his chest and prescribed an antibiotic.
She advised him to return to healthcare if his condition did not improve.
23. On 2 December, the man was seen in the healthcare unit by a nurse as he
was experiencing pain in his shoulder. The nurse examined him and
prescribed paracetamol for pain relief. The man was told to return to
healthcare the following day if he was still in pain. Nine days later, he saw a
doctor and she examined his shoulder which was still causing him pain. The
doctor prescribed an ibuprofen based medication and a cream to rub into the
shoulder area.
24. The man attended a smoking cessation session on 23 December, but
decided to leave the session and said he would rejoin after Christmas. A
week later, he was seen by a nurse complaining of rectal bleeding. The
nurse arranged an appointment for him to see the doctor.
25. A doctor examined the man on 7 January 2009, and noted that his rectal
bleeding might have been haemorrhoids. A blood test was taken to check for
any other illness and a cream was prescribed to soothe the condition. A
month later, the man was prescribed Simvastatin, as his blood test results
had noted a high cholesterol reading.
26. A nurse examined the man’s knee on 16 February, after he complained of
pain and his knee ’giving out’. The nurse also noted that the man had a red
rash on his lower leg. He therefore asked a nurse prescriber (a nurse
qualified to prescribe medication) for a cream to help with the rash. A week
later, a doctor examined the man’s knee. There was good movement to the
knee with minimal pain. The man was told by the doctor to return to
healthcare if there was increased pain or stiffness in the joint.
27. On 24 March, a nurse wrote that the man had not taken his Simvastatin and
advised him to ensure that he ordered his medication on a regular basis.
Three weeks later, the man was prescribed Niquitin patches to help him stop
smoking. However, it was later noted that he had not attended smoking
cessation sessions.
28. Following a routine blood test, a doctor increased the man’s Simvastatin
medication on 27 May. A nurse saw him in the healthcare unit on 2 July, as
he was complaining of a sore throat. On examination the nurse noted that
his throat was red but there was no sign of an infection. She advised the
man to take paracetamol and return to healthcare if the symptoms persisted.
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29. The man returned to healthcare on 20 July and saw a nurse. His throat was
still sore and his voice hoarse. The nurse noted that whilst his throat was not
too red there was thrush (a fungal infection) in his mouth. The nurse asked a
doctor to prescribe a mouthwash. Ten days later, a nurse saw the man in the
healthcare unit. He still had a sore throat and loss of taste. The man’s
symptoms were discussed with the doctor and it was agreed to prescribe
Lansoprazole (a drug used to restrict the flow of gastric fluid into the mouth).
30. A doctor examined the man on 12 August, he still had a sore throat and a
hoarse voice. Following examination, the doctor referred the man to an Ear
Nose and Throat (ENT) specialist at hospital under the two week rule (i.e. an
urgent referral when cancer is suspected). Twelve days later, the man was
seen in the healthcare unit with chest pain and shortness of breath. On
examination, a nurse noted that there was no obvious cause of the pain or
any injury. The man was advised to continue with paracetamol and
ibuprofen, and would be seen the following day.
31. A nurse saw the man on 25 August. His pain had eased by taking maximum
doses of pain relief. The nurse wrote a letter to the hospital outlining the
man’s symptoms with reference to his referral to an ENT specialist. The
following day the man was escorted to hospital to see the ENT specialist.
32. On 2 September, a doctor noted in the man’s medical notes that following his
visit to hospital he had a suspected malignant tumour of the lung (cancer)
and a DVT of the lower limb. The following day, a nurse saw the man in the
healthcare unit and recorded that he had constipation and a laxative had
been prescribed.
33. The man was seen by a nurse as an emergency on 8 September. He was
short of breath and struggling to speak. The man told the nurse that,
following his hospital appointment, he had been told his windpipe was partly
blocked and there was a shadow on his lung. The nurse referred the man to
a doctor. The doctor examined the man and noted that he was waiting for a
biopsy appointment at the hospital. He prescribed medication and an
antibiotic for a suspected chest infection.
34. A nurse reviewed the man on 9 September and wrote that his breathing was
easier but he had little voice left. The nurse further noted that the man would
have a CT scan on 21 September. When the prison was notified of the
results of the scan, staff should be aware that it might confirm cancer.
35. A nurse saw the man on 14 September as he was feeling unwell, cold, and
wanted to go to bed and sleep. His observations were taken and recorded
as blood pressure 93/98 (a normal reading is 130/80), pulse rate 96 beats
per minutes (a normal reading is between 60-100), and a blood oxygen
saturation rate of 98%. The man was advised to rest in his cell and to drink
plenty of fluids.
36. Three days later, a nurse saw the man in the healthcare unit. He was still
feeling very unwell and complained of pain in the left side of his calf. The
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nurse spoke to a senior nurse and an urgent blood test was taken. Following
the result of the blood test, the nurse spoke to an out of hours doctor service
and it was agreed that the man should be taken to hospital. An escort was
arranged and the man was transferred to hospital with two officers and on an
escort chain. (An escort chain is a 1.8 metre length of chain with one cuff
attached to the prisoner and the other to an officer.)
37. The following day, the man returned to Whatton and was seen by a nurse.
He told the nurse that hospital staff had told him he had lung cancer and a
DVT. On his return to the wing, the man spoke to his personal officer and
received support following this diagnosis. The hospital had prescribed
Clexane for the man to self administer. (Clexane is an injected medication to
stop the formation of blood clots.) The nurse watched whilst the man used
his injection of Clexane.
38. On 19 September, the man was seen in the healthcare unit by a nurse. He
was tearful but did not wish to discuss his diagnosis. The nurse assured him
that staff were there to support him and he could talk to any member of staff
when he wished to. Later, the nurse made a telephone call to the out of
hours doctor’s service as the man was experiencing pain in his leg. The
doctor advised that these symptoms were consistent with a DVT and the man
should rest as much as possible.
39. Three days later, the man had an appointment with A doctor. The doctor
wrote that he was short of breath and had lost weight. She prescribed a food
supplement and morphine tablets to help with pain control. A nurse spoke to
the man and told him her role was to support him following his diagnosis.
The nurse noted that the man was tearful.
40. A nurse saw the man on 23 September and he told her that he had been to
the hospital the previous day. The specialist was making arrangements for a
lung biopsy and a bronchoscopy. The nurse wrote that the man was less
tearful and they were able to talk about his illness. The man was also noted
now to be retired from his job in the recycling workshop.
41. The man was visited in his cell the following day by a nurse who noted that
he was breathless. The nurse wrote that wing staff were concerned over his
mental health and that he seemed to have given up. The nurse advised wing
staff that the man was obviously very unwell and his diagnosis of lung cancer
had been a shock to him. The nurse recorded that the man would need a
larger cell and his social visits might need to be arranged in his cell rather
than in the visits hall. She noted that special aids of a bed, mattress,
commode and pillows were to be ordered to offer some comfort for the man.
42. On 28 September, a nurse visited the man on the wing. He told the nurse
that he did not wish to have the bronchoscopy, saying that he felt too unwell
to attend hospital. The man signed a disclaimer form with an option to
change his mind. It was decided that the man should move to Alpha eight
(A8) wing where he could be cared for in a more suitable environment and
have a bigger cell. The following day, he decided to undergo the
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bronchoscopy and was escorted to hospital for the procedure. On his return
to Whatton, the man was taken to A8 wing, where his personal possessions
had been transferred in readiness.
43. The man was seen by a nurse in his cell on 2 October. The nurse
administered morphine to help with pain control and noted that the man was
very lethargic, lying in bed. Later, a doctor visited the man and they
discussed his prognosis. The doctor wrote that he was very distressed and
tearful. However, after a long chat, the doctor re-assured the man that his
pain could be controlled with medication and staff were on hand to offer
support. The doctor told the man that he could have visits in his cell, which
she arranged with wing staff. She would see him next week, whilst his
partner was visiting, so they could talk through any issues. Furthermore,
healthcare staff would visit him daily to ensure he was comfortable.
44. A nurse noted on 4 October that the man’s pain was controlled with an
increased dose of morphine and he had visited a friend on A7 wing in a
wheelchair. Five days later, a doctor visited the man and his partner on A8
wing. They spent time discussing his present medical condition and ways in
which he could be cared for following his diagnosis of lung cancer. Because
of the man’s loss of voice, the doctor made arrangements for his partner to
have email communications with the man through wing officers.
45. On 10 October, the man’s personal officer on A8 wing introduced himself to
the man. (This officer is also a trained family liaison officer.) The officer
wrote that they had a chat about his current illness and he had offered any
support the man might need. Later, the man’s partner visited him on A8
wing. The officer spoke to her and gave her his contact details in both his
role as a family liaison officer and as a personal officer.
46. A nurse wrote that on 11 October the man was in a more positive mood,
moving around the wing, and that his pain was well controlled. However, the
following day it was noted that the man was very sleepy and spending the
day in bed. The nurse wrote that on 13 October the man was experiencing
pain. The nurse asked that staff use the assessment tool (a plan that
monitors the efficiency of pain relief medication) to ensure that he was pain-
free. Observations were to be carried out to look for any increase in pain,
which in turn should be reported to the doctor.
47. The following morning a nurse saw the man on A8 wing. He was
complaining of dizziness when standing. The man now had a hospital type
bed with a pressure mattress to aid his comfort. He was spending more time
in bed. The nurse noted she would discuss the implementation of a care
plan with healthcare staff to ensure all interventions were documented.
48. At 5.00pm, the nurse attended the man’s cell to offer personal care and
observed that he was very short of breath and had diarrhoea. After several
attempts to get a reading, the man blood pressure was noted to be low at
80/40. A temperature reading was recorded at 38.6 degrees, higher than a
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normal reading of 36.5. He self-scored his pain at 10/10 and the man was
unable to swallow his medication. The nurse contacted a senior nurse.
49. Following a further examination, the senior nurse contacted a doctor at his
community surgery and explained the man’s symptoms. The doctor was
concerned but unable to offer advice as he was not involved in the man’s
care. Clinical matron decided that the man should be admitted to hospital as
a matter of urgency. An escort was arranged and the man was transferred to
hospital. A risk assessment was carried out and restraints were not applied.
(A risk assessment is an appraisal of the prisoner’s threat to the public whilst
being escorted away from the prison.) The man’s personal officer made
contact with the man’s partner to tell her of the transfer to hospital, and
suggested that she should start to make arrangements to visit him.
50. On arrival at hospital, the man was taken to a side room on a ward. It is
recorded in the bed watch notes that at 2.05am on 15 October a doctor told
the man he had pneumonia and his kidney function was poor. The doctor
said he was seriously ill and his condition was terminal. The man was
distressed by this news and asked the escort officers if his partner could be
contacted. The escort officer made contact with the duty governor who in
turn asked prison staff to telephone the man’s partner to tell her the latest
poor prognosis and to advise her to travel to the hospital as soon as possible.
51. At 3.00am, the man was transferred to the high dependency unit. His
personal officer made contact with the escort officers at 11.20am to tell them
that the man’s partner, and his ex-wife and children, were on there way to the
hospital. They arrived at 1.10pm. The man’s family remained by his
bedside, taking it in turns to comfort him.
52. The man’s personal officer and another officer took over bed watch duties at
7.00pm. An hour later, it was noted that the man had died. His partner was
by his bedside. The man’s death was confirmed at 8.45pm by a doctor.
53. The man’s personal officer supported the man’s partner and family following
his death, and later a memorial service was held in the prison chapel.
Friends of the man arranged for a floral tribute to be sent to his funeral
service on 5 November. The funeral was attended by his personal officer
and the Deputy Governor. The prison offered to meet the funeral expenses.
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ISSUES
Clinical care
54. A review of the man’s medical care whilst in custody was undertaken by a
general practitioner (GP), on behalf of Nottinghamshire County Teaching
PCT. The GP reviewed the man’s medical notes and made a chronology of
the medical interventions and consultations.
55. The clinical reviewer records that the man had been seen by a chest
physician in 2007, before he was taken into custody, when a chest x-ray had
shown suspected abnormalities. Further medical investigations were
concluded in 2008 when a CT scan showed an improvement and he was
discharged from seeing the specialist.
Reception into Whatton
56. The clinical reviewer notes that the man’s reception health screen was
completed appropriately. It was recorded that he was not suffering from a
mental disorder despite being anxious at being in prison. A vaccination
history was documented and he was prescribed medication of an inhaler for
asthma. The man was also informed of health promotion facilities that he
could access.
Summary of healthcare treatment
57. The man had contact with the healthcare services when he felt the need to
see a member of staff. Over the last 12 months of his life he had 83 contacts
with healthcare staff and was offered relevant health screening and
promotion facilities. The clinical reviewer writes:
“Towards the end of his life, when his mobility had become a
problem, the man was visited on the wing every day. At the most
significant time in the course of his illness, the man and his partner
were seen together in his cell. In my opinion, the healthcare
department and discipline staff should be commended for facilitating
this. I cannot find any significant shortcomings in how the man was
managed whilst at HMP Whatton and can confirm that, in my opinion,
his standard of care was more than comparable to that of an NHS
patient treated in the community.”
58. I share the clinical reviewer’s commendation of healthcare and prison staff
in facilitating the man’s visits in his cell, and ensuring his partner was fully
informed of medical interventions.
Family Issues
59. One of my family liaison officers made contact with the man’s partner.
She did not raise any specific issues to be included in the investigation but
did ask if her partner had cancer before he was sent to prison. As noted
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in the report by the clinical reviewer, medical investigations had been
completed in 2007-2008 for a shadow on his lung. However, doctors
noted that there was an improvement in his condition in early 2008 and
the man was discharged. I cannot say categorically that he had not
contracted cancer while in the community, but the evidence would
suggest not. As my investigation has shown, the man was referred by the
doctor at Whatton, under the two week rule, as soon as his symptoms
became a concern.
Restraints
60. It is noteworthy that the man was escorted to hospital without restraints
being applied. This was good practice.
Family Liaison
61. An officer, a trained family liaison officer, became the man’s personal
officer on his transfer to A8 wing. The practice of using trained family
liaison officers to become a prisoner’s personal officer when they are
seriously or terminally ill is commendable, and a further example of good
practice.
62. The officer was able to build a relationship with the man, and his partner,
before his death. As time progressed, the officer updated the man partner
on his condition before he was taken into hospital. Following his transfer
to hospital, the officer ensured the man’s partner was notified and
arrangements made for her to visit him.
63. Following the man’s death, the officer maintained contact with the partner
and offered her support. It was also advantageous that on this occasion
the officer was on bed watch duty when the man died.
64. As well as commending the practice of using trained family liaison officers
to become personal officers for terminally ill prisoners, I further note the
professional manner in which the officer carried out both those roles. The
Governor may wish to consider if the officer’s actions should be formally
recognised. I would certainly be grateful if my own comments could be
passed on to him.
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CONCLUSION
65. The man was referred for further medical investigation at an appropriate time.
When his diagnosis of cancer was confirmed he was cared for by healthcare
and prison staff in a highly supportive and dignified manner. the clinical
reviewer comments that the care the man received was more than
comparable with that he would have received in the community. He has
commended both healthcare and prison staff for allowing the man’s partner
to be actively involved in discussion around he partner’s illness and allowing
in cell visits, and I share his views.
66. The support given to the man by his personal officer during the last few days
of his life, and that given to his partner, was very good practice. A kind and
appropriate decision was taken that the man should not be restrained when
he was admitted to hospital for the final time.
67. All in all, this report reflects hugely well upon Whatton and upon HM Prison
Service as a whole.
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GOOD PRACTICE
1. Facilitating the man’s visits in his cell and allowing his partner to be kept
fully informed of his medical interventions was good practice.
2. Using trained family liaison officers to become personal officers for
terminally ill prisoners is good practice from which other jails might learn. I
further note the professional manner in which his personal officer carried
out both those roles.
3. I note the good practice that the man was not restrained when he was
admitted to hospital.
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