Individual at Whatton

Investigation into the circumstances surrounding the
death of a man at Queen’s Medical Centre, Nottingham,
while a prisoner at HMP Whatton,
in July 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2009
This is the report of an investigation into the death of a prisoner at HMP Whatton.
The man died on 7 July 2008 at Queen’s Medical Centre, Nottingham. He was aged
81. I offer my sincere sympathy and condolences to all those affected by his loss.
The man was already 78 years old when he was first sent to prison in 2005, and he
already had significant health problems. He suffered from asthma, diabetes, had
received skin cancer treatment, and often had chest pain and chest infections. He
continued to suffer from these health problems throughout his time in prison, but was
well supported by prison healthcare and NHS healthcare staff. In early July 2008 he
was admitted to hospital, and died five days later.
The investigation was carried out by one of my colleagues. The man’s medical care
in prison was independently reviewed by a doctor on behalf of Nottinghamshire
County Primary Care Trust. As ever, I am most grateful to the doctor for his
assistance.
I would also like to thank the Governor and staff of Whatton for their full and ready
co-operation during the course of the investigation. I am particularly grateful to the
support and liaison officer who provided such a good service to my investigation
team.
I make two recommendations in this report, one of which is an amended version of a
recommendation I made in a previous investigation report in June 2008. This
concerns the use of restraints - and the very difficult balance between the needs of
security and what is decent and civilised in the care of an elderly patient at the end of
his life. The Prison Service has accepted both these recommendations and I have
included their comments at the end of this report.
Stephen Shaw CBE April 2009
2
CONTENTS
Summary 4
The investigation process 5
HMP Whatton 6
Key findings 8
Issues
Concerning the man’s clinical care 14
Concerning Prison Service related matters 15
Recommendations 18
3
SUMMARY
The man was sentenced to 12 years imprisonment by Truro Crown Court on 27 May
2005. After his initial admission to HMP Exeter, he was transferred to HMP Bristol
and HMP Dartmoor. On 10 May 2006, the man transferred to HMP Whatton where
he spent the remainder of his time in prison before he died in hospital in Nottingham
in July 2008.
The man was already aged 78 when he was sentenced and came to prison with a
number of health problems. Despite this, he managed to adapt to prison life quite
well and was described by staff as a quiet, co-operative, elderly man who rarely gave
any cause for concern except regarding his health.
Before the man was sentenced to imprisonment, he had been diagnosed and treated
for skin cancer. It recurred in January 2008, and he was placed under the care of a
consultant dermatologist at Nottingham University Hospital. He also had diabetes
before he arrived in prison, and the condition became progressively worse so that he
required insulin injections rather than tablets to control it. The man also suffered
from asthma and contracted chest infections regularly whilst in custody.
In July 2008, the man felt unwell and the local community paramedic team were
called to review his medical condition. They undertook an ECG (an electrical tracing
of his heart), and found that there were some changes to his heart rhythm but that he
did not require admitting to hospital on this occasion. A short while later, the man
was seen by the prison doctor who thought it appropriate to have him admitted to
hospital for further tests and treatment. He was taken to Queen’s Medical Centre,
Nottingham, under prison officer escort and admitted to a ward at the hospital. The
man remained there for a further five days, becoming more and more unwell. He
died from his illnesses one evening in July 2008.
4
THE INVESTIGATION PROCESS
1. This investigation was undertaken by one of my investigators. They first
visited HMP Whatton on 10 July 2008 where they were shown around the
prison and given access to the man’s prison records. They met members of
the local branch of the Prison Officers’ Association (POA) and the
Independent Monitoring Board (IMB). (Each prison has an Independent
Monitoring Board. IMB members are independent and unpaid. They monitor
the day-to-day life in the prison and ensure that proper standards of care and
decency are maintained. The IMB produces an annual report on their prison.)
Neither the IMB nor the POA had anything specific to bring to my
investigators’ attention at this time, but both said they would help wherever
they could for which I am grateful. Whilst on this visit, my investigator held
informal discussions with a number of prison staff who had known the man.
2. Nottingham County Primary Care Trust (PCT) was asked to undertake a
clinical review of the care the man received while in custody. A doctor was
appointed to carry out this review on their behalf. My investigator asked the
doctor to judge specifically whether the care afforded the man was of an
equivalent standard to what might have been expected for an 81 year old man
if he were not held in custody.
3. One of my Family Liaison Officers contacted the man’s son, as his listed next
of kin, to discuss the aims of the investigation and to offer the family the
opportunity to raise any concerns or questions they wished to be considered
in my investigation. The man’s son asked about the return of an item of his
father’s property. I understand this matter has since been resolved. I hope
this report helps the man’s family better understand the events leading to his
death.
4. Once the draft report had been issued, the man’s family raised one additional
matter which my investigator has endeavoured to answer. When the man’s
family visited him in hospital, they were distressed at him being looked after
on the general ward, with two officers in uniform beside the bed at all times.
This made private conversation very difficult. As the family appreciate, it is for
the hospital to determine where in a hospital a patient is looked after, but the
prison do try and ask for side rooms where possible. In respect of uniform, it
is the Local Security Strategy that staff on outside escort should wear uniform
for security reasons (to be easily identified in the case of emergencies).
5. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation and to request a copy of the post mortem and
the toxicology reports. Upon completion, a copy of my report was sent to the
Coroner to assist his enquiries into the circumstances surrounding the man’s
death. The inquest was held on 25 February 2009. The jury concluded that
the man died of natural causes.
5
HMP WHATTON
6. Whatton is a category C training prison for sex offenders. It currently has
capacity for 841 adult male prisoners. Since May 1990 it has held sex
offenders who participate in the Sex Offender Treatment Programme.
7. In 2006, new accommodation opened, resulting in an increase in the prison’s
population and significant changes to the type of offender held. Previously,
the prison only took sex offenders who had agreed to address their offending
behaviour. Having undergone a large expansion programme, Whatton now
accommodates a mixture of sex offenders, many of whom are in denial of
their offences.
8. HM Chief Inspector of Prisons, Dame Anne Owers, wrote in her report
following an announced inspection in January 2007 that the prison had
undergone a period of dramatic and rapid change. She commented that the
management of the prison had not had very long to accommodate those
changes. Ms Owers said that, “there is much excellent work to build on, but
clearly a lot more to do.” Her inspection report also said that “care for the
disabled and the elderly, was well managed” and that “as a national sex
offender resource, managers at Whatton also deserve national support to
embed change and overcome the evident teething problems.” In June 2008,
Ms Owers reported in her follow-up to the thematic review of older prisoners
from 2004 that Whatton was the only prison where she found evidence of care
plans for older prisoners being written and shared with wing staff. She also
commented on the good entries made by discipline staff in wing files about
elderly and disabled prisoners.
9. The latest available Independent Monitoring Board’s report (for the period
June 2006 – May 2007) made generally favourable comments about the
prison healthcare services, but raised concerns in two important areas. The
first was in the commissioning arrangements from the local PCT. The IMB felt
that the PCT fell short of its duty of care at the time. The second area was
that of social and palliative care. In their report the IMB said:
“The IMB considers that the social and palliative care in the prison is
inadequate. We are in particular concerned about the palliative and
social care of terminally ill prisoners – highlighted by the death from
cancer of a prisoner earlier this year.
“A second prisoner died from cancer in a local hospice some months
later but was only permitted to remain there before his death because
the prison management refused to accept him back to the prison.
“A third terminally ill prisoner is currently being held at the prison and is
receiving care that is as inadequate as that experienced by the two
prisoners highlighted above. Prisoners are asked to look after him and
currently he has no means of contacting staff when he needs
assistance as his bell is on the other side of the cell to his bed.
Officers informed the IMB that ‘if he needs help he will shout and
6
someone will attend’. We question whether this is suitable care for a
terminally ill prisoner. We note, however, that the prison is working
with the PCT on new palliative care arrangements and are pleased to
report that the prison management have negotiated a greater level of
care under such circumstances.”
Healthcare
10. Healthcare within the prison is provided by Nottinghamshire County Teaching
Primary Care Trust (NCtPCT). There is no 24 hour healthcare service in the
prison and no medical staff work on site during the evening or overnight. An
out of hours service is provided under contract by Nottingham Emergency
Medical Service (NEMS).
Previous deaths at Whatton
11. At the time of issuing this report, there had been 16 deaths of prisoners at
HMP Whatton since 2004 when I became responsible for investigating all
deaths in prison custody in England and Wales. The death of this man is the
13th due to natural causes (in part, a reflection of the number of elderly
prisoners held at Whatton). The issue I raise in this report regarding the use
of restraints is one I have highlighted in a previous investigation. Aside from
this, there are no concerns identified in the man’s death that occurred in the
other investigations I have conducted to date.
7
KEY FINDINGS
12. The man was sentenced to 12 years imprisonment on 27 May 2005 at Truro
Crown Court and arrived at HMP Exeter the same day. He was transferred
from Exeter to Bristol on 2 June and on 2 August arrived at Dartmoor.
13. The man’s wing file shows that he settled well at Dartmoor. The file states
that he was very active for his age and got used to the prison routine. He
started work in one of the workshops and had a good work record throughout
his time at the prison. However, he was not prepared to admit the offences
for which he had been imprisoned and therefore he could not be put forward
for the Sex Offender Treatment Programme (SOTP) or casework. The man
was not seen as a problem at Dartmoor and was said to have been polite to
staff.
14. Notes in his wing history sheet say that he was interviewed by a psychologist
on 23 November and was accepted to go to the new unit at HMP Whatton in
March 2006.
15. A note in his wing file of 19 February 2006 said that he was pursuing grievous
bodily harm (GBH) charges against certain people from Truro Crown Court,
and asking for help from his probation officer regarding his wife selling his
house.
16. The man received confirmation on 3 April 2006 that he would be transferring
to HMP Whatton in the near future. On 15 April, the wing file notes state that
a melanoma (a growth) on the man’s forehead was benign and he was very
happy about that. (he had been treated for skin cancer in December 2004
and had follow-up appointments with a dermatologist.) However, the notes
also say that the man was unhappy about the outcome of proceedings in
Truro Crown Court regarding the GBH charges. The wing file states that the
man was “a feisty old man who said he won’t let it lie”.
17. On 4 May, the man was informed that he would be going to Whatton on 10
May. On 5 May, a note in his wing file said that he was unhappy about
moving to Whatton. He had applied to see a wing Principal Officer (PO) and
he was contacting his solicitor for advice. On 10 May 2006, the man did
transfer to Whatton.
18. The man had a spirometry test (a test of his breathing capability) on 22 May
which showed him to have mild asthma and a little difficulty breathing. He
was prescribed inhalers for this condition.
19. On 29 June, he had chest pain during the night and was assessed by the
prison doctor the following day after an electrocardioagraph (ECG). The
results showed nothing of significance, and the man reported he had felt
better after he had taken his inhaler. The prison doctor advised him to return
if he had further problems of this nature.
8
20. The man was seen a number of times by healthcare staff in September and
October 2006 because of chest infections. He was successfully treated with
antibiotics on each occasion. However, in November, he was also diagnosed
with angina following further episodes of chest pain.
21. On 16 November 2006, the man’s chest pain was sufficiently severe to
require that he be taken to the local hospital. He was admitted to the Queen’s
Medical Centre in Nottingham where he was diagnosed as having suffered a
mild heart attack. Whilst in the hospital, the man developed a chest infection.
He remained in hospital until 27 November.
22. The man stayed well for the next few months until, in February 2007, he again
started to suffer with infections. He was prescribed antibiotics on 7 February
for a chest infection. He also had an infection of the skin of his left leg
(cellulitis) which required treatment on 21 February. On 23 February, he was
admitted to Nottingham City Hospital because his cellulitis was no better and
the prison doctors thought he might have a deep vein thrombosis (DVT – a
blood clot).
23. The hospital doctors checked the man for other ongoing medical complaints
and, after many tests, diagnosed that he was suffering from Barrett’s
oesophagus (an inflammation of the lower gullet which is potentially
precancerous). He was discharged back to prison on 28 February 2007.
24. A personal officer review on Tuesday 27 March states that the man had no
problems on his wing and was looking forward to his solicitor visiting him on
Friday. The man was making enquiries into some unresolved issues with his
ex-partner. His wing file also says that he was awaiting medication from
healthcare but he had said he had been feeling a lot better lately.
25. On 12 May, the man had an incentives and earned privileges (IEP) review
and was said to have no problems on the wing and was happy.
26. The man attended the Hand Clinic at Queen’s Medical Centre on 21 June
where he was seen by a specialist registrar at the hospital. He examined the
man’s left hand which had developed a lump on the middle and ring fingers.
The registrar diagnosed that the man had a flexor sheath ganglion that would
be suitable to be removed under a local anaesthetic procedure in a day
surgery some time in the future. The man was put on the waiting list for this
minor operation.
27. In his wing history report of 23 June, the man is reported as saying he was
still awaiting a few health scans. He was due to have the minor operation to
remove the lump on his left hand. He was also thinking about an appeal to
reduce his sentence and his solicitor was working on this and other issues
regarding his ex-partner.
28. The man’s blood sugar levels were reported to be high on 1 July. A doctor
was telephoned and nursing staff were advised to check his blood sugar
levels hourly and then every two hours. The doctor was to be called again if
9
the man’s condition worsened. There is no record of the doctor needing to be
called again. On 21 July, it was noted in the man’s wing file that his blood
sugar levels appeared to be satisfactory at the time. However, according to
his medical record, he was referred to the diabetic specialists for
consideration of changing his tablets to insulin injections.
29. The out of hours emergency service attended to the man on 29 July because
he had a high blood sugar reading.
30. The next healthcare contact was on 6 September 2007 when the man was
referred urgently to Nottingham City Hospital for assessment of possibly
cancerous skin on his forehead.
31. On 10 September, the man was finally seen by the diabetic nurse specialist,
and prescribed insulin injections. The injections began on 17 September,
following some initial teaching and training on how to self-administer insulin.
Checks on 23 October found that he was doing well with his new prescription.
However, because of concerns about his diabetes, the local hospital had
taken him off the list for proposed hand surgery. He was put back on the list
on 9 January 2008.
32. An officer met the man on 14 January 2008 for an interview and OASys
review. (OASys is the Offender Assessment System which is used by the
Observation, Classification and Allocation department as part of the sentence
planning process. It is a risk assessment tool to make proper assessment of
needs, and to assist staff with selecting an appropriate prison for a sentenced
prisoner.) At the interview the man maintained his innocence and therefore it
was difficult to discuss targets relating to offending. The man also asked to
move back to Dartmoor because his family lived in Cornwall and he did not
receive any family visits whilst at Whatton. The wing record states:
“He is 81 years old and does not enjoy good health. He states that he
does feel a bit DOWN sometimes due to no visits. He would like to
maintain contact and visits with family but it is difficult here.”
33. The man was seen on 16 January by the skin specialist at Nottingham City
Hospital, and diagnosed with skin cancer (a basal cell carcinoma).
34. Two weeks later, on 29 January 2008, the entries in the man’s wing history
record say that he was in a good mood as he had been accepted by
Dartmoor.
35. Throughout February, March and April, he was still waiting to be moved to
Dartmoor and it was noted that he remained a well behaved prisoner and was
polite to staff.
36. On 9 May, an entry on the man’s wing file states that he was worried about
the cancer growth on his face and it appears that he had been awaiting an
appointment for five months. An officer informed his healthcare colleagues
about the delay and they undertook to look into the matter. Later that day, the
10
man was seen by the nurse on the unit and listed to see the doctor the
following week. The man’s medical notes also show an entry on 9 May that
says “Chronic kidney disease stage 3” entered by the prison doctor.
37. The prison healthcare administration department telephoned Nottingham
University Hospital to pursue the man’s referral by the consultant
dermatologist.
38. On 5 June, a Governor received a telephone call from a friend of the man who
was worried about the man’s medical problems. The man was seen and he
assured staff that he was fine. An officer received a further call from the same
friend who accused staff of failing to give the appropriate care and attention
that was expected.
39. In the early hours of the morning of 6 June 2008, the man collapsed in his
cell. The out of hours service was contacted and advised that paramedics
should be called. The paramedic team arrived at 6.30am and treated the
man, but did not consider he needed admission to hospital. Nursing staff saw
him later that morning and noted that he was still experiencing chest tightness
and pain. The nursing staff thought he might have a chest infection and,
because his inhalers had run out, had been unable to relieve his symptoms.
They saw him later that day when he felt much better.
40. However, the paramedics were called to see him again the following morning
at 7.15am. They diagnosed possible angina and a chest infection, and
started antibiotics following a telephone consultation with the local out of
hours doctor.
41. On 8 June, the man reported to the office and said he had coughed up blood
in the morning. He was given the opportunity to attend healthcare but
declined.
42. The man was seen by the doctor on 26 June, and diagnosed with another
chest infection, possible cardiac failure, and also that his kidneys were not
working as well as they should. He was given medication to rectify all these
problems. He was reviewed and treated by the prison doctor on 30 June
when he had a hypoglycaemic attack (a diabetic low sugar problem). This
was the first time he had had such a problem (previously his diabetic
problems had been caused by too much sugar in his system).
43. Wing staff called nursing staff to come and visit him on the morning of 2 July.
He felt sick and dizzy, but was otherwise alert and well. The nursing staff
called upon the services of the community paramedic team who found,
following a tracing of his heart, that he had “no acute changes, though does
have some flipped T waves. No specific reason for acute admission.” (This
means that the paramedics had carried out an ECG but they were not unduly
concerned by the results and were happy not to admit the man to hospital,
preferring instead that he should be reviewed by the doctor at Whatton later.)
11
44. A prison doctor reviewed the man later that morning, and decided that he
should be in hospital. She therefore made arrangements for his admission to
Queen’s Medical Centre in Nottingham.
45. On 7 July, one of the officers taking part in the man’s bed watch told my
investigator that, even though he was not the man’s personal officer, he knew
him pretty well. (A bed watch is an escort to hospital whereby a prisoner is
accompanied by Prison Service staff and admitted to a hospital bed.) When
this officer was asked in interview how the man had seemed whilst in prison,
the officer replied:
“In my opinion he was fairly mobile. He made his own way to the
servery to get his own tea, his own lunch, active enough for his age I
would say. It was noted maybe his health was normal of an 83 year
old. From my recollection he pretty much stayed watching TV and
associating on the landing.”
46. The officer told my investigator that he arrived at Ward D55 at Queen’s
Medical Centre about 6.50pm on 7 July, where he saw other officers, one of
whom was due to do the bed watch with him. He noticed that this officer was
in possession of the escort chain which was in his hand and gave an
indication that something unusual had occurred. (An escort chain is a long
chain with a handcuff at both ends. The officer is attached to the prisoner via
this chain to enable the use of a toilet or to allow medical examinations when
the prisoner is in hospital. It is often used when a prisoner is confined to bed
in hospital to allow greater freedom of movement.)
47. The two officers leaving duty told the two remaining officers that the man’s
health had declined at about 6.30pm and they had requested permission to
take off his escort chain as the medical staff needed to gain access to treat
him. Through a gap in the curtain round the man’s bed, the officer could see
that the medical staff were quite busy attending to the man’s care. The officer
told my investigator that he decided to telephone the prison to ask that the
cuffs be removed for the rest of the night. The officer could see that the cuffs
would need to be taken off later and did not want to delay the process of care
that the man was receiving.
48. The officer said that he spoke to a Principal Officer at the prison who informed
him that permission had been granted by a Governor. It was part of the PO’s
duties as the Orderly Officer for the day (the senior uniformed officer in charge
of the prison at the time) to give advice and guidance to more junior staff such
as the officer on the bed watch.
49. The bed watch officer told my investigator that at about 7.30pm it became
apparent to him that the man’s health was declining further as more medical
staff had started to work behind the curtain. The officer said:
“… I could hear people trying to, they were saying things like ‘come on’,
‘try and wake up’, ‘are you with me’, so there was something going on
there. And about 7.50pm, it seemed to go a bit quiet. Then some
12
medical staff came behind the curtain and I remember there was a
charge nurse or one of the nurses there, he informed me that they’d
failed to resuscitate the man and that they would get the doctor down
to confirm that.”
50. When the duty Governor was informed of the man’s death, he arranged for
staff involved in the care of the man to return to the prison where a debrief
was arranged. The officers from the bed watch, together with the Governor
and the night orderly officer, attended the debrief. Staff were offered the
opportunity to see the staff care and welfare team at this debrief and the offer
was repeated in the days that followed the man’s death. A notice to inform
prisoners of the death of the man was issued by the governor on 7 July and
displayed on the various wings in the prison.
13
ISSUES
Concerning the man’s clinical care
51. The doctor reports in his clinical review that:
“The medical care of this man at HMP Whatton was on the whole
appropriate. The man had multiple medical problems. He required
regular routine follow up appointments at healthcare for his ongoing
diabetic, cardiac and asthma needs. He also required emergency input
whenever he suffered a relapse of his chronic conditions.”
52. The doctor’s only criticism is in relation to the length of time it took for the
man’s referral to the local diabetic nurse specialist team to be acted on. It
took from 12 July 2007, when the referral letter was written, until 17
September when the man had his first insulin injection.
“If there can be any criticism, then it is with the commencement of
insulin therapy, which was protracted. However, this had no bearing
on his death. Indeed, at the time of his last illness his average sugar,
blood pressure and cholesterol were all well controlled and within the
target levels for his condition.”
53. The doctor writes that prison healthcare staff should be trained to manage
prisoners with diabetes, and especially those who are recently diagnosed. At
the moment the prison relies on external diabetes specialists and he
recommends that prison healthcare staff receive appropriate training.
The healthcare department should consider having some of its staff
trained to a higher level to allow them to give better care for diabetics,
including those prisoners newly diagnosed.
54. There is a similar theme of delay when it comes to the man being followed up
by the consultant dermatologist. The man was seen on 16 January 2008 and
diagnosed with a basal cell carcinoma on his forehead. The letter received by
Whatton on 24 January says: “His histology and reports from previous
excisions and previous radiotherapy suggest that this is going to be a difficult
lesion to treat and I have arranged for him to come into our multi-disciplinary
clinic to be discussed with the plastic surgeons, as he may well need inpatient
treatment with general anaesthetic to remove the tumour. I will let you know
the outcome of that discussion.”
55. Nothing happened until early May when an entry in the man’s wing history
sheet reports that he was concerned about the cancer on his forehead.
Prison staff asked healthcare staff what was happening about his
appointments. Healthcare staff then tried a number of times to follow up the
enquiry with the local hospital. Despite their efforts, the man was not actually
seen before his death. The Clinical Review doctor was unable to ascertain
exactly why the delay occurred. However, I observe that, had the healthcare
record system at Whatton been more sophisticated, the absence of further
14
information from the Consultant Dermatologist would have been noticed long
before May. I hope the recent introduction of an electronic records system at
Whatton will mean this type of problem will not recur in the future.
Concerning Prison Service related matters
56. There is also an apparent time lapse in respect of the man’s transfer to HMP
Dartmoor. The man appears to have first requested a move back to Dartmoor
on 14 January 2008. He heard that he had been accepted by Dartmoor on 29
January, but does not appear to have learned anything more before his death
on 7 July.
57. My investigator spoke with Prison Service Headquarters Population
Management section, and the allocations department at Whatton who handled
the man’s request for a transfer to Dartmoor. Both departments said that the
man’s move was dependent upon a place being available at Dartmoor, and
none became available for the man in that time. Whatton’s allocation centre
also made the valid point that the man was undergoing frequent hospital
attendances which might have had a bearing on his circumstances.
58. All of this may be true but, having accepted that it was appropriate for the man
to move back to Dartmoor on grounds of being closer to his family, I judge
that it took the Prison Service too long to arrange the transfer. I am all too
aware that the prison population is extremely high, and that pressures on
individual prison places can be acute. Nevertheless, the man was an 81 year
old, far from his family, and unable to receive visits. I do not think it was
acceptable that he was left waiting more than six months for a transfer.
59. Population Management added that the man could (and perhaps should) have
been offered the opportunity to be transferred to Exeter for a short period of
accumulated visits. Prisoners on accumulated visits return to a local prison
near their home so that their family can make a number of visits to them in a
concentrated period of time, usually a month. It does not appear that this
option was considered for this man.
60. In other reports, I have reflected extensively on the issue of the use of
handcuffs for prisoners who are elderly, frail or very unwell. The man was
transferred to hospital on 2 July under restraint. He was maintained on a
bedwatch, with two members of staff, and had an escorting chain applied for
much of his stay in hospital. On 7 July, the day of the man’s death, an officer
came on bedwatch duty and:
“… noticed that [another officer] was in possession of the closet chain
and that it was in his hand and this gave him [the reporting officer] an
indication that something unusual had occurred. [The officer’s going
off duty] told him that the man’s health had declined at about 6.30pm
and that they had requested permission to take off his handcuffs as the
medical staff needed to gain access to help him [the man].”
15
61. My investigator enquired if the prison has a protocol for considering the
removal of handcuffs during external escorts to hospitals. I have investigated
and reported on a previous occasion on the use of restraints for prisoners at
Whatton. I recommended then that changes in a prisoner’s circumstances
should lead to new risk assessment being completed. In this man’s particular
circumstances, an escort risk assessment form was completed when he first
went to hospital. I could find no evidence that the initial risk assessment was
formally reviewed when it became clear he would be staying in hospital. At
that point, prison staff had more time to make an informed decision about the
real risk he posed.
62. My investigator spoke with the duty governor of the day who gave permission
for the removal of restraints on the afternoon of 7 July 2008. He told my
investigator that it had been done because of a request from the hospital staff
to undertake medical interventions on the man. These interventions would
have been made more difficult with the presence of an escorting chain. His
understanding was that the removal of restraints was to be a temporary
measure. He expected the chain to be replaced at some point, once the
medical staff said they did not require further interventions to be made. As it
happens, it is unclear whether the chain was ever re-applied, but the principal
reason for removal was for a medical intervention – not a consideration of
dignity and decency, balanced with risk.
63. Policy and practice in the Prison Service regarding the use of restraints on
prisoners in hospital is extremely cautious, and I am aware that the balance
between decency and security can be a difficult one to find. The nature of this
man’s offences would, of course, have needed to be considered, particularly
in relation to his risk to the public. Nevertheless, my own sense is that the
Service has become too risk averse and that an elderly man with limited
mobility, in serious ill health, and with no geographically close relatives or
associates, did not constitute a remotely likely escapee. (I am certainly not
aware of any specific evidence to suggest the man was an escape risk.)
64. I do understand the decision taken by Whatton given the prevailing climate
and the expectations of the Service as a whole. However, I also wonder
whether the staff undertaking the managerial bedwatch checks are able to
balance risk and concern for decency at the end of life in a timely manner. I
judge that restraints could have been safely removed sooner, and that the
presence of two prison officers would have been an adequate safeguard for
the public. I therefore repeat my earlier recommendation (in a revised format
to meet this man’s circumstances).
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 is admitted to outside hospital, and should be reviewed at
least every 24 hours or when the prisoner experiences a significant
change in circumstances.
65. Although I criticise the decision to keep the man restrained until the last day of
his life, I also recognise that staff at Whatton were compassionate and caring
16
in respect to most other aspects of the man’s care. They looked after an
elderly man through many illnesses with kindness and consideration for his
condition. They engaged him in appropriate activities, and treated him with
respect. I am sure this is in part due to the systems in place at Whatton that
were commended by Dame Anne Owers in her recent follow-up review.
17
RECOMMENDATIONS
The Prison Service accepted the draft report recommendations with the following
comments:
1. The healthcare department may wish to consider having some of its staff
trained to a higher level for diabetes initiation therapy.
One nurse has already completed training and another started in January
2009.
2. 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 is admitted to outside hospital, and should be reviewed at least every
24 hours or when the prisoner experiences a significant change in
circumstances..
The current policy is for a risk assessment to be carried out prior to a
prisoners discharge to hospital. The use of restraints and the staffing level of
the escort is considered at this point and also includes consideration for any
comments recorded on the assessment by a member of the healthcare
department. This is approved by either the Head of Operations or the Duty
Governor. Once the escort becomes a bedwatch a management check is
carried out during each 24 hour period. During each management check
consideration is given to the level of restraint required and to releasing the
prisoner on temporary licence. In light of the recommendations by the PPO a
review of our procedures is to take place. The conclusions from this review
will be included as an instruction in the prisons LSS [Local Security Strategy].
18