Individual at Whatton

Investigation into the circumstances surrounding the
death of a man in hospital, whilst released on
temporary licence from HMP Whatton, in August 2007
Report by the Prisons and Probation Ombudsman for
England and Wales
June 2008
This is the report of an investigation into the death of a man at HMP Whatton.
He died in August 2007 in a hospital in Nottinghamshire, with his wife and
other family members at his side. He was 56 years old. I offer my sincere
sympathy and condolences to the man’s wife and her sons, and to all of those
affected by the loss of her husband.
The man had been diagnosed with lung cancer around one month before his
death, having been admitted to hospital with a chest complaint. A post
mortem examination confirmed the cause of death to be carcinoma of the
right lung with metastases.
The investigation was carried out on my behalf by one of my colleagues. An
independent review of the man’s medical care in prison was carried out by a
medical practitioner on behalf of the Nottinghamshire County Primary Care
Trust. As ever, I am most grateful to the clinical reviewer 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 prison’s liaison officer for the support that she provided.
I make six recommendations, including three to HMP Lincoln, and highlight
one example of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2008
CONTENTS
Summary
The Investigation Process
HMP Whatton
Key Events
Issues
Recommendations and Good Practice
SUMMARY
The man was sentenced to one year’s imprisonment in April 2007, and was
received at HMP Lincoln on the same day. He was an epileptic, and was
taking medication to control it. On his arrival at Lincoln, he also reported a
history of depression and anxiety.
The man was diagnosed with a chest infection on 1 May 2007, having
reported to a prison doctor that for a period of around two weeks he had been
producing a frothy sputum when coughing. He had also recently reported
weight loss and a loss of appetite. He was prescribed a course of amoxicillin
(an antibiotic) by the doctor.
Over the course of the next week, he continued to complain of weight loss.
He also said he had difficulty swallowing and, on one occasion, complained of
chest pain in the early hours of the morning. As a result of these symptoms,
he had an x-ray at the local hospital on 11 May. The results showed that he
had chronic obstructive pulmonary disease.
On 1 June, he transferred to HMP Whatton. His medication was not given to
him prior to his transfer, and it is not clear when he received a new supply.
He was booked for an appointment with the prison doctor on 15 June.
However, the appointment did not take place - for reasons that are not
recorded.
The man subsequently saw a doctor at Whatton on 19 June, and complained
of increased shortness of breath and chest pain. He was noted by the GP to
have a “widespread wheeze”. The doctor diagnosed a chest infection, and
amoxicillin was again prescribed.
On 25 June, he again complained of “problems with his chest” and was
prescribed a further course of amoxicillin. He again saw a prison doctor on 27
June, after his symptoms worsened overnight. On this occasion, he was
admitted to hospital for tests.
The man did not return to Whatton. On 11 July, he was diagnosed with lung
cancer and, on 17 July, released on a temporary licence for compassionate
reasons. The cuffs that had been in place since his admission to hospital
were removed on the same day.
The man’s condition continued to deteriorate and, on 27 July, he moved to a
community hospital in Nottinghamshire. He died in the beginning of August
2007, with his wife and other family members at his side.
My report shows that the man received satisfactory care at Whatton.
However, the clinical review raises several concerns, including the possibility
that the man’s transfer from Lincoln may have led to a delay in diagnosing
cancer. I make a total of six recommendations, three of which are directed at
Lincoln, and highlight one example of good practice.
THE INVESTIGATION PROCESS
1. The investigation was opened on 14 August 2007 when my investigator
issued notices announcing the investigation to staff and to prisoners.
The notices included an invitation to those who wished to submit
information relating to the man’s death to make themselves known to
my investigator. No prisoners came forward as a result.
2. My investigator was given access to the man’s prison files, including
the medical record. He visited Whatton on 5 December 2007, and
interviewed two members of staff during the course of the investigation.
An independent clinical review of the man’s health needs whilst he was
in custody was carried out by the clinical reviewer on behalf of the
Nottinghamshire County Primary Care Trust.
3. My senior family liaison officer wrote to the man’s wife on 23 August
2007. The senior family liaison officer and the investigator
subsequently met with the man’s wife on 24 October 2007. At the
meeting, the widow praised the conduct of the prison officers who were
on bedwatch duty when her husband was in hospital. She also raised
the following issues that she wanted the investigation to address:
(cid:127) That she and her sons were very concerned and upset about the
use of restraints during the man’s time in hospital.
(cid:127) That it was difficult to have a private conversation with the man in
the last few days of his life because, even though he had been
released on a temporary licence, a prison officer was present in the
room.
(cid:127) Whether his transfer to Whatton from Lincoln was appropriate,
given his illness?
(cid:127) That his medication was not forwarded to Whatton when he
transferred.
(cid:127) That she was not notified by the prison about his transfer to
Whatton.
(cid:127) Was there a delay to the man receiving treatment following the
diagnosis of cancer due to uncertainty over the best place for him to
be at that time?
(cid:127) That the man may have been undernourished due to receiving
supplement drinks at Lincoln but not at Whatton.
(cid:127) That she tried to claim money for petrol expenses from the Assisted
Prison Visits Unit, but found the forms too time-consuming and
complicated to complete.
HMP WHATTON
6. Whatton is a category C prison that currently has capacity for 821 adult
male prisoners (at the time of the man’s death, capacity was 761
prisoners). It first opened as a detention centre for juveniles, but its
role changed in the early 1990s to that of a prison for vulnerable adult
offenders. During this time, the prison developed as a specialist
establishment for adult male sex offenders to enable them to
participate in the Sex Offender Treatment Programme. Whatton
has recently undergone a large expansion programme. All applicants
for a place at Whatton must be adult males and category C sex
offenders. They should not require the services of a full-time medical
officer.
7. Healthcare within the prison is commissioned and provided by
Nottinghamshire County Teaching Primary Care Trust. There is no 24
hour healthcare service in the prison, and no medical staff are on site
during the evening or overnight. An out of hours service is provided
under contract by Nottingham Emergency Medical Service (NEMS).
8. Medication is administered on a weekly and/or monthly basis to those
prisoners who have been risk assessed as suitable to hold it in their
own possession. It is administered on a daily basis to other prisoners,
when either they are considered to be at risk or the medication is
considered unsuitable to be held in their possession.
9. Whatton was last inspected by Her Majesty’s Chief Inspector of Prisons
in January 2007. She found that, whilst the healthcare unit was a clean
and clinical environment, “waiting times for the GP were unacceptably
long and a major concern”.
10. The death of the man who is the subject of this report was the tenth
death to have occurred at Whatton since April 2004, and the eighth
from natural causes. There have subsequently been two further
deaths of prisoners at Whatton, both from natural causes.
11. Of the previous cases that I have investigated at Whatton, two were of
patients suffering from terminal cancer. Other than this, however, there
are few similarities between these cases and that of this man.
KEY EVENTS
12. The man was sentenced to one years imprisonment on 13 April 2007,
and arrived at HMP Lincoln on the same day. A first reception health
screen (a routine health screen for all new arrivals into prison) was
carried out that afternoon by a nurse. The man said that he was taking
various forms of medication for depression, anxiety and epilepsy, but
was unsure what they were. He said that he had last had a fit two days
previously, and that he had seizures quite regularly. The nurse tried to
contact his GP to confirm the medication that he was taking, but was
unsuccessful.
13. On the same day, the man requested vulnerable prisoner status. He
said that it was his first time in prison and he did not think he would
cope on normal location. The man’s request was granted, and he was
allocated a place on the vulnerable prisoners’ unit.
14. On 14 April, the man was seen again by the reception nurse. He said
that he was a heavy smoker, and usually smoked 40 cigarettes a day.
The nurse had again been unable to contact his GP. Following
discussion with a prison doctor, the man was prescribed epilim 500mg
(medication used to control epilepsy). On 16 April, his GP was
contacted and he confirmed that the man’s medication included epilim.
15. The man was seen by a prison doctor on 18 April, after he complained
of weight loss and a loss of appetite. The doctor noted that he had
experienced no diarrhoea or vomiting, but that he appeared to be
dehydrated. He asked that blood samples be taken for tests. The
doctor also prescribed him a 14 day course of co-codamol (a strong
painkiller), the reason for which is not recorded in the medical record.
However, when she met my investigator, his wife said that the man had
slipped in the shower on 14 April and cracked a rib.
16. The results of the blood test were returned on 25 April, and were
normal. On 1 May, the man was seen by a different doctor after he
said that he had been producing a frothy green sputum when coughing
over the last week or two. The doctor diagnosed a chest infection, and
prescribed a course of amoxicillin (an antibiotic).
17. A nurse was called out to see the man at around 3.15am on 7 May
2007, after he complained of pain in the left side of his chest. The
nurse took his blood pressure, which was normal, and noted that he
had no pain in his arms and could move them fully. She offered him a
dose of ibuprofen, which he took.
18. At around 9.30am, the man was seen in follow-up by a different nurse.
She took his blood pressure and pulse, which were again normal, and
noted that he had lost 800g (around 1.75lbs) in weight since 18 April.
The man also told her that he had lost weight prior to coming to prison
and had suffered from dysphagia (difficulty swallowing) for around two
years. The nurse thought that the man looked very gaunt and unwell.
She later discussed him with a prison doctor, who suggested that he be
listed to see a doctor on the following day and for a chest x-ray.
19. The man was seen by a prison doctor on 8 May. His recent chest
infection, chest pain and weight loss were noted. The doctor also
recorded that the man appeared to be pale, and requested a repeat of
the blood tests.
20. On 11 May, the man had a chest x-ray at the local hospital. The
results showed chronic obstructive pulmonary disease (COPD, a
condition comprising chronic bronchitis and emphysema, the
accumulation and slow release of air in the lungs). In the man’s case,
emphysema was the predominant feature of his COPD. There was no
mention of the rib injury that he had apparently sustained on 14 April.
21. At a review by a prison doctor on 17 May, it was noted that the
existence of COPD explained the man’s recent chest infection. The
man was noted by the doctor to be wheezy. He was given a
salbutamol inhaler (medicine that helps the airways to open), to use as
required, and the doctor ordered more blood tests. The results, which
were returned on 23 May, showed raised inflammatory markers (a sign
of redness, swelling, heat, or pain in the tissue due to injury or
infection).
22. On 1 June, the man transferred to HMP Whatton. The transfer was a
progressive one, moving him from a local prison to one where he could
complete the offending behaviour courses necessary to proceed
through his sentence. He was seen by a nurse on arrival, who noted
that no medication had been supplied to him on transfer. It is not clear
when he received his medication.
23. On 6 June, the man was seen by a nurse. His epilepsy and COPD
were noted, and he was booked for an appointment with the prison
doctor on 15 June (the first available). On 13 June, a prison GP, noted
his most recent blood test results, and requested a repeat.
24. The man did not attend his appointment with the doctor on 15 June, the
reason for which is not known. He did attend on 19 June, however,
and was seen by the GP. The man said that he had recently been
experiencing increased shortness of breath, chest pain, and had been
producing coloured sputum that was tinged with blood. The doctor
noted that the man was able to speak in full sentences but that he had
a “widespread wheeze”. Blood results, returned that day, showed an
elevated white cell count consistent with infection. The man was
prescribed amoxicillin, and the doctor requested that an appointment
be booked for a chest x-ray. A pro forma was subsequently sent to the
local hospital (although no appointment was received before he was
admitted as an inpatient eight days later).
25. On 25 June, the man went to healthcare as “special sick” (a short
notice appointment with a nurse). He told the nurse that he had
“problems with his chest” and had been producing a frothy sputum
when coughing. The man also said that he was unable to sleep at
night and had a poor appetite. His weight was checked and was 45kg,
an increase of 5kg since he arrived at Whatton. After discussion with a
prison doctor, he was given a further course of amoxicillin.
26. The man was seen by another prison GP, on 27 June, after his
symptoms worsened overnight. The GP noted that his breathing was
poor and very wheezy. He gave him salbutamol through a nebuliser (a
device similar to an inhaler). This had little effect. As the man was still
significantly short of breath, the doctor advised that he be admitted to a
local hospital for further investigations.
27. The man was accompanied to the hospital by two prison officers, and
was cuffed to one of the officers by means of an escort chain (a long
chain with a handcuff at both ends). Tests undertaken following his
arrival at hospital indicate that he suffered a heart attack that day (27
June).
28. The man went on to have a CT scan of his chest on 4 July and, on the
following day, a chest x-ray. The results of these tests, which were
given to him on 11 July, showed that he had lung cancer that had
spread to his bones.
29. Around an hour and a half after the man was given his diagnosis, an
officer who was on escort duty at the time telephoned the prison and
spoke to the duty governor. The officer asked if a risk assessment
could be conducted to assess the removal of restraints “due to sores
appearing on the prisoner’s wrists, his limited mobility, and considering
above diagnosis”. Later that afternoon, a Principal Officer (PO)
completed the “Management Daily Visit Security Risk Review” form.
The PO noted that “due to the location of the ward, the removal of cuffs
could be considered”.
30. On 13 July, the Consultant Respiratory Physician at the local hospital
wrote to the Healthcare Manager at Whatton with further details of the
man’s diagnosis. The doctor explained that the man would be having
chemotherapy, as both an inpatient and an outpatient, and said that he
would need oxygen therapy (the administration of oxygen at a greater
concentration than in the air, to increase the supply to the lungs). He
went on to say that he was unable to provide a prognosis at this time.
31. A staff nurse visited the man on 16 July to review and assess whether
he was suitable to return to Whatton. The nurse completed a detailed
report, in which she described how the man was extremely short of
breath and only able to walk for four to five metres before becoming out
of breath and requiring oxygen. She added that he was, at present,
able to look after his personal care needs, but that this was likely to
change quickly as his condition deteriorated. The nurse also noted that,
officially, the Consultant would not give a prognosis until palliative
treatment (care that focuses on reducing the severity of disease
symptoms, rather than providing a cure) had begun. Unofficially,
however, it was thought that the man had only weeks to live and that
his condition would deteriorate.
32. Following the nurse’s assessment, the man was released on temporary
licence (a temporary release from custody, in this case for
compassionate reasons so that he could receive hospital treatment) on
17 July, and his cuffs were removed. A condition of the licence was
that the man remained in the company of at least one prison officer at
all times. His escort at the hospital remained at two officers.
33. On 18 July, the discharge co-ordinator at the hospital contacted the
duty nurse at Whatton to say that they were very keen for the man to
return to the prison. However, healthcare staff did not consider
Whatton to be a suitable environment for him at this stage of his illness
owing to the lack of 24 hour care should he require assistance
overnight. They raised these concerns with the Governor, and it was
agreed to investigate the possibility of him being admitted to a local
hospice.
34. Following this, the staff nurse attended a multi-disciplinary team
meeting at the local hospital on 24 July. It was agreed that it was not
possible to manage his needs at Whatton, and that he should be
transferred to a community hospital in Nottinghamshire.
35. Arrangements were subsequently made for the transfer, and the man
moved to a community hospital on 27 July. He continued to be
accompanied by two officers, but they were required to attend in
civilian clothes rather than prison uniform.
36. The man’s condition continued to deteriorate. He died at 6.30pm on 8
August, with his wife, son and grandson at his side. A post mortem
report gave the cause of death as carcinoma of the right lung with
metastases. The man’s funeral was held on 23 August.
37. My investigator found that the prison acted appropriately in accordance
with PSO 2710, the Prison Service Order that sets out the actions to be
taken following a death in custody.
ISSUES
Issues raised by the clinical review
38. As noted earlier, the clinical review was conducted by a doctor on
behalf of the Nottinghamshire County Primary Care Trust. The clinical
reviewer concludes that the medical care that the man received at
Whatton was satisfactory. However, he raises some concerns that I
address below.
Prescription of co-codamol on 18 April 2007
39. The man was seen by a prison doctor at Lincoln on 18 April, apparently
after complaining of weight loss and a poor appetite. He was
prescribed co-codomol (a strong painkiller) by the doctor at this
appointment, although the reason for this was not recorded. It is only
through speaking to the man’s wife that the likely reason became
apparent, that the man slipped in the shower a couple of days
previously and injured a rib. However, there is no mention of this event
anywhere in the medical record. Indeed, only by examination of the
prescription chart can it be seen that co-codamol was prescribed. The
clinical reviewer notes that, “the reason for prescribing co-codamol
should have been recorded in the Medical Record”. I agree.
The Head of Healthcare at HMP Lincoln should remind prison GPs
to record the reasons for prescribing medication in the patient’s
Medical Record.
The man’s transfer to HMP Whatton
40. The man transferred from Lincoln to Whatton on 1 June 2007, a move
designed so that he could progress through his sentence. When she
met my investigator, the man’s wife questioned whether his transfer to
Whatton was appropriate given his illness.
41. At the time of his transfer to Whatton, the man had been diagnosed
with chronic obstructive pulmonary disease around three weeks
previously. He had not yet been diagnosed with cancer. The clinical
reviewer notes:
“Transfers between prisons invariably affect ‘Continuity of care’.
Practitioners often have a lower index of suspicion when they
see a patient with a chronic disease for the first time, than when
they see them for follow up when they are no better. The
radiologist’s chest x-ray of 11 May, the smoking history and
weight loss were together strong indicators for underlying
malignancy (a cancerous tumour). At this point, the man could
have been placed on medical hold.”
42. The clinical reviewer goes on to say that:
“It is not unreasonable to assume that the man would have been
diagnosed sooner with lung cancer if he had not been
transferred. The delay in diagnosing lung cancer would only
have been a couple of weeks at the most, and this would not
have changed the ultimate and fatal outcome.”
43. Before a prisoner transfers to Whatton, a nurse at their sending
establishment is requested to complete a form to consider their
suitability for a move to a prison without 24 hour healthcare facilities. A
copy of the man’s form was not held either in his medical record or in
the archive at Whatton. It is not certain, therefore, that one was
completed in his case.
44. In his clinical review, the doctor notes that, “if a transfer was necessary,
better liaison between prisons would have alerted staff at Whatton that
the man was unwell and required early GP review.”
The Governor and Head of Healthcare at HMP Lincoln should
review local systems to ensure that appropriate prisoners are
transferred and those needing early GP review are identified.
45. When the man transferred to Whatton, his medication was not
transferred with him. My investigator spoke to the Healthcare Manager
at Lincoln, with regard to this matter. At the time, the man was written
up for epilim (medication to control epilepsy) and citalopram (an
antidepressant). Both were prescribed as ‘not in possession’, meaning
that the man had to collect them each day from the healthcare centre
at Lincoln. She confirmed that both of these medications were named
drugs. As such, they would be ordered into stock at Lincoln specifically
for the prisoner to whom they were prescribed, rather than held in stock
for use as required. The Head of Healthcare said that these medicines
should therefore have been given to him to take with him to Whatton.
She thought that it might have been due to human error that they were
not.
46. Chapter 5 of Prison Service Order (PSO) 3050 provides instructions on
continuity of healthcare for prisoners when transferring between
establishments. Section 5.3 instructs that, when arranging the routine
planned transfer of a patient, “medication, appropriate to clinical need,
is provided to ensure supply until a GP prescription can be obtained”.
47. The clinical reviewer notes that, “administrative failures with prescribing
when transferring between prisons are regular, and wholly avoidable,
occurrences”. However, he goes on to say that, “in this case, it would
not have been detrimental to the man’s health”.
48. Nevertheless, it is worrying that a man with a history of fits was
transferred between establishments without his preventative
medication. I make the following recommendation:
The Head of Healthcare at HMP Lincoln should ensure that
systems are in place to guarantee that medication is transferred
with a prisoner when moving between establishments.
Missed GP appointment
49. At his reception health screen at Whatton, the man was identified as
requiring an appointment with the prison GP. An appointment was
subsequently scheduled for 15 June 2007.
50. The man did not attend the appointment. The reason for his non-
appearance is not known. A clinic list is held at Whatton for GP
appointments, which should give the reason for his absence.
Unfortunately, the report for 15 June is missing. The man was,
however, seen by a GP on 19 June, when he reported shortness of
breath.
51. The clinical reviewer makes the following recommendation:
HMP Whatton healthcare needs to be satisfied that they have
arrangements in place for patient review by a GP within
acceptable timeframes.
Nutritional requirements
52. The man was significantly underweight when he was first received into
prison. At his reception health screen of 13 April he was recorded 6’ 2’’
tall (although his wife later told my senior family liaison officer that the
man was 5’ 6’’). His weight, however, was recorded as just 7st (around
44.5kg). Between his reception to Lincoln and subsequent admission
to the local hospital on 27 June, his weight fluctuated between 40 and
46kg.
53. The clinical reviewer concludes:
“The man’s nutritional requirements, bearing in mind his poor
appetite, were never really addressed and he only received one
200ml high calorie drink per day. However, the weight he
seemed to have lost leading up to his transfer to HMP Whatton
was largely regained.”
Prescription of amoxicillin
54. The man was diagnosed with a chest infection on 1 May 2007, and
prescribed a course of amoxicillin (an antibiotic) by a prison GP at
Lincoln. On 19 June, he was prescribed a further course of amoxicillin
by a doctor at Whatton, having complained of symptoms including
increased shortness of breath, chest pain and wheeziness. The clinical
reviewer judges:
“For pneumonia associated with COPD an antibiotic other than
amoxicillin could have been considered, especially on the
second occasion when the dose was increased during the
course. However, the ultimate outcome would not have
changed.”
Compassionate release
55. Chapter 12 of Prison Service Order 6000 sets out the following criteria
for compassionate release on medical grounds:
(cid:127) the prisoner is suffering from a terminal illness and death is likely to
occur soon; or the prisoner is bedridden or similarly incapacitated;
and
(cid:127) the risk of re-offending is past; and
(cid:127) there are adequate arrangements for the prisoner’s care and
treatment outside prison; and
(cid:127) early release will bring some significant benefit to the prisoner or
his/her family.
56. The Head of Security and Operations at Whatton, told my investigator
that compassionate release “would only ever be in exceptional
circumstances from Whatton, due to the nature of the offences
involved”. She added that it was “considered briefly” for the man, but
“given the nature of his offence and the corresponding risk
assessment, was not taken further”.
57. Additionally, in the man’s case, it was difficult to get a prognosis that
would satisfy the first condition in PSO 6000 above. On 13 July, the
Consultant Respiratory Physician at the local hospital wrote to the
Healthcare Manager at Whatton with details of the man’s diagnosis.
He said that he was unable to provide a prognosis at this time. On 16
July, the staff nurse was told that the Consultant would not provide a
prognosis. There is no further evidence of any formal prognosis being
provided to prison staff for the remainder of the man’s life. In such
circumstances, it is very unlikely that an application for compassionate
release would have succeeded.
Family concerns
58. My investigator and senior family liaison officer met with the man’s wife
on 24 October 2007. At the meeting, she raised a number of concerns
regarding the care that her husband had received during his time in
custody. I have addressed some of these concerns in the section of
this report relating to the clinical review, and discuss the remainder
below.
Cuffing arrangements
59. The man’s wife expressed concern that her husband was chained to a
prison officer during his first weeks in hospital. She said it was
distressing for her and her sons to see him like this when he was ill,
and also that the cuffs prevented him from sleeping at night. She said
that she wrote to the Governor to request removal of the cuffs, but this
did not happen for some time afterwards.
60. The man was initially taken to hospital on 27 June 2007. He was
accompanied by two officers, and was cuffed to one of these by means
of a closeting chain. The decision on whether or not to cuff a prisoner
is made by means of an ‘Escort Risk Assessment’ form, with the final
decision being made by someone of governor grade. The risk
assessment considers factors such as the prisoner’s escape risk, risk
to the public, and the prisoner’s conduct during their time in custody.
An assessment of the prisoner’s medical condition, including whether
the condition restricts the prisoner’s ability to escape unaided, is also
considered.
61. The Escort Risk Assessment completed on 27 June, when the man
was taken to hospital, noted his risk to the public as being “high”, and
escape potential to be “low”. The escort was recommended to be two
officers due to the “type of offences” that the man had committed.
62. The man was told of his diagnosis on 11 July. On the same day, the
officer who was on escort duty at the time, telephoned the prison and
spoke to the duty governor. The officer asked if a risk assessment
could be conducted to assess the removal of restraints “due to sores
appearing on the prisoner’s wrists, his limited mobility, and considering
above diagnosis”.
63. Later that afternoon, the Principal Officer (PO) completed the
“Management Daily Visit Security Risk Review” form. This is a
standard form completed each day by a duty manager, usually a PO or
Senior Officer (SO). The PO noted that “due to the location of the
ward, the removal of cuffs could be considered”. However, it is not
clear if these views were passed on to the duty governor.
64. My investigator spoke to the Head of Security and Operations at
Whatton. She said that, although prisoners at Whatton are category C,
“if a prisoner is mobile, conscious, able to get around, they are likely to
be cuffed if going from Whatton, due to the nature of their offences”.
65. A protocol has been in place for security provision between Whatton
and the local hospital since July 2005. The protocol says that:
“Prisoners will normally be single cuffed and escorted by two
Prison Officers, one of whom will be attached to the prisoner by
restraints.”
66. However, the protocol goes on to list a number of exceptions to this.
Exception (iii) says:
“Where the prisoner’s condition or lack of mobility is such that he
cannot escape unaided, and there is no evidence an escape
attempt is likely, the escort may be manned with a singleton
member of staff without restraints.”
67. On 16 July, the staff nurse carried out a detailed nursing assessment.
Her report included an assessment of the man’s mobility, in which she
noted that he was unable to walk for more than four or five metres
unaided before needing oxygen. She added that he found any physical
activity draining.
68. As I frequently reflect in my reports, the decision whether to cuff a
prisoner at hospital is a difficult one. The balance between decency
and security can be hard to find. Nevertheless, the man was a very ill
man who could not move more than four or five metres unaided. I am
aware of no evidence to suggest that he was an escape risk. In these
circumstances, I consider that it would have been reasonable to have
removed his cuffs when he was diagnosed with cancer on 11 July.
Given his condition, I judge that the presence of the two prison officers
would have been an adequate security arrangement.
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 in outside hospital experiences a
significant change in circumstances.
Privacy in the last days of the man’s life
69. The man’s wife was very complimentary about the conduct of the
prison officers who escorted him when he was in hospital. She
described them as “brilliant”, and said that they became “more like
friends than officers”. She specifically mentioned two officers who
were brothers, and who were particularly kind to her husband.
However, she said that it was difficult for her to have a private
conversation with the man in the last few days of his life because of the
presence of prison officers in the room.
70. My investigator discussed this with the Head of Security and
Operations. She said that the instruction given to officers is that one of
them should be in the room at all times. She added, “if a prisoner was
likely to die, and the question was asked of the duty governor, then it is
likely that they would agree to a private moment with next of kin.”
71. However, it seems to me unlikely that the man’s wife, or any relative of
a terminally ill prisoner, would be sufficiently familiar with the workings
of a prison to know that she could make such a request to the duty
governor. It may be appropriate in future to offer such an opportunity
to the next of kin of a terminally ill patient, subject to a suitable risk
assessment.
The Governor should consider amending the Escort Risk
Assessment Form to give the opportunity for the next of kin to
have some private time alone with a terminally ill patient, subject
to an appropriate risk assessment.
The conduct of the officers on bedwatch duty towards the man
and his wife was exemplary. The Governor will wish to consider
issuing a formal commendation.
The man’s transfer to Whatton
72. The man’s wife said that, when her husband was transferred from
Lincoln to Whatton, she was not notified by Lincoln. She said that the
man panicked, wanting her to be told. He had tried to call her from six
different telephones in Lincoln, all of which had problems. The man
was eventually able to get through shortly before lock-up to tell her that
he was moving to Whatton the following day.
73. PSO 4411, section 2.4, instructs that convicted prisoners should be
issued with a special letter (in addition to their usual weekly allowance)
when they are about to be transferred to another establishment.
However, there is no requirement for prison staff to inform a prisoner’s
next of kin of the transfer. Indeed, it would be presumptuous of staff to
do so as there may be reasons why the prisoner does not wish their
next of kin to be informed. In the man’s case, I am concerned by the
suggestion that so many of the phones at Lincoln may have had
problems. That aside, I am satisfied that he was given sufficient
opportunity to communicate the news of his transfer to his wife.
Treatment following the man’s diagnosis
74. The man’s wife was concerned that, due to uncertainty over the best
place for him to be cared for, there was a delay in him receiving
treatment following the diagnosis of cancer.
75. The man was diagnosed with cancer on 11 July 2007. On 18 July, the
discharge co-ordinator at the local hospital contacted the duty nurse at
Whatton to say that they were very keen for the man to return to the
prison. However, prison healthcare staff did not consider Whatton to
be a suitable environment for the man at this stage of his illness, owing
to the lack of 24 hour care should he require assistance overnight.
These concerns were raised with the Governor, and it was agreed to
investigate the possibility of the man being admitted to a local hospice.
76. Following this, the staff nurse attended a multi-disciplinary team
meeting at the local hospital on 24 July. It was agreed that it was not
possible to manage the man’s needs at Whatton, and that he should be
transferred to a community hospital. Arrangements were subsequently
made for the transfer, and the man moved to a community hospital on
27 July.
77. The clinical reviewer notes that:
“Once the diagnosis of cancer was confirmed at the local
hospital, it was unlikely that the man would ever have been fit to
return to HMP Whatton, and an alternative facility for future care
was quite rightly sought. There are often delays with finding
appropriate care facilities for patients with terminal care and this
case is no exception.”
78. I am satisfied that staff at Whatton took appropriate steps to seek
alternative accommodation for the man, once it became apparent that
he was unable to return to the prison.
Assisted prison visits
79. The man’s wife said that she tried to claim money for petrol expenses
from the Assisted Prison Visits Unit (APVU), but found the forms too
time-consuming and complicated to complete.
80. My investigator spoke to the Head of APVU. He confirmed that an
application for assisted visits was received on 7 August 2007, relating
to visits made on 3-4 August. The application was accompanied by a
supporting letter from a senior officer, who confirmed that the man was
in outside hospital.
81. The widow’s application was initially rejected because she had not
included proof of being in receipt of tax credit. The caseworker in
APVU subsequently wrote to her on 23 August to request proof, and
the appropriate documents were received on 29 August.
82. Unfortunately, she did not meet the rules to qualify for assistance. The
caseworker wrote to her again on 14 September with advice on
applying for a health certificate issued by the Department of Health
(had this been awarded, the man’s wife would normally have qualified
for assistance from APVU). She did not reply.
83. Many forms requiring details of one’s finances are time-consuming and
complicated to complete. It is quite understandable that the man’s wife
found this to be the case, given the strain of travelling to visit her
husband every day.
84. The Head of APVU told my investigator that the application was
received on a type of form that had been taken out of use and replaced
some time ago. He said that the form was not requested from APVU,
and would therefore almost certainly have been obtained from
Whatton. He added that the out of date form did not make a difference
to the way that the widow’s application was dealt with, nor the
outcome.
85. Whilst I do not consider it necessary to make a formal recommendation
on this matter, the Governor of Whatton will wish to ensure that his
stock of APVU application forms is up to date.
86. I received the following comment after circulating my draft report:
“the stock of APVU forms at Whatton has been reviewed. All
the forms they have been able to find are up to date.”
RECOMMENDATIONS
The Head of Healthcare at HMP Lincoln should remind prison GPs to
record the reasons for prescribing medications in the patient’s Medical
Record.
Accepted – a notice has been placed in all GP rooms in the prison to remind
them and a verbal instruction has been given.
The Governor and Head of Healthcare at HMP Lincoln should review
local systems to ensure that appropriate prisoners are transferred and
those needing early GP review are identified.
Accepted – all prisoners for transfer or release are seen and assessed by a
member of healthcare the day before transfer. A verbal healthcare to
healthcare handover is made when this is clinically necessary with the
receiving prison healthcare. This can include ongoing healthcare needs,
medication and outstanding appointments. This is documented in the
prisoner’s medical records. There is a local protocol for the transfer/release of
prisoners.
The Head of Healthcare at HMP Lincoln should ensure that systems are
in place to guarantee that medication is transferred with a prisoner when
moving between establishments.
Accepted - medication is prepared ready to go with the prisoner following the
pre-transfer assessment of the prisoner. A minimum of a week’s supply of
medication is sent with the prisoner. Pharmacy order and supply any
medication required. The medication policy is currently being revised and
covers the issue of medication for patients being transferred.
HMP Whatton healthcare needs to be satisfied that they have
arrangements in place for patient review by a GP within acceptable
timeframes.
Accepted – access to appointments has now been simplified and urgent
appointments are now available within 24 hours.
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 in outside hospital experiences a significant change in
circumstances.
Accepted – this matter will be taken forward by Whatton’s Security
Committee. The escort risk assessment form will be amended so that, in
cases in which the patient is terminally ill, the duty governor should be
contacted and asked for permission to remove restraints.
The Governor should consider amending the Escort Risk Assessment
Form to give the opportunity for the next of kin to have some private
time alone with a terminally ill patient, subject to an appropriate risk
assessment.
Partially accepted – the idea of allowing family members to have time alone
with a terminally ill patient is accepted in principle. But it is difficult to use the
escort risk assessment form for this purpose, especially as HMP Whatton has
promised local hospitals (because of public and child protection concerns)
that it will never leave prisoners on bedwatches unaccompanied by staff.
Instead the work on the escort risk assessment form mentioned above will
include a reference along the lines of any special requests made by the family
of a terminally ill patient should be referred to the Governor. This cannot be a
mechanistically determined issue. There has been a recent experience of a
patient being gravely ill and then recovering enough to be returned from
hospital.
GOOD PRACTICE
The conduct of the officers on bedwatch duty towards the man and his
wife was exemplary. The Governor will wish to consider issuing a
formal commendation.
Accepted – the Governor has written to the officers.