Individual at Winchester

An investigation into the circumstances surrounding the
death of a man in hospital
whilst in the custody of HMP Winchester
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2008
This is a report into the circumstances surrounding the death from natural causes of a
man in hospital in April 2007. The man was 63 years old and a prisoner at HMP
Winchester. He had been at Winchester for seven months having been transferred
from HMP Kingston on 1 September 2006.
The man had been in prison for over 30 years. He was a life sentence prisoner who
grew old in jail and had a history of physical and mental health problems. He was not
a well man when he transferred to Winchester and over the coming months his health
deteriorated further. He was transferred to hospital , and was diagnosed with chronic
liver failure. Following a post mortem, evidence of advanced cancer was also found.
The death of a loved one is always distressing. I would like to extend my condolences
to the man’s family, and to all those touched by his death.
The investigation was undertaken by one of my investigators. I would like to thank the
Governor of Winchester, and his staff for their co-operation during the investigation. I
would like to extend particular thanks to the Head of Healthcare.
I asked a representative from Mid-Hampshire Primary Care Trust to carry out a review
into the man’s clinical care whilst he was at Winchester. A panel of clinical staff from
the PCT looked into the healthcare he received. I am grateful to the PCT for their
assistance and attach the review as an annex to this report.
The circumstances reported here have been difficult to piece together. It became
clear to my investigator that the man’s time at Winchester was not always recorded
appropriately. He was an older prisoner in poor health and known to Kingston’s
healthcare unit when he was transferred out for disciplinary reasons. The healthcare
team at Winchester were not made aware of his transfer in advance, and he suffered
delays in being followed up and treated. Initially, he fell through the net. Although
earlier detection of his chronic disease history would not have changed the outcome
for him, it might have provided better continuity of care in the months leading up to his
death.
The issues relating to the management of the man at Winchester were largely clinical,
and I have relied heavily on the clinical review. The review makes five
recommendations. Of these, one is a repeat recommendation from a previous clinical
review at Winchester. I have also repeated a recommendation made in one of my
previous reports at the prison and make an additional five of my own.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2008
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CONTENTS
1. Summary 4
2. The Investigation Process 6
3. HMP Winchester 7
4. Key Findings 9
5. Issues 19
6. Recommendations 30
3
SUMMARY
The man was young when he was sentenced to life imprisonment in 1975, and he
spent the majority of his adult life in prison. His medical history shows that he had
ongoing chronic physical and mental health problems. In 1996, he was diagnosed
with cirrhosis of the liver and a history of viral hepatitis. He suffered from depression
and took medication to alleviate his low mood. The man also had a history of long
term drug dependency and underwent a detoxification programme that same year.
As a life sentence prisoner, he served his sentence at a number of different prisons.
He moved to HMP Kingston in 2001, and whilst there was admitted to hospital with
chest pain and suspected angina. He was prescribed an inhaler to treat the condition.
Between June and August 2006, he saw the healthcare team regularly and weight
loss was recorded. He was taken to hospital again for chest pain and complained of
experiencing some pain when passing urine. The man continued to use an inhaler for
his angina. Three days before his transfer to Winchester, he reported to healthcare
for a blood test. He had lost weight again and an appointment was made for him to
see a doctor.
The man was unable to keep the appointment and was transferred to Winchester the
same day. The move was for disciplinary reasons thought, at the time, to be of a
serious nature. The transfer arrangements were agreed locally between the two
prisons, and his move was swift.
When he arrived in Winchester’s reception on 1 September, he was not picked up
appropriately through the healthcare screening process. As a high risk prisoner, he
was moved to A wing’s first night in custody centre and was placed in a single cell.
The following day, he went to the medications hatch on the wing to ask for his inhaler
prescription. He saw a nurse and his request was logged in his medical record, but an
opportunity to pick up his ongoing care from Kingston was missed for a second time.
The man did not see a doctor until approximately two weeks after his arrival at
Winchester. Once he was seen, he continued to take his anti-depressants and use
his inhaler. From December 2006, he was seen by a nurse and a doctor regarding an
ear complaint. He was told he would need a syringe procedure but never underwent
the treatment.
From January 2007 onwards, the man complained of chest pain which worsened
when he coughed. He was diagnosed with chronic obstructive pulmonary disease
(COPD) and was medicated for the condition. His weight loss was also recorded and,
after a review by a doctor, he was referred for an x-ray and lung function test.
On 1 March 2007, the man’s medication for severe indigestion was changed. His
further weight loss was noted by a doctor who ordered urgent blood tests and further
examination of his symptoms. Approximately two weeks later, a nurse queried the
result of his x-ray and was told the report was not ready. He was assessed by a
doctor again on 21 March. The man appeared slightly jaundiced and to be losing
weight but said he was not in any pain. The doctor also noticed that his blood had not
been tested and ordered the sample to be taken that day. The man experienced
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another delay. His blood was taken on 27 March and his liver function test was
carried out the following day.
On 1 April, he fell on the stairs on B wing. A nurse went to see him and assessed that
he had not sustained any injuries from the fall. His blood test results were followed up
the same day.
Two days later, the man was admitted to hospital as an emergency. He remained a
high risk prisoner, and was escorted under restraints. He went straight to the
Emergency Medical Assessment Unit and from there to an appropriate ward. He was
then examined and monitored by hospital staff who told the escort officers that he
would be in hospital for at least another week.
The man stayed in hospital for just over two weeks. His security risk was reduced
once it was apparent his physical condition had deteriorated. His restraints were
removed three days after he arrived. The following week, after another review, his risk
level was further reduced to one bedwatch officer.
The man did not return to Winchester. His health deteriorated rapidly and he was
made as comfortable as possible in hospital. He became distressed, and on several
occasions his behaviour became challenging as his condition worsened. One of the
governors at Winchester telephoned his next of kin shortly after he was admitted to
hospital and told her that he was very poorly and not likely to survive. Arrangements
were also made for his nephew to pass a message to him during the last few days of
his life.
The man’s health deteriorated again. He died at 6.10pm with an officer close by.
My investigation was hampered by the lack of recorded information presented to my
office. The man’s wing history, his medical record and B wing’s observation book did
not provide the level of detail expected in an individual prisoner’s files. The clinical
review panel drew a similar conclusion and said that, on reflection, there were unable
to come to any firm conclusions over the quality of healthcare he received at
Winchester.
The panel considered the timeliness of the medical interventions the man received
from the information gathered, and have made five recommendations to improve
healthcare screening in reception, staffing levels, training to use the new IT record
management system, chronic disease management, and to prevent delays in taking
and obtaining the results of bodily samples.
In addition to the man’s care, I have also focused on how Winchester responded to his
death and urge the prison to review its local contingency plans and family liaison
arrangements.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 24 April 2007. On that date, my investigator,
wrote to the Governor of HMP Winchester and asked him to display notices of
the investigation into the man’s death to staff and prisoners.
2. A liaison officer was appointed by the Governor. The liaison officer arranged
for the the man’s main prison records and his medical record to be sent to me.
My investigator subsequently visited Winchester on in August 2007 and spoke
to three members of staff. Unfortunately, not all the key members of staff were
available that day and the liaison officer was asked to arrange another visit.
The Head of Healthcare assisted him and made healthcare staff aware of the
investigation and forwarded additional documentation to my office.
3. The Clinical Governance Manager for Mid-Hampshire Primary Care Trust, was
invited to undertake a clinical review into the medical care the man received
during his time in custody. Two clinicians from the PCT accompanied my
investigator to HMP Winchester for a second set of joint interviews on in
September 2007. Unfortunately, they were not able to speak to all the
members of staff identified, but did interview one member of the healthcare
team. My investigator also interviewed a Governor separately. Subsequent
interviews with prison staff took place over the telephone.
4. The Coroner was informed of the Ombudsman’s investigation. He kindly
agreed to send me a copy of the post mortem report. The report concluded
that the man’s cause of death was due to:
1a. Hepatocellular carcinoma
1b. Cirrhosis
1c. Hepatitis C infection
2. Chronic obstructive pulmonary disease
A draft copy of this report was sent to the Coroner, to assist him with his
enquiries.
5. One of my family liaison officers (FLO), contacted the man’s next of kin shortly
after the investigation was opened. The FLO explained my office’s role,
provided information about the investigation process, and offered the man’s
family the opportunity to discuss any issues or concerns. His family did not
want a visit and raised no concerns.
6. A draft copy of this report was sent to the man’s family and the prison service.
His family made no comments on the draft. I will send them a copy of this
report. Of the eleven recommendations made, the prison service accepted ten
and partially accepted one. The prison service response can be found on page
30 of this report.
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HMP WINCHESTER
9. HMP Winchester is a category B local male prison, located just outside the
main city centre. Built in 1846, most of the prison is of a Victorian radial design
and has a maximum capacity of 697. .
10. The prison contains four residential units and one separate unit, West Hill,
which is training unit for category C adult males. B wing holds approximately
173 convicted and remand prisoners.
11. Her Majesty’s Chief Inspector of Prisons (HMCIP), last inspected Winchester in
April 2007. HMCIP published her report in June 2007 and commented that:
“Like all local prisons, it faces considerable pressures and increased demands.
There was some evidence, at this inspection, that this combination was testing
the prison’s ability to sustain and continue improvements”.
Healthcare
12. Winchester provides nurse-led primary care, inpatient care and a pharmacy
service. It is separate from the main prison, although some healthcare and
treatment takes place in wing-based treatment facilities on A and B wings.
Healthcare services are commissioned by Hampshire Primary Care Trust
(PCT) and the doctors are provided by a local general practice.
13. The Head of Healthcare is supported by a deputy who is also a clinical nurse
manager and responsible for the care of older people. Winchester also draws
upon doctors’ services from the local GP Practice. In addition, the healthcare
centre is staffed by both general and mental health trained nurses and
healthcare officers.
14. The healthcare unit has recently inherited an electronic record keeping system
of all prisoners in its care. The “Vision” system went live in June 2007 and has
widened access to records in all clinical areas. It is enabling healthcare staff to
change the way they store and use medical data. Vision is designed to provide
a full audit trail of medical histories and the interventions that each prisoner
receives or is due to receive. It is a permanent electronic record that will be
used to monitor the healthcare needs of transfers in and discharges to other
prisons or the community.
Reception
15. On arrival in reception, a prisoner is seen by a nurse or, more commonly, a
healthcare officer (HCO), and is screened in order to identify immediate
healthcare needs. Prisoners then have the opportunity to see a doctor within
24 hours if required. Prisoners are also asked to sign a medication compact
and to give consent for the prison to access their previous medical history.
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Personal Officer Scheme
16. Winchester introduced a new personal officer scheme in early 2007. As part of
the scheme, officers are required to introduce themselves within one week of a
prisoner’s arrival, and to make regular and relevant entries in a prisoner’s wing
history sheet. HMCIP found that the policy behind the personal officer scheme
was good, but it did not reflect the work taking place in the main prison.
Detailed personal officer entries were exceptional as many wing files contained
few entries and considerable gaps between entries. Some entries were also
unhelpful and unprofessional. The report found that few files showed any
evidence of personal knowledge of a prisoner or reference to their personal
needs. HMCIP recommended more training for officers on the role of a
personal officer, and the inclusion of care plans in wing files for elderly or
disabled prisoners.
Elderly Prisoners
17. Prisons are not principally designed for the elderly, and it is difficult for an
individual establishment to accommodate an aged population. A thematic
review by HMCIP in 2003 found that, although older prisoners (60 years and
over) make up a small percentage of the overall prison population, the number
of elderly prisoners had trebled between 1992 and 2002 and was continuing to
grow. The study also said that there was no overall strategy throughout the
prison estate for assessing and delivering a regime that addressed the needs of
older prisoners.
18. The thematic review found that some elderly prisoners will inevitably spend the
rest of their lives in prison. Early release from prison on medical grounds for
severely or terminally ill prisoners is subject to restrictive criteria and the
thematic review stressed that the prison environment must be geared towards
meeting the specific needs of its ageing population.
19. A report, Growing Old in Prison, published by the Prison Reform Trust in 2003
quoted a Department of Health study that focused on older prisoners. The
study said that out of 203 prisoners aged 60 and over, 85 per cent had one or
more major illnesses reported in their medical records. The most common
illnesses were psychiatric, cardiovascular, musculoskeletal and respiratory.
20. With the exception of a small number of establishments, prisons do not provide
a separate regime for elderly prisoners. The man’s experience is no exception
to this. He was located on an ordinary residential wing. The healthcare centre
at Winchester is currently devising an older prisoner policy and hopes to finalise
a working document by mid-December 2007. Whilst this is being developed,
older prisoners are being assessed in the Wellman clinic.
8
KEY FINDINGS
The man’s transfer from HMP Kingston
21. The man was transferred from Kingston to Winchester on in September 2006.
His transfer, following a serious allegation against him by another prisoner at
Kingston, was locally arranged between the two prisons. Prior to his move, he
had been seen in Kingston’s healthcare centre for blood tests and was due to
see a doctor on the day he was moved.
22. When the man arrived in Winchester’s reception, he was booked in at the front
desk and his property was checked and logged accordingly. His Prisoner
Escort Risk Form said that he was a high risk prisoner as a result of the
allegations against him. The man was next seen by a Senior Officer (SO) who
carried out the Cell Sharing Risk Assessment Form (CSRA). The SO
completed the relevant parts of the form and assessed his risk to others as
high. The form also put him down for single cell occupancy in accordance with
CSRA guidelines. Section four, to be completed by the locating or duty officer,
was left blank.
23. At some point during the reception process, a reception Healthcare Officer
(HCO), saw the man to complete section three of his CSRA. This section
assesses a prisoner’s risk to others based on information obtained during the
reception healthcare screening. On the man’s form, the HCO assessed him as
low risk and suitable for multi-cell location. This indicated that the HCO saw no
evidence from the information available that he was a risk to others.
24. Prior to completing section three, the HCO should have conducted a First
Reception Healthcare Screening with the man. The purpose of this is to
determine whether there are any immediate concerns about a prisoner’s
physical or mental health on arrival. The man’s medical record did not contain
a copy of the health screen and made no mention of the HCO seeing him in
reception.
25. The man was located to a single cell on A wing. This wing doubles up as the
first night in custody centre. As he was so far into his life sentence, he was
familiar with custodial environments and therefore did not undertake a full
induction into Winchester. An SO, who worked on A wing, told my investigator
that he carried out two separate cell sharing risk assessment reviews whilst the
man was on the wing and, although he denied the allegations against him, he
remained in a single cell as a high risk prisoner. The SO said that, as a
consequence of his risk status, the man stayed on A wing for longer than is
usual whilst a suitable single cell was located for him elsewhere.
26. The man requested the medication he had been prescribed at Kingston the day
after his transfer. He saw a nurse at the medications hatch on A wing and a
prescription chart was ordered. He then reported to the triage clinic on 13
September and to a doctor two days later. This was two weeks after his arrival
at Winchester. The doctor wrote in the man’s medical record that he needed
his blood taken. The doctor also noted that he had lost weight.
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27. During his first week on A wing, the man should have had a follow-up
secondary healthcare screening. This is normally carried out a few days after a
prisoner’s reception and consists of a more in depth assessment of a prisoner’s
healthcare needs. He had a history of chronic disease and, as an elderly
prisoner, he might have benefited from a healthcare screening specifically
tailored for the older prisoner population. The Head of Healthcare confirmed
that Winchester did not conduct an older prisoner healthcare assessment.
28. On 1 November, the man was relocated to B wing and to a single cell on ‘the
threes’. This is, in fact, the first floor landing of the wing. He was allocated a
personal officer, and settled into his new environment. The man kept himself to
himself for the first few weeks. He chose not to participate in the daily regime
on the wing and did not work. His wing history sheet said that he was happy
with the move and had not caused staff any problems.
29. The man was next seen by a doctor on 29 November, and by another doctor on
30 November, for a review of his medication (dosulepin). His prescription was
continued. He moved to another cell on the same landing after complaining
that he was too cold. His wing history sheet said that he continued to comply
with the regime and remained polite and quiet around staff. A review of his
CSRA was due on 23 December.
30. The next time the man saw healthcare was on 30 December. According to his
medical record, he was due to have his ears syringed. A nurse told him that
this was not possible because there was not a suitably qualified member of
staff available to carry out the procedure. He was told to continue with the ear
drops he had been prescribed when previously reviewed by a doctor.
31. An appointment was made for the man to see a doctor on 5 January 2007.
After an ear examination, the doctor agreed that he needed the syringe
procedure and made a note for it to be arranged. The man’s prescription was
also repeated. During a routine management check of the quality of entries in
his wing history, a Governor noticed that his CSRA review was overdue. He
made a note of this and asked for the review to be completed as soon as
possible. The man was reviewed by an SO the following day and remained
high risk.
32. On 11 January, the man complained at the medications hatch, this time to a
nurse, that he still needed his ears syringing. Again, he was told that there was
nobody trained to carry out the procedure. The nurse made a note which said
that this was becoming an issue and that she would bring it to the manager’s
attention.
33. On 25 January, the man saw a doctor after complaining of chest pain. He told
the GP that the pain increased when he coughed. He was prescribed
amoxicillin, an antibiotic, and ibuprofen (a pain-killer and anti-inflammatory).
When the doctor saw him one week later, he felt there had been some
improvement but requested a spirometry (a lung function test). This was
recorded in the man’s medical record. The doctor also said that he should
10
continue with his medication and should be reviewed if the pain he was
experiencing continued.
34. The man was reviewed by a doctor on 13 February and was referred for a
chest x-ray. His medical record said that the spirometry results were not
available and he would need to be reviewed again following the results.
35. The man continued to lose his appetite. Two officers told my investigator that
other prisoners made sure he got his meals if he did not turn up himself. A B
wing officer, also noticed that the man had not been eating properly due to his
chest infection. The officer made a note in his wing history which said that he
was making sure the man had his dinner and tea.
36. The next day, the man had an x-ray of his chest. On 20 February, an entry in
his medical record said that the results were not available. The entry did not
say where the procedure was carried out and by whom.
37. On 1 March, the man saw a doctor and his weight loss was noted. The doctor
also requested a blood test and a stool sample. He was prescribed
lansoprasole instead of omeprazole to alleviate his indigestion. Two weeks
later, on 15 March, the doctor noted that he indigestion had improved but that
the tests ordered had not been carried out. The following day, a nurse chased
up his chest x-ray result and was told that the report had not been done.
38. During a review of the man’s prescription for dosulepin on 21 March, a doctor
noticed that he appeared to be jaundiced, was still losing weight, but was not in
any pain. The doctor also noticed that the blood test, requested on 1 March,
was still outstanding and wrote ‘do urgently today’. He was then scheduled for
an urgent review with the doctor once the test results were available.
39. The man’s blood was taken by a nurse on 27 March. This was six days after
the doctor had made an urgent request for the tests to be done immediately.
When interviewed, the nurse explained that prisoners experienced frequent
delays when it came to blood tests. The nurse said that there was no
scheduled blood clinic at Winchester. Staff shortages and a handwritten
booking system had caused delays for prisoners. The blood tests were divided
into urgent and non-urgent books, but there were only two nurses qualified to
carry out all the blood tests for the whole prison.
40. At some point during the day on 1 April, the man fell on the stairs. A nurse
attended and examined him, but could find no sign of any injury. The nurse
recorded his fall in his medical record but it is not clear whether an injury form
(F213) was also completed. A B wing officer, recalled the incident and told my
investigator that he had been frail and weak prior to his fall. His wing history
sheet made no reference to his physical condition and no mention of his fall on
the wing. There was also nothing in the wing observation book. Later the
same day, a nurse from healthcare telephoned the hospital’s Haematology
Department to chase the man’s blood test results. The hospital confirmed that
the results had been sent back to Winchester.
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41. It is difficult to say with any accuracy what happened over the next two days.
The man’s medical record, wing history sheet and wing observations book did
not contain any information about the deterioration in his health, when he was
next seen by a member of the healthcare team, or why he was transferred to
hospital and how. His wing history did confirm that on 2 April the police
dropped the charges against him.
The man’s stay in hospital - 3 April to 20 April
42. The man arrived at the hospital on 3 April accompanied by two escort officers.
He was attached to one officer using restraints (these security arrangements
were authorised by a Governor at Winchester). A nurse filled in the healthcare
section to say he was fit to be restrained. The Head of Healthcare at
Winchester, told my investigator that she had no recollection of being consulted
about his risk or that he had been admitted to hospital. He did not have a
Prisoner Escort Record form (PER) for the transfer. Another Governor, told my
investigator that the risk assessment acted as a valid transfer form in this
instance.
43. The man went straight to the hospital’s Emergency Medical Assessment Unit
(EMAU). A referral letter from one of the prison’s doctors, provided a medical
history (chronic disease), the man’s current symptoms of anorexia, jaundice,
weight loss, and his recent test results. The letter was not copied into his
medical record or repeated as a continuous medical entry and was not made
available to my investigator.
44. From the EMAU, the man was placed on one of the wards, and he saw a
hospital doctor. At 2.45pm, the doctor took a blood sample, examined him, and
then moved him to another ward later that evening. He had a settled night and
an SO and Officer, on night escort duty, began a bedwatch log of his condition.
45. At 7.30 am the following morning, two officers came on duty and recorded the
medical interventions the man received throughout the day. The bedwatch log
said that at 9.40am he was taken for an x-ray on his chest and abdomen. My
investigator could not determine whether he was attached to an officer for the
procedure. However, in light of the fact that x-rays are carried out in radioactive
areas, I assume that his restraints were removed temporarily.
46. The doctor sent the man for an ultrasound scan at 3.10pm. One of the
bedwatch officers made an entry in the log which said that he had experienced
a disturbed afternoon and evening. The prison was kept informed of his
condition throughout the day.
47. The man’s discomfort continued throughout the next day. A log entry made by
an officer at 11.00am on 5 April said that the doctor had decided to change his
medication and move him to another ward. The doctor also told the officer that
the man would be staying in hospital until 10 April. He did chat to officers and
tried to get some sleep, but was in a lot of discomfort. A management check
was carried out by the duty governor at 5.10pm and the prison was told that he
would remain in hospital.
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48. The next morning (6 April), the Duty Governor visited the hospital and
authorised the removal of his restraints. The Governor amended his risk
assessment form to reflect the change in security arrangements and said that
they would be kept under review on a daily basis. His bedwatch log also
recorded the change. One of the officer’s on escort duty that day, made a
further entry which said that the man had not eaten much and had been seen
by the Registrar early that afternoon. When evening duty escort officers
relieved the officer, they were given a full handover and told that the man was
not to be restrained.
49. A typed note recording the contact made between Winchester and the man’s
next of kin was made available to my investigator. The note, typed by an
administrator at Winchester, said that on 7 April a Governor telephoned the
man’s sister to tell her that he was in a serious condition and “due to die in the
near future”. The note also said that his sister expressed a wish to be
contacted when he died.
50. The man’s next 24 hours were uncomfortable. During the morning of 8 April,
he was sick and was moved to the bay area of the ward. The ward nurse told
escort officers that there had been an outbreak of sickness and diarrhoea. This
was recorded in the bedwatch log. The Duty Governor visited the ward at
11.00am to review the security arrangements and made no changes.
51. At Winchester, the man’s personal officer learnt that the man was now in
hospital and updated his wing history sheet to reflect this. The assistant
chaplain went to see him in the afternoon. At approximately 8.15pm, escort
officers from another prison came on duty to relieve Winchester’s officers.
They received a handover and continued to complete the bedwatch log for that
evening. The doctor on duty examined the man at 11.15pm and asked a nurse
to take some blood. He had a quiet night but appeared weak. The chaplain
visited him again the following morning.
52. Escort officers from the other prison continued to assist with bedwatch duty on
10 April. Throughout the day, a Governor, a Principal Officer and a
representative from the Independent Monitoring Board (IMB), visited the ward.
The man saw the doctor again at approximately 1.30pm and, following an
examination, he went for another ultrasound scan later that afternoon. The
Governor authorised a further reduction in his security arrangements that
evening. The governor amended the man’s risk assessment to reflect the
change and that he was “currently very ill”. If his situation improved, escort
officers should inform the orderly officer or duty governor immediately. At
8.10pm, his bedwatch was reduced to a single officer.
53. An SO was the first officer to carry out bedwatch duty alone. The officer
updated the man’s bedwatch log as required and noted that he seemed a bit
happier in mood. The SO wrote, “this is due to him taking on more fluids, staff
should encourage more.” The SO was relieved by an officer at 7.00am on 11
April. Another SO, this time from another prison, also reported for duty that
morning, not having been told that security arrangements had been reduced to
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one officer only. The SO was re-deployed to other duties at lunchtime once the
prison was told of the changes.
54. At 12.50am on 12 April, the man became restless and attempted a trip to the
toilet on his own. The escort officer on duty, saw him try to pull his medical
equipment out as he fell to the floor. The nurses on duty assisted him before
putting him back into bed. Another officer came on duty at 7.30am and
recorded that the man remained uncomfortable throughout the day. An SO
took over the night duty at 8.00pm, but was replaced by an officer at 4.00am
due to sickness.
55. The man began to experience difficulty in taking his medication orally. He
remained uncomfortable and was visited by the prison’s chaplaincy team the
next day. Soon after, nurses on the ward began to move patients having
suspected that another patient had a sickness virus. An officer wrote in the
bedwatch log that the patient was “constantly being sick”. The officer also said
that the virus was airborne and that staff should be aware. The
communications staff at Winchester were told that the man had been moved to
a two-bed room to reduce the risk of infection. The doctor saw him at 4.25pm
and decided to administer his pain relief medication and fluids intravenously.
56. On 14 April, the man became more aggressive as his health worsened and he
was warned by nursing staff. Later that evening, he used the buzzer above his
bed to call for a nurse. When she arrived he said, “Turn all these machines off,
I just want to die.”
57. The man refused to take his fluids or eat his breakfast throughout the morning
of 15 April. After speaking to the doctor, he agreed to comply. For the rest of
the day, he became restless, buzzed for the nurse at regular intervals, but then
refused help. He asked for more pain relief and an officer’s entry in the
bedwatch log said that the man had asked the nurse to “make it all stop”. He
was given a painkiller intravenously, slept for short periods and then buzzed the
nurse for assistance to use the commode.
58. The man’s restless behaviour worsened and the officers on duty during the day
and evening of 16 April made a number of entries to that effect. He began to
refuse help and treatment from both nurses and the consultant on duty. At
approximately 10.40am, the consultant told one of the officer’s that the man
would remain in hospital “for at least another week”. Winchester’s
communications staff were updated immediately. That afternoon, he swore at a
nurse and told her to leave him alone. A few hours later, he swore at another
nurse attempting to give him his medication and he was warned about his
behaviour and attitude.
59. A PO carried out a security assessment at approximately 4.20pm. He spoke to
the nurse in charge and was told that the man remained weak, unable to walk
without assistance and was still refusing his food and fluid. The PO decided to
leave the level of supervision as it was, but said that the single officer
arrangements would need to be reviewed regularly. He informed the duty
governor of his decision and recorded it on the bedwatch log.
14
60. Throughout the morning of 17 April, the man became increasingly disturbed.
An officer made lengthy and regular entries in his bedwatch log, describing his
behaviour as poor and abusive to nursing staff. The man continued to use his
buzzer to ask for pain relief and to use the commode. He was given
paracetamol via a drip at approximately 2.00am, but used his buzzer again to
ask for more. He was refused further medication until approximately 3.30am
when he was given oral morphine.
61. Between 5.15am and 7.00am, officers noticed that the man pulled at his drip
machine and tapped his bed to get the attention of staff. An officer made an
entry in his bedwatch log which said he had been shouting for an hour and was
a nuisance to staff. The officer telephoned Winchester and updated staff.
Another officer then took over and, following attempts by nursing staff to wash
the man, the officer gave him another warning for his behaviour and language.
One of the nurses told the officer that, because the man was getting weaker, he
was more confused and argumentative.
62. The man remained agitated and refused medical attention. He had a quiet
night and during the morning of 18 April did take his medication. He became
agitated again when another nurse tried to give him a bed bath. He attempted
to hit the nurse and this was recorded in his bedwatch log by one of the
officer’s. At Winchester, the man’s personal officer learnt that he remained in
hospital and was not improving. The officer made a note in his wing history
sheet.
63. The next morning (19 April), he became delirious. He was washed by nursing
staff, and one of the doctors inserted a drip into his arm to enable him to take
fluids. At midday, one of the escort officers received a telephone call from a
member of staff at another prison. The officer was told that a member of the
man’s family wanted to speak to him but passed on his family’s regards
instead.
64. The man was moved to a single room. At approximately 7.00pm, an SO from
the prison telephoned the hospital again and spoke to one of the officers. The
SO explained that a member of the man’s family had been told that he was not
expected to live. The officer then spoke to the man’s family member and said
he would pass on a message. Shortly after this telephone call, the ward sister
told the officer that she would be surprised if the man made it through the
weekend.
65. On the morning of 20 April, the man deteriorated further. At 7.00am, an SO
came on duty and noticed that he was sleepy. Nursing staff encouraged him to
eat, but the man only managed a small amount of food. At lunchtime, he was
given a wash and his bedding was changed. The doctor came to see him at
3.45pm, but found it difficult to wake him and told nursing staff to keep him as
comfortable as possible. The man was offered liquid and painkillers by a nurse
but refused to take anything.
15
66. At some point that afternoon, the Head of Healthcare at Winchester telephoned
the staff nurse and discussed palliative care for the man. The Head of
Healthcare told the staff nurse that it was not appropriate for the man to return
to prison, and that a hospice would be a dignified environment given his
circumstances. An entry in his medical record said that the hospital would be in
touch about a transfer.
67. The man died at 6.10pm. An SO, who was at the hospital, telephoned the
communications staff at Winchester. A few minutes later, the Duty Governor,
arrived at the hospital. Both the SO and Duty Governor gathered his personal
belongings and took them back to the prison.
16
Events following the man’s death
68. When the Duty Governor returned to the prison at approximately 6.20pm, he
went to the control room and took over from communications staff. The
incident log sheet, normally filled in by communications staff, was also
completed by him.. The Duty Governor recorded that both he and the Orderly
Officer (Oscar One) were told of the man’s death at 6.10pm along with staff at
the gate. The Governor was contacted at 6.15pm, followed by other relevant
internal and external parties.
69. According to the incident log, the Prison Service press office was contacted at
6.30pm and the man’s next of kin approximately 20 minutes later. The Duty
Governor spoke to his sister on the telephone and told her that he had died.
According to the record of contact, the man’s sister expressed a wish not to act
as next of kin for the purposes of arranging the funeral. His sister suggested
that his daughter might wish to. The Duty Governor was given his daughter’s
name and asked Winchester’s Police Liaison Officer (PLO) to assist him in
finding contact details for her. There was nothing in the record of contact to
confirm that the other family member, who had been in contact, was also told
about his death.
70. The following day, a Governor contacted Winchester’s healthcare and told
nursing staff that the man had died. A nurse made an entry in his medical
record which said that the Head of Healthcare had been informed. His wing
history sheet was not updated to reflect his death. His personal officer was on
leave at the time and was told verbally by one of the Governors on her return to
work. The wing observation book had one entry relating to his death. It was
dated 21 August and noted that B wing had received notification of my
investigation that day, and that interviews would take place on 23 August.
71. The Duty Governor told my investigator that the PLO found contact details for
the man’s daughter a few days after he died. On 26 April, the Duty Governor
telephoned her to break the news and left a message on her answer machine
to call him back. The man’s daughter returned the Duty Governor’s call shortly
afterwards and agreed to act as next of kin. They discussed funeral
arrangements. An offer from Winchester to assist with the arrangements and
the financial cost was accepted. The Duty Governor then asked a member of
the chaplaincy team to help with the arrangements and telephoned his sister to
check that she was happy to be put in touch with his daughter. The man’s
sister confirmed that she was content with the arrangements.
72. The chaplain passed the details of the funeral to an administrative officer at
Winchester on 14 May. The following day, the same member of staff liaised
with the funeral directors and arranged for the relevant paperwork to be signed
the prison’s Governor. On 16 May, the man’s daughter rang Winchester and
spoke to the administrative officer. She explained that she wanted his property
returned to her by post if possible. The administrative officer said that he would
pass her request to the Duty Governor to discuss the best way to send it, and
would telephone her back.
17
73. The Duty Governor told my investigator that, after co-ordinating the relevant
death in custody paperwork, he gathered the man’s property together and
telephoned his daughter. He asked if she wanted the property returned to her.
He also explained that there was a considerable amount of property to send.
His daughter said she was happy for valuables to be sent by post. The Duty
Governor arranged to bring the rest of his belongings to the funeral.
74. The man’s funeral took place on 29 May and Winchester’s chaplaincy team
conducted the service. The Duty Governor attended and handed over his
belongings, packed into boxes and Prison Service bags, to his daughter.
18
ISSUES
75. As I mention in my foreword to this report, the gaps in record keeping,
particularly from a healthcare point of view, have made this a difficult story to
tell accurately. In addition, the investigation process did not always run
smoothly and my investigator experienced some organisational problems in
securing a suitable time and place to interview staff.
76. The man was not picked up appropriately by the reception healthcare
screening, designed to do exactly that. An opportunity to follow up his care with
a secondary screening was also missed. Once in contact with healthcare, he
went on to experience delays in his care, and his eventual transfer to hospital
was, on paper, a mystery.
77. That said, the lack of continuity of care following his transfer, the failure to pick
up his chronic disease history, and the delays in taking his blood and receiving
his results would not have saved the man’s life. His post mortem found
evidence of advanced cancer. He presented as a man older than he was. This
is possibly because he had been in the prison system for much of his adult life.
His medical history was extensive with evidence of chronic disease and mental
health problems.
78. Once the man was admitted to hospital, he was managed appropriately by
Winchester’s senior management and officers. After his death, the prison
followed its own contingency plans for a death in custody and paid for his
funeral. However, I have made numerous observations about the way
Winchester followed up his death and these were raised with the Governor
during the investigation itself. The recommendations I have made, based on
these observations, will enable Winchester to strengthen its response in future.
Additionally, the recommendations made by the clinical review panel are
designed to better manage prisoner healthcare. I deal with these below.
The man’s transfer, reception and induction
79. The man’s transfer took place on the day he was due to see a doctor at HMP
Kingston. This followed blood tests taken two days earlier. Transfer
arrangements were made between the duty governors at Kingston and
Winchester. Kingston’s healthcare did not see him before he was moved to
Winchester and therefore he was not assessed as fit to travel.
80. When the man arrived in Winchester’s reception, he was seen by a HCO as
evidenced by his CSRA. The HCO ticked the low risk box on his form which is
surprising considering that sections 1 and 2 of the same CSRA considered him
to be high risk and a single cell occupant only. It is particularly surprising given
sections 1 and 2 are routinely completed before a prisoner sees a member of
the healthcare team in reception. The HCO’s assessment had no bearing on
the man’s location. Operational staff rightly placed him in a single cell and
communicated through his wing history sheet that he remained high risk.
Despite this, I remain concerned about the order in which this may have been
19
completed, and the lack of attention paid to important documentation affecting
the security arrangements for a prisoner on arrival.
81. Winchester could not provide a first or second healthcare screening. This is a
document I would have expected to have seen in the man’s medical records.
Furthermore, there is no evidence to suggest that he received a healthcare
screening at all. What I can say is that I have criticised the lack of routine
healthcare screenings at Winchester in a previous report. One of the nurses
told my investigator that both screenings would usually be carried out at the
same time, rather than days apart. The Head of Healthcare said that
conducting both screenings together was due to the tight staffing levels.
82. The Head of Healthcare also confirmed that she had recently circulated a
number of protocols for reception, first and second healthcare screenings,
continuity of healthcare and palliative care at Winchester. The protocols,
forwarded to my office, were based on the best practice evident in other
prisons. They provide clear guidance to staff in accordance with Prison Service
Orders and other relevant documents. As I mentioned earlier in my report, the
healthcare centre is also devising an older prisoner policy to tailor ongoing
assessment towards the specific needs of this group. The policy draft is due in
December 2007. The reception protocol was adopted by Winchester in
September 2007. Whilst I am pleased to see that other mechanisms are
theoretically in place to ensure a prisoner, like the man, experiences a smooth
journey through the healthcare process in future, I am not aware of the
timescales for implementation.
83. Healthcare screening forms an integral part of reception, induction and ongoing
care. They are not something that can wait. Winchester has recognised where
improvement needs to be made and already introduced new reception
guidance to healthcare staff. For that reason, I will not repeat the
recommendations I have made in previous reports. However, I do urge the
Head of Healthcare to give the remaining protocols the highest priority for
immediate implementation. I also urge the Head of Healthcare to add to the
recently circulated memo on reception healthscreens that CSRA management
checks will also be carried out by the duty healthcare manager.
84. If the man’s medical record from Kingston did not arrive with him on 1
September 2006, Winchester received it the day afterwards. On 2 September,
the man spoke to a nurse on A wing about his medication. The nurse
appropriately recorded it in his medical record. It was written directly
underneath the last two entries from Kingston about his pending doctor’s
appointment and blood test. The nurse made that entry and would, perhaps,
have assumed that his blood test results and appointment at Kingston had
already been picked up in reception at Winchester. That said, his record did
not say that the reception HCO had seen him. This is a mandatory entry in
medical records. In the absence of written confirmation, an opportunity to pick
up his healthcare soon after his arrival was missed for a second time.
85. The man’s experience of reception and induction is indicative of a breakdown in
communication. The clinical review panel share my criticism of the reception
20
process and communication. With the new electronic system in mind, the panel
repeat the recommendation they made following a previous death in custody at
Winchester. The review says the following:
The process for assessment on admission (reception-screening) needs to
be audited to ensure compliance in relation to the completeness of the
assessment tool and the accurate identification of patients requiring a
medical assessment. A comprehensive template for recording this
assessment should be available on the computerised clinical system
which is now in place at HMP Winchester. Healthcare staff should have
access to this system where they undertake their work and not just in the
Healthcare wing.
86. I endorse the panel’s view. However, I remain concerned that Winchester
could not provide my investigator with evidence of a secondary healthcare
assessment whilst the man was being inducted on A wing. The absence of
both a first and second healthcare screening, coupled with no entry in his
medical record to confirm that he had been seen in reception, led to the two
week delay in seeing a doctor. Another consequence was no follow up in
relation to his overdue test results. In addition to the clinical review panel’s
recommendation, I make the following recommendation:
The Chief Executive of Hampshire PCT should conduct an audit into the
policies and procedures around receiving both new receptions and
prisoners on transfer to ensure effective, ongoing healthcare is afforded
to individuals in a timely manner.
87. The clinical review panel recommend that medical records and a summary of a
prisoner’s healthcare should always be available in reception. Prison
healthcare should, in the main, reflect the standard practices seen in the
community, and I have said in a previous report that medical records are not
automatically sent with a patient transferring from GP to GP as the man
effectively did. The HCO did not necessarily have to see his full medical record
to ascertain if there were any immediate concerns, but would have benefited
from a summary of his care at Kingston. In any case, the HCO should have
obtained immediate information from him during screening and married this up
with his record when it did arrive.
88. The computer system is designed to capture the issues of concern that both
myself and the clinical review panel have highlighted. Winchester’s healthcare
inherited the system in June 2007 and the Head of Healthcare is confident that
it will improve screening, continuous care and medical information sharing
when prisoners are transferred or released from the prison. Inevitably, a new
IT system needs time to settle before it will be embedded into mainstream ways
of working in healthcare. The clinical review panel make the following
recommendations which I endorse:
All healthcare staff should be adequately trained in the use of the new
computer clinical system for both the recording and summarising of
entries. A comprehensive and up to date note summary should always be
21
available on the system to ensure that the doctors working in the
healthcare team can easily identify relevant medical history when
reviewing patients. All members of the healthcare team should
understand the structure of the system and how it is to be used.
Organisational processes should be introduced to ensure medical
records are complete and that all relevant medical correspondence, or
summaries thereof, are included in the health records. This should
ensure that all prisoners receive appropriate healthcare and enable the
healthcare team to provide a summary of the healthcare record when
transferring prisoners to other establishments.
89. A new IT system is not a cure-all that can remedy every issue highlighted in the
man’s case. It is incompatible with other IT systems currently being used
across the prison estate, and the prison sits outside the local PCT where IT is
concerned. This means that effective communication still needs to be
maintained between Winchester and other clinical areas. Of course, any IT
system is heavily reliant on the healthcare staff using it to input the correct data.
Whilst it will in future prompt staff that blood tests are overdue, or that a
prisoner has a doctor’s appointment pending, it will only do so if the information
has been entered onto the system at source. I make the following
recommendation:
The Prison Health Partnership must satisfy themselves that the protocols
and procedures around the use of computerised medical records does
not negate the need for continued communication and dialogue between
healthcare professionals, both internally and externally.
Delays in the man’s ongoing healthcare
90. The man experienced a significant delay in getting to see a doctor. When he
did see one, he had already been on A wing for approximately two weeks. The
clinical review panel say that Winchester’s healthcare team did not seem to
know about his chronic illness history and recent health problems. Most
notably, it was not mentioned in his medical records that the doctors at
Winchester knew he had a history of cirrhosis of the liver. The doctor did
recognise that he was receiving medication and continued his prescription in a
timely way. The review panel say that his prescription charts were clearly
annotated with the dose and strength of medication he was taking. The doctor
also correctly identified his weight loss and recorded this. The man
experienced two further delays to have his ears syringed and his blood taken.
The first delay came in December 2006. The second delay came in March
2007. In relation to this latter delay, one of the nurses interviewed provided my
investigator with an overview of both the old and new procedures for taking
blood samples. The nurse also explained that she had suggested the setting
up of a blood clinic every week to better manage the volume of tests requested.
The nurse stressed that she was one of only two healthcare professionals
qualified to take blood.
22
91. The clinical review panel comment negatively on the delays the man
experienced. The panel focus particularly on the delay in taking his blood, and
conclude that this was significant as his abnormal liver function could have
been identified earlier. In a previous report at Winchester, I made a
recommendation to the PCT to agree a protocol with the local GP Practice to
follow up and review prisoners’ test results. I repeat this recommendation and
fully endorse the review panel’s recommendation (which I have edited slightly):
The PCT should agree a protocol with the local GP Practice to follow up
and review prisoners’ test results.
Winchester should ensure that the healthcare team is adequately staffed
and resourced to provide appropriate and timely healthcare to their
population. Procedures should also be reviewed to ensure investigations
are carried out when requested, or patient dissent documented.
Record keeping
92. The review panel conclude that the man’s medical records were factual,
consistent and accurate, but not comprehensive. They were written in a timely
manner but did not necessarily provide current information about the care and
condition of the patient. The records were not perfectly legible, nor accurately
dated and timed. The records were respectful, consecutive, with a lack of
jargon or abbreviations. They identified problems and the action to be taken.
However, the timeliness of the actions identified was very poor. I agree with
these comments. I have already said that it is surprising to see no entry
relating to his reception by the HCO. I am also surprised that his medical
record did not document his admission to hospital, provide a summary of why
he was admitted, or why it was not married up with the referral letter by the
referral doctor, that presumably accompanied the man to hospital. The IT
system is designed to improve the quality and consistency of record keeping in
future but is reliant on the staff accessing the system to enter the correct
information. I have reworded the clinical review panel’s recommendation:
The Head of Healthcare should remind staff that medical records should
always be kept in chronological order and updated appropriately. Medical
records should include appropriate sections for the continuous
healthcare record, test results, medical correspondence and medical
charts.
93. The man’s health was mostly managed on the wing and he was never admitted
as an inpatient. He did go to the triage clinic on one occasion and left his cell to
see the doctors. Aside from that, he came into contact with nurses on the wing.
His wing history said little about his interactions on the wing and the events
leading up to his transfer to hospital. Entries made were generally in relation to
his quiet and polite mood and his conformity to the wing regime. His personal
officer, told my investigator that he chose not to speak to her personally about
his health. The officer made regular entries as did other officers on B wing. All
entries were management checked in line with the personal officer scheme
requirements. In fact, were it not for his personal officer’s entries on 4 and 18
23
April, his wing history would not have reflected that he went into hospital. The
officer was not on duty when the man died. Unfortunately, his wing history
stopped with the entry dated 18 April.
94. B wing’s observation book, in place to record events on the wing, mentioned
the man on one occasion four months after he died. This single entry said less
about his death and more about my investigation. The entry, dated 21 August,
confirms that notices about my investigation into his death were received on
that day and that my terms of reference were being circulated on B wing. This
was two days before my investigator was scheduled to interview staff.
However, of more concern is the apparent under-use of the B wing observation
book in his case. There were incidences involving the man that I would have
expected to see recorded, particularly his fall on the wing, his transfer to
hospital and his death. Wing observation books are a useful vehicle for sharing
both positive and negative information about prisoners. Similarly, a wing
history sheet is a record of a prisoner’s time on that wing, and should not be
used purely to record conformity or non-conformity to a wing regime.
95. HM Chief Inspector of Prisons, made a recommendation to address this issue
in her last report on Winchester. The recommendation centred on the personal
officer scheme (as mentioned on page 9 of this report). I make no formal
recommendation about the scheme. However, I do urge the Governor to
remind staff of the purpose of wing history and wing observation books and the
expected quality of entries, both positive and negative.
96. The man’s bedwatch logs were generally thorough with clear and regular
updates. Bedwatch officers were particularly conscientious in carrying out their
duties at the hospital. From the records, it is clear that some officers had to
manage his challenging behaviour when his health deteriorated further. I have
no doubt that this must have been stressful for officers at times. The
importance of good quality bedwatch logs was significant in this case. They
became invaluable for the purposes of both my investigation and the clinical
review panel. Without such a thorough log of the man’s stay in the hospital,
and in the absence of any updated medical records, I would not have been able
to talk about the last two weeks of his life. I would be grateful if the Governor
could share these views with the staff concerned.
Risk assessment and bedwatch
97. The man stayed in hospital for approximately 17 days before he died. A
prolonged bedwatch, such as his, puts severe pressure on staffing levels for an
individual prison. His first risk assessment for transfer to hospital on 3 April
stated that he would be escorted by two officers and attached to one officer at
all times. The document was authorised by the appropriate members of staff in
healthcare, the security department and the duty governor. Winchester
deployed its own officers and drew on volunteer officers from other prisons to
manage his security arrangements. This worked well.
98. The security arrangements were reviewed by a Duty Governor on 6 April as
part of his duty governor role that day. The Governor appropriately recognised
24
that the man’s health had deteriorated and had, in turn, reduced his security
risk. The Governor updated his risk assessment and authorised removal of his
restraints with the proviso that this should be reviewed if his health improved. It
did not, and on 10 April a further bedwatch management check and review of
his risk reduced his security arrangements further. Again, this was in light of
his deteriorating health.
99. With immediate effect, the man’s bedwatch was reduced from two officers to
one and this lower level of security remained in place until he died. His risk
assessment differed from the previous one in that the healthcare section was
not completed by a member of the healthcare team but by a prison officer. I am
concerned that a member of operational staff completed a section meant for
medically trained staff.
100. That said, the completion of the risk assessment had no bearing on the man’s
risk management in an outside hospital which was both regular, considered and
well documented. I make no formal recommendation, but ask the Governor to
remind senior managers who authorise risk assessments to ensure that
individual sections are completed by the correct staff in future.
Continuity of Care
101. As I have mentioned above, the man’s care at the hospital was recorded by
operational staff for security reasons. There is nothing in his documentation to
evidence that he was additionally managed by healthcare staff, remotely or
through visits to the hospital. His medical record did not record that he had
been transferred to hospital and why. A referral letter or summary of it from the
doctor to the hospital was not married up with his prison medical record.
Throughout his stay in the hospital, just one entry was made by the Head of
Healthcare (on the day he died). A nurse told my investigator that she was not
aware that healthcare staff had a duty to maintain regular contact with outside
hospitals when a prisoner was on bedwatch. Anecdotally, the nurse said that
there was no requirement for healthcare staff to visit the prisoner externally,
and where contact had been made in the past it had been difficult to obtain a
suitable update from prison officers due to medical in confidence issues.
102. PSO 3050 ‘Continuity of Care of Prisoners’ sets out the expectations for
maintaining contact with hospitals following a prisoner’s admission. The PSO
stipulates that daily contact must be made between healthcare staff and
hospital staff and updates should be appropriately recorded. Elsewhere in this
report, I have said that the Head of Healthcare has adopted a protocol taken
from the best practice at another prison where it is already in operation. The
protocol will remove any misunderstanding or ambiguity over the role of
healthcare staff in future. It will also require doctors to copy referral letters into
a prisoner’s medical record for audit purposes. I urge the Head of Healthcare
to implement the protocol as soon as practicable and make the following
recommendation to capture all planned improvements to healthcare services at
Winchester:
25
The Head of Healthcare should incorporate all protocols into the
induction programme for new members of healthcare staff.
Contingency plans and family liaison
103. The Duty Governor on 20 April, was already on his way to the hospital to carry
out a management check when the bedwatch SO reported that the man had
died. On arrival at the hospital, the Duty Governor spoke to the SO and asked
him to make a statement, recording what had happened, before going off duty.
A previous Ombudsman’s report following the death of another man at
Winchester was issued in August 2007. This commented that staff statements
were not made available to my investigator. I made a recommendation at that
time, and I am pleased to see that the Duty Governor ensured that the SO
provided a written statement as soon as possible after the man died.
104. The Duty Governor then made his way back to the prison and began to follow
the incident log which forms part of contingency plans for a death in custody.
He notified the appropriate members of staff and external agencies. He then
contacted the man’s next of kin by telephone and told her that he had died. My
investigator asked the Duty Governor for a copy of the contingency plans and
was told that the incident log was all that was available. He also said that there
were no local instructions for deaths in custody and that Winchester took its
guidance directly from Prison Service Order 2710 ‘Follow up to deaths in
custody’.
105. There is no mandatory requirement placed on Governors to localise the
instructions and guidance set out in Prison Service Orders. Governors have
the discretion to issue local instructions to staff, specific to their own prisons, or
to follow the national guidelines. I do not underestimate the importance of
maintaining discretion in these matters. However, it is considered good
practice to develop full contingency plans tailored specifically to individual
prison environments. Winchester’s plan consisted of one action sheet which
instructs control room staff and the Duty Governor in what to do immediately
following a death. The instruction to the Duty Governor to ‘Consider contacting
next of kin yourself’ does not appear to reflect the philosophy behind PSO
2710, which is to consider who should contact next of kin. My investigator
raised this issue, as part of her feedback on the investigation, with the
Governor of Winchester. The Governor explained that he had since tasked one
of his senior managers with drafting local instructions for deaths in custody to
staff. I am grateful to The Governor for his speed in identifying a senior
member of staff to take this work forward. For this reason, I make no
recommendation.
106. The duty Governor contacted the man’s sister in accordance with the
instructions I have mentioned above. Further down the incident log, another
instruction asks the Duty Governor to arrange a meeting between the prison
chaplaincy, a nominated governor and a prisoner’s next of kin if the next of kin
are ‘within reasonable travelling distance’. The Duty Governor told my
investigator that one of the reasons he telephoned the man’s sister was
because she lived more than an hour away from the prison. The Duty
26
Governor further explained that, as Duty Governor for a death in custody, it
would not have been practical for him to travel further away from the prison to
inform the man’s next of kin in person. Likewise, when his daughter was
contacted, the Duty Governor left a message on her answer machine to contact
him. She also lived over an hour from Winchester.
107. Chapter 4 of PSO 2710 sets out the role of the Family Liaison Officer (FLO). In
relation to contacting a prisoner’s next of kin, it is considered good practice to
break the news in person as far as possible. There are a number of
circumstances where this may not be possible. One of these is the distance a
Governor and Family Liaison Officer may have to travel. Where this is the
case, Chapter 4 provides guidance on contacting the nearest prison to where a
family live and asking a FLO from that prison to make a personal visit. The
man’s sister lived in the South West of England and had already been
contacted by another Governor at Winchester prior to his death. During the
telephone conversation she was prepared for the man’s death, and I am sure
that when the Duty Governor broke the news this was not a shock to her.
However, I am not entirely certain that the man’s daughter was equally
prepared. I remain concerned that breaking such difficult news by telephone is
being used first, rather than a last resort.
108. The Duty Governor was assisted by the chaplaincy team and an administrative
officer when making arrangements for the man’s funeral. His offer to help both
arrange and assist with the financial cost of the funeral was appropriate, timely
and in accordance with PSO 2710. Ongoing contact with his family, and liaison
with the funeral directors, was recorded by the administrative officer on a sheet
forwarded to my investigator. The Duty Governor told my investigator that he
did not keep a family liaison log and that this was the only record of contact on
file.
109. The man’s property was then returned in two stages. Having spoken to his
daughter by telephone, the Duty Governor arranged to send his valuables by
post and to bring the remainder of his property to the funeral. He told my
investigator that the man’s daughter was happy with the arrangement. When
the Duty Governor attended the funeral on behalf of Winchester, he presented
the man’s daughter with the property in boxes and Prison Service bags.
Despite the prior arrangements made with his next of kin, I do not consider that
Prison Service bags are a suitable receptacle for returning property. Nor do I
consider a funeral to be a suitable time and place to return property. Chapter 4
sets out how to make arrangements to return a prisoner’s belongings.
Paragraph 4.25 says:
“The Family Liaison Officer should consult the family about how they would like
to retrieve their relative’s belongings. Some families like to collect them
themselves from the prison, others appreciate having them delivered to their
home. This can be an emotional time for them when the Family Liaison Officer
should be prepared to listen to reminiscences. Some families like to have
clothes laundered, others want them just as they are. In either event, pack them
neatly in a suitable bag or container, not a black sack or a bag recognisable as
prison issue.”
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110. My investigator asked for a copy of Winchester’s local policy on the role of the
Family Liaison Officer. The role, embedded in PSO 2710, forms a large part of
handling a death in custody. The Duty Governor confirmed that Winchester did
not have a local policy and that Duty Governors usually assumed the role of
Family Liaison Officer. However, one of the problems in allocating FLO
responsibilities to Duty Governors is the capacity to carry out both roles
effectively. Duty Governors are central to deaths in custody and have specific
responsibilities to carry out. It is not impossible, but certainly difficult, for a Duty
Governor to then be released from duty in order to remain the single point of
contact and support for the bereaved family.
111. I accept that chapter 4 of PSO 2710 says:
“Family Liaison Officers are not a mandatory or prescriptive requirement for
individual prisons. This is to allow governors the discretion in decision-making
and local practice.”
The only mandatory requirement is the following:
“Governors/Directors of contracted prisons must have in place a local protocol
explaining what support will be offered to a family bereaved by a death in
custody.”
112. It is also important to recognise that the role is still relatively new and was
introduced after my office took over responsibility for investigating deaths in
custody in April 2004. Since then, many prisons have adopted local policies to
identify, train and deploy Family Liaison Officers to provide an uninterrupted
service to bereaved families.
113. The man had not been in contact with his family for many years. Once
contacted by the Duty Governor, the man’s sister stressed that she did not want
next of kin responsibilities. The Governor respected her request and contacted
his daughter who took over responsibility. From then on, his funeral was
arranged with the costs met. I am aware that the man’s family were happy with
the service Winchester provided and raised no concerns with my office.
However, I feel that the prison can only benefit from having a local FLO policy
in place to improve its service to bereaved families in future. I make the
following recommendation:
The Governor should consider implementing a local policy on the role of
Family Liaison Officer in accordance with Chapter 4 of PSO 2710.
The Governor should consider placing suitable volunteers on the Family
Liaison Officer training course waiting list as soon as practicable to
ensure that there are dedicated staff available to carry out the role when a
local policy is implemented.
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RECOMMENDATIONS
To the Primary Care Trust
1. The process for assessment on admission (reception-screening) needs to be
audited to ensure compliance in relation to the completeness of the assessment tool
and the accurate identification of patients requiring a medical assessment. A
comprehensive template for recording this assessment should be available on the
VISION computerised clinical system which is now in place at HMP Winchester.
Healthcare staff should have access to this system where they undertake their work
and not just in the Healthcare wing.
The prison service accepted the recommendation. In response, they said:
Already have a system in place. Audited on a daily basis by the manager on
duty. Healthcare manager to ensure that the quality of assessment is to the
required standard. Healthcare manager to put filing system in place for
management check list. Templates are being reviewed along with reception
protocol. Vision system in place in all areas of healthcare.
2. The Chief Executive of Hampshire PCT should conduct an audit into the policies
and procedures around receiving both new receptions and prisoners on transfer to
ensure effective, ongoing healthcare is afforded to individuals in a timely manner.
The prison service partially accepted the recommendation. In response, they
said:
Reception protocols reviewed and redrafted.
3. All healthcare staff should be adequately trained in the use of the new computer
clinical system for both the recording and summarising of entries. A comprehensive
and up to date note summary should always be available on the system to ensure that
the doctors working in the healthcare team can easily identify relevant medical history
when reviewing patients. All members of the healthcare team should understand the
structure of the IT system and how it is to be used.
The prison service accepted the recommendation. In response, they said:
Reception protocol to be amended to include summarising. To ensure that
training is included in staff induction.
4. Organisational processes should be introduced to ensure medical records are
complete and that all relevant medical correspondence, or summaries thereof, are
included in the health records. This should ensure that all prisoners receive
appropriate healthcare and enable the healthcare team to provide a summary of the
healthcare record when transferring prisoners to other establishments.
The prison service accepted this recommendation. In response, they said:
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Vision IT system is in place and all medical correspondence is scanned into
medical records. Transfer protocol drafted, to be disseminated to all healthcare
staff.
5. The Prison Health Partnership must satisfy themselves that the protocols and
procedures around the use of computerised medical records does not negate the
need for continued communication and dialogue between healthcare professionals,
both internally and externally.
The prison service accepted the recommendation. In response, they said:
Develop the role of administration staff. Improve communication between
healthcare departments in other prisons by sharing the recommendations and
action plan with HMP Kingston. To develop wing based nurses to improve
continuity of care and promote accountability.
6. The PCT should agree a protocol with the local GP Practice to follow up and
review prisoners’ test results.
The prison service accepted the recommendation. In response, they said:
Arrange a meeting to discuss with the local GP Practice.
7. Winchester should ensure that the healthcare team is adequately staffed and
resourced to provide appropriate and timely healthcare to their population.
Procedures should also be reviewed to ensure investigations are carried out when
requested, or patient dissent documented.
The prison service accepted the recommendation. In response, they said:
Profile has been reviewed and recruitment is underway. A training plan in place
to address the medical needs of prison population. Protocol to be drafted to
ensure investigations are carried out when requested or patient dissent
documented.
8. The Head of Healthcare should remind staff that medical records should always be
kept in chronological order and updated appropriately. Medical records should include
appropriate sections for the continuous healthcare record, test results, medical
correspondence and medical charts.
The prison service accepted the recommendation. In response, they said:
The Vision IT system does this automatically. PCT supporting Head of
Healthcare in accessing relevant reed codes from the local GP Practice.
9. The Head of Healthcare should incorporate all protocols into the induction
programme for new members of healthcare staff.
The prison service accepted the recommendation. In response, they said:
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Already included in the secondary healthcare screening pack. Healthcare
manager to ensure that this is in place.
To the Governor
10. The Governor should consider implementing a local policy on the role of Family
Liaison Officer in accordance with Chapter 4 of PSO 2710.
The prison service accepted the recommendation. In response, they said:
Policy drafted and implemented.
11. The Governor should consider placing suitable volunteers on the Family Liaison
Officer training course waiting list as soon as practicable to ensure that there are
dedicated staff available to carry out the role when a local policy is implemented.
The prison service accepted the recommendation. In response, they said:
Volunteers are being sought to fill the role. Training to commence in the new
year.
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