Individual at Winchester

Investigation into the circumstances surrounding the
death of a man at Royal Hampshire County Hospital in
September 2006, whilst a prisoner
at HMP Winchester
Report by the Prisons and Probation Ombudsman for
England and Wales
September 2007
This is a report into the circumstances surrounding the death of a man at the Royal
Hampshire County Hospital in September 2006. He was 59 years old and a prisoner
at HMP Winchester. He had only been at Winchester for a couple of months, having
been transferred from HMP Bullingdon.
The man who died was a life sentenced prisoner who had been in custody since
August 1971. He had served his sentence at 13 different prisons. As appears to be
common amongst those serving very long sentences, imprisonment seems to have
had a detrimental effect on his health. At the time of his death he was diagnosed
with chronic diabetes, angina, osteoarthritis, cardiovascular disease, partial
blindness and deafness. One doctor involved in his care wrote that his state of
health was consistent with someone much older than 59.
The death of a loved one is always distressing. I would like to add my condolences
to the man’s family and loved ones to those already expressed by one of my Family
Liaison Officers.
This investigation has been undertaken by a member of my team. I would like to
thank the Governor of Winchester and his staff for their co-operation.
A review of the care the man received whilst in prison and in hospital was carried out
by Hampshire Primary Care Trust. The extent of his health problems and care
needs has meant that the report took longer to complete than I would have liked.
Indeed, the Coroner has already held the inquest into the man’s death and is
satisfied that he died as a consequence of natural causes. However, the complexity
of the case warranted thorough investigation and I thank the clinical reviewer for
taking the lead in interviewing healthcare staff and for her comprehensive report.
This was an unusual case in that it became apparent at an early stage that all of the
issues relating to the man’s management were clinical in nature. For that reason I
have relied heavily on the clinical review. The review makes 13 recommendations in
total, ten of which are directly relevant to my investigation. The rest are reminders of
best practice, and I have addressed these to the Chief Executive of the Primary Care
Trust in a separate letter. I also comment on one example of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2007
2
CONTENTS
Summary 4
The Investigation Process 5
HMP Winchester 6
Key Findings 7
Issues 11
Recommendations 14
Good Practice 15
3
SUMMARY
The man who is the subject of this report was remanded into custody in August
1971. On 2 November of the same year, he appeared at Chelmsford Crown Court
and received a sentence of life imprisonment.
Over the years, he made slow but steady progress through the prison system. In
1999, he was transferred to open conditions but he struggled to adapt to the regime.
He was returned to a closed prison in June 2000 after his security category was
upgraded.
Over the course of his sentence, the man’s health noticeably deteriorated. In 1987,
he had a heart attack and three years later he was diagnosed with diabetes. In
1994, a disorder of the nervous system was noted and in 2001 he developed facial
paralysis. In 2002, he suffered a series of small strokes and had another heart
attack. In January 2006, he developed a severe pressure sore at the base of his
spine and spent time in Queen Alexandra Hospital in Portsmouth. Later in the year,
he spent a further period in hospital with anaemia and kidney disease. Shortly after
his discharge to HMP Bullingdon, he was transferred to HMP Winchester where he
was admitted to the inpatient unit. His health needs were assessed and a nursing
care plan was drawn up. This focussed on managing his various health problems
and encouraging him to mobilise.
From July 2006 onwards, the man’s health deteriorated further. Tests revealed that
he had a urinary tract infection for which he was prescribed a course of antibiotics.
Two days later, a doctor recorded that he had developed kidney disease and he was
referred for blood tests. A week later, he attended the Accident and Emergency
Department of the Royal Hampshire County Hospital for a scheduled appointment
relating to the management of the pressure sore on his spine. He was given advice
on pain reduction and control and returned to the prison.
During the early hours of 29 July, the man was found on the floor of his cell
complaining of neck pain. He was checked for injuries before being helped back to
bed by healthcare staff. On 5 August, he was assessed by a doctor as he was
unable to swallow, was not eating and was unable to take his medication. After
discussion between the doctor and the local hospital, the man was sent to the
Emergency Assessment Unit at the hospital. He was admitted as an inpatient
shortly afterwards.
Over the next few weeks, the man who later died was subject to a series of tests and
examinations. His family was told that he had been admitted to hospital but
unfortunately personal reasons meant they could not visit him. During the morning
of 20 August, the man suffered a heart attack. He was moved to the Intensive Care
Unit, where it was established that he had suffered brain damage.
On 31 August, a comprehensive assessment of the man’s condition was undertaken.
Based on the results, a senior consultant at the Royal Hampshire decided to
withdraw treatment at 7.15pm. Over the next few hours, hospital staff attempted to
make him as comfortable as possible. He stopped breathing at 2.50am on 1
September and was formally pronounced dead at 3.45am.
4
THE INVESTIGATION PROCESS
1. My investigator opened the investigation on 13 September 2006. He obtained
copies of the man’s prison documentation, including his clinical records, and
spoke at length to one of the prison governors. The governor told my
investigator that the man had been transferred from Bullingdon as it was
thought his health problems could be better managed at Winchester.
2. Prior to my investigator arriving at Winchester, notices were issued to staff and
prisoners announcing the investigation and inviting anyone who had information
relevant to the man’s death to make themself known to the investigator. In the
event, nobody came forward.
3. One of my Family Liaison Officers contacted the man’s next-of-kin (his sister)
to offer her the opportunity to participate in the investigation process. She did
not raise any concerns about the circumstances surrounding her brother’s
death, but did tell us that the man had been concerned at times about his
diabetes. She said she and her husband visited the man in prison regularly and
wrote to him every two weeks, providing him with support. She asked to see
our report when complete and I hope it answers any outstanding questions she
may have.
4. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of the investigation. An inquest into the man’s death has since been
held and recorded that it was the result of natural causes.
5. Hampshire Primary Care Trust (PCT) conducted a review of the care the man
received whilst in prison and in Royal Hampshire County Hospital.
5
HMP WINCHESTER
6. Winchester is a category B local prison, with a category C resettlement unit,
West Hill. The prison was last inspected by HM Chief Inspector of Prisons in
November 2004, when a short unannounced inspection was carried out.
Acknowledging that Winchester was, like many other local prisons, around 50
per cent overcrowded, the Chief Inspector found Winchester to be a prison with
a number of improvements still to make. However, the Chief Inspector also
commented upon the vision and commitment of managers and many staff and
welcomed improvements in certain areas including healthcare.
7. The man who is the subject of this report spent all of his time located in the
Healthcare Centre whilst he was at Winchester. The prison has a 22 bed in-
patient healthcare facility and medical cover 24 hours a day. From Monday to
Saturday, doctors from the local Friarsgate surgery provide a full range of
General Practitioner services. There is also a senior healthcare officer,
healthcare officers and a mixture of general and psychiatric nurses. During the
night, the prison’s healthcare cover is provided by a nurse who is based in the
Healthcare Centre. In addition to the nurse, there is always an Officer Support
Grade (OSG) on duty overnight. An out of hours paramedic service is provided
by Hampshire Ambulance Service.
8. Prior to the man’s death, three other prisoners had died at Winchester since
April 2004 when I assumed responsibility for investigating all deaths in custody.
Two of these were due to natural causes. The investigations into the deaths
highlighted issues of concern regarding the delivery of healthcare at
Winchester, particularly in relation to the quality of record keeping. I am
disappointed to be repeating similar recommendations as a result of this
investigation. Since the man’s death, two more prisoners have died at
Winchester, apparently of natural causes.
6
KEY FINDINGS
9. Prior to being moved from Bullingdon to Winchester, a nurse from Winchester
visited the man to assess his suitability for transfer. According to the clinical
review, the nurse concluded that Winchester could offer no better care than that
which he was already receiving. However, this opinion was not recorded in the
man’s clinical records and the transfer went ahead as planned on 7 July 2006.
10. Upon reception, the man was admitted to the inpatient unit in the Healthcare
Centre where it was recorded that he was mobile, catheterised and had
unstable blood sugars. It was noted that his physical health was deteriorating,
that he had a pressure sore, diabetes, angina, a history of strokes and poor
eyesight and hearing.
11. On 9 July, a nursing care plan was completed by a Registered General Nurse
(RGN). The nursing care plan is a single page document with four sections
which detail how the patient’s health problems will be managed. Section one
asks for information about the problems, and sections two and three require the
person filling out the form to set short and long term goals. The final section
asks how the goals are going to be achieved in terms of the actual approaches
and interventions used.
12. On the man’s nursing care plan, angina, reduced mobility, deafness in left ear,
blindness in left eye, long term use of a urinary catheter and a pressure sore
were identified as the problem areas. The short term goals were to prevent
further deterioration and promote healing and reduce the risk of infecting the
pressure sore. The long term goals were to heal the sacral sore, optimise
mobility and increase independence. The interventions were described as
follows:
• encourage catheter care and change regularly
• encourage mobility and use of aids, if appropriate
• ensure diabetic diet, monitor bowel movements give insulin as
prescribed
• dress sacral sore every three days
• encourage position changes and use of pressure aids as required
• review regularly.
The plan is dated 9 July and a review date of 16 July has been set. (These
dates are written under two other dates which have been crossed through with
a single line – 9.10.7 and 16.10 respectively, which are obviously incorrect.)
13. During the afternoon of 15 July, the man was seen by the prison doctor for the
first time. He was noted to have high blood sugar levels and to require insulin,
which was administered on a sliding scale according to need. The doctor also
documented that a ripple mattress was put on his bed in order to alleviate the
pressure sore. The following day, it appears the man’s nursing care plan was
reviewed. No changes were made to it and that day’s date (16 July) was struck
through with a single line. A review date of 30 July was written next to it.
7
14. On 17 July, tests revealed that the man had a urinary tract infection. He was
prescribed a course of trimethoprim, an antibiotic widely used in the treatment
of this condition. Two days later, on 19 July, the Consultant Diabetologist from
the Royal Hampshire County Hospital reviewed the man’s clinical notes and
recorded that he had kidney disease. The doctor specified that the man
needed various blood tests to be carried out, and these were done the following
day. A urine test was also requested.
15. Three days later, the man was assessed by the prison doctor for faecal
incontinence. His pressure sore was also reviewed and it was noted that the
ripple mattress was broken. The prison doctor’s assessment was that the man
was less mobile and less able to look after himself. He recorded that it might
be worth considering a referral to a geriatrician because the man’s health was
consistent with someone older than 59 years of age. He also indicated that a
new nursing care plan was required to take into account his deteriorating
mobility and ability to look after himself.
16. On 25 July, the man attended the Accident and Emergency Department of the
Royal Hampshire County Hospital for a scheduled appointment relating to the
management of his pressure sore. He was given advice on pain reduction and
control and returned to the prison.
17. At 1.45am on 29 July, he was found on the floor of his cell complaining of neck
pain. He was checked for injuries before being helped back to bed by
healthcare staff. He was given painkillers and slept until the morning.
18. The man’s deteriorating health was discussed on 1 August by a doctor and the
healthcare team. In the clinical notes, the doctor wrote that a GP review was
required. In her interview with the clinical reviewer, the doctor said that she
could not recall the details of the discussion, but indicated that such an entry
usually results from a conversation about a prisoner’s medication.
19. Three days later, on 4 August, it was recorded that the man was moving about
again. He walked to the treatment room in the healthcare centre for a new
catheter to be inserted.
20. The following day, the man was seen by the prison doctor who found that his
condition was a stark contrast to that of the previous day. He was unable to
swallow, and so was not eating and was unable to take his medication.
Following discussion between the prison doctor and the Medical Registrar at
the Royal Hampshire County Hospital, the man was sent to the Emergency
Assessment Unit at the hospital. He was accompanied by bedwatch officers
from the prison and restrained, as per the Prison Service’s bedwatch guidance,
with handcuffs.
21. Upon admission, the man underwent a series of tests. These showed that his
pulse was raised and he was suffering from a fever. His blood pressure was
also abnormal and he was found to have paralysis of one side of his body. The
initial diagnosis was a stroke with blood poisoning.
8
22. At 3.45pm on 7 August, in view of the man’s serious condition, the prison
authorised that the handcuffs could be removed. Later that day, he was given
a blood transfusion.
23. On 11 August and 14 August, the man was visited in the hospital by the prison
chaplain. On 15 August, he also received a visit from a member of the prison’s
Independent Monitoring Board to check that everything was in order and that
he was being looked after. Later in the day, an electrocardiogram (ECG) was
carried out. The doctor who examined the results told the bedwatch officers
that the man required surgery to repair a faulty heart valve.
24. During the morning of 17 August, the man’s intravenous drip was removed and
so he was more mobile. Consequently, he was restrained by the use of an
escort chain. However, the chain was removed the following day when the drip
was reinstated.
25. At 1.25am on 20 August, the man suffered a heart attack. He was moved to
the Intensive Care Unit where it was established that he had suffered brain
damage. At 4.40am, one of the bedwatch officers noted in the man’s records
that he was paralysed and heavily sedated.
26. Over the next few days, the man’s condition was stabilised although he
remained very poorly. He was visited by the prison chaplain on a number of
occasions. At 8.00pm on 23 August, the prison authorised that the man’s
bedwatch should be reduced from two officers to one.
27. During the morning of 28 August, the man was assessed by a physiotherapist
who expressed concern about his continued lack of consciousness, despite the
fact that sedation had been withdrawn earlier in the day. However, when the
physiotherapist visited him later in the day, he was observed to be more
responsive. He regained consciousness at 6.00am on 30 August. At 2.50pm,
an x-ray was carried out which revealed that he had fluid on his lungs.
28. On 31 August, a comprehensive assessment of the man’s condition was
conducted. Based on the results, a senior consultant at the Royal Hampshire
took the decision to withdraw treatment at 7.15pm. Over the next few hours,
hospital staff attempted to make him as comfortable as possible. He stopped
breathing at 2.50am on 1 September and was formally pronounced dead at
3.45am.
29. At 4.50am, a governor from the prison arrived at the hospital and was briefed
by both the bedwatch officer and nursing staff. The governor was told by the
nursing staff that one of the doctors had spoken to the man’s sister the previous
evening and the family was fully aware that treatment, including life support,
was going to be withdrawn. The nurses told the governor that they would
contact the man’s sister around 7.00am to tell her that her brother had died.
30. At 8.15am, the governor telephoned the man’s sister who confirmed that the
hospital had already contacted her. She told the governor that the hospital had
kept her informed of the man’s condition throughout the time he spent there.
9
My investigator has been unable to establish whether the prison already knew
the hospital was in regular contact with the man’s sister.
31. Support was offered to her, together with an invitation to visit the prison to
speak to staff or have a look around. Winchester subsequently contributed
financially to the costs of the man’s funeral.
10
ISSUES
32. As I say in my foreword to this report, the complexity of the man’s health needs
has meant I have relied heavily on the specialist input of the clinical reviewer. I
was pleased to learn that there is no evidence to suggest that the man’s death
was directly linked to the care he received, and it is a matter of speculation as
to whether it could have been reasonably delayed. Given how poorly he was in
the last two weeks of his life, it is debatable whether prolonging his life would
have been desirable in any event.
33. That said, the clinical review makes numerous observations about how his case
could have been better managed. I will deal with these in turn.
The man’s transfer and reception
34. There was a delay of eight days between the man being received at Winchester
and seeing a doctor. Given that the rationale for him transferring from
Bullingdon to Winchester was for better care to be provided, this is
unacceptable. The clinical reviewer has suggested that, if the transfer had
been arranged by clinical staff, it is more likely that the man’s care would have
been continuous. I therefore endorse the following recommendation which I
have reworded slightly for the sake of clarity:
Prisoner patients with chronic disease or complex care management
needs should be identified on admission and seen by a doctor at the
earliest possible time. Management plans should include regular review.
35. The clinical reviewer has made an associated recommendation that the
accuracy of the health status attributed to prisoners, for example ‘fit for
transfer’, should be audited and appropriate action taken if inappropriate
handovers are found to occur. Whilst I support this recommendation in
principle, I refrain from making it a formal recommendation as the research
would be a huge undertaking, disproportionate to the circumstances
surrounding the man’s death. Since I assumed responsibility for investigating
deaths in custody in 2004, I have not noticed that inaccurate information about
the health status of prisoners is a widespread problem.
Transfer of clinical records
36. The man who later died was transferred from Bullingdon to Winchester on 7
July. His clinical records, which are extensive, did not go with him and only
arrived about a week later (it has not been possible to establish the exact date).
The clinical reviewer is of the opinion that this had a negative impact on
Winchester’s ability to carry out an informed assessment of his needs upon his
admission to healthcare. She has recommended that clinical records always
accompany transferred prisoners.
37. Prison Service Orders (PSO) 3050 ‘Continuity of healthcare for prisoners’ and
6200 ‘Transfer of prisoners: inter prison escorts’ provide guidance to prisons on
how transfers should be managed. However, neither specifies that clinical
11
records should accompany prisoners and they are often sent at a later date.
This is akin to what happens when a person in the community registers with a
new doctor – the records are sent at a later date. As the ethos of prison
healthcare is that it should be comparable with that in the community, what
happened in the man’s case would seem at first sight to be entirely reasonable.
38. However, given that the reason for the man’s transfer was to provide a level of
care better suited to his needs, I am surprised that his records were not
transferred with him. Best practice would certainly have indicated that this was
desirable, if not essential. I therefore suggest that, when a prisoner is
transferred directly from one inpatient unit to another, their clinical records
should always accompany them.
Clinical records should always accompany prisoners who are transferred
directly from one healthcare inpatient unit to another.
Ability of prison healthcare services to care for prisoners with complex health
problems
39. As the number of prisoners serving indeterminate or life sentences grows, it
seems inevitable that the number of more elderly prisoners will increase. It is
likely that, as a result, there will be a substantial increase in the number of
prisoners suffering from chronic, long term medical conditions.
40. The clinical review has suggested that the Department of Health and Prison
Service, which are jointly responsible for the healthcare of prisoners, should
conduct a review into the ability of prisons to manage those with complex
health needs. I endorse this recommendation, which is similar to a
recommendation I have recently made to the National Offender Management
Service (NOMS) about the ability of approved probation premises to meet the
needs of increasingly frail offenders. In this case, the clinical reviewer thought
that clinical interventions were only made in response to specific medical
episodes, with no clear objective. She concluded that prison healthcare
services currently lack the expertise and resources to manage prisoners like
the man who is the subject of this report.
The Department of Health and Prison Service should jointly review their
ability to manage prisoners with complex, long term medical conditions.
This review should encompass the resources, expertise and training that
is required to manage those with complications, difficult behaviour or
complex nursing needs.
Other issues
Quality of record keeping
41. The clinical reviewer has found that the quality of record keeping, from the day
the nurse visited the man at Bullingdon to assess his needs until he was
transferred to the Royal Hampshire County Hospital, left a lot to be desired.
She cites examples of referral letters not being dated, clinical entries being
12
deleted or rendered ineligible, care plans not being updated and medication
being brought into the prison on transfer without being recorded.
42. Accurate and timely record keeping should be an integral part of any
organisation’s day to day practices. However, when the records in question
relate to the care and treatment of a person with significant health problems, it
is imperative that decisions and actions are clearly documented. This is the
only way in which care can be delivered consistently and the health needs of
the prisoner met. I therefore fully endorse the following recommendations,
some of which I have reworded slightly:
Healthcare reception documentation should be audited to ensure it is
filled in accurately and signed by the person completing the assessment.
Where a prisoner’s history indicates that a full medical assessment is
required, this should be recorded and an appropriate referral made.
A record of medicines should be made from the day of admission.
Medication brought into the prison on transfer must be recorded and, if it
is deemed to be for use ‘in possession’, this must be made clear.
Care plans should be updated at regular intervals, and always when
requested. The person completing the review must sign the review.
All referral letters must be dated. Where appropriate they should include
details of current medication as well as the medical condition and the
reason for the referral.
Entries in clinical records must never be deleted or otherwise rendered
ineligible. If they are incorrect they should be crossed through once and
initialled by the person overwriting them.
Arrangements between Winchester and Friarsgate GP Practice
43. The clinical review describes aspects of the man’s care that fell short of what is
expected. She suggests this was because of a lack of clarity about the
respective roles of prison healthcare and Friarsgate Practice which provides
GP services to the prison. In particular, the clinical reviewer criticises the
apparent failure to follow up and review a set of blood tests requested on 20
July.
44. I have addressed one of the associated recommendations directly to the Chief
Executive of the PCT in a separate letter as I do not think it is directly relevant
to my investigation. However, I am concerned that the man’s blood test results
were apparently not followed up and therefore endorse the recommendation
that:
Winchester and the Friarsgate Practice should agree a protocol for
following up and reviewing prisoners’ test results.
13
RECOMMENDATIONS
To the Department of Health and Prison Service
1. The Department of Health and Prison Service should jointly review their ability
to manage prisoners with complex, long term medical conditions. This review
should encompass the resources, expertise and training that is required to
manage those with complications, difficult behaviour or complex nursing needs.
2. Clinical records should always accompany prisoners who are transferred
directly from one healthcare inpatient unit to another.
The Department of Health and the Prison Service, in their joint response to the
draft version of this report, have accepted recommendation 2 and say that
procedures are already in place to ensure that records are always transferred.
At the time of writing they have not provided a response to recommendation 1. I
have been assured that I will receive one in due course.
To the Primary Care Trust
3. Prisoner patients with chronic disease or complex care management needs
should be identified on admission and seen by a doctor at the earliest possible
time. Management plans should include regular review.
4. Healthcare reception documentation should be audited to ensure it is filled in
accurately and signed by the person completing the assessment. Where a
prisoner’s history indicates that a full medical assessment is required, this
should be recorded and an appropriate referral made.
5. A record of medicines should be made from the day of admission. Medication
brought into the prison on transfer must be recorded and, if it is deemed to be
for use ‘in possession’, this must be made clear.
6. Care plans should be updated at regular intervals, and always when requested.
The person completing the review must sign the review.
7. All referral letters must be dated. Where appropriate they should include details
of current medication as well as the medical condition and the reason for the
referral.
8. Entries in clinical records must never be deleted or otherwise rendered
ineligible. If they are incorrect they should be crossed through once and
initialled by the person overwriting them.
9. Winchester and the Friarsgate Practice should agree a protocol for following up
and reviewing prisoners’ test results.
Hampshire PCT has accepted all of these recommendations and at the time of
writing has either implemented them or has plans to do so.
14
GOOD PRACTICE
1. The way in which Winchester maintained contact with the man whilst he was in
hospital is worthy of note. I was particularly pleased to learn that the prison
chaplain visited on a number of occasions.
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