Individual at Woodhill

Investigation into the circumstances surrounding the death of a prisoner
released on temporary licence from HMP Woodhill, at a hospice, in
September 2005
Report by the Prisons and Probation Ombudsman for England and Wales
October 2006
This is the report of an investigation into the death of a man in September 2005. The
man died in a Hospice in Milton Keynes, having been released on temporary licence
from HMP Woodhill. He was 38 years old at the time of his death and had liver
disease.
An inquest into the man’s death was held in September 2005. The Coroner
recorded that the man died from natural causes.
My colleagues and I would like to extend our condolences to his family and all those
touched by his death.
The investigation was conducted by one of my colleagues. An independent clinical
review into the man’s care was carried out by Milton Keynes Primary Care Trust. I
must apologise for the delay in completing this report.
I am critical of aspects of the clinical care the man received while in prison custody,
and make recommendations directed to HMP Bedford and HMP Woodhill.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2006
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SUMMARY
The man was received into HMP Bedford in June 2005, having been charged with a
number of offences of shoplifting. He had a long history of drug and alcohol abuse.
On reception into prison, he was noted to be under the care of a hospital consultant
as he was suffering from hepatitis C and liver cirrhosis. Although the man’s liver
disease was identified on reception, little was done at HMP Bedford, or subsequently
at HMP Woodhill, to ensure appropriate continuing care of his condition. The man
was issued medication to manage his withdrawal from drugs, and the pain
associated with the liver problems, but these were not fully thought through. On at
least one occasion, he was prescribed medication that is clearly contraindicated in
liver disease. Whilst I do not believe this had a direct bearing on the final outcome, it
is worrying that a standardised approach was taken to detoxification with no
consideration of personal clinical needs. Furthermore, the standards of record
keeping at times fell below required standards.
Towards the end of August 2005, the man was referred by Woodhill to the local
hospital in Milton Keynes. He was admitted for further tests and what ultimately
turned out to be terminal care. The man was appropriately transferred from the local
general hospital to a hospice for palliative care, where he spent his last few days.
The man died in September.
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KEY FINDINGS AND ISSUES
The man was born in Northamptonshire. He had begun sniffing glue at the age of
13, and at 14 had begun to drink alcohol. By the age of 28, he was injecting heroin.
At the time of his arrest, the man admitted to using three to four bags of heroin and
occasionally smoking cannabis.
The man had left school without any formal qualifications, but was numerate and
literate. He had a number of transient labouring jobs, but had not worked for a
number of years because of his ill-health and was dependent upon Income Support.
The sum he received each week was insufficient to meet his everyday living needs in
tandem with his substance misuse.
His pre-sentence report notes that he was under the care of specialists at hospital in
Cambridge for cirrhosis of the liver and hepatitis C. He was also noted to be taking
prescribed dihydrocodeine for pain control. The man had engaged with the local
community drug team, but they were struggling to identify a suitable detoxification
programme because of his health needs and the number of medications that are
contraindicated in people with liver disease. The community drug team were liaising
with the man’s hospital to see what they could safely prescribe.
In May 2005, the man spent a period of eight days on remand at HMP Woodhill,
charged with shoplifting offences, but was then released on bail. In June, he was
arrested for a further offence and taken to the local police station where he was seen
by the Forensic Medical Examiner. He was prescribed medication to help with the
symptoms of withdrawal and his painkillers were continued. The next day, the man
appeared at Corby Magistrates’ Court and was remanded into prison custody. From
court he was taken to HMP Bedford, arriving about 7.30pm.
On arrival, the man was seen by the reception staff and a cell sharing risk
assessment was completed. This identified him as being a high risk, after he told
staff that he could become aggressive as a result of his withdrawal from illicit drugs.
Section four of the risk assessment requires a referral to a duty manager in the event
of a prisoner being assessed as a high risk. This section has been signed, but the
boxes identifying the type of accommodation (single, shared or other cell) have not
been completed. Whilst the failure to complete this section fully had no bearing on
what was to follow, it could be vital in the case of other prisoners.
The Governor of Bedford should remind all managers of the importance of
fully completing cell sharing risk assessments.
The man was also seen by a healthcare worker and a new reception health
assessment was completed. This process correctly identified his liver problems and
his continuing care at hospital. A note was made of his current prescriptions and
substance misuse. The reception screening document and an entry in the medical
record appropriately refer the man to the medical officer for a further assessment.
The entry also indicates that the man was issued with the standard ‘First night
detox’. The three medications contained in this pack - two painkillers and one
sleeping tablet - are not recognised detoxification medication, but would provide
some relief for the symptoms of withdrawal. For this reason, they should not be
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referred to as ‘detox’ medication. It is also of concern that no consideration appears
to have been given to the man’s current medication, or his presenting clinical
conditions which would have restricted the nature and type of medication he could
take.
The healthcare manager at HMP Bedford should ensure that the care of
substance misusers is individualised and takes into account clinical needs
which may contraindicate the prescribing and issue of certain medications.
The man was seen by the medical officer on 1 July, and the plan of care was for him
to commence an opiate detox and for contact to be made with the hospital treating
him for further information. The contact telephone number and hospital number are
noted in the continuous clinical record and a subsequent entry notes that the man
had an appointment for 1 September. The entry does not contain any further
information about the man’s condition, treatment or prescribed medication.
Later that day, he was visited on the residential units by a member of the healthcare
team to issue his Lofexidine. However, he refused his new prescription, saying that
he still had his ‘first night detox’ in his cell. As a result, only a sleeping tablet was
given to him on this occasion. The entry in the clinical record notes that his blood
pressure and pulse were checked and were found to be within normal limits.
Apart from the administration of his Lofexidine, there are no further entries in the
clinical record over the next week. Clinical guidelines indicate that patients should
have their blood pressure and pulse monitored for the first three days when
administering Lofexidine, but the clinical record does not reflect that this occurred.
The healthcare manager will wish to remind healthcare staff of the need to take
these observations for at least the first three days.
In July, the man appeared in court and was sentenced to 243 days imprisonment.
Following sentencing, he was taken to HMP Woodhill. On arrival, a further cell
sharing risk assessment was fully completed, and the man was seen by a doctor
who noted his past medical history and prescription medication. The doctor referred
him to the substance misuse team. The man was seen by a member of the team the
following day, and the entry notes that he was not showing any signs of withdrawal
and was refusing any further medication.
The next entry in the medical record is dated 21 July when he saw the doctor for a
repeat prescription. A doctor examined him and found his liver to be palpable. It
appears that this was the first time the man was physically examined. However, as
the clinical reviewer notes, it is not clear why further examination or tests were not
considered. Furthermore, there is no documentary evidence to show that any further
information or advice was sought from the man’s outside hospital.
The Milton Keynes Primary Care Trust and the healthcare manager at HMP
Woodhill should ensure that systems are in place for promptly obtaining past
medical records to assist the understanding of clinical conditions and future
multi-disciplinary care planning.
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On 11 August, the man complained of pain that was not being well controlled. The
entry in his medical record notes that he had an enlarged abdomen with prominent
veins, but this still did not prompt a referral to either he specialist hospital or the local
hospital in Milton Keynes. The presenting clinical symptoms should have alerted
clinicians to the seriousness of the man’s condition and prompted such a referral.
During the evening of 13 August, staff in healthcare were asked to see the man who
was complaining of ‘abdominal / chest pain’. A nurse visited the man and contact
was made with the on-call doctor who prescribed paracetamol. This is clearly
contraindicated in patients with liver conditions. The man was also offered
admission to the healthcare centre, but he refused.
The following day, he was seen by the medical officer and the entry notes that the
man asked to be referred to the hospital where he had previously been treated and
this was agreed. There is no evidence to show that a further physical examination
was undertaken. An entry dated four days later makes reference to the scheduled
appointment at hospital, originally booked for 1 September, having been rebooked,
but gives no further information. A later entry notes this rescheduled appointment to
be on 22 September.
On 31 August, a doctor saw he man for his ‘distended painful abdomen’. The doctor
completed a thorough and well documented examination of the man and noted that
he required ascetic draining. The doctor requested that the hospital be contacted to
bring forward the appointment as soon as possible. There is no evidence that this
occurred. On 2 September, the same doctor saw the man again and arranged for
him to be admitted to the local hospital. The man was taken to the local hospital that
day and admitted for drainage of the collection of fluid in his abdomen.
The doctor should be commended for his record keeping. This is in direct contrast to
some of the other entries. They are difficult to read, do not reflect the plan of care,
and have signatures that are unclear with no printed name or designation.
Healthcare professionals at HMP Woodhill should be reminded of the need for
good standards of record keeping. A clinical audit should be developed to
monitor compliance with the standards of records and record keeping required
by professional bodies.
The man remained in hospital until mid-September when he moved to a hospice for
palliative care. In early September, Release on Temporary Licence papers had
been completed, and he was issued with and signed a temporary release licence the
following day. The licence noted that one officer would remain with him at all times
to offer support. The licence was appropriately reviewed and extended seven days
later. The following day, it was amended to reflect his admission to a local hospice.
The man died early evening on a day in September as a result of his liver problems.
An inquest held at the end of September 2005 concluded that his death was from
natural causes.
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RECOMMENDATIONS
1. The Governor of Bedford should remind all managers of the importance
of fully completing cell sharing risk assessments.
2. The healthcare manager at HMP Bedford should ensure that the care of
substance misusers is individualised and takes into account clinical
needs which may contraindicate the prescribing and issue of certain
medications.
3. The Milton Keynes Primary Care Trust and the healthcare manager at
HMP Woodhill should ensure that systems are in place for promptly
obtaining past medical records to assist the understanding of clinical
conditions and future multi-disciplinary care planning.
4. Healthcare professionals at HMP Woodhill should be reminded of the
need for good standards of record keeping. A clinical audit should be
developed to monitor compliance with the standards of records and
record keeping required by professional bodies.
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