Individual at Wymott

Circumstances surrounding the death of the man, a prisoner at HMP Wymott,
in January 2005
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2005
This is the report of an investigation into the circumstances of the death of the
man, a prisoner at HMP Wymott. The man had been unwell for some time
and died in January 2005 in hospital. He had been diagnosed with lung
cancer in October 2004 and his death was not unexpected. The day before
his death, he had moved from HMP Ford (a prison at the other end of the
country) to be closer to his family.
The investigation was led by one of my Investigators. A clinical review into the
man’s care and treatment was commissioned from a doctor, of the Primary
Care Trust (PCT).
I offer my condolences to the man’s family for their loss.
I would like to thank the Head of Healthcare at HMP Ford, the Governor of
HMP Wymott, and other staff at both prisons for their assistance with this
investigation.
Stephen Shaw CBE October 2005
Prisons and Probation Ombudsman
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Contents
Summary .........................................................................................................4
Investigation.....................................................................................................5
HMP Ford ........................................................................................................6
The man...........................................................................................................7
Events Leading up to January 2005.................................................................8
Issues Considered.........................................................................................10
Conclusions and Recommendations..............................................................11
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Summary
The man died at hospital in January 2005. He was aged 62. The cause of
death was lung cancer. His death was not connected to the fact that he was in
prison or to the level of care that he received there.
The man had been taken to the hospital by ambulance from HMP Wymott the
evening before he died as healthcare staff were concerned about his
condition. He had only arrived at Wymott a few hours earlier, having been
transferred from HMP Ford to be closer to his family.
The man had been diagnosed with lung cancer in October 2004 when his
condition was treated with surgery and medication. However, a few months
later it was discovered that the cancer had spread to his spine. He was given
a prognosis of not more than three months to live.
Various options were considered by staff at Ford concerning palliative care for
him. These included temporary release, early release on compassionate
grounds as well as a move to a prison nearer his family. In the event, the man
arrived at Wymott just a matter of hours before being taken to hospital. He
died the next day at 5.40pm.
The Governor and staff at both Ford and Wymott responded to the man’s
illness and death with professionalism and sensitivity.
There are no recommendations arising from this investigation. The clinical
review raised no concerns, but highlighted some procedural considerations for
the prescribing of certain medications and suggested that the local hospice
might have become involved earlier in the man’s care. The post mortem
indicates that he had good medical care locally, and died from lung cancer in a
clinically understandable timeframe.
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Investigation process
My practice in investigations into a death from apparently natural causes is to
conduct an initial review to determine the extent of investigation required.
My colleague visited HMP Ford. She met the Head of Healthcare, and the
Governor who was involved in managing the man’s care. My investigator had
already been provided with the man's prison record and copies of the notices,
reports and other paperwork that followed his death. She also visited the wing
where he had lived and spoke to staff who worked there.
My investigator gathered details of the man's next of kin, the Coroner’s officer
and the appropriate contact in the Primary Care Trust (PCT). One of my
Family Liaison Officers subsequently contacted the man's brother.
A doctor was commissioned by the PCT to carry out a clinical review.
No formal interviews with staff were conducted. This report is based upon informal
meetings with the Governor involved in managing the man’s care, the Head of
Healthcare, and other staff at Ford, as well as discussions with the Governor at
Wymott. Additionally, a thorough review of all relevant paperwork was conducted
and the findings of the clinical review considered.
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HMP Ford
Ford prison is situated outside Arundel in Sussex. It opened as a prison in
1960, having been converted from a military airfield into its current use. It is a
category D open prison for men with its main role being one of resettlement
and rehabilitation. The majority of prisoners undertake a wide range of
voluntary and paid work in the community.
The prison has two residential units. A wing houses about 200 men along with
a kitchen, dining room, library and healthcare centre. B Wing provides a range
of dormitory style accommodation.
Owing to Ford’s open status there are no in-patient healthcare facilities.
Prisoners access healthcare directly from services in the local community.
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The man
The man was born in London but brought up in Lancaster, where the family
had relocated when he was still an infant. He had two siblings, with whom he
enjoyed a close relationship. He described his childhood as a happy one.
Having joined the army after leaving school, the man travelled the world,
returning home to care for his father who was ill after four and a half years of
military service. He settled in the Morecambe area and initially worked as a
lorry driver. He then completed a four-year apprenticeship and qualified as a
painter and decorator.
After a series of unsuccessful business and employment ventures and the
breakdown of a relationship, he moved to Spain in 1997. He worked
successfully as a gardener and caretaker for several years until, after a period
of ill health, he was forced to retire.
The man was subsequently arrested in Jersey attempting to import cannabis
into Britain. He was convicted in 2002 and given a sentence of nine years.
This was later reduced to seven and a half years on appeal. Given that he
had been arrested and tried in Jersey, he was subject to the island’s laws,
even when he subsequently transferred to prisons in Britain.
The man began his sentence at La Moye prison in Jersey and was later
transferred to HMP Winchester on a Restricted Transfer. (Restricted Transfer
means that the prisoner retains the release dates previously notified to him by
the Jersey authorities.) In the man’s case, this meant that he would not be
eligible for parole or Home Detention Curfew and would not be released on a
supervision licence under the rules obtaining in England and Wales.
The man moved to Ford in December 2003 and lived on A wing. Staff there
described him as a diligent worker, and as a respectful and friendly man. His
health had not been good for some time. He suffered from heart problems
and depression.
The man had contact with family members during his time in prison.
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Events leading up to 14 January 2005
The man was detained in HMP Jersey following his conviction in 2002. On
reception, it was noted that he had a history of heart disease and depression.
He had various appointments and was prescribed a number of medications for
his presenting illnesses. In October 2003, while at Winchester, he was
admitted to hospital for a short period for angina. However, for most of the
time he remained reasonably well.
On 13 August 2004, the man saw a doctor at Ford and complained of a cough
and phlegm and a "fleck of fresh blood" in his sputum. He was referred for an
urgent chest X-ray which showed a mass in his right lung. The man was seen
in the chest clinic as an urgent case later that month because of the
appearances on the chest X-ray. By October 2004, he had been diagnosed
with a lung malignancy, namely a ‘non small cell lung carcinoma of the right
middle and lower lobes’.
The man was referred to a London hospital, for surgical intervention, and
underwent surgery on 4 November 2004. After a short delay, because of an
abnormal heart rhythm, he was discharged back to Ford on 10 December
2004.
The man was admitted to another hospital a week later with severe lower
back pain. His discharge from hospital was delayed again because of further
complications and he returned to Ford on 5 January 2005. A doctor at this
hospital comments in the medical records of 6 January, "his life expectancy is
probably now a matter of months and possibly just weeks". This was the first
time the prison became aware how serious the man’s illness was.
The following day (7 January), the Governor at HMP Ford gave instructions
that compassionate release should be sought and, in the interim, temporary
release arrangements should be made. It was at this point that staff at Ford
became aware that the man had been sentenced in Jersey and was therefore
subject to the restrictions of that jurisdiction. At the same time, the medical
officer at Ford was of the view that the man could not stay in Ford.
Over the next few days, staff made enquires about his home area, and with
his family. Initially it was agreed the he would stay with his brother, until he
needed hospice care. However, it soon became apparent that the man would
require a level of care beyond that which his brother could provide.
The man’s brother then contacted a Macmillan nurse who tried to help with
accommodation and with finding a GP for the man. However, the Probation
Officer at Ford believed that, as the man had not lived in the area, finding
services locally for him might prove time consuming. For these reasons, the
procedures necessary to arrange temporary release were abandoned and
consideration was given instead to transferring him to a prison near his family.
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This would enable him to have visits from his family and subsequent days out
if his health permitted it.
However, the man’s brother continued to work closely with the Probation
Service in Lancaster and suitable accommodation was found for the man,
pending his release on the agreement of the Jersey authorities.
On 10 January, the deputy Governor at Ford, spoke to the Governor of La
Moye prison in Jersey. They discussed the requirements for releasing the
man, given Jersey regulations. The Governor of La Moye prison confirmed
that an application could be made to the Bailiff (a public official) with whom the
final decision would rest. Shortly afterwards, the deputy Governor of Ford
completed the relevant paperwork and faxed the request to La Moye.
Over the next week, the man remained breathless and was coughing up
blood. On 11 January, the local hospice was contacted and a hospice doctor
agreed to visit him, should he require ongoing hospice treatment in that area.
A prison place was found for the man at HMP Wymott near Lancaster. There
was concern about the journey from Ford to Lancaster. It was clear he was
not well enough to travel alone.
The man's condition deteriorated on 12 January, but he was considered well
enough for the transfer to take place. On 13 January, the man left Ford for
Wymott. Ford made provision for the Red Cross to provide an ambulance and
two paramedic’s for the journey. He arrived at Wymott at 4:35 pm on 13
January 2005. He was described as very short of breath and lethargic.
The man’s condition further declined during that evening, and during the night
he was admitted to hospital by ambulance because of increasing
breathlessness, distress and agitation. Once at the hospital, the escorting
staff rang the prison for advice on the use of handcuffs. The Governor
advised that, for the preservation of dignity, these should not be used.
The man’s brother was aware of the situation through contact with the local
Probation Office. They phoned him on the morning of 14 January to let him
know that the man had been moved to hospital. As he was on his way to a
business meeting, he arranged to call at the hospital that evening.
At 4:30 pm on 14 January, the Governor at Ford was informed that the man
had been granted 12 months temporary release by the Jersey authorities.
She informed Wymott directly. However, he died at 5:40 pm in the hospital.
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Issues Considered
Wymott followed its contingency plans relating to deaths of prisoners.
Statements were taken from staff, the IMB were informed and notices to staff
and prisoners were issued. The post-incident response was fully compliant
with Prison Service instructions and policies on managing a death in custody.
The decision not to use any form of handcuff or restraint was entirely
appropriate given the circumstances. However, given that the man had
moved from Ford to Wymott for health and not security reasons, it is
surprising that restraints were considered at all.
The hospital local to Ford had discharged the man on 5 January because
there was nothing further they could do for him. The Governor at Ford then
directed that early release on compassionate grounds should be sought. In
the interim, a temporary release licence would be considered. Ford rightly felt
the man should have been released into the care of his family. However, with
the worsening of his condition, this became impossible.
The prison probation officer’s view that finding accommodation and support
services in Lancaster might prove difficult and time consuming was
reasonable in the circumstances, taking into account the urgency of the need
to move the man to his brother’s home area. I believe the decision to
abandon plans for temporary release and concentrate on moving him to a
prison closer to his brother was entirely proper. In fact, the application for
early release on compassionate grounds was processed speedily by La Moye
prison and the Jersey authorities. The decision to grant release for 12 months
came sadly just too late for the man.
I am pleased that, despite the difficulties of the situation, the need to involve
the Jersey authorities, and the worsening of the man’s health, the move to be
closer to his brother was accomplished. No-one could have known that his
death would have followed so quickly thereafter.
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Conclusions and Recommendations
The clinical review did not find any deficiencies in the man’s medical treatment
while at Ford or Wymott but did identify some learning points. The man had a
terminal medical condition. I note that he was a lifelong smoker and that his
father had also died prematurely from lung cancer.
The man appears to have settled well at Ford. I have seen no evidence to
suggest that he had specific problems that were affecting his mental or
physical health. Ford acted quickly and compassionately to deal with his
situation once the extent of his cancer and his prognosis became clear on 6
January. I commend the Governor and her staff for that.
I am myself sending a copy of this report to the Governor of La Moye prison,
Jersey, for his information. Although the man died while a prisoner at Wymott,
he had only been there a matter of hours. I trust that the Prison Service’s
North West Area Office will also ensure that a copy of this report is sent to the
Governor at Ford.
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