Individual at Long Lartin

Investigation into the circumstances surrounding the death
of a man in March 2010
at hospital whilst in the custody of HMP Long Lartin
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2011
This is the report of an investigation into the circumstances of the death of
a man, a prisoner at HMP Long Lartin, in March 2010. He was born with bronchial
pneumonia and suffered from lung disease throughout his life. He was 58 years old
when he died. I would like to offer my sincere condolences to his family and to all those
who knew him and were saddened by his death.
An investigator conducted the investigation. An independent review of the man’s
medical care was undertaken by clinical reviewers on behalf of the local Primary Care
Trust (PCT). I am very grateful to them for their comprehensive review and very
valuable contribution to my report.
I would also like to thank the Governor of Long Lartin and his staff for their cooperation.
I would like to express my appreciation and thanks to the prisoners and staff on Perrie
Wing who knew the man well and provided valuable information to the investigator.
The man’s life expectancy was significantly reduced due to his chronic lung disease. In
the light of his medical history, I accept that his death at the age of 58 was
understandable and unavoidable. The clinical review has found a number of examples
of good practice in managing his health with evidence of good care planning, record
keeping and prescribing. The reviewers placed particular emphasis on the
professionalism of healthcare staff and the standard of care offered to him whilst he was
at Long Lartin. He refused a number of hospital admissions and often declined to take
his medication because he found the side effects difficult to tolerate. Healthcare staff
made significant efforts to find alternative solutions that he would accept.
In the last few months of his life, the man relied on nutritional supplements rather than a
normal diet. However, owing to poor organisation in stocking adequate quantities, he
was not always given the amount prescribed. There was also some confusion as to
where some medication was held. The investigation also revealed a difficulty in
supplying developer fluid for x-rays which resulted in staff being unable to carry out an
urgent x-ray at a critical stage of his care. I make three recommendations regarding the
need for better coordination and procurement of medical supplies. I also question why
compassionate release from prison was not considered when his condition was known
to be terminal and I make a further recommendation in this regard. My final
recommendation concerns the absence of a hot debrief for staff following his death.
My recommendations aside, the investigation found that healthcare and prison staff
provided a very high standard of care for the man despite his lack of cooperation at
times.
The National Offender Management Service has accepted my recommendations and
their response is documented on page 26 of my report.
This version of my report, published on my website, has been amended to remove the
names of the man who died and those of staff and prisoners involved in my
investigation.
2
Jane Webb
Acting Prisons and Probation Ombudsman January 2011
3
CONTENTS
Summary
The investigation process
HMP Long Lartin
Key findings
Issues
Conclusions
Recommendation
4
SUMMARY
The man was born with lung disease and he was suffering from emphysema when he
was remanded to HMP Woodhill in May 2005. He received a life sentence for murder in
December 2006 and was sent to HMP Long Lartin in August 2007. This was not his
first experience of prison.
In an interview at Woodhill on the day he arrived, the man told healthcare staff of his
lung related health problems and also that he had an alcohol problem. Staff placed him
on constant supervision in the inpatient healthcare centre as he felt suicidal and an
automatic referral was made to the Mental Health Inreach Team because of his offence.
He was prescribed medication for depression and detoxification, although it was not
specifically mentioned in the clinical record that he was suffering from alcohol
withdrawal. After spending a short time in healthcare, he was considered fit to live on a
wing.
While at Woodhill, the man attended a number of healthcare clinics including those for
management of his lung condition. He transferred to HMP Long Lartin on 22 August
2007 and again, had a first reception healthcare interview with a member of the
healthcare staff. His history of chronic obstructive pulmonary disease (COPD)1,
depression, emphysema, alcohol misuse and previous overdose attempt were
recorded. He was assessed as unfit for work and his chest problems gave cause for
concern so he was referred to a prison doctor.
The man had been referred to a hospital for his chest problems while he was living in
the community. The prison wrote to the Consultant Physician at hospital to ascertain
diagnosis and treatment in the past. The Consultant confirmed that the man had
previously suffered from a non-contagious form of tuberculosis. Tests showed that he
had mycobacterium kansasii2. He was prescribed rifampicin,3 ethambutol4 and
clarithromycin5.
Throughout his sentence, the man’s health deteriorated. He was unwilling to take the
medication prescribed to treat the tuberculosis on the basis that he had taken it in the
past and it made him worse. Despite encouragement by staff, he took his medication
sporadically, and continued to smoke against medical advice. Staff adopted a flexible
attitude with him to try to find acceptable compromises. He also refused to go to
hospital on occasion because he felt that wearing restraints was undignified.
As the man’s health deteriorated, he had difficulty in eating and lost weight. He was
prescribed nutritional supplements, but at times, the prison did not order sufficient
1 Chronic obstructive pulmonary disease (COPD) is the collective name for lung disease.
2 Mycobacterium kansasii is a non transferable form of tuberculosis contracted from contaminated water. The man
had worked in drainage sewers in the past.
3 Rifampicin is an antibiotic drug of the rifamycin group. It is typically used to treat mycobacterium infections.
4 Ethambutol is a drug prescribed to treat tuberculosis.
5 Clarithromycin is an antibiotic used to treat a wide range of infections caused by bacteria and other micro-
organisms.
5
supplies to satisfy the demand for all the prisoners who needed them. In addition, on
one occasion, staff were unable to carry out an urgent x-ray owing to a lack of
developer fluid for the x-ray machine. The clinical review also identified a lack of
communication regarding the storage of medication which caused a short delay in him
receiving vital treatment. I have made recommendations regarding these issues
concerning medical supplies.
In late December 2009, the man underwent a mental health assessment to gauge his
mental ability to make decisions for himself. The assessment concluded that he was
capable. His health continued to deteriorate but he was not allowed to have oxygen in
his cell because this, combined with his smoking, was a fire risk. He was adamant that
he wanted to remain on the wing and refused to stay in healthcare where oxygen was
available and he could be monitored.
The wing history sheet completed by discipline staff on 16 February shows that they
were aware that the man knew he was terminally ill. Healthcare staff also knew that he
had completed the paperwork to confirm that he did not want to be resuscitated in the
event of a collapse. There is no evidence to suggest that a release from prison on
compassionate grounds was considered at this or at any other point and I have made a
recommendation reminding the Governor to consider the suitability of terminally ill
prisoners for release on this basis.
On 25 February, the man was taken to hospital with severe breathing difficulties. His
family were told and visited him two days later. Despite the efforts by healthcare and
hospital staff, he died in March. His next of kin were told in accordance with their
instructions previously given to the prison.
The clinical review judged overall that the clinical care the man received at the prison
was good. The clinical reviewers commented on the professionalism of healthcare staff,
quality of history taking and appropriate prescribing. Care plans and their
implementation are described as “excellent”. I concur with their view that he was well
cared for in spite of his reluctance to adhere to medical advice.
6
INVESTIGATION PROCESS
1. The man died in March 2010. This office was notified of his death later that night.
Terms of reference and notices were issued to staff and prisoners at Long Lartin
telling them that an investigation would be taking place, and inviting those who
wished to see the investigator to make themselves known. The investigator
requested copies of his core record, clinical record, and other records relevant to his
time in custody and his death.
2. The investigator also contacted HM Coroner to inform him of the nature and scope
of my investigation and to request a copy of the post mortem report.
3. The investigator visited Long Lartin on 20 April. She toured Perrie Wing, where she
met and spoke with prisoners and staff who knew the man well. She spoke with the
governor responsible for Perrie Wing, the Head of Healthcare and a prison officer on
Perrie Wing.
4. A clinical review of the man’s medical care was commissioned from the local
Primary Care Trust and undertaken by two clinical reviewers. They also interviewed
relevant staff and prisoners jointly with the investigator. Their comprehensive
review appears as annex to the report.
5. One of my family liaison officers contacted the man’s sister, as his next of kin, to
advise her about my investigation and give her the opportunity to raise any
questions or concerns to be considered. His sister had no concerns regarding the
care her brother received at Long Lartin.
7
HMP LONG LARTIN
6. HMP Long Lartin is part of the high security estate and accommodates prisoners
with a sentence of four years or over, including those serving a life sentence. During
the past year, the prison has increased its maximum capacity from 454 to 622
prisoners. The prison population at Long Lartin includes both remand and
sentenced category A and B prisoners6.
7. The man was accommodated in Perrie Wing, one of the six residential wings. The
unit holds a mix of category A and B prisoners and is divided into two spurs, red
spur and blue spur holding 44 and 76 prisoners respectively. He was a category B
prisoner on blue spur.
12. The Independent Monitoring Board (IMB)7 report for the period 1 February 2009 to
31 January 2010 acknowledged the challenges the prison faced in dealing with the
sudden significant increase in the population at Long Lartin and specifically the
increase in older prisoners held at the prison.
13. Following an announced inspection in July 2008, HM Inspectorate of Prisons,
praised Long Lartin for successfully managing the recent significant increase in
vulnerable prisoners while ensuring the prison remained a generally safe place,
despite a very challenging population.
14. The Inspectorate described primary healthcare services as good with a broad range
of nurse led clinics and visiting consultants. The recent rapid increase in the
population was not matched by a corresponding increase in healthcare staff,
although a nurse had been appointed as a specialist elderly care nurse. At the time
that my investigator visited, the head of healthcare said that the prison was in the
process of recruiting healthcare staff to address the issue. Prisoners who spoke to
the investigator said that healthcare staff were stretched with additional prisoners to
care for. The Inspectorate found some deficiencies in the pharmacy arrangements,
including difficulties with named prisoner medicines being mixed with ordinary stock.
A recommendation was made that the pharmacist should control stock supplied and
introduce a dual-labelling system to ensure that it can be audited. Issues with
prescribed pharmacy supplies for the man have been highlighted in my report.
6
Prisoners are risk assessed and given a category based on their offence and the risk that they pose to the public should they
escape. There are four levels: A, B, C and D. Category A prisoners are those whose escape would be highly dangerous to the
public, the police or to the security of the state. Category B are prisoners for whom the highest security conditions are not
necessary but for whom escape must be made very difficult.
7
All prisons in England and Wales have an Independent Monitoring Board (IMB). The IMB is staffed by volunteers from the local
community. They have access to every area of the prison, monitoring standards of decency, answering prisoners’ queries and
investigating complaints. The IMB is required to publish an annual report to the Secretary of State highlighting good practice and
areas of concern.
8
15. There have been three self-inflicted and two natural cause deaths at Long Lartin
since my office assumed responsibility for investigating deaths in custody in 2004.
There are no similarities between the man’s death and those of previous prisoners
at Long Lartin.
9
KEY FINDINGS
16. The man was remanded into custody at HMP Woodhill on 19 May 2005. This was
not his first experience of prison.8 Prison staff completed a Suicide/Self-Harm
Warning Form on his arrival as he had told a member of the escort staff taking him
from the court to the prison that he would take his own life at the first opportunity.
He was sentenced to life imprisonment for murder on 20 December 2005, with a 13
year tariff9.
17. A First Reception Healthscreen assessment was completed when he arrived at
Woodhill on 19 May. The document said that a referral to the Mental Health Inreach
Team (MHIT) should be made automatically because of the nature of his offence
and this was done. He told healthcare staff completing the form that he had
emphysema and had been tested for tuberculosis (TB) bacterium kansaii, (a non-
contagious form of TB) in the past. He also said that he suffered from a persistent
cough and had difficulty on exertion. While he denied drinking alcohol to excess or
taking drugs, sentence planning records show that he had a longstanding problem
with alcohol.
18. Detailed clinical notes were completed by healthcare staff on the evening of 19 May.
The man told staff he was under the care of a consultant physician at hospital and
was last seen a year before when he was admitted as an emergency case for his
COPD to be treated. On that occasion, he was given medication to treat his
condition and sent home. He revealed that in the past he had smoked around 80
cigarettes a day, but had managed to reduce this to ten to 15 per day at that time.
Three years before, he had been referred to a psychiatrist at hospital for depression
and was prescribed Librium.10 He confirmed that he was not taking antidepressants
although he had attempted suicide in the past. He described being found in a coma
following an overdose after a serious attempt to take his life. He told healthcare staff
he felt suicidal but was uncertain how he would carry out any attempt to take his life.
He was described as “dishevelled, tired and tearful” on interview.
19. Healthcare staff were concerned that the man was at risk of suicide and an action
plan to support him was created. He was to be accommodated in the healthcare
centre immediately. He was also to be given 30mg of Librium, 40mg of Sominex at
night 11 and 10 mg of citalopram12 with referrals to the Mental Health Inreach Team
and for detoxification. It is unclear what the detoxification process specifically
referred to.
20. Staff completed an undated Healthcare Centre Inpatient Assessment form. The
man was noted to have a number of chronic physical complaints, a known history of
8 The First Reception Healthscreen said he had been in prison at Woodhill two years previously.
9 A tariff is set by a court and is the minimum amount of years that must be served before the first application for release into the
community can be considered by the Parole Board for England and Wales.
10 Librium is a tranquiliser used in the treatment of anxiety and acute alcohol withdrawal.
11 Sominex is to aid sleep.
12 Citalopram is an antidepressant drug used to treat major depression.
10
depression with serious suicide attempts in the past,13 and he had expressed
suicidal thoughts and intentions. Care plans to manage his physical and mental
wellbeing were made. He was taken to the inpatient healthcare centre where he
was placed under close supervision by staff. Staff also put in place the prevention of
suicide and self-harm procedures and opened an Assessment, Care in Custody and
Teamwork (ACCT)14 document. He remained in the healthcare centre until 6 June
2005, when a doctor assessed him as having improved and well enough to move to
a residential wing.
21. While at Woodhill, the man saw healthcare staff on a number of occasions for help
with dentistry and COPD management. He failed to attend asthma clinics on two
occasions but the reasons were not recorded.
22. He transferred to Long Lartin on 22 August 2007. Entries in the computerised
clinical record at Long Lartin start on that date. His COPD, depression,
emphysema, alcohol misuse and previous overdose attempts were recorded. Nurse
A saw him on the day he arrived. She recorded that she was unhappy to assess
him as fit for work and he needed to be seen by a prison doctor for review because
of his chest problems.
23. Nurse A’s detailed entry in the clinical record two days later questions whether the
man had tuberculosis. She was aware that he had undergone investigations around
two years before and plans were made to ask for information from the Consultant
Physician at hospital who had treated him in the past.
24. On 24 August, Prison Doctor A, wrote to the Consultant Physician. He believed that
the man was suffering from COPD and emphysema and asked if the Consultant
could comment on whether the man had ever had TB.
25. The Consultant Physician gave a comprehensive reply on 6 September. He said
that he first saw the man in 2003 in the casualty department. The man described a
family history of TB and having a lifelong cough that had worsened in the previous
five or six months. Tests showed that he had mycobacterium kansasii15. He was
prescribed rifampicin, ethambutol16 and clarithromycin for at least 12 months. He
had started the course in 2004, “but unfortunately as predicted his attendance was
sporadic and compliance was a problem”. The Consultant said that he had never
proved that the man had tuberculosis.
26. In February 2008, healthcare staff advised the man to stop smoking, but he
continued to do so against medical advice. He went to healthcare for repeat
13 Overdose with tablets prescribed for diabetes.
14 The ACCT process is opened to monitor and support prisoners at risk of suicide or self-harm. Staff interact with, observe and
monitor the prisoner at regular intervals depending upon the level of the risk. Regular multidisciplinary reviews should be held
where the prisoner and all staff involved in their care attend to review progress and offer practical and emotional support until the
crisis has passed.
15 Mycobacterium kansasii is a non transferable form of tuberculosis contracted from contaminated water. The man had worked in
drainage sewers in the past.
16 Ethambutol is a drug used to treat tuberculosis. It is used in combination with other drugs.
11
prescriptions of salbutamol17 and for other minor ailments, such as backache, for
which he was prescribed paracetamol.
27. The man went to the evening healthcare clinic on 10 March 2009. When he arrived,
he was unable to talk in complete sentences because of shortage of breath. He
complained of having been unwell for the previous three weeks with worsening
emphysema. He was given salbutamol by a nebuliser. Nurse B added his name to
the list of prisoners to be seen by the doctor in the morning, despite noting that the
list was already full.
28. Nurse B notified the out of hours doctor18 in the community of the plan she had
made to manage the man’s condition overnight to ensure that it was appropriate for
him to wait for the following day to see the prison doctor. The out of hours doctor
said that the man should be given penicillin and prednisolone (a steroid to treat
inflammatory and allergic conditions) eight times a day for two days. He faxed
confirmation of his opinion to the prison. This appears to be the first indication that
his physical condition was deteriorating.
29. The man’s health continued to worsen. On 23 March, Prison Doctor B wrote that the
man preferred to continue to work as resting in his cell “felt like being in
segregation”. In this entry, the doctor reflected on whether the man may have a
tumour and considered whether a chest x-ray would confirm this. If there was no
improvement by Wednesday (two days later), he planned to make an urgent referral
for an appointment with the respiratory physician. The case would then be reviewed
after the results of the chest x-ray were known. The doctor noted in the “history”
part of his entry that the man did not have a chest x-ray the previous week because
there was “no developer fluid”. This presented an avoidable delay and the clinical
review comments on the consequences of this problem.
30. Prison Doctor C reviewed him on the following day. The doctors concluded that an
urgent referral should be made to a respiratory physician for an opinion. The doctor
wrote to the respiratory team at hospital describing the man as “having kept himself
largely below prison healthcare radar” until two weeks before. The doctor
summarised the condition, including his concern that there may be an underlying
tumour.
31. A second consultant physician at hospital assessed the man in his clinic on 15 April.
He gave further information to the consultant, who summarised his findings in a
letter to Prison Doctor B. The man told him that he was currently smoking at least
three packets of tobacco each week and had previously worked in the building trade
as a plasterer. There was a family history of TB. The Consultant prescribed further
medication and arranged for him to undergo a computerised tomography (CT)19
scan.
17 Salbutamol is used in the treatment of asthma.
18 The out of hours doctor attends the prison during the evenings and weekends when no doctor is on duty in the prison.
19 A computerised tomography (CT) scan takes detailed three dimensional pictures of the body in order to diagnose disorders.
12
32. An entry in the clinical record dated 28 April, showed that Nurse C spoke with a TB
specialist nurse. The specialist’s advice to was that the man should stay in the
healthcare centre for the first two weeks of his TB treatment. Staff considered that
there was no need for barrier nursing20 until there was a confirmed diagnosis.
33. While awaiting the results, the man told healthcare staff that he was unhappy living
in healthcare. He said it was “like being punished”. He complained that he was late
for a visit with his brother whom he had not seen for five years. He refused to take
the medication prescribed for TB as he remembered that it had made him ill when
he took it before. He told medical staff that he may consider looking at different
options once the results of the tests were known. Medical staff continued to
encourage him to take the medication but without success. Prison Doctor C asked
him who he used to spend time with on the wing, in case he had TB and healthcare
staff had to screen other prisoners. He replied that he was a ‘bit of a loner’ and did
not spend time with anyone.
34. On 14 May, the second Consultant Physician wrote to Prison Doctor B confirming
that, as before, the man had tuberculosis kansasii. He suggested treating him with
the same medication he had received in the past. The clinical record shows that,
while the prescription was given on 14 May, healthcare staff did not find the
medication until 16 May when it was given to him to start with immediate effect. I
refer to this in the Issues section of the report.
35. The second Consultant Physician reviewed the man again on 28 May. He was very
breathless on exertion. The doctor suggested a further review in September.
36. A prisoner on Perrie Wing knew the man well and spoke to my investigator and
clinical reviewer. He recalled that a year before his death, the man was working in
the prison craft workshop. He remembered that he had a chest infection in addition
to his emphysema but he was still mobile. He was unhappy with the medication
prescribed and showed him the medication leaflet. The prisoner described the list of
potential side effects as “horrendous” and advised him to give the details to his
family. The man thought that the medication was doing more harm than good.
37. The prisoner was aware that the man was in healthcare and friends on the wing
could not visit. He described him as being “locked in a cell and fed through a hatch”
and concluded that healthcare staff must have thought he had TB. In the prisoner’s
opinion, the man would not have had his medication but for his carer collecting it for
him. He told the investigator and clinical reviewer that the prison “kept running out
of Ensure21”. He said that wing staff were not involved in the man’s care and he was
looked after by other prisoners. The man had numerous visits from healthcare staff
during the last fortnight of his life.
20 Barrier nursing is the practice of nursing of patients with infectious diseases in isolation to prevent the spread of infection.
21 Ensure is a liquid nutritional supplement.
13
38. Officer A who worked on Perrie Wing spoke to the investigator and clinical reviewer.
She said that the man knew that he was dying before he came into prison and
wanted to be left alone because he felt it was all a “waste of time”. She described
him as a quiet man who was not a problem to staff. The prisoners to whom my
investigator spoke said that he knew that he was terminally ill.
39. The investigator and clinical reviewer spoke with another prisoner on Perrie Wing
who knew the man well. The prisoner described the wing as having a high
percentage of elderly and very sick prisoners. He was aware that healthcare
resources were thinly spread with trying to deal with four wings of vulnerable
prisoners. He said that he collected water and medication for the man and knew
that there were periods of time when he did not come out of his cell. He added that
the man should have had two Ensure drinks each day and, although he could
remember healthcare staff bringing them to him, he could only once remember
collecting all prescribed 14 Ensure drinks. He described him as a very private man
inferring that he would not have wanted to make a fuss.
40. However, in June, the man seems to have lost patience with healthcare staff. He
was prescribed 14 Ensure drinks and had only been given six. Healthcare staff told
him that the prison did not have enough and, had he been given 14, the drinks
would have been in short supply for other prisoners. On 9 August a mental health
nurse visited him on the wing. He told her that he had not had the Ensure drinks “for
some time” although they have been prescribed to him. She discussed the matter
with colleagues who agreed that he was fit enough to collect the drinks himself from
treatment sessions on the wing. The next prescribed 14 drinks were due on 11
August. The clinical reviewer is critical of this aspect of the care and I refer to this
matter in the Issues section of the report.
41. In mid-June, Prison Doctor B wrote to the second Consultant Physician with his
concerns regarding the man’s “dire spirometry results”22. He said he could not
persuade him to take his medication. He had refused to take antibiotics after the
first few days because he had chest pains when taking them. He felt constantly sick
and could not eat.
42. In August, the man refused to go to a hospital appointment with the second
Consultant Physician. An entry in the clinical record dated 4 September says that
the prison did not tell the healthcare department that he had refused to attend and
they found out by chance. This appears to be the only instance where they were not
told. Healthcare staff made an appointment with the prison doctor to assess
whether another referral was needed.
43. The clinical record charts a series of refusals to attend clinics for immunisations and
a further hospital appointment on 11 November. The man signed a Refusal of
Treatment disclaimer the following day. His reason for refusing to go to hospital was
22 Spirometry is a lung function test.
14
because he did not wish to attend outside hospital appointments while in handcuffs
attached to officers.
44. The man’s health deteriorated in late December. Healthcare staff were asked to
attend the wing as he had difficulty in breathing. He saw a prison doctor later that
day but refused to have prednisolone23 because he said his health had worsened
since it was last prescribed. An entry in his wing history sheet on 12 December
shows that he was due to attend a sentence planning meeting which would look at
ways to reduce his risk of harm and re-offending. He told wing staff that he had no
intention of doing offending behaviour courses in prison.
45. On 30 December, he refused to go to a hospital appointment. The clinical record
says that he refused steroids, nebulisers and admission to the healthcare centre
although he was smoking in his cell.
46. The following day, a second mental health nurse visited the man on the wing to
assess his mental capacity to make decisions for himself. The nurse found him
“lucid and focussed with no evidence of thought disorder or mental illness”. He said
the man was angry and frustrated “due to his perception of security protocols”
around being taken to hospital and the use of restraints. He made his feelings
known to the nurse regarding why he was being prescribed medication that had
made him ill in the past. He continued to take the antibiotics.
47. The man spoke with his personal officer on 14 January 2010. (Each prison has a
personal officer scheme in which a certain number of prisoners are allocated to a
named officer as a point of contact. The officer completes reports on prisoners for
which they are responsible, ensures entries are made in their wing history files and
offers general advice.) He told the officer that he felt a little better and was eating,
but still felt weak and breathless. When asked if healthcare staff had been in
contact with him, he said they had not and he had no faith in their ability to help him.
48. The personal officer spoke with him again on 2 February while he was still managing
to walk a little around the wing. A week later Prison Doctor D visited the wing and
saw him walking about. The doctor spoke to the wing principal officer who
confirmed that the man was able to walk slowly about the wing.
49. On the morning of 14 February, Nurse D visited the man on the wing to deliver his
Ensure drinks. She recorded that, on examination, he had lost 8 kilograms in weight
since May. He now relied on the Ensure drinks as he ate very little and was
beginning to suffer from pressure sores on his lower back. A special mattress to
help relieve pressure was ordered the following day and delivered two days later.
However, he said he could not use it as he “falls off it” and could not lie down as he
was unable to breathe. He wanted oxygen in his cell but this was refused as he still
smoked. The combination of oxygen and smoking was an explosion risk. She
suggested to him that he should be admitted to healthcare but he refused. As a
23 Prednisolone is a synthetic steroid similar to cortisone to treat lung conditions.
15
compromise, she suggested that he remain on the wing during the day for
association with his friends but be admitted to healthcare at night where he could
have oxygen. Healthcare staff would take him to and from healthcare in a
wheelchair every evening. Later that day, he agreed to go to healthcare in the
evening on a trial basis.
50. The following day, Prison Doctor E reviewed him in the healthcare centre and noted
that his health had deteriorated generally over the past six weeks. The man asked
for a Do Not Resuscitate form, meaning that he did not want to be resuscitated if he
was taken ill. The doctor indicated that he would re-refer him to the chest physician
as previously planned.
51. Nurse D saw the man on 16 February. He had decided that he did not wish to
remain in the healthcare centre overnight again, but wanted to return to the wing.
He told her that he had not been having any visits from family or friends as he could
not walk far. She offered to take him in a wheelchair to the visits hall. She
commented in the clinical record that there needed to be more communication
between prison and healthcare staff. She also advised him to speak to his family
about his health. The wing history sheet shows that staff thought he knew that he
was terminally ill. He was also aware that help was available to him if he needed it.
There is no evidence to suggest that a release from prison on compassionate
grounds was considered at this or at any other point.
52. A case conference was held on the wing on 16 February. This is not noted in the
wing history sheet but is recorded in the clinical record. The man, wing and
healthcare staff attended. He told staff he wanted to remain on Perrie Wing where
prisoners, who were also his friends, looked after him. They helped him collect
meals and to shower. Wing staff said they were happy to take him in a wheelchair
to visits so that he could see his family. He did not have any religious beliefs and
did not want to see the chaplain.
53. On 16 February, it was recorded that the man looked very tired and breathing was
difficult. Staff were aware that he had asked not to be resuscitated in the event he
collapsed and that the appropriate paperwork was being completed. An oxygen
machine was given to him in his cell on 23 February. He was shown how to use it
and advised to stop smoking.
54. Nurse C sent an email to the head of security asking for access to the man’s cell at
night and at any time during the day when prisoners were usually locked in their
cells. This was to allow healthcare staff to give him his medication and help him
when necessary.
55. The following day, Prison Doctor B wrote to the second Consultant Physician again.
He said that on his return to the prison following a five week absence, the man had
deteriorated considerably. The doctor asked for an opinion as to whether he was
terminally ill and what other measures the prison could take. He still refused to take
16
his medication on the basis that it made him feel worse. He had, however, agreed
to see the physician again. In the physician’s absence and, following a conversation
between the doctor and a third consultant physician, the consultant replied in a letter
dated 18 February. He said that the TB treatment regime should start again. The
doctor visited the man on the wing and noted that he sounded “fed up with it all and
resigned to not improving”.
56. An entry in the wing observations book by prison staff, dated 23 February, said that
the man was very ill and had lost his voice. Healthcare staff would see him daily
and more often if necessary. He did not want to go to hospital but could change his
mind if he wanted to. However, he was adamant that he wished to remain on the
wing. Later that day, his case was discussed. It was agreed that a member of
healthcare staff would contact the Macmillan Nurses (specialist nurses in palliative
care). Pain relieving medication would be ordered in case he deteriorated rapidly
and the use of specialist oxygen equipment would be discussed with wing staff and
himself.
57. The wing governor spoke with the man the following day and recorded the contents
of their conversation in the history sheet. The man remained adamant that he
wanted to remain on the wing despite the provision in the healthcare centre which
would offer him a better level of care.
58. It is recorded in the wing observation book that, on 25 February, during the lunch
period when prisoners are locked in their cells, the man pressed his cell bell at
12.20pm. (Each cell has a bell to be used by prisoners in the event of emergency or
if they require a member of staff’s attention.) Officer B went to the cell and found
him in distress and wearing his oxygen mask. The officer made a code blue24 radio
call over the radio net to ask healthcare staff to go to the wing urgently. Nurse E
responded to the call. When she arrived at his cell she found him breathless and
complaining of pain in his chest. He agreed to go to hospital and an emergency
ambulance was called. The paramedics arrived at 1.00pm and gave him
hydrocortisone and venflon25 medication intravenously.26 The Person Escort Record
(PER) shows that he left the prison by ambulance at 1.41pm and arrived at the
hospital at 2.10pm. (The PER is a form that accompanies staff on all prisoner
escorts. It provides a chronological record of the escort, eg meals served, times
journey started and so on. It also serves as a communication tool about the risks a
prisoner poses on escort or transfer.)
59. The Bedwatch Shift Log shows that the man was taken to the hospital under
restraint (handcuffs) and, following permission from the prison, an escort chain was
applied when they arrived at the hospital. His wish not to be resuscitated was
recorded in his hospital notes. (The bedwatch log is a history, recorded by officers,
24 Code blue and code red are the radio codes used by the prison to call medical staff to deal with an urgent medical incident. Code
blue means that a prisoner is having difficulty with or is not breathing; code red means that there has been an incident of self-harm
or accident involving blood.
25 Hydrocortisone is used to treat inflammatory conditions and venflon is a catheter.
26 Intravenously is by means of a needle into a vein.
17
of the time and events which take place while a prisoner is out of the prison as an
inpatient at hospital. An escort chain is a single handcuff attached to the prisoner
with a length of chain to connect it to another cuff worn by an officer. This allows
more freedom of movement for the prisoner and makes it easier for nursing staff to
administer treatment.) The investigator spoke with a governor of Perrie Wing who
explained that current and historical risks are considered in determining the level of
restraint and escort. The man would have been accompanied by a senior prison
officer and two main grade prison officers.
60. An entry in the clinical record shows that Nurse A contacted the hospital later that
day and was told that the man had improved slightly but he still refused any
medication. She contacted the hospice and left a message for them to contact her.
As he continued to refuse medical treatment, the hospital planned to discharge him
back to the prison.
61. The Bedwatch Shift Log covering the escort officers’ day shift on 26 February
confirmed that the man’s Do Not Resuscitate form from the prison was within the
hospital file. The hospital asked for his next of kin to be told of the seriousness of
his condition.
62. At 3.25pm, a Principal Officer (PO) contacted the prison and asked the duty
governor if the man’s restraints could be removed in the interests of decency. The
risk assessment was reviewed at 3.45pm and the restraints removed. At 4.05pm,
the log shows that the man’s next of kin telephoned the prison and told officers that
they hoped to visit the following day. The Bedwatch Management Checklist shows
that he was anxious to receive a visit from his family.
63. In the early hours of 27 February, Officer C commented on the Bedwatch Shift Log
that a nurse came to treat the man at around 4.10am. He asked her if the morphine
he had been given would “help him pass away”. The nurse confirmed that it would
not, to which the man replied that he would have to do it himself. Despite the
comment, there is no evidence to suggest that he actually made any attempt to end
his life.
64. The clinical record shows that prison and healthcare staff visited the man on 27
February. They asked him if he wished to return to the prison or to have any items
from his cell. He said he did not. Hospital staff confirmed that he was taking his
medication.
65. Comments made by prison staff on duty at the hospital show that he had a good
relationship with hospital staff. He seemed content with the standard of care he was
given and appeared to be as comfortable as possible. His family visited at around
10.00am on 27 February.
66. On the same day, an entry in the clinical record shows that Nurse A telephoned the
healthcare centre from the hospital, following her visit to the man. She said he
18
looked frail and unwell and had received visits from his relatives. The plan was for
him to remain in hospital over the weekend and he would be reviewed by the
consultant on Monday. She said he would think about whether he wanted to return
to Long Lartin.
67. On the day that the man died, he told hospital staff that he wanted to return to Long
Lartin. Meanwhile, a senior management meeting was held at the prison regarding
the management of his care. The Head of Healthcare commented to my
investigator that he had deteriorated much more rapidly than the prison expected.
68. Later that day, at the prison, a referral was made to a hospice for palliative care.
Nurse A visited again, but the man found it too much effort to try to speak. He
managed to say that he wished to remain in hospital. His medication had been
reviewed and he was prescribed Fentanyl patches,27 Diamorphine28, paracetamol,
Atrovent29 and Ventolin. She spoke to a staff nurse at the hospital and said that he
could be referred to the Macmillan team at the hospital. The staff nurse said she
would pass this information to medical staff.
69. The bedwatch log shows that the man was visited by a number of senior members
of prison and healthcare staff. He was noted to be very poorly. Prison staff asked if
he had made a will and he said that his sisters and brothers knew his wishes.
Officer A told the investigator that she was aware that he had a living will30. He
asked that his carer be given his toiletries and that he wanted his sister to be
contacted after his death.
70. At around 5.00pm, the Governor spoke with the man’s sister and asked if she would
like to be told of his death immediately if it was known that he had died. She said
she did not need to be told if he died during the night, but the next day would be
appropriate. The Governor offered support from the prison. She said that she was
happy with the care her brother had received. He died at 8.10pm that evening.
Records show that his sister was given the news of his death at 8.20pm.
71. Officer A told the investigator that a hot debrief for staff (in accordance with Prison
Service Order 2710, paragraph 5.3) was not held. She said that it was a difficult
time for staff as two prisoners on Perrie Wing had died only days apart from each
other.
72. The Governor issued a notice to the prisoners on the wing announcing the man’s
death and staff from the chaplaincy went to the wing to provide support for those
who needed it. My investigator and the clinical reviewer spoke to staff about the
27 Fentanyl patches are for pain relief.
28 Diamorphine is a narcotic for pain relief.
29 Atrovent is an inhaler.
30 Advance health care directives, also known as living wills, advance directives, or advance decisions, are instructions given by
individuals specifying what actions should be taken for their health in the event that they are no longer able to make decisions due to
illness or incapacity.
19
level of care they received from the prison after his death. Some members of staff
said that they did not feel supported by senior management at the prison.
20
ISSUES
Clinical care
73. The clinical review was undertaken by two clinical reviewers for the local Primary
Care Trust (PCT). Their review is based on prison medical and other records,
interviews with staff and prisoners as well as documents and interviews with
hospital staff.
74. The review has judged that, overall, the care the man received at Long Lartin was
generally well organised and documented by healthcare staff. In addition to the
general good care he received, the reviewers have commented on the
professionalism of healthcare staff, quality of history taking and appropriate
prescribing. Care plans and their implementation were described as “excellent”.
75. The review commented that the man had a serious chest disease before he went
into prison and this accounted for his symptoms during his time there. It is judged
possible that he was never free from mycobacterium kansaii, diagnosed in 2004. In
the circumstances, he survived for longer than his respiratory physician would have
expected. This was especially notable considering that he frequently refused
medication and did not heed medical advice.
Shortage of prison and medical supplies
76. On 23 March, Prison Doctor B noted in the clinical record that the man should have
had an x-ray at the prison the previous week but this did not take place because
there was no “developer fluid”. Another x-ray was scheduled for 25 March but was
not reviewed by a prison doctor until five days later on 30 March. The clinical
reviewers comment that, even though it was 12 months before his death, this was a
critical time in his care, diagnosis and treatment. The “inability to provide an urgent
chest x-ray in the prison for at least a week is a cause for concern”. I endorse these
findings and support their recommendation.
The Governor and Head of Healthcare should ensure that adequate supplies of
developing fluid for the prison x-ray machine are always available. This will
prevent unnecessary delays in the diagnosis and treatment of serious chest
conditions in the future.
77. From June 2009 onwards, the man relied upon Ensure food supplement drinks
because he was not eating and losing weight as a result. Initially, there was a
misunderstanding as to whether they would be delivered to the wing or whether he
was expected to collect them. Also, on one occasion, it was recorded that he was
given insufficient supplies, only six of the 14 drinks prescribed, as there were not
enough for all the prisoners who needed them. The second prisoner, and the man’s
friend, remembered collecting a complete prescription on only one occasion and
other prisoners recalled that he was rarely given the prescribed amount as “it was
21
not in stock”. Another entry in February 2010 indicated that he had been without it
for two weeks as the healthcare centre had run out. It is evident that there were
shortcomings in the ordering process and, as a result, there were insufficient
supplies to meet prisoners’ needs. I believe that this is unacceptable and avoidable.
The clinical reviewers considered that this would have caused some distress and
“would not have supported the care plans that were in place”.
The Head of Healthcare should ensure that ordering procedures and
responsibilities are reviewed and, there are ample supplies of nutritional
supplements to meet the needs of prisoners.
78. On 14 May, the second Consultant Physician at hospital wrote to Prison Doctor B
confirming that the man had tuberculosis kansasii. He did not receive the
medication which the Consultant prescribed until two days later on 16 May. The
clinical reviewers conclude that the delay in finding the medication was of some
concern given the importance that healthcare staff placed on him taking the
medication to prevent “irreversible lung damage”. They judge that the slight delay is
unlikely to have had any harmful effect, particularly as he was refusing his
medication some days later. However the review has found a lack of
communication “from one healthcare contact to another and a lack of clarity as to
where ‘current’ medicines might be stored and checked”. I endorse their finding and
recommendation.
The Head of Healthcare should ensure that healthcare and pharmacy staff
responsible for accounting for and storing medicines, advise all healthcare
staff where medicines prescribed for specific prisoners are held. This should
ensure that prisoners receive their medication in a timely manner.
Restraints
79. The clinical review has raised the question of whether the restraints were
appropriate given the man’s condition. I note the comment from a doctor who
appears to agree with the man’s issue about being sent to hospital wearing
restraints.
80. The investigator discussed the use of restraints with one of the governors on Perrie
Wing. She also reviewed the risk assessment paperwork and Bedwatch log
completed by the escort officers. Although unwell, the man was a life sentenced
prisoner who did not comply with his sentence plan by working to reduce future risks
of offending when returned to the community. I am satisfied that restraints were
used appropriately in accordance with security policies and procedures. The
restraints were removed on 26 February, the first appropriate opportunity in
accordance with prison guidelines.
22
Compassionate release
81. Records show that prison and healthcare staff were aware that the man was
terminally ill in February 2010. Prison Doctor E, who had been absent from the
prison for a five week period, noticed the marked deterioration in his condition on 15
February. Nurse D saw him in his cell on 16 February and discussed end of life care
and the completion of “Do Not Resuscitate” forms. A case conference was held on
the wing on the same day where options for managing his condition were discussed.
They included consideration that he was terminally ill and felt that he was dying.
There is no evidence that any discussions took place with him to ask whether he
would like to apply for compassionate release to a hospice because of his terminal
condition. It may have been the case that he would not have wished to do so, but
that conversation should been recorded if it took place. The evidence suggests that
it did not. Neither is there evidence that the prison consulted the National Offender
Management Service regarding the possibility of release on compassionate grounds
or the medical professional for an opinion as to life expectancy.
The Governor should ensure that terminally ill prisoners are considered for
their suitability for compassionate release in accordance with Prison Service
Order 6000, Chapter 12. The multi agency decision making process should be
recorded in both the clinical and core record.
Hot debrief
82. Although the man died in hospital, the circumstances leading to his admission had
been difficult for both staff and prisoners. He was attended by both healthcare staff
and paramedics before being taken to hospital. He was then under escort for
several days. Prison Service Order 2710 requires prisons to hold a hot debrief after
the death of prisoner. Many staff and prisoners had been involved in the care and
treatment of him over an extended period and this was the second death on that
wing within a matter of days. A debrief would have provided coordinated
reassurance and support for those involved.
The Governor should remind managers of the need to hold a hot debrief after
the death of a prisoner, in accordance with Prison Service Order 2710.
Visits by other prisoners to the man while in the healthcare centre
83. The clinical reviewers commented that prisoners’ friends are unable to visit sick
prisoners in inpatient healthcare and recommended that the policy be reviewed and
appropriate facilities provided. Long Lartin is part of the high security prison estate,
therefore security of the prison is paramount. I judge that the decision as to whether
a prisoner, accommodated on a normal wing, should be allowed to visit another
prisoner in healthcare, is a decision for the Governor, taking account of all relevant
circumstances and resources. In the circumstances, I am unable to support this
recommendation. However, I encourage the Governor to consider the suggestion.
23
Many Long Lartin prisoners will have developed long term friendships and been
supported by other prisoners. Being able to see his friends might have encouraged
him to agree to admission to the healthcare centre.
Good practice
84. The clinical reviewers have highlighted good practice which I am pleased to
endorse. They found that although healthcare do not have a formal end of life
pathway, the healthcare arrangements for managing the man’s terminal illness were
excellent. The review highlights his involvement in the decision-making processes.
85. The man refused a number of hospital admissions, and did not always listen to
medical advice or take his medication. The clinical review has suggested that this
may have hastened his death although it acknowledges that he found the treatment
very unpleasant and remembered how he felt the first time he took it. However staff
always encouraged him to take it and found alternatives where possible. They were
proactive in seeking compromises that he would accept. This was apparent when
he refused to go to healthcare, where oxygen was available, when he struggled to
breathe and wanted to remain on the wing. Nurse D suggested that staff could take
him to healthcare to spend each night and they could bring him back in the morning.
After some hesitation, he agreed to try this. This demonstrated flexibility and
sensitivity to his wishes and the ability to seek compromises to improve his health
and wellbeing.
24
CONCLUSION
83. The man was a life sentenced prisoner who was already in poor health when he
went into the prison system in poor health. He had a serious chest condition and
tuberculosis kansaii. He did not always take his medication and continued to smoke
against medical advice. At times he refused to go to hospital for treatment because
he found that wearing restraints a degrading experience. The clinical review has
commented that his life expectancy was significantly reduced, but he exceeded the
expectation of his chest physician.
84. The clinical review has judged that, overall, the man received good clinical care at
Long Lartin, with areas of good practice. Healthcare staff were professional, caring
and flexible in their approach to him. His fellow prisoners also assisted him when he
felt unable to leave his cell. My recommendations aside, I judge that the care he
received was comparable to and possibly exceeded that which he would have
received in the community.
85. In particular, I am pleased that the man was consulted about the sort of treatment
which he would accept and that the restraints were removed for the last few days of
his life.
25
RECOMMENDATION
1. The Governor and Head of Healthcare should ensure that adequate
supplies of developing fluid for the prison x-ray machine are always
available. This will prevent unnecessary delays in the diagnosis and
treatment of serious chest conditions in the future.
Accepted. The ordering system has since been revised to ensure that there is
always a spare supply of developing solution in stock.
We hope to replace the existing x-ray machine with a new digital machine which
will negate the need for x ray solution.
2. The Head of Healthcare should ensure that ordering procedures and
responsibilities are reviewed and, there are ample supplies of nutritional
supplements to meet the needs of prisoners.
Accepted. The ordering system for pharmaceutical supplies have been reviewed
and revised. The process is supported by a Senior Pharmaceutical adviser and
the appointment of a pharmacy technician.
3. The Head of Healthcare should ensure that healthcare and pharmacy staff
responsible for accounting for and storing medicines, advise all healthcare
staff where medicines prescribed for specific prisoners are held. This
should ensure that prisoners receive their medication in a timely manner.
Accepted. The ordering, stock control and administration systems system for
pharmaceutical supplies have been reviewed and revised. The process is
supported by a Senior Pharmaceutical adviser and the appointment of a
pharmacy technician.
4. The Governor should ensure that terminally ill prisoners are considered for
their suitability for compassionate release in accordance with Prison
Service Order 6000, Chapter 12. The multi agency decision making
process should be recorded in both the clinical and core record.
Accepted. We did not consider the man to be terminally ill at that point, he had
an acute exacerbation of a chronic illness and may have recovered if he had
accepted treatment. Each case will be judged on its own merits and
consideration will be given for future cases should they arise.
5. The Governor should remind managers of the need to hold a hot debrief
after the death of a prisoner, in accordance with Prison Service Order 2710.
Accepted. Contingency plans will be reviewed in line with PSO 2710.
26