Individual at Wormwood Scrubs

Investigation into the death of a man
whilst in the custody of HMP Wormwood Scrubs in
March 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2011
This report considers the circumstances of the death of the man at Chelsea and
Westminster Hospital in March 2010, whilst in the custody of HMP Wormwood
Scrubs. The man had complex health needs. He had a serious physical illness, was
mentally ill, refused medication and was monitored closely by staff due to the risk of
self harm. The post mortem showed that he died from cancer.
I offer my condolences to his family and friends for their loss. My senior family
liaison officer had contact with the man’s family at the start of the investigation and
explained the investigation process.
The investigation was carried out by one of my investigators. I would like to thank
the governor and his staff for their co-operation during the course of our enquiries. I
particularly thank the prison’s liaison officer.
I also thank Hammersmith and Fulham Primary Care Trust for appointing a review
panel. As the man died from natural causes, the findings of the clinical review play
an essential part in my report. The review judges that the man received good care
whilst he was in custody which was equitable to what he could have expected in the
community.
I make two recommendations regarding formal mental capacity assessments and the
appropriate levels of observation. I endorse the clinical review panel’s comments
about record keeping and clinical notes. I recognise the good practice adopted by
Wormwood Scrubs in the use of restraints during the man’s final days in hospital. I
also endorse the clinical review panel’s commendation of the quality of engagement
between healthcare staff and the man.
The 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.
Jane Webb
Acting Prisons and Probation Ombudsman February 2011
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CONTENTS
Summary
The investigation process
HMP Wormwood Scrubs
Key events
Issues
Conclusion
Recommendations
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SUMMARY
The man was born in June 1969 in Liverpool. He was single and had lived in the
London area for a number of years. He had human immunodeficiency virus (HIV).
He was diagnosed with advanced retroviral disease (AIDS) and suffered from mental
illness. He had a history of using illicit drugs. The man was 41 years old when he
died.
On 10 July 2009, the man was remanded into custody for conspiracy to supply
drugs. He was sent to HMP Pentonville. On arrival at the prison he said that he had
been diagnosed with AIDS and had refused to take the medication prescribed for his
condition. He said he had a history of mental illness and self harm and had
previously been treated in hospital.
As a result of the man’s history of harming himself, he was closely monitored by the
prison’s suicide monitoring (Assessment, Care in Custody and Teamwork or ACCT)
procedures and he continued to refuse to take his medication. The man appeared at
Blackfriars Crown Court on 21 September, and was remanded back into custody.
Instead of returning to Pentonville, he was sent to HMP Wandsworth where he
continued to be closely monitored by staff. He was transferred to HMP Wormwood
Scrubs on 11 December, still being monitored by the ACCT procedures.
The prison doctor referred the man to St George’s Hospital on 14 February 2010 due
his poor health. He remained there for two days until he was transferred to the
Chelsea and Westminster Hospital on 17 February.
On 8 March, he was told by hospital doctors that he had inoperable cancer. Five
days later he contacted his family in Liverpool to inform them of the diagnosis and,
due to a significant deterioration in his health, unrestricted family visits were
permitted. The restraints were removed on 13 March and his family were present
when he died two days later at 1.00am in March.
Wormwood Scrubs followed the requirements of Prison Service Order 2710 ’Follow
up to death in custody’ and offered financial assistance towards the cost of the
funeral.
In general I am satisfied that the care and attention the man received at Wormwood
Scrubs was equitable to that he could have expected to receive in the community.
However I draw the Director of Offender Management’s attention to the man’s moves
around London prisons and the threat this posed to the continuity of care for a man
with complex needs.
I make two recommendations regarding formal mental capacity assessments and the
appropriate levels of observation. I draw the Head of Healthcare’s attention to the
clinical review panel’s comments about record keeping and clinical notes. I would
like to recognise the good practice adopted by Wormwood Scrubs in the use of
restraints during his final days in hospital. I also commend the quality of
engagement between healthcare staff at Wormwood Scrubs and the man.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 16 March 2010 when my investigator issued
notices to staff and prisoners. The notices included an invitation to those who
wished to submit information relating to the man’s death to make themselves
known. No prisoners came forward as a result. My investigator visited
Wormwood Scrubs on 26 March and was given a copy of the man’s prison
records.
2. Hammersmith and Fulham Primary Care Trust (PCT) asked to chair a review
panel to carry out a review of the man’s clinical care. I am grateful to them for
undertaking this review. The investigator discussed aspects of the man’s
treatment with both staff at Wormwood Scrubs and with the clinical review
panel.
3. The investigator contacted Her Majesty’s Coroner for Westminster to inform her
of the nature and scope of my investigation and to request a copy of the post
mortem report. Upon completion, my report will be sent to HM Coroner to
assist her enquiries into the man’s death.
4. One of my family liaison officers contacted the man’s parents at the beginning
of the investigation. They told my family liaison officer that they did not have
any concerns about the treatment and care that their son received.
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HMP WORMWOOD SCRUBS
5. HMP Wormwood Scrubs is a local prison that accepts all suitable male
prisoners over the age of 21 from the courts in its catchment area. The
establishment has five main wings and a number of smaller dedicated units. A
and B wings manage both remand and sentenced prisoners. C wing
accommodates prisoners on the Intensive Drug Treatment System that offers
enhanced support for offenders with substance misuse problems.
6. Her Majesty’s Chief Inspector of Prisons, conducted a full unannounced
inspection of Wormwood Scrubs between 9 and 13 June 2008. The Chief
Inspector’s report judged that progress that the prison had made since her
previous inspection had halted in 2005, and there had been “an appreciable
drift” in all the key areas namely safety, respect, purposeful activity and
resettlement. However, the report acknowledged the difficulties the prison
faced in coping with constant daily pressure.
7. Each prison in England and Wales is also monitored by an Independent
Monitoring Board (IMB) formed of volunteers from the local community. IMB
members have full access to every prisoner and all parts of the prison. The
Board produces an annual report, with the most recent available for Wormwood
Scrubs was for the period 1 June 2008 to 31 May 2009. The report made the
following comments concerning healthcare:
“The Board is greatly relieved that the PCT has funded the post of a second
doctor to be available in the First Night Centre for reception screening. The
PCT has funded a refurbishment of primary clinics including the dental
suite.
“The number of prisoners attending primary clinics has recently been
restricted to 20 per am and pm session, following a security review. This,
along with absences from those scheduled to attend due to illness, visits,
court appearances etc, has resulted in lower numbers of patients seen at
each session. The Board has raised the issue with the Governor.”
8. The IMB had specific concerns about the recruitment and retention of
healthcare staff and stated the following in the report:
“Once again the recruitment of permanent nursing and GP staff has proved
problematic and health services in the prison are heavily reliant on agency
staff. This is unsatisfactory and does not represent parity of treatment with
those outside prison.”
9. The IMB also considered aspects of safer custody and made the following
comments in the report:
“The Board is represented at meetings of the Suicide Prevention Committee.
The Suicide Prevention Co-ordinator has been in post some time and has an
in-depth knowledge of the policy and procedures. Residential staff are aware
of the risks of self-harm and suicide.
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“There have been 5 deaths in custody in the reporting year. On each
occasion the Chair or Vice Chair was informed and attended the prison. The
Board is satisfied that in each case the situation was handled appropriately.”
10. The rules that govern all aspects of running a prison are set out in a series of
documents called Prison Service Orders (PSOs). PSO 2700 – ‘Suicide
prevention and self-harm management’ details prison procedures for looking
after prisoners at risk of suicide or self harm. Assessment, Care in Custody
and Teamwork (or ACCT) is the system used by prisons to identify, monitor and
support prisoners at risk of self harm. The ACCT process is used in all prisons
in England and Wales. Any member of staff can start the ACCT process, by
raising a Concern and Keep Safe form, explaining the reasons for their
concern. An Immediate Action Plan is written by the manager of the wing
where the prisoner is located and within 24 hours an ACCT assessment is
carried out by a member of staff who has the required training.
11. After the ACCT assessment has taken place, a multi-disciplinary ACCT case
review is held to determine what measures can be taken to monitor and support
the prisoner effectively. The prisoner attends the case review and is
encouraged to contribute to the decisions being made. An ACCT CAREMAP is
drawn up with details of each of the actions required to keep the prisoner safe
and identifies who is responsible for carrying out each action. Case reviews are
held at regular intervals, usually monthly, to review the actions and the
prisoner’s level of risk.
12. On each occasion a prisoner is escorted outside the prison to hospital, a risk
assessment considers the risk to the public, potential for escape and likelihood
of outside assistance. The assessment informs the decision about the number
of escorting officers and the type of restraint to be used (single cuffs or two
metre long escort chain with a cuff at either end). It also determines the
circumstances and the authority required for the restraints to be removed. The
risk assessment is reviewed each day that a prisoner is in hospital and
amended where necessary.
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KEY EVENTS
13. The man was born in February in Liverpool. He was single and had lived in the
London area for a number of years. He was HIV positive and diagnosed with
AIDS. He had a history of mental illness and using illicit drugs.
14. On 10 July 2009, he appeared at Knightsbridge Crown Court and was
remanded into custody for conspiracy to supply drugs. He was sent to HMP
Pentonville. On arrival at the prison he was interviewed by a nurse for a first
reception healthscreen. (A first reception healthscreen takes place every time a
prisoner arrives at a prison to determine any immediate physical and mental
health conditions that require treatment, substance misuse matters that need to
be addressed, and any risk that the prisoner may pose of harming himself or
attempting suicide.) The man said that he had been diagnosed with AIDS, and
had refused to take the prescribed medication. He also said he had a history of
mental illness, being prescribed citalopram (an anti-depressant) and had been
treated at the Chelsea and Westminster Hospital. He also said that he had
harmed himself since he was 17 years old.
15. As a result of his history of self harm, an Assessment, Care in Custody and
Teamwork (ACCT) document was opened in accordance with PSO 2700. The
ACCT monitoring remained in place until the man died eight months later. It
was assessed that the man required hourly observations until the ACCT
assessment was completed. He continued to refuse to take his medication.
16. The man appeared at Blackfriars Crown Court on 21 September, and he was
further remanded into custody and sent to HMP Wandsworth. The ACCT had
been transferred with him and the monitoring and support continued.
17. The next morning the first nurse who assessed the man who said that he had
taken an overdose of tablets when he was at court. The nurse immediately
sent him under escort to St George’s Hospital. A risk assessment was
completed which assessed that the man should be escorted by two officers.
They applied an escort chain (a two metre chain with a cuff at either end) which
was to be removed when he was being treated. At hospital the man told the
doctor that he had taken 20 paracetamol tablets. Full blood tests were
undertaken and the results were negative for paracetamol and the remaining
tests were all normal.
18. The man returned from hospital at 1.00am on 23 September, and was seen by
a second nurse. The nurse noted that he was very anxious, and explained the
services that were available such as the chaplaincy and Samaritans. The nurse
recorded that she would be referring him to the mental health team and the
doctor.
19. The following evening a third nurse went to see the man in his cell as he
complained of abdominal cramps. The nurse recorded in the medical records
that when the man was offered medication he became verbally abusive and
wanted a second opinion or to be sent to hospital. The nurse told him that no
8
doctor was on duty until the morning and that she was able to issue pain relief
medication.
20. The first prison doctor saw the man the next morning, 25 September. The
doctor recorded that the man said he was HIV positive and had stopped taking
his prescribed medication some time ago as he wanted to die. He told the
doctor that prior to entering custody he had used crystal meths
(methamphetamine - a potent stimulant that affects the mechanisms
responsible for regulating heart rate, body temperature, blood pressure,
appetite, attention and mood), cocaine and Valium. He told the doctor that he
had wanted to kill himself for months but had no plans to so at the present time,
although he was likely to harm himself. The doctor prescribed citalopram and
diclofenac (a non-steroidal anti-inflammatory drug taken to reduce inflammation
and as an analgesic for pain relief). He also referred the man to the mental
health team.
21. Four days later the man saw a nurse from the mental health team. The nurse
recorded that the man had a long history of depression, and he said he heard
voices at times and felt quite fragile. He said that he had been treated by a
consultant physician at the Chelsea and Westminster Hospital.
22. Later that same day a second prison doctor, saw the man as he had
complained of abdominal pain in the liver area. The doctor recorded that the
man did not tolerate the pain well and prescribed dihydrocodiene (an
analgesic).
23. On 2 October, Wandsworth healthcare obtained a detailed medical history from
the consultant physician, at the Chelsea and Westminster Hospital. It
confirmed the man’s medical and blood test history.
24. Ten days later a second mental health nurse assessed the man and produced
a comprehensive report. It referred to his past psychiatric history, including that
he had been prescribed citalopram. It also mentioned his history of drug and
alcohol abuse, that he was diaqnosed with HIV some 20 years ago and AIDS
ten years ago. He had refused to take the prescribed medicaton, and had
pancreatitis (inflamation of the pancreas) and abdominal pains. The nurse
noted that the man had a history of self harm and assessed that he was at risk
of accidental death due to his compulsive self harming behaviour. As a result
of this assessment the ACCT support remained in place. However it is not
clear from the medical records whether a nursing plan, taking into account his
complex needs, was put into place.
25. On 19 October, the man appeared at Blackfriars Crown Court and was
remanded back into custody. On return to prison he saw a fourth nurse who
noted that the man had said he was fit and well. The next day the man failed to
attend an appointment with a third prison doctor.
26. Two weeks later the second mental health nurse attempted to see the man but
he refused to be seen because he said he was tired and did not want to get out
of bed.
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27. On 12 November, a fifth nurse saw the man who complained of abdominal pain,
diarrhoea, vomiting and blurred vision. Because of these symptoms and the
man’s other medical conditions, he was admitted to hospital. A risk
assessment was completed which repeated the same arrangements of a two
officer escort and an escort chain which could be removed when he was being
treated.
28. The man remained in hospital for five days. Various tests were conducted, and
the escort officers recorded that he was well and comfortable. The hospital
doctor concluded that no cause could be found to account for the symptoms
described by the man. In addition he saw a member of the hospital psychiatry
liaison team who assessed that he was mentally stable but needed to remain
under observation because of likelihood that he would harm himself.
29. On 20 November, the man appeared in Blackfriars Crown Court and was
remanded back into custody.
30. The fourth prison doctor to assess the man saw him on 21 November as he
complained of pains in his abdomen and was concerned about his liver. The
doctor told him that he had only been in hospital a few days earlier and, if
something serious had been identified, the hospital would have given the
necessary treatment and care. The doctor noted the man’s refusal to take the
medication prescribed for AIDS.
31. The same doctor saw the man two weeks later as he said he had vomited 20
times and was unable to digest any food. The doctor noted that the man had
become quite dehydrated, his blood pressure was 91/70 and felt dizzy when he
stood up. (The normal range for blood pressure is 100/70 to 140/90, although
this does vary throughout the day depending on the individual’s activities. A
blood pressure reading of greater than 140/90 is classed as high and a reading
of 90/60 or below is classed as low.) The doctor decided to re-admit him to
hospital.
32. The risk assessment confirmed the same level of escort and the escort chain,
to be removed when he was being treated. The man was taken to St George’s
Hospital but immediately discharged himself against the advice of hospital staff,
and returned to prison.
33. On 10 December, the man saw a fifth prison doctor (the fifth to see him at
Wandsworth), as he said he had vomited five times that day and had not eaten
but had been drinking coffee. He told the doctor that the reason he discharged
himself from hospital was because he heard voices talking about him (the
voices were deemed to be a symptom of his mental health condition). The
doctor noted that the ACCT was still open and considered that it should remain
in place. The doctor prescribed Dioralyte (a rehydration salts drink).
34. The next day the man was transferred to HMP Wormwood Scrubs. The first
doctor who saw him at reception and recorded his medical history, his
medication and his refusal to take the drugs prescribed to treat his AIDS
10
condition. The doctor noted that the man was on an open ACCT and confirmed
that this was appropriate and should continue. The doctor also referred the
man to the mental health team. Again it is not clear from the medical records
that a nursing care plan was put in place.
35. Four days later the first nurse from the mental health team at Wormwood
Scrubs assessed the man who spoke about his mental health history, previous
drugs misuse and his compulsion to harm himself. He also told the nurse that
he hoped to be released from custody at his next court appearance. The nurse
assessed that the ACCT monitoring should continue at the same level.
36. On 6 January 2010, the man appeared at Blackfriars Crown Court. He was
further remanded into custody and returned to Wormwood Scrubs.
37. The next day a nurse saw the man in the treatment room as he had cut his left
forearm superficially. He told the nurse that he had cut himself because the
voices told him to do so. The nurse dressed the wounds and recorded that his
blood pressure was 115/70. An ACCT review took place later that day and the
level of observation remained unchanged.
38. Two days later the second doctor to assess him at Wormwood Scrubs saw the
man and noted that the wounds on his arm were clean and redressed. The
man told the doctor that he was hearing male voices that called him by name.
39. On 14 January, the man attempted to hang himself using bed sheets but was
prevented from doing so by uniformed staff. The first doctor, who met the man
at reception, was called to the wing to see him again. The doctor recorded in
the medical records that the man was alert and laughed. When asked why he
attempted to hang himself, the man replied that he did not know. The doctor
admitted the man to the healthcare centre and put constant staff observations
in place to protect his safety and wellbeing.
40. The next day a full ACCT review was undertaken by a third doctor he had not
met before, a senior nurse, senior officer, an officer and the man. An ACCT
care plan was put in place which included accommodation in a single gated cell
(a cell without a door to provide full visibility of the prisoner), constant one to
one supervision, a weekly review by a psychiatrist, encouragement to take his
prescribed medication and to take part in unit activities.
41. On 18 January, another ACCT review took place. Present at the review were
the first prison doctor, a matron, the senior nurse, a nurse, the senior officer, an
officer and the man. (I note that several members of staff attended both
reviews and that the man was present on both occasions.) They agreed that
his risk of self harm had significantly reduced and the observations should be
reduced from constant supervision to once per hour, with no other changes
made. The man appeared at Blackfriars Crown Court later that day, and was
remanded back into custody at Wormwood Scrubs.
11
42. In the days that followed the man remained in healthcare, the ACCT support
conditions were reviewed regularly and the level of observation maintained.
The man continued to refuse to take the medication prescribed for AIDS but did
take his other medication and there were no more instances of self harm.
43. The fourth doctor to treat the man at Wormwood Scrubs, saw him on
8 February. The man told the doctor that it was painful to eat and he was not
taking his AIDS medication because he wished to die. The doctor recorded that
the man was able to walk but his abdomen was tender. He prescribed tramadol
(for treatment of severe pain).
44. For the next five days the man continued to refuse the prescribed AIDS
medication but did take his other prescribed medication. It was recorded in the
medical records that he was suffering from hiccups. His ACCT conditions were
reviewed regularly and the ACCT observation conditions remained unchanged.
45. On 14 February, the second doctor who saw the man again as the hiccups
were continuous and he had not eaten anything for two days. The doctor
recorded that the man’s blood pressure was 104/68, he had a rash on his skin
and pain in his abdomen. The doctor referred him back to St George’s
Hospital. The risk assessment confirmed the same level of restraints, that is
two officers to escort the man and the escort chain, which could be removed
when he was being treated.
46. The man remained at Hammersmith Hospital for two days until he was
transferred to the Chelsea and Westminster Hospital on 17 February. Prison
healthcare staff maintained contact with the hospital staff to obtain an update
on the man’s condition. Management checks were made to assess the
bedwatch arrangements.
47. On 8 March, after three weeks in hospital, the man was told by the hospital
doctors that he had inoperable cholangiocarcinoma (a cancer affecting the liver
and bile duct system). He contacted his family in Liverpool to inform them of
his diagnosis.
48. The man’s health deteriorated and, on 13 March, the Governor authorised the
removal of the restraints. The Governor also permitted unrestricted family visits
to take place. The man’s family were allowed to stay in the hospital on 14
March and were present when he died at 1.00am the next day.
49. Wormwood Scrubs followed the requirements of Prison Service Order 2710
‘Follow up to death in custody’ and offered financial assistance towards the cost
of the funeral. In the days that followed, the prison family liaison officers
maintained contact with the man’s family.
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ISSUES
Clinical care
50. The clinical review panel examined in depth the care the man received from the
healthcare staff at Wormwood Scrubs, Wandsworth, Pentonville and external
medical professionals. The review made the following comments:
“Based on the information available the panel would like to acknowledge that
the man received appropriate care in accordance with his needs and also
equitable to what he could have expected to receive in a community
healthcare setting.
“The panel would like to commend prison healthcare staff for the quality of
engagement that occurred between them and the man.”
51. Notwithstanding the reviewer’s approval of the man’s treatment, I note the
number of London prisons that he was in and the effect this may have had on
the continuity of his healthcare. I also note that he saw several doctors within
each prison, including five at Wandsworth and another five at Wormwood
Scrubs. It is not clear whether nursing care plans were prepared which, for a
man with his complex needs, seems to me to be a notable omission. I draw
these matters to the attention of the Director of Offender Management and
suggest that the Regional Offender Health team considers whether there are
adequate arrangements which provide consistent treatment.
Capacity to refuse treatment
52. The man was admitted to St Georges’ Hospital from 12 to 17 November 2009
as he complained of abdominal pain. The results of the assessment and tests
conducted did not highlight the requirement for any further investigation. He
was re-admitted to the same hospital on 9 December with the same symptoms
but he discharged himself the next morning against medical advice.
He exercised his right to refuse treatment and medication. Indeed, prior to
coming into custody, he had refused to take the medication prescribed for AIDS
and continued to do so whilst he was in custody.
53. The clinical review highlights that the man exercised his right to refuse
treatment but made the following comment:
“The panel acknowledges that while the man exercised his rights to refuse
medication/treatment and despite seeing a psychiatrist, a formal mental
capacity assessment into the man’s refusal to take medication was not
carried out.”
Prisoners who refuse medical treatment, and especially those diagnosed with a
mental illness, should be properly assessed by a psychiatrist to ensure that, in
the legal sense, they have the mental capacity to decide whether to accept
treatment. I therefore make the following recommendation:
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The Head of Healthcare should ensure that formal mental capacity
assessments are conducted when a prisoner refuses medical
treatment, and especially when the prisoner has a diagnosed mental
illness.
Assessment, Care in Custody and Teamwork
54. PSO 2700 provides clear guidance for staff on the process to follow when a
prisoner is assessed as at risk of harming himself and ACCT monitoring is put
in place. In addition the Governor of Wormwood Scrubs issued Governor’s
Order 21/09 on 5 June 2009 for the attention and action of all staff which states
the following:
“Levels of support and observation —this contains mandatory
instructions.
“The levels of supervision are listed below and all members of staff should
be familiar with them.
“Level 1; Constant supervision — where a designated person keeps a
prisoner under constant visual observation and provides appropriate
support for prisoners actively suicidal or where there has been recent self-
harm with suicidal intent.
“Level 2: intermittent supervision — a designated person makes 5
checks per hour at irregular intervals of between 10 and 20 minutes apart.
Daytime checks are interactive, night time are visual unless concern has
been raised. This level of observation is for prisoners not considered
actively suicidal but still a high risk or where there has been recent self-
harm with some suicidal intent.
“Level 3: Unit supervision — where all staff monitor and provide discreet
support recording at least one interactive record for each session with
irregular checks throughout the night, (one on taking over, three at
irregular times and one before handover). Prisoners on this level of
observation are not considered high risk but may have self-harmed with
little or no suicidal intent, or may have other risk factors e.g. depression.
“Levels of observation are initially determined by the manager completing
page 2 of the ACCT and should be reviewed and recorded following any
incident, and on subsequent reviews. Managers recording levels of
observation need to state not only the level, but also the frequency of
checks, i.e. ‘level 2 observations, five irregular checks per hour.”
55. The ACCT was opened from the time the man entered custody until he was
admitted to hospital in February 2010. I am satisfied that the ACCT process
was correctly followed and, as a result, staff prevented the man from attempting
to hang himself.
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56. However, I am concerned that following the man’s attempt to hang himself on
14 January 2010, the assessment of risk reduced the level of observations from
constant supervision to hourly checks. This is opposite to the guidance in PSO
2700 and the local instruction from the Governor, which should have led to a
gradual reduction in the levels of observation.
The Governor should ensure that staff adhere to PSO 2700 and local
instructions regarding any reduction in the level of ACCT
supervision.
Record keeping
57. The clinical review considered the standard of record keeping of the man’s
medical records and comments:
“An improvement in the quality of the documentation made using the
electronic records keeping system (Systm1) was noted. A reiteration of
staff responsibilities for record keeping as set out by professional
regulatory bodies (General Medical Council and Nursing and Midwifery
Council) and within local records management policies and record keeping
standards is recommended.
“The documentation sent to the panel did not include the man’s Genito-
Urinary Medicine (GUM) clinical notes. Whilst the panel recognises it is
historical practice for GUM services records to be kept separate from other
records, the panel review would not have been completed without the
panel obtaining these records. The panel were fortunate to have the
presence of a GUM consultant who was familiar with the man’s case,
following a few inpatient admissions at St George’s Hospital, and was able
to give an account.”
I endorse the Clinical Review Panel’s recommendation that:
The Head of Healthcare should ensure that staff are reminded of the
responsibilities for record keeping as set out by professional
regulatory bodies General Medical Council and Nursing and
Midwifery Council and within local records management policies.
Use of restraints
58. Unfortunately there have been too many reports in which the Ombudsman has
criticised the level of restraints used when prisoners are taken to outside
hospital. It is pleasing to recognise the good practice adopted by Wormwood
Scrubs to ensure that the man was treated with dignity and respect in the final
two days before his death. This coincided with his family’s visits and I hope that
removing the restraints and the escort officers made a difficult situation easier to
bear.
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CONCLUSION
59. I judge that attention was paid to the man’s health needs and appropriate
treatment and care was provided. I accept the opinion of the clinical review
panel that the standard of care the man received in prison was equitable to that
which he could have expected to receive in the community.
60. The man exercised his right to refuse medication and treatment. However
there was no formal assessment of his mental capacity to make such decisions,
given his known mental illness, despite frequent contact with health
professionals. In my view, his capacity to refuse treatment should have been
formally assessed by a psychiatrist.
61. He was correctly placed on the ACCT suicide monitoring process due to his
history of self harm. In many ways, and despite moving between prisons, the
ACCT arrangements worked well and certainly, in the main, kept the man safe.
I am concerned however that the safeguards of the PSO and the local
instruction were not used before the level of ACCT supervision was reduced
from constant to once an hour..
62. I believe that the man was treated with dignity and respect both at Wormwood
Scrubs and when he was in hospital, especially when the restraints were
removed in his last days. Following his death I am satisfied that Wormwood
Scrubs appropriately followed the guidance given in PSO 2710, ‘Follow up to
death in custody’.
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RECOMMENDATIONS
1. The Head of Healthcare should ensure that formal mental capacity
assessments are conducted when a prisoner refuses medical treatment, and
especially when the prisoner has a diagnosed mental illness.
Partially accepted. There has to be a clear distinction between prisoners
refusing life threatening treatment and those who refused non life threatening.
It would not be possible to carry out assessments on every prisoner who
refuses medication on an ad hoc basis but it would be appropriate to conduct
such an assessment to assess an individual who has serious underlying
medical conditions or who is terminally ill. We will develop a protocol to
explain this.
2. The Governor should ensure that staff adhere to PSO 2700 and local
instructions regarding any reduction in the level of ACCT supervision..
Not Accepted. Having consulted the relevant PSO and sought advice from
the national policy department (Safer Custody Group) they have confirmed
that the guidance contained within PSO 2700 on the reduction of any level of
supervision is exactly that, guidance. It was emphasised that it is a matter for
the ACCT Multi-disciplinary Review Team to set the level of supervision as
their risk assessment demands.
3. The Head of Healthcare should ensure that staff are reminded of the
responsibilities for record keeping as set out by professional regulatory
bodies General Medical Council and Nursing and Midwifery Council and
within local records management policies.
Accepted. The NMC are currently sending out updated information to all staff
on the register regarding record keeping responsibilities. We will also locally
send out reminders to both staff on the NMC and GMC registers.
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