Individual at Acklington

Investigation into the circumstances surrounding the
death of a man at HMP Acklington in April 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2010
This is the report of an investigation into the death of a man, a prisoner at HMP
Acklington. He died in April 2010 at hospital. He was 67 years old. I offer my
sincere sympathy and condolences to his family and all those affected by his loss.
He was sentenced to four years imprisonment at Crown Court on 25 September
2009. He was initially taken to HMP Altcourse and after a month was moved to HMP
Holme House. On 8 December, he was transferred to HMP Acklington and it was
here that after complaining of chest pains he was diagnosed with cancer of the liver
on 8 February 2010. It was not known at the time whether this was the primary site
of the cancer or whether it had spread from elsewhere.
He began chemotherapy treatment in March but his condition suddenly deteriorated
the following month and, having been transferred to hospital on 11 April, he died four
days later. At the time of writing, I have not had sight of the post mortem
examination but am aware that a preliminary cause of death has been recorded as
stomach cancer.
The investigation was carried out by my colleague. An independent review of the
man’s medical care in custody was carried out by the clinical reviewer and her
assistant on behalf of the local PCT. I am most grateful to them for their assistance.
I would also like to thank the Governor and staff of Acklington for their full and ready
co-operation during the course of the investigation. I am especially obliged to the
liaison officers for their help in liaising with my investigators.
Whilst the man was at Altcourse, the prison doctor referred him to a local hospital
consultant. However, details of this referral were not entered in the continuous
medical record, nor was the referral followed up when he transferred.
Notwithstanding this, both my investigator and the clinical reviewer found he
received a high level of clinical care whilst at Acklington. Having complained of
chest pains, he was referred for appropriate investigations and a diagnosis made
and treatment started within national guidelines. Furthermore, both healthcare and
discipline staff at the prison displayed a great deal of compassion towards him and
liaised with the hospital as appropriate. I endorse one recommendation made by the
clinical reviewer regarding the introduction of a measurement tool to monitor a
patient’s blood pressure, pulse, pain and respiration and make one recommendation
of my own.
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.
Thea Walton
Acting Deputy Prisons and Probation Ombudsman December 2010
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CONTENTS
Summary
The investigation process
HMP Acklington
Key findings
Issues
Conclusion
Recommendations
Family comments
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SUMMARY
Having been sentenced to four years imprisonment for a sexual offence on 25
September 2009, the man was taken to HMP Altcourse. This was his first conviction
and, therefore, first time in prison. He remained at Altcourse for around a month.
His only health need was identified as a Salbutomal inhaler to treat his asthma. He
said he had no outstanding hospital appointments in the community. However, on
30 September, the prison received a letter with details of an appointment at hospital,
following investigations which had been undertaken of his colon. Since he was now
residing in a different area, the prison doctor cancelled this appointment and made a
referral to the local hospital. This referral was not entered in the continuous medical
record, nor was it highlighted in documentation when he was transferred. I make a
recommendation in this regard.
He was transferred to Holme House on 26 October. He had no significant
appointments with healthcare staff there and was transferred to Acklington on 8
December. Neither prison noted the outstanding referral following investigations of
his colon when he was in the community. Nine days later, he complained of chest
pain and a nurse treated him with antacid medication (used to neutralise stomach
acidity). On 30 December, he told the prison doctor he was suffering chest pain
again. Following a physical examination, the doctor made an urgent referral to
hospital for a chest x-ray, blood tests and ultrasound scan.
On 8 February 2010, the ultrasound scan showed cancerous lesions in his liver.
When the prison doctor received these results he immediately referred him to the
hospital’s consultant oncologist (cancer specialist). Following further tests and
investigations, he started chemotherapy on 27 March. This involved him attending
hospital to receive the medication by an intravenous drip and then returning to the
prison where he was given oral medication twice daily for the following two weeks.
Staff at the prison monitored his condition several times a day and liaised with the
hospital staff where appropriate. He was admitted to hospital for three days on 1
April and treated for a chest infection, as well as having fluid drained from his
abdomen. On 11 April he was readmitted following a worsening of his condition,
since he had had fallen over in the night, was vomiting and appeared dehydrated,
weak and unkempt.
It was initially thought that he might have returned to prison and therefore early
release on compassionate grounds was not considered. Also, an earlier prognosis
had given him six months to two years to live. I find this decision entirely
reasonable. However, on 15 April his condition rapidly worsened and he was
assessed as being in the last stages of his life. Appropriately, prison managers
ordered his restraints to be removed and his wife was contacted. She was present
at the hospital, along with her sister and his son and daughter, when he died in the
early hours of the following morning.
I have concluded that he received a high level of care whilst at Acklington and make
only one recommendation. This is in relation to healthcare staff using a
measurement tool to monitor his blood pressure, respiration, pulse and pain. I have
also asked the Governor to ensure that the personal officer scheme is running as
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intended, since he was effectively without a personal officer for the first and last
periods of his time at Acklington. However, despite this, I found that he received the
necessary support from other staff, both healthcare and discipline, such that his lack
of personal officer does not seem significant.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 16 April 2010, when the investigator issued
notices announcing the investigation to staff and prisoners. The notices
included an invitation to those who wished to submit information related to the
man’s death to make themselves known to the investigator. No one came
forward as a result.
2. The investigator was given access to his prison files, including the medical
record. She visited Acklington with an assistant ombudsman on 30 June and
1 July and interviewed five members of staff. She also met with
representatives from the Independent Monitoring Board (IMB) and Prison
Officers’ Association (POA).
3. An independent clinical review of the man’s health needs whilst he was in
custody was carried out by a clinical reviewer and her assistant on behalf of
the local PCT. The clinical reviewer joined the investigator for some of the
interviews at Acklington on 1 July.
4. One of my family liaison officers telephoned the man’s wife on 19 May to
advise her of the investigation and invite her to raise any matters she wished
to be addressed. She said she felt that her husband had been well cared for
by the prison and that the family liaison she had received since her husband’s
death had been good.
5. However, his wife had two main concerns. Firstly, she wanted to know why
he had been transferred to Acklington prison which was around four hours
drive away from their home in Crewe. Secondly, when his health deteriorated
on 15 April, prison staff telephoned her. Although she managed to see him
before he died, he was not awake or aware that she was there. She said that
if she had known how ill he was she would have gone to the hospital sooner.
I hope that this report helps the family and friends to better understand what
happened in the time leading to his death.
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HMP ACKLINGTON
6. HMP Acklington opened in 1972 as a category C prison for convicted adult
male prisoners. On arrival into prison, prisoners are risk assessed and given
a category based on their offence and the risk that they pose to the public
should they escape. Category C prisoners are defined as those who cannot
be trusted in open prison conditions but who would not have the ability or
resources to make a determined escape.
7. The prison is situated on a former RAF station near Amble in Northumberland
and can accommodate 946 prisoners. This includes a vulnerable prisoner
unit which holds 460 prisoners, who are considered to be at risk from other
prisoners if placed on normal location. For example, if they have accumulated
debts to other prisoners or committed an offence of which other prisoners
would disapprove.
8. Healthcare is provided by the Northumberland Care Trust Adult Directorate.
Nurses and a prison doctor (provided through a local practice) deliver primary
healthcare during the daytime, seven days a week. There is no out of hours
medical cover, although a doctor can be contacted by prison staff by
telephone after 6.00pm. Prisoners who require inpatient nursing care are
transferred to an outside hospital or another prison.
9. The then Chief Inspector of Prisons last reported on Acklington following an
unannounced inspection in June 2009. She found since the last inspection in
2006, “a greatly energised and much better managed prison”.
10. An IMB is appointed to each prison by the Secretary of State for Justice. Its
members are wholly independent of the National Offender Management
Service (NOMS) and the prison’s management team. Each IMB is required to
produce an annual report to the Secretary of State, highlighting good practice
and areas of concern.
11. Acklington’s latest IMB report covers the period July 2008 to June 2009. The
Board considered that,
“Since the new Senior Management Team arrived at HMP Acklington
there have been quite a few changes. The staff morale has increased and
the prisoners seem happier with their lot.”
12. The Board members had concerns about the standard of accommodation on
some of the wings, the amount of purposeful activity available for those with
literacy issues and delays in prisoners receiving their mail in the vulnerable
prisoners unit. With regard to healthcare services, they wrote:
“As the prison population changes and becomes older there is an
increasing need to manage prisoners with illnesses associated with aging
… The staff are also struggling to find appropriate consultation space
within Healthcare and are constantly juggling sessions; this is restricting
recruitment of extra staff who could be helping to manage the increasing
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caseloads. Access to appropriate consultation rooms in which to see
prisoners on the wings is also very poor, with little opportunity for prisoners
to be offered confidential consultation.”
13. NOMS is responsible for the management of prisons in England and Wales.
Every three months it publishes an assessment of each prison’s performance
against 34 measures. Prisons can gain a rating of between one (serious
concerns) and four (exceptional performance). Acklington has scored threes
(good performance) for the last four quarters.
14. The Ombudsman assumed responsibility for investigating deaths in custody in
2004. Since that time, this office has investigated 19 other deaths at
Acklington, of which 13 were due to natural causes. There are no significant
similarities between these previous deaths and that of the man.
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KEY EVENTS
15. The man was employed as a refuse collector for forty years. He had two
children from his first marriage, aged 36 and 30 years, with whom he enjoyed
a good relationship. He separated amicably from his first wife and later
remarried. His second wife remained supportive of him and he intended to
return to live with her in Crewe on his release from prison.
16. On 25 August 2009, he was convicted of sexual offences at Crown Court. He
had no previous convictions. He remained on bail for a month, then was
sentenced to four years imprisonment and taken to HMP Altcourse. As is
routine on arrival at a prison, he was screened by healthcare staff and his only
identified problem was long term asthma (chronic inflammatory disease of the
airways) for which he was prescribed a Salbutamol inhaler. He said he had
no outstanding medical appointments in the community. He was granted
vulnerable prisoner status due to the nature of the offences he had committed
making him potentially at risk from other prisoners.
17. Staff at Altcourse received a letter on 30 September, which said that he had
an outstanding outpatient’s appointment at hospital on 26 November. This
was to follow up a colonoscopy (an examination of the colon with a camera)
and biopsy (the removal of cells for investigation), which he had had on 29
June. In discussion with the clinical reviewer, she commented that since the
follow-up appointment was five months later, this would not suggest any
urgency. Since he was now in a different National Health Service area, the
prison doctor cancelled the appointment and sent a referral letter to the local
hospital consultant gastroenterologist (specialists in the digestive system).
18. There is no record of him being offered a hospital appointment or that this
referral was followed up by the prison. Furthermore, whilst the referral letter
was placed at the back of the clinical record file, its details were not noted in
the continuous medical record and therefore not immediately obvious to
someone reviewing his treatment.
19. Since this was his first time in prison, he was also interviewed by a Registered
Mental Nurse (RMN) on 1 October. The nurse concluded that he had no
mental health issues, was a low risk of suicide or self-harm and was coping
well within the prison environment. No further assessments of him or
significant events took place while he was at Altcourse.
20. On 26 October, he was transferred to HMP Holme House. The movements
department at Altcourse explained that this was so that he could complete the
sex offender treatment programme. (He was later assessed as unsuitable for
this programme due to his denial of the offence.) The distance from his home
was not unusual in such circumstances. Again the routine healthscreen
identified his only need as a Salbutamol inhaler and he did not disclose that
he had an outstanding hospital appointment in the community.
21. He had no further significant contact with healthcare staff whilst at Holme
House and was transferred to HMP Acklington on 8 December. This was
9
because he was classed as a vulnerable prisoner and Acklington would
usually be allocated such category C prisoners from Holme House. He again
had a routine healthscreen, which identified his current health concerns as
asthma and the need for immunisation for Hepatitis B. He was deemed fit for
the gym and employment. He was concerned about the effect being located
four hours away from home would have on the number of visits he received.
In the next few days, he also had an elderly health assessment and an annual
asthma review.
22. On 17 December, he told a nurse that he had pain in his abdomen and chest
for which she gave him some antacid medication. A fortnight later, he told
Prison Doctor A that his general practitioner (GP) in the community had
planned to start B12 injections. As this is treatment for pernicious anaemia (a
shortage of red blood cells due to a vitamin B12 deficiency), the doctor
ordered blood tests. He also said that he had had pain in his right lower chest
and upper abdomen and he complained of being short of breath. The doctor
made an urgent referral to hospital for a chest x-ray as well as the blood tests.
23. Following the tests, abnormalities were found in his blood and on 21 January
2010, the doctor discussed these with him. He explained the results showed
that there was some liver dysfunction and microcytic anaemia (meaning that
the red blood cells were paler than normal which could be caused by a
number of factors). He told the doctor that he had had an endoscopy (an
internal examination of organs in the body) in June. He said that a lump had
been found and removed on a number of occasions before his imprisonment
but did not elaborate any further than this.
24. The doctor requested further information from his GP. He received
information that he had undergone some bowel investigations including a
biopsy, but no diagnosis had been confirmed. He said he felt well and denied
losing weight despite the doctor’s observation that he looked thin. As a result
of this information, the doctor ordered an ultrasound scan of his liver.
25. Officer A introduced himself as the man’s personal officer on 25 January.
(The personal officer scheme was introduced so that prisoners are given a
named officer that they can approach for advice or assistance.) He told the
officer that he was happy being employed in the laundry, got on well with his
cellmate and had no concerns.
26. He attended hospital on 8 February for the ultrasound scan of his liver. The
results showed multiple cancerous lesions which may have been present in
other organs too. They could identify little normal liver. The hospital staff
typed these results on the same day as the appointment, although it is not
clear when they sent them or when the prison received them. Prison Doctor A
first had access to the results on 16 February, when he sent an urgent referral
fax to the hospital consultant oncologist.
27. The oncologist telephoned the doctor the following day and said that he would
arrange all necessary investigations and would let the prison know of
appointments in advance. Later that day, the doctor discussed the scan
10
results with him and explained the process for onwards referral and treatment.
The doctor told my investigator that from that point on he provided more of a
supportive role for him, while the oncologist at the hospital directed his
treatment.
28. That afternoon, Officer B visited him in his cell to find out how he was coping
with the news about his diagnosis. He was very distressed and the officer
arranged for him to call his wife that evening from the office telephone, so
they could speak in private.
29. On 24 February, the doctor spoke to the oncologist who asked that further
investigations take place in preparation for the planned outpatient
appointment on 19 March. The prison also began to monitor his weight since
he was having some difficulty and pain with digesting food, as well as
vomiting. The oncology multi-disciplinary team at the hospital also discussed
him and agreed an action plan for treatment.
30. The following day, he was assessed by the prison doctor who noted that his
pain had increased and he was prescribed ibuprofen (an analgesic and anti-
inflammatory). The clinical reviewer comments that this is the first treatment
option recommended in the World Health Organisation (WHO) Pain Ladder.
(This is a three-step scale which determines what pain relief should be given
for cancer sufferers). She notes that he did not progress any further up the
ladder.
31. When Officer A met with him on 6 March, he said he was coping, although
anxious, and waiting to go to the hospital for more tests. He attended the
hospital for a Computerised Tomography (CT) scan two days later. (A CT
scan is a three dimensional x-ray). Through his own choice, he remained
working in the laundry, as he felt able and preferred to occupy his time as
much as he could.
32. He told the doctor on 18 March that he was having difficulty sleeping and the
doctor therefore prescribed zopiclone to help with this. The following day, he
attended an appointment with the oncologist, who told him he most likely had
primary cancer of the bowel which had spread to his liver and lung. He was
given a life expectancy of six months without treatment and two years with
treatment. The consultant obtained his permission to start chemotherapy.
When he returned to the prison he was tearful and was supported by wing
officers and healthcare staff. He was told to contact healthcare if he had any
concerns or questions. Officer A spent some time with him and he asked the
chaplain to visit him.
33. On 27 March, he began chemotherapy via an intravenous drip at the hospital.
His wife and son were present at the time. On his return to the prison later
that day, he was moved wings so that he could have a single cell due to his
increased risk of infection and lowered immune system as a result of the
treatment. Although he did not want to move cells, as he had friends on his
current wing, he understood why this was necessary. Later, when he started
11
to feel unwell following the treatment, he told staff that he appreciated having
the privacy of his own cell.
34. He was also concerned that, since he had literacy difficulties, he would not
know when to take his medication as he no longer had a cellmate to help him.
However, Nurse A assured him that healthcare staff would keep possession
of his medication and give it to him twice a day. This would take place for two
weeks following the hospital treatment. Then he would have a week free of
medication before beginning the chemotherapy cycle again by returning to
hospital for an intravenous drip. The only medication which he kept in his
possession was loperamide, which is used to treat diarrhoea.
35. The hospital gave him and prison staff a comprehensive leaflet regarding
chemotherapy and its possible side effects. In addition, the prison staff were
given contact details for the specialist nurse, with supporting management
recommendations. He was visited several times each day by prison
healthcare staff to monitor his symptoms and record his temperature. In
particular, a raised temperature can be an indicator of complications for those
undergoing chemotherapy.
36. On 1 April, his temperature increased. Staff immediately told the prison
doctor and the oncology unit and he was admitted to hospital. The prison
staff kept in contact with the hospital and he was discharged three days later,
having been treated for a chest infection. He also had fluid drained from his
abdomen during this time.
37. Healthcare staff in the prison continued to regularly monitor him. At times he
appeared dehydrated and had episodes of nausea and diarrhoea as a side
effect of the chemotherapy. The staff sought advice from the oncology unit as
necessary.
38. On 11 April, at around 9.30am, Nurse A visited him in his cell. He told her
that he had fallen over in the night, continued to experience nausea, vomiting
and diarrhoea. He appeared dehydrated, weak and unkempt. Due to this
deterioration in his condition, the nurse called an ambulance and he was
admitted to hospital as an emergency.
39. As is routine when prisoners are transferred to hospital, a risk assessment
was completed by healthcare staff and the security department to assess the
level of restraint and number of escorts necessary for him. This assessment
is based on the prisoner’s current medical condition and any past behaviour
which indicates they may be an escape risk. Since there were no special
security measures deemed necessary for him, a governor decided that two
staff would accompany him to hospital, with the use of single handcuffs. (He
would be attached by one arm to an officer). One of the prison managers told
my investigator that this would be the standard level of restraint for a category
C prisoner. The level of restraint would be reviewed if there was any change
in the prisoner’s condition or if the daily management check at the hospital
necessitated it.
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40. Over the next few days his condition continued to deteriorate. He was
transferred to the Medical Assessment Unit and then Ward 17. On 14 April,
prison staff were told that the consultant was due to assess whether he could
return to the prison the following day. They telephoned his wife to update her
on her husband’s condition and a visit was arranged for 16 April.
41. However, by the next day, his condition had worsened and he was not fully
aware of his surroundings, his blood pressure was fluctuating, he was unable
to eat or drink and was incontinent. Hospital staff considered that he was now
in his last stages of life.
42. One of the officers with him telephoned the prison at around 2.00pm to speak
to the duty governor. The officer explained that his condition had
deteriorated, he was very frail and not expected to live much longer. The
governor therefore spoke to the acting governing Governor. They decided to
remove his restraints. The duty governor therefore asked the officer to
remove the restraints and informed them a further risk assessment would
follow. The man’s wife was also immediately told of her husband’s condition
and she began the journey to see him. An officer was appointed as the prison
family liaison officer (FLO).
43. Two officers took over the bedwatch at 7.30pm that evening. They received a
full handover and were told of his condition. He remained asleep for the
whole time the officers were there. At around 7.45pm the man’s wife, sister-
in-law, son and daughter arrived at the hospital. They stayed with him until
around 10.00pm, when they all went to the visitor’s room, apart from the son
who stayed with his father, talking to the escorting officers.
44. The following morning at around 3.10am, the officers noticed that his
breathing had become laboured. They called the nurse, who in turn called his
family to the room. Around ten minutes later, he stopped breathing and was
pronounced dead at 3.45am.
45. The officers returned to the prison where they had a debrief meeting with a
governor and were offered the support of the care team. Both officers then
went home around 6.00am. Two governors met the family at the hospital at
10.20am to express their condolences.
46. Following the man’s death, his family were offered appropriate support by
prison staff including offering to contribute to the funeral costs. The funeral
took place on 26 April, without anyone from the prison attending, in line with
the family’s wishes. The family have been complementary about the liaison
and care both they and he received from the prison.
47. Staff interviewed felt adequately supported following the death. Prisoners
were also informed in a sensitive manner and a memorial service was held for
him in the prison chapel on 29 April.
48. At the time of writing I have not had access to a post mortem report. I am
aware that on 19 April a provisional cause of death was given as metastatic
13
carcinoma of stomach (stomach cancer) and an interim certificate of death by
natural causes was issued.
14
ISSUES
Clinical Care
49. Before being imprisoned, the man had a colonoscopy in June 2009. Although
he did not disclose this to staff at Altcourse, on 30 September they received
confirmation of an outstanding review appointment at hospital. Since he was
now residing in a different NHS area, the prison doctor cancelled this
appointment and made a referral to the local hospital. Although the referral
letter was placed in the back of the clinical record, the details of this referral
were not entered in his continuous medical record. No note was made of this
outstanding referral in the transfer documentation when he was moved to
Holme House under a month later. I therefore make the following
recommendation:
The Head of Healthcare at Altcourse ensures all referrals and
appointments to outside hospitals are entered in the continuous medical
record. Any outstanding referrals or appointments should also be
highlighted in transfer paperwork.
50. He did not tell staff about this outstanding referral when he was transferred to
Holme House or Acklington. Ideally, healthcare staff would have read the
referral letter in the back of the medical record and made a further referral to
the local hospital. However, given this information was neither flagged up on
transfer documentation nor detailed in the continuous medical record it is
understandable that the referral was missed. Although I do not make a formal
recommendation in this regard I would ask that the Heads of Healthcare at
Holme House and Acklington ensure a prisoner’s medical record is reviewed
in detail on transfer.
51. In any event, the clinical reviewer told my investigator that since the review
appointment had originally been scheduled for around five months after the
colonoscopy, in November, this would imply the appointment was not urgent.
Shortly after this appointment was due, the prison doctor had referred him to
the local hospital due to his own concerns regarding his condition.
52. Having complained of chest pains to him and following abnormal blood test
results, he attended an ultrasound scan on 8 February which showed
cancerous lesions. The doctor referred him to the consultant oncologist on 16
February and had an appointment with him the following day. The clinical
reviewer notes that this is in accordance with the Department of Health (DOH)
Cancer Plan which recommends that following assessment and abnormal x-
ray results a referral must be made to hospital for consultation and further
investigations and the patient must be seen within two weeks.
53. His diagnosis was discussed by the oncology team at the hospital and an
action plan agreed for treatment. The clinical reviewer says that this met the
standards within the DOH Cancer Plan and Yorkshire Cancer Networks which
is 31 days from the initial abnormal results. He began chemotherapy on 27
15
March which again met the DOH Cancer Plan and Yorkshire Cancer
Networks guidance of a maximum of 62 days from the initial detection.
54. The clinical reviewer concludes that the hospital responded in a timely
manner to a request from the prison doctor on 30 December 2009 for a
consultation to a confirmed diagnosis and treatment commencing on 19
March 2010, eleven weeks later. She says that the prison doctors, in
particular Prison Doctor A, were robust in making referrals and following up
outcomes to meet the national standard in accordance with the DOH Cancer
Plan. She writes that Prison Doctor A,
“responded to clinical presentation, prescribing treatments, ordering
investigations and making a referral to oncology. He communicated
his findings to the man.”
55. Prison staff communicated appropriately amongst themselves and with the
hospital as necessary if his condition changed. The clinical reviewer writes
that the hospital responded in a timely manner to referrals and communicated
effectively with prison staff, providing support and information as required.
She says that prison staff successfully monitored and supported him following
his diagnosis including his blood pressure, pulse and temperature. He only
volunteered that he was in pain on three occasions and was prescribed
appropriate medication in these instances.
56. However, she believes that since he had told staff he was experiencing pain,
she would expect staff to ask about this routinely when doing other
observations. This is so that a more accurate account of any deterioration
could be noted and acted upon. She comments that using a measurement
tool such as the MEWS (Modified Early Warning Signs) scoring system or
other validated pain assessment tools would enable staff to respond to
problems earlier. She therefore makes the following recommendation, which I
endorse:
The Head of Healthcare should implement a robust base line
measurement tool to incorporate blood pressure, pulse, pain and
respiration; for example the MEWS (Modified Early Warning Signs)
scoring system.
57. In terms of palliative care, Nurse A explained that care plans would usually be
put in place for prisoners and they would invite Macmillan Nurses (who
provide support for cancer sufferers) to visit the prison. However, due to the
sudden deterioration in his health it was not possible to organise this.
However, he had been able to access support via the Macmillan Nurses at the
hospital.
58. Overall, the nurse and others on the wing showed a high level of care to him,
going to see him whenever they could to check on his welfare and not just
when dispensing medication. I agree with the clinical reviewer that, “Overall
he appears to have received a high quality of care provision”.
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Personal Officer Scheme
59. The man was transferred to Acklington on 8 December 2009 but was not
appointed a personal officer until 31 December 2009. He therefore had over
three weeks without a personal officer. It is not clear from the paperwork
whether the officer had the opportunity to introduce himself before Officer A
was appointed as his personal officer on 6 January 2010, following his move
to a different wing.
60. Officer A introduced himself to the man around three weeks later and saw him
on a regular basis over the next two months. This was in line with
Acklington’s personal officer scheme policy which says a minimum of
fortnightly entries must be detailed on the offender’s record. The officer
provided him with support and encouragement at what was clearly a very
difficult period in his life.
61. At Acklington, personal officers are appointed according to the wing that a
prisoner is on. However, following his transfer to another wing after his initial
chemotherapy treatment, on 27 March, my investigator was told by a governor
that Officer A remained his personal officer. When interviewed, it was
apparent that the officer was unaware of this and had assumed, as is normally
the case, that the man would have been assigned another personal officer on
the wing he moved to. This would be in line with Acklington’s personal officer
policy and a much more practical arrangement. As a result there are no
personal officer entries after 19 March.
62. Nevertheless he received much support after this time, both from nurses and
other officers on the wing. He also spent some time in hospital. Given this, I
do not make a formal recommendation but ask that the Governor ensures that
the personal officer scheme is operating effectively and in accordance with
local protocol.
Removal of restraints
63. When he was admitted to hospital on 11 April, he was subject to the standard
level of escort and restraints for a category C prisoner – two officers
accompanying him and single handcuffs. This risk assessment was reviewed
as appropriate over the following days.
64. On 14 April, prison staff were told that the oncologist was due to review him
the following day to decide whether he could return to the prison. It was
therefore appropriate that he remained restrained at this stage. However, his
condition deteriorated rapidly on 15 April such that he was assessed to be in
his last stages of life.
65. One of the escorting officers immediately contacted the duty governor at the
prison who consulted the acting governing Governor. They told the officer
that his restraints should be removed and this was done without delay at
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around 2.00pm. This seems an entirely appropriate decision from a risk and
decency perspective.
Consideration of transfer to a prison closer to home
66. He had originally been transferred to Acklington since he was a category C
vulnerable prisoner and the prison has a large unit housing such prisoners.
The duty governor told my investigator that under usual circumstances a
prisoner could apply for a transfer to another prison after three months.
67. All staff my investigator spoke to confirmed that his condition deteriorated very
quickly. Prison Doctor A said that following the results of the ultrasound in
mid-February, he may have been fit for transfer. However, after that, a long
journey of several hours would not have been appropriate. Furthermore, he
said any transfer would have led to a disruption in his treatment.
68. The clinical reviewer agreed with the doctor’s view that treatment would be
disrupted by a transfer. She also highlighted that there were ten weeks from
his diagnosis to his death. Therefore, she said that by the time his treatment
started, the symptoms were so advanced that the prognosis was not
optimistic and transfer to another prison would have been difficult for him.
She also said that the unpredictability of lung and liver cancer made it very
difficult to know how quickly the disease would progress.
69. Given these circumstances including the sudden deterioration in his health, it
seems reasonable that he was not transferred to a prison closer to home.
Consideration for early release on compassionate grounds (ERCG)
70. Prison Service Order (PSO) 6000 says ERCG may be considered when
“a prisoner is suffering from a terminal illness and death is likely to
occur soon. There are no set time limits, but three months may be
considered to be an appropriate period. It is therefore essential to try
to obtain a clear medical opinion on the likely life expectancy. The
Secretary of State will also need to be satisfied that the risk of re-
offending is past and that there are adequate arrangements for the
prisoner’s care and treatment outside prison.”
71. In order to apply for ERCG, a form must be completed by a registered medical
practitioner with details of the medical condition, the seconded probation
officer with details of the care available in the community and the Governor
with details of the risk the prisoner presents. This is then forwarded to the
Public Protection Casework Section (PPCS) at Prison Service Headquarters,
who will obtain the opinion of a medical director, prison health and the Parole
Board, as necessary. A decision to release can only be made by Ministers
and is usually made within two weeks, but can be more quickly if
circumstances require it. The PSO also says that if there is a medical
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application involving a very short life expectancy, the PPCS must be alerted
by telephone at an early stage.
72. Staff my investigator spoke to said that his condition had deteriorated too
quickly for ERCG. The prison doctor understood that in mid-March he had
been given a life expectancy by the oncology consultant of six months without
treatment and two years with treatment. He started chemotherapy at the end
of the month but was admitted to hospital for three days at the beginning of
April and received treatment for a chest infection. He was then admitted
again as an emergency on 11 April. However, it is clear that initially it was
thought he may return to the prison. It was not until 15 April, the day before
he died, that his condition deteriorated rapidly and the hospital confirmed he
was in the end stages of his life.
73. Since his initial prognosis was six months to two years, an ERCG could not be
completed at this stage. His condition then deteriorated very quickly on 15
April. It is clear that a full application for ERCG could not have been
completed in time at this stage but in line with the above guidance a
telephone call could have been made to the PPCS to alert them to his
condition. However, it is unlikely to have made any significant difference for
him and I therefore do not make any formal recommendation in this regard. I
would, however, ask the Governor to ensure that staff are aware of the
contents of PSO 6000 in relation to consideration for ERCG.
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CONCLUSION
74. The man entered prison a reasonably well man, apart from a diagnosis of
asthma which was well controlled with medication. It later became apparent
that while in the community he had undergone investigations of the bowel,
including a biopsy to which no diagnosis was confirmed.
75. Having been transferred to Acklington in December 2009, he complained of
chest pains later that month and was quickly referred by the doctor for further
investigations. After cancerous lesions were found in his liver, he started
chemotherapy on 27 March and a high level of care and liaison with the
hospital was shown by prison staff. Unfortunately, the following month,
having been admitted to hospital, his condition deteriorated very suddenly and
he died, with his family present, in the early hours of 16 April.
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RECOMMENDATIONS
1. The Head of Healthcare at Altcourse ensures all referrals and appointments to
outside hospitals are entered in the continuous medical record. Any
outstanding referrals or appointments should also be highlighted in transfer
paperwork.
This recommendation was partially accepted and the response is below:
“A checklist is conducted by nursing staff the afternoon prior to transfer; this
included outstanding hospital appointments. The checklist is attached to the
envelope that contains the print out of the medical record and was in place at
the time of transfer.
Admin staff will scan all appointments onto systm1 as soon as they are
received and a copy will go with the print out of the medical record.”
2. The Head of Healthcare should implement a robust base line measurement
tool to incorporate blood pressure, pulse, pain and respiration; for example
the MEWS (Modified Early Warning Signs) scoring system.
This recommendation was accepted and the response is as follows:
“HMP Acklington Healthcare have adapted the MEWS (Modified Early
Warning Signs) score that is used in the general hospitals. It is a robust
baseline measurement tool which will incorporate blood pressure, pulse pain
and respiration.”
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FAMILY COMMENTS
The man’s wife asked for the following comments to be added to the final report:
She was upset that the prison doctor cancelled the appointment at hospital
without checking why it was needed. Also, that it was not entered into the
record and followed up when he transferred to another prison. She feels both
caused an unnecessary delay in the diagnosis and care he received.
When he attended the hospital to hear his diagnosis he had to ask the doctor
at the hospital to call his to inform her – she therefore found out by phone that
he had little time to live which was very distressing. She feels she should
have been allowed to attend this appointment with him to offer him support as
they were aware in advance that he was to receive news of the diagnosis.
When his family attended the hospital to be with him for his chemotherapy it
was most upsetting to see that he was handcuffed and chained – this drew
attention to him and remarks from other people at the hospital – it was also
obvious how ill he was as he could barely walk. Thankfully, the officers
removed the chains as they were in the way of the attached drips but it was
upsetting that they were there in the first place.
She visited her husband at the prison one further time after the
chemotherapy. This was the last time she saw him where he was awake and
able to speak to her. She spoke of how hard it was to have this visit in the
normal visits area. Firstly because he was so weak walking there was hard
for him. He had sickness and diarrhoea so had to leave the room for a long
period. He looked so unwell again it drew attention to him which was
humiliating for him. She feels that he was so ill that a private room should
have been arranged for this visit.
She was upset to see that the hospital staff were aware what he was in prison
for as it states that female staff were not comfortable treating him and male
staff had to do so instead. This is judgmental and she does not know how
they knew his offence and he deserved to be treated as like any other person.
From reading the nurses interview it seems that not enough information was
recorded in the medical notes as the nurse did not seem to know much
despite having them in front of her – she thinks everything should be recorded
in these documents.
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