Individual at Nottingham

Investigation into death of a man
at HMP Nottingham in April 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2013
This report considers the circumstances surrounding the death of the man at HMP
Nottingham in April 2010. The man had been diagnosed with cancer in June 2009
and died as a result of the disease’s progression.
I offer my sincere condolences to the man’s family and all those who knew him. I
apologise for the long delay in issuing this report and for the additional distress this is
likely to have caused. I would also like to thank the man’s family for their
engagement with my investigation under the most distressing of circumstances.
The investigation was conducted by one of my investigators. We would like to thank
the Governor of HMP Nottingham and his staff for their co-operation. We also
extend thanks to the liaison officer to the PPO. In addition, we thank the clinical
reviewer who conducted a review of the man’s clinical care.
When at Nottingham, the man first complained of health problems in May 2009. He
had previously complained of similar problems whilst at HMP Lincoln. The man was
subsequently diagnosed with penile cancer. He underwent surgery and
chemotherapy but these treatments were unsuccessful. Although he was given the
option of moving to a hospice in the last few weeks of his life, the man said he
preferred to remain in the prison. Consideration was given to him moving closer to
his family, but he was thought to be too unwell to move such a distance. He died in
April 2010.
This is the third death from natural causes at Nottingham since 2004, when the office
began investigating deaths in prison custody. It is the first time that we have
investigated the death of a terminally ill prisoner at Nottingham.
The investigation has examined the clinical care that the man received, the suitability
of his accommodation at HMP Nottingham, delays in his diagnosis and treatment,
and a number of issues raised by his family. I endorse one recommendation made
by the clinical reviewer, which concerns the delays in the treatment he received.
Whilst not the fault of the prison, these delays could have seriously impacted on the
man’s illness.
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.
Nigel Newcomen CBE
Prisons and Probation Ombudsman February 2013
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CONTENTS
Summary
The investigation process
HMP Nottingham
Key events
Issues
Conclusion
Recommendations
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SUMMARY
1. The man transferred to HMP Nottingham from HMP Lincoln in March 2009.
At the time of his arrival, no health issues were recorded. He did not attend
appointments for more detailed health screenings which were scheduled
shortly after he arrived.
2. On 11 May, the man complained of what was described in the clinical record
as a “testicular lump”. He was prescribed antibiotics and referred to the local
hospital’s urology department. (Urology is a surgical speciality, covering the
diagnosis and treatment of disorders of the kidneys, bladder, prostate and
male reproductive organs.) The man also said he had begun to bleed when
passing urine, which was painful. He was prescribed painkillers.
3. The man moved to the urology ward at Nottingham City Hospital on 16 May.
He underwent a circumcision operation the next day and returned to the
prison. A biopsy was also taken for analysis at this time. He did not appear
to be in discomfort and could move around the wing, but he did have a
urethral catheter (used to drain the bladder) that required regular attention.
Throughout May and June, he was seen almost daily for attention to his
wound dressing and catheter. The clinical record noted that he became
skilled at managing this himself.
4. In late May, the man saw a doctor at the prison and said he felt as if he
needed to pass urine very frequently, and was also passing blood. On 5
June, the prison healthcare staff were notified that the man had been
diagnosed with penile cancer. They were asked to refrain from breaking this
news to the man, who would be given his diagnosis and treatment plan at his
next hospital appointment.
5. The man was made aware of his diagnosis on 12 June. He was shocked and
felt that he had been let down by other previous prisons and subject to
incorrect diagnoses. Throughout June and July, he attended numerous
appointments with prison healthcare staff, and his care plan remained under
review. On 20 July and 5 August, he underwent MRI scans (tests that can
provide detailed images of inside the body). The man continued to attend
appointments with prison healthcare staff throughout August and September.
6. Between 30 September and 12 October, the man underwent major and
traumatic surgery, a partial penectomy (the surgical removal of part of the
penis) and inguinal lymphanedectomy (the removal of the lymph glands in the
inguinal canal), at Leicester General Hospital. He was seen by healthcare
staff at the prison when he returned on 13 October. He seemed generally
positive and socialised with other prisoners on the unit.
7. Between October 2009 and February 2010, the man continued to receive
regular medical attention from medical staff within the prison, and when
attending outpatient appointments at hospital for chemotherapy. He received
antibiotics for post-operative infections, and was seen almost daily by medical
staff in the prison whilst his wounds healed. Numerous entries were made in
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the clinical record, often more than once per day. On 18 February, a nurse
noted that the man was becoming increasingly withdrawn and spending a lot
of time in his cell, sleeping.
8. On 11 March, the man attended a hospital appointment with the oncologist (a
physician that specialises in treating cancer) and was told that the
chemotherapy had been unsuccessful. Throughout March, various
arrangements were made to accommodate his deteriorating health. A
protocol was developed so that a nurse could visit the man during the night,
and a named nurse helped to co-ordinate his care and support. Authorisation
was given for a more comfortable mattress to be provided, and he received
visits from Macmillan nurses.
9. An occupational therapist and a Macmillan nurse visited Nottingham on 9 April
to discuss various pieces of medical equipment that would be necessary for
the man’s end of life care. Three days later, his condition had deteriorated
and end of life care was implemented. The man was not eating, had difficulty
holding things, and suffered periods of confusion.
10. On 13 April, an open door policy was agreed, so that the man’s cell would not
be locked overnight. A member of the healthcare team was present
throughout the night to offer support. An application for release on
compassionate grounds was accepted, with permission given for the man to
move to a local hospice. However, he was adamant that he did not want to
die in a hospice, and chose to remain in the prison. Consideration was given
to the man moving closer to his family, but he was thought to be too unwell to
make the journey. He continued to be cared for at the prison.
11. The man was awake and alert on 15 April and was asked if he wanted to
move to a hospice. He replied that he would not. Over the next few days, his
condition deteriorated and nurses continued to offer him support. He died at
8.00am in April.
12. I have investigated the man’s clinical care, his accommodation at Nottingham,
delays in his diagnosis and treatment, and a number of issues raised by his
family. I endorse one recommendation made by the clinical reviewer.
5
THE INVESTIGATION PROCESS
13. One of the senior investigators was appointed to conduct the investigation.
Notices of the investigation were sent to the prison for distribution and display,
giving staff and prisoners the opportunity to contact the investigator with any
relevant information. No-one came forward in response to the notices.
14. The investigator visited HMP Nottingham to open the investigation on 2 June
2010. During the visit, he met with:
• the liaison officer to the PPO
• the head of healthcare
• the healthcare service team leader
• the liaison officer to the man’s family
• Chair of the Independent Monitoring Board (IMB)
• from the Prison Officers’ Association
15. During this meeting, the investigator discussed with the people present some
of the circumstances of the man’s time at Nottingham and the way in which he
had been cared for during his illness.
16. The investigator visited the unit and the cell where the man had died. He also
collected copies of his prison record, including his medical file.
17. The investigator returned to HMP Nottingham on 28 and 29 September. He
interviewed eight members of staff. The interviews were recorded and
transcripts are included as annexes to this report. He also spoke to a prisoner
who was a friend of the man and helped him with his personal care.
18. One of the family liaison officers (FLOs) contacted the man’s family to explain
the purpose of the investigation and provide them with an opportunity to raise
any issues or questions about the care that the man received in prison. The
family liaison officer and the investigator subsequently met with the man’s
mother and three of his sisters. A number of questions and concerns were
raised during these meetings, most notably:
• Disappointment at the way in which the prison communicated information
about the man.
• The visiting arrangements at HMP Nottingham.
• Whether HMP Nottingham was suitable for the man, given his medical
condition.
• Various aspects of the man’s medical care, including pain relief, sedation,
palliative care, and the implementation of the Liverpool Care Pathway
(LCP).
• The professional boundaries of staff at HMP Nottingham.
• The application for release on compassionate grounds.
• The way in which the family were informed of the man’s death.
I hope this report will help them to better understand the circumstances of the
man’s death.
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19. A clinical reviewer was appointed to conduct a review of the man’s care whilst
in custody. The purpose of a clinical review is to examine the medical care
that a prisoner received in custody, which should be an equivalent standard to
what might have been expected in the community. The clinical reviewer
consulted the man’s medical records to inform her review. My investigator
asked the clinical reviewer to comment on a number of issues raised by the
man’s family about his medical care, and she has done so. The clinical
reviewer produced an addendum to her report, in which she wrote about
delays to the man’s diagnosis, surgery and chemotherapy. She also wrote a
short report about the man’s medical treatment prior to his arrival at HMP
Nottingham. The clinical reviewer’s findings are summarised within this
report, and her full reports are included as annexes.
20. Following the publication of the draft version of this report, we received written
comments from the man’s father and from the National Offender Management
Service. The man’s mother and sisters requested a visit from the investigator
and FLO. The comments from these parties are summarised below.
Comments from the man’s father
21. The man’s father asked why the man was moved from HMP Lincoln to
Nottingham. We have amended the first paragraph in the Key Events section
of this report to more accurately reflect the man’s sentencing. He was moved
(via HMP Ranby and HMP Leeds) as his trial was being held at Nottingham
Crown Court.
22. The man’s father asked us to note that he thought that the man should have
been moved to an open prison, a hospice or a prison closer to his family. He
said that he was disappointed that Nottingham did not have a hospital wing.
23. While the man’s father understood why the man had chosen to remain at
Nottingham towards the end of his life, he questioned why the man was not
moved before he became so ill.
24. He did not think that he was allowed to spend enough time with the man, and
did not think that this time was private enough. He also said that there should
better facilities for relatives to visit ill prisoners, such as a hospital wing or
hospice.
25. The man’s father expressed his gratitude to the liaison officer to the man’s
family, and said that the man had been comforted by his presence. He added
that he thought that the prison authorities had done their best for the man, for
which he was grateful.
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Comments from the man’s mother and sisters
26. The investigator and FLO visited the man’s mother and sisters on 25
November 2011. Where possible, they answered their concerns during this
meeting, which was followed up in writing. However, some issues remained
outstanding, which are dealt with below.
27. The man’s mother and sisters felt that there was an “overwhelming sense of
reluctance” by the Prison Service to take responsibility for what happened and
to acknowledge their role in the man’s death. They also found it difficult to
understand how the man had slipped through the net of so many healthcare
professionals.
28. They thought that the prison’s liaison officer to the man’s family should be
interviewed as part of this investigation as they remained concerned about the
appropriateness of the relationship she had with the man. The investigator
discussed this with an Assistant Ombudsman, who decided that there was
clearly a difference of opinion between the family and the prison about the
prison’s liaison officer’s role and it was unlikely that interviewing her would
add any new information at this stage.
29. The man’s mother and sister were distressed by many of the personal
comments made by prison staff when interviewed. They thought that the
transcripts of these interviews might have influenced other parties and that
their interests might have been prejudiced. We believe that transcripts are
relevant documents to the investigation and that it is appropriate under our
terms of reference that they should be disclosed to the proper parties.
30. The man’s mother and sister were concerned that their involvement in the
man’s care was not accurately represented in the report. In particular, they
mentioned that they visited him every day and played a key role in supporting
him through his illness.
31. The man’s mother and sisters told us that they felt misled by staff about their
grades and seniority. They were frequently told that they were speaking with
senior governor grades and were not aware that there are several different
grades of governor working in prisons.
32. The man’s mother and sister remain concerned that the prison claims there
were no missed or cancelled appointments during the man’s treatment.
However, there is a complaint form which suggests the man’s MRI scan was
cancelled in July 2009 due to problems with transport. They feel strongly that
the prison has no right to delay appointments when a prisoner has a
progressive condition and that priority must be given to these appointments.
They are pleased this is recognised in the report and that a recommendation
is made to improve practice in this area for the benefit of other prisoners.
33. The man’s mother and sister were concerned about discrepancies in the
man’s medical notes. They believe that although the notes suggest that he
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was on IV drip towards the end, this was not the case as the only noticeable
line was the one in his chest for the syringe drive.
34. The man’s mother and sisters were concerned that his cell was not closed
following his death. They noticed that there was no syringe driver or catheter,
and everything was clean and tidy. They are concerned that evidence was
lost.
35. The man’s mother and sisters were concerned that the conditions of the
man’s compassionate release licence were changed from the original
application. As explained in the report, the prison initially sought an address
in Birmingham for release, but after medical advice suggesting that the man
was too unwell to travel, a hospice in Nottingham was used as the approved
release address. No other conditions of the compassionate release
application were amended.
36. The man’s mother and sisters were concerned by information from the
Coroner that the man’s first reception healthscreen check was carried out by a
prison officer and not a healthcare professional. We have updated the report
to reflect that this healthscreen was completed by Nurse A.
37. The man’s mother and sisters were concerned that the man missed medical
appointments, and that they could not be sure that he had been collected for
these. They were also concerned that he was not seen by a doctor on a daily
basis and that medication was once increased over the telephone. They
questioned the appropriateness of this.
38. The man’s mother and sisters were concerned that the man was kept at the
prison rather than being moved to a hospice so that the prison could learn
how to care for a terminally-ill prisoner. (We have found no evidence of this.)
39. The man’s mother and sisters also said that there was an urgent need for a
protocol to be developed to ensure that the prisoner, staff and family
understand what is expected of them at key stages of a terminal illness. The
protocol should include visiting arrangements, the role of the FLO and what
happens when an individual is no longer well enough to make decisions for
themselves. (Since the man’s death, the Prison Service has issued a new
instruction – PSI 64/11 – which states that prisons must ensure that
arrangements are in place for an appropriate member of staff to engage with
the next of kin or a nominated person of prisoners who are either terminally or
seriously ill.)
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HMP NOTTINGHAM
40. HMP Nottingham is a local prison serving the courts in Nottinghamshire and
Derbyshire. During 2009, when the man was there, it accommodated 550
adult male prisoners, approximately half of whom were on remand awaiting
trial. The other half were convicted and either awaiting sentence or
undergoing assessment before being transferred to a suitable alternative
prison. In February 2010, Nottingham became a community prison holding up
to 1060 prisoners. The expansion of the prison included a new offender
management unit, reception, visits suite, healthcare centre and workshops.
HM Chief Inspector of prisons’ report
41. The then HM Chief Inspector of Prisons conducted an announced inspection
of Nottingham in February 2010. The HM Chief Inspector of Prisons made
the following comments:
“Health services were commissioned by NHS Nottingham City Primary
Care Trust. CitiHealth NHS Nottingham provided primary care services
and Nottinghamshire Healthcare NHS Mental Health Trust provided a
mental health in-reach service.
“The healthcare centre provided GP and specialist clinics. The mental
health in-reach team was based in the same building that housed
pharmacy and dental services. Medicine administration and, on occasion,
minor treatments were carried out in treatments rooms on each of the
wings. All areas used for the treatment and care of patients were
appropriately equipped, clean and well decorated.
“Health services provided 24-hour cover. A range of clinics was available,
including some provided by visiting specialists. Good arrangements with
the PCT facilitated the acquisition of specialist equipment when required.
“There was an in-possession [medication] policy and steps had been taken
to increase the provision of medicines in possession. In-possession risk
assessments were documented and could be carried out by doctors,
nurses or the pharmacist.
“There was a good mental health service, including six mental health
nurses in primary care, who met twice weekly with the secondary care in-
reach team. Routine referrals were seen within seven days and urgent
ones within 24 hours.”
Previous deaths at HMP Nottingham
42. The Prison’s and Probation Ombudsman’s office has been responsible for
investigating deaths in prison custody since April 2004. Prior to the man’s
death, I have investigated five deaths at Nottingham and also two deaths
which occurred shortly after prisoners were released from Nottingham. Two
of these were from natural causes, two were a result of illicit drug overdoses,
10
and three were self-inflicted. This is the first occasion on which I have
investigated the death of a terminally ill prisoner at Nottingham.
11
KEY EVENTS
43. The man was convicted of serious offences in 2005, and sentenced to five
years imprisonment. He was released on licence, but was arrested again in
2008. His licence was revoked and he was taken to HMP Lincoln. After short
stays at HMP Ranby and HMP Leeds, the man was taken to HMP Nottingham
in March 2009 as his trial was being held at Nottingham Crown Court. He
was sentenced on 8 April 2009 and was given an indeterminate sentence
(which means that a prisoner will only be released after serving a tariff
determined by the trial judge, and then satisfying the Parole Board that the
risk of harm to the public has been reduced to a safe level.) The man was
required to serve a minimum of four years.
44. An initial health screening was completed when the man arrived at
Nottingham by Nurse A. No health issues were recorded. He did not attend
appointments for a secondary health screening (a more detailed screening,
offered to all prisoners) on 30 March and 1 April.
45. On 11 May, the man saw one of the prison doctors and complained of what
was described in the clinical record as a “testicular lump”. A penile swab was
taken for testing, and the man was prescribed antibiotics. He was also
referred to the urology department at the local hospital. Five days later, he
saw Nurses B and C and said his penis had begun to bleed when he passed
urine. He also said that passing urine was painful. The man was advised to
drink plenty of fluids and try to pass urine as normal. He was offered
painkillers and later moved to the urology ward at Nottingham City Hospital.
The following day, 17 May, he underwent a circumcision operation and
returned to the prison. A biopsy was taken for analysis during the man’s time
in hospital. Nurse A noted that the man did not appear to be in discomfort,
and was moving around the wing without problems. He did, however, have a
urethral catheter that required regular attention. Throughout May and early
June, he was seen almost daily by nurses for attention to his wound dressing
and catheter. The clinical record notes that he became skilled at managing
this himself.
46. On 29 May, the man saw Dr A, and said he felt as if he needed to pass urine
very frequently. Blood had also been present in his urine. The doctor noted
that there did not appear to be any infection and thought the problem was
likely caused by irritable bladder. He prescribed a 14 day course of
tolterodine (a medication used to treat urinary incontinence).
47. A member of healthcare staff wrote in the clinical record on 5 June that he
had received a telephone call from the Queen’s Medical Centre. The biopsy
taken during the man’s time in hospital had been analysed, and he was
diagnosed as having penile cancer. The prison healthcare staff were asked to
refrain from breaking this news to the man, as the diagnosis and treatment
plan would be given at his next hospital appointment.
48. The man was made aware of his diagnosis on 12 June. He was also told that
he was on the waiting list for a magnetic resonance imaging (MRI) scan to
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obtain more detailed information about his cancer so that decisions could be
made about his treatment. Another member of healthcare staff noted in his
clinical record that it would need to be done “very urgently”. Nurse D wrote in
the clinical record that the man was “understandably rather shocked”. He said
he felt let down by previous prisons and had been subject to incorrect
diagnoses. The next day, Nurse E saw the man to offer support and to review
his care plan.
49. Throughout June and July, the man attended numerous appointments with
prison healthcare staff, and his care plan remained under review. On 20 July,
the man attended hospital for an MRI scan of his groin. He underwent a
similar scan of his penis on 5 August. Throughout August and September, he
continued to attend appointments with healthcare staff at the prison.
50. Between 30 September and 12 October, the man was in Leicester General
Hospital. During this time, he underwent major and traumatic surgery, a
partial penectomy and inguinal lymphaenectomy. Following his return to the
prison on 13 October, the man was seen daily by healthcare staff whilst living
on a residential unit. Entries were made in the clinical record about care
planning, wound care, and management of the man’s catheter. His mood
seemed generally positive, and he associated with other prisoners on the unit.
51. On 22 October, the man was seen by Dr A, who noted that the wound site
was infected and an abscess was present. The man was admitted to
Leicester General Hospital and remained there until 10 November. During
this time, regular entries were made in the clinical record and the clinical team
manager visited the man in hospital.
52. When he returned to Nottingham, the man continued to receive daily post-
operative care from the nursing staff. He continued to associate with other
prisoners, seemed upbeat in mood, and was able to manage his own wound
dressings. Part of the care plan involved the man moving to G wing, to an
adapted cell on the ground floor, with a hospital bed.
53. The man attended an appointment at the hospital in Leicester on 19
November. The clinical team manager wrote in the clinical record that the
doctor did not know the man’s medical history, and this led to a breakdown in
communication. Throughout November and December, the man continued to
receive daily care from the medical staff at Nottingham. Lengthy entries were
made in the clinical record about the ongoing care plan and the contact with
nursing staff.
54. On 5 and 6 January 2010, the man attended hospital for outpatient
appointments and was told that his wounds had healed. The oncologist told
the man that he would need to determine whether inflammation to the lymph
nodes (part of the immune system which helps the body recognise and fight
infection) was due to an infection or progress of the illness. This would
determine the type of chemotherapy given. (Chemotherapy is a treatment for
cancer which uses medication to kill cancerous cells. The treatment can vary
13
according to the type of cancer, how advanced it is and a person’s general
health.)
55. Over the next few days, the man was seen regularly by healthcare staff at
Nottingham. However, he also said he did not want people “fussing round
him” and wanted to be treated like anyone else. On 13 January, he attended
an appointment with a nurse for support, prior to him going to hospital to start
chemotherapy. The next day, he attended an appointment with the oncologist
at Leicester General Hospital. The proposed chemotherapy was discussed,
including the possible side effects. The man consented to the treatment.
56. The man did not attend a mental health clinic appointment on 15 January. He
told a nurse that he wanted to concentrate on his physical health problems.
The nurse advised him that the chemotherapy might cause him to feel
physically and mentally low, and that he should let healthcare staff know if he
wanted any support from the mental health team.
57. On the same day, a multi-disciplinary meeting was held to discuss the man’s
ongoing care, including end of life care if necessary. A referral was made to
the Macmillan nursing team (Macmillan nurses specialise in cancer and
palliative care, providing support and information to people with cancer, and
their families, friends and carers), and the end of life care team (a service
provided by the PCT but based outside the prison) were invited to the next
review meeting, scheduled for 29 January.
58. The man was admitted to hospital to start chemotherapy, and returned to the
prison on the evening of 19 January. Over the next few days, he was seen
regularly by nurses. He was prescribed antibiotics due to a fever, but was
found to be stockpiling them in his cell. The man explained to nurses that he
did not want to take them as he did not believe he had an infection. Notes in
the clinical record state that the man felt unwell for several days after
returning from hospital, but by 27 January he had started to feel better. The
same day, he saw two nurses from the Macmillan team, who reported that he
engaged easily with them and agreed to see them again.
59. During the same period, paperwork relating to the man’s application for
release from prison on compassionate grounds was completed. Such release
has to be approved by the Secretary of State for Justice and, although it is
considered on the basis of a prisoner’s medical condition, it is granted only in
the most exceptional cases. A probation officer at Nottingham, completed a
short report about the man’s family circumstances, his level of risk in the
community, and proposed accommodation arrangements for release. The
probation officer wrote that the man presented a medium risk of reconviction
for a violent offence, and posed a high risk of harm to the public and to a
known adult.
60. On 28 January, the man attended an appointment at hospital, but refused
intravenous antibiotics that were to be provided to manage the side effects of
his chemotherapy. He returned to the prison the same day and told nurses
that he wanted to ‘fight it on his own’. The next day, Dr B, one of the doctors
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based at Nottingham, spoke to the consultant at the hospital, who was keen
for the man to return and have the antibiotics as he was concerned about
possible septicaemia (blood poisoning). The doctor spoke to the man, who
said he felt well and did not want to go back to the hospital. He agreed to
return if he became unwell. The doctor told the man that he might jeopardise
having further chemotherapy if the specialists felt that they could not follow
him up closely enough.
61. A case conference was held on Friday 29 January, involving the residential
governor, offender management unit, family liaison officer, healthcare staff
and the end of life care team. The discussion was primarily centred around
the man’s refusal to attend hospital for treatment. It was reported that he had
agreed to return to the hospital the following Monday (1 February) but did not
want to go over the weekend. He accepted that this might mean remaining in
hospital for a few days.
62. After further discussions with members of healthcare staff, the man accepted
that he required treatment from the hospital, and was admitted the same day.
He returned to the prison on the evening of 31 January, and reported that he
felt well.
63. On 3 February, Dr B completed a report about the man’s medical condition.
This was part of the compassionate release application. He wrote that the
prognosis was “very poor” and went on to say:
“His condition is likely to deteriorate in the near future so that he requires
24 hour care. He currently requires strong painkillers and his pain control
will become more difficult in the [coming] weeks and months. He is
undergoing chemotherapy which is not likely to be curative.”
64. The deputy governor at Nottingham, considered the man’s application for
release on compassionate grounds on 12 February. He wrote that the man’s
behaviour in prison had not been good, and that he had failed to comply with
the regime. He also noted that the man posed a risk of re-offending. In terms
of moving to a hospice, the deputy governor said it had been considered for
the man as the condition progressed. He did not support the application for
compassionate release, based on “nature of offence, sentence and behaviour
in prison”.
65. In terms of medical treatment, the man was seen by members of healthcare
staff almost daily between 1 February and 3 March. Numerous entries were
made in the clinical record, frequently more than once per day. The clinical
reviewer noted that the man was “offered numerous opportunities to share
any concerns but clearly [was] not willing to discuss any psychological
aspects in great detail”. A mental health referral was made, although the man
was reluctant to engage with this process. On 18 February, a nurse reported
in the clinical record that the man was becoming increasingly withdrawn and
was spending a lot of time in his cell, sleeping. The same night, he fainted in
his cell but recovered quickly. He was reviewed the next morning but had not
suffered any injuries.
15
66. The clinical reviewer wrote in her clinical review that, during the week of 9
March, it became clear that treatment options were severely restricted.
Indeed, the clinical record shows that on 11 March, the man attended a
hospital appointment and was told that the chemotherapy had not been
successful. She noted that healthcare staff continued to see the man daily,
and there were “frequent documented assessments of his pain control and
mental well-being”. She summarised the entries in the clinical notes that she
felt were pertinent to his care, and these are described below.
67. The clinical record indicates that on 10 March, the Acting Head of Residence,
was writing a protocol for the night staff so that a nurse could visit the man
during the night, and this would be reviewed and the frequency of nursing
visits increased as necessary. In addition, the night officers on G wing were
instructed to alert a nurse when the man required assistance, including pain
relief. A named nurse was specified to help co-ordinate care and support.
68. Authorisation for a more comfortable mattress was given on 11 March. Six
days later, the probation officer at Nottingham completed another short
assessment for a renewed application for compassionate release. He wrote
that the man’s family members were fully aware of his medical condition and
were supportive of him returning home during the last stages of his illness.
Regarding the risk presented by the man, the probation officer wrote:
“The man was convicted of a serious violent offence, for which he received
his current sentence. From conversation with his offender supervisor I am
well aware that the man is in a significantly weakened physical condition. I
therefore consider that the risk of his offending has decreased in these
circumstances.”
69. The probation officer went on to write about the involvement of healthcare
staff both within and from outside the prison.
70. On 19 March, the Macmillan nurses visited the man and discussed pain
management with him. Three days later, his pain relief medication was
increased after a recommendation by the Macmillan nurses. On the same
day, the man was again assessed by Dr B regarding compassionate release.
The doctor again concluded that the man’s prognosis was “very poor” and
went on to say:
“The man is suffering pain, shortness of breath and extreme lethargy. He
struggles to walk up one flight of stairs or more than thirty yards. His
condition makes it very unlikely that he would commit violent acts in the
future.”
71. Nottingham’s governing governor, considered the man’s application for
compassionate release on 24 March. He wrote that it was “very unlikely that
the man would have the physical capability of violent or other offending”. He
went on to say that: “The man is nearing the end of his short life. Early
release would be appropriate.”
16
72. The paperwork relating to the man’s application for release on compassionate
grounds was sent to the National Offender Management Service (NOMS) on
the same day. This was followed by information from the man’s probation
officer in the community about the suitability of the proposed release address.
73. On 28 March, the dosage of the man’s pain relief medication was increased
again after discussion with the palliative care team at Nottingham City
Hospital.
74. On 31 March, another prisoner told members of healthcare staff that the man
‘put on a brave face’ when dealing with officers and healthcare staff, but was
often in tears, angry or in pain. Two days later, a nurse spoke to the man,
who told her about some of his fears as well as his anger.
75. On 1 April, the man’s probation officer in the community emailed the national
offender management to inform her that a full risk assessment of the man and
his proposed home circumstances had been carried out.
76. The clinical team manager spoke to another prisoner on 5 April. This prisoner
was a close friend of the man, and had been helping him with his personal
care for some time. Although both the man and the other prisoner were
adamant that they were coping with the situation, the clinical team manager
felt that the man’s needs were becoming too onerous for another prisoner and
would be better managed by healthcare staff. A case conference would
discuss the gradual withdrawal of the other prisoner in terms of personal care
needs.
77. On 7 April, the man’s probation officer emailed the national offender
management to ask if there had been any progress with the compassionate
release application. The national offender management replied on 9 April,
and said the report had gone to the Parole Board for their consideration.
78. An occupational therapist and a Macmillan nurse visited the prison on 9 April
to discuss various pieces of medical equipment that would be necessary for
end of life care. The end of life care team (based outside the prison) was
contacted to discuss the provision of a syringe driver. This was delivered the
same day, with support provided around using it correctly.
79. The clinical reviewer reported that by 12 April, the man’s condition had clearly
deteriorated. She also noted that end of life care was “clearly being
implemented at this stage”. The man was not eating, had difficulty holding
things steadily, and had periods of confusion. She concluded that “this
deterioration was likely to be the result of disease progression and end of life
changes”.
80. The next day, 13 April, a multidisciplinary team meeting was held. It was
agreed that an open door policy would be implemented from that night, so that
the man’s cell was not locked overnight. An additional member of the
healthcare team would be present throughout the night to offer support. The
man required assistance with all aspects of his personal care, and with food
17
and fluid intake. The Liverpool Care Pathway (an outline of the standard of
care that a patient can expect in the final stage of life) was in place. On the
same day, discussions took place between healthcare staff about the man’s
ability to make decisions for himself. It was agreed that he no longer had the
capacity to make decisions, and that healthcare staff would act in his best
interests. A syringe driver was set up to administer pain relief medication.
81. The same day, conversations took place between the national offender
management and the man’s offender supervisor about the suitability of the
man’s proposed release address. Because his health had deteriorated, the
release address was no longer considered suitable for addressing his
complex medical needs. In an email to the man’s offender supervisor, the
national offender management said the application would be sent to
government ministers for their consideration. Dr B also emailed the national
offender management:
“I can confirm my opinion to be that the condition is extremely poor and the
deterioration in the last 12 days has been extreme. I feel that the patient is
unlikely to survive more than two weeks, and that death may be sooner
than this.”
82. Although consideration was given to the man moving to Birmingham, closer to
his family, Dr B noted in the clinical record that he was “extremely ill, and the
risk of dying in transit … is high”. A decision was made that the man would
continue to be cared for at the prison. The clinical reviewer wrote that “it may
have been inappropriate and clinically unsafe to have moved him at such a
stage unless the care he was receiving was inappropriate”.
83. On 15 April, the man was awake and alert, and was asked directly if he would
like to go to a hospice. He replied that he would not. The following day, the
national offender management informed that a bed was available at a local
hospice, and asked whether this would be approved as a release address.
She said she had no objection but knew that the man did not want to move to
a hospice. (She noted in an email to the man’s offender supervisor that this
had been “evidenced by a number of staff who have been working with [the
man].) The compassionate release application was approved, with the
hospice listed as the release address in the event that the man changed his
mind. The only change to the conditions of the compassionate release from
the original application to its approval was the release address. All other
conditions remained the same.
84. The clinical reviewer wrote in the clinical review that over the following few
days, the man’s condition continued to deteriorate. She thought the clinical
record indicated that he was nursed closely and well, and that both personal
and pain management care were prioritised. The man died at 8.00am in April.
85. At the time of the man’s death, his mother was already on her way to the
prison. As a result, she was informed of her son’s death when she arrived at
the gate. This caused her considerable distress and is discussed in the next
section of the report.
18
86. Liaison between the prison and the man’s family following his death was not
harmonious and eventually broke down. This is again discussed in the next
section.
19
ISSUES
The man’s medical care before his transfer to HMP Nottingham
87. The clinical reviewer wrote a brief report about the man’s medical care before
his transfer to Nottingham. She noted that the first time the man complained
of any problems relating to his subsequent illness was on 11 August 2008.
He was examined by a doctor at HMP Lincoln because of a penile lump. This
was diagnosed as an infection, and the man was prescribed antibiotics as a
result. He was referred to the genitourinary clinic within the prison. The
clinical reviewer thought this course of action was appropriate.
88. On 23 September, the man was reviewed but he had not been seen by the
genitourinary clinic. The appointment was chased, and he was seen by a
sexual health nurse on 20 November. The man told the nurse that he had
had a lump ‘for some time’. He was advised of appropriate hygiene
measures, and the possibility of circumcision was discussed. The medical
reviewer noted that sexual health nurses see genitalia frequently and on this
occasion, nothing suspicious was observed.
89. The man saw a doctor again on 15 December with another infection. There
was no reference to a lump on this occasion, but the man was referred to the
urology outpatients department to determine whether circumcision would offer
a definitive treatment. However, he was transferred out of Lincoln on 7
January 2009, and as a result did not see an urologist until he was referred by
staff at HMP Nottingham.
90. The clinical reviewer concluded that:
“When [the man] did present to healthcare he was seen and appropriately
examined, treated and referred. As he was seen by three different
healthcare professionals within four months, one of whom was a specialist
in genitourinary medicine and hence very familiar with conditions of
genitalia, I assume that the appearance of the condition was not one which
caused concern.”
91. The clinical reviewer went on to say that she could not comment upon
whether the delay of approximately four months in the man seeing an
urologist would have made any difference to the outcome.
Delay between diagnosis and treatment
92. The clinical reviewer examined delays between the time of the man’s
diagnosis and the commencement of his treatment, as part of her clinical
review. She obtained the man’s hospital records from Nottingham City
Hospital and Leicester General Hospital.
93. The clinical reviewer reported that, following the man’s referral and diagnosis,
his case was referred to the joint multidisciplinary team for Nottingham and
Leicester hospitals. His case was discussed at the next available meeting,
20
which was on 3 June 2009. At this point, an MRI scan was recommended
and the need for surgery was discussed.
94. The man underwent MRI scans on 20 July and 5 August. These scans
showed the spread of cancer to a lymph node in the groin. After the initial
scan, he was seen on 24 July by the urology consultant at Leicester General
Hospital. The man’s case was discussed at a multidisciplinary meeting on 5
August, when surgery was recommended and chemotherapy was considered
as a possibility.
95. Surgery took place on 6 October. The clinical reviewer wrote that when the
man’s cancer was first diagnosed, it was ‘Grade 2 keratinizing squamous cell
carcinoma’, but by the time of the surgery, it was classified as ‘Grade 3’. His
prognosis was stated to be “probably very, very poor”.
96. On 17 November, further scans showed possible spread of the cancer into
deeper pelvic areas. Discussion at the multidisciplinary meeting took place
about the possibility of further surgery or chemotherapy. By January 2010,
the cancer had spread to the man’s lungs, and chemotherapy was
recommended.
97. The clinical reported on a number of delays. She noted that there was a 60
day wait from the initial diagnosis of cancer to the first MRI scan, and a delay
of 47 days from the time that the MRI scan was first recommended at the
multidisciplinary meeting. The clinical reviewer described this as
“unacceptable”. She found that, although the multidisciplinary meeting on 3
June agreed that the man would be referred to Leicester for treatment, he saw
the urologist at Queen’s Medical Centre, Nottingham on 22 June. Only at this
point was a formal referral made to Leicester, even though the decision had
been made some 19 days earlier. In fact, the consultant urologist had written
to the urologist at Queen’s medical centre on 4 June, the day after the
meeting, confirming that he had agreed to take over the man’s care. The
clinical reviewer concluded that “the referral [process] between hospitals
following multidisciplinary meetings is not smooth and certainly in this case
delayed follow-up investigation and treatment”.
98. In addition to the delays in the further investigation of the man’s cancer, the
clinical reviewer looked into the time that elapsed between diagnosis and
surgery. She said this was 136 days, and 125 days from when surgery was
recommended at the first multidisciplinary meeting. The clinical reviewer
again concluded that this was unacceptable. Some three months after the
man’s care had been referred to the urology consultant at Leicester, he was
seen by the urologist at Queen’s Medical Centre at Nottingham. The urologist
at Queen Medical Centre then wrote a letter to the urology consultant in,
which explained:
“The man arrived at my clinic today, probably through some administrative
problem at our end. He is still awaiting surgery under your care and I said
I would write to you to make sure that arrangements are in hand for this.”
21
99. The clinical reviewer provided the predicted survival rates for penile
carcinoma, which state that when one lymph node is involved at presentation,
there is an 80 percent chance of survival after five years. When two lymph
nodes or abdominal lymph nodes are involved, there is a 40 percent chance
of survival after five years. Regarding these statistics and the man’s case, the
clinical reviewer wrote:
“It is always impossible to know whether delays in treatment affect the final
outcome in cancer cases, but from the medical records it appears the man
presented with a Grade 2 moderately differentiated cancer with one
affected lymph node which, by the time of surgery had progressed to a
Grade 3 poorly differentiated cancer. Scans four weeks later revealed
likely spread into the pelvis. Earlier surgery with chemotherapy may have
given a chance of slowing disease progression, or even cure.”
100. In addition, the clinical reviewer commented that although chemotherapy was
discussed at multidisciplinary meetings in August and November 2009, it was
not recommended until January 2010.
101. The clinical reviewer concluded that the man was “let down badly, possibly
negligently, by the hospital system”. She said it was surprising that the
hospitals relied on letters between the consultants, particularly when the
investigation and treatment of the man’s illness was delayed. Furthermore,
the clinical reviewer was disappointed that, for someone of such a young age
with a very rare form of cancer, no healthcare professionals at the prison
seemed concerned about the delays. Despite the fact that the man was
receiving regular treatment from the healthcare team at the prison, “the delay
of four months seems to have caused no concern from the point of view of
wondering whether there had been a system failure”.
102. The clinical reviewer recommended a further independent investigation to
specifically examine delays in the man’s investigation and treatment, as she
believed that his death may have been preventable. I endorse this
recommendation.
The Chief Executive of Nottingham City Primary Care Trust (PCT) should
undertake an independent investigation to examine the delays in the
man’s investigation following diagnosis, and his subsequent treatment.
Cell accommodation
103. HMP Nottingham does not have an inpatient medical facility therefore it was
not possible to locate the man on a dedicated healthcare wing. For most of
his time there, the man lived in a normal, residential cell. Towards the end of
his life, when his medical needs became more complex, he moved to a
specially adapted ground floor cell.
104. The clinical reviewer viewed the cell where the man spent the last part of his
life, and was shown by prison healthcare staff how it was arranged for
palliative care. She commented that the cell was en-suite and comparable in
22
size to a side room in a hospital. It was also located opposite a room which
was used to facilitate visits to the prison by the man’s family. The clinical
reviewer concluded that the space was adequate for the delivery of palliative
care and that the en-suite facility was likely to have greatly assisted the
delivery of personal care.
105. The clinical reviewer noted in her clinical review that the exercise yard for the
wing was outside the window of the man’s adapted cell. This meant that the
curtains had to be drawn for around 90 minutes every day to afford him
privacy whilst other prisoners were exercising. She said that although this
was unfortunate, it was a reasonable negative aspect to accept given that in
all other ways, such as size, location and en-suite facilities, the cell was the
most appropriate in the prison.
106. In addition to concerns about the exercise yard, the clinical reviewer
mentioned that “prisons are inherently noisy environments and perhaps … not
how one would design the acoustics of a perfect palliative care setting”. She
did not know if the man found it problematic and there is nothing in his clinical
record to suggest that this was the case.
107. In general, when referring to palliative care, the clinical reviewer concluded
that the man received “exemplary medical care within the prison setting”. She
went on to say:
“He had access to all aspects of palliative care available in the community,
including psychological support and Macmillan nursing, and community
pathways for end of life care were adopted. He was supplied with an
appropriate hospital bed, mattress and allied equipment. Pain control was
appropriate and delivered as in a community setting. Family visits were
facilitated and towards the end of [his] life the man had a continuity and
intensity of nursing care which is often not possible in a community
setting.”
108. The man’s family members were concerned that he should not have been in a
prison setting at all, given his deteriorating medical condition. However, the
man made it clear to members of staff at Nottingham that he did not want to
move to a hospice. According to a number of staff, he felt supported on the
residential units and did not want to be treated significantly differently from
other prisoners. Whilst he clearly had additional care needs, particularly
towards the end of his life, the man was keen to stay in the same environment
as other prisoners. The clinical reviewer concluded that the care he received
was equitable to, and in some cases superior to, what might have been
expected in the community.
Specific aspects of the man’s medical care
109. The man’s family members asked questions about some specific aspects of
the man’s medical care. My investigator asked the clinical to comment on
these issues, and her findings are summarised below.
23
The Liverpool Care Pathway (LCP)
110. The clinical reviewer commented that the LCP is designed to guide care at the
end of life, to ensure a holistic approach to the dying patient. It encompasses
physical, emotional and spiritual care needs. The Pathway documentation
includes paperwork prompting the healthcare team to consider these areas
regularly when caring for the patient.
111. The clinical reviewer concluded that “during the last two weeks of his life, the
physical and emotional needs of the man were well attended to and that his
clinical management was appropriate”. She went on to say that all aspects of
the LCP were considered, and that it was followed daily.
Fluids
112. The man’s family members were concerned about the man’s fluid intake
during the last few days of his life. The clinical reviewer commented that
there were detailed nursing notes covering the last five days of the man’s life,
and these record fluids being offered. The man was passing urine via a
catheter. This was recorded daily and, the day before his death, he passed
500ml of urine. The clinical reviewer said this suggested he remained
hydrated.
113. The clinical reviewer said that although there was not a formal record of the
fluids taken orally, there was no evidence that fluids were withheld from the
man. She went on to explain that:
“During the end stage of life it is often difficult to maintain a good state of
hydration as patients are often very drowsy and unable to swallow without
choking. Within a community setting parenteral (intravenous or
subcutaneous) fluids are rarely if ever given in the terminal stage of life.
As mentioned previously, the fluid balance records show that urine output
indicated a reasonable state of hydration for this stage of life. Even in
hospice settings, intravenous fluids are not often given as the drip can
cause distress to the patient and add little to quality of life. Mouth care is
the more important aspect of comfort in the last few days of life.”
114. In response to the draft report, the man’s family members said that they were
concerned that Nottingham might have been referring to out of date guidance
on the LCP, and that current guidance states that fluids should be maintained
and not withdrawn. The clinical reviewer, however, is satisfied that the man
was appropriately hydrated during the final days of his life. The healthcare
department at Nottingham confirmed that they used version 4 of the LCP,
which was current at the time of the man’s end of life care.
24
Pain relief and sedation
115. The clinical reviewer noted that, during the last week of the man’s life, his pain
was managed during a syringe driver. This facilities the administration of pain
relief and other drugs to help with agitation and nausea during the end stage
of life. The medication can cause sedation and the aim is to achieve a
balance whereby there is adequate relief from pain and agitation, with minimal
unnecessary sedation. He went on to say that disease progression causes
patients to become very drowsy in the end stage of life.
116. The clinical reviewer did not have concerns about the man’s pain relief and
sedation. She emphasised that the main aim is compassion, to ensure that
the patient is comfortable and free from pain and distress. The dose of
morphine and sedative in the man’s syringe driver was increased on 17 and
24 April 2010, and his medical notes indicate that this was in response to
increased pain and agitation.
Application for compassionate release
117. The man’s family members were unhappy with the way in which the
application for compassionate release was handled. The man’s mother had
sought to have her address, or a hospice close to her address, approved for
the man’s release. She felt that, as compassionate release was granted by
the Ministry of Justice, the prison should not have had any influence over the
man’s release address, and that they could have avoided him dying in prison.
118. The investigator interviewed a number of staff at Nottingham who told him that
the man was adamant that he did not want to go to a hospice. This proved
problematic in terms of finding a suitable release address, because his
medical needs were complex. Although the man’s mother thought she could
care for him at home, the medical professionals involved in the man’s care
concluded that he needed intensive support. Furthermore, when the
compassionate release application was approved, the man’s health had
deteriorated quickly, and the doctor at Nottingham thought he might not
survive the journey. A bed at a hospice local to the prison was secured, and
his release papers were prepared with that address, in case he changed his
mind about going to a hospice.
119. I understand that the man’s mother finds it particularly distressing that her son
died in prison when she would willingly have accommodated him at her home.
However, the healthcare staff at Nottingham had a duty of care to the man,
and were responsible for ensuring that he received medical care
commensurate with the seriousness of his condition. He had told a number of
staff that he did not want to go to a hospice, even when a place was available.
120. The investigator found no indication, during interviews with members of staff
at Nottingham, that there was any motive to keep the man in prison.
Numerous members of staff had facilitated the compassionate release
application and had attempted to expedite the process. During interview,
members of prison staff spoke of their concern that the man received
25
appropriate medical treatment and that the last stage of his life was in
accordance with his wishes. Release was approved to a hospice near the
prison, but this was not what the man wanted.
Liaison with the man’s family
Communication about the man’s medical condition
121. The man’s family members were concerned about the level of information that
they received with regard to his medical condition. In particular, the way in
which they discovered that the man was unwell was distressing for them.
Someone describing herself as an old friend of the man had called at their
house and told them that he was dying, and that they should contact the
prison. The man’s mother felt strongly that a representative from the prison
should have told her about her son’s illness. (In response to the draft report,
Nottingham said that when the man decided to tell his family about his illness,
he only had limited contact details for them.)
122. After the man’s family members started to visit him in prison, they continued
to experience difficulties obtaining information about his diagnosis, his
ongoing medical treatment, and his prognosis. They thought the healthcare
team at the prison could have been more forthcoming in relaying information
to them.
123. My investigator asked the acting head of prison health, about this issue. She
said:
“If the patient requested that healthcare staff inform the family then they
would do, or if the patient asked healthcare to be present while they inform
the family to give them more information than we would do. But we
wouldn’t go and share that information without patient consent.”
124. There are confidentiality issues associated with most medical matters. In the
community, medical staff would not routinely inform the family members of an
adult about a medical diagnosis. It would be for the adult in question to
decide whether or not to inform other people. The same principle is applied in
the prison setting. At the time of receiving his diagnosis, the man was an
adult capable of making independent decisions. He could, therefore, have
informed his family members about his illness had he chosen to do so. It
would have been inappropriate for medical staff at Nottingham to disclose
information about the man’s illness to third parties without his consent. Whilst
the manner in which the man’s family members found out about his illness
was distressing, this was unfortunately beyond the control of the prison. In
response to the draft report, Nottingham asked us to point out that “conveying
private medical information was a confidential matter for the man himself and
not for the prison or healthcare professionals”.
125. In terms of ongoing issues regarding information about the man’s condition,
the same principle applies. Until shortly before his death, the man was
26
capable of deciding how much information to share with his family members
about his illness.
Concerns about the man’s medical care
126. The man’s family members said he developed open wounds in his groin from
abscesses and was having to dress his own wounds for a number of months.
They questioned how this was possible if he was receiving 24-hour care.
127. The clinical record suggests that, following his surgery, the man received
regular and intensive medical intervention to help with wound care. He was
taught how to care for his wounds and dress them by himself. This is not an
unusual state of affairs and indeed, with his wound in such a sensitive area,
the man may well have preferred this arrangement. His wounds were
checked regularly by medical staff and he was treated for post-operative
infections. The clinical reviewer did not criticise the arrangements regarding
the man’s wound care.
Visiting arrangements for family members
128. Towards the end of his life, the man was too unwell to receive visitors in the
normal visits area of the prison. As such, visits from his family members were
facilitated in his cell. However, both the man’s mother and father explained
that there had been a number of problems. Although the man’s mother was
told that no visiting order was required, she experienced problems at the gate
with members of staff who did not appear to understand the special
arrangements that were in place. The man’s mother also felt that she was not
afforded sufficient privacy with her son when visiting him in his cell.
Furthermore, two of the man’s sisters were not permitted to visit him in his
cell, because they were under 18. The man’s father said that on one
occasion, the man was too ill to go to the visit centre and he had to return
home without seeing him.
129. My investigator spoke to one of the governors, who acted as the liaison officer
for the PPO about these issues. He was aware that there had been some
‘teething problems’ with the arrangements for visits without visiting orders, but
he felt that this was rectified quickly. A notice was produced and displayed in
the gate area so that staff members on duty at the gate were aware of the
arrangements that were in place. A letter was sent to the man’s mother
informing her of steps that had been taken, and advising her to present the
letter at the gate if she continued to experience problems.
130. The man’s mother did not feel that the issues were resolved quickly, and that
this issue added further inconvenience and distress to what was already a
very difficult situation. I acknowledge positive attempts by the prison to rectify
the problem, but I also suggest that the policy around this issue is considered
and updated.
27
131. Regarding the issue of privacy, the governor who acted as the liaison officer
for the PPO explained that the prison had a responsibility to ensure the safety
and security of the man, his visitors, and the other prisoners on the wing.
Furthermore, towards the end of his life, the man had medical equipment in
his cell that would not ordinarily be kept on the wing. Members of staff
interviewed felt that the man’s family members were afforded some privacy,
but the unusual nature of the visiting arrangements meant that they were not
usually left alone in the cell.
132. In terms of the man’s sisters being unable to visit him on the wing, the
governor who acted as the liaison officer for the PPO again spoke about
issues of safety and security. He emphasised that family visits taking place
on the wing is an unusual arrangement, and that ensuring the safety and well-
being of those visitors was of paramount importance. He explained that the
wings of a prison hold a number of prisoners who have been convicted for
various different offences, and that a number of unplanned incidents could
occur on any given day. The decision to restrict visits on the wing to over-18s
was made on the basis of ensuring that children were safe and did not
witness anything unnecessarily distressing that might occur.
133. I understand that the man’s sisters were very upset about not being able to
say goodbye to their brother. However, I also accept that the visiting
arrangements had become difficult for everyone concerned. The man was
too unwell to receive visits in the main visiting area, and he did not want to
move to a hospice. It would therefore appear that facilitating visits in his cell
was the best option open to the prison. I also accept that, for issues of safety
and security, a decision was made to restrict those visits to adults.
Professional boundaries of staff at HMP Nottingham
134. The man’s mother thought that professional boundaries had not always been
respected at Nottingham. In particular, she felt that the family liaison officer to
the man’s family had become too involved with the man. On one occasion,
she had greeted the family for a visit with red eyes, and it was clear that she
had been crying. Although the family appreciated her empathy, they said they
would have found it more helpful had she maintained composure in front of
them. On other occasion, the man’s mother was shocked to see her
attending to the man’s intimate personal care needs, something that she felt
should have been done by medical staff. (In response to the draft report,
Nottingham said that the family liaison officer for the family had definitely not
been crying before this meeting, and had at no time attended to the man’s
personal needs beyond giving him a glass of water.)
135. The family liaison officer was appointed in November 2009. It is clear from
the extensive records kept that she was in contact with the man and his family
members on an almost daily basis. During interview, the Acting Head of
Residence, explained that between November 2009 and April 2010, the family
liaison officer for the family built up a close but professional relationship with
the man, as well as liaising with his family about visits and the progression of
his illness.
28
136. My investigator was not able to interview the liaison officer for the family
during the course of the investigation, and so it was not possible to ascertain
how onerous she found this task. Nevertheless, interacting on a daily basis
with a person of declining health over a period of five months, whilst also
liaising with family members in what was not always an easy relationship,
cannot have been easy.
137. As we have not interviewed the liaison officer for the family, it is difficult to
determine whether she went beyond her role as family liaison officer, and if
she did, whether this was to the man’s benefit or detriment. It is clear that she
spent a lot of time interacting with the man, helping him to reinstate contact
with his family members and providing a source of support. However, the
primary role of the family liaison officer is, ultimately, to engage with the
family, act as a point of contact, ensure the family’s needs are met in terms of
access, information and engagement, and help them to prepare for what to
expect following the death. Whilst she kept extensive logs of her contact with
the man’s family, it was not always completely harmonious, particularly after
the man’s death. In the end, the relationship between the man’s family and
the liaison officer broke down.
138. I do not intend criticism of the liaison officer for the family, who clearly took on
a very demanding role. However, there is no evidence to suggest that the
scope and nature of the role was given sufficient consideration prior to her
appointment. In the future, the Governor may wish to consider whether it is
appropriate to have a single member of staff responsible for such wide-
ranging responsibilities. (In response to the draft report, Nottingham
commented on this paragraph as follows:
“The Governor has commented that this paragraph is inaccurate
speculation. He has commented that the phrase “I do not intend
criticism…” comes across as exactly the opposite. There is ample
evidence of the nature and scope of the role being given sufficient
consideration. The matter was frequently reviewed after the daily
operational meeting and the liaison officer for the family was supported by
two senior managers – the governor who acted as the liaison officer for the
PPO and the acting head of residence”)
139. After the relationship between the family and the liaison officer for the family
broke down, no alternative liaison officer was appointed. The family did not
receive a letter of condolence from the prison. The Governor will want to look
into how the family liaison role is continued in such circumstances, and that
bereaved family members receive letters of condolence.
140. In response to the draft report, Nottingham commented on this paragraph as
follows:
“The Governor has noted that the relationship with the family and the
family’s liaison officer did not break down. But different members of the
family had different opinions and this made it difficult for the prison to deal
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with them. … He explained that Nottingham had spent so much time
supporting the family that a letter did not seem appropriate.”
Informing the man’s family about his death
141. The man died at 8.00am on 20 April 2010. At the time of his death, his
mother had already left home and was on her way to the prison to visit him.
She said that when she arrived, she was informed in the gate area that her
son had died earlier that morning. She felt that this obviously distressing
news was delivered insensitively, with other members of staff and building
contractors present.
142. My investigator spoke to the governor who was the liaison officer for the PPO
about this issue. He explained the thought process that had been involved in
deciding how to break the news to the man’s mother, and the difficulties in
doing so anywhere other than at the gate. He felt that it was not feasible to
take the man’s mother to another area of the prison, such as an office on the
wing, as it would take around five minutes to get there and would almost
certainly involve a conversation about the man. During interview, he recalled
that on a previous occasion, he had wanted to speak to the man’s mother
about an issue, but she rightly insisted on seeing her son first. He thought the
same issue might arise if he had tried to take her to an office on this occasion.
He therefore decided that the best course of action was to break the news to
the man’s mother when she arrived at the gate.
143. The governor who was the liaison officer for the PPO told my investigator that
he personally ensured that no other members of staff were in the gate area
when the man’s mother arrived and was informed that her son had died. This
is contrary to the account presented by the man’s mother, but he felt that the
news was delivered as sensitively as possible given the circumstances.
144. Informing family members that a loved one has died is always difficult and will
inevitably result in distress. This was a particularly difficult situation, and it is
unfortunate that the governor who was the liaison officer for the PPO and the
man’s mother do not agree about the news being delivered appropriately and
sensitively.
145. I accept that the governor who was the liaison officer for the PPO considered
how best to break the news to the man’s mother, and that the decision he
took was based on nothing but the best intentions. However, it is clear that it
caused the man’s mother considerable distress. In general, the gate is not an
appropriate place to break such news to family members. The Governor may
wish to consider how this situation might be resolved before it arises again.
146. In response to this paragraph, Nottingham asked us to delete the final two
sentences. We have declined to do so, as we remain of the opinion that the
gate is not the best place to break such news (although we understand why it
happened on this occasion). Nottingham said that there is a clear difference
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of opinion as to who was in the gate at the time, which they do not think is
resolvable. Nottingham added:” The prison did its best to convey the
information in the right way. It is unfortunate that [the man’s mother] does not
agree.”
Consideration of the man moving to a hospice or to the family home
147. Members of staff at Nottingham were clear that the man’s wish was to remain
in prison. However, his family members told my investigator that, during a
meeting about the man’s needs, they informed members of staff that he had
told them his only wish was not to die in prison. The man’s mother said the
liaison officer for the family took a note of this at the meeting, but later denied
all knowledge.
148. I have not been able to find evidence that the man had a strong desire to
leave the prison before his death. Certainly, he was afforded the opportunity
to do so, with a place at a hospice available for him to move to if he so
desired. I do not intend to cast doubt on the information presented by the
man’s family. Unfortunately, however, I have been unable to substantiate it.
149. A further issue raised by the man’s family members was the conclusion that
the man was too unwell to return home. In particular, they felt that this was
inconsistent with him being transported the 20 miles to Leicester for treatment
in a taxi.
150. The man last travelled to Leicester for treatment in March 2010. By mid-April,
when his compassionate release application was being finalised, his condition
had deteriorated. The conclusion that the man was not well enough to move
to Birmingham and that such a move would risk him dying during the journey
was reached by a doctor, not by managers at Nottingham. It was for this
reason that the approved release address for the compassionate release
application was a hospice local to the prison.
The man’s property
151. The man’s family members were concerned by a lack of hospital appointment
letters in his property. They questioned what had happened to these. They
also said that the man had made legal enquiries about a medical negligence
claim, but only one letter about this was found amongst his belongings. In
response to the draft report, Nottingham have asked us to add that, because
of security reasons, prisoners are never given hospital appointment letters
and do not know in advance when they will be going to appointments
152. I am unable to offer an explanation as to why there were no further
appointment letters, or documents relating to a legal claim, amongst the
man’s property.
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CONCLUSION
153. The man first complained of a penile lump in August 2008, whilst at HMP
Lincoln. Until December of the same year, this was treated as an infection.
When he transferred to HMP Nottingham, he did not initially complain of the
same problem.
154. When the man complained to healthcare staff at Nottingham about the
problem, the matter was investigated and he was diagnosed with penile
cancer. However, there were long delays between his diagnosis and the
commencement of treatment, to such an extent that the clinical reviewer,
thought that his death might have been preventable. I am sure that the
coroner and the Primary Care Trust will want to investigate this matter further.
155. The man remained in HMP Nottingham until his death in April 2010. Although
release on compassionate grounds was agreed, the man was too unwell to
travel to his mother’s home, and there were concerns about the level of
medical intervention that he would require. Although a place was obtained at
a hospice local to the prison, the man did not want to go there.
156. The clinical reviewer concluded that the man received an exemplary level of
palliative care, equivalent to and in some ways superior to what could be
expected in the community.
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RECOMMENDATIONS
1. The Chief Executive of Nottingham City Primary Care Trust (PCT) should
undertake an independent investigation to examine the delays in the man’s
investigation following diagnosis, and his subsequent treatment.
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