Individual at Wymott

Investigation into the circumstances surrounding the
death of a man while in the custody of HMP Wymott.
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2010
This is an investigation into the circumstances surrounding the death of man
at HMP Wymott in December 2008. The man was aged 66 when he died. I
would like to extend my condolences to his family and friends for their loss.
An independent review of the man’s clinical care was conducted on behalf of
Central Lancashire PCT. I have written to Central Lancashire PCT outlining
the clinical reviewer’s recommendations.
The man suffered from insulin dependent diabetes. He did not comply
properly with his treatment, which often made him very unwell. On the day of
his death he was rushed to hospital because of his unstable diabetic
condition.
I must apologise for the delay in issuing this report, although this has not
delayed the giving of feedback to the prison itself.
I would also like to thank the Governor and staff at Wymott for their full and
ready cooperation during the course of my investigation. I am particularly
grateful to staff from the Business Development Unit at Wymott for their
assistance as liaison officers. I make one recommendation. I am pleased to
see that the recommendation has been accepted.
Jane Webb
Deputy Prisons and Probation Ombudsman March 2010
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CONTENTS
Summary
The investigation process
The man
HMP Wymott
Key events
Issues
Conclusions
Recommendations
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SUMMARY
The man was sentenced to three years imprisonment on 8 February 2008.
This was his first time in prison but he quickly settled into prison life and
developed positive relationships with staff and prisoners.
The man was received at HMP Preston on 8 February and remained there
until early November 2008 when he transferred to Wymott. First reception
healthscreen identified that the man was diabetic and epileptic. Healthcare
staff identified that the man had a history of poor compliance with his medical
treatment and care plan.
During those nine months at Preston, attempts by the healthcare team were
focused to stabilise his diabetic condition through improved compliance and
self management. There were numerous episodes of care specifically to help
the man improve control of his condition.
On several occasions during February, the man was found to have collapsed.
Healthcare staff attended and treated him accordingly. They would reassure
him and continue to support him to improve his management of diabetes,
albeit with little success.
The man was received at Wymott on 7 November. Healthcare staff assessed
him on reception and considered he was capable of administering his insulin
though they noted the history of poor compliance with his medical regime.
Healthcare staff were called to see the man on 1 December. He was
confused and very poorly. He was taken to the Accident and Emergency
Department at Chorley Hospital by ambulance and admitted to the intensive
care unit (ICU). He was diagnosed as suffering from ketoacidosis (most
common in untreated type 1 diabetes mellitus, when the liver breaks down fat
and proteins in response to the body’s need for oxygen and which tends to
occur when blood glucose is too high).
Later that day, the man was transferred from ICU to a ward where he was
treated for both diabetic ketoacidosis and pneumonia. He started to improve
but remained at Chorley Hospital for the next two weeks. He was discharged
back to Wymott on 15 December.
I wing staff were soon concerned about the man again and, on 17 December,
they found he was short of breath and very ashen in colour. Healthcare staff
were asked to visit and give treatment.
On the morning of 27 December 2008, prison staff alerted healthcare staff
that they were concerned about the man. Healthcare staff went to see him on
I wing. They took emergency medical equipment with them from the
treatment room.
The man was lying on his bed and was unconscious. Healthcare staff
immediately requested an emergency ambulance. They examined him and
4
administered treatment. The prison doctor inserted a cannula (for the delivery
of fluids into the vein) and set up sodium chloride solution (salt based fluid) to
be administered intravenously. They administered oxygen to help the man
breathe.
When the paramedics arrived they tested the man’s blood sugar and found it
was high. He was taken by emergency ambulance to the Accident and
Emergency Department at Chorley Hospital. Prison bedwatch staff were
instructed not to apply mechanical restraints because of the man’s poor
condition. Later, hospital nurses told the officers that the man “had arrested
(heart momentarily stops) three times and that if he arrested again they would
leave him”.
At around 4.30pm the hospital nurses told bedwatch staff that the man had
“passed away at 4.20pm”. The coroner’s officer was called and attended the
hospital. The duty governor contacted the man’s brother, as his listed next of
kin, to inform him of the news.
I make one recommendation which asks the Governor of Wymott to consider
providing prison staff working within the elderly and disabled community with
training to raise awareness of how they should respond to the health
problems experienced by prisoners in that community,
5
THE INVESTIGATION PROCESS
1. The investigation was opened on 28 December 2008. The investigator
issued notices announcing the investigation to the staff and prisoners
of HMP Wymott. The notices included an invitation to those who
wished to contribute to the investigation to make themselves known.
No prisoners or staff came forward although the investigator spoke to a
number of prisoners and staff within the elderly and disabled
community and healthcare department.
2. The investigator made a preliminary visit to the prison on 23 February
2009. He met the Governor, the chair of the local branch of the Prison
Officers’ Association, and the chair of the Independent Monitoring
Board. A member of staff from the Business Development Unit acted
as the investigation liaison officer.
3. The investigator made a tour of the prison and visited I wing annexe of
the elderly and disabled unit to see the man’s room. He talked to a
number of staff and prisoners who had known the man. The unit
accommodates around 75 prisoners within a small contained unit.
4. The investigator had access to the man’s prison and clinical records.
He reviewed all relevant documents, which included the man’s core
record, clinical record, wing documentation, care plans and other
custodial and clinical documents. The investigator constructed a
chronology of significant events from his review of the man’s case files
and identified any emerging issues.
5. The investigator made arrangements to interview staff at the prison.
He interviewed the man’s personal officer, his prison doctor and a
senior nurse, the key people who were involved in the man’s care.
6. The investigator asked Central Lancashire Primary Care Trust (PCT) to
organise a clinical review of the healthcare the man had received whilst
in custody. The PCT commissioned the review. I am grateful to the
clinical reviewer for completing her work expeditiously.
7. One of the Ombudsman’s Family Liaison Officers (FLOs) telephoned
the man’s brother who lives in the south of England. He was not
available so the FLO talked to his wife. The man’s sister-in-law told the
FLO she did not think her husband would have any specific concerns
or questions about his brother’s time in custody. She explained that
the man had always been prone to neglecting himself and both she
and her husband felt the prison had done all they could to care for him.
She also spoke very highly about the help and support they had
received from prison staff following the man’s death.
8. The FLO followed up her telephone call with a letter to the man’s
brother suggesting he get in touch should he wish to add to his wife’s
comments. The FLO did not receive any further correspondence. I
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hope this report provides the man’s family with a better understanding
of his time in prison and the events leading to his death.
7
THE MAN
9. The man was born on 3 April 1942 in London and was 66 years old
when he died. He lived in Lancashire before he was sent to prison.
His next of kin was his brother, who lives in the south of England.
10. The man was convicted on 19 December 2007 at Preston Crown Court
and sentenced to three years imprisonment on 8 February 2008. He
had not been in prison before but prison staff said “[He] is a chirpy,
polite elderly man who is just getting to grips with wing regimes. Do
not foresee any problems with him settling in.”
11. The man suffered from diabetes, high blood pressure and epilepsy.
His home GP confirmed that he had not cooperated with treatment and
attendance at the surgery for years and his attendance for hospital
appointments was poor. Prison staff noted that the man “was a slightly
built man who looked much older than his years”.
12. The man was quiet and introvert by nature. His personal officer said
“he kept himself to himself. He just tended to sit in his cell smoking all
day. He was no problem at all, but he got quite confused sometimes”.
His doctor described how “he liked some attention but not over-the-top
attention. He was very good”.
13. Staff said they were shocked when the man died because he seemed
to be “generally coping”. They were concerned at times because he
did not always take his medication and administer his insulin properly.
The investigator found that staff and prisoners spoke about the man
with compassion.
8
HMP WYMOTT
14. HMP Wymott is a large category C closed training prison (category C
prisoners cannot be trusted in open conditions, but do not have the
resources and will to make a determined escape attempt), which holds
both vulnerable prisoners and prisoners on ordinary location.
15. Mainstream prisoners and vulnerable prisoners are held in separate
accommodation and so Wymott is effectively two separate prisons with
their own range of workshops, education and training facilities. The
prison opened in 1979 and new accommodation was added in 1996.
Vulnerable prisoners mainly live in the original house blocks.
16. A new residential block of two wings was opened in 2004 and this is
used as the induction wing. Wymott can hold an Operational Capacity
of 1144 prisoners with a Certified Normal Accommodation 1081
prisoners. There are two specialist units: a drug therapeutic
community and an elderly and disabled community. Healthcare
services are commissioned and provided by Central Lancashire
Primary Care Trust.
17. Healthcare services at Wymott are commissioned and provided by
Central Lancashire Primary Care Trust. Services are classified as
Type 3 healthcare which provides 24 hour nursing care, 7 days per
week but with no inpatient facility. This does not include inpatient beds
so prisoners often go to HMP Preston, which has an inpatients unit.
HM Chief Inspector of Prisons’ inspection in 2008
18. HM Chief Inspector of Prisons, Dame Anne Owers, last inspected
Wymott in October 2008. She commented in her report:
“Wymott is a large category C training prison, holding over a
thousand men. It has expanded 25% since its last inspection in
2003. Unlike many training prisons which have undergone
similar expansion, Wymott has managed to sustain its
performance and the quality and quantity of activity available to
its prisoners.”
19. Dame Anne also wrote:
“The needs of older prisoners and those with disabilities were
not met. The disability policy did not reflect current practice and,
although a high proportion of prisoners reported some form of
disability, support was ad hoc, with no formal care plans and
only limited adjustments, even on I wing, which was supposed to
be a specialist unit. Staff on I wing were caring and supportive
but there was insufficient input and training to make it an
effective unit for older prisoners and those with disabilities.
Social care workers were due to be appointed. There were few
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links to health services and limited activities for those unable to
leave the wing.”
Diversity
20. Dame Anne recommended:
“A diversity policy should be developed and implemented,
covering all distinct minority groups, including gay prisoners,
those with disabilities and older prisoners, and based on an
analysis of their needs.”
I wing
21. Dame Anne reported:
“A policy for the management of older prisoners had just been
developed but had not been fully implemented. Over 10% of the
population were regarded as older prisoners (over 55) and a
separate unit had been established on I wing to cater for some
of them, as well as those with disabilities, but the criteria for the
wing were unclear. This included an annexe in the healthcare
centre of six cells more appropriate for use by prisoners with
physical disabilities. None of these prisoners had care plans
and little had been done to make reasonable adjustments to
living conditions; for example, prisoners using a wheelchair were
accommodated in ordinary cells. However, prisoners on this
unit were generally unlocked all day, limited low level work was
available on the unit, and a communal dining and television
facility had been provided. Interactions between staff and
prisoners on this wing were positive.
“I wing held up to 75 prisoners and was the only wing where
prisoners could eat out of their cell. A stair lift allowed prisoners
to access the association facilities on the upper landings. I wing
also had a separate annexe in the nearby healthcare centre,
with cells more suitable for use by prisoners with disabilities, but
they were too isolated for such prisoners to be held there.”
22. Dame Anne recommended:
“Individual care plans should be developed for older prisoners
with special needs and those with disabilities. Activities for older
prisoners and those with limited mobility should be improved to
provide more stimulating and purposeful occupation.
“Cells for prisoners with a disability or limited mobility should be
adapted to meet their needs.”
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Older prisoners in England and Wales: a follow-up to the 2004 thematic
review by HM Chief Inspector of Prisons June 2008
23. In 2004, Dame Anne published a report on the treatment and
conditions of the growing number of older prisoners in England and
Wales. A short follow-up report revisited the issue, four years on, to
detect whether there had been any changes. Dame Anne comments in
the follow-up report:
“The population of men over 60 in prison has risen slightly over
that period, reaching nearly 3% of the population; at the same
time, the population of women over 50 has increased
significantly, reaching nearly 7% by mid-2007. It is well-known
that prisoners are likely to have earlier onset of chronic health
and social care needs than the general population.
“There have clearly been some positive developments over the
last four years. Survey responses from older prisoners are more
positive than they were; healthcare arrangements have in
general improved; some individual prisons, or prison staff, are
carrying out good and innovative work to meet the specific
needs of these prisoners.
“Older prisoners are a relatively compliant population – hence
the title of our previous report, No problems – old and quiet,
taken from a prisoner’s wing file. In an increasingly pressurised
prison system, their needs are therefore likely to be overlooked
unless there is specific provision – yet the issues they pose are
likely to become more acute, as an increasing number of long-
sentenced prisoners grow old and frail in prison.
“The voluntary and healthcare sectors have done a great deal of
important and useful work in this area. It now falls to the
National Offender Management Service to make full use of that
work and of the recommendations in our last report, and ensure
that prisons properly reflect, and can provide for, the needs of
their ageing population.
“There were some good examples of provision for older
prisoners organised and managed by health services staff, but
this was largely done in isolation with little evidence of
multidisciplinary working. It was disappointing that the social
care needs of older and disabled prisoners were still considered
the responsibility of health services. A lead nurse for older
prisoners was not evident in all inspections, despite the
requirements of the National Service Framework for Older
Prisoners. However, there were some good examples of care
for this older age group. But there was a complete lack of staff
training in identifying the signs of mental health problems among
the elderly.”
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The Independent Monitoring Board (IMB) Annual Report 2008/09
24. The Prisons Act 1952 requires every prison to be monitored by an
independent board appointed by the Secretary of State for Justice from
members of the community in which the prison is situated. The Board
must satisfy itself as to the humane and just treatment of those held in
the prison it monitors.
25. Wymott IMB’s most recent annual report was published in May 2009.
The executive summary contains the following remarks:
“The Board considers that the Prison is providing a safe
environment in which prisoners are treated with decency and
respect and have access to an extensive programme of
education and skills. The Senior Management of the Prison
have set out to address those areas where prisoners are not
treated decently within the limitations of what the Prison can do
given its national resource allocation.”
Healthcare and Mental Health
26. The section of the IMB’s report dealing with Statutory Reporting Areas:
Healthcare and Mental Health reports:
“Generally Healthcare in the Prison has improved since its
takeover by the PCT and the appointment of a new Healthcare
Manager in 2008. However the Board considers that the Unit
still has some way to go before it achieves the NHS aim of
treating prisoners to the same standard as patients in the
community. Given the high concentrations of poor physical and
mental health, drug addiction, general low self-esteem and lack
of access to private medicine and retail pharmacies, the Board
considers the PCT should be offering a service that exceeds
what it provides for the general population.
“A lead nurse for elderly prisoners has been designated. Care
plans for elderly prisoners are now being developed and the
prison has produced an Elderly Prisoner Action Plan as a
response to the HMCIP Thematic Review. However due to
staffing shortages and pressure of work, the lead nurse has
been delayed in producing an individual healthcare plan for each
elderly prisoner. A revised induction document has been
designed to more fully assess elderly prisoners' medical and
social needs and is implemented.”
12
Elderly and disabled community (I wing)
“Consider the introduction of specialist training for I Wing
officers to enhance the quality of care for elderly and disabled
prisoners. Although I Wing is identified as the elderly and
disabled community it does not appear to have attracted
significant additional funding to reflect the specific requirements
of that role. In the course of the year, however, the Governor
was able to find sufficient funds to appoint two care workers, to
install a stairlift on I Wing and to set up a daycare activity centre,
all of which enhance significantly the facilities on the wing. The
appointment of the care workers, in particular, provides much-
needed assistance with daily living. Although the activity centre
had been completed by the end of the reporting year it had not
yet been commissioned.
“The layout of I Wing creates difficulties for wheelchair users.
However, the installation of the stairlift is a welcome addition,
and the social environment of the wing and the good staff-
prisoner relationships provide further benefits.”
27. The section of the IMB’s report dealing with Reports on Other Areas of
the Prison: Elderly and Disabled, reports:
“The Prison now employs two Care Workers located on the
elderly and disabled wing and the Board welcomes this. The
Careworkers provide the assistance that some disabled and
elderly prisoners require on a daily basis. The Board also
recognises the important role that prisoners play in the care of
their fellow inmates. Careworkers are developing their own day-
to-day care plans under the supervision of the named nurse for
elderly or disabled prisoners. However medical care plans for
each prisoner have not yet been constructed. There is a
growing collaboration between Careworkers and Healthcare,
which may lead to opportunities for improved care. At the time
of writing there does not appear to be arrangements for the
development of the careworker role.
“Whilst the Board considers that the care provided by discipline
staff for elderly and disabled prisoners on I Wing is good and
that the careworkers will provide vital support it is concerned
that there is no specialist training for officers; for example
recognising early geriatric mental health deterioration. However
the introduction of the careworkers may help to bridge this gap.
The Board welcomes the development of a day care centre for
the elderly and disabled, which promises an improvement on the
previously poor arrangements for association, education and
work.”
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Previous deaths in custody at Wymott
28. Since 2004, the Ombudsman’s office has investigated 25 deaths at
Wymott, which include 22 deaths by natural causes and three apparent
self-inflicted deaths. I am satisfied that there is no link between the
circumstances surrounding this investigation and the other deaths,
although a number of the deaths by natural causes were also
associated with chronic disease and long term medical conditions.
29. Four of the deaths were elderly men who were, or had been, located
on I wing within the elderly and disabled community. These were all
deaths by natural causes and associated with long term conditions
such as coronary heart disease.
30. I investigated the death of a man at Wymott in November 2007 and
made a recommendation that the Head of Healthcare should ensure
tighter monitoring and follow-up of delays and missed appointments,
particularly those of chronically ill patients. The investigator found no
evidence from the circumstances surrounding the man’s death that he
missed any scheduled appointments because of a lack of monitoring
by the prison. This was confirmed by the clinical review.
14
KEY EVENTS
31. The man was convicted on 19 December 2007 at Preston Crown Court
and sentenced to three years imprisonment on 8 February 2008. It
was his first experience of imprisonment.
32. A first reception healthscreen identified that the man had type 1
diabetes (insulin dependent diabetes which required a daily injection of
insulin), and epilepsy, although healthcare staff could not find a
definitive diagnosis of epilepsy recorded in his medical record. The
reception nurse made a note to send for his GP records and also made
a referral to the diabetic specialist nurse.
33. The man was admitted to the healthcare centre and located on H2.
Staff reported that he was “orientated and conversing with other
prisoners and staff. He quickly settled into prison life and ate his meals
and accepted his medication”. Healthcare staff contacted the man’s
home GP, and requested full details of his medical history, prescribed
medication and any pending hospital appointments.
34. The man was found collapsed on the floor on 19 February. Healthcare
staff attended and administered glucose (which aids recovery when a
diabetic patient has collapsed because of low blood sugars). He had
not injured himself and his diabetes quickly stabilised after he was
given glucose. Later, the man asked the staff what had happened. He
was seen by the doctor the following day and a plan put in place to
ensure “close monitoring”.
35. Two days later, the man was found unconscious. He was suffering
from hypoglycaemia (a medical condition where blood sugar level has
fallen causing collapse). Healthcare staff attended and administered
glucose and oxygen (to help breathing). The man regained
consciousness and staff provided reassurance. A prison doctor,
reviewed the man and agreed a plan to observe him, supervise his
insulin dosage, and take blood tests.
36. Over the next few months, healthcare staff continued to monitor the
man’s diabetes. He cooperated sporadically and blood sugar tests
indicated that his diabetes was often unstable.
37. On 4 June, the man was reviewed by the specialist diabetes nurse who
recommended a change in his insulin. She advised the healthcare
team of the suggested changes.
38. The man complained of hip pain on 5 November. He was reviewed by
the doctor and prescribed co-codamol (pain relief medication).
39. During those nine months at Preston, healthcare delivery was focused
on attempts by the healthcare team to stabilise the man’s diabetic
condition through improved compliance with care and self
15
management. There were numerous attempts to improve the man’s
control of his diabetes, as evidenced by the written entries in his
medical record.
40. Preston provides type 4 healthcare services over the 24 hour period for
prisoners who need acute care and comprehensive clinical assessment
and this includes inpatient beds. The man remained at Preston until 7
November when he was transferred to the elderly and disabled
community at Wymott. The care team at Preston considered that the
elderly and disabled community would be preferable for the man
because he would be located with other prisoners with similar needs.
41. On 7 November, healthcare staff at Wymott assessed the man on
reception and considered he was capable of administering his own
insulin, though they noted his history of poor compliance.
42. Reception staff completed the first night check and the man signed the
relevant custodial behaviour agreements. Because of his limited
mobility and disabilities he was located in the elderly and disabled
community on I wing.
43. Prison staff visited the man in the elderly and disabled community to
interview him and agree his custodial plan. He was of retirement age
and did not want to work, nor did he wish to attend education.
However, the man said that he was willing to participate in any
appropriate offending behaviour programmes.
44. The man was happy to be located on I wing and was introduced to his
personal officer who wrote in his F2052A (inmate personal record
system):
“[The man] is a bit of a loner. [He] has never been married and
looked after his mother until she died. His hobby is watching
TV. He has no friends on the outside and did not go out of his
flat to socialise.
“He is very happy here at Wymott on I wing and has no issues.
He does not seem to have any contact with friends or family and
does not work. He is 65 years old. He is polite and I have
explained the need for him to keep his medication and needles
safe and out of sight at all times which he assures me he will.”
45. The Security Department advised healthcare staff on 17 November that
the man should not be allowed insulin syringes and a sharps box
(container for disposal of syringes) in his possession. The investigator,
could not ascertain the rationale for this decision. Healthcare staff
reviewed his insulin administration regime accordingly to change to a
‘Novorapid flexi pen’ (a functional ‘pen’ to self administer insulin), which
was considered both easier and safer to use.
16
46. On 27 November, the man was seen for diabetic review. Healthcare
staff noted:
“[The man] has been a diabetic patient for years. His blood
glucose has been unstable for some time. He claims to be
compliant with diet and insulin regime. Blood sugar this morning
with BM machine = 28 (excessively high). Has had diabetic foot
screening earlier this year. States has not had recent eyesight
test.
“Plan: Ensure listed for diabetes specialist nurse clinic. List for
eye sight test and diabetic retinopathy (non-inflammatory
damage to the retina of the eye) screening. Relist for diabetic
blood tests next month.”
47. Healthcare staff were called to see the man on 1 December. He was
confused and could not tell staff his age or where he was. Blood sugar
testing recorded a very high reading. Staff recorded his vital signs
(pulse, blood pressure and oxygen saturation level), administered
oxygen and called an emergency ambulance. His oxygen saturation
levels did not improve. The man was taken to the Accident and
Emergency Department at Chorley Hospital. The investigator could not
find any evidence to indicate that attempts had been made by the
prison to inform the man’s family of his admission to hospital despite
the seriousness of his condition.
48. The next day, the Head of Healthcare, telephoned Chorley Hospital,
where the man had been admitted to the intensive care unit (ICU), for
an update on his condition. He had been diagnosed with ketoacidosis.
Hospital staff said he was currently stable and could be transferred to a
ward later that day. Later that day, the man was duly transferred from
ICU to a ward where his condition started to improve.
49. The man remained at Chorley Hospital for the next two weeks and was
discharged back to Wymott on 15 December. Prison healthcare staff
reviewed the man’s hospital discharge plan on his return. (It is
common practice that when a prisoner is discharged from hospital he
returns to prison with a discharge letter and plan.)
50. On the morning of 27 December, prison staff alerted healthcare staff
that they were concerned about the man. Two nurses and the doctor
went to see him on I wing. They took emergency medical equipment
with them from the treatment room.
51. The man was lying on his bed and was not conscious. The healthcare
staff found that he did not respond to “voice and painful stimulus” (such
as pinching the skin of the patient). They immediately requested the
control room to call an emergency ambulance.
17
52. The nurses took the man’s vital signs observations: his blood pressure
was very low at 67/45 (abnormally low), the pulse oxymeter could not
record his oxygen saturation levels at all, and they tried to test his
blood sugar but again could not get a reading. Their equipment simply
recorded a reading ‘Err’ (error).
53. The doctor inserted a cannula (for the delivery of fluids into the vein)
and set up sodium chloride solution (salt based fluid) to be
administered intravenously. They then administered oxygen to help
the man breathe.
54. When the paramedics arrived they tested the man’s blood sugar on
their machine which tested ‘high’. The man was taken by emergency
ambulance to the Accident and Emergency Department at Chorley
Hospital.
55. At the hospital, the prison officers escorting the man were instructed
not to apply mechanical restraints in view of the gravity of his condition.
Hospital staff attended and later told the officers that the man’s heart
had momentarily stopped three times and that if it stopped again they
would not administer any more treatment.
56. The duty governor tried to contact the man’s brother and after a
number of attempts, she managed to speak to him on the telephone at
4.00pm. She informed him that his brother was seriously ill in hospital.
57. At around 4.30pm, hospital nurses told the prison officers that the man
had “passed away at 4.20pm”. His family spoke positively about their
interaction with the prison following his death.
58. At 5.00pm, the duty governor telephoned the man’s brother again and
informed him that his brother had died. Later that evening the man’s
sister-in-law contacted the prison and asked that the family be advised
of the funeral date. She explained that they did not want to make the
funeral arrangements. Another governor acted as the prison family
liaison officer to support the family and kept them informed of all follow-
up arrangements.
18
ISSUES
Clinical care
59. The clinical reviewer concluded that the man received “an appropriate
level of general healthcare, and had the opportunity to see a health
professional on a regular basis”.
60. She continues:
“[The man] had access to emergency care from professionals
throughout the 24 hour period and also had access to a
paramedic service in the same way as any other resident of
Central Lancashire. He was also treated in Chorley Hospital.”
She makes reference in her report to both healthcare services at
Wymott and Preston.
61. The clinical reviewer found:
“Concerns that, in some cases, information was not documented
as fully as it could have been or was missing altogether. There
was no consistent record of communication between
departments and there is no record of a discharge plan from
Chorley Hospital.
“The recording of information, particularly around hospital
transfers and subsequent management plans is limited. There
should be clear pathways of communication between the
healthcare team at Wymott and outside hospital departments.
This communication should be documented in the patient’s
record. All staff should have access to a patient’s management
plan. This plan should include the most recent reviews,
evaluation and recommendations.
“In a small number of instances, records had been stored
without a date or a name attached.
“There is a clear national and local protocol for record keeping.
In order to improve communication systems the medical/nursing
documentation could be audited. This will demonstrate
compliance with the guidelines for records and record keeping
as defined by the Nursing and Midwifery Council. From this,
managers will be able to identify any training needs for staff and
instigate policies and recommendations to achieve compliance.
“The care and treatment offered by consultants and out-patients
clinics was maintained and monitored by the healthcare team at
Wymott. As far as can be determined from the medical record,
all scheduled appointments went ahead. Again, some records
of activity are limited.
19
“In terms of health services for older people, a Band 6 (a senior
nurse grade) nursing sister had recently been appointed within
the prison healthcare to specifically look at the needs of the
older population. She has commenced work based on the
National Service Frameworks for older people to review the
policies for working with this client group to ensure that the
services offered are equal to those offered in the wider NHS.
The policies for older people form part of the wider older
person’s strategy within the prison.
“The development of policies for delivering care to elderly
prisoners will improve the way care is delivered at Wymott. [The
clinical reviewer] considered that any lack of current policy
development would not have negatively affected the overall care
package [the man] received. The urgency of the clinical
situation often dictated the way that [the man’s] care was
provided by healthcare staff.
“From what is reported and recorded [the man] appeared to be
content with the care he received. There are no recorded
complaints or concerns.
“Although there are no records available of a debriefing session
following the incident all staff commented that one did occur and
it served to relieve anxieties that staff may have felt by sharing
their experiences. It also provided the manager with a profile for
‘lessons learned’ in terms of emergency procedures.”
62. The clinical reviewer makes five recommendations with the objective of
improving healthcare practice and standards at Wymott. I have written
to Central Lancashire PCT outlining these recommendations and
attach my letter as an appendix to this report.
63. The clinical reviewer also identifies a number of areas of good practice
which include:
“[The man] had a number of long term health conditions which
were all treated by professionals who specialised in that
particular area. He had access to a specialist diabetic nurse
who saw him on a regular basis and ensured that all care was
offered in accordance with NICE guidelines and PCT policy.
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64. The clinical reviewer finds that the level of service provision the man
experienced at Wymott:
“ … arguably exceeded the provision offered in the general
community as [the man] was able to access health professionals
as he needed to within minutes.”
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CONCLUSIONS
65. The man was a quiet and perhaps rather lonely person, but he did
settle in the elderly and disabled community at Wymott. He had never
married and had few friends at home. The investigator found that
earlier on in his sentence whilst at Preston, the man did not properly
comply with his insulin regime despite staff support and
encouragement.
66. He had a number of health conditions, but his main problem was
diabetes, which remained unstable throughout his time in custody,
despite the considerable efforts of healthcare staff and the intervention
of a specialist diabetic nurse. Staff found that the man often did not
administer his insulin correctly and would also consume sugar and
other unsuitable foodstuffs, which had the potential to destabilise his
diabetic condition.
67. The man was transferred from Preston to Wymott on 7 November 2008
and was located in the elderly and disabled community. The
investigator found this decision to be appropriate because the man was
able to live and associate with other prisoners of similar needs and
circumstances. The man was a quiet and introverted individual and
location in the community helped him develop positive relationships
with other people. It also aimed to encourage him to greater self-
reliance, particularly with regards to his diabetes.
68. The clinical reviewer, judged that the man received comprehensive
healthcare of a standard equivalent to what could be expected in the
community in terms of access and quality. My investigation of the
circumstances surrounding the man’s death concurs with the clinical
reviewer’s judgement.
69. The investigator found that prison staff working in the elderly and
disabled community care for prisoners with a variety of chronic health
problems, such as diabetes. This group of staff would benefit from
additional training as they are often the first people approached by
prisoners to help them with their health needs and problems. The IMB
has previously identified staff training as a gap that needs to be
addressed.
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RECOMMENDATION
To the Governor
1. The Governor should consider providing prison staff working within the
elderly and disabled community with training to raise awareness of how
they should respond to the health problems experienced by prisoners
in that community.
Locally training for prison staff working with elderly and disabled
prisoners to raise awareness of how they should respond to health
problems will be scheduled between February and June 2010. Target
date for completion is June 2010.
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