Individual at Acklington

Investigation into the circumstances surrounding the
death of a man, a prisoner at HMP Acklington, at Morpeth
Cottage Hospital in January 2008
Report by the Prisons and Probation Ombudsman for
England and Wales
March 2009
The man was 57 years old when he died on 25 January 2008 of natural causes at
Morpeth Cottage Hospital. He was a prisoner who was serving his sentence at HMP
Acklington. My report shows that the man had been diagnosed with cancer at an
early stage of his sentence.
My investigator and I offer our sincere condolences to the man’s family and friends
for their sad loss.
I wish to thank the Governor of Acklington for making the necessary facilities and
information available to my investigator, and for the assistance of the Liaison Officer.
In the course of the investigation, I also asked for a clinical review to be carried out
into the care and treatment the man received in custody. I am grateful to the Doctor
from the North of Tyne Primary Care Trust for his assistance and report.
My investigation identified a number of issues which required action on the part of
HMP Acklington. I am pleased to say that once my investigator made the Governor
aware of concerns regarding hospital referrals and the use of disclaimers by
prisoners who declined hospital appointments, the governor of Acklington gave the
investigator an assurance they would be corrected immediately. As a result, I have
only made one formal recommendation (to the Durham Probation Area). However,
the investigation has, like so many others I have issued, drawn attention to the risk
averse approach that is taken to the use of restraints on seriously ill and dying
prisoners. In paragraph 82, I have described “a macabre pantomime” in which
handcuffs were first removed, then re-applied, then removed again from the man, a
man who was frail and just days from dying.
This report also raises a matter for the Parole Board, and I will send a copy to the
Board for their consideration.
I must apologise for the length of time it has taken to complete and issue this report.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2009
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CONTENTS
Summary
The Investigation Process
HMP Acklington
Key Findings
Issues
Conclusion
Recommendations
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SUMMARY
In October 2005, the man was sentenced to six years imprisonment, which included
a two year extension to his sentence, after he had been found guilty of a serious
offence against a child. He was initially sent to HMP Hull but later transferred to
HMP Acklington where he settled in well.
The first noticeable problem with the man’s health was when he was referred
urgently by a doctor at Acklington to a dermatologist at the Royal Victoria Infirmary,
Newcastle, in August 2006, with what was described as a “suspicious skin lesion”.
Unfortunately, the urgent referral, which should have meant he was seen within 14
days, was not dealt with correctly by Acklington’s healthcare department and the
referral was not sent. However, a further urgent referral was made in September
that same year and a new appointment made for the following month. On the day of
the appointment, the man decided not to attend the hospital and a new appointment
was requested and made by Acklington’s healthcare for the following month.
After attending the re-scheduled appointment on 19 October, the man was
diagnosed as having a malignant melanoma. He was treated in hospital and
returned to prison. Over the following months he returned to hospital for routine
assessments and for a CT scan. The clinical reviewer identifies further hospital
appointments that were cancelled at the man’s request.
During this time the man was eligible to apply for release on licence, which he did.
However, because of a failure by his home probation office to return the parole
documents within the correct timescale, his application was not dealt with and the
documents were returned to the prison for rewriting.
Over the next few months the man’s health deteriorated and he was eventually
transferred for end of life care. He died on 25 January 2008 at Morpeth Cottage
Hospital.
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THE INVESTIGATION PROCESS
1. Following notification from the Prison Service that the man had died, the
investigation was allocated to my investigator. He contacted the Governor of
HMP Acklington and arranged for the relevant prison files to be forwarded to
him. In addition, my investigator asked for my notice of investigation to be
displayed to all prisoners and prison staff inviting anyone with any information
to make themself known. I can confirm that no one responded to the notices.
2. In March 2008, the investigator and one of my family liaison officers visited the
man’s family at their home address and met three members of his family. The
man’s family made my staff very welcome and asked them to look at a number
of issues and concerns they had relating to the man’s care and treatment
whilst in custody. I hope that my investigation has covered all their questions.
3. After reviewing the files, my investigator went to the prison on 21 April 2008
where he met the clinical reviewer appointed by the doctor from North of Tyne
Primary Care Trust and the prison’s liaison officer and Acting Deputy
Governor. The investigator and Doctor spoke to members of the prison
medical team. Before leaving the prison to complete his clinical review, the
North of Tyne Primary Care Trust Doctor was given details of the family’s
concerns and asked to comment in his review on those within his competence.
4. Over the following two days, my investigator met a number of prison staff and
managers, all of whom cooperated fully with my investigation. The purpose of
speaking to prison staff was to try and answer the family’s questions and to
assess how well the man’s needs were catered for.
5. On 23 April, the investigator met the Governor and liaison officer and fed back
his findings at that time. The Governor accepted the feedback and agreed to
implement a number of changes (as a consequence, this report contains fewer
formal recommendations than would otherwise be the case). However, the
investigator reminded the Governor that there could be additional
recommendations resulting from the clinical review.
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HMP ACKLINGTON
6. HMP Acklington is a category C establishment, situated close to the village of
the same name in Northumberland. It was built on the site of a former RAF
base and accommodates convicted adult male prisoners including men serving
life sentences. About half the population are vulnerable and/or sex offender
prisoners. The prison can hold a maximum of 871 prisoners. It provides
employment in farms and gardens, education and a variety of workshops.
7. Between Monday and Friday, prisoners are unlocked in the morning at
7.55am. They are locked up for the night at 7.15pm. At weekends, the prison
is unlocked at 8.30am and on Saturday is locked up at 7.15pm. On Sunday
the prison is locked up for the night at 5.20pm.
Bedwatch
8. Bedwatch is the term used by the Prison Service to describe a prisoner who
has been admitted to hospital and usually requires a minimum of two officers
to be present throughout the stay. In the majority of cases, the prisoner is
handcuffed to an officer.
Healthcare
9. Acklington does not have 24 hour medical cover. Outside the normal
operating hours, the prison relies on the services of an on call doctor or, if
necessary, the emergency services.
Her Majesty’s Chief Inspector of Prisons’ Reports
10. In April 2003, Her Majesty’s Chief Inspector of Prisons, made an unannounced
follow up inspection of the prison. The inspection found that Acklington was
largely a safe establishment. However, in her report the Chief Inspector
commented on suicide prevention and anti-bullying, highlighting the need for
more extensive training especially for permanent night staff.
11. Three years later in December 2006, Her Majesty’s Chief Inspector of Prisons
carried out an announced inspection of the prison. In the introduction to her
report, she said she was disappointed to find that, despite raising concerns
over three years earlier about expanding the prison, those concerns had gone
unheeded. She said that the expanded prison had not only failed to provide
sufficient purposeful activity places, it had struggled to sustain a safe and
decent environment. However, the chief inspector acknowledged that there
were few incidents of self harm. She also described commendable examples
of care for those at risk. She said that a new group of senior managers had
been transferred into the prison.
12. The Chief Inspector recommended that emergency resuscitation equipment
and emergency assistance should be immediately available to all staff and
prisoners.
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Independent Monitoring Board (IMB)
13. Each prison has its own IMB made up of volunteers from the community. The
Board’s role is to ensure that the prison is properly run and that prisoners are
treated decently. Each Board produces an annual report for the Secretary of
State.
14. In line with my normal practice, my investigator asked to speak with a
representative of the Board. He was told that, on the occasions when a death
had occurred at the Acklington, the Board had been properly notified. The
Board did not raise any concerns regarding healthcare.
Prison Service Orders (PSO)
15. Prison Service Orders are long term mandatory instructions which are
intended to last for an indefinite period. Any mandatory instructions to
Governors are written in italics. Each PSO is given a title and unique
reference number.
PSO 4400 Incentives and Earned Privileges Scheme (IEP Scheme)
16. All prisons operate a local IEP scheme for prisoners. The scheme is intended
to encourage and reward responsible behaviour, participation in constructive
activity including addressing offending behaviour, and progression through the
prison system.
17. There are three levels to the scheme (Basic, Standard and Enhanced).
Prisoners assessed as being at basic level are given the minimum allowable
regime and facilities. Those on standard and enhanced levels are allowed
access to higher spending power, additional visits, in cell television and other
facilities depending upon the resources available, with enhanced providing the
most rewards.
Multi-Agency Public Protection Arrangements (MAPPA)
18. The MAPPA is a formal partnership between police, probation, prisons and
other statutory and non-statutory agencies which assesses and manages
offenders in order to minimise the risk of serious harm they may pose to the
public. There are four core functions:
• identification of offenders with the potential to commit serious violent and
sexual offences
• sharing relevant information between agencies
• assessing the risk of serious harm
• Managing that risk.
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19. Offenders who come within the MAPPA remit are classified according to the
nature of the risk and its management. The higher the risk, the higher the level
at which they are managed. Level one offenders are managed by one agency,
usually the police or probation service. Level two offenders are managed
jointly by all the MAPPA agencies, and level three offenders are managed by
the Multi-Agency Public Protection Panel (MAPPP), made up of senior
managers from the MAPPA agencies.
Previous Deaths at Acklington
20. Since my office took over the responsibility for investigating all deaths in prison
custody on 1 April 2004, there have been three apparently self inflicted deaths
at Acklington and nine, including the man’s, due to natural causes. I have not
identified any common factors between my previous investigations and this
one.
Sexual Offences Prevention Order (SOPO).
21. The Sexual Offences Act 2003 gives the courts the power to impose civil
preventative orders against individuals convicted of sexual offences and
whose behaviour suggests they may commit further similar offences. One of
the orders is the Sexual Offences Prevention Order (SOPO), which is intended
to protect the public from serious sexual harm. Offenders subject to the order
are prohibited from engaging in specified activities, such as entering schools or
swimming pools. Orders last for a minimum of five years. A breach of any of
the conditions constitutes a criminal offence punishable by up to five years
imprisonment.
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KEY FINDINGS.
22. The man was convicted of a serious sexual offence and when he appeared at
York Crown Court on 28 May 2005. He was bailed and told to return to court
on 3 October, for sentencing. When he returned to court, he was sentenced to
four years imprisonment and given a two year extended sentence, which
meant that his actual term of imprisonment would take him to 2 October 2011.
He was taken from court to HMP Hull to begin his sentence. Because of the
length of his sentence, the man would not be eligible for release on licence
until 3 October 2007.
23. Due to the nature of the man’s offence, an order was made disqualifying him
from working with children for life. He was also issued with a copy of the
Sexual Offences Prevention Order and told that he would be required to sign
the Sex Offender Register on his discharge from prison.
24. On 16 December 2005, the man was transferred from Hull to Acklington. Due
to the nature of his offence, he was allocated to a vulnerable prisoner wing
which provides a higher degree of safety from other prisoners. In addition, and
because he was subject to MAPPA level two, arrangements were made by the
prison’s security department to routinely monitor his letters and telephone
calls.
25. Six days later, the man attended a Well Man Clinic at the prison. The clinical
reviewer notes there were no health problems identified. The man’s weight
was recorded as 58kg.
26. The man appears to have settled in well at Acklington. The clinical review
notes that on 1 August 2006, the man was seen by a doctor at the prison. The
doctor referred the man for an urgent appointment with a dermatologist at the
Royal Victoria Infirmary (RVI) Newcastle, due to what was described as “a
suspicious skin lesion”. The urgent referral meant that the man should have
been seen within 14 days.
27. On 26 September, the man saw a nurse at the prison as he had not received
his dermatology appointment. Three days later, another prison doctor re-
referred the man urgently to the dermatologist. On this occasion, the referral
was acknowledged and an appointment made for 10 October at the RVI.
However, at the man’s request, the appointment was cancelled. He had
signed a disclaimer showing that it was his decision.
28. The man was given a fresh date and, on 19 October 2006, he attended the
dermatology department at the RVI as an outpatient. Arrangements were
made for him to return to hospital on 16 November for tests and an operation.
29. Seven days later, on 24 November, the man returned to hospital and was
given the result of the tests carried out the previous week. These showed that
he had a malignant melanoma. The clinical reviewer notes that he was fully
informed about the diagnosis and an appointment made for him to be seen on
1 December by a plastic surgeon.
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30. On 11 December, the man underwent a second operation. The clinical
reviewer notes that it is normal practice when a malignant melanoma is
diagnosed for the patient to have a second operation shortly after the first.
31. Between 18 December and 26 January 2007, the man attended six RVI review
appointments and according to his own diary, an MRI scan on 7 February.
The clinical reviewer notes that the man’s dressings were routinely changed
and that he also had a CT scan.
32. In the meantime, the man made an application under the Prison Service’s
Incentives and Earned Privileges (IEP) Scheme asking to be considered for
enhanced status. The IEP application was considered by a wing manager and
rejected on the basis that the man was appealing against his sentence and
therefore not engaging with his sentence plan.
33. On 17 April 2007, the man was due to go to hospital for a medical appointment
with his plastic surgeon. Prison records show that he refused to go as he had
a legal visit booked for the same day which he wanted to attend instead. As it
was his choice, prison staff asked the man to sign a disclaimer acknowledging
that it was his decision. This he did. A new appointment was scheduled for
later in the year.
34. In preparation for his possible release on licence and on schedule, the prison
parole clerk sent the man a parole application form at the beginning of April
2007, asking him to return it to her. The purpose of the form is to give any
eligible prisoner the opportunity to either opt in or out of the parole process. In
the man’s case, he opted into the parole process, and six days later he
returned the completed form to the parole clerk.
35. Once the prison’s probation clerk received the completed form from the man,
she began the formal process of obtaining up to date conduct reports which
the Parole Board requires before considering an application. As well as asking
for information from areas such as his workplace, specific requests were sent
to the seconded probation officer based at Acklington, to the man’s home
probation officer and to his personal officer at the prison. The timescale for
returning the completed forms to the parole clerk was two months. With the
exception of the man’s home probation officer, all the others returned them
within this time.
36. On 18 September 2007, after rescheduling his earlier cancelled appointment,
the man was due to go to hospital as an outpatient to see a plastic surgeon.
However, as before, he cancelled the appointment and signed a disclaimer, as
he had a social visit booked.
37. The clinical reviewer notes that from 16 October 2007 onwards, the man
attended seven more appointments at the RVI. He also underwent a further
operation to his arm glands and had his dressings changed regularly.
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38. On 16 November, one of the prison chaplains, a reverend, made an entry in
the man’s prison record noting that he had received a call from the man’s
brother who was concerned about him missing a hospital appointment. The
Reverend telephoned healthcare, who assured him that the matter was being
dealt with and that a new appointment had been made, although no reason for
the cancellation was given. The record shows that the Reverend telephoned
the man’s brother to tell him what was happening.
39. Later that same month (22 November), the man was interviewed by the prison
race relations officer regarding something that the man had said to another
prisoner on 4 November. The entry in the man’s prison record notes that he
acknowledged that he had caused offence to another prisoner. This is the first
and only negative entry about his prison behaviour.
40. On 28 November, some seven months after making her first request for parole
reports to be completed and returned, the prison’s parole clerk finally received
the report from the man’s home probation officer. The prison’s parole clerk
told my investigator that she had previously made a number of requests to the
home probation officer for the missing report to be completed and returned, but
had had no success until then. I understand that the delay was as a result of
the man’s home probation officer being re-allocated, and not being given his
files.
41. After receiving the report, the prison’s parole clerk sent a copy of the parole file
to the man that day so that he could read it and add any comments should he
wish to do so. Six days later (4 December), the man returned the form to the
clerk. In his submissions to the Parole Board he said he had had a malignant
melanoma which had cleared. (I understand from his family that the man had
received the all clear from the hospital.) He went on to say that something
else had been found that would require radiotherapy, and he wanted to obtain
the treatment from home rather than from prison.
42. Having received the completed form, the parole clerk sent the man’s files to
the Parole Board. She explained to my investigator that, once the file was
received by the Parole Board, the Board then had 25 days to set a hearing
date. However, prison records show that the files were returned by the Parole
Board to the prison on 11 December. The reason for the Parole Board
returning the files was that, with the exception of the home probation report,
the remaining reports were over six months old and therefore not eligible for
consideration. Unfortunately, despite the original reports being completed
within the correct timeframe, the delay in obtaining the home probation report
meant that the other reports had to be re-written before the Parole Board
would consider them.
43. On 9 December, an entry was made into the man’s prison record noting that,
because he had had an operation, he was unable to work. The note said that
the man was eager to work, but that this had not been authorised by
healthcare.
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44. Four days later, the man was seen by a nurse and referred to a prison doctor.
The doctor, saw him on 17 December and took blood samples which he sent
for analysis.
45. In the meantime, an entry was made in the man’s prison record on 23
December that said he was stressed due to lack of progress with his parole
application, his illness, and an unidentified issue. The entry did not say what, if
anything, was done to assist him.
46. The next day, the prison doctor received the results of the man’s blood test.
The clinical reviewer notes that the results were inconclusive and
arrangements were made to repeat the test three weeks later.
47. A week later on 2 January 2008, the man’s consultant agreed that he could
resume work. Prison records suggest that this decision made the man a lot
happier.
48. Nine days later, at the request of a fellow prisoner who had said that the man
was not well, a staff nurse went to see the man in his cell. She advised him to
see a doctor, but he said he would do so as he was going for a scan. The
nurse offered the man medication (paracetamol) for the relief of his symptoms,
but he declined.
49. The nurse told my investigator that the man looked thin and pale, but was not
in distress. She said he made it clear to her that he did not want to see her.
The Nurse said she told the man that, if he wanted to change his mind, then
she would refer him to a doctor immediately. When she returned to
healthcare, she checked the man’s records and saw that he had a hospital
appointment for a scan a few days later.
50. On 15 January, one of the wing officers made an entry in the man’s prison
record noting that the man was depressed at the lack of action with his parole
application and his illness. The officer also noted that the man appeared to be
losing weight. (Prison records show that the man’s weight was noted as 48kg,
ten kilograms lighter that when he weighed in December 2005.)
51. The next day, a staff nurse made an entry in the man’s prison record noting
that wing staff had contacted healthcare about his declining health. She went
to see him and told my investigator that he looked weak and frail, and was out
of breath. She said she discussed with the man the option of moving him to a
ground floor cell on another wing. This would have been easier for him as he
would not have to climb stairs. However, the man declined the offer and told
the nurse that his friends were on the wing where he lived and he wanted to
remain with them.
52. On 18 January, at the request of a staff nurse, arrangements were made with
the prison catering department for them to supply the man with a special diet.
The diet supplied was yoghurt and milk.
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53. Four days later, on 20 January 2008, the nurse was asked by wing staff to
assess the man again as he was unwell. She went to his cell and found him
confused, disorientated and vomiting. The nurse telephoned an on call doctor
and he recommended that the man should be admitted to Wansbeck Hospital
as an emergency patient. The nurse told my investigator that the man’s
medical condition deteriorated rapidly towards the end of his life.
54. In the meantime, the results of an earlier CT scan were received which
showed that the man had “Advanced disseminated cancer disease”. Once the
full extent of the man’s illness and prognosis was known, the prison doctor
wrote to the Governor of Acklington asking him to consider early release or a
transfer to a hospice.
55. Having received the doctor’s letter, the Governor made the Head of
Resettlement aware of its content, and asked him to look at the options for
releasing the man early on compassionate grounds. When the head of
resettlement checked the instructions contained in PSO 6000, he realised that
he had to refer the case to the Parole Board for a decision, rather than follow
the route for compassionate release which is a different process.
56. The Head of Resettlement asked the parole clerk to contact the Parole Board
on his behalf and make them aware of the man’s condition. In addition, a letter
was sent by special delivery from healthcare to the Parole Board explaining
the man’s medical condition. The prison parole clerk said she followed up the
healthcare letter by telephoning the Parole Board for a decision. She said she
was unable to obtain an answer from the person whom she spoke to, other
than being told the “file would be looked at”.
57. At about the same time as this was taking place, the man was being prepared
by medical staff for transfer from Wansbeck Hospital to Morpeth Cottage
Hospital. A Senior Officer (SO) was in charge of the escort. He told my
investigator that he had met the man previously in the prison, but when he saw
him on this occasion the man was “a shadow of himself”. He said the man
was able to talk but only in short bursts and, because he was weak, could only
manage to sit up in bed. The SO told my investigator that the security
assessment, which has to be carried out on every prisoner taken out of prison,
meant that the man was required to be handcuffed to an officer.
58. When they were ready to leave Wansbeck Hospital, the SO removed the
handcuffs to allow nursing staff to place the man on a trolley. The SO said the
man had to be assisted onto the trolley as he was unable to move unaided.
Once he was on the trolley, the Ward Sister spoke to the SO and asked if the
handcuffs needed to be reapplied as the man was dying. However, due to the
security assessment, the SO had no option at that time but to reapply the
handcuffs whilst the man was being transferred to the hospital by ambulance.
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59. When they arrived at the hospital the SO telephoned the prison and spoke to
someone (whose name he could not remember in interview), about the use of
handcuffs. He said he told the person that nursing staff had told him that the
man was dying. The SO was told that a member of staff would visit the
hospital later that day to reassess the handcuff risk assessment.
60. Following concerns about the use of handcuffs, the Head of Security, spoke to
the then Deputy Governor. Sadly, this Deputy Governor has himself since
died and I am only able to give the head of security’s and the Senior Officer’s
account of events.
61. The Head of Security said he agreed with the Deputy Head to reassess the
situation and, as he was going to be travelling past the hospital later that day,
he decided to carry out the assessment himself. His said his intention was to
undertake a “dynamic risk assessment”, which he described as being an
assessment where he would give verbal feedback to the Deputy Head rather
than in writing.
62. When he arrived at the hospital, the head of security was met by the SO who
told him that the man’s family were upset at him being handcuffed. The Head
of Security told my investigator that the SO also told him that nursing staff had
briefed him to say that the man was dying.
63. The Head of Security told my investigator that the man’s room was on the third
floor of the hospital. He said there was one door into the room and that the
room had a window. He added that, although the window would open, there
was no risk of escape as there were no stairs outside the window, only a sheer
drop to the ground. The Head of Security said he went into the room where
the man was. He described the man as looking very ill and drowsy. The only
way he could communicate was by blinking his eyes or nodding his head.
64. After seeing the man, the Head of Security sat in on a handover meeting with a
ward sister and a nurse. Between them, the nursing staff confirmed that the
man was in the final stages of his life and that his death was expected
imminently. Having received the latest prognosis, and being told that the man
would not be required to leave the room, the Head of Security decided to
remove the handcuffs.
65. When he returned to the prison, the Head of Security went to speak to the
Deputy Head to tell him what he had done. However, he was not available
and so the Head of Security spoke to the Governor instead. The Governor told
the Head of Security that he did not have the authority to remove handcuffs
and the decision could only be taken by him or, in his absence, the Deputy
Governor.
66. The Governor spoke to the Deputy Governor about the situation and asked
him to go to the hospital to undertake a further risk assessment. In the
meantime, the Head of Security telephoned the SO to tell him that he had
made a mistake in authorising the removal of the handcuffs. The SO told my
investigator that the Head of Security asked if it would cause a problem if the
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handcuffs were reapplied. He replied that it would be distressing to the man’s
family.
67. Unfortunately, due to the Deputy Governor’s death, it is not certain what
happened next but we do know that he gave instructions for the handcuffs to
be re-applied. We also know from the SO’s interview with my investigator that
the Deputy Governor told the SO that he was reapplying the handcuffs
because of a recent escape from a hospital escort. It is not known what
escape the Deputy Governor had been referring to.
68. At some point, members of the man’s family returned to the room and the SO
explained to them why the handcuffs had been reapplied. He said a family
member then produced a camera and tried to photograph the man. The SO
told my investigator he did not know why the family member had attempted to
take a photograph. The SO told the person concerned that photographs could
not be taken and the camera was put away.
69. The following day (23 January 2008), another SO carried out a routine daily
security check at the hospital. When he went to the man’s room he was told
by the escorting staffs (who by now were sitting outside the room) that the man
was unable to move. The SO told my investigator he went into the room and
that the man looked weak and frail. He confirmed that the man was not
handcuffed, as the Governor had authorised their removal the day before.
After completing the security check, the SO fed the information back to the
Governor.
70. On 24 January, the prison parole clerk rang the Parole Board once again for
an update, and was told that it would be at least one week and possibly two
before a hearing would take place. The Parole Clerk told my investigator that
she explained the urgency of the case to the person at the Parole Board, but
said she was not given a review date and felt frustrated at the lack of
assistance from the Parole Board office. (The actions of the Parole Board and
its secretariat are outside my terms of reference. However, I will send a copy
of this report to the Board for its consideration.)
71. In the meantime, the man’s personal property had been gathered together for
his family. The SO took the property to the hospital and handed it over to
them. He said the family were upset at the treatment they had received from
the Prison Service, but appeared happy with how the escorting staff had
treated them and the man. The following day (25 January 2008), the man
died.
After the man’s death
72. The man’s family told my investigator and FLO that, on the night of the man’s
death, they received a telephone call from the prison at 11:30pm, and the
caller offered condolences. They felt it inappropriate to telephone at that time
of night and said they would have preferred it if the call could have been made
the following day.
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73. At the meeting with my staff, the man’s family said they wanted to pass on
their thanks to two members of staff for their support, although they were
unable to identify one of the people concerned. They mentioned that one
woman in particular was always helpful and would call them back whenever
they called to enquire how the man was. However, they compared this
member of staff’s actions to those of a healthcare nurse, who they said would
not tell them anything and asked them to write to the Governor. The other
person, whom they wished to recognise as being helpful, was an officer on
bedwatch duty. The man’s family described him as compassionate towards
them and the man, and believe it was an officer. They asked me to pass on
their thanks to the officer and the prison chaplains.
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ISSUES
Incentives and Earned Privileges Scheme
74. My investigator asked the Prison Service for an explanation why an appellant
could not be considered suitable for enhanced status. He was told that it
should not be the case that a prisoner is denied access to enhanced status
simply by being an appellant. However, because the Prison Service has to
assume that someone is correctly sentenced and therefore guilty, the
continued assertion of innocence (“denial”) can be seen as refusing to take
part in sentence planning.
75. In the man’s case I understand that he had been advised by his solicitor not to
take part in any offending behaviour courses as he was an appellant, and to do
so could jeopardise his appeal. Because the man would not take part in
addressing his offending behaviour, his decision effectively meant that he was
not complying with his sentence plan, which in turn meant he could not be
granted enhanced status.
76. The person advising my investigator added that in February 2008, the Prison
Service Interventions Group issued new guidance to prisons in relation to this
issue. The advice is that, “if a prisoner is denying their guilt and their case is
being dealt with by the Criminal Cases Review Commission and they have a
criminal appeal number then there may be a case for the prisoner to attain or
retain enhanced status until their case has been heard”. In the man’s case my
investigator could not find an appeal reference number and, as his application
was made before February, it would appear that his IEP review was correctly
assessed by the manager.
Parole Reports
77. The timescale for completing reports for submission to the Parole Board is two
months. It was seven months after the initial request for the information that
the home probation officer returned the documents to the parole clerk. I
understand the reason for the delay was due to the probation officer being re-
allocated. However, it is evident that the parole report was not tracked
correctly by the home probation area, as they failed to pick up on the delay
and deal with the application in a timely fashion. Whatever the reason, a delay
of five months for such an important document is unacceptable and for this
reason I make a recommendation to the Chief Officer for Durham Probation
Area.
The Chief Officer for Durham Probation Area should review procedures
to ensure that reports for the Parole Board are tracked correctly and
submitted within the appropriate timescales.
17
Use of Handcuffs and other security matters
78. The man’s family told my investigator and FLO that they were concerned that
he was handcuffed until late in his illness and that the officers were in prison
uniform. Additionally, they were unhappy that the officers would not leave
them alone with the man.
79. In relation to prison staff being in uniform, this is a mandatory instruction and
not something that I feel inclined to criticise. Additionally, due to the man’s
security category, prison staff were not authorised to leave him unattended at
any stage, although they were allowed to sit outside the room at the final
stages of his life.
80. The use of handcuffs, especially on a prisoner admitted into hospital, is a
sensitive and difficult matter often considered in my fatal incident reports. The
decision to use handcuffs in some cases is mandatory and cannot be
overruled, for example in the case of a high risk prisoner. However, in other
cases, the decision is devolved to the Governor or, in the Governor’s absence,
to the Deputy Governor.
81. In this case the decision to use handcuffs was devolved to the Governor and
he had to balance security against decency. I have said in many reports that
these decisions have become unduly risk averse, although I understand the
culture within which this has become the case. I am satisfied that once a new
risk assessment was carried out at the hospital, the Governor took the correct
and proper decision to remove the handcuffs. Strictly speaking, the Governor
was also entirely right to tell the Head of Security that he had no authority to
instruct the earlier removal of handcuffs. However, the consequence was a
macabre pantomime in which handcuffs were first removed, then re-applied,
then removed again from a man who was frail and clearly dying.
82. In a recent report, I have called upon the Prison Service to look again at its
guidance relating to the use of restraints on prisoner-patients. I therefore need
make no further recommendation here. However, I do have a lot of sympathy
with the family. The Governor will wish to consider if there are lessons to be
learned, especially regarding the timing of risk assessments of those like the
man who are in the terminal stages of disease and who are unable to move
freely.
83. The clinical reviewer asked a representative from Wansbeck Hospital and
Morpeth Cottage Hospital whether they had any concerns about the man’s
privacy and decency. He was told that hospital and staff believe the man was
treated with all due privacy and decency. His report says that both hospitals
felt unable to comment on the use of handcuffs.
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Clinical Review
Referral to Royal Victoria Infirmary (RVI) Dermatology Department
84. The North of Tyne Primary Care Trust Doctor says in his review that there was
reasonable evidence in the medical records and from interviews with
healthcare staff that, after the man was seen on 1 August 2006, an urgent
referral was completed by the prison GP. However, there is no record of this
being received at the RVI. He adds that there is no formal system for logging
and following up urgent referrals and that, on the balance of probability, the
referral was not sent by the prison. He believes this to be an important finding,
as the delay “may have had an adverse effect on the outcome for the man”.
My investigator fed the finding back to the Governor as an urgent issue and
was told that it would be dealt with immediately.
Healthcare disclaimer
85. There is evidence in the medical records that on three occasions the man
cancelled his medical appointments at the RVI. His family wondered if he was
given sufficient notice about the appointments to allow him to re-schedule his
legal visits, and my investigator has asked about this on their behalf. The
family added that a senior manager at the prison told them it was common
practice for the prison to book hospital appointments in the knowledge that a
prisoner had other appointments booked, and the prisoner would then sign a
disclaimer.
86. My investigator has examined this issue and was told that the reason for the
man, or any other prisoner, not knowing an outpatient appointment date and
time is because of the security risk that could be posed if they did. It would be
all too easy for a determined prisoner to make an escape attempt if they knew
the full escort details. The rule is applied across the board and not on an
individual basis.
87. The Primary Care Trust Doctor has concluded that the main point to consider
is whether a prisoner should be asked to sign a healthcare disclaimer only
after receiving counselling from an appropriate member of healthcare staff.
From his own investigations he found that, on occasions when healthcare staff
are not in the prison, prison officers deal with disclaimers. He suggests that,
wherever possible, healthcare staff should speak to the prisoner about the
likely effects or outcomes if the appointment is cancelled. My investigator fed
the finding back to the Governor and he agreed to deal with it.
88. The Primary Care Trust Doctor adds that, although the man missed three
appointments, over the period of his illness he was taken on many occasions
to hospital for reviews, operations and tests. For the majority of time, the
system worked well. The Primary Care Trust Doctor commends healthcare
and prison staff for their efforts to ensure the efficiency of the system.
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Return to prison
89. Following the meeting between the man’s family and my investigator and FLO,
the investigator asked the Primary Care Trust Doctor if he could identify any
occasion when the man had been returned to prison from hospital because the
escorting officers’ shifts ended before the appointment time. The Doctor says
in his clinical review that there was no record in the prison medical files that
this ever happened. Additionally, The Primary Care Trust Doctor says he
asked the Medical Director for RVI, if there was any record in hospital files of
this happening. The medical director for RVI wrote to the Primary Care Trust
Doctor that, “there is nothing within the records at the hospital to indicate that
this occurred”. On the evidence of the Primary Care Trust Doctor and Doctor
of Medical Director For RVI, I am satisfied that there is nothing to support the
suggestion that prison officers returned to the prison before the man had been
seen.
Dignity
90. The man’s family also raised concern at him being handcuffed to a female
prison officer when in hospital in October 2007. The Primary Care Trust
Doctor asked the medical director for RVI if there was anything in the man’s
medical record to suggest medical staff were concerned about this. The
Doctor for RVI confirmed there was not.
91. I appreciate that it is normal practice for the Prison Service to allow female
prison officers to be handcuffed to male prisoners, and understand that female
officers do not accompany male prisoners to the toilet. However, I have some
sympathy with the family’s view that the man may have felt uncomfortable in
asking to use the toilet when a female was present in the room. Whilst I make
no formal recommendation, the Governors may wish to give this matter further
consideration.
Fitness to return to work
92. In his clinical review, the Primary Care Trust Doctor notes that it was the man
who asked the doctor during his 20 November appointment whether he could
return to his work as a cleaner. The doctor whom the man saw agreed to his
request, and said he thought it would help improve the movement in his
shoulder.
93. The Primary Care Trust Doctor discussed the issue with prison healthcare
managers. He was told, “… this should be seen in context and is not
equivalent to being advised fit to work outside of prison. In prison, fit to work is
a privilege which allows the prisoners to get out of the cell and socialise with
other inmates and even during illness this is usually preferred by most
prisoners. There would not have been an expectation that the man would
perform duties he was not fit to undertake.”
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Late stage illness
94. In relation to the family’s question about the man’s failing health in prison, the
Primary Care Trust acknowledges in his review that in January 2008 the man’s
appearance was deteriorating, which must have been difficult for the family.
However, he is satisfied that the man’s health needs were being addressed
appropriately. He is satisfied that the clinical assessment was appropriate and
does not believe that the medical advice given would have been any different
for anyone else.
95. Primary Care Trust Doctor adds that there is evidence to show that on 11 and
16 January 2008, the man declined some of the recommendations from
healthcare which would have moderated some of the difficulties he was facing.
Nursing staff to whom the Primary Care Trust Doctor spoke said that the man
was able to express his own needs and they felt it appropriate to respect his
wishes.
96. The Doctor says it appears that prisoners at Acklington have good access to
medical assessment without undue delay. He adds that prisoners, where
appropriate, are seen quickly and on the same day. He commends the prison
healthcare department for providing timely and appropriately sensitive support
to the man during the late stage of his illness.
21
CONCLUSION
97. It is clear that the man himself cancelled a number of appointments and, since
he was fully aware of his diagnosis, it may be presumed he was aware of the
consequences of his decision. However, the clinical review confirms that he
attended the vast majority of appointments and was treated appropriately.
98. I have been concerned to learn that the first urgent appointment was not dealt
with within correct timescales, despite the doctor’s instructions for an
appointment to be made. It would appear from the clinical review that the
prison did not deal with the referral correctly. My investigator raised the issue
as an urgent finding with the Governor, and was given an assurance that he
would deal with the matter immediately to prevent further failure.
99. Although I do not know if the man would have been granted release on
licence, I am not satisfied at the way the home probation service dealt with his
application. The late response by the Durham Probation Area meant that his
application was not seen or assessed at the earliest opportunity. This is
manifestly not acceptable. However, I would like to acknowledge the efforts
made by the prison’s parole clerk and invite the Governor to share my
comments with her.
100. I have been pleased to learn from my investigator that the Governor has dealt
positively with all of the feedback given to him during the investigation process
and made changes as necessary. This means that, with the exception of one
recommendation for the Probation Area, I have no further formal
recommendations to make. However, the Governor will wish to consider my
comments on the risk assessment process governing the use of restraints on
prisoner-patients, and the particular consequences this had for the man and
his family. I also draw the attention of the NOMS Safer Custody and Offender
Policy Group to my comments in paragraphs 82-83.
22
RECOMMENDATIONS
1. The Chief Officer for Durham Probation Area should review procedures to
ensure that reports for the Parole Board are tracked correctly and submitted
within the appropriate timescales.
The Chief Officer for Durham Probation Area has not commented on the
report and recommendation.
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