Individual at Holme House

Investigation into the death of a man
whilst in the custody
of HMP & YOI Holme House in June 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
This is the investigation into the circumstances surrounding the death of the man,
who did not respond when staff entered his cell. He was terminally ill, and died
shortly afterwards in the company of prison staff. He was 55 years old. I offer my
sincere sympathy and condolences to his family and friends for their loss.
The investigation was carried out by my investigator. A clinical review of the man’s
healthcare was undertaken by a clinical reviewer on behalf of the local PCT. I am
grateful for his review. I would also like to thank the Governor of Holme House and
his staff for their co-operation and assistance. Particular thanks go to the liaison
officer for his help throughout the investigation.
In 2006, the man was sentenced to an indeterminate sentence for public protection.
He was adamant that he had been unfairly convicted and was bitter about his
detention. He served almost two years in prison before he was diagnosed with
cancer.
The man was keen to be able to die at home with his family and, in the first half of
2009, made several requests for compassionate release. All of which were refused.
However, he was transferred to HMP Holme House on 24 June in order to be closer
to his family.
After only five days at Holme House, the man died. His sister was in the prison on
the morning of his death but unfortunately did not manage to see him before he died.
When my investigator met with her she raised several concerns about the way she
and her brother were treated by Holme House. I hope that this report answers her
questions.
The man had suffered from a terminal illness for a long time. Although he was not
released, he was moved to a prison closer to his family. Although I raise several
concerns regarding his care, I believe it was largely satisfactory. However, I was
disappointed to hear of the way the news of his death was broken to his sister.
The version of my report, published on my website, has been amended to remove
the names of the woman/man who died and those of staff and prisoners involved in
my investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman
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CONTENTS
Summary
The Investigation Process
HMP & YOI Holme House
Key Findings
Issues
Recommendations
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SUMMARY
The man was sentenced to an indeterminate sentence for public protection in August
2006. He began his sentence at HMP Leeds, where he occupied a single cell as he
was registered disabled.
The first two years of his time at Leeds, were largely uneventful. He was briefly in
trouble for verbally abusing nurses regarding his medication and complained of
being bullied. However, this allegation was not investigated fully as he would not say
who was responsible.
In June 2008 he exhibited certain symptoms of illness including jaundice and dark
coloured urine. The prison doctor was concerned and referred him to a specialist. In
September he was told that he was suffering from a form of pancreatic cancer. He
underwent chemotherapy in October and November, but it was later confirmed that
the cancer was untreatable.
He returned to hospital in March 2009 in order to relieve his jaundice but he
continued to physically decline. He applied for compassionate release three times
between April and June but it was rejected each time. His risk of re-offending was
still considered to be too high to warrant his release.
Staff at Leeds contacted HMP Holme House, which was nearer to his family home,
to see if they would consider accepting him. This was agreed, and he transferred on
24 June 2009. He was housed in the healthcare centre due to his medical condition.
He did not respond to staff when they entered his cell and died shortly afterwards.
This report looks closely at certain aspects of his care, and four recommendations
are made with regard to record keeping, medication, visits and family liaison.
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THE INVESTIGATION PROCESS
1. The investigation was carried out by my investigator. He contacted HMP
Holme House and requested the paperwork concerning the man. This
included documents from his time at HMP Leeds. Notices of the investigation
were sent to Holme House. No-one came forward in response to the notices.
2. My investigator asked the local PCT to undertake a review into the clinical
care received by the man at Leeds and Holme House. A clinical reviewer was
commissioned to undertake this review.
3. My investigator and one of my family liaison officers visited the man’s sister
on 15 September to discuss the investigation. The man’s sister raised the
following issues:
• Was his medication given to him at Holme House?
• Why was he brought to the visits section, instead of allowing visits in the
healthcare centre?
• Were his offences noted on his door?
• Was his bed too uncomfortable to sleep?
• Who was with him when he died?
• Had he died earlier than the prison claimed?
4. I sincerely hope that this report answers the questions of the man’s family.
5. My investigator travelled to Holme House on 6 October to interview prison and
healthcare staff. The clinical reviewer was provided with the transcripts of the
interviews.
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HMP LEEDS
6. Leeds was built in 1847 and expanded in 1994 and 2002. It is a category B
local prison accepting prisoners from West Yorkshire. It has an operational
capacity of 1,004. Prisoners live in six residential wings, a segregation unit
and in-patients healthcare unit.
Independent Monitoring Board
7. Each prison has an Independent Monitoring Board (IMB) made up of
members of 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. The most recent report from the
Leeds IMB is that of 2009. The report noted the improved healthcare that
prisoners received, but claimed that the personal officer scheme was not
working well. (This scheme gives each prisoner a specific officer that they can
approach and talk to should they wish to.)
HM Chief Inspector of Prisons
8. HM Chief Inspector of Prisons conducted an unannounced inspection of
Leeds from 5 to 14 December 2007. The report commented on how the
prison’s senior management were strenuously attempting to improve a prison
that was still falling short of standards. Many prisoners still felt unsafe. Anti-
bullying, self-harm and suicide prevention procedures were still poorly
implemented on the wings. The report noted that staff shortages affected
healthcare provision, and record-keeping was sometimes inadequate.
Previous deaths at Leeds
9. Leeds experienced two deaths from natural causes in 2007, three in 2008 and
two in 2009.
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HMP & YOI HOLME HOUSE
10. Holme House is purpose built category B prison, which opened in May 1992.
Its population is primarily drawn from Tees Valley, South West Durham, East
Durham and North Yorkshire. It has an operational capacity of 994. The
healthcare department has room for 28 prisoners.
Independent Monitoring Board
11. There was no report available from the Holme House IMB for the last three
years.
HM Chief Inspector of Prisons
12. HM Chief Inspector of Prisons conducted an unannounced short follow-up
inspection of Holme House from 16 to 18 March 2009. It was described as a
reasonably safe prison that had made progress in all areas since the last
inspection. The report included the following description of the healthcare
services provided at Holme House:
“Healthcare services needed further development, but there were plans
to improve governance, pharmacy and dentistry.”
Incentives and earned privileges scheme (IEP)
13. The IEP system is a means of monitoring prisoners’ behaviour and rewarding
good behaviour and punishing poor behaviour. Prison Service PSO 4000
describes it as follows:
“The IEP scheme complements the discipline system by rewarding
good behaviour. In addition to any local aims, it is intended to
encourage prisoners and YOs [young offenders] to behave responsibly,
to participate in constructive activity, and to progress through the
system. This will foster a more disciplined and controlled, and
therefore safer environment for prisoners and staff. It should also
contribute to the reduction of re-offending by encouraging prisoners to
lead law-abiding, productive and healthy lives.”
14. Within the local system prisoners are able to move up a level (basic, standard
or enhanced) and earn various privileges. Poor behaviour can result in
moving down a level or losing privileges. Privileges include association time
and extra visits.
Previous deaths at Holme House
15. Holme House experienced one death from natural causes in 2007, and two in
2008. Although, in the first case, the prisoner also died shortly after arriving at
Holme House there are no direct similarities between the deaths at Holme
House since 2007.
7
KEY FINDINGS
16. The man was convicted of sexual offences against a child. He was sentenced
to an indeterminate sentence for public protection with a minimum of 239 days
on 7 August 2006. He began his sentence in HMP Leeds. The cell sharing
risk assessment contained a reference to the man as being at low risk of
attacking a cellmate. The nurse who filled out section three of the form noted
that the man required a cell on the second landing (ground floor) due to being
registered disabled. Having a cell on the second landing prevented the man
from having to climb stairs to reach the facilities on the wing.
17. In August and September, the man complained of being threatened by other
prisoners. Although officers investigated the claim, they were unable to
determine whether he was being threatened as he did not provide staff with
the names of the alleged perpetrators.
18. He was prescribed medication to treat arthritic pain, excess stomach acid and
migraines. He was abusive to the nurse dispensing his medication on three
occasions in November as she was only able to give him enough medication
for one day, rather than two days. The nurse placed him on report, and
issued a “strike” for abusive behaviour. (This was a warning under the
Incentives and Earned Privileges scheme.) Having pleaded not guilty at the
adjudication board, the man later apologised for his behaviour.
19. The man declined to participate in a parole interview in April 2007 as he
complained that it was merely “a paper exercise”. When the parole report
was discussed with him, he became angry and complained about what he felt
to be his wrongful conviction.
20. In early June 2008, he complained of a pain in his back. He saw the prison
doctor at the end of July as he was jaundiced and was passing dark urine.
The doctor recorded that he had lost a stone in weight in the last month. The
doctor wrote in his medical notes that the man might have cancer of the
pancreas. He referred him for tests at the hospital under the two week
referral system (where the patient is seen by a specialist within two weeks).
Blood was also taken to be tested. The doctor recorded on 1 August that the
blood tests revealed some malignancy, and the man was told that he had
been referred to hospital.
21. The man went to hospital on 12 August and remained there as an in-patient
until 3 September. He was referred to a specialist in gastrointestinal cancer
medicine, for consideration of palliative chemotherapy. He was told in
September that he was suffering from cholangiocarcinoma (a form of biliary
tract cancer) and was offered palliative chemotherapy. The prison doctor
noted that the man appeared to have lost more weight and remained
jaundiced.
22. The chemotherapy took place throughout October and November. They
occurred every Friday for three weeks followed by a week’s respite. He was
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described in his medical notes as gradually physically deteriorating during this
time.
23. The man did not receive his medication over the weekend of 18 and 19
October due to a failure to reorder his prescription. A second nurse wrote that
the man was unhappy about this as he did not have access to Dihydrocodeine
(a pain-relief medication). He was given his pain relief after returning from a
hospital visit on 21 October, and the prison doctor saw him the following day
to confirm his prescription.
24. The man applied for enhanced status on the Incentives and Enhanced
Privilege system on 6 November 2008. Although wing staff considered him
unsuitable for enhanced status, it was granted in early December as a result
of his medical prognosis. He was refused compassionate release by the
Secretary of State on 5 December. He was deemed to be insufficiently
incapacitated as he was still able to walk unaided for a short distance. His
risk to others was also deemed to be still too high for him to be released.
25. On 30 December, the man legally changed his name and made a will.
26. He told staff on 20 February 2009 that his urine had changed colour to a vivid
yellow/brown. His medical record included reference to his poor prognosis
and a third nurse suggested that plans should be started for his palliative
care. However, the man was adamant that it was his family that should
provide this care.
27. On 6 March, the man underwent surgery to relieve his bile duct. He stayed in
hospital until 20 March, and was very jaundiced. The specialist at the hospital
thought that further chemotherapy was not warranted, and that palliative
symptomatic care should begin. The man was reviewed by the prison doctor
on 17 April who was struck by his weight loss and reduced mobility. His
morphine pain relief was increased as he was suffering from further
abdominal pain. The prison doctor wrote in his medical record that the man
was content with his treatment and had declined referral to Macmillan care
(Macmillan Cancer Support provides practical and medical support to those
affected by cancer.)
28. The prison doctor increased the strength of the man’s morphine medication
on 8 May and noted that he still refused to see the Macmillan nurses. The
doctor wrote that the man was increasingly unsteady on his feet on 29 May
and was declining solid food, so Ensure was prescribed. (Ensure is a liquid
food supplement.) The doctor sent a memorandum to the prison’s lifer
manager, regarding the application for the man’s compassionate release.
The doctor concluded that the man had advancing terminal cancer.
29. On 1 June, healthcare staff received an enquiry from a member of staff in the
Ministry of Justice (MOJ) regarding visiting arrangements for the man should
he be placed in the healthcare unit. The MOJ staff member was told that
visiting arrangements could be facilitated if a palliative care plan was in place.
(Palliative care is the emotional, spiritual and nursing care for terminally ill
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patients.) It was noted in the man prison file that three applications for a
compassionate release were rejected from April to June.
30. The man told a fourth nurse that he was ready to move to the healthcare unit
on 11 June and this was arranged later that day. The following day, the
prison doctor saw him and wrote that, following a discussion, he told the
doctor he did not wish to be resuscitated if he suffered heart failure. A full
nursing care plan was started in line with the Gold Standards Framework and
Oramorph (a morphine-based pain relief medication) was prescribed. (The
Gold Standards Framework is a system used to optimise the care for people
nearing the end of life.) The doctor also referred him to a consultant in
palliative care at Wheatfield’s Hospice, who agreed to visit him and make an
assessment.
31. A fifth nurse wrote that the man was able to attend to his personal hygiene,
although he found it difficult to move. The nurse contacted the prison’s
disability officer for advice and ensured that the man was made comfortable.
The nurse advised him speak to staff if he had any problems or concerns.
32. On 15 June, the prison doctor noted that the man’s pain was seemingly under
control. Two days later, a MacMillan nurse saw the man in the healthcare
unit. The prison doctor noted that he would write to the lifer manager about
the possibility of the man being transferred to HMP Holme House, so that he
could be nearer to his family.
33. A second doctor examined the man on 20 June and noted that his blood
pressure had dropped to a reading of 111/73 (a normal blood pressure
reading is 130/80). The doctor asked healthcare staff for his blood pressure
reading to be repeated and 30 minutes later it was recorded as being within
normal range. The doctor wrote that staff should check on the man’s well-
being every four hours and, if his blood pressure fell, then a transfer to
hospital must be arranged. The doctor further wrote that the man was going
to be transferred the following week.
34. Two days later, an out-patient appointment was cancelled, as the man was
not well enough to attend. Later, the fifth nurse wrote that the man was going
to be transferred to Holme House in two days time. The nurse spoke to the
palliative care services to tell them of the man’s transfer so that information
could be passed on by their teams.
35. The man was transferred to Holme House on 24 June. I understand he was
accompanied on the journey by a nurse. Leeds had contacted the Head of
Offender Health at Holme House and asked if they would accept the man so
he could be closer to his family. The Head of Offender Health at Holme
House agreed to receive the man, having discussed it with the Head of
Residence. The cell sharing risk assessment undertaken upon his reception
at Holme House recorded that the man was at low risk of attacking a cellmate,
but required a single cell due to his medical condition. The first nurse at
Holme House who undertook the initial healthscreen with the man
immediately upon his arrival due to his health conditions. The first nurse who
10
saw the man at Holme House told the Ombudsman’s investigator that she
wanted to complete the process quickly to minimise the time he spent in
reception because of his poor health. She recorded his terminal illness and
the treatments related to it in the healthscreen document. The nurse said that
the man told her that he assumed that he would live for at least another
month. He was accommodated in a cell in the healthcare centre.
36. A professor from the Butterwick Hospice visited the man in the afternoon and
recommended that the prescribed medication should continue as required. At
Holme House, the man was prescribed medication for many reasons including
pain relief, nausea, inflammatory conditions, constipation and stomach acid.
The professor from the Butterwick Hospice left contact details for himself and
for the Macmillan nurses who were willing to come and visit the man.
37. There was initially some confusion at Holme House due the man’s prisoner
number being different to the number on his medication. A second nurse
from Holme House called the Head of Offender Health who clarified that the
man should be given his medication. The numbers were different due to a
new prison computer system at Leeds which gave the man a number that was
not in use at Holme House. The Head of Offender Health asked for the
medication to be returned to the pharmacy to be re-numbered to prevent any
further confusion.
38. The man told staff that he slept in a chair on the first night as he found the bed
uncomfortable. The Head of Offender Health asked if he would prefer to
move into the crisis suite which contained two hospital beds. (A crisis suite
can be used for prisoners requiring emotional support. The second bed
allows the presence of a prison listener, for example.) The man declined,
saying that he had just tidied and organised his room and did not want to
move again. She said that she would look into whether a hospital bed could
be moved into his current cell, but he in the event chose to move to the crisis
suite on 26 June. (Following the publication of the draft report, the
investigator was informed that the bed the man used in the crisis suite had
previously been purchased for another terminally ill prisoner in order to
provide him with more comfort.)
39. The man’s sister had spoken to staff after her brother’s arrival at Holme
House. She was told that she could book a visit to see him, and arranged one
for 25 June. When the family arrived at Holme House, one of the man’s
sisters was refused access to the prison as the ID she had was not deemed
appropriate by the prison. The man’s family said that she had used the same
ID when visiting the man at Leeds. The man’s other sister was under the
impression that the visit would happen in the healthcare centre. However,
upon arrival at the prison, she was told that the visit would occur in the usual
visits area. The man’s family were kept waiting for a little while before he was
wheeled over to see them. The man’s sister told the investigator that she was
shocked by how ill he seemed, and by the bruises on his legs that she thought
had been caused by the wheelchair. He also mentioned that his pin number
for the telephone was incompatible with the Holme House phone system.
11
40. A note was made in the medical record that the man did not receive his
morphine medication until 11.00pm on 27 June. (It was usually administered
in the late afternoon.) There was no explanation in the medical notes why this
medication was given to him later than usual.
41. Early on 28 June, a note was made in his record explaining that the man did
not like the taste of Oramorph (an opiate pain-killer) and so would refuse it
until the pain became unbearable. He had taken a dose during the preceding
night and had another one at 5.30am that morning. The first doctor who saw
him that afternoon and agreed to increase MXL (morphine capsules) to four
doses of 120mg daily to see if that would reduce his need for Oramorph.
(However, he was still able to have the Oramorph when he needed it.)
42. A third nurse made a note in his medical file at 8.42am the following morning.
She wrote that the man did not feel well, and had refused breakfast and his
medication. He looked very frail and weak. The nurse noted that she left a
message on a Macmillan nurse’s answer machine asking her to call her back.
However, the first nurse to see the man at Holme House told the investigator
that the man had not actually refused his medication that morning. She had
gone up to his cell at approximately 7.50am and asked him if he would like to
come down to take his medication. The man replied by asking if he could
come down later. The first nurse told him this would be fine, and she and the
healthcare assistant had turned the man onto his side. The nurse recalled
that the man had not spoken of any pain, and had not given her any cause for
concern. She explained that although the man was ill he was still able to walk
to collect his medication:
“Up till that point the man was coming down twice a day, however
many times. He was fully mobile coming down to the treatment room
to get his medication.”
43. At approximately 10.00am the third nurse asked a fourth nurse to review the
man as he looked unwell. The fourth nurse agreed that he appeared to have
declined, and asked a doctor to assess him.
44. The fourth nurse said he was lying in his bed and did not respond to them.
The doctor wrote in the medical file that the man was unconscious and did not
respond to verbal stimuli. The Macmillan nurses arrived at 10.25am and went
to the man’s bedside. The man’s sister was also informed of the deterioration
in his health and invited to come to the prison to be with him.
45. The fourth nurse again went to ask the doctor to assess the man as he had
declined further. When she reached the cell the Macmillan nurse was at the
man’s bedside holding his hand. A specialist palliative care nurse and the
fourth nurse were also in the room. The man was observed to stop breathing
at 10.37am. The doctor examined him and established that there was no
pulse, no respiration and his pupils did not respond to light. The staff agreed
not to resuscitate the man because of the terminal nature of his illness, and
the doctor pronounced his death at 10.45am.
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46. The man’s sister had arrived at the prison at approximately 10.40am and was
taken over to the healthcare unit. She was taken to a small waiting room
where she sat at first with the third nurse and then with the fourth nurse. After
a few minutes the Governor entered the room. He was under the impression
that the man’s sister was aware that her brother had died. When he realised
this was not the case, he broke the news to her. The man’s sister was
understandably upset and wished to go and see her brother. She asked if he
had died alone, but was reassured that staff were present with him when he
died.
47. The investigator was told by the prison that the man’s sister and the Governor
went to the man’s cell. His sister told my investigator that the room felt
‘staged’ and her brother felt cold to the touch. She said that this prompted her
to suggest that her brother had actually died significantly earlier than the
prison said. She told the investigator that when she put this to the fourth
nurse who responded with words to the effect of ‘this is how I found him’. This
troubled her as she said that she had previously believed that her brother had
not died alone. (The fourth nurse told the investigator that he did not recall
this conversation, and the Governor stated that it did not happen in the room
where the man died.)
48. The man’s sister wished to leave the prison after seeing her brother, and the
Governor accompanied her towards the gate. On the way, they were stopped
by the family liaison officer. The man’s sister did not wish to speak to him
then but agreed to accept a call from the family liaison officer the following
day. In the event, the man’s sister spoke to the family liaison officer that
same afternoon. The family liaison officer noted her concerns which related
to her brother’s medication, and who was with him when he died.
49. The family liaison officer and a PO visited the man’s sister on 1 July 2009 to
hand over his property and cash. The Governor contributed to the cost of the
funeral.
13
ISSUES
Clinical care
50. The clinical reviewer, commented on the care provided by both Leeds and
Holme House:
“The man’s condition was promptly detected and well managed by
HMP Leeds. His transfer to HMP Holme House appears to have been
appropriately arranged and he was assessed that same day by a
consultant in palliative care who did not make any changes in his
treatment ... His care on the morning of his death seems appropriate
although the way the death was communicated to his sister was poor.”
51. The clinical reviewer commented that the man was not seen by a doctor until
28 June in Holme House, which meant that it was not clear who had overall
responsibility for his care. Despite this, the clinical reviewer writes later in his
report that this did not lead to any problems in his care.
52. The clinical reviewer concluded in his review that:
“His transfer to HMP Holme House and subsequent medical care was
comparable to that he would have received in the community.”
Medication
53. The man’s sister was very concerned that her brother did not receive his
medication properly while at Holme House. This investigation has found that
there was some initial delay regarding his medication due to the prison
number used. I am satisfied that this was resolved quickly when the Head of
Offender Health authorised the dispensing of the medication to the man. The
administration of medication to prisoners must be monitored closely due to the
numerous risks of prisoners receiving the wrong medication. As the man’s
prison number did not match the number on the medication it was important
for staff to clarify the situation. I believe that the Head of Offender Health,
once she was sure that it was the correct medication, acted quickly to ensure
that any delay was minimised. Any delay is regrettable when a prisoner is as
ill as the man, but I do not think that this delay was unreasonable given the
circumstances.
54. However, there was a delay administering of the man’s morphine medication
on 27 June. The clinical reviewer was unable to offer a reason for this delay.
When prisoners are suffering from painful conditions it is important that their
pain relief medication is not delayed unreasonably.
The Head of Offender Health should ensure that medication is provided
at the appropriate times as far as this is operationally possible.
14
55. The man did not have his medication on the morning of his death. Although it
was recorded that he refused his medication, the first nurse to see the man at
Holme House explained that he had actually asked if he could collect it later.
It appears that his rapid decline in health prevented him doing so. Following
the publication of the draft report, the man’s family told the investigator that
they did not accept this account. They said that they believed him to be too
unwell to get about without a wheelchair. As noted in the ‘Key Events’ section
of this report, the nurse explained that, the man walked to collect his
medication. The investigator also spoke to the Head of Offender Health who
said:
“He was, in inverted commas, “fit, mobile”, we know he was terminal
but he wasn’t bed-bound, he wasn’t unconscious.”
Record keeping
56. The record keeping at Holme House with regard to the man was
disappointing. It was brief and, in places, inaccurate. The clinical reviewer
wrote in his review:
“The standard of clinical record keeping at HMP Holme House is poor
compared to that of HMP Leeds and should prompt a review. For a
patient with a terminal illness I would expect regular clinical observation
both by nursing and medical staff of his overall condition and symptom
control and clear entries made in the medical record.”
57. The clinical reviewer explained that, between the man’s admission to Holme
House and his death, there was a lack of clinical observations. He also
pointed out there was a entry in the ‘care plan’ section of the medical record
dated 25 June containing information that does not appear to relate to the
man, but to another prisoner entirely. This raises the concern that the
information may not have been written in the correct prisoner’s records.
58. A further issue with regard to record keeping was the ‘care plan’ section of the
man’s medical record. It is dated 28 June (meaning that it was not completed
for four days after his admission) but also contains information about his
death which did not happen. Although this is worrying, I do not consider it to
reveal anything other than poor administration. Recommendations of this
type have been made many times in the Ombudsman’s reports (including
those regarding deaths at Holme House), and it is disappointing to have to do
so again:
The Head of Offender Health should undertake a review regarding
record keeping, and ensure that the record keeping is consistent with
the Nursing and Midwifery Council guidelines.
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The man’s family visit to Holme House
59. One of the man’s sisters was refused access to the prison on account of her
ID not being accepted. Hi family said that she had used the same ID without
any problems when visiting him at Leeds. The investigator spoke to Holme
House staff who said that his sister had tried to use a bus pass as ID which
was not acceptable at Holme House.
60. The visit that the man’s family arranged took place in the usual visits section,
rather than in the healthcare unit which his sister had anticipated. This seems
to have placed an unnecessary physical effort on him as it would have been
more comfortable for him had the visit taken place in the healthcare centre.
As his sister pointed out, the wheelchair used to bring him to the visits area
may have added to his discomfort. I am surprised that the visit did not take
place in the healthcare centre, affording him more dignity and comfort. The
prison’s Head of Offender Health was also surprised that he had been taken
over to the visits area. She told the investigator:
“I personally [would] of have expected a visit to have taken place in
healthcare had the patient been unwell and wasn’t able to go to
Visits … “
61. The clinical reviewer shared this concern and wrote in his report:
“It was totally inappropriate for the man to be taken by wheelchair to
the normal prison visits area.”
62. The clinical reviewer made a recommendation with regard to this issue which I
endorse:
The Head of Offender Health and Governor should consider facilitating
visits in alternative locations when significantly ill patients are involved.
Access to the telephone
63. When the man’s family visited him on 25 June, he told them that he did not
have access to a telephone because his pin number was incompatible with
the Holme House telephone system. His sister raised this issue with the
investigator following the death of the man.
64. The family liaison officer said in his interview with the investigator that,
because of the nature of the man’s offences, all telephone numbers on his
PIN account had to be verified and checked. The investigator asked Holme
House to provide further information on this issue. The investigator was told
that, due to the nature of the man’s offences, a particular process is carried
out with regard to access to the telephone. Since no public protection file
came to Holme House with the man, it was necessary for the prison to follow
the usual child safeguarding procedures. These procedures involve the
16
numbers being checked by the security department and then, if necessary,
being passed to the public protection unit (PPU). The PPU would then
contact the numbers to seek approval for contact before they are put on the
PIN system. The investigator was told that this process can take from a few
days to a few weeks depending on the prisoner.
65. I understand that the man’s PIN account was identified for screening by the
PPU on 26 June and his PIN phone request was sent to the man to nominate
his numbers but he died before it could be returned to him. The investigator
was told that the man was able to make telephone calls on an office
telephone while the PIN system was being set up.
The alleged publication of the man’s offences
66. The man’s sister told the investigator that her brother said that staff had put
details of his offences on a piece of paper and stuck it by his door. The
nature of the man’s offences meant that he was fearful of reprisals were they
to become widely known. Any such publication of a prisoner’s offence by staff
would be inappropriate.
67. The investigator asked the first nurse to see the man at Holme House whether
she was aware of such a situation occurring. Her response was:
“Absolutely a 100 per cent not. All the years I’ve worked in this prison
things like that it just wouldn’t happen … I couldn’t tell you what his
offences were; I’ve no idea at all. And we have people in healthcare
with some not so nice offences and there’s no difference in anything.
As nurses we’re not interested in their offences, we’re only interested in
looking after them.”
68. The investigator also spoke about this issue with the Head of Offender Health.
She was adamant that this did not occur.
Contact with the man’s next of kin
69. The man’s sister was very upset by the manner in which the prison broke the
news of her brother’s death. Once she arrived at the healthcare unit, she was
shown to a waiting room where she waited with the third nurse, and then the
fourth nurse. Neither told her that her brother had died. The Governor arrived
at the healthcare unit in his role as Duty Governor expecting the man’s sister
to have been told of the man’s death. When it became clear that she did not
know, the Governor broke the news to her.
70. It is unfortunate that no-one in the healthcare unit took responsibility for telling
the man’s sister that her brother had died. While I understand that staff were
concerned that they did not interfere with the prison’s contingency plans for a
death in custody and did not know who should perform such a role, any delay
risks looking like insensitivity or collusion. Although this was a relatively
uncommon situation, this is not the first time the Ombudsman has found that a
family has been in the prison when their relative has died. I would therefore
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suggest that the Governor and Head of Offender Health consider a protocol
for any similar occurrence.
The Governor and Head of Offender Health should consider developing
a protocol to manage the breaking of news of someone’s death when
the next of kin is already in the establishment.
71. The man’s sister also wished to know who was with her brother when he died.
The second doctor, the Macmillan Nurse, palliative care nurse and the fourth
nurse were all with the man when he died.
72. The man’s sister thought that he felt cold and was concerned that this
suggested that he had died significantly earlier than the prison claimed. I can
confirm that the man was seen to stop breathing at 10.37am and declared
dead at 10.45am. The investigator was told by the clinical reviewer that when
people decline and die over a few hours their body temperature can cool
down considerably so that at the point of death their body is already much
cooler than a healthy person. This may have been why he felt cold to the
man’s sister.
Good practice
73. I commend Leeds and Holme House for arranging the transfer of the man.
This allowed the man to spend his last days closer to his family, and should
be recognised as good practice.
CONCLUSION
74. The man was a very ill man for the last 18 months of his life. Despite this, he
was not released on compassionate grounds. This upset him and his family
as he wished to die in their company. However, he was transferred to a
prison closer to where they lived. Although I am satisfied that he was
generally well cared for, it is unfortunate that his medication and the visit of his
family presented problems. It is also regrettable that the news of his death
was broken in the manner it was to his sister.
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RECOMMENDATIONS
1. The Head of Offender Health should ensure that medication is provided at the
appropriate times as far as this is operationally possible.
The National Offender Management Service accepted this recommendation.
2. The Head of Offender Health should undertake a review regarding record
keeping, and ensure that the record keeping is consistent with the Nursing
and Midwifery Council guidelines.
The National Offender Management Service accepted this recommendation.
3. The Head of Offender Health should ensure that visits to significantly ill
patients take place in the Healthcare Unit.
The National Offender Management Service accepted this recommendation.
4. The Governor and Head of Offender Health should consider developing a
protocol to manage the breaking of news of someone’s death when the next
of kin is already in the establishment.
The National Offender Management Service accepted this recommendation.
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