Individual at Wandsworth

A Report by the
Prisons and
Probation
Ombudsman
Nigel Newcomen CBE
Investigation into the death of a man in April 2010,
at a local hospital, while in the custody of
HMP Wandsworth
Our Vision
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a model to others, that makes a significant contribution
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2
This is the report of an investigation into the circumstances of the death of
a man at a local Hospital on 26 April 2010, while in the custody of HMP Wandsworth. .
The man had been diagnosed with a chronic heart and chest condition for which he was
treated in prison and in the community prior to his recall to prison in October 2009. His
condition deteriorated during early 2010 and a terminal prognosis was made.
I would like to offer my sincere condolences to the family of the man and to the staff and
prisoners at Wandsworth who were involved in his care and affected by his death.
My colleague conducted the investigation on my behalf. A review of the man’s medical
care was undertaken by a doctor on behalf of Wandsworth Primary Care Teaching
Trust. I am grateful to the clinical reviewer for his contribution.
I would also like to thank the Governor of Wandsworth and his staff for their
cooperation. I would also like to express my appreciation and thanks to the prisoners
and staff on the Onslow Unit who provided valuable information for the investigator.
My investigation has found that, overall, the man was well cared for at Wandsworth. I
make three recommendations. They relate to the need to ensure that terminally ill
prisoners are referred to palliative care services and that restraints are removed from
terminally ill prisoners in hospital who are immobile and have a short life expectancy. A
debrief for staff was not held after he died. My recommendations aside, I judge that the
care the man received while at Wandsworth was appropriate, timely and equitable to
that which he would have received in the community.
This version of my report, published on my website, has been amended to remove the
names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman July 2011
3
CONTENTS
Summary 4
The investigation process 6
HMP Wandsworth 9
Key events 11
Issues 19
Conclusion 21
Recommendations 22
4
SUMMARY
The man who died was imprisoned in August 2005 and released on licence in August
2006. He was recalled to prison following a breach of his licence conditions in October
2009. He died from right sided heart failure due to lung disease (core pulmonale).
While in the community, the man’s doctor referred him to hospital as an emergency
because he complained of shortness of breath and chest pain. The hospital discharged
him on 10 February with a diagnosis of infective chronic obstructive pulmonary disease
(COPD1) with future treatment planned for his heart condition. His condition was
managed on the Onslow Unit with oxygen in his cell, support from the disability orderly
and regular visits from healthcare. (A disability orderly is a trusted prisoner who is
responsible for assisting disabled prisoners with everyday tasks such as cleaning cells
and collecting meals for them.)
In late October, the man was recalled to prison. He was taken to HMP Wormwood
Scrubs where, following an initial routine reception healthscreen, he was immediately
admitted to the healthcare inpatient unit for observation because of his poor mobility
and breathing problems.
Medical and healthcare staff contacted the man’s doctor and the hospital for further
information on his medical history. In the meantime, he remained on the healthcare
unit, took his medicine and was discharged to a residential wing on 6 November 2009.
He transferred to Wandsworth on 19 November 2009.
In January 2010, the man was sent to hospital as an emergency because he
complained of shortness of breath and chest pain. The hospital discharged him on in
10 February with a diagnosis of infective chronic obstructive pulmonary disease (COPD)
and arranged future treatment for his heart condition. His condition was again managed
on the Onslow Unit with oxygen in his cell, support from the disability orderly and
regular visits from healthcare staff.
The heart procedure was carried out in early April, but other serious conditions were
identified with a plan for him to attend a follow-up clinic in 12 weeks. The hospital
discharge letter dated 9 April suggested that he would benefit from the help of the
palliative care team in the management of end stage COPD.
The man was sent back to hospital on 16 April with breathing difficulties and discharged
back to the prison on 24 April. Nursing staff were called to the wing on 26 April because
he was again experiencing severe difficulty breathing. He was sent to the local hospital
as an emergency. Hospital staff advised the prison to contact the man’s next of kin who
arrived at around 1.00pm. Sadly, despite the efforts of staff, he died later that day.
1 Chronic obstructive pulmonary disease is lung disease such as emphysema
5
The clinical reviewer has judged that the man suffered from chronic lung disease for
which he received appropriate treatment. The prison managed his condition and
hospital referrals were made when necessary. The clinical reviewer makes one
recommendation regarding the lack of a timely referral by the prison to the palliative
care team which I endorse. I make two further recommendations. The first relates to
removing restraints from prisoners in hospital who are immobile, have a terminal
condition and a short life expectancy. The second relates to the need for a hot debrief
at the first opportunity after an emergency. There is no evidence that a hot debrief was
held for staff to raise any concerns with senior managers or to ask for support from the
prison care team.
6
INVESTIGATION PROCESS
1. The man who is the subject of this report died on 26 April 2010 at 4.05pm. This
office was notified of his death on the same day at 4.50pm. Terms of reference
and notices were issued to staff and prisoners at Wandsworth telling them that
an investigation would be taking place, and inviting those with relevant
information to contact the investigator. The investigator requested copies of his
core record, clinical record, and other records relevant to his time in custody and
his death. Two prisoners wrote to my investigator.
2. The investigator also contacted HM Coroner to inform him of the nature and
scope of my investigation and to request a copy of the post mortem report. The
Coroner’s Officer told my investigator that the man died of:
1a Core pulmonale2
3. My investigator visited Wandsworth on 25 May and 16 September. She spoke
with liaison staff and the family liaison officer, the Reverend. She also spoke with
prisoners and staff on the Onslow Unit who knew the deceased.
4. A clinical review of his medical care was commissioned from Wandsworth
Primary Care Teaching Trust and undertaken by a doctor from the local
community. The doctor focussed on the clinical care the man received at
Wandsworth.
5. One of my family liaison officers spoke with the man’s daughter. She explained
the purpose of my investigation and provided his family with an opportunity to ask
any questions about the care he received in prison. The man’s daughter said
that she felt her father had been well cared for at Wandsworth. He appeared to
receive appropriate and timely healthcare and was taken to attend hospital
appointments, as required, without hesitation. His daughter spoke regularly with
her father who was always very positive about the treatment he received and told
her he was being well looked after. She felt her father had adapted well to prison
and enjoyed a good rapport with prisoners and officers alike. The man’s
daughter also spoke very positively about the support she received following her
father's death, particularly from the prison chaplain.
6. The man’s daughter said that her only concern was that her father remained
restrained, while in outside hospital, until shortly before his death and she
questioned why this was. Although she understood the need for security she felt,
given her father's age and deteriorating health, that it was unnecessary and
inappropriate. She said this had caused her family significant distress. I hope
that my investigation addresses her concerns.
2 Core pulmonale is right sided heart failure due to lung disease.
7
7. The man’s daughter received a copy of my draft report as part of the consultation
process. In her response, she said the most significant concern for her and her
family remained the prolonged and unnecessary use of restraints prior to her
father’s death. She agreed with the recommendation about this and hopes this
will lead to improved practice in this area for the benefit of other prisoners.
8
HMP WANDSWORTH
8. HMP Wandsworth is a category B3 male prison located close to a residential area
of London. It houses remand, recalled and sentenced prisoners and has a high
percentage of foreign national prisoners. It is the largest prison in the United
Kingdom and has the capacity for 1665 men.
9. HM Inspectorate of Prisons most recent inspection was in June 2009. The
resulting report was critical of a number of aspects of Wandsworth’s functions.
At the time of the inspection, the prison had 217 prisoners over the age of 50 and
20 over 70 years. The prison worked with the Age Concern charity to develop
services for an older population.
10. The Independent Monitoring Board for England and Wales (IMB)4 Annual Report
for the period June 2009 to May 2010 raises a variety of concerns. They include
staff shortages and difficult relationships between staff and prisoners leading to
an increase in incidents. There were improvements in the overall running of the
Onslow Unit, but a lack of staff and an increase in older and disabled prisoners
on the unit was an issue.
11. The man who is the subject of this report was accommodated on the Onslow
Unit, a 360 place unit for vulnerable prisoners5. Older prisoners on the unit are
placed on the second floor of the wing as this is nearer to the staff. There are
two healthcare emergency equipment bags held in the prison and one of these is
on the Onslow Unit. The other is on the A wing Heathfield Unit. There are two
disability orderlies who are prisoners who help less able prisoners by cleaning
their cells and collecting their meals.
12. In July 2007, Wandsworth Teaching PCT commissioned a private company,
Secure Healthcare, to provide healthcare services at Wandsworth and employ
the medical staff. However, the company went into liquidation in September
2009. The healthcare team is currently employed by the part of NHS
Wandsworth which provides services, rather than commissions them.
13. My investigator spoke with Head of Healthcare. He said that inpatient mental
health services were provided by South West London, and St George’s NHS
Trust but there was no provision for inpatient care for prisoners such as the man
3 Prisoners are categorised. On arrival into prison, prisoners are risk assessed and given a category based
on their offence and the risk that they pose to the public should they escape. Category B prisoners are
those for whom the highest security conditions are not necessary but for whom escape must be made
very difficult.)
4 The Independent Monitoring Board comprises volunteers from the community. They monitor daily life in prison to
ensure that decency is maintained, deal with prisoners’ complaints and submit an annual report to the Secretary of
State for Justice.
5 Vulnerable prisoners are those who ask to be segregated for their own protection, for example, if they fear
for their safety because they have committed an offence of which other prisoners might disapprove or
have accumulated debts.
9
with physical illness. In addition to nursing staff, there is one full-time prison
doctor. General practitioner (GP) sessions are run regularly on each wing, with
an out of hours service by the local community service provider.
14. The Inspectorate found that a number of vacancies had led to the overuse of
agency and bank staff with a number of outside hospital appointments being
cancelled. The Head of Healthcare said that the prison was actively recruiting
medical staff but there were difficulties in recruiting and retaining staff. This had
led to the high dependency on agency staff. Regular clinics such as dentistry,
podiatry and an optician were also held. He also said that the prison had not
addressed the issue of caring for elderly prisoners, however they were currently
developing an end of life policy with the local hospital and a monthly liaison
meeting was already in place.
15. The Prisons and Probation Ombudsman was tasked with investigating deaths in
prison custody in 2004. Since then, there have been ten deaths, prior to the
man’s, attributed to natural causes at Wandsworth. In some of the investigations
that followed these deaths, recommendations about healthcare provision were
made.
10
KEY EVENTS
16. The man was sentenced in August 2005. He received a two year prison
sentence, plus a two year extended licence6 on release. He was released from
HMP Littlehey on licence in August 2006.
17. In October 2009, while living in the community, he was referred to a hospital in
his local area by his general practitioner.. At the hospital appointment, he told a
consultant at the General Medicine and Care of the Elderly Unit, that he had
experienced shortness of breath for the past two years and could only walk 20
yards without stopping. He had been in hospital for about six weeks in 2008 and
given inhalers on the assumption that he was asthmatic. The consultant
concluded that the man’s breathlessness was related to atrial fibrillation7,
possible heart failure and high blood pressure. He felt that an electrocardiogram8
(ECG) should be carried out and that he would benefit from oxygen therapy. He
was given a follow-up appointment for two to three weeks later.
18. Later in October the registrar to the consultant, referred the man to a doctor. .
She asked the doctor to see the deceased urgently because of his longstanding
breathing problems and possible heart condition. She also asked for guidance
as to further investigations, managing his condition and his suitability for home
oxygen.
19. On 29 October, the man breached the terms of his licence. He was immediately
recalled to prison and taken to HMP Wormwood Scrubs. This meant he was
unable to attend his doctor or go to hospital appointments in the community.
HMP Wormwood Scrubs
20. When he arrived at Wormwood Scrubs, he was seen by healthcare staff in the
early evening on 29 October as part of the reception process. The investigator
noted good quality completion of the First Reception Healthcare Screen with a
clear care plan.
21. As part of the reception process, a Cell Sharing Risk Assessment form (CSRA)
was completed the same evening. (This assesses a prisoner’s suitability and
potential risk of harm to another prisoner when sharing a cell.) The man was
assessed as a medium risk of harm to others. However, the situation would be
regularly reviewed. He was assessed as suitable to share a cell as long as he
was on the ground floor of a wing (because of difficulty with the stairs) and not
6 An extended licence is given to those who are considered to pose a higher risk than most offenders and need a
lengthier period of supervision by Probation Trusts to complete work with Offender Managers to reduce risk of harm
to others and of re-offending. This is particularly important if offenders do not undertake offending behaviour courses
in prison for whatever reason.
7 Atrial fibrillation is a particular type of very fast heartbeat.
8 An electrocardiogram is a test that measures the electrical activity of the heart.
11
sleeping on the top bunk bed. However, the man identified a prisoner who he
was happy to share with and in those circumstances he accepted the top bunk.
22. The First Reception Healthscreen document evidences that the man told the
healthcare worker that he had seen a doctor a month earlier because of a
breathing problem. He had also undergone an ECG at the hospital he
previously attended in his local area because of heart problems the day before
his recall to prison and was awaiting a further appointment. His medication at
that time included bendroflumethiazide9, warfarin (to prevent blood clots) and
digoxin (to treat heart conditions). He did not have any physical injuries,
however, he was concerned about his health as he was breathless and blue
(cyanosed). The healthworker observed that generally that he was unfit, with
poor mobility and laboured breathing. He was referred to the doctor.
23. Staff assessed the man as requiring admission to the inpatient healthcare unit
from reception. This was for a medical assessment because of his history of
chronic obstructive pulmonary disease (COPD) and the medication he was
taking. An Inpatient Admission Sheet to the prison healthcare unit was
completed. The man’s clinical observations at the time included pulse, blood
pressure, height and weight and respiration. His mood was described as
“depressed”. He was able to care for himself and walked with the aid of a stick.
24. Handwritten notes in the clinical record confirm that he went to the inpatient
centre directly from reception. An entry dated 30 October (the following day),
said that the man told staff that he and his doctor had discussed having oxygen
supplied to him at home because of his breathing problems. He had smoked
around 60 cigarettes a day in the past but had given up smoking.
25. A care plan showed that his breathing was to be monitored. Nursing action
would be to establish a good patient/nurse relationship with a review on 6
November. The man would be encouraged to sit or lie down to allow him to
breathe properly and tight clothing was not encouraged. He was to be monitored
daily until he was judged to be stable in respect of his medication and heart
problem.
26. On 30 October, a prison doctor assessed the man. The doctor noted that he was
cyanosed, there was “clubbing”10 and his face was grey. The doctor rang his
community doctor for further information about whether he had been hypoxic11 in
the past. The doctor confirmed this. The doctor rang the hospital previously
attended in his local community the same day for further information. He spoke
with a member of the medical staff who had agreed to respond to him within the
hour once he had read the clinical notes. However, the hospital did not call back.
9 Bendroflumethiazide is used to treat high blood pressure.
10 Clubbing is a condition in which the ends of toes and fingers become wide and thick; a symptom of heart or lung
disease.
11
Hypoxic means inadequate oxygen reaching the body's tissues.
12
The prison doctor spoke with the man who told him that his condition had not
deteriorated in the last few months.
27. Throughout his stay in the healthcare centre, the man was considered by staff to
be pleasant, he ate well and took his medication. His international normalised
ratio12 (INR) was checked on 2 November. Staff continued to monitor him
throughout his stay.
28. On 6 November, the man’s condition was assessed as stable and he was fit to
be discharged to the wing. A Cell Sharing Risk Review was carried out the same
day by a wing officer. He was assessed as a medium risk of harm to a cellmate.
He told staff that he felt vulnerable due to his offence but was willing to share
with trusted prisoners. Although he had a single cell while in healthcare, this
could be reviewed after he had settled on to the wing. He transferred from the
healthcare centre to the First Night Centre on 8 November when his bed was
needed for another prisoner who had to be placed on overnight observation.
29. A week later, on 13 November, the man made an application to be segregated
from other prisoners because of the nature of his offences. He asked to be
located in a vulnerable prisoner unit as he feared for his safety if placed in a cell
on a normal wing. Documentation authorising that he could be held in the
segregation unit was completed and showed that he was held there pending a
space in the healthcare centre. He was to remain in the segregation unit until 16
November when a review would be held to decide whether segregation would
continue. Records show that he transferred to HMP Wandsworth on 19
November.
30. The computerised clinical record held at Wandsworth shows that the man was
assessed as suitable for sharing a cell. No immediate medical action was
necessary but he was referred to another prison doctor.
31. On 25 November, the Parole Board reviewed his case and were unable to
recommend release. The National Offender Management Service (NOMS)
emailed the prison and the London Probation Trust asking for information to help
the Recall Team in the Public Protection Casework Section consider whether his
risk of harm and of re-offending had reduced sufficiently to allow release again
into the community. This information was needed by 11 June 2010 which was
when he was next due to be reviewed.
32. The man’s personal officer made an entry on his wing history sheet on 11
December confirming that he was sharing a cell with another prisoner. The
officer said there were no problems and that he had settled in well to the wing
routine.
12 International normalised ratio is used to assess the clotting ability of blood. This is particularly relevant in the case
of those patients who are taking Warfarin, a drug to thin the blood.
13
33. In speaking with the investigator, the man’s personal officer recalled that he
generally stayed in his cell or sat outside it in the corridor so that he could
socialise with others. She remarked that he had obvious breathing difficulties but
she never heard him complain and, in her opinion, he was resigned to his illness.
34. On 20 January, the man was awaiting an urgent appointment for the chest clinic
at the hospital. He had asked for oxygen and healthcare staff told him that he
would need an assessment at the chest clinic to determine whether he met the
criteria for having oxygen in his cell. The healthcare worker said that he would
pursue the urgent appointment with the healthcare administration staff. The man
went to the local hospital for an appointment on 26 January.
35. He was admitted as an inpatient and a nurse spoke with the hospital who said
they would telephone back to confirm the diagnosis. The investigator spoke with
the nurse who said that the man’s condition had raised some concerns at the
hospital and so doctors decided to admit him. He returned to the prison later that
day but without a discharge letter. A doctor typed in the clinical record that he
would telephone the hospital the following day because he had been treated in
the resuscitation unit.
36. The man was admitted to the local hospital, two days later on 28 January
suffering from shortness of breath and chest pain on exertion. He was
diagnosed with infective COPD. He would need a left heart catheterisation in the
future and a Professor‘s team would perform a right heart catheterisation. The
man was to attend the Professor‘s clinic in 4 weeks. His daily medication
comprised:
• warfarin
• digoxin13
• paracetamol
• omeprazole14
• irbesartan15
• diltiazem16
• Gaviscon
• tiotropium inhaler17;
• simvastatin
• aspirin; prednisolone18
• co-amoxiclav19
• amoxicillin
13 Digoxin is for heart failure.
14 Omeprazole is for excess stomach acid.
15 Irbesartan is for the treatment of hypertension.
16 Ditiazem is for hypertension, angina or heart failure.
17 Tiotropium is for COPD
18 Prednisolone is for allergies.
19 Co-amoxiclav is an antibiotic.
14
He was discharged from hospital on 10 February and returned to the Onslow Unit.
37. On 19 February, a list of medical recommendations included a bed board and an
extra pillow to help with the man’s breathing. An entry in the wing history sheet
by his personal officer showed that he was allocated in a single cell because he
had an oxygen machine and it was in constant use. Wing staff also recorded that
he was polite and spent his time in the day room.
38. Cell sharing risk assessment (CSRA) reviews were carried out on 26 February
and 16 March in order to assess whether he posed a risk of harm to his cellmate
while using oxygen, as he was now sharing a cell. A note was made on the
CSRA review on 16 March that healthcare staff should update the assessment.
39. The wing observation book showed that the man’s cell door should remain
unlocked between 8.00am and 8.00pm to allow the disability orderly access to
the man and because of healthcare concerns. On 2 April, the nurse checked on
the man and found his condition “stable”. She advised him to press his cell bell
immediately if he felt unwell.
40. The man went to court on 15 March for a hearing regarding a Sexual Offences
Prevention Order. The Application for Production of Prisoner form completed by
the prison on 5 February highlights that wheelchair access was needed and this
had been arranged with the court manager by the prison. (This was sensitive to
the man’s needs and good practice.)
41. A prisoner friend of the man, recollected that he went blue when he went out to
court. In an earlier letter to the investigator, the prisoner friend said he believed
that Wandsworth did all it could for the man and he appreciated their help.
42. The prisoner friend was allocated in the cell next door to the man’s and would
speak to him for about half an hour a day. He said that he felt a certain amount
of respect for him as he had been in the armed forces. He described the man as
“in a state” and said that he “went blue” on two occasions and the prisoner friend
went for help. He said he helped the man where he could. He praised the
nursing staff and confirmed that he never complained.
43. On 2 April, a healthcare worker went to the man’s cell to help him with his
personal care. He did not want help to wash and dress but needed someone to
help him to remove and then replace the oxygen after he had washed himself.
He was embarrassed at having help with his personal care from female staff.
While encouraging him to keep his independence, the healthcare worker made it
clear that help was available if he needed it.
44. The investigator spoke to a prisoner and the wing disability orderly. The prisoner
and wing disability orderly said there were two orderlies available on the Onslow
15
Unit. They had completed an approved cleaning course and help with cell
cleaning. Prisoners such as the man who need help, complete a self-referral
form. the prisoner and wing disability orderly said that, while encouraging
prisoners to do as much as they can, the orderlies help with tasks such as
collecting meals and cleaning cells. They do not collect medication and are not
allowed to help with personal care.
45. An entry in the clinical record on 8 April showed that the man had returned from
hospital and mentioned the contents of the discharge summary. However, there
is no record to show when he had been taken to hospital. The following day, the
oxygen concentrator arrived and after initial problems using it, the man did not
appear to have contact with healthcare until 16 April when he was sent to
hospital again with breathing difficulties. The nurse spoke with a nurse on
Amyand Ward the same day. The nurse said that the man was very unwell and
had been diagnosed with end stage COPD. The hospital had referred him to the
palliative care service.
46. A cardiothoracic operation note also dated 8 April, explained that he had
undergone cardiac catheterisation. There would be a follow up clinic with the
Professor in chest clinic in 12 weeks. Other serious conditions identified were a
previous stroke (paralysis affecting one side of the body) and COPD.
47. The discharge summary letter dated 9 April from Registrar in Respiratory
Medicine confirmed that the man had undergone a catheterisation procedure to
the right side of his heart. The Registrar in Respiratory Medicine observed that it
seemed he did not have the same levels of oxygen available to him in prison as
he did in hospital and this should be corrected. They said that the palliative care
team could help manage the end stage COPD. There is no evidence that a
referral was made to the palliative care team.
48. On 8 April, a respiratory nurse at the prison wrote to the hospital formally asking
for an increase in the oxygen to five litres, with a plan to increase this to six litres
when the hospital could arrange for the oxygen company to deliver another
container.
49. The man was discharged back to the prison on 24 April, and a humidifier20 was in
place in his cell. The hospital said they would contact the prison with a discharge
plan once the medical team had been consulted. The doctor on duty saw the
man at the prison on the same day. He noted that he was to attend a chest clinic
at the hospital in four weeks.
50. On 26 April, at around 7.00am, the nurse received an emergency call from the
prison control room to go to the Onslow Unit. The nurse told the investigator that
she had met the man on two or three occasions previously and knew that he was
physically frail with chest problems. She arrived at his cell to find that he was
20 A humidifier is a device for increasing humidity in a room.
16
very blue. He had oxygen in place but was having extreme difficulty breathing.
She carried out clinical observations and he responded to her at times but she
was unable to take his blood pressure. She said that it was obvious by looking at
him that he needed to go to hospital for intensive treatment. She asked the
officers to call for an ambulance. The telephone log shows that control room
staff called an ambulance at 7.20am. They gave an update to the ambulance
crew at 7.27am on the man’s breathing, heart rate and colour. The ambulance
crew arrived and administered Atrovent21 and a salbutamol nebuliser.
51. The nurse told the paramedics that the man had experienced a bout of diarrhoea.
Nursing staff at the hospital telephoned the prison and asked how long he had
been suffering from this because he had told them he had had it for a while. She
explained that he had only been back in the prison for the past 48 hours and
nothing relating to that had been observed.
52. Prisoners are normally searched before they leave the prison to go to hospital.
However, the Person Escort Record (PER) shows that the man was not
searched before he went into the ambulance at 7.50am because he was very ill
and unable to respond. However, he was placed in a single cuff restraint and
accompanied by two prison officers. The ambulance left the prison at 7.59am
arriving at the local hospital at 8.06am.
53. The PER shows that at 8.25am, nursing staff suggested that the prison contact
the man’s family to tell them that he was poorly. However, by 11.30am, he was
responding to treatment. The man was wearing restraints at the hospital which
were removed for treatment at the request of the hospital staff. They were
reapplied following treatment and he was moved to Amyand ward.
54. An operational manager gave permission for the man’s daughter to visit him in
hospital. The Reverend was appointed as family liaison officer and she
contacted his daughter to tell her that he had been re-admitted to the local
hospital, and medical staff had asked her to contact his next of kin. The
Reverend gave her the hospital telephone number so that she could contact
them directly.
55. The PER shows that the family visited at 1.00pm. Escort staff contacted the
prison and asked for permission for the restraints to be removed at 3.40pm
because his condition had deteriorated and the doctors needed to attempt
resuscitation. Despite their efforts to resuscitate him, he was pronounced dead
at 4.03pm that day. His family were with him at this time.
56. The Reverend met the man’s daughter at the hospital at 4.55pm. She offered
support and help to answer any questions the family had about what would
happen next. The man’s daughter spoke very positively about the support she
received following her father's death, particularly from the Reverend.
21 Atrovert is used with an inhaler.
17
57. Prisoners told the investigator that they had felt supported by staff. There is no
evidence of a hot debrief. This would have given those involved in the
emergency and the escort officers the opportunity to raise any concerns about
the man’s death and seek support from the prison care team if they needed it.
18
ISSUES
Clinical care
58. The clinical review was undertaken for Wandsworth Teaching Primary Care
Trust. This would review the clinical management of the man’s chronic lung
condition and has judged that, overall, his condition was managed
appropriately and he received the correct medication.
Referral to the palliative care services
59. The Clinical Reviewer makes one recommendation. This refers to the
prison’s apparent failure to refer the man to a palliative care team when he
was released from hospital on 8 April 2010. The discharge letter from the
hospital dated 9 April said that he would benefit from the support of the team.
However, no referral was made and the man did not receive their help and
advice.
60. An entry in the clinical record dated 16 April, some eight days later, suggests
that he was re-admitted to hospital and a telephone conversation took place
between a member of the healthcare staff and the hospital. The hospital had
diagnosed the man with end stage COPD and they referred him to the
palliative care service as there were no plans for him to be discharged back to
the prison at that stage.
The Head of Healthcare should ensure that healthcare staff take responsibility
for referring prisoners diagnosed with end stage illness to palliative care
services in an appropriate and timely manner.
Use of restraints
61. The use of restraints is a judgement made by the prison based upon a risk
assessment. However, in the man’s case, the decision appears to me to have
been risk averse. He had severe mobility problems and was extremely limited in
his ability to care for himself. I question whether he was physically capable of
escaping and consequently whether the use of restraints at the hospital was
appropriate. I am pleased to note that escort officers initiated the process for the
removal of restraints on two occasions on the day he was admitted to hospital
and subsequently died. However, I am disappointed that they were reapplied
and were still in place when his family arrived. They were only removed later that
afternoon for medical treatment.
62. The hospital discharge letter of 9 April and an entry in the clinical record on 16
April shows that his condition was terminal and that he was dying. I am
conscious that protection of the public is paramount, nevertheless, I judge that on
16 April, when his prognosis was certain, restraints should not have been used.
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The Governor should ensure that restraints are removed at the earliest
opportunity, particularly following a diagnosis of terminal illness when the
prisoner is immobile and has a very short life expectancy.
Hot debrief
63. There is no evidence that a hot debrief for staff was held after the man died.
Prison Service Order (PSO) 2710 paragraph 5.3 instructs that there must always
be a hot debrief immediately after this type of incident and provision should be
made in local contingency plans. This is not optional. A senior member of staff
must act as debriefer and a duty care team member must also attend.
The Governor should ensure that a hot debrief is held in accordance with PSO
2710, at the first opportunity after a death in custody.
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CONCLUSION
64. When the man was recalled to prison in October 2009, he was in poor health with
a chronic lung condition and heart problems. He died six months later and his
death, although sudden, was not unexpected.
65. The clinical reviewer has judged that, overall, the care he received was
appropriate. However, we have made a recommendation about palliative care.
Further recommendations relate to the absence of a hot debrief to support staff
and to see if lessons could be learned from the management of the emergency
which preceded his departure to hospital and eventual death and the use of
restraints in hospital.
66. My recommendations aside, I judge that the care the man received was
comparable to that which he would have received in the community.
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RECOMMENDATIONS
1. The Head of Healthcare should ensure that healthcare staff take responsibility for
referring prisoners diagnosed with end stage illness to palliative care services in
an appropriate and timely manner.
“Partially accepted. The service is normally provided by main stream NHS
facilities when a patient is identified in the outside hospital setting as requiring
palliative care.
Healthcare in the prison will however, if required, make a direct referral to this
service. Robust links have been made with prison healthcare and both the
palliative care teams to ensure appropriate and seamless service delivery. It is
unclear why the consultant did not refer the man to a palliative care service
directly in this instance; patients who are referred to this service do occasionally
return to the prison environment. In the past, the palliative care team have
contacted the prison directly to maintain contact.”
2. The Governor should ensure that restraints are removed at the earliest
opportunity, particularly following a diagnosis of terminal illness when the
prisoner is immobile and has a very short life expectancy.
“Partially accepted. I accept in principle with this recommendation. Each case is
individually assessed accordingly but in this specific instance a risk assessment
was conducted and initial application of restraints was based on a number of
factors, not least of these was that the man was charged with a serious sexual
offence against a minor. Our duty to protect the public (and especially children) in
a public ward of a busy hospital has primacy over other considerations. The
subsequent removal of the restraints was reflective of the consideration given to
his final hours of life.”
3. The Governor should ensure that a hot debrief is held in accordance with PSO
2710, at the first opportunity after a death in custody.
“Partially accepted. A hot debrief was held with a duty manager however, there
was no attendance from PICT (due to it being late in the evening when staff
returned and them wanting to go home). The officers were informed who to
contact/ speak to if they needed any further support. In future we would ensure
that in the situation where it is not feasible for PICT to attend, that this should be
chased up via the PICT team the following day.”
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