Individual at Gartree

A Report by the
Prisons and
Probation
Ombudsman
Nigel Newcomen CBE
Investigation into the death of a man in June 2010, at
hospital, while in the custody of HMP Gartree
Our Vision
To be a leading, independent investigatory body,
a model to others, that makes a significant contribution
to safer, fairer custody and offender supervision.
2
This is the report of an investigation into the circumstances of the death of a man at
hospital in June 2010, while a prisoner at HMP Gartree. He was 56 years old and had
been diagnosed with diabetes, chronic liver disease and hepatitis after a long history of
severe alcohol abuse. His condition deteriorated during his sentence and his death was
expected. An inquest was held on 2 November 2010 and a verdict of death from natural
causes was recorded. I would like to offer my sincere condolences to his wife and
daughter and to the staff at Gartree who were involved in his care and were affected by
his death.
A colleague conducted the investigation on my behalf. A clinical reviewer undertook a
review of the man’s medical care, on behalf of the local Primary Care Trust. His
contribution to my investigation is invaluable and I am grateful for his report. I would
also like to thank the Governor of Gartree and his staff for their cooperation. I am
particularly grateful to the healthcare and discipline staff who spoke to the investigator
on her visit.
My investigation has highlighted excellent practice in respect of multi-agency working
between HMP Gartree, Morton Hall and the social services department of the local
authority. Visiting arrangements between the man, his wife and daughter were complex
not least because his wife was a serving prisoner and their young daughter was in
foster care.
The clinical reviewer has judged that the care given to the man was equal to and
possibly exceeded that which he would have expected in the community. He made no
recommendations as he could suggest nothing that would have improved the high
quality of care that the man received from healthcare staff at HMP Gartree.
Overall, I commend the prison and the healthcare department at Gartree for the care
and consideration given to the man and the efforts made on his behalf. I am particularly
impressed with the excellent standard of communication and cooperation between
Gartree and Morton Hall in ensuring that the man’s wife was granted release on
temporary licence quickly in order to visit him in prison and hospital. This is in keeping
with the highest standards of the National Offender Management Service.
I apologise for the delay in issuing this report, and any additional distress this may have
caused.
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.
Thea Walton
Acting Deputy Prisons and Probation Ombudsman July 2011
3
CONTENTS
Summary 5
The investigation process 6
HMP Gartree 7
Key events 8
Issues 12
Conclusion 19
4
SUMMARY
The man was convicted of conspiracy to murder on 19 July 2001, at Crown Court. He
had served lengthy prison sentences in the past and was sentenced to life
imprisonment for his part in this offence. He had a longstanding history of severe
alcohol misuse while living in the community and was found guilty of distilling illegal
alcohol in prison during his life sentence.
He had an extensive clinical history and was diagnosed with cirrhosis of the liver in
November 2004 and hepatitis C a month later. A move from the high security prison,
HMP Whitemoor, to a lower category prison was approved. However, this was difficult
to achieve as other prisons were reluctant to accept him because of the complexity of
his condition and his high medical needs. HMP Gartree eventually accepted him and
he transferred in August 2007.
Throughout his sentence and until his death, he went to hospital as an inpatient on
numerous occasions, with varying medical conditions linked with cirrhosis and hepatitis
C. His ailments included poor mobility, confusion, a decreased appetite, memory loss,
confusion and sickness, numerous urinary infections, abdominal pain, jaundice due to
the liver disease, gastritis, constipation and fluid in his stomach.
In February 2008, the man was diagnosed with insulin dependent diabetes and
healthcare staff appropriately referred him to specialist diabetic clinics for management
and monitoring. A consultant hepatologist at the hospital regularly reviewed his
cirrhosis and hepatitis C conditions. He was not an easy patient to nurse and frequently
failed to follow medical advice by refusing his food and medication and discharging
himself from hospital.
The head of security and the head of healthcare held a meeting in December 2009, to
discuss his release on compassionate grounds. They agreed that he was not eligible
because his life expectancy could not be estimated to within the advised three month
limit required. Despite this, the prison made two applications but both were refused as
the National Probation Service considered him to be high risk and accordingly, did not
support the application.
He married his partner while in prison. Family liaison and communication between HMP
Morton Hall, Gartree and the social services department of the local authority
throughout his illness was excellent and his wife and daughter regularly visited him.
Gartree liaised with Morton Hall so that his wife could be released on temporary licence
and his wife and daughter were with him when he died.
The clinical reviewer found nine areas of good practice and made no clinical
recommendations. I concur with his view that he was given a high standard of care at
Gartree and I am pleased to say that I found no failings in his management and
therefore make no recommendations. I commend the prison for the excellent clinical
care and family liaison arrangements he received.
5
THE INVESTIGATION PROCESS
1. The man died in June 2010 at hospital. My office was notified of his death the same
day. Terms of reference and notices were issued to staff and prisoners at Gartree
telling them that an investigation would be taking place, and inviting those who
wished to make themselves known to the investigator. No one came forward. The
investigator requested copies of his core, clinical and probation records as well as
other records relevant to his time in custody and his death.
2. My 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 the investigator that the man died of multiple organ failure and cirrhosis
of the liver. The inquest was held on 2 November 2011. A finding of death by
natural causes was recorded.
3. The investigator visited Gartree in June 2009. She met the Head of Residence, who
also acted as the prison’s liaison officer, the Head of the Offender Management Unit
and the Head of Healthcare, who knew the man well and had previously cared for
him during his imprisonment at HMP Whitemoor.
4. A review of the man’s clinical care was commissioned from the local Primary Care
Trust (PCT) and undertaken by a clinical reviewer. The clinical reviewer focussed
on the clinical care he received at Gartree.
5. My senior family liaison officer contacted the man’s wife as his next of kin, to advise
her about my investigation and give her the opportunity to raise any questions or
concerns to be considered as part of this. She did not raise any concerns and has
praised the prison for their care of her husband.
6
HMP GARTREE
6. HMP Gartree is the largest of three dedicated prisons for life sentenced prisoners in
England and Wales. The prison comprises six residential units holding around 689
adult males. Each prisoner is accommodated in a single cell.
7. Health services are provided by the local Primary Care Trust. Prison doctors are
contracted from a local practice and provide eight surgery sessions a week. There
is a registered nurse on duty in the prison at all times. The healthcare inpatient unit
was closed for extensive refurbishment during June 2010. This coincided with the
terminal stage of the man’s illness. However, nursing care was delivered through
wing-based nursing staff.
8. An inspection by HM Chief Inspector of Prisons in May 2010 found that Gartree had
progressed considerably since the previous inspection. The prison was judged to be
well ordered and calm, with healthcare provision described as “good and was
expected to improve further with the imminent opening of a new healthcare centre”.
The inspection found that the life sentenced population provided stability to the
prison, although there needed to be more work, educational or recreational activity
for prisoners.
9. The Independent Monitoring Board1 (IMB) Annual Report for 2008/2009 described
the prison as operating close to its operational capacity of 689 during the reporting
period. The IMB acknowledged that recruitment of nursing staff was difficult and
that the healthcare team were understaffed. However, despite this, healthcare was
described as “very able”.
10. The Prison and Probation Ombudsman was tasked with investigating deaths in
prison custody in 2004. Since then, there have been nine deaths prior to the man’s
attributed to natural causes at Gartree. In some of the investigations that followed
the deaths, recommendations about healthcare provision were made.
1
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.
7
KEY EVENTS
11. The man, together with his partner and co-defendant, was convicted of conspiracy to
murder on 19 July 2001, at Crown Court. A sentence of life imprisonment was
imposed on both. He had previous convictions for serious offences for which he had
served lengthy prison sentences. Following an appeal against his tariff (the
minimum amount of years a prisoner must serve before being considered for
parole), he was expected to serve a sentence of ten years and 55 days before he
could be considered eligible for release on parole licence.
12. Throughout his sentence he was assessed as a high risk prisoner, based on a
number of factors, including an escape from prison during a previous sentence in
1998 and a longstanding and severe problem with alcohol before his latest period in
custody. He was also found guilty and disciplined for distilling illegal alcohol in
prison. During his time at HMP Norwich in 2001, he failed a mandatory drug test
and remained on closed visits for three months.
13. The clinical record shows that he was a heavy smoker. Further significant medical
events are recorded from early February 2002, when he suffered from helicobacter
pylori2. In November 2004, he was diagnosed with cirrhosis of the liver followed by
hepatitis C in December of the same year. A year later, he suffered liver failure
followed by a left sided cerebral hemisphere cerebrovascular accident (a stroke) in
March 2006. An incident of self-harm is recorded on 1 January 2007 and a drug
overdose noted on 21 July 2007.
14. On 29 August 2001, a “Record of Contact with a Life Sentenced Prisoner” shows
that he was told he was due to be transferred to HMP Whitemoor prison. Although
he accepted the transfer, records show he was unhappy as his preference was a
transfer to HMP Wormwood Scrubs.
15. Throughout his sentence, he managed to maintain contact with his partner through
inter prison telephone calls while she was serving her sentence at HMP Bullwood
Hall. Their daughter was brought to the prison on family visit days so that he was
able to continue contact with her throughout his sentence. He married his partner in
Whitemoor on 22 November 2002, while they were both in custody.
16. He did not always comply with the prison regime to a satisfactory standard to qualify
for an enhanced level under the incentive and earned privileges scheme but
remained on standard level on occasion.3 He was subject to restricted visits and in
2 Helicobacter pylori is a bacterium that infects the mucus lining of the human stomach. Many peptic ulcers and some types of
gastritis are caused by this.
3 The Incentives and Earned Privileges scheme was introduced to encourage and reward good behaviour in prisons. Governors
have devolved responsibility to draw up their own schemes however the scheme must operate on at least three tiers: Basic,
Standard and Enhanced. Prisoners move between levels according to their behaviour and performance. The key earnable
privileges/incentives are: extra and improved visits, eligibility to earn higher rates of pay, access to in-cell television, opportunity to
wear own clothes, more private cash to spend and time out of cell for association. In addition to the key earnable privileges,
prisons may make other privileges and incentives available to suitable prisoners according to local circumstances.
8
February 2004, he lost his job as a trusted prisoner. As a result, family visits
facilitated by social services bringing his daughter to see him were stopped. He
failed a number of mandatory drugs tests, the results of which he disputed, claiming
that the medication he was taking (chlorphenamine4) affected his urine sample and
created a positive result. He went through the adjudication process and was found
guilty.
17. In January 2006, the man was re-categorised from a category A prisoner (the
highest level of risk in the prison estate) to a lower risk category B. This entitled him
to move to a prison outside the high security estate in order to progress in his
sentence. The transfer was delayed and his solicitors wrote to the Governor on 30
April, asking for the transfer to Gartree to take place as soon as possible. The
prison replied on 8 May, confirming that he had been granted a transfer out of high
security conditions, but prisons were reluctant to accept him because of his medical
condition. The prison admitted that the situation was “not ideal” and they were
making ongoing efforts to find a suitable prison place for him.
18. He transferred to Gartree in late August 2007. On 6 September, he became unwell
and a nurse manager examined him. She found him disorientated, unstable on his
feet, hot to the touch, and noted that he had not been eating or drinking very much.
She admitted him to healthcare for observation and to await the doctor the following
day.
19. Later the same day, she spoke to the doctor, who advised that the man should be
sent to hospital for further assessment. An ambulance was called because of his
poor mobility. He remained in hospital and returned to the prison on 11 September.
Healthcare staff did not know what tests or treatment he had been given because no
discharge information was provided by the hospital.
20. On 26 October, a practice manager made a note in the clinical record that he
resided in the healthcare centre because of population pressures in the prison and
for respite care with his chronic and long term health problems. His appetite
remained poor.
21. His assessment by healthcare staff on 6 September and the subsequent admissions
to the healthcare centre and hospital were the first of a large number of admissions
until his death in June 2010. During the remainder of 2007, he was admitted to
healthcare and hospital for treatment on a number of occasions. This was because
of memory loss, confusion and sickness, numerous urinary infections needing
intravenous antibiotic treatment, abdominal pain, jaundice due to chronic liver
disease, gastritis, constipation and fluid in his stomach. However, despite his
illnesses, there were also days when he told staff that he felt well.
22. He was admitted to hospital again in January 2008. A discharge letter from the
hospital said that although he had been relatively well since his last admission in
4 Chlorphenamine is an antihistamine medicine for allergies.
9
November 2007, he was complaining of feeling drowsy. A Consultant Hepatologist
diagnosed this as being in keeping with “some low grade encephalophy”5. He
described him as clearly having quite advanced liver disease, but felt unable to treat
his hepatitis C condition as this would counteract the treatment for the liver disease.
He considered the only option would be for a liver transplant.
23. On 2 February 2008, Nurse A became concerned about the man’s condition. He
was complaining of stomach pain, and an unusual frequency in passing urine. Staff
contacted the out of hours doctor service and he was taken to hospital. The clinical
record shows that he returned to the prison with a diagnosis of insulin dependent
diabetes. Plans were made for him to be referred to the optician to check for
diabetic eye disease. He was advised to change his diet and understood the need
for doing so.
24. It is evident from a clinical record entry for 6 February that he could manage to
monitor his insulin but needed supervision during the procedure. He had also been
told “in no uncertain terms” that he must heed dietary advice and not add sugar to
his food or eat sweets. He did not always listen to medical advice because he
considered that his diet was already restricted because of his liver problems.
25. Healthcare staff gave the prison kitchen dietary advice relating to his diabetic and
liver conditions. Staff in the kitchen were aware of his poor appetite and provided
suitable food to ensure that he was eating a diet appropriate to his medical
conditions, particularly his diabetes. However, despite effective collaboration
between the kitchen and healthcare, he did not always eat the food given to him
because he did not like it and chose poor alternatives. He was reminded that other
alternatives were available, including the facility to make his own food on the wing.
The kitchen manager visited him on 30 September in response to the difficulties. He
said he was unhappy with the food he was being served and until the matter was
resolved, he refused to take his medication.
26. A reminder to healthcare staff from the practice manager was placed in the
healthcare record in March, warning staff that protective clothing was necessary
when dealing with blood matters from the man. This was because he had hepatitis
C and also suffered from oesophageal (food pipe) bleeding because of his liver
condition.
27. Healthcare staff continued to monitor and treat his various chronic conditions and
adjust his insulin if he was unable to eat. In October, he admitted to Prison Doctor A
that he was being pressured by other prisoners to obtain medication on their behalf.
In January 2009, Prison Doctor B made an entry in the clinical record to advise that
there had been problems with the man’s insulin syringes being used by other
prisoners in healthcare and therefore it was necessary for him to change to using an
insulin pen instead. However, as his eyesight was poor, using the pen was not
advised and staff intended to seek advice from the specialist diabetic nurse.
5 Encephalopathy is brain malfunction due to liver disease.
10
28. In addition to frequent hospital admissions, he attended review appointments to
monitor his liver condition at hospital under the Consultant Hepatologist’s care. He
attended the joint hepatitis clinic at the same time.
29. In January, 2009, the man’s health deteriorated and he experienced ascites6,
confusion and loss of balance due to liver disease. There is evidence from the
clinical record that staff from HMP Morton Hall, where his wife was imprisoned,
called the healthcare centre to ask about his condition on her behalf. His wife
wanted to know whether she could visit him in hospital and healthcare staff said they
would contact Morton Hall with the information. A senior officer at Morton Hall would
ask permission of the head of security at Gartree for the wife to visit him in hospital if
he was admitted.
30. He was discharged from hospital on 17 February, with a letter saying that the excess
fluid in his stomach had been drained. In April, he was noted to have a pronounced
tremor to his mouth and right arm. However, he was able to manage day to day
living with the help of fellow prisoners. Care plans were in place and a review took
place on 11 April. The outcome was that he would have daily blood pressure and
weight checks. His blood glucose level was to be taken twice daily before meals or
as necessary. Any improvements or deterioration were to be recorded on the
healthcare computer system (SystmOne). He continued to complain of sickness
and stomach pain.
31. His sickness meant that he was unable to absorb his medication. Therefore it was
agreed that he would take his anti-sickness tablet first, followed by the rest of
medication. This appeared to be an effective method of dealing with the problem.
32. A note in the clinical record made on 28 April, by a prison mental health nurse, said
that the man was finding everyday activities increasingly difficult. He was unable to
drink because of the uncontrollable tremors in his arms and hands and became
concerned when he was unable to shave. Staff found solutions such as providing a
feeding cup with a spout and an electric razor for his use, with the promise of
assistance from staff if he needed it. He was noted to be exhausted from lack of
sleep because the tremors were constant. His health continued to decline and staff
and prisoners helped with everyday tasks.
33. A report from the Consultant Hepatologist dated 12 May, said that the man’s tremors
were not attributable to Parkinson’s Disease, although the symptoms were similar.
He therefore did not respond to medication for that disease. His medication was
adjusted accordingly and Neomycin (an antibiotic) was prescribed, although he was
told that this was not to be taken long term as it caused hearing problems.
34. On 3 June, Nurse Manager B, spoke with the man about his general condition.
HMP Norwich had a specialist unit for older life sentenced prisoners and he said he
6 Ascites is the accumulation of fluid in the stomach.
11
would be happy for a referral to be made because it would move him closer to his
family. He had falls in his cell in the healthcare centre and needed help to get up.
He needed assistance with personal care and healthcare staff gave this when
necessary. Healthcare staff made a referral to the physiotherapist, who assessed
him and advised that he needed a walking stick and this would be arranged for him.
He had been prescribed antidepressants and believed they were lifting his mood.
35. The clinical record for the remainder of 2009 records the efforts of healthcare staff to
manage his fluctuating appetite, nausea, falls, abdominal pain, bloating and monitor
his blood glucose levels. He was admitted to hospital on a number of occasions for
excess fluid to be drained from his stomach, difficulties with blood clotting and
encephalopathy7. However, in between periods when he was unwell, there were
days when he felt well enough to walk up and down the healthcare unit and
associate with staff and other prisoners. Prison healthcare professionals were
sensitive to his discomfort and when it was clear that the hospital did not have an
available bed for a planned admission, the prison arranged for a hospital admission
via the hospital bed bureau.8 In September, staff referred him to the Leicestershire
Nutrition and Dietetic Service for help with his food intake and management of his
liver and diabetic condition.
36. Entries in the clinical record for November 2009, describe the man as frail and weak
with shorter periods between hospital admissions to drain fluid from his stomach.
On 11 November, he moved cell in healthcare to be nearer to the nurses’ station.
He was seen to be comfortable in his new cell and his pain was better controlled
since starting on phantanyl patches.9 However, it is evident from the clinical record
that he was spending the majority of his day in bed as he did not sleep well and tired
easily. In December, he was noted to be suffering from breathing difficulties and
asked for oxygen which helped ease his breathing.
37. The clinical record shows that on 14 December, prison managers considered
release on compassionate grounds. A meeting was held with the head of healthcare
and the head of security. They agreed that he was not eligible for compassionate
release because his life expectancy could not be estimated. His treatment would
continue, he would be seen regularly by the doctor and his condition was to be
monitored on a daily basis as before.
38. On 23 December, the healthcare department and discipline staff made plans for him
to see his wife and daughter. The visit was initially kept from him until the
arrangements were confirmed and in place. He was seen to be relatively well on
Christmas Day. On 29 December, he went to hospital for fluid removal. Prison
escort staff told their healthcare colleagues that nine litres of fluid had been drained
and he had been fitted with a drainage bag. An entry the following day implies that
7 Encephalopathy is brain malfunction due to liver disease.
8 This is a centralised unit for finding a hospital bed within a number of hospitals in a given area.
9 Phantanyl patches are patches placed on the skin, usually the upper arm, that release pain relieving medication.
12
the hospital had told him of the seriousness of his condition. In early January 2010,
he was given a wheeled walking frame to help his poor mobility.
39. Prison Family Liaison Officer A and a practice manager met with the man to discuss
the family liaison officer’s visit to his wife. The purpose of the visit was to prepare
her for the seriousness of his condition and the unlikelihood of his recovery. He said
he was happy for the family liaison officer to share information with his wife about his
condition and treatment.
40. On 13 January, the Head of Healthcare, Head of the Offender Management Unit and
prison Family Liaison Officer B, discussed with the man his final wishes in view of
his poor prognosis. They had also arranged to visit his wife at Morton Hall regarding
future visits and ongoing support for her. His daughter was due to visit with her
foster parents in February and the Head of Healthcare agreed to contact the Social
Services Department of the local authority to ask if his wife could visit at the same
time.
41. The family liaison log shows that a meeting was held on 8 February to discuss the
management of his condition. A sentence plan review was completed which would
prompt a review of his categorisation which was currently at level B.10 Prison staff
considered that in view of his condition he could be re-categorised to a category C
risk status and also because the healthcare department at Gartree was closing for
refurbishment. The concern was that he would not receive such good support in a
category C prison and it would be difficult to manage his complex health needs on
the wing in the face of closure of the healthcare centre. A transfer to HMP
Moorland, which had an inpatient unit, was considered and noted as an action point
for further exploration.
42. The man’s condition continued to deteriorate with increasing periods of confusion.
Further hospital admissions to drain fluid took place and his medication was
reviewed as necessary. On 1 April, he was found unresponsive in his cell and an
emergency ambulance was called. More excess fluid was drained and he was given
antibiotics intravenously for an infection. He was reviewed by a consultant who
advised a salt free diet. A family visit to the hospital was arranged.
43. A discharge letter from the hospital, dated 22 April, said that he had been admitted
with increasing confusion and a recurrent swollen stomach. He had a cranial
computed tomography (CT) scan of his head and the results were normal. (A CT
scan uses X-rays and a computer to create detailed images of the inside of your
10
Prisoners are risk assessed when they come into prison and given a category based on their offence and the risk
that they pose to the public should they escape. There are four categories: A, B, C and D, with category A prisoners
being the most dangerous. Category B are prisoners for whom the highest security conditions are not necessary but
for whom escape must be made very difficult. Category C are prisoners who cannot be trusted in open prison
conditions but who would not have the ability or resources to make a determined escape.
13
body. It can monitor many different health conditions and give views of structures
inside the body including internal organs, blood vessels, bones and tumours.)
44. During his time as an inpatient, hospital staff drained fluid from his stomach on two
occasions. Medical professionals also discussed his suitability for a liver transplant.
It was agreed to refer him to the liver transplant unit at hospital two weeks later for
assessment. The Head of Healthcare confirmed to the investigator that this was
under discussion.
45. On 2 May, he was admitted to hospital again and his health was noted to be rapidly
deteriorating. The prison contacted his wife at Morton Hall to tell her. The clinical
record showed that the restraints were removed as he was unconscious and
unresponsive. However, on 4 May, he appeared to have recovered to some extent
and wanted to discharge himself from hospital because he was not allowed to
smoke. The Head of Healthcare told the investigator that on occasions such as this
when he had wanted to discharge himself, she had driven over to the hospital and
spoken firmly to him about his decision. He changed his mind on this occasion.
46. Prison healthcare staff visited the hospital the following day. They explained that the
prison did not have the facilities to deal with his complex needs. This was because
the healthcare unit was due to be closed for refurbishment and he would be
accommodated in the main prison. They suggested that the withdrawal of treatment
would be detrimental to his health.
47. The Head of Healthcare spoke with the investigator. She said that closure of the
healthcare inpatient facility for refurbishment meant that he had to be managed on a
residential wing. She said that they managed without inpatient healthcare by
introducing the primary care community model into the prison. There were eight
sessions per week from a local GP practice and 17 nurses with a range of skills.
There was a registered nurse on duty in the prison at all times. However, she said
that healthcare and wing staff were concerned that he could die on the wing.
48. The Head of the Offender Management Unit said that around eight weeks before the
man’s death, a seriously ill prisoners meeting was held to discuss his management.
Representatives from healthcare, family liaison, the Head of Residence, Head of
Security and a member of the chaplaincy attended. Compassionate release was
discussed and was subsequently applied for. In an informal interview with the
investigator, he said that the National Probation Service were unable to support the
man’s application for release as he was still considered high risk. He added that
probation’s view was that he should be in hospital but were not prepared to discuss
it further. However, the investigation revealed that he had brewed illegal alcohol in
the prison in the past, including during a stay in healthcare. The Head of Healthcare
told the investigator that alcohol was a risk factor as he had told her that even if he
could not get to an off-licence, he would send someone to go for him.
14
49. The man returned to the prison from hospital unexpectedly on 19 May and was
given a cell on G wing. Neither the wing, nor healthcare staff had prior warning of
his return. A mental health nurse and Nurse A went to the wing, where they found
him in a distressed state. He told them that he was refusing all his medication
because he did not want to be on G wing and would rather die than stay there. The
suicide prevention and management of self-harm procedures were put in place an
Assessment, Care in Custody and Teamwork (ACCT) plan11 was opened with
observations by staff to take place every 15 minutes, reflecting the level of concern.
50. The Head of Healthcare told the investigator that he refused some aspects of his
treatment during the last weeks of his life. She said she knew him when he was at
Whitemoor Prison and described him as stubborn but knowing what he wanted. She
considered his treatment refusal was his last effort at controlling a situation. In her
view, while he refused his treatment, the outcome would be the same.
51. On 20 May, Prison Doctor B spoke with the man. Despite refusing his medication as
a protest at being accommodated on G wing, he described him as “looking like his
normal self” and ”coherent and alert”. He advised him against refusing medicine as
it would put him at risk of death, but he replied that he did not care.
52. An entry in the clinical record shows that later the same day, healthcare staff visited
him three times during the day. At around 12.00pm, the practice manager and an
operational manager spoke with him, who repeated to them that he was unhappy on
G wing. They were aware that he was refusing his medication and so attempted to
negotiate a solution to the problem. They suggested a move to another cell on G
wing that would be able to accommodate a hospital bed as this would be more
comfortable for him. However, he did not accept this because he believed that if he
did so it would delay his move off the wing.
53. Healthcare staff visited again in the afternoon. He remained adamant that he would
not take his medication and he agreed to sign a treatment disclaimer form.
However, he had given more thought to having a hospital bed and had decided that
he would like to have one despite the fact he would have to move cells.
54. At around 8.00pm, Nurse B visited with Nurse Manager B. Although eating and
drinking, he still refused his medication. An ACCT review followed and he was to be
observed by staff once every two hours. He was noted to be happier with a reduced
level of observations and with the care he was given on the wing. He declined the
offer of a copy of his nursing care plan. He also refused to sign the ACCT
11
The ACCT system is used to monitor and support prisoners assessed as at risk of suicide or self harm. Once
placed on ACCT, the prisoner will be subject to regular case reviews that will direct observations/conversations to be
carried out at intervals determined by their perceived level of risk. The observations continue during the day and the
night.
15
documentation, but signed a treatment disclaimer form which would enable
information to be provided to wing staff and operational managers with regard to his
medical and nursing care. The form also confirmed that he refused to take his
prescribed medication or to be physically examined and understood that his refusal
was against medical advice.
55. In late May, the man said he wanted to move to B wing where he could be with other
prisoners who would collect his food from the prison servery and carry out other
necessary tasks for him. Healthcare staff were unhappy with this. They considered
it was not possible to allow him on B wing as he needed to use the stairs. The
matter was left that it would be referred to the Head of Residence as wing transfers
were not within healthcare’s role or responsibility. The family liaison log shows that
his wife contacted the prison on 28 May to raise her concerns about her husband’s
accommodation on B wing. The prison said that they were unable to move him but
would arrange for a prisoner whom him knew well to come from B wing and support
him. An evening visit was arranged for him and his wife, agreed with Morton Hall.
56. His health noticeably deteriorated. On 29 May, he refused to go to hospital or
accept treatment because he could not smoke and thought he was being unfairly
treated. He agreed to go to hospital later that day as he was experiencing severe
pain in his stomach. He was admitted but refused to take any medication, including
his insulin. He underwent an endoscopy12 and no further treatment was planned
until the results were known.
57. The Head of Healthcare visited the hospital on 7 June. She spoke with staff and
then visited the man. He appeared to be frail and had difficulty eating, drinking and
walking and was assessed as not well enough to return to the prison. The senior
registrar told her that life expectancy was at the most around two months and
possibly only weeks because he had stage three cirrhosis which was a “definite
diagnosis of a terminal condition”. He said the consultant would confirm this in
writing to the prison, which could help with moving him to the End of Life Unit at
Norwich Prison, or elsewhere on compassionate release.
58. The clinical notes show that the Head of Healthcare discussed the man’s end of life
care with the Head of Operational Management Unit, who would look into this. The
entry said that the deputy governor and Head of Security reviewed the security
arrangements regarding the use of restraints and it was agreed that they would not
be in place when he was lying in bed.
59. On 8 June, the man demanded to return to Gartree. Nurse Manager C and a
healthcare officer went to the ward. While waiting for the discharge letter to be
produced, he began coughing blood and continued to refuse food and medication.
He was adamant he was discharging himself back to the prison, despite complaining
of chest and stomach pain. He collapsed while they were lifting him from his bed to
12 An Endoscopy is where the inside of the body is examined internally with an endoscope, a long thin flexible tube
with a camera.
16
the wheelchair and was placed back in bed. He eventually agreed to accept
treatment. The prison told his wife at Morton Hall.
60. The family liaison log shows that two days later on 10 June, prison staff telephoned
Morton Hall and left a message for the man’s wife with an officer. The message was
that a doctor at the hospital had asked if his wife could go to the hospital urgently.
The officer agreed to pass the message onto her and added that she was unwell at
the time.
61. In his statement, Officer A, a prison escort officer, said that at around 7.30am on 11
June he went to hospital to carry out bedwatch escort duties. (If a prisoner is
admitted to outside hospital, depending on the risk assessment carried out by the
prison, they will generally be escorted by two officers who will stay beside their bed
at all times. Two or three daily shifts of officers will stay with the prisoner until
treatment is completed.) The officer said that the man died at 1.25pm that day with
his wife and daughter by his side.
62. The Head of Healthcare said that after the man’s death, a memorial service was
held at the prison. His wife was invited to visit the prison to see the cell he occupied
in his final days at Gartree and to speak with those who knew him. The prison paid
for the cost of the funeral and healthcare and prison staff attended.
17
ISSUES
Clinical care
56. A clinical reviewer carried out a review of the man’s clinical care on behalf of the
local Primary Care Trust. He reviewed the clinical management of the diabetes and
liver condition. He found that hospital admissions were arranged in a timely manner
and the man attended regular appointments with the Consultant Hepatologist. He
described the decision to move him from one hospital to another for end of life care
as “an appropriate and considered decision”. He concluded that he could make no
recommendations that would improve upon the high quality of care given to the man
by healthcare staff at Gartree and in both hospitals and that this exceeded that
which he could have expected in the community.
57. The clinical reviewer also commented on the issue of compassionate release and
whether this could have been considered. It is evident from the documentation that
it was considered but the investigator was told that the National Probation Service,
when considering all the relevant risk factors, was unable to support the decision.
When the inpatient healthcare unit at Gartree was due to close, healthcare and
prison staff with responsibility for the man’s care considered whether a move to a
category C prison would be appropriate but decided not to pursue this.
58. Within the clinical review, the reviewer highlights nine areas of good practice,
including regular monitoring for diabetes with referral to a dietician, appropriate
medical investigations, medication reviews and clearly documented care plans. He
also found good practice regarding interdisciplinary working between healthcare
staff in the community and at the prison, with effective communication as a strong
feature of the man’s care.
59. I agree that the liaison and subsequent arrangements between Gartree, Morton Hall
(where the man’s wife was serving her sentence) and Social Services to ensure
successful family visits was impressive, demonstrated compassion and is an
example of excellence. This is an aspect of his care of which both discipline and
healthcare staff at Gartree and Morton Hall can rightly be proud.
18
CONCLUSION
60. The man entered the prison system in 2001 with hepatitis C and cirrhosis of the
liver, a chronic and life threatening condition. He developed insulin dependent
diabetes later in his sentence, but chose not to heed medical advice regarding his
diet and refused treatment on a number of occasions. Overall, the investigation has
judged that, while he was not an easy man to nurse, his complex medical conditions
were well managed by prison and healthcare staff at HMP Gartree.
61. The success of his care management was partly due to the good relationship forged
by healthcare and prison staff with the local hospitals. Effective communication
between Gartree and the hospitals ensured that there were planned admissions and
regular reviews. Gartree, Morton Hall and social services also put in place the
necessary complex arrangements for his wife and daughter to visit.
62. I am pleased to say I concur with the clinical reviewer’s view that the care he
received at Gartree was comparable to, and possibly exceeded, that which he would
have received in the community.
19