Individual at The Verne

Investigation into the circumstances surrounding the
death of a man at hospital, whilst a prisoner at
HMP The Verne, in July 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2010
This is the report of an investigation into the circumstances surrounding the death of
a man at hospital in July 2008. He was a prisoner at HMP The Verne and died from
natural causes.
I offer my sincere sympathy and condolences to the man’s son and to his friends for
their sad and untimely loss.
The investigation was conducted on my behalf by my colleague. I also
commissioned a clinical review of the management of the man’s health needs while
he was in prison custody. The review was conducted by a clinical reviewer on behalf
of the local Primary Care Trust.
I should like to thank the Governor and her staff at HMP The Verne for their
assistance during the investigation.
The man, a 69 year old Mexican, had suffered from emphysema and arthritic pain
prior to entering prison in this country in November 2007. The investigation has
found that the treatment he received for his emphysema and arthritic pain was
satisfactory. However, a post mortem examination showed that he died of lung
cancer. This was not detected until it had reached an advanced stage. In his clinical
review, the clinical reviewer judges that a chest x-ray should have been considered
upon his arrival at The Verne in February 2008. However, even if this had this been
done, he does not think the outcome would have been different.
My report makes three recommendations and draws attention to one example of
good practice.
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.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2010
2
CONTENTS
Summary 4
Investigation process 5
HMP The Verne 6
Key events 7
Issues 14
List of recommendations 18
3
SUMMARY
In November 2007, the man, a Mexican national, and his son were arrested at
Heathrow Airport for being in possession of illegal drugs. After appearing in court,
they were remanded in custody to HMP Wormwood Scrubs. During his initial
reception screen, the man mentioned that he had “chest problems” and that he was
a smoker. He told prison staff he did not want to give up the habit and did not want
to engage with any clinics. He also said he suffered from arthritic pain. At a general
health assessment a few days later, he said he was not interested in receiving
information about health promotion and did not wish to see a doctor. In February
2008, he was sentenced to seven years imprisonment. Both he and his son were
transferred to HMP The Verne two weeks later. Upon his arrival at The Verne, the
man underwent a further health screen during which he expressed concern about his
physical condition, saying that he had suffered from arthritis for eight years and
breathing difficulties (emphysema) for two years. The nurse who assessed him
thought he looked under-nourished and not well. She referred him to the prison
doctor to assess his general physical health. The doctor saw him the same day. He
found evidence of emphysema and therefore planned to monitor him regularly.
During an evening in July 2008, the man was found by wing staff to be struggling to
breathe and to be urinating and defecating without control. An ambulance was
called and he was taken to hospital, where he was admitted. He was assessed by a
consultant in respiratory medicine who arranged for him to undergo a chest x-ray the
following day. The x-ray revealed that the man had a cancerous tumour in his left
lung. He remained in hospital, but the consultant considered that he was too ill to
cope with any invasive surgery. Sadly, his condition deteriorated, and in July he
succumbed to his illness.
In judging whether the man’s condition was properly diagnosed and treated while he
was in custody, I have relied heavily on the professional opinions of the clinical
reviewer. He concludes that whilst there was “nothing fundamentally wrong” with the
man’s healthcare, consideration should have been given to a chest x-ray when he
arrived at The Verne. He takes the view that, had an x-ray been taken, the presence
of a tumour might have been detected at that stage and the care given to him would
have been different. However, it is his opinion that an earlier detection of the tumour
would not have influenced the final outcome.
I have recommended that medical records should accompany any prisoner taken to
hospital for admission. The clinical reviewer has made two further
recommendations. I have also drawn attention to some good practice on the part of
HMP The Verne.
4
INVESTIGATION PROCESS
1. The investigation was opened in July 2008. Notices were issued to staff and
prisoners at The Verne, inviting anyone with information relating to the man’s
death to make themselves known to my investigator. No one came forward.
The same day, my investigator met the man’s son at The Verne to offer his
condolences and to explain the investigation process.
2. My investigator and one of my Family Liaison Officers met with the man’s son
in September 2008 to offer him an opportunity to raise any issues of concern
about his father’s treatment prior to his death. He expressed his view that his
father had not received the correct treatment at The Verne and that his death
could have been prevented. These matters are considered within this report.
3. I also commissioned a clinical review of the management of the man’s health
needs while he was in prison custody. This was conducted by the clinical
reviewer on behalf of the local Primary Care Trust.
4. Both the clinical reviewer and my investigator conducted separate informal
discussions with members of the healthcare staff at The Verne and with the
man’s son.
5
HMP THE VERNE
5. The Verne is a category C training prison for up to 595 male adult prisoners.
There are six identical wings which include dormitory accommodation with
curtained bed spaces. A1 and C1 wings hold prisoners who have attained the
highest level in the Incentives and Earned Privileges scheme. A2 wing is the
induction unit; at the time of the investigation its primary role was to hold
foreign national prisoners. The man was a Mexican national, and whilst he
was at The Verne there were numerous other Spanish speaking prisoners
there.
6. Health services at The Verne are commissioned and provided by the local
Primary Care Trust. The healthcare centre is a single storey building located
at one end of the prison. There are no inpatient facilities. Prisoners who
need inpatient care are normally taken to the County Hospital in Dorchester,
some 14 miles away.
7. The Verne was last inspected by HM Chief Inspector of Prisons in August
2007. In the report of that inspection, published the following October, the
Chief Inspector made a number of recommendations about healthcare but
none is relevant to this investigation.
8. In their report on The Verne for the period November 2006 - May 2008, the
prison’s Independent Monitoring Board (IMB) also drew attention to some
aspects of the provision of healthcare by the local Primary Care Trust.
However. these are also unrelated to the issues arising from this investigation.
9. I have investigated three other deaths at The Verne. In my report into one of
those deaths, I drew attention to the absence of defibrillators and
recommended that the Primary Care Trust should provide a defibrillator for
use in the establishment. I am pleased to be able to record that this
recommendation was implemented and that, more recently, a second
defibrillator has been provided. None of the issues that arose from the
investigation of the previous deaths is relevant here.
6
KEY EVENTS
The man’s background
10. The man was born in Veracruz, Mexico, in July 1939. He grew up and went
to school in the same city. He excelled in mathematics and left school with a
number of qualifications. He later moved to Mexico City to find work and got a
job as a car salesman. He remained in this employment for most of his
working life. At the time of his arrest at Heathrow Airport in November 2007,
he was unemployed through poor health.
11. The man had two children, one of whom died in 2007. He divorced his wife in
1996. He is survived by his son.
12. His command of English was limited and in prison he often needed the
assistance of other Spanish speaking prisoners in communicating with staff.
Arrest and imprisonment
13. The man and his son arrived at Terminal 4 at Heathrow Airport in November
2007 from Mexico. They were questioned by an Immigration Officer who
became dissatisfied with some of their responses. A search of their luggage
revealed quantities of cocaine. Both men were arrested at about 2:30pm that
day and charged with illegal possession of drugs. They appeared at the
Magistrates Court in November where they were remanded in custody. The
man and his son were taken to HMP Wormwood Scrubs that day.
HMP Wormwood Scrubs: November 2007 – February 2008
First reception health screen
14. Upon his arrival at Wormwood Scrubs, the man underwent an initial health
screen, the purpose of which was to identify his immediate healthcare needs.
Although his prison file does not make clear whether he was assisted by an
interpreter, a note was made in the record of the health screen that he
communicated effectively during the process. The following table shows the
results of that screen:
Question Answer
Are you currently registered with a GP? No
Is a medical/psychiatric report required? No
Health information received from outside sources? No
Have you been in prison before? No
Have you seen a doctor in the last few months? No
Do you have any outstanding hospital or doctor’s No
appointments?
Are you receiving prescribed medication? Yes: Inhaler (for breathing
difficulties)
Have you received any physical injuries over the last few No
days?
Do you have any problems with:
Asthma: Yes
7
Diabetes No
Epilepsy or fits No
Chest pain No
TB No
Sickle cell disease No
Allergies No
Do you have any other concerns about your physical Yes: Chest problem.
health?
Record any health related observations about the Productive cough
prisoner’s physical appearance
Do you drink alcohol? No
Have you used drugs in the past month? No
Do you take any drugs intravenously? No
Is there anything else you would like to ask me or None.
anything about your health you think I should know?
Do you think there is any reason why you might need to see a Yes. Referred to doctor for
doctor? physical health. (There is
no evidence to show
whether the man actually
saw the doctor.)
General health assessment
15. Three days later, the man underwent a general health assessment. This
assessment was designed to identify any longer term healthcare issues that
needed to be addressed. The table below provides the details of that
assessment.
Question Response
Are you registered disabled? No
Do you smoke? Yes
Do you want to give up? No
Is there a history of illness running in the family? Yes, mother
diabetic
Would you like a referral to
Asthma clinic No
Diabetic clinic No
Well man clinic No
Would you like further information on any aspect of health No
promotion?
Do you think there is any reason why you might need to see a No
doctor?
16. During the three month period the man spent at Wormwood Scrubs, he was
given inhalers to help him cope with the breathing difficulties he had
mentioned. He was allocated a cell on the ground floor of C wing because of
his medical condition. He initially shared the cell with another Spanish
speaking prisoner but was later co-located with his son. In December, he was
described as being a little unsteady on his feet. A month later he was
described as very frail. However, an entry in his prison record in January
2008 shows that his health was thought to have improved as he was walking
more briskly.
8
17. In February 2008, the man was sentenced at Crown Court to seven years
imprisonment. Two weeks later, he and his son were transferred to The
Verne on the island of Portland in Dorset.
HMP The Verne: February –July 2008
Cell sharing risk assessment
18. Upon arrival at The Verne, the man underwent a cell sharing risk assessment,
the purpose of which was to measure any risk he presented of harming
another prisoner were he to share accommodation. This assessment is
carried out in respect of every prisoner. The assessment concluded that he
presented no such risk and he was therefore considered suitable to share a
cell. He explained that, as he spoke little English, he wanted to share a cell
with his son. Both men often relied on the assistance of other Spanish
speaking prisoners to interpret for them. As soon as his induction period was
completed, he and his son were allocated to the same cell on A2 Wing.
Initial health screen
19. The day after his arrival, the man underwent a reception health screen
conducted by a nurse. The following table shows the issues covered during
the screen, including the responses given to the questions asked of him:
Questions asked by the nurse Responses given by the man / issues
noted.
Have you received treatment by a No
psychiatrist outside prison?
Have you ever tried to harm No
yourself?
Have you ever been a psychiatric No
inpatient?
Do you have a psychiatric nurse or No
care worker in the community?
Emotional state observations Calm
Do you have any concerns about Yes
your physical health?
Have you received any injuries in No
the last few days?
Impressions of the prisoner’s Appropriate in manner
behaviour and mental state
Reasons for the prisoner to see a About his health
doctor
What health information is important History of arthritis for 8 years and
to you? emphysema for 2 years
Have you received any medication No
for mental health problems?
Referral to drug abuse counsellor? No
Referral for mental health No
assessment?
Fit for normal location, work and Referred to doctor about his physical
any cell occupancy? health
Referred to drug service? No
9
Prisoner receiving medication? Yes
Health information received from No
outside source?
Prisoner homeless in the past year? No
Medical/psychiatric report required? No
Body mass index. 23.59 kg
On examination: Blood pressure – 94 mmHg. Smoker.
Weight 10 stone 3lb. Appears not
healthy, under weight and un-nourished.
No outstanding appointments but has
seen doctor in previous few months.
20. A prison doctor saw the man the same day shortly before noon. He noted
that there was an interpreter present during the consultation. The doctor
recorded that the man had a history of emphysema [a condition in which the
air sacs in the lungs are damaged and enlarged, causing breathlessness] and
had arthritis in the knees and elbows. The record also shows that the man
had in his possession a ventolin inhaler he had brought with him from Mexico
and a Qvar inhaler (a steroid inhaler for the inflammation of the airway) given
to him at Wormwood Scrubs. He told the doctor the paracetamol he was
taking for the pain in his knees was not helping. The doctor recorded that
there was “nothing else serious”. On examination, the doctor found evidence
of current emphysema and planned that the man should continue to use his
Qvar inhaler twice daily but that he should also take ibuprofen [a painkiller and
anti-inflammatory drug] for the pain in his knees. The doctor prescribed
400mg ibuprofen tablets and 500mg paracetamol tablets. The man’s medical
record shows that, thereafter, his breathing difficulties were monitored
regularly.
21. In March, a nurse tested the man’s breathing capacity in the presence of his
son. After being provided with an additional inhaler, his respiratory function
improved. In April, he joined a ‘stop smoking’ clinic run by a member of the
healthcare centre. A week later, he was prescribed Niquitin patches as
nicotine replacement therapy.
22. An entry was made in the man’s wing history sheet in May that, in light of his
inability to walk up and down stairs easily, he was to be moved to a dormitory
on the ground floor.
23. In May, the man was seen by a nurse about his emphysema, his arthritic pain
and incontinence. His emphysema was not regarded as having a significant
problem as he was using his inhalers as advised and had reduced his
smoking level to one cigarette a day. However, he complained that the
ibuprofen he had been given for his arthritic pain had not given him much
relief. He told the nurse that he preferred to take artridol, a medication he had
been prescribed in Mexico. An appointment was therefore made for him to
see a doctor two days later. However, he did not appear for the appointment.
At interview, the nurse could offer no explanation as to why he had failed to
keep the appointment.
24. In June, the man made his own way to the healthcare centre to consult the
doctor. As far as the doctor could tell, the man was not especially concerned
10
about his breathing problems on this occasion but was worried about his
arthritic pain. He denied being incontinent.
25. A week later two members of the wing staff brought to the attention of the
Governor that the man’s incontinence was having an adverse effect on other
prisoners in his dormitory. They reported that the other prisoners were “fed
up of covering up and cleaning up after him”. The matter was referred to the
nurse who spoke to his son. She recorded that his son knew of no previous
history of incontinence, and that he had agreed to speak to his father about
the problem. At interview, the nurse confirmed that she had detected no signs
that the man was incontinent.
26. In June, further evidence came to light suggesting that the man was
experiencing incontinence in his dormitory. An officer was asked by a number
of prisoners to attend a meeting at which they complained that the man was
allegedly “urinating in his clothing and leaving soiled clothing in his bed
space”. After the meeting, a decision was made to move him out of the
dormitory to a single cell on A2 wing.
27. Two days later, the doctor saw the man in the presence of an interpreter. He
continued to deny that he was incontinent. The doctor concluded that there
was no evidence of “nocturia” [overactive bladder] and planned to continue to
monitor him. He also recorded the view expressed by the man that “some
prisoners were against him”.
28. In June, a prison carer [a prisoner entrusted to support other prisoners] took
the man to the healthcare centre in a wheelchair. At interview, the nurse
explained that wheelchairs were available for prisoners whose mobility
warranted their use. She thought that he had possibly been using a
wheelchair for about a week at that stage. She also confirmed that the reason
he reported to the healthcare centre that day was to attend a planned review.
It was discovered that he had not been using his inhaler. He was reminded of
the importance of doing so.
29. Shortly before 10.00am the next day, the man was seen by another nurse in
his cell on A2 wing at the request of staff who had discovered that he was
having breathing difficulties and feeling dizzy. The nurse made an entry in his
medical file to record that when she arrived at the cell, in the company of an
interpreter, he was in bed but sitting up independently. The nurse gave him
oxygen and took his blood pressure which, she said, was “stable and steady”.
She wrote that he was not eating and that this might explain his dizziness. He
told the nurse that he did not feel short of breath. She therefore ceased to
administer oxygen and advised him that it was necessary for him to eat
properly if he was to maintain any strength. The nurse recorded that he did
not complain of any pain or discomfort elsewhere. She described him as
stable and coherent when she left, and advised wing staff to contact the
healthcare centre if they had any further concerns.
30. Three days later the man was taken once more in a wheelchair to the
healthcare centre because his feet were swollen and painful. The same nurse
11
saw him. On this occasion, he did not complain of any breathing difficulties.
The nurse noted that he was showing signs of having pitting oedema [a
condition characterised by an excess of watery fluid collecting in the cavities
or tissues of the body] and capillary refill [an indicator of the level of
circulation]. She also recorded that his feet were very cold and his toes were
purple. She saw no signs that he was having breathing difficulties. The nurse
decided to contact the on-call doctor for advice. The doctor arrived at the
prison at 2.00pm and saw the man straightaway. After the consultation, she
made the following notes:
“Reported condition: patient suffers from emphysema, both feet are
painful and he cannot walk on them. Feet are freezing and purple.
“Diagnosis/outcome: Peripheral vascular disease. Seen by prison
doctor in last few days – suffers from emphysema. Feet swollen and
freezing cold, skin purple, nurse cannot feel pulses. Worried about
circulation. Nurse finishes at 5.00pm today.
“Visit – history of emphysema. Currently on qvar, salbutamol, Different
form of action by the inhaler, paracetamol and ipratropium [yet another
type of inhaler] Uses wheelchair to get longer distances – limited by
knee pain, not chest nor claudication [a condition in which cramping
pain in the leg is induced by exercise, typically caused by obstruction of
the arteries]. Concern today regarding feet. However, patient states
they are not painful. Long history of smoking. Currently on 1-2 a day.
Palpable L popliteal [i.e. in the hollow at the back of the knee] pulse,
unable to move toes. No indication for admission [i.e to hospital].
Advice re smoking. Suggest review of analgesia [i.e. painkilling tablets]
- main complaint from patient is joint pain. ? for aspirin. Nurse will
liaise with GP.”
Admission to hospital and subsequent death
31. During the ensuing fortnight, no events of any significance were recorded in
the man’s file. However, at 7.51pm, an ambulance was called for him. The
following note was made in his medical record by a member of the ambulance
crew::
“Patient is urinating and defecating all over the place. Patient has no
strength. Patient is struggling to breathe. Asthmatic, inhalers not
helping. Not sure if clammy, dizzy, no sickness, chest pains, unsure if
history of heart problems.”
32. The man was taken to hospital and was admitted as an emergency. He was
assessed by a consultant in respiratory medicine. In a report submitted to the
Coroner after the man’s death, he wrote:
“On examination, he was very breathless, cyanosed [blue] and cachetic
[thin] and ill looking …The admission chest x-ray showed a mass in the
upper left lobe of his lung and a moderately large left plural effusion
12
[water filling part of his chest] … I reviewed him the next day. He had
improved a little. It was arranged for him to have a CT [scan] of his
chest. This was undertaken in July. It showed that most of the left
upper lobe was abnormal … The radiologists did not suggest a
diagnosis. The appearances were consistent with infection or
replacement of the left upper lobe with tumour. I favoured the latter.
“I am unaware of any consultation or hospital input prior to this
admission nor am I aware of any issues with regard to this patient’s
care whilst he was in prison.”
33. It was the consultant’s opinion that the mass was a malignant tumour and,
despite attempts to improve the situation, it was judged that the man was too
ill to withstand further invasive investigation.
34. Such was the man’s condition that a decision was made shortly before
midnight that his physical restraints (handcuffs) should be removed.
35. At 1.00am, the man was transferred to the high dependency unit in the
hospital. His son visited him between 1.50am and 2.20am. The following
day, a member of the chaplaincy team at The Verne visited. Whenever the
nursing staff needed to communicate with him they employed an independent
interpreter. The man’s son visited him again.
36. Sadly, the man’s condition continued to deteriorate. He died in the hospital
shortly before 8.00am.
Informing the man’s next of kin and offers of support
37. The news of the man’s death was telephoned through to the Orderly Officer at
The Verne straightaway. His son was informed of his father’s death by the
prison chaplain very shortly afterwards. Arrangements were then made for
his son to view his father’s body at the chapel of rest at the hospital. He was
also offered an opportunity to telephone his sister in Mexico but declined.
38. The Governor of The Verne wrote a letter of condolence to the man’s son. He
gave permission for his father to be cremated locally. This took pace. The
man’s son was present.
13
ISSUES
39. Here I examine whether the man’s health needs were adequately met while
he was in custody and whether the condition that led to his death was
properly diagnosed and treated. In relation to these matters I rely heavily on
the clinical review. I also examine whether the man’s family were informed of
his death promptly and sensitively, and whether they were offered appropriate
courtesies and support thereafter.
Were the man’s health needs adequately met while he was in custody and was
the condition that led to his death properly diagnosed and treated?
40. When the man underwent his initial health screen at HMP Wormwood Scrubs
in November 2007, he mentioned that he had “chest problems”. He also said
he was using an inhaler because of breathing difficulties and that he suffered
from asthma. The records show that he asked to see a doctor about “his
physical health”. There is no evidence to show whether this happened. At his
general health assessment a few days later, he admitted to being a smoker
and said he did not want to give up the habit. He expressed no interest in
being referred to any of the available clinics, including the asthma clinic, and
did not wish to see a doctor for any reason. He did not mention that he
suffered from arthritic pain. Upon his arrival at The Verne at the end of
February 2008, he underwent a further health screen during which he
expressed concern about his physical condition, saying that he had suffered
from arthritis for eight years and breathing difficulties for two years. He said
he therefore wanted to see a doctor. The nurse who conducted the health
screen described him as under-nourished and not well.
41. The clinical review concentrates on the manner in which the man’s health
needs were managed at The Verne. The reviewer says the man’s records
show that, although his emphysema profoundly affected his mobility and
general health, his major concern was his arthritic pain, especially in his
knees.
42. The reviewer describes emphysema as a “miserable condition in which the
patient’s ability to breath steadily deteriorates”. He says that it is almost
always the result of long-term cigarette smoking and that death usually occurs
as a result of a chest infection. However, he points out that the man actually
died of lung cancer. He writes:
“It is always easy to be wise after the event and if a chest x-ray had
been arranged on admission, the cancer, in my opinion, would
probably have been visible then. I do not believe that the outcome of
his death in the middle of July would have been any different had his
cancer been diagnosed as soon as he arrived at The Verne.”
43. The reviewer remarks that he discussed with the prison doctor whether he felt
a chest x-ray might have been indicated earlier. The doctor maintained that
he could not see any justification for this. The reviewer points out that the
course of the man’s condition seemed to be following that of someone with
14
emphysema (i.e. rather than lung cancer) until the end of June, when the
rather more rapid deterioration associated with a malignant process set in.
He says that, had the man presented to him as a new patient as unwell as he
was in March 2008, he would have arranged a chest x-ray. However, he goes
on to say that he believes the prison doctor was right in his assertion that, at
the time, this would not have influenced the man’s management.
44. The reviewer expresses concern that there were three instances at The Verne
when the man was seen by a member of healthcare staff, or his case was
discussed by them, when no documented consideration was given to referring
him to a doctor for review. The first such instance was in June, when the
nurse saw him in his cell when he was feeling dizzy. The second occurred
three days later when a prison doctor assessed him, and the third was a week
after that when the healthcare department was told that the Mexican Embassy
was expressing concern about his health. (The reviewer was unable to
establish what had led to this enquiry being made.) He comments:
“I should have been happier that standards of communication between
members of staff in the healthcare department at The Verne were
robust if each of these instances had been followed by an entry by the
doctor to show that he was at least aware of it, and I am disappointed
to see that it wasn’t. Nurses in outside practice and within prisons are
the doctor’s eyes and ears. When instances such as these occur, it is
important that the doctor, at the very least, is informed so that he can
judge whether or not further action needs to be taken. After each of
these incidents, I should have been happier had the man been
assessed by the prison doctor. The records do not show whether he
was informed of them.”
45. Amongst the reviewer’s concluding remarks are the following:
“An important principle in medicine is not to perform investigations
merely because they are available. They should only be done because
some action would be taken if there were abnormalities. Cigarette
smoking undoubtedly causes emphysema but it causes lung cancer
too.
“There was nothing fundamentally wrong with the man’s care. From
the record, it seems that he was expressing more concern about his
arthritis than he was about the restrictions his breathing caused, until a
very short time before his death.”
46. The clinical reviewer makes the following recommendations, both of which I
endorse:
The PCT should satisfy itself that procedures are in place for adequate
communication between members of healthcare staff to ensure that everyone
is aware when significant incidents in a prisoner’s health journey occur.
15
In its pursuit of equality of care with the outside world, the PCT should
continue to negotiate with their custodial colleagues to ensure that
investigations are as freely available to prisoners as they are to the rest of the
PCT’s clientele.
47. The consultant physician, who saw the man upon his admission to hospital on
6 July, told the Coroner he was unaware of any issues with regard to his care
while he was in prison. This suggests that the man’s prison medical record
did not accompany him to hospital.
The PCT, in liaison with the Governor of The Verne, should ensure that
medical records accompany prisoners who are taken to outside hospital for
emergency admission.
48. During an informal discussion with my investigator in July 2008, the man’s son
said he thought his father’s death could have been prevented had his illness
been properly diagnosed and had he received the correct treatment. The
investigation found no evidence to support this. The clinical reviewer has
expressed his concern that a chest x-ray was not arranged when the man
arrived at The Verne and that, had this taken place, the cancer from which he
died might have been visible at that stage. However, he takes the view that
the final outcome would not have been different. He says, “Despite advances
in palliative care, lung cancer remains an aggressive tumour which presents
late (i.e. at an advanced stage) and responds poorly to treatment.” However,
he does remark that, had the cancer been uncovered earlier, “his care (as
opposed to his condition) would undoubtedly have been very different.”
49. The man’s son also claimed that his father was told he would be sent to an
outside hospital for treatment. The investigation found no evidence to show
whether this was the case.
Were the man’s family informed of his death promptly and sensitively and
were they offered appropriate courtesies and support thereafter?
50. The man’s son was his next of kin and, as this report shows, was resident
with him at The Verne. The news of his father’s death was conveyed to him
by the prison chaplain very shortly afterwards. Arrangements were then
made for the son to view his father’s body at the chapel of rest at the hospital.
He was also offered an opportunity to telephone his sister in Mexico but he
declined. The Governor of The Verne wrote a letter of condolence to him in
July. The son gave permission for his father to be cremated locally. This took
pace in July. The son was present. The costs of the cremation were met by
the Governor.
51. I am satisfied that the care and support given to the man’s son was
appropriate. In particular, I consider that the visits to his father’s bedside and
his attendance at the funeral were sensitively handled. This is an example of
good practice.
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LIST OF RECOMMENDATIONS
1. The PCT should satisfy itself that procedures are in place for adequate
communication between members of the healthcare staff to ensure that
everyone is aware when significant incidents in a prisoner’s health journey
occur.
The Prison Service accepted this recommendation and said;
“Notes are made on System One which all staff can access, issues are
be discussed at the team meeting and the lead nurse update staff
verbally.”
2. In its pursuit of equality of care with the outside world, the PCT should
continue to negotiate with their custodial colleagues to ensure that
investigations are as freely available to prisoners as they are to the rest of the
PCT’s clientele.
The Prison Service accepted this recommendation and said;
“Where possible this is normal practice as with any patient in any other
PCT setting. However, owing to the restriction of available escorts this
is not always achieved. There is an ongoing dialogue at the Escort and
Bed watch meeting and the PHAT to address this shortcoming.”
3. The PCT, in liaison with the Governor of The Verne, should ensure that
medical records accompany prisoners who are taken to outside hospital for
emergency admission.
The Prison Service partially accepted this recommendation and said;
“A verbal up date given to A&E by GP and print out of medical history
summary from current and previous history from System One would be
sent with prisoner. Prisoners’ medical records are not being sent to
hospital due to the confidential information contained in those records
which is the responsibility of the healthcare. Once the records were
entered into the hospital system there would be no certainty of the
records being returned. This is the same process which happens in
the community. GPs only send referral letters to the hospital not the
patient’s records.”
Good practice
4. I consider that the man’s son’s visits to his father’s bedside and his
attendance at the funeral were sensitively handled. This is an example of
good practice.
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