Individual at Woodhill

Investigation into the circumstances surrounding the
death of a man at HMP Woodhill
on 7 May 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2010
This is the report of an investigation into the death of a man at HMP Woodhill on 7
May 2009. He was aged 45, had arrived at Woodhill on 16 June 2008 after being at
HMP Whitemoor since September 2001. I offer my sincere condolences to all those
touched by his passing.
He had a history of asthma and respiratory infections which led to a consultant
diagnosing him as suffering from Chronic Obstructive Pulmonary Disease (COPD) in
July 2004. (COPD is a disease that restricts the airflow to the lungs.) His
breathlessness increased in severity over the following years and he could not move
far without the support of oxygen therapy. He continued to smoke heavily
throughout his life.
In late 2004 he started to suffer Transient Ischaemic Attacks (TIAs, often called mini-
strokes). It was thought that these might be related to his COPD and the interaction
between oxygen saturation levels in the blood and the brain. However, the TIAs
were never fully investigated because he refused to allow any health interventions,
including assessment of the cause of his TIAs.
The man wrote a letter in September 2004 setting out his wishes in a living will
format. This was witnessed and a copy sent to his solicitors as proof of his intent.
On 25 November 2005, he signed an Advance Directive and, after some time, he
was formally assessed as having capacity to refuse life saving treatment.
Throughout the following years, the man’s TIAs developed into regular seizures. He
continued to suffer from COPD and to smoke heavily. His seizures became more
frequent and the effects lasted longer. On 7 May 2009, following two earlier seizures
that day, he suffered a third seizure. Staff sat with him whilst he recovered but, in
accordance with his wishes, they did not actively intervene other than to ensure that
oxygen therapy was provided via a face mask. He slipped into unconsciousness and
ceased breathing at approximately 7.15pm. A doctor and nurses attended and
pronounced him dead at 7.20pm.
An Investigator conducted the investigation on my behalf. I thank the Governor of
Woodhill, and his staff for their co-operation and assistance; in particular, I would like
to mention the staff of Safer Custody Group. In addition, a review of the man’s
medical care in prison was carried out on behalf of Milton Keynes Primary Care
Trust. I must apologise for the delay in issuing this report.
I find that Prison Service staff at Woodhill managed the man in an entirely proper
and dignified manner, complying fully with his wishes not to be resuscitated or have
any life saving interventions. I ask the Governors of HMP Whitemoor and Woodhill
to share with their staff my favourable comments on the way they honoured the
wishes of a man who clearly knew how he wanted his life to end.
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
Prisons and Probation Ombudsman April 2010
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CONTENTS
Summary 4
The Investigation Process 5
Advance Directive and Mental Capacity Act, 2005 6
Chronic Obstructive Pulmonary Disease 7
HMP Woodhill 8
Key Findings 9
Issues 19
Conclusion 22
Recommendations 23
3
SUMMARY
The man first arrived in prison on 13 December 1999 having been charged with
kidnap, false imprisonment and murder. He was found guilty and sentenced to life
imprisonment on 9 November 2000. He was sent to HMP Belmarsh and moved to
HMP Whitemoor on 7 September 2001.
On his arrival in prison he was found to be a heavy smoker and an asthmatic who
frequently suffered from chest infections. Over the years these chest infections left
him with Chronic Obstructive Pulmonary Disease (COPD) which led him to struggle
for breath whenever he exerted himself. Slowly his COPD got worse so that he
needed almost constant oxygen to be provided via a face mask. He became
incapacitated and required a wheelchair to move about. A special bed was provided
and he often slept in a chair because he found it impossible to lie down.
He also developed Transient Ischaemic Attacks (TIAs), probably because his blood
oxygen levels were affected and his brain was not receiving sufficient oxygen. The
seizures he suffered as a result of the TIAs gradually became more frequent and
their effects lasted longer.
At Whitemoor, he started refusing appointments for investigation of his TIAs at
outside hospital. He went further by refusing to allow himself to be taken to outside
hospitals in emergency situations when he had seizures. He would often discharge
himself from the prison in-patient unit if he had been admitted following a seizure.
This eventually led to him writing an Advance Directive or living will that reflected his
wish not to receive life saving treatment. The Directive included instructions not to
actively resuscitate him in the event of a cardiac arrest. Several attempts were
made to change his mind, including by psychiatrists who were tasked with assessing
his capacity to make such decisions. At the conclusion of these assessments, he
had a well publicised list of instructions on what he would accept - and what he
would not - by way of treatment and intervention.
On 16 June 2008, he was transferred to HMP Woodhill with their full knowledge that
an Advance Directive and a Do Not Attempt Resuscitation order were in place.
Despite continued attempts by doctors and nurses to persuade him to change his
mind about these interventions, he remained resolute in his decision.
On 7 May 2009, the man was being supported by two prisoners throughout the day.
They were joined by two prison staff at approximately 6.00pm. A senior nurse called
in to check on him at about this time and also witnessed him having a third episode
of seizures. He began to settle and recover from the seizures, and by approximately
7.00pm he was quiet and appeared to be sleeping. At approximately 7.10pm, the
staff observing him realised that he was not breathing and they summoned
assistance. A nurse arrived, followed by a doctor and other healthcare staff. After
checking him for any vital signs, they concluded that he had passed away quietly in
his sleep, much in line with his wishes. The man was certified dead at approximately
7.20pm.
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THE INVESTIGATION PROCESS
1. The investigator visited Woodhill and spoke to staff who had come into contact
with the man during his time there. Notices were posted to staff and prisoners
about the investigation, inviting them to contribute if they wished. The
investigator interviewed eight members of staff and four prisoners. He also
interviewed a friend of the man, who had written to this office saying he had
information relating to the circumstances of the man’s death.
2. The investigator studied all relevant prison records relating to the man. These
included his main prison record, medical records, and statements made by staff.
The investigator also visited the unit where he was housed when he died.
3. A member of staff from Milton Keynes Primary Care Trust carried out a review of
the man’s clinical care whilst he was at Woodhill. I am grateful to her for
undertaking this review. My investigator discussed aspects of his treatment in
particular relating to the Advance Directive and Do Not Resuscitate instructions
with staff from Milton Keynes Primary Care Trust.
4. My investigator contacted HM Coroner to inform him of the nature and scope of
my investigation and to request a copy of the post mortem report. Upon
completion, my report will be sent to the Coroner to assist in his enquiries into the
man’s death.
5. The Family Liaison Officer (FLO), spoke to his nephew, and arranged that she
and the investigator would visit him at his home. During a visit on 18 September
he raised the following matters:
He was concerned that the man had not been moved to a lower category
prison, or one closer to his family, before he died. He had been waiting a long
time for the move and his nephew thought that a suitable prison had been
identified.
He was concerned that the man had to wait a long time for some of his
medical equipment.
Finally, he was concerned that the man’s Advance Directive required a doctor
to be present at the time of his death, and it was his belief that no doctor was
present.
6. I hope this report goes some way to answering those questions for his nephew.
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Advance Directive and Mental Capacity Act, 2005
7. An Advance Directive is a document giving instructions specified by the patient
as to what healthcare interventions and actions should be carried out if they
become ill and unable to make decisions for themself. The man supplemented
this directive with a ‘Do Not Attempt Resuscitation’ (DNAR) instruction which
meant that he did not want anyone to revive him or provide life saving treatment,
under certain specified conditions. He was of the view that his medical condition,
chronic obstructive pulmonary disease (COPD), and the seizures he suffered,
might leave him in a vegetative state if resuscitation were attempted and only
partially successful. He was adamant that he did not want this to happen to him.
8. The Mental Capacity Act 2005 sets out the circumstances governing the status
and legal validity of an Advance Directive. The Act makes it clear who can take
decisions, in which situations, and how they should go about this. It enables
people to plan ahead for a time when they may lose capacity. The Act is
underpinned by a set of five key principles, three of which are particularly
pertinent to his circumstances:
• A presumption of capacity - every adult has the right to make his or her
own decisions and must be assumed to have capacity to do so unless it is
proved otherwise;
• The right for individuals to be supported to make their own decisions -
people must be given all appropriate help before anyone concludes that
they cannot make their own decisions;
• Individuals must retain the right to make what might be seen as eccentric
or unwise decisions.
9. The Act sets out a single clear test for assessing whether a person lacks capacity
to take a particular decision at a particular time. It is a “decision-specific” test.
No one can be labelled ‘incapable’ as a result of a particular medical condition or
diagnosis. The Act makes it clear that a lack of capacity cannot be established
merely by reference to a person’s age, appearance, or any condition or aspect of
a person’s behaviour which might lead others to make unjustified assumptions
about capacity.
10. A person is thought to be unable to make a decision for him/herself if unable:
(a) to understand the information relevant to the decision,
(b) to retain that information,
(c) to use or weigh that information as part of the process of making the
decision, or
(d) to communicate the decision (whether by talking, using sign language or
any other means).
11. The Act says a person is not to be regarded as unable to understand the
information relevant to a decision if he is able to understand an explanation of it
given to him in a way that is appropriate to his circumstances (using simple
language, visual aids or any other means). The fact that someone is able to
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retain the information relevant to a decision for a short period only does not
prevent them from being regarded as able to make the decision. Finally, the
information relevant to a decision includes information about the reasonably
foreseeable consequences of:
(a) deciding one way or another, or
(b) failing to make the decision.
12. The Mental Capacity Act also covers advance decisions to refuse treatment. It
says that people may make a decision in advance to refuse treatment should
they lose capacity in the future. It is made clear in the Act that an advance
decision will have no application to any treatment that a doctor considers
necessary to sustain life unless strict formalities have been complied with. These
are that the decision must be in writing, signed and witnessed. In addition, there
must be an express statement that the decision stands “even if life is at risk”.
Chronic Obstructive Pulmonary Disease (COPD)
13. Chronic Obstructive Pulmonary Disease (COPD) is an 'umbrella' term for people
with chronic bronchitis, emphysema, or both. COPD is usually caused by
smoking and results in the airflow to the lungs being restricted. Symptoms
include a cough and breathlessness. The most important treatment is to stop
smoking. Inhalers are commonly used to ease symptoms. Other treatments
such as steroids, antibiotics and oxygen medicines are sometimes prescribed in
more severe cases, or during a flare-up of symptoms.
7
HMP WOODHILL
14. HMP Woodhill is a local prison, purpose built to high security prison standards in
the early 1990s. It is rated as performing well (level 3 out of four levels) against
the performance rating criteria set by the Prison Service, and has been at this
level since before the man died. It holds some category A prisoners (the highest
level of security) as well as some of the most disruptive prisoners in the system in
the close supervision centre. He was a category B prisoner (Category B
prisoners are lower security prisoners than Category A, but they still require high
levels of security such as high walls and locked doors around the prison).
15. An inspection by HM Chief Inspector of Prisons, Dame Anne Owers, in 2005 led
to a description of the prison as ‘depressing and disappointing’. However,
following a subsequent inspection in 2007, Dame Anne found ‘a very different
prison’. Safety at Woodhill was said to have ‘improved considerably, with
extremely good reception and first night procedures’.
16. Before his death there had been seven deaths from natural causes at Woodhill
since I became responsible for all investigations into deaths in prison custody in
2004. Aside from the issue of poorly maintained health records, there are no
significant similarities between this report and those resulting from earlier
investigations I have conducted at Woodhill.
17. Milton Keynes Primary Care Trust is responsible for commissioning healthcare at
Woodhill. The provider arm of the PCT provides a nursing healthcare team
based in the prison, a Mental Health In-Reach Team, and x-ray, dental,
pharmacy and podiatry services. Milton Keynes PCT also commissions a
number of other agencies to provide healthcare services at Woodhill including:
• Resuscitate Medical Services Limited, who provide general medical
services.
• The Seagrave Trust, who provide substance misuse services, and
• Howcroft and Selly, who provide ophthalmic services.
In addition, Woodhill provides some additional staff who support the functions of
the healthcare department.
8
KEY FINDINGS
18. The man first arrived at HMP Pentonville on remand on 13 December 1999
having been charged with kidnap, false imprisonment and murder. He was found
guilty after a trial and sentenced to life imprisonment.
19. He started his sentence at HMP Belmarsh but was moved to HMP Whitemoor on
7 September 2001. He remained there until June 2008 when he was transferred
to HMP Woodhill.
20. When he first arrived at Whitemoor, he was identified as not having any medical
problems, although he was referred to the urologist by the prison doctor (Prison
Doctor A) on 15 October for a cyst that had developed while he was at Belmarsh.
He was assessed by healthcare staff in reception as not needing any help as
regards his mental health, and that he was not suicidal or at risk of harming
himself. He was also noted to be a heavy smoker, asthmatic, overweight and in
need of increased exercise.
21. On 8 January 2002, he cut himself with a razor blade. He was admitted to the
healthcare centre on continuous observation and a F2052SH document was
opened. (F2052SH was the Prison Service’s then system for supporting and
monitoring prisoners in crisis. This has been superseded by the ACCT process.
An Assessment, Care in Custody and Teamwork (ACCT) document is now used
as a tool for keeping prisoners safe.)
22. It is not clear from the records how long he was in healthcare. It appears that he
was referred to a psychologist for help with flashbacks resulting from abuse he
had received when he was young, and he asked if he could be transferred to
HMP Dovegate’s therapeutic community. The F2052SH was closed on 2 March.
23. The man again felt that he might harm himself on 11 October as he had read a
newspaper article about his case and his impending appeal. This worried him
and he asked staff to take away his razor blades and to keep an eye on him.
Staff on his wing started an F2052SH form and kept closer observation. The
F2052SH was closed on 14 October.
24. In November 2002 he was seen by the visiting urologist regarding a cyst on his
testicles. There is no detail about this consultation in the clinical record aside
from a letter from the man to the Prison Doctor A. In that letter he says that the
urologist was intending to arrange for him to have an operation. It is also evident
from a letter sent by a visiting doctor in July 2004 to a specialist chest physician
at the local Hospital that he had been experiencing increasing problems with
chest infections and asthma over an 18 month period. However, there is little
other information in his clinical record about these problems.
25. On 6 February 2004, he went to the local Hospital for surgery on the cyst. When
he arrived, he refused to undergo an operation as he objected to being restrained
in handcuffs until the point when he was unconscious and sedated. His
consultant urologist, discharged him from his list.
9
26. The man had a chest infection on 4 July 2004 that required his admission to the
in-patient unit of the prison healthcare centre. When he had first had problems
breathing that day, prison staff called for an ambulance to take him outside to a
hospital. He had refused to go and signed a disclaimer to that effect. The
paramedics who attended and assessed him also noted on their patient report
form that he had refused to go to hospital with them and that he was aware of the
consequences of his actions.
27. He was seen at the local Hospital on 3 August by a consultant in respiratory
medicine. Who prescribed a course of steroids to help his breathing (a steroid
works by reducing inflammation) and asked that he return to his clinic three
weeks later. It is not clear that he actually returned to the consultants clinic on or
around 24 August. On 10 September he was admitted to the local Hospital
because of shortness of breath and a swelling to his calf (lower leg). It was
thought that he might have a deep vein thrombosis (DVT – a blood clot in the
veins in the legs) or a pulmonary embolism (a blockage of the main artery of the
lung or one of its branches by a substance that has travelled from elsewhere in
the body through the bloodstream). This turned out not to be the problem, but
the man discharged himself from hospital without having a final diagnosis. For
the first time his medical condition was referred to as COPD (Chronic Obstructive
Pulmonary Disease).
28. On 16 September, he was admitted to the prison in-patient unit where he
continued to be monitored for shortness of breath, possible chest infection,
COPD and a potential embolism. He was put onto a fluid balance regime (which
means the amount of fluid he took in was measured against the amount of fluid
he passed out). He had frequent blood tests to measure how well his blood
clotted as part of his treatment was to receive a drug that thinned his blood (to
reduce any embolism present or the risk of an embolism forming).
29. On 23 September, he formally instigated a Living Will document. He set out in
letter form and on a templated document his wishes about what he would and
would not accept by way of treatment or help for his medical problems. This was
witnessed by the Chairman of the Independent Monitoring Board (IMB). (Each
prison has an Independent Monitoring Board. IMB members are independent
and unpaid. They monitor day-to-day life in the prison and ensure that proper
standards of care and decency are maintained. The IMB produces an annual
report on the prison.) He also wrote a letter to the Governor of Whitemoor, a
copy of which was to be stored in his clinical record. In that letter he said:
‘One of my main reasons for requesting my solicitor … to obtain and retain a
copy of a living will, is to afford me a dignified death and to regain a level of
control over how my health is managed. The living will will also prevent the
prison from enforcing its duty of care upon my body even if I am no longer in a
position to verbalise my requests/wishes and should also serve to protect the
prison’s healthcare department from any form of negligence in that duty of
care as this will was completed and signed as witnessed by the chairman of
the establishment’s Independent Monitoring Board and is countersigned to
that effect.’
10
30. He wanted to return to his own living unit in early October, but was advised that
he needed to stay in the prison hospital. He was insistent, and staff at
Whitemoor considered asking the governor to issue him with an order to remain
in the hospital. He told staff that if this happened, he would refuse all treatment,
including oxygen via a bottle. He could not be persuaded to stay, and on 6
October he discharged himself back to C wing.
31. A consultant forensic psychiatrist, went to C Wing on 7 October 2004 to see the
man. She had been asked to assess whether he had capacity to make the
decisions he had been making recently (the inference being that he might have a
mental impairment to decision making). He refused to see the consultant
forensic psychiatrist and she was unable to say for sure whether he had capacity
to make his own decisions.
32. The next entry in his clinical record is by a visiting doctor, who reviewed the
man’s medical condition on 26 October. He noted that he wanted to return to his
wing (so presumably he had been re-admitted to the in-patient unit) and that he
should be referred to the local Hospital for further tests. He recommended
continuing him on anti-coagulant medicine (to stop his blood clots) until the
multidisciplinary team (MDT) considered his care at a meeting the following day.
33. The MDT met on 27 October but the record is incomplete as to their decisions. It
would appear that he remained on the in-patient unit.
34. On 1 November, the visiting doctor again saw him and listed his medical
problems as COPD. He queried whether the man had also suffered transient
ischaemic attacks (TIAs – which are mini-strokes) or was suffering with hypoxia
(a lack of oxygen in his system). The visiting doctor wanted to check the
progress of the referral to the consultant of respiratory medicine he had
previously seen at the local hospital for the man’s blood clotting test results.
35. Later that day, the visiting doctor was asked to see him again as he was vomiting
and feeling dizzy. The doctor diagnosed that he was suffering from labyrinthitis
(an inner ear infection that causes dizziness and vomiting). He prescribed
medication to ease the symptoms. When the man was seen by the visiting
doctor again on 5 November, he was feeling no better.
36. The doctor saw him again on 10 November and made no mention of the
labyrinthitis, but concluded that he had probably been having TIAs. Entries in the
clinical record of 18 November and 2 December say that the man reported that
the TIAs were getting more frequent, occurring at least weekly. On 4 December,
he was witnessed having one of the TIAs. He was seen shaking and the right
side of his body was weak. He also reported losing track of about one hour of
time.
37. He saw, a consultant psychiatrist, on 9 December and had a very full and frank
discussion about his thoughts and feelings. The consultant psychiatrist made
eight pages of notes, but in the end had to finish her session with him without
reaching a firm decision whether he had capacity to make his living will decision.
11
She did record amongst those notes that he understood what was wrong with
him:
‘I have chronic obstructive airway disease … no known cure … attacks the
respiratory system and that has four levels. I have level four emphysema …
end state emphysema … I understand this to be at the end of the illness …
the fatal end. Coupled with that … TIAs … like tiny strokes that cause me to
lose consciousness. I am obviously incapacitated by both. This illness …
eventually I will drown in my own body fluid. I understand they can drain the
lung and cut bits out here and there and use surgery to remove blood clots.
My greatest concern is not that I am dying … it is that I am afforded a certain
level of dignity that I would not have if I was taken out of here to the hospital.
I can not think of a set of circumstances that would make me change my mind
e.g. if in the community.’
38. When the consultant psychiatrist returned to complete her assessment on 16
December, he refused to see her.
39. Healthcare staff saw him a number of times throughout the rest of that year and
in January 2005, usually about his feelings of sickness and the fact that he was
not eating. It was recorded that he had lost a lot of weight, but this was not
quantified. On 24 January, he had a TIA which left him with right sided weakness
and slurred speech. He went to the healthcare centre for tests and observation,
but would not stay. He returned to his cell on C wing and was visited by nursing
staff throughout the day. He recovered and by the end of the day he was back to
his usual self, saying that he was feeling a lot better.
40. There are several entries in his clinical record about him having shortness of
breath and pain in his calves (the lower legs) – a possible DVT – throughout
April. On each occasion he was offered further care by being admitted to the
healthcare unit, but on each occasion he declined.
41. On 17 May, he was worried about pain he was having in his chest or lungs and
was concerned that, if he needed help during the night, he might not be able to
ask for it. He therefore agreed to be admitted to the healthcare centre. He felt
much better by 19 May and discharged himself, against the advice of Prison
Doctor A.
42. Nurse 1 was asked to see him on 4 June because he was complaining of feeling
breathless and wheezing when he breathed. When the nurse arrived at his cell
he found him sitting in his chair, with oxygen being given to him via a nasal tube.
He was smoking. The man said he did not need any urgent assistance, but
wanted to see Prison Doctor A after the weekend. When Prison Doctor A saw
him he found that he was quite well, although he did have some wheezing noises
from his lungs when he breathed. On 8 June, he was admitted to the healthcare
centre for observation after feeling unwell during the previous 24 hours. On 13
June, he was discharged back to his wing.
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43. When Prison Doctor A saw him on 10 July, he was having breathing difficulties
but refused to be admitted to the healthcare centre. He was again short of breath
on 8 and 13 September but once again refused to be admitted to healthcare.
44. On 20, 22 and 23 September, he had a number of ‘falls’ in his cell. On each
occasion staff called for nurses to come and see him. The nurses found him to
be in various states of recovery when they saw him: from not able to get up off
the floor himself, to being alert and aware of his surroundings. On each occasion
he refused to be admitted to healthcare. He was also seen and assessed by
doctors on a number of occasions. It is unclear from the records how many falls
he actually had, but there appear to have been at least three separate episodes
of falling over and losing consciousness.
45. The man’s clinical record also has a number of entries regarding the validity of
his living will from September 2005. It appears from the entries that staff felt it
could not be valid as he had refused to co-operate with the psychiatric
assessment of his capacity and competency to make a living will.
46. On 29 September, a consultant forensic psychiatrist, interviewed and assessed
him regarding his living will. She wrote:
‘He has capacity. His living will and expressed wishes should be followed.
He understands the risks of his decision. He wishes to be given pain relief
and oxygen. He has agreed with this paragraph.’
47. Nurse 2 was asked to see him in his cell on 5 October. She was accompanied by
two senior prison staff. The man told staff that he had changed his mind about
going to hospital for treatment of his TIAs. Nurse 2 asked him if he would go to
hospital and stay for the duration of any treatment offered to him. He said that he
would. The nurse agreed to ask Prison Doctor A to see him the following day.
48. On 6 October, the man saw Prison Doctor A and re-affirmed his willingness for
the cause of his TIAs to be investigated. Prison Doctor A wrote an urgent referral
letter to the local hospital. However, the ,man wrote to Prison Doctor A again on
9 October, indicating that he had changed his mind once more and did not now
want active treatment. He wrote that his legal team had advised him not to go
ahead with treatment.
49. On 22 October two nurses were asked to see the man in his cell as he felt that he
was about to have another fit. As they were assessing him, he began to fit
violently and lost consciousness. The fit lasted for about eight to ten minutes. As
he settled down and relaxed, the nurses were able to put him on his bed in the
recovery position. He remained unresponsive for about 30 - 40 minutes and his
observations at the time were: pulse 138 (fast,) blood pressure 122 over 54 (a
little low), and temperature 37.4 (normal). An ambulance had been called and he
remained confused and incoherent throughout the nurses’ assessment. The
paramedics decided to take him to hospital for further investigations. When
officers made to put handcuffs on him, he protested about going out to hospital
and eventually refused, signing a disclaimer to that effect. He did, however,
13
agree to go to the prison’s in-patient unit to be observed over lunchtime and see
the doctor there.
50. The doctor who saw him that day wrote that he thought the man’s fits were
related to vascular problems and he would need a scan to find out where the
problems were. However, ‘The man remained adamant that he will not go out for
further investigations.’
51. On 25 November, he signed a new Advance Directive or living will. This set out
his express wish not to be resuscitated in the event he should become
unconscious or unable to communicate his wishes. The directive added that the
man would be content to receive food, water, prescribed pain relief, oxygen and
first aid for any injuries he might suffer in a fall, whilst he was conscious and able
to communicate. The Advance Directive was typed, signed by him and
witnessed by a nurse.
52. The Head of Healthcare at Whitemoor, wrote to the man’s solicitors on 22
December following a number of letters from them complaining about his
treatment. In her letter they said:
‘I am sorry that he has regarded any actions taken as resuscitation. I can find
no record in his IMR [Inmate Medical Record] that any active resuscitation
procedures were performed. I am of the belief that although he was brought
to the Healthcare Department on one occasion there was no active
resuscitation procedures performed. Oxygen was administered, but it is my
understanding of his Directive that he still wishes to receive this form of
treatment. He was kept comfortable on a trolley until he regained some
consciousness, enough to assist his transfer to a bed in the interests of his
comfort, and then when fully conscious was taken back to his cell on the
wing.’
53. A Senior Officer from C wing asked the Mental Health In-Reach Team (MHIRT)
to see the man on 1 February 2006 as he was feeling low in mood, partly
because of his physical condition. He was seen on 9 and 16 March when he
disclosed a number of issues that were causing him distress. After these
sessions, ,an assistant psychologist with the MHIRT, wrote to the Head of
Healthcare at Whitemoor. She said the MHIRT were concerned that all his
worries might have been impacting on his mental health and affecting the validity
of his living will. They asked for him to be re-assessed as to his capacity to
decline active treatment.
54. The consultant forensic psychiatrist saw him on C wing on 20 April 2006. She
reported to the Head of Healthcare that he was confused why she had been
asked to see him. He thought the consultant forensic psychiatrist was there to
help with his mental health concerns, not to judge capacity again. He feared that
she was there to ‘nut him off’ and questioned her impartiality as she worked for
the prison authorities. She told him that she would see him again if he wished to
assess his capacity or his mental health needs or both, but she made it clear that
he must consent to these assessments. On 5 July, Prison Doctor A wrote
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another referral letter to the consultant forensic psychiatrist, asking her to assess
the man’s capacity to make an Advance Directive.
55. On 10 July, the man wrote to the consultant forensic psychiatrist and said:
‘I have been advised by Prison Doctor A that I have apparently agreed, during
one of our sessions, to go to outside hospital. As I am unable to recall such a
conversation I do not feel it would be practical or beneficial to either of us for
me to continue seeing you.’
56. HMP Whitemoor kept a running nursing log of visits to his cell between 2004 and
2007. There are literally hundreds of entries recording times when nursing staff
looked in, or were asked to visit him in his cell. Often this was following one of
his TIAs, but sometimes it was simply to check he had no problems that he
wished to bring to the attention of healthcare staff. When nursing staff offered
some form of treatment, he would usually decline. But at other times he would
accept help. There does not appear to have been any pattern to the man’s
refusals of offers of help.
57. On 1 January 2007, an Officer saw that the man was coughing up blood, but he
did not wish healthcare staff to attend to him. On 1 February, he was breathless
and asked to be seen by Prison Doctor A. On 17 February, C wing staff called
healthcare staff to see the man. When they arrived he was sitting in his chair, no
more short of breath than usual, without his oxygen mask on. He said he had
had ‘one of his turns’ and declined any further intervention. On 18 February, staff
again asked nurses to see him. This time when they arrived he was slipping in
and out of consciousness. His pulse was 108 beats per minute (fast) and was
very weak. After 15 minutes he became more lucid and said that he was having
more and more of these ‘turns’. The same happened on 19 February. On both
occasions he declined to go to healthcare.
58. When he was seen by a nurse on 26 March following one of his seizures, the
nurse (who cannot be identified from the record) advised that he should increase
the amount of oxygen he was taking. His response was that this would ‘get in the
way of my cigarettes’. Prison Doctor A recorded that he was smoking about 40 -
50 cigarettes a day when he saw him on 6 July.
59. The man was moved from Whitemoor to HMP Woodhill on 16 June 2008. On his
arrival at Woodhill he was admitted to the in-patient unit and assessed by Prison
Doctor B there. He recorded as follows:
• The man had COPD and was on two litres of oxygen for 15 hours of the
day.
• He also had chronic back pain.
• He had suffered from depression for the past year and had cut the artery
in his right arm in 2000.
• He was incontinent of urine.
• He suffered seizures (TIAs) which lasted between 15 and 90 minutes.
• He did not have a history of epilepsy.
15
• He had signed a Living Will and a Do Not Resuscitate (DNR) order on 25
November 2005 and a later version 29 December 2006.
• He did not want any referral to hospital or hospital admission at any time.
• He denied any mental illness, thoughts of self harm or suicide.
60. The man remained in the in-patient unit at Woodhill until 26 June when he was
moved to a cell on house unit 4B. Prison Doctor B had written details of the DNR
and Living Will in his clinical notes. These were confirmed by the man in a letter
dated 2 July that was used by the Governor in charge of healthcare, and set out
formally what was expected of staff in a range of different circumstances. The
Governor’s instructions informed staff that:
‘If the man should stop breathing or his heart stops beating he will NOT be
resuscitated using artificial ventilation (‘mouth-to-mouth’ or using breathing
equipment) or have attempts to re-start his heart (defibrillation or CPR). Staff
may put him in the recovery position and attempt to make him comfortable.
‘He has made an Advance Decision to Refuse Treatment which sets out his
wishes more specifically in relation to medical treatment, which includes being
given oxygen therapy, food, hydration, pain management and first aid for
injuries unrelated to his chronic condition.
‘In order to adhere to his wishes and plan his future care, the following must
be adhered to, if he is found unresponsive or unconscious:
1) Contact Healthcare Hotel 1/Hotel 5 via urgent message.
2) Healthcare staff, including a doctor if available, will attend and assess his
condition.
3) If he is found to be not breathing, he will NOT be resuscitated. If the doctor
has not yet attended, s/he will be called in to assess him.
4) If he is breathing but is unresponsive, then he will be given oxygen but no
other treatment and a doctor will review him.
5) If he is responsive and is able to talk to us, then we will follow his
instructions regarding what treatment he would like to receive.
6) An ambulance may be called in line with normal procedures. However,
treatment by paramedics will only commence on the instruction of the senior
nurse or doctor at the scene. The Paramedics must be made aware of both
the DNAR and Advance Directive.’
61. Following seizures on 12 August and again on 18 August, he was moved
temporarily to the in-patient unit. He returned to his cell shortly after he had
recovered from the seizures.
62. On 29 August, the man complained of an enlarged scrotum. He was seen by
Prison Doctor C, and advised that he would need an ultrasound investigation and
appointment with the urology department at the local hospital. He agreed to that
referral. However, on 14 September, he wrote a letter to healthcare staff stating
that he had been pressurised into agreeing to the urology and ultrasound
appointment. At his request, the appointments were cancelled.
16
63. Prison Doctor C saw the man on 11 November and it was agreed that he should
be referred for an ultrasound again, in case his enlarged testes were cancerous.
The man’s ultrasound appointment was on 18 November. The test results were
disclosed on 23 December. He was told that he did not have cancer but did have
a large bilateral hydrocele (this is a collection of fluid in the scrotum and is
completely harmless – it needs no treatment usually).
64. On 9 March 2009, Prison Doctor B saw the man while he was having a seizure.
Prison Doctor B monitored him throughout this seizure and asked if he would go
to hospital. At 2.25pm he declined, but at 2.50pm he agreed to an ambulance
being called. The ambulance arrived at 3.00pm but at 3.10pm he refused to go
with the paramedics to hospital. At 3.15pm he consented but at 3.30pm he
withdrew consent and this time signed a disclaimer for the paramedics. He also
refused to be admitted to the prison’s in-patient unit. Prison Doctor B recorded in
his clinical record that he had signed a DNAR order on 8 July 2008 with a review
scheduled for January 2009.
65. The man together with Governor of Woodhill, a nurse and Woodhill’s, Head of
Healthcare, reviewed his Advance Directive on 17 March 2009. The only change
was that, instead of reviewing it after every time healthcare were called to see
him, they would review the document if there was a major change to his
circumstances and at six monthly intervals.
66. On 7 May at 4.20pm, Prison Doctor B was asked to review the man who had
been having seizures during the day. Two nurses had seen him earlier and
made sure he was receiving oxygen via a mask. Prison Doctor B found him to be
conscious, but slightly confused with slurred speech. He checked his vital signs
and recorded them as blood pressure 97/60 (low), pulse 146 (fast), temperature
35.7 (normal), and blood sugar 5.7 (normal). The man’s chest was clear (no
signs of any infection). Prison Doctor B then recorded the man’s vital signs
seven further times over the next hour. His blood pressure showed improvement
over that time, although his pulse remained fast at 133 beats per minute at
5.10pm. Prison Doctor B left the man shortly after 5.10pm as he did not want any
further medical intervention.
67. Throughout the day, as was usual when he had fits, a fellow prisoner would sit
with him while he recovered. This was to offer assistance, such as a drink, and
to help the man orientate himself as he would often be confused following a
seizure. On this particular day, from early afternoon, two fellow inmates were
sitting with him. They were joined by a principle and a senior officer at
approximately 6.00pm.
68. At approximately 6.15pm, Nurse 3 visited his cell at Prison Doctor B’s request.
He found that the man was having another seizure. He was breathing without
difficulty, sitting in his chair. When he started to recover, The nurse asked him if
he wanted any assistance, but he did not respond. Some time between 6.30pm
and 6.45pm, his two fellow inmates were asked to go back to their cells as all
other prisoners were being locked up for the night. Nurse 3 was called away
from the cell at approximately 7.00pm to an incident elsewhere in the prison. The
17
man’s seizure had ended and he was left breathing without difficulty while the
principle and senior officer were in attendance.
69. Shortly after Nurse 3 left his cell, the principle and senior officer became aware
that he was no longer breathing. They both checked him for signs of life or some
response to their calls but there was none. The principle officer left the cell in
search of the nurse who was working on the unit, Nurse 4.
70. Nurse 4 arrived at the man’s cell but was unable to find a pulse or any blood
pressure. He called on the radio for a doctor to attend the cell. At this point
Nurse 3 returned, followed shortly afterwards by a senior officer who brought
emergency equipment. There was no attempt to use the equipment, but it was
brought in case it was needed.
71. Prision Doctor B arrived and checked for signs of life but was unable to find any.
He confirmed that the man had died at 7.20pm. The prison’s contingency plans
for a death in custody were then put in place. The cell was locked, and police
and Coroner’s office were informed. Staff wrote out their statements and held a
hot de-brief. Care and welfare services were offered to all staff who were
involved with his care. The two prisoners who had last been with him were told
that he had died. The chaplain came to the cell and said prayers for the man.
18
ISSUES
72. An instruction to Woodhill staff, developed over time in line with the man’s
wishes, was issued on 6 July 2008 and amended on 19 March 2009. It set out
his wishes as follows:
• ‘If he is found unresponsive or unconscious contact Healthcare Hotel 1/
duty manager via urgent message.
• Healthcare staff, including a doctor if available, will attend and assess his
condition.
• If he is found to be not breathing, he will NOT be resuscitated. If the
doctor has not yet attended, s/he will be called in to assess the man.
• If he is breathing but is unresponsive, then he will be given oxygen but no
other treatment and a doctor will review him.
• If he is responsive and is able to talk to us, then we will follow his
instructions regarding what treatment he would like to receive.
• An ambulance may be called in line with normal procedures. However,
treatment by paramedics will only commence on the instruction of the
senior nurse or doctor at the scene. The paramedics must be made aware
of both the DNAR and Advance Directive.’
73. This is largely in line with the instruction completed by HMP Whitemoor before
the man arrived at Woodhill. There was a need to review these instructions and it
had been agreed that this should be following an incident, a change in his
condition or every six months. There should have been a review of the Advance
Directive (AD) and Do Not Attempt Resuscitation (DNAR) in January 2009, but
this did not happen until two months later. In the event, the delay had no adverse
impact on the care he received.
74. The man used his solicitors to reinforce his AD and DNAR wishes. He freely
discussed the matter with staff and prisoners who wanted to know why he had
chosen this path. He said he did not want to be left in a vegetative state following
one of his many seizures or a failed resuscitation attempt. He was fearful of
being totally dependent on others for his every need. He said he did not want to
die, but was explicit about receiving no interventions to prolong his life. He was
fully aware that compliance with his wishes might well hasten his death.
75. He was full of praise for staff at Whitemoor and Woodhill, as can be seen from
two letters to Inside Time, a newspaper for prisoners, .In a letter about disability
services at Woodhill he wrote:
‘Much of the credit has to go to the ‘foot soldiers’ and I would like to thank all
those that have instigated these improvements, especially those that have
had to meet us head on in some, shall we say, less than dignified situations.
They have made a difficult situation much more tolerable.’
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In a letter about Whitemoor staff he wrote in 2005:
‘The reality is that there really are people who joined the Prison Service
believing they could make a difference. I know this to be true, because I've met
them right here in Whitemoor … and at all levels too.’
‘ … I find myself saying time and time again not that I was ‘being looked after’,
but that I was being cared for. Can you imagine how that feels?’
76. Staff at both Whitemoor and Woodhill honoured his wishes and they should be
commended for doing so. It was particularly difficult for those staff involved at the
time of his death. The resilience they showed in following his instructions to take
no action were completely at variance with the professional standards to which
they normally work.
The Governors of HMP Whitemoor and HMP Woodhill should commend
their staff for adhering to Do Not Attempt Resuscitation orders and
Advance Directive instructions instigated by the man.
77. The Clinical Review says that some of the clinical record entries are poor. Some
entries were illegible, unsigned or did not include the person’s name, while others
were not in chronological order. By and large, his medical notes are
comprehensively written, with just a few exceptions. However, I reiterate the
clinical reviewer’s recommendation that record keeping should be improved.
The Healthcare Manager should develop an action plan to ensure that
record keeping practice is of a standard consistently in line with Milton
Keynes PCT’s Record Keeping Policy and other professional standards.
78. During the man’s time at Whitemoor, there were a number of attempts to judge
his capacity to make an Advance Directive. He was seen by a consultant
psychologist specifically to judge his mental capacity on 7 October 2004, 9
December 2004 and 20 April 2006, but she was unable to make a categorical
judgement about his mental capacity at these assessments. A consultant
forensic psychologist saw him on 29 September 2005 and did feel able to say
that he had full capacity to make an Advance Directive.
79. The man would often change his mind about agreeing to hospital admissions (for
example paragraphs 50, 51 and 58 above), but he held true to his underlying
refusal to accept any life saving interventions. He seems to have occasionally
agreed to further tests, but these were usually to investigate the cause of his TIAs
or regarding his testicular cysts. I think his explicit wishes regarding the
interventions he would allow were always honoured by prison staff, much to their
credit. I appreciate that it was part of their function to test his resolve by
frequently asking if he had changed his mind, and do not think they abused that
position. I note that he wrote to his legal advisors on at least one occasion
because he felt that the prison authorities had overstepped the mark (see
paragraph 54), but the head of healthcare’s response is equally clear that staff
had not attempted resuscitation at any time. Her response appears to have been
20
accepted by him and his solicitors as there is no further correspondence on the
matter in the files.
80. The family’s three main concerns were that there should have been a doctor
present when he died, that some of his medical equipment took a long time to be
installed, and that he should have been moved closer to Wales during the latter
part of his sentence before his death.
81. My investigator explained to the man’s nephew, at their meeting on 18
September 2009 that, although there was no doctor present at the actual moment
of the man’s death, he had been seen by a doctor a short time before. Together
with the fact that he was not alone when he died, and staff who knew and cared
for him were present, this was a comfort to his nephew.
82. The man’s letters in Inside Time indicate to me that he understood the lengthy
process that prisons have to go through to have adapted cells or extra equipment
installed for disabled prisoners. He was a man who made certain that his
concerns were heard, and would not simply take ‘no’ for an answer. From the
interview transcripts and the views offered by staff and fellow prisoners, I am
confident that he would have made his feelings known if he had thought there
had been undue delay in providing him with medical equipment.
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CONCLUSION
83. At the time of the man’s remand in custody in 1999, he was a heavy smoker who
suffered from asthma and was overweight. Over the next ten years he developed
breathing difficulties that became progressively worse, restricting his mobility and
the oxygen that reached his brain. This oxygen shortage led to transient
ischaemic attacks that also worsened and induced seizures. The seizures
became ever more frequent and strong so that he took correspondingly longer to
recover from them.
84. The man declined any investigations of the cause of those TIAs and seizures.
Furthermore, he declined any sort of active medical intervention. He went one
stage further by engaging solicitors and writing instructions that he should not be
resuscitated if he became unconscious. He did not want to run the risk of being
left in a vegetative state following a seizure or failed resuscitation attempt.
85. It is clear to me that he knew his own mind in this matter. Everyone who spoke of
him liked him and respected his wishes. In the end, he passed away exactly as
he had requested. He slipped into unconsciousness, was not resuscitated and
died with dignity.
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RECOMMENDATIONS
The Prison Service have accepted both the following recommendations and have
commented in respect of each as follows:
The Governors of HMP Whitemoor and HMP Woodhill should commend their staff
for adhering to Do Not Attempt Resuscitation orders and Advance Directive
instructions instigated by the man.
The Governor of HMP Woodhill has commended staff for their care of him and
their adherence to the DNAR order and Advanced Directive instructions (by
personal letter after his death).
Staff will be reminded of the commendation as part of the Staff Information
Notice which is to be issued detailing the findings and recommendations of
the Prison and Probation Ombudsman investigation into the death of the man.
The governor of HMP Whitemoor has commended all staff for their work with
him whilst in custody at Whitemoor.
The Healthcare Manager should develop an action plan to ensure that record
keeping practice is of a standard consistently in line with Milton Keynes PCT’s
Record Keeping Policy and other professional standards.
The Electronic Patient Record System was introduced in November 2009.
This has ensured that there is a greater accessibility to a single record which
can be reviewed by all departments contemporaneously.
Advice has been sought from different departments in relation to governance
issues surrounding electronic record systems and this will be incorporated into
a new Electronic Patient Records Policy. The scheduled completion for this is
by the end of April 2010.
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