Failings in care of transgender inmate who later died – report

APRISONER who died in hospital did not receive the care that she would have received in the community, a report has found.

Jane Hills died in hospital on January 25, 2019, of chronic obstructive pulmonary disease (COPD) while a prisoner at HMP Cardiff.

The prison has now been criticised in a report by the Prisons and Probation Ombudsman, which found the care received by the 66-year-old, who identified as a transgender woman, was not equivalent to what she might have expected in the community.

Staff failed to keep proper clinical records and failed to put a care plan in place to manage Ms Hills’ COPD.

Ms Hills’ medical record contained no details at all about the events on December 9 that led to her admission to hospital.

The ombudsman’s report said Ms Hills was remanded in custody, charged with possessing an imitation firearm and sent to HMP Cardiff on November 8, 2018.

Ms Hills had COPD, asthma, arthritis and a history of high blood pressure. She was treated in hospital for pneumonia, but she did not recover and died.

Ms Hills’ was the fifth HMP Cardiff prisoner to die since January 2017. Of the previous deaths, two were from natural causes, one was drugrelated and one self-inflicted.

The report said that interactions between prison healthcare staff and Ms Hills might not have been recorded.

“The clinical reviewer was concerned that Cardiff had no formal protocols in place for the management of chronic conditions,” the report said.

“The authorising governor noted the form to say that he had taken Ms Hills’ health and the risk she presented into account and agreed to the proposed escort and restraint arrangements. A nurse had not, however, given him [sic] all the information to enable him to make a fully informed decision.

“Although restraints were removed on December 10, we do not consider that Ms Hills should have been restrained at all given her poor health and mobility.”

As Ms Hills’ medical record gave no details about what had happened on December 9, the investigator asked the prison to provide statements from the healthcare staff involved. The investigator requested this infor mation on February 26 but did not receive the first of the statements until a month later and waited six weeks for the last statement. This delay was labelled as “unacceptable” in the report.

The report also added: “The clinical reviewer had concerns that other interactions between prison health care staff and Ms Hills might not have been recorded. She was unable to say on the information available whether Ms Hills’ admission was due to a sudden deterioration or whether there had been previous consultations on the same issue.

“We are concerned that the medical section of the escort risk assessment did not fully reflect Ms Hills’ mobility and state of health, which meant she was restrained inappropriately when taken to hospital.

“There was an unacceptable delay in the prison providing information to the PPO investigator. Retrospective statements show that three members of healthcare staff attended, but none of them made an entry in the medical record.”

A spokesman for Cardiff and Vale University Health Board said: “We express our deepest condolences to Ms Hill’s family and friends. We have fully accepted the recommendations of the Ombudsman. We have been working with healthcare staff to implement the required actions to address the issues in the report.”’