Zeeyad Hamadi · Prevention of Future Deaths report

On 6th January 2014 I commenced an investigation into the death of Zeeyad Hamadi. The investigation concluded at the end of the inquest on 8th January 2014. The conclusion of the inquest was Natural Causes.

The deceased was a prisoner serving a sentence at HMP Frankland. He became unwell and after the prison GP had been unable to make a diagnosis he was transferred to University Hospital of North Durham. Thereafter he was diagnosed with Hodgkins Lymphoma. The deceased sought a transfer to St Bartholomew’s Hospital, West Smithfield, London so that he could receive a form of chemotherapy treatment from the world’s leading expert in such matters on a private paying basis. There was considerable urgency attached to the proposed move to London as the deceased’s health was rapidly deteriorating and medical advice was that treatment should commence as soon as possible. It took some time for arrangements to be completed to facilitate the transfer from UHND to Bart’s. The deceased’s health deteriorated during this time.

(1) The evidence disclosed that the deceased had not been weighed at the times of medical appointments and a history of weight loss would have been a useful diagnostic tool. Not all medical consulting rooms at HMP Frankland had scales to do so and doctors/nurses did not routinely weigh patients.
(2) It was accepted in evidence that the standard of record keeping in the patient’s medical notes was not as good as it could or should have been. There was lack of clarity as to when certain medical information (for example blood tests results) were available for interpretation by a doctor, by paper or electronic means, there was lack of clarity as from the computer printouts of medical records when entries were inputted into the system and were available for view, who was the author of the entry (as opposed to who inputted the data).
(3) There was limited liaison between health care staff in HMP Frankland and medical staff at UHND to monitor the deceased’s medical condition once he had left the prison. When a decision was made by the deceased to seek treatment in London on a private paying basis this information was not speedily communicated to those responsible for health care in HMP Frankland and contact was made by a hospital doctor with a duty governor at the prison who in turn had to refer to the health care manager. Confusion developed as to the basis of the proposed move to Bart’s from UHND; whether this was a prison to prison transfer or whether it was a relocation of the deceased from one hospital to another whilst remaining the responsibility of HMP Frankland. There was confusion over the funding arrangements for this proposal; whether the local NHS would be responsible for the medical treatment or the costs of transport, the form of such transport and/or the costs of bed watch. The brother of the deceased confirmed to different people at different times that he would undertake to be responsible for the costs incurred (subject to a challenge by Judicial review) and it took some time for the issues of funding to be identified before being addressed and resolved. There was a lack of clarity of understanding who would be responsible for what and when, so far as money was concerned and who would have the responsibility for payment in the first place prior to reimbursement by the deceased’s brother. There was no formal policy in place to deal with the situation. There was lack of clarity in the rules that were referred to in evidence as to how and when a convicted prisoner is entitled to private health care as opposed to a prisoner on remand.
(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented.

Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS.