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§ Ms Sally Keeble (Northampton, North) (Lab)I am grateful to have secured this Adjournment debate on the treatment in prison of the late Mr. John Tero, who was my constituent. It is the second Adjournment debate about him that I have initiated. Since the previous one, which was held last July, Mr. Tero has sadly died. He spent a year in prison before his conviction was quashed in December 2001. Sadly, he finally succumbed to the cancer that he developed and that went untreated while he was in prison. He was 72 when he went into prison and 74 when he died. Although progress has been made in clarifying his treatment in prison, there are still some outstanding issues. In particular, there is the quite appalling delay in getting the case resolved. I am grateful for this opportunity to deal with some of those issues. The case also raises wider issues involving prison medical services, and it is right to take the opportunity afforded by an Adjournment debate to consider some of those too.
First, I welcome the prison ombudsman's report on the case and the fact that the two prison governors have apologised for different aspects of the administration of Mr. Tero's appeal and release. I also welcome the changes that have been made as part of the independent clinical review, and I am glad that my hon. Friend the Minister set it up. The recommendations are substantial. Each prison should have and use the current guidelines for treatment of suspected cancer. I suspect that there is quite a long way to go to ensure that those are in place and that people know how to use them properly.
Other recommendations are that each prison should have regular clinical effectiveness meetings and that changes should be made in referral systems and record keeping. Greater accountability on getting prisoners to hospital appointments is needed. It is important that these changes are fully implemented as they will go some way towards preventing some problems that my constituent so sadly experienced. More changes are needed, however, and I will set them out.
One of the biggest issues for me in dealing with this case, and for the family as well, has been the time it is has taken to get even the most basic information. Moreover, some of that information is wrong or misleading. I will give two examples. One of the first things that my constituent raised with me was his weight loss in prison, which he rightly attributed to his illness, yet I received three letters—two from my hon. Friend's predecessor and one from the director-general of the Prison Service—giving his only recorded weight as 77.5 kg, 75 kg or 77.8 kg. I repeatedly asked what explanation the Prison Service had for John Tero weighing only 66 kg when he arrived at Northampton general hospital on 8 January 2002, which was about 10 days after he left prison.
The letter from my hon. Friend's predecessor stated that Mr. Tero's weight
remained fairly stable throughout the period in question".Phil Wheatley, the director-general, wrote to me on 27 March 2003 saying that Mr. Tero's weight had increased slightly, adding that62WH
his records show no requirement to weigh him more often.When I got a copy of his prison medical records earlier this year—as a result of the ombudsman's reports and findings, not in response to my requests—I discovered that those statements are not accurate. There was a clear entry on the inmate medical record in October of John Tero's weight falling to 73 kg and a further clear entry on 14 December stating, "BW 68 kg". I take that to mean body weight 68 kg.It is clear that the Prison Service knew how much weight Mr. Tero had lost. There was no need for a review or an inquiry. All that was needed was someone being honest about what was in the prison medical records and providing the obvious explanation for it, which is that my constituent had developed a serious illness. Just yesterday—this is an example of how frustrating the case has been—I received a letter from Preston hospital with John Tero's medical records. I had asked for them some months ago. They list under his indications for an endoscopy
reflux symptoms and weight loss".It was clearly known that he had been losing weight.Furthermore, John Tero complained of being sick and unable to eat. Mr. Wheatley's letter said that there was no reference in the records to the fact that he was
declining food at this period, the only complaint recorded was one of gastric reflux.However, the records show an entry for 15 October of
vomiting after meals x 3/12".I take that to mean vomiting after meals for three months. The same note is repeated in the information that I received yesterday. Those are just three examples, and there are others. They have been profoundly damaging in the months after Mr. Tero's death as we have tried to take the family through what happened to their husband and father.Reading the inmate medical record gives a sad picture of an elderly man trying to attract attention to his steadily fading health. A steady catalogue of complaints starts on 26 April and ends when he was finally found to have cancer—on 17 December, the day before he won his appeal against conviction and two days before he went home. This is a completely different picture from that painted in the three Home Office letters that came in response to my early inquiries.
This place relies on Members being told the truth the whole truth. It is impossible for us to represent our constituents properly and to take up issues with the Government on their behalf if we do not get full and honest answers. What makes this particularly galling is the fact that if that information had been provided with those explanations—as it should have been—on the basis of an exchange of letters 17 months ago, my constituent would have probably got what he wanted, which was an apology before he died.
The issue of access to information is a big one. People have a right to information about themselves, and Departments and other agencies must respect that. On a more practical level, if prisoners are to be able to manage their health, they need access to their medical files and they need the ability to complain—as they will have the right to do—and to get improvements in their care. A closed medical system inside a closed institution 63WH will leave vulnerable the most frail and elderly prisoners. My constituent was a pensioner when he was sent to prison.
Another issue about which I am very concerned is a muddle in the record keeping. There appears to be little consistency about what is recorded and in how much detail. There is certainly enough detail in John Tero's medical records to see after the event how my constituent's health deteriorated, but I am not sure that there was enough for the doctors treating him at the time.
There are also failures in how the notes were recorded. I have spoken to my hon. Friend about that, and I think that he observed the same thing. Some entries, to put it politely, did not withstand being photocopied. For example, there is still a dispute over the date on which John Tero first reported his stomach problems. My photocopy shows 26 April; Dr. Blackburn's photocopy, which was of worse quality, showed 17 July. That is a small point, but I have requested revised copies of some pages and I would be grateful for those. The family still cannot see exactly what happened because we have not had a fair copy of some pages of the records. I will give my hon. Friend a note of those pages later.
Dr. Blackburn's review deals with many of those issues, and I certainly welcome the changes that he proposes on record keeping, but it does not deal with some of the muddle that is the reality that lies behind the records. For example, I understand that there is a procedure for getting to see someone at some prison health care units. Prisoners do not get to see a medical officer on demand; there is some gate keeping or referral by prison officers. I am not clear whether John Tero's repeat visits to the health care unit represent all his requests for medical treatment or whether he spoke to prison officers several times without a referral note going through.
It is also not clear from the records exactly who John saw when he visited the prison health care unit, whether they were doctors or nurses and what authority their notes carried. For the protection of the staff and prisoners, there must be clear, standardised procedures to allow prisoners to see health care staff, with the requests recorded. There also needs to be some clarity as to who the prisoner should see and whether they should be a nurse or a doctor. I assume that the rights of prisoners in that regard should be the same as for people outside prison in wider society. The records also show how John Tero very nearly got access to the treatment that he needed and how his hopes were cruelly dashed—not just once, but twice—because of weaknesses in the administration of the prison system.
Bizarrely, John did not get to see the more specialist doctor the first time because in the six days or so between the referral and the appointment he was declared medically fit to be moved. On the very day he was supposed to see the doctor, he was transferred to a prison almost at the other end of the country. We must ask why prisoners are transferred when they have appointments and such outstanding medical difficulties. There is a problem with churning in the prison system, which I am sure the Minister is aware of. The repeated moving of prisoners disrupts education and other programmes. Why a person who has been referred for 64WH medical treatment should be moved before they are due to receive that treatment is quite incomprehensible. It should not happen.
John Tero did not get access to a specialist doctor for a second time because a hospital appointment was cancelled owing to the lack of a prison escort. That is also completely unacceptable. It did not help that, when he finally got to the hospital, the request form for the appointment was only partially completed. I am sure that we could dispute how much priority he should have received, but it is a fact that he was not given high priority and he did not receive an urgent appointment.
I want to raise issues involving Dr. Blackburn's reports and what happens when things go wrong. It is of course helpful to have a review and I am grateful to my hon. Friend for that. However, a closed investigation of a closed institution will not persuade the outside world, much less a grieving family. The ability to have an open and transparent review when things go wrong would help to build confidence and it is also consistent with our obligations under various human rights legislation. That ability would also help to avoid some basic mistakes that have, to an extent, marred the Blackburn review for some members of John Tero's family.
One result of the decision to wait until after the report had been written to open up the review and allow the family to speak, question and give their own evidence is that now, some 17 months after John first came to see me, some basic facts are still unclear, including the date on which he first complained about stomach problems. The sequence of his complaints is also unclear, because of mix-ups involving the dates in some prison medical records. I hope that my hon. Friend understands that having to haggle over the most basic facts at this late stage continues the hardship that Mrs. Lilian Tero and her family have suffered when they need to put some of the sadness behind them. It is quite incredibly and needlessly cruel.
Therefore, I ask my hon. Friend to do the following quickly, but of course properly. He should ensure that Dr Blackburn agrees with the family the correct sequence of events during John Tero's period in Woodhill and Wymott prisons. The various evidence from the prison medical records, the prescription records, evidence from Northampton general hospital and Preston primary care trust, the information from the ombudsman's investigations and the original records—not the poor photocopies—should all be compared. My hon. Friend should deal with the outstanding request for compensation that I first made in November 2002. He should provide assurances on how the recommendations of the Blackburn review will be implemented and monitored, so that the rest of the Tero family and prison reform groups can be certain either that such cases will not happen again or that there will be proper means to deal with them if they do. I am sure that my hon. Friend has come across other cases where the family want to know not only that recommendations have been made, but that they have been implemented.
My hon. Friend would also do well to consider some wider implications of the case. What does it say about the provision of information by the Home Office and the Prison Service? How can prisoners better access health care services and, in particular, how can older and more vulnerable prisoners be protected? The problems of the 65WH prison medical service have been well documented by the chief inspector of prisons and by prison lobby groups, in particular the Prison Reform Trust. The chairman of the British Medical Association civil service committee has described the prison medical service as a "crisis waiting to break". That was in 2001, but many of those criticisms still hold true. With an ageing prison population and serious levels of mental illness among prisoners, the demands on the service are huge and growing. It needs to be able to meet those needs in a professional manner that provides proper medical care and respects the humanity and dignity of the prisoner.
It will not do to say that John had a terrible form of cancer and that the outcome would sadly have been the same, because that is not the point. He could have been spared much physical suffering and mental anguish, including that of dying with a burning sense of injustice over the treatment he received. My constituent wanted other people to be spared what he suffered, and I hope that that is the final outcome of this very sad case.
§ The Parliamentary Under-Secretary of State for the Home Department (Paul Goggins)I congratulate my hon. Friend the Member for Northampton, North (Ms Keeble) on securing this debate. Once again, she has rightly brought to the attention of the House in a fair and balanced way her concerns about the health care and medical treatment that was given to her late constituent, Mr. John Tero, when he was in prison.
My hon. Friend first raised this issue in correspondence with my predecessor at the Home Office and subsequently raised it in a debate in the House on 14 July last year. As she mentioned, Mr. Tero sadly died on 22 September last year. Even at this late stage, I join her in expressing my condolences to Mrs. Tero and other members of her family.
I listened carefully to the points made by my hon. Friend, and I have had the opportunity to discuss the matter with her several times outside the Chamber. I pay tribute to the tenacity with which she sought to get at the facts of the case. It is clear that if she had not done so, some of the information that we now have would have remained unclear or even unknown. I hope that she will find it helpful if I respond initially by setting out some of the background.
Mr. Tero was first received into Woodhill prison on 15 December 2000. In May 2001, he successfully underwent surgery for a condition that had been diagnosed before he went to prison. At around the same time—I shall return to this issue later in my speech—he began to report symptoms of what turned out to be a different condition. During the next few months, he was seen several times by the NHS general practitioners working at Woodhill, who prescribed medication for him.
Mr. Tero was transferred to Wymott prison on 9 October 2001. During the routine reception health screening, his continuing health problem was again identified and recorded. On 15 October 2001, he consulted a doctor at Wymott with more symptoms. In view of that development, he was referred to a local NHS hospital for special investigation. Regrettably. the first appointment made for him for 20 November was cancelled at short notice. A new one was arranged for 12 66WH December. When the investigation eventually took place, it revealed a serious condition—cancer of the oesophagus—that merited further intervention. The hospital made another appointment for him on 19 December. As my hon. Friend explained, however, he was released from Wymott on that day, and subsequently underwent treatment for his condition from the NHS in his home town of Northampton.
Mr. Tero's weight remained largely stable until October 2001, but it dropped significantly when he was released from prison because of the development of his illness. On 1 April, I wrote to my hon. Friend to apologise for the erroneous information provided in earlier letters from the Prison Service and the Home Office about his weight loss. It is clear from Mr. Tero's medical records that between 4 October and 14 December 2001, his weight fell from 77 kg to 68 kg. It is regrettable that this was not confirmed earlier to my hon. Friend. The letters were written in good faith, but they fell short of the standard that should be expected. Again, I apologise.
Last July in the House, my hon. Friend voiced several serious concerns about Mr. Tero's treatment in prison, which she felt merited at the very least a full apology for the suffering and hardship that he had experienced. I said in my response that I would be the first to offer such an apology on behalf of the Home Office and the Prison Service if one was merited. To enable me to make a proper judgment, I asked the director of prison health to arrange for an independent clinical review of Mr. Tero's care and treatment in prison. In turn, he commissioned Dr. Joseph Blackburn, a general practitioner and clinical governance lead for North Surrey primary care trust, to conduct that review. I welcome the welcome that my hon. Friend gave to that clinical audit.
Dr. Blackburn submitted the report of his review on 25 November, but was then asked, at my hon. Friend's suggestion, to take into account Mr. Tero's own notes, which he had passed to her. She also asked that Dr. Blackburn interview Mr. Tero's family before completing his report. However, although there was sympathy for the family's position, it was not readily apparent that asking Dr. Blackburn to interview them was likely to add anything of substance to what was intended to be a tightly focused clinical review of Mr. Tero's care and treatment in prison.
One recommendation in Dr. Blackburn's report was that an NHS consultant oncologist should be asked for a specialist opinion on whether an earlier diagnosis might have increased Mr. Tero's chances of being cured of his oesophageal cancer by treatment. That recommendation was accepted, and Dr. Blackburn commissioned Dr. Daniel Hochhauser, the Kathleen Ferrier reader and consultant in medical oncology at the Royal Free and University College medical school in London, to provide that report.
After Christmas, I wrote to Mrs. Tero to offer her the opportunity of a meeting with officials at which the contents, conclusions and recommendations of Dr. Blackburn's report could be disclosed to her together with the Prison Service's response, including any appropriate apology. Dr. Hochhauser completed his report on 27 February. That enabled me to send copies of both reports to Mrs. Tero in good time for that 67WH meeting, which took place in the House on 15 March. I am very grateful to my hon. Friend for helping to arrange that.
In my covering letter to Mrs. Tero, I gave an indication of both doctors' principal conclusions. I also offered her my sincere apologies for the failures that Dr. Blackburn had identified in the medical treatment afforded to her husband at both prisons. Dr. Blackburn's principal findings, which we accept entirely, were that Mr. Tero should have been referred for specialist opinion at an earlier stage during the time that he was in Woodhill prison, and through the urgent cancer referral guidelines. If that had been done, it is clear that we would not have transferred Mr. Tero to Wymott prison in October 2001. In addition, Dr. Blackburn concluded that the appointment for the endoscopy made for Mr. Tero while he was at Wymott should not have been delayed owing to a lack of escort staff.
I should add for completeness that we have also accepted two findings of the prisons and probations ombudsman, whom my hon. Friend asked to look into other aspects of Mr. Tero's treatment. Those findings were that there was maladministration at Woodhill prison in his appeal paperwork and that the Prison Service should have taken more care when releasing him and in helping him to travel home.
At the meeting on 15 March, my hon. Friend raised several questions about the documentation used by Dr. Blackburn that it had not been not possible to resolve at that time. One significant issue was that copies of entries in Mr. Tero's medical record, of which she had obtained a copy, suggested that he had complained about a stomach problem some time earlier than was indicated in Dr. Blackburn's report. It appeared that Dr. Blackburn's conclusions were based on an incomplete copy of Mr. Tero's medical record. It was therefore agreed that the prison health team would obtain and check my hon. Friend's assertion against Mr. Tero's original inmate medical record. Dr. Blackburn would then, as a matter of urgency, consider whether the points made by my hon. Friend affected his report and revise it if appropriate.
It was agreed that Dr. Blackburn and Dr. Howells, the medical director in the prison health team, who was also present at the meeting, would then meet Mrs. Tero and her son again, this time in Northampton, to discuss the outcome of the further work. Dr. Howells went on to offer Mrs. Tero and her son a personal apology for the failures in the care and treatment afforded to Mr. Tero. He also explained the specific actions that were being taken to ensure that the lessons of his experience were fully learned at both local and national level. I am sure that my hon. Friend and the House will want me to set out some of those this afternoon.
First, the prison health team will ensure that all prison health care managers are reminded of the referral guidelines for suspected cancer that were issued to all general practitioners in health service circular 2000/13.
Secondly, managers will also be asked to ensure that those guidelines are considered at local clinical effectiveness meetings as part of their local clinical 68WH governance systems. I assure my hon. Friend that appropriate action on both issues is already being taken at the two establishments most immediately concerned.
Thirdly, the prison health team will seek to ensure that every prison establishment has a system in place for identifying priority out-patient referrals to hospital and managing them appropriately. They will do so by including appropriate material in proposed prison service orders, both on improving continuity of care and governors' responsibilities.
Fourthly, the prison health team will produce guidance on the special circumstances of discharging prisoners who are physically ill, which will also be included in the new Prison Service order on improving continuity of care. When the new prisoners' clinical record comes into use later this year, it will be accompanied by guidance to staff on the proper completion of medical entries. That point was made by my hon. Friend and I assure her that issues such as the sort of pen that should be used when making notes will be important, particularly with reference to the medical record to which she referred.
Finally, to ensure that issues raised about the performance of NHS organisations outside prison are also reviewed, the prison health team will send copies of the reports from Dr. Blackburn and Dr. Hochhauser to the clinical governance leads at the relevant NHS trust.
Dr. Howells concluded the meeting with Mrs. Tero and her family by explaining the general background of the changes now under way to the organisation and delivery of health services to prisoners, which will culminate in primary care trusts assuming full commissioning responsibility for prison health services by 2006. He agreed to set that out fully in writing to Mrs. Tero and her son after the meeting in Northampton. With regard to the powerful point that my hon. Friend made towards the end of her speech, with that move to commissioning in 2006—it has already begun, but it will be complete by 2006—there will be proper NHS oversight of the health care that is available in all our prisons. That will lead to higher standards.
A number of outstanding issues remain in this case and I believe that the best way to resolve them is, in the first instance at least, to proceed along the lines agreed with my hon. Friend, Mrs. Tero and her son at the conclusion of the meeting on 15 March. In addition, my right hon. Friend the Home Secretary agreed to meet my hon. Friend, Mrs. Tero and her family in an attempt to bring this sad experience to a conclusion.
With regard to the request for compensation in the form of an ex gratia payment to Mr. Tero's family, I will establish immediately a process for giving careful consideration to this matter. It will not, of course, be possible to reach a final conclusion until Dr. Blackburn has concluded his further work.
I will continue to liaise with my hon. Friend as matters progress towards a conclusion. Nothing can put right the errors that have been made and nothing can bring Mr. Tero back, but I shall not be happy until Mrs. Tero and my hon. Friend are happy that they are in full possession of all the facts and that all the appropriate action has been taken.
§ It being half-past Four o'clock, the motion for the Adjournment of the sitting lapsed, without Question put.