Investigation report into the death in custody of Armondo Jose Nunes

Published on March 09 2012

The Prisoner Ombudsman for Northern Ireland, Pauline McCabe, today published her report into the death of 52-year-old Armondo Jose Nunes, who died of Metastatic Pancreatic Carcinoma while in the custody of Magilligan Prison on Thursday 18 November 2010. Metastatic Pancreatic Carcinoma is a cancer arising in glandular tissue that spreads to other regions of the body. In the last weeks of Mr Nunes’ terminal illness his health deteriorated quickly.

A Do Not Attempt to Resuscitate (DNAR) document, which allows a patient to instruct medical staff not to attempt to resuscitate them, was not completed before

Releasing the report, Mrs McCabe said:
“The investigation found evidence that members of healthcare staff, prison officers
and other prisoners were kind to Mr Nunes during his last weeks and days and many
efforts were made to support him. He was aware that he did not have long to live and
repeatedly refused offers of a move to Maghaberry, where his care needs could have
been better supported by the nurse-led palliative care clinic, as he wanted to spend
his remaining time in familiar surroundings with friends. His wishes were respected
and he remained at his preferred place of care at Magilligan until his death.”

The Prisoner Ombudsman identified four issues of concern requiring action by the
Northern Ireland Prison Service and South Eastern Health and Social Care Trust.

These were: Mr Nunes died. While the issue of resuscitation had been raised with Mr Nunes directly on 8 November 2010, he expressed a wish to discuss it with his family before making a decision and the issue was not followed up;

A ‘cold de-brief’, required by Prison Service policy and normally held within 14
days of the date of incident, was not carried out. This meeting would have provided
an opportunity for staff who cared for Mr Nunes to express their views and share
their thoughts with colleagues on the circumstances and their role and involvement;

There were some delays in implementing recommendations made by a hospice
nurse for adjustments to Mr Nunes’ medication. Mr Nunes was assessed on 27
October 2010 by a hospice community nurse, however the two medications
recommended were not prescribed until 4 November 2010 and 9 November 2010;

The South Eastern Health Social Care Trust had not yet engaged with specialist
palliative care organisations to develop specific pathways / models of care for
prisoners with advanced cancer and other life limiting conditions following the
publication of the “Living Matters, Dying Matters” report by the Department of Health
and Social Services and Public Safety in March 2010 to help improve palliative care
across all settings including the prison setting.

Mrs McCabe added: “These issues of concern must be addressed by the Northern
Ireland Prison Service and the South Eastern Health and Social Care Trust as part of
the current Prison Service programme for change.”