Source · Prevention of Future Deaths

Christopher Smith

Ref: 2023-0420 Date: 7 Jul 2023 Coroner: Laurinda Bower Area: Nottingham City and Nottinghamshire Responses identified: 1 / 1 View PDF

Serious neglect in prison healthcare included unsafe cell door observations, failure to use the NEWS2 system, inadequate GP visits, and poor leadership resulting in a lack of a safe care plan.

Date 7 Jul 2023

56-day deadline 1 Jan 2024 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths

Coroner's concerns

AI summary

Serious neglect in prison healthcare included unsafe cell door observations, failure to use the NEWS2 system, inadequate GP visits, and poor leadership resulting in a lack of a safe care plan.

View full coroner's concerns

The accounts detailing Christopher’s decline over the course of a week; from a young, fit, engaging and polite gentleman, to a man who could not speak, eat, or properly stand, were harrowing for all to hear, not least his family. These accounts were supported by CCTV footage demonstrating Christopher’s extreme vulnerability on account of his acute ill health.

I remain unable to comprehend how, in the face of Christopher’s clear need for urgent medical assistance, this was not facilitated for him by those charged with the responsibility for his care, at a time when Christopher was unable through illness to ask for help. This was a clear case of the most serious neglect contributing to Christopher’ tragic death.

1. An inability to provide prisoners at HMP Lowdham Grange with safe clinical care

I heard evidence, and the jury reached findings, that there was an unsafe practice of staff conducting important healthcare and wellbeing observations via the cell door observation hatch. Observing an unwell prisoner through a hatch slightly larger than a letterbox undermines the safety of the clinical assessment.

Healthcare staff did not utilise the NEWS2 system of monitoring the condition of an acutely unwell prisoner, despite the Trust having adopted this recognised healthcare tool many years prior. The Forensic Directorate has continued to lag behind other areas of the Trust where NEWS2 is fully embedded and this has previously been identified as an issue linked to other deaths.

There was a lack of robust GP visits, despite such being mandated by the Prison Rules. When visits did take place, they were often via the cell door observation hatch and conducted as “fleeting glances” rather than robust clinical assessments. Again, this is unsafe.

There was a lack of effective leadership of the healthcare department to ensure that staff had created a safe plan of care for Christopher. Senior personnel were not aware of Christopher’s week-long deterioration in the segregation unit until very late in the chronology of events, nor were they aware of a dispute between the mental health and physical health teams as to the differential diagnoses that might be causing his concerning symptoms and deterioration. Despite daily lunch time meetings, there was a stark lack of professional curiosity from senior staff as to the plan of care for Christopher and what safety netting, if any, was in place.

2. An inability to record, retain and supply HM Coroner with material relevant to the inquest

The progress of this inquest, taking places years after Christopher’s death, was halted many times due to the late disclosure of material relevant to the inquest. Policies and procedures said to exist at the time were produced mid-hearing.

Despite the Trust having conducted their own review of the case, being provided with ample notice of the inquest hearing, and having attended multiple pre-inquest review hearings, there was an inability to identify key material and to supply that to the court in good time.

The ability to reflect on the care provided in advance of a prisoner’s death is dependant on the Trust’s ability to isolate the relevant evidence, and to analyse it. Without the appropriate professional curiosity to understand exactly what happened, the Trust will repeatedly miss opportunities to learn from deaths and to take action to seek to prevent future deaths. An example of this, is the issue of a lack of safe system for NEWS2 monitoring of acutely unwell patients. This issue has repeatedly been raised at inquests involving the Trust’s forensic division.

3. A complete lack of candour, openness and honesty when engaging in post death investigations.

Without exception, each witness from the healthcare trust accepted some level of failing in the care they provided to Christopher. Yet none of the witness statements submitted in advance of the inquest contained any such reflection of what went wrong or what should have happened. Despite a Direction from the court that the Head of Healthcare was to submit a statement “nailing colours to the mast” as to what the genuine issues of care were i.e. what policies were in place at the material time and whether care had departed from those policies, a candid statement satisfying this Direction was not forthcoming. This left the Coroner and the other Interested Persons, especially Christopher’s family, at a distinct disadvantage in identifying the actual issues, because of an overwhelming unwillingness to act in an open and honest manner, contrary to the expectations of a state agency when engaging in an inquest.

If staff are either unwilling, or are not given the opportunity, to reflect on what went wrong in an open and honest manner, then the Trust cannot seek to learn from events at the earliest opportunity, and these issues of concern will persist, leading to further deaths.

Responses

1 respondent

Nottinghamshire Healthcare NHS Foundation Trust NHS / Health Body

27 Sep 2023 PDF

Action Taken

Nottinghamshire Healthcare NHS Foundation Trust has implemented several improvements, including drill-based NEWS2 training, clear escalation pathways, and additional resources to support the rollout of NEWS2 training. They have also improved processes for supporting staff through the inquest process, including additional training and support from the Medico Legal Team. (AI summary)

View full response

Dear HMC Bower

Further to the Inquest into the death of Christopher Howard Smith I write in response to the Prevention of Future Deaths order Nottinghamshire Healthcare NHS Trust were issued on 1st August
2023.

Mr Smith died on 19th May 2019 at the Queens Medical Centre having been a serving Prisoner at HMP Lowdham Grange.

We accept the findings from the Inquest and would like to assure you that we take the findings and actions very seriously and will provide the updates below:

1. An inability to provide Christopher with safe clinical care:

Nottinghamshire Healthcare NHS Foundation Trust has undertaken a number of improvements which have been implemented by the Trust and Offender Health Care Group on NEWS 2. This includes the quality and delivery of the training (drill base) and expectations of the Trust of its attending GPs. The segreation pathway and clear escalation pathways have been implemented and are being reviewed to support safe patient care.

As a result of identifying a need to develop a training programme and approach that would ensure our staff have a greater understanding of NEWS 2 and the application of NEWS2 in a patient setting, a number of actions have been undertaken in order to address this:

• The Offender Health Care Unit brought in specific resource to support the rollout of NEWS2 training. This was in the form of the Trust’s Resus Lead who is seconded into Offender Health for two days a week for six months initially (June-December), with a view to potentially securing this resource long term to ensure there is an all-year-round training programme providing support, training, and coaching to staff on Hospital Life Support and assessing, and managing deteriorating patients. This means Offender Health have dedicated support that

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

will train staff on site and will shadow live situations within the prison and provide onsite support, training and guidance / debriefs as necessary.
• Additionally, training has been made available online to provide ease of access for staff members.
• NEWS2 training package was developed by the Clinical Leads (includes Sepsis and SBAR) which was delivered to all staff including GPs back in April 2023. Additionally, this now forms part of the local induction undertaken by the Clinical Leads for all new starters. This is delivered every month to capture any new starters during that period.
• As part of the onsite training delivered by the Trust Resus Lead, recognising deteriorating patient scenario drills are undertaken with staff. Weekly reports on the training such as any further identified training needs, are provided on a weekly basis into the Head of Nursing / Area Managers. Additionally, as an aide, a patient assessment form has been developed and put in place for staff to use in clinical situations. This now forms part of the core Emergency Response Kit and has been incorporated into the Emergency Response policy.
• The Resus Lead is attending code calls with staff on site so that he can shadow, assess competencies, and staff response, and provide feedback via a hot de-brief (one undertaken 19th July 2023).
• Escalation flow chart has been developed to assist staff and provide scenarios / context of when this might apply and what to do if unable to access an unwell patient. This has been ratified and disseminated to staff.
• There has been extensive work with the prison provider to develop relationships and clearer lines of communication. It is recognised that where there are issues around escalation or an emergency, this should be escalated to Victor 2 and / or Deputy Director or Prison Director.
• Incidents are being monitored weekly and shared with commissioners and prison provider to enable better sharing of concerns and development of joint responses to issues.
• Development of an audit programme relating to NEWS2, latest audit undertaken in August 2023, report and recommendations being compiled which will feed into internal governance infrastructures and be disseminated.
• Prison provider has changed its practice relating to the Segregation and will endeavour to ensure two staff members and a senior experienced member of staff are available in Segregation at all times. Where this is not happening, this is incident reported and / or escalated to the Prison Provider for action.
• Amendments have been made to the SystmOne Unit to ensure it is easier for staff to capture and record observations relating to NEWS2.
• A SOP describing the process of: o Admission to segregation o Healthcare review o Medication administration o Assessments from Neuro Diversion o Assessments from Substance Misuse o Assessment from Mental Health o Transfer to a secure Mental Health Unit o Assessment of access and patient risk o Management of food o ACCT o Access to GP o Complex cases and review

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

As of September 2023, all staff were 100% trained in NEWS 2 across Lowdham Grange. As a Care Unit, we have 223 staff trained out of 231 which translates as 97% compliant. The outstanding staff will be trained as a priority.

Segregation training is also being delivered as an ongoing programme by Clinical Leads, this has been done via specific, tailored sessions and forms part of the staff induction programme in both the face-to-face induction element and the physical induction pack. Additionally, Clinical Leads are also conducting spot checks on a recurring basis to ensure Segregation processes are being conducted in line with the SOP.

2. An inability to record, retain and supply HM Coroner with material relevant to the inquest

It is with deep regret that we were not able to supply you with the relevant materials to support the Coronial proces. We recognise the impact this had on your investigation but also the distress to the family, which is not acceptable. We are committed to improving this process across the Trust to ensure you and your team are provided with all relevant information to support your enquiries, and that there is support for Clinical Teams post serious incident, including where a death has occurred.

We recognise that post serious incident it can be difficult for the clinical areas to be clear on what information needs to be collected and stored to support both the investigation process and importantly, the HM Coronial process. We have therefore agreed a checklist of core information that must be collated. This will be supported by a weekly oversight group led by a senior team to both support the team but to oversee the Trust’s process for collating and storing the correct information.

We recognise that across Nottinghamshire Healthcare NHS Foundation Trust, Care Groups and Units have developed numerous policies in isolation. We introduced a Trust wide Clinical Policy Group (CPPG) approximately 3 years ago to review and amend the oversight and governance of Policies. The CPPG continue to work towards reducing the quantity of clinical policies and procedures to support ease of access and clarity for staff and also to eliminate individual Care Group Policies. To date, reduction has been achieved by producing single combined Trustwide clinical policy/procedure documents via Topic Expert Groups relating to specific areas of clinical practice, and archiving all related local clinical procedures. The CPPG has also expanded its activities to include oversight of the processes governing the creation of any new local clinical procedures and now requires approval from the group before any new policy can be implemented. Further improvements include:

• Attendee to include Learning and Development Lead to join up the training requirements form each policy.
• Production of concise and accessible Clinical Policies Bulletins providing information regarding clinical policy/procedure activity.
• Explore possibility of the addition of QR codes to Trust clinical policies/procedures for increased colleague accessibility.
• To produce a one page brief per policy to support understanding the key information.

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

• CPPG will ensure that the nominated writer has liaised with the Clinical Audit Team to determine how, when and by whom monitoring will take place to determine compliance and performance against the requirements of the policy.
• CPPG will determine that the nominated writer has identified any necessary training and agreed this with Learning and Organisational Development.

3. A complete lack of candour, openness and honesty when engaging in post death investigations

We recognise and regret that we did not undertake our duty of Candour with Mr Smith’s family on this occission. We have reviewed the process of how we embed a meaningful culture of candour in the Offender Health Care Group. This includes access to support and training from the Family Liason Team specifically in relation to Duty of Candour.

You will be aware that we have undertaken a formal review of all Offender Health cases which are due to be heard as a Coronial process and this has idetifed a number of cases where further review is required. This review recognised that not all investigations unfortunately met the Trust’s high standards of quality, candour and reflection. The further infomration provided as part of these reviews aims to strengthen our evidence and understand more about the required learning.

I can confirm that moving forward, I have bought in two indepndant investigators to support and work alongside Offender Health and they will also be allocated new Serious Incident Investigations with the aim of improving, supporting and providing leadership in this area of practice.

The Trust’s Medico Legal Team have worked hard to review their processes in terms of preparing staff members for inquests, particularly those carried out in line with Article 2. As part of this review, the Trust witness statement template has been improved upon, with clear and specific guidance included in a number of areas, including relevant training and policies, reflections and duty of professional candour.

The Medico Legal Team and senior managers now hold a weekly Inquest Oversight Meeting whereby the specific requirements of each case are reviewed and updated to ensure documents and staff members required are identified and located at an earlier stage of the process. Discussions are held in terms of any witness conflict concerns, noting the important learning that came from Mr Smith’s inquest in this regard. In addition, any staff members not engaging with the process are identified and this is escalated appropriately, with clear guidance that the Trust cannot represent staff members who do not engage with the Trust support in terms of statement provision and preparation for the inquest itself. During the pre-inquest preparation meetings with the Medico Legal Team, and where relevant any legal representative, provide a further opportunity for staff members to raise concerns as a group or individually in terms of their professional duty of candour, and addendum statements will be supported in any case whereby staff raise their concerns or reflections at a later date than their initial statements were made.

There have been four Inquest Training Days within the last 18 months, with another two planned, which have equipped attendees with the information required to fully understand and engage with the coronial process. In addition, the Medico Legal Team have been providing bespoke training

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

sessions to smaller groups in person and via MS teams and will continue to do so in order to share the important message regarding inquest requirements. These have been with team groups in general upon request but also at a relatively early stage following a death with the care team(s) involved in order to introduce the coronial process and requirements, answer any immediate questions and importantly, to ensure the messages regarding being open and reflective within their statements for the inquest and during other processes such as the serious incident investigation are shared and staff are live to their obligations and the fact they will be supported by the Medico Legal Team and Trust management in doing so.

I hope that the information contained within this response provides assurance to you and Mr Smith’s family that we, as a Trust have heard and understood the significant concerns raised throughout and as a consequence of this inquest, and that we are committed to continuing to make these important improvements to services and processes for future patient care.

Please do not hesitate to contact me should you require any further information.

Report sections

Investigation and inquest

On 06 June 2019 I commenced an investigation into the death of Christopher Howard SMITH. The investigation concluded at the end of an Article 2 compliant inquest, conducted before a jury, between 12 December 2022 and 19 January 2023. The conclusion of the jury was that:

Christopher Howard Smith, was a 35-year-old gentleman who was a serving prisoner at HMP Lowdham Grange, Nottinghamshire. Christopher died on the 19th of May 2019, at Queen’s Medical Centre, Nottingham, from a cardiac arrest, due to a massive Pulmonary Embolism, predisposed by Deep Vein Thrombosis. In spite of prolonged efforts to resuscitate him, Christopher passed away. He had a severe and enduring Mental Health condition known as Schizo-affective disorder which was controlled with anti-psychotic medication (Promethazine and Olanzapine).

The jury found multiple failings in the care and treatment provided by prison and healthcare staff. His death was contributed to by neglect.

Circumstances of the death

The jury reached the following findings of fact –

On the 23rd April 2019, Christopher was transferred to the segregation unit (known as the RIU). He was seen and recorded to be behaving strangely from the 1st of May and was recorded in the observation log by a PCO as being "off his head". A variety of staff from the 1st of May onwards, thought his presentation was due to him being under the influence of an NPS. This unusual behaviour included smashing up his cell, not engaging in the daily regime or with staff, and shadow boxing. His condition deteriorated over the course of the following days since the cessation of his mental health medication on the 1st of May. His presentation included an inability to communicate, drooling, vomiting, difficulty breathing, jerking of his limbs and inability to mobilise. This progressive deterioration was noted by both prison and healthcare staff over the following days up to the 8th May when Christopher was hospitalised. Christopher was also not eating or drinking adequately, and concerns were raised in this regard as of the 3rd of May. There were insufficient checks and inadequate record keeping by prison staff and the concerns that Christopher’s presentation raised were not thoroughly escalated through the correct channels between the 1st and the 6th of May. Prison officers were reluctant to challenge Healthcare staff regarding the lack of clinical assessments being carried out.

His progressive deterioration was recorded by both prison and healthcare staff in their respective logs and in spite of this and in spite of the stipulations of rule 45 and PSO 1700, his assessments were inadequate, and his healthcare needs were not met. His failure to take his medication was not adequately assessed nor was his mental capacity questioned. The food and fluid log was not opened until the 7th May and an NPS not opened until the 6th of May. Consequently, there were significant missed opportunities to help Christopher. A NEWS2 score was not calculated until the 8th of May, as which point it was 8. Healthcare staff were not refused or prevented from entering Christopher's cell, although there were occasions of reluctance from prison staff to open the cell door due his presentation and behaviour. Healthcare staff had adopted the unsafe practice of conducting clinical observations through the observation hatch.

On the 6th of May, Christopher was moved from his cell for hygiene reasons and to facilitate observations via CCTV. An NPS log was opened on that day for the first time but opportunities to examine him were missed. Further opportunities were missed on the 7th of May, when a food and fluid log was opened. There was confusion between physical and mental healthcare staff as to who was responsible for assessing Christopher’s health condition and providing appropriate care. There was insufficient communication between healthcare departments which was exacerbated by chronic understaffing.

On the 8th of May, the GP round was inadequate being conducted quickly through the observation hatch. Once again, opportunities for appropriate clinical observations were missed.

Clinical observations were eventually made by nursing staff for the first time shortly after 1PM on the 8th of May 2019, but there was further significant delay before the ambulance was called via contacting 999 and a code blue was not called at this time.

The 999 call was made at 1:57pm but inaccurate and insufficient information was conveyed to the call centre. A further assumption was made that Christopher was displaying symptoms due to exposure to spice.

On arrival at QMC accident and emergency department, there was no written handover given to hospital staff as per healthcare policy.

On admission, Christopher was very unwell, and hospital staff took the decision to sedate him and put him on artificial ventilation, in order that they could investigate him further. He was rehydrated and was given prophylactic treatment for DVT. There are conflicting accounts as to whether Christopher had swollen foot or feet, but this was not conveyed to the medics at QMC. Based on the fact that a fellow prisoner on RIU and prison staff at Lowdham Grange witnessed Christopher having a swollen foot or feet, we believe that on the balance of probability, Christopher did have swelling of his foot or feet.

Christopher remained on ventilation for 5 days, after which there was an improvement in his condition, but he remained unwell. He was subsequently transferred to the neurology ward on the 17th of May and a diagnosis of probable Neuroleptic Malignant Syndrome was made. This diagnosis was not considered by healthcare staff at HMP Lowdham Grange.

The probable cause of NMS could not be firmly determined based on a lack of clear understanding of the condition, which is rare. We are unable to say whether the condition was caused by either the taking or the cessation of anti-psychotic medication.

Christopher’s extended immobility in his cell resulting from NMS, in combination with his dehydration, predisposed him to the development of DVT which ultimately lead to his death due to Pulmonary Embolism.

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Report details

Reference: 2023-0420
Date of report: 7 July 2023
Coroner: Laurinda Bower
Coroner area: Nottingham City and Nottinghamshire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 1 Jan 2024 (estimated).

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Nottinghamshire Healthcare NHS Foundation Trust

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3 reports

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