Source · Prevention of Future Deaths

John Henderson

Ref: 2023-0025Deceased Date: 17 Jan 2023 Coroner: Ian Brownhill Area: Mid Kent and Medway Responses identified: 1 / 1 View PDF

There was no clear process for sharing critical medical information about prisoners with chronic conditions with frontline staff, leaving officers unaware of potential medical emergencies and appropriate responses.

Date 17 Jan 2023

56-day deadline 15 Mar 2023

Responses identified 1 of 1

State Custody related deaths

Coroner's concerns

AI summary

View full coroner's concerns

The MATTER OF CONCERN is as follows. – In my decision at the end of the inquest, I stated, amongst other things: During the course of evidence, I also established that John was not being monitored any more closely than other prisoners due to his seizure activity. That was confirmed by in the course of their evidence. They indicated to me that sometimes they will be asked to monitor prisoners more closely but this had not been applied to John. Likewise, nobody had checked the welfare of John at the start of the day on 27 May 2021. I asked additional questions of witnesses and asked to have sight of policies and procedures in respect of information sharing protocols and procedures in respect of prisoners with chronic conditions, (be is seizure activity, diabetes, cardiac issues). My concern being that there did not appear to be a clear process for prisoners to consent to disclosure of medical information to front line officers so that they could be made aware that a particular prisoner may be prone to sudden or unexpected medical episodes.

My concern was that a prisoner could have a sudden (but perhaps predictable) acute medical episode and front line prison staff may not be made aware of what was causing the issue or how to respond thereto.

Responses

1 respondent

Oxleas Forensic and Offender Healthcare Services NHS / Health Body

13 Mar 2023 PDF

Action Taken

Oxleas NHS Foundation Trust has introduced a Personal Management Plan (PMP) in collaboration with HMPPS, which allows healthcare staff to share information with prison officers about prisoners with chronic conditions, including alerts on their NOMIS record and guidance for staff. (AI summary)

View full response

Dear Mr Brownhill

Re. Response to Prevent Future Deaths Report touching the death of Mr John Henderson (Date of Death: 27 May 2021)

This response is made on behalf of Oxleas NHS Foundation Trust in response to the Regulation 28 Report to Prevent Future Deaths dated 17 January 2023 following the inquest touching the death in custody of Mr John Henderson who died in custody in HMP Rochester on 27 May 2021, with the matter of concern outlined below;

My concern being that there did not appear to be a clear process for prisoners to consent to disclosure of medical information to front line officers so that they could be made aware that a particular prisoner may be prone to sudden or unexpected medical episodes.

My concern was that a prisoner could have a sudden (but perhaps predictable) acute medical episode and front-line prison staff may not be made aware of what was causing the issue or how to respond thereto.

Since this inquest, Oxleas NHS Foundation Trust has worked closely with HMPPS to introduce a Personal Management Plan (PMP) which provides a way of sharing information between healthcare staff and prison officers.

Healthcare staff identify prisoners with chronic conditions who need to be monitored closely during the induction process and seek consent to disclose medical information. When this is granted, they place an alert on the prisoner’s NOMIS record and provide guidance to staff about the level of observations necessary and the actions to take should the prisoner’s condition deteriorate. This is also recorded in the wing observation book and diary so that it is accessible to all staff. Prison staff conduct the appropriate observations and record them on NOMIS. Prisoners with PMPs are discussed daily at the multidisciplinary morning briefings held by the Governor and at the weekly Safety Interventions Meeting, both of which are attended by healthcare staff. A copy of the PMP document is attached for your information.

Private & Confidential Ian Brownhill Assistant Coroner for Mid Kent and Medway Cantium House County Hall Sandling Road Maidstone Kent, ME14 1XD Pinewood House Pinewood Place Dartford Kent DA2 7WG

Tel: 01322 625700

oxleas.nhs.uk ADD EMAIL@nhs.net

I hope my response has adequately addressed your concerns.

Report sections

Investigation and inquest

On 7 June 2021 I commenced an investigation into the death of John Allen Martin HENDERSON. The investigation concluded at the end of the inquest . The conclusion of the inquest was Natural causes 1a Ischaemic Heart Disease 1b

Circumstances of the death

Mr Henderson was found dead on his bunk in the morning by other HMP Rochester inmates. His cell mate was concerned that Mr Henderson had not moved and asked another inmate to check on him. When this was done, the deceased was discovered to be cold to the touch and no pulse could be detected. Staff were informed upon this discovery. The Ambulance Service attended and confirmed that Mr Henderson had died. Following a post mortem it was confirmed that Mr Henderson had died of ischaemic heart disease. Throughout the inquest, various evidence was heard as to how Mr Henderson had previous acute medical episodes which had required hospitalisation. Mr Henderson was undergoing neurological investigations at the time of his death and was receiving treatment for hypertension. I recorded on the record of inquest that: John Henderson was a serving prisoner at HMP Rochester. He had physical health problems which were subject of ongoing treatment and investigation. Those investigations were continuing at the time of his death but had been delayed by administrative issues. At some point late in the evening of 26 May 2021 or early 27 May 2021, Mr Henderson had a sudden and fatal haemorrhage into the wall of the left circumflex artery which caused him to die. Mr Henderson was found in his cell at HMP Rochester on 27 May 2021 having died.

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Report details

Reference: 2023-0025Deceased
Date of report: 17 January 2023
Coroner: Ian Brownhill
Coroner area: Mid Kent and Medway

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: 15 Mar 2023.

Sent to

HM Prison and Probation Service, HMP Rochester and OXLEAS NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.