Practice Plus Group
Private Sector
Action Taken
Practice Plus Group has updated its Naloxone disclaimer form to clarify risks of refusal and revised its information-sharing process for patients discharged from HMP Moorlands, implementing new clinical handover templates and quality assurance for discharge summaries. (AI summary)
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Dear Madam
The Inquest touching upon the death of Mr Jamie Lee Bennett
Thank you for your Report to Prevent Future Deaths issued pursuant to Regulation 28 Coroners (Investigations) Regulations 2013 dated 11th May 2022 and following the inquest touching upon the death of Mr Jamie Lee Bennett, who sadly passed away on 2nd May 2020 whilst residing at Norfolk Park Bail Hostel in Sheffield following his release from HMP Moorlands on 1st May 2020.
I would like to take the opportunity on behalf of Practice Plus Group to offer my sincere condolences to Mr Bennett’s family and friends for their loss.
This letter addresses the matters of concern insofar as they relate to Practice Plus Group.
Matter of Concern
Below are the concerns quoted in the PFD report: “There were gaps in the information provided by HMP Moorlands to Norfolk Park Bail Hostel, in particular his history of substance misuse and that Jamie had refused Naloxone. The Court heard evidence that information sharing with third parties is in line with national guidelines, but also that there should have been another report by the offender management services that would have been more detailed and would have given this information to Norfolk Park. I do feel that if Norfolk Park Bail Hostel had that information, they would have been in a better position to support Jamie during those first crucial 48 hours and that may have reduced the risk of him using substances and dying.
It is my view there should be a process by which crucial information about a patient is communicated to the Approved Premise, specifically substance misuse history, any substance misuse work, any detox or re-toxification processes undertaken, and whether the patient has accepted or refused Naloxone and any community drugs services referral. It is my view this will assist the Approved Premise to determine the level of support to be offered to a resident, especially those that are released on a Friday and will have limited support from anywhere
other than an Approved Premise during the first 48 hours.
It is my opinion there is a risk that future deaths may occur unless such a process is developed.”
Response
The following actions have now been taken to address the concerns raised.
• A reflective practice session has been held with the Healthcare team following the inquest to review our processes around Naloxone.
• Information regarding a patient being released is requested from Healthcare. Such requests can come directly from the Approved Premises, as was the case for Mr Bennett. Requests for information from the Approved Premises/Probation Service are often sent as a letter to healthcare with a very brief form attached for completion, and submission back to the requesting Approved Premises. The information requested on the form for the Approved Premises (AP) is limited information. In this case the form in question provided a section to list any current medications only. However, it is acknowledged that the covering letter sought additional information.
Following the Inquest, PPG Healthcare reflected on the type of information being requested and determined that more information should be shared. Therefore, Healthcare have drafted a more detailed template (attached for reference), which provides more specific information including, medical conditions, medication, COVID vaccinations, social services input, mental health concerns including history of self- harm, and specific equipment the patient may require, substance misuse involvement including SMS history, any current substance misuse work, any detox or re-toxification processes undertaken, whether the patient has been offered and trained for Naloxone and details of any community drugs service referrals that may have been made.
The template drafted by PPG (Appendix A) if used in future would by provide the Approved Premises with the type of information which the Coroner highlighted.
It should be noted that the template provided in the case of Jamie Lee Bennett was not created by PPG; we are not responsible for the requests and templates provided by the Approved Premises/Probation service.
• A process has been immediately implemented for managing all Approved Premises information requests: − Requests for patient information received are logged onto a spreadsheet for tracking the process. − All information/medical report requests received are scanned onto the patient record on SystmOne. − Consent to share information is signed by the patient and scanned onto the patient record (SystmOne). − The Medical Record template is completed by a manager, quality assured and shared with the requesting provider. − The completed report is scanned onto the patient record (SystmOne) providing an audit trail.
• Patients are provided with advice on discharge, where appropriate, about Naloxone. I understand this occurred in the case of Jamie Lee Bennett. However, in order for greater clarity and clinical safety, the disclaimer form for Naloxone has now been updated to make the risks of not accepting Naloxone clearer, please see Appendix B. When a
patient refuses to accept Naloxone, as in this case, they should be asked to sign the disclaimer which would be scanned onto SystmOne. Such a refusal would also be recorded on the Medical Record template to a third party as noted above.
As well as the information above I understand that an additional witness statement from the Head of Healthcare, Nicola Wraith, was provided following the conclusion of the Inquest. This also provides information on the changes made.
I hope that the above information provides you with reassurance that action has been taken, to improve the processes for sharing of information for patients being released from HMP Moorlands and the level of information shared is appropriate to the patient’s needs when released into the community.
Practice Plus Group is committed to ensuring the high quality provision of healthcare services to all prisoners at HMP Moorlands and that this extends through the gate when being released. We will also ensure that the lessons learnt as a result of this inquest are shared across all of Practice Plus Group’s services.
I do hope that this letter provided the necessary reassurance sought and if I can be of any further assistance you should not hesitate to contact me directly.
The Inquest touching upon the death of Mr Jamie Lee Bennett
Thank you for your Report to Prevent Future Deaths issued pursuant to Regulation 28 Coroners (Investigations) Regulations 2013 dated 11th May 2022 and following the inquest touching upon the death of Mr Jamie Lee Bennett, who sadly passed away on 2nd May 2020 whilst residing at Norfolk Park Bail Hostel in Sheffield following his release from HMP Moorlands on 1st May 2020.
I would like to take the opportunity on behalf of Practice Plus Group to offer my sincere condolences to Mr Bennett’s family and friends for their loss.
This letter addresses the matters of concern insofar as they relate to Practice Plus Group.
Matter of Concern
Below are the concerns quoted in the PFD report: “There were gaps in the information provided by HMP Moorlands to Norfolk Park Bail Hostel, in particular his history of substance misuse and that Jamie had refused Naloxone. The Court heard evidence that information sharing with third parties is in line with national guidelines, but also that there should have been another report by the offender management services that would have been more detailed and would have given this information to Norfolk Park. I do feel that if Norfolk Park Bail Hostel had that information, they would have been in a better position to support Jamie during those first crucial 48 hours and that may have reduced the risk of him using substances and dying.
It is my view there should be a process by which crucial information about a patient is communicated to the Approved Premise, specifically substance misuse history, any substance misuse work, any detox or re-toxification processes undertaken, and whether the patient has accepted or refused Naloxone and any community drugs services referral. It is my view this will assist the Approved Premise to determine the level of support to be offered to a resident, especially those that are released on a Friday and will have limited support from anywhere
other than an Approved Premise during the first 48 hours.
It is my opinion there is a risk that future deaths may occur unless such a process is developed.”
Response
The following actions have now been taken to address the concerns raised.
• A reflective practice session has been held with the Healthcare team following the inquest to review our processes around Naloxone.
• Information regarding a patient being released is requested from Healthcare. Such requests can come directly from the Approved Premises, as was the case for Mr Bennett. Requests for information from the Approved Premises/Probation Service are often sent as a letter to healthcare with a very brief form attached for completion, and submission back to the requesting Approved Premises. The information requested on the form for the Approved Premises (AP) is limited information. In this case the form in question provided a section to list any current medications only. However, it is acknowledged that the covering letter sought additional information.
Following the Inquest, PPG Healthcare reflected on the type of information being requested and determined that more information should be shared. Therefore, Healthcare have drafted a more detailed template (attached for reference), which provides more specific information including, medical conditions, medication, COVID vaccinations, social services input, mental health concerns including history of self- harm, and specific equipment the patient may require, substance misuse involvement including SMS history, any current substance misuse work, any detox or re-toxification processes undertaken, whether the patient has been offered and trained for Naloxone and details of any community drugs service referrals that may have been made.
The template drafted by PPG (Appendix A) if used in future would by provide the Approved Premises with the type of information which the Coroner highlighted.
It should be noted that the template provided in the case of Jamie Lee Bennett was not created by PPG; we are not responsible for the requests and templates provided by the Approved Premises/Probation service.
• A process has been immediately implemented for managing all Approved Premises information requests: − Requests for patient information received are logged onto a spreadsheet for tracking the process. − All information/medical report requests received are scanned onto the patient record on SystmOne. − Consent to share information is signed by the patient and scanned onto the patient record (SystmOne). − The Medical Record template is completed by a manager, quality assured and shared with the requesting provider. − The completed report is scanned onto the patient record (SystmOne) providing an audit trail.
• Patients are provided with advice on discharge, where appropriate, about Naloxone. I understand this occurred in the case of Jamie Lee Bennett. However, in order for greater clarity and clinical safety, the disclaimer form for Naloxone has now been updated to make the risks of not accepting Naloxone clearer, please see Appendix B. When a
patient refuses to accept Naloxone, as in this case, they should be asked to sign the disclaimer which would be scanned onto SystmOne. Such a refusal would also be recorded on the Medical Record template to a third party as noted above.
As well as the information above I understand that an additional witness statement from the Head of Healthcare, Nicola Wraith, was provided following the conclusion of the Inquest. This also provides information on the changes made.
I hope that the above information provides you with reassurance that action has been taken, to improve the processes for sharing of information for patients being released from HMP Moorlands and the level of information shared is appropriate to the patient’s needs when released into the community.
Practice Plus Group is committed to ensuring the high quality provision of healthcare services to all prisoners at HMP Moorlands and that this extends through the gate when being released. We will also ensure that the lessons learnt as a result of this inquest are shared across all of Practice Plus Group’s services.
I do hope that this letter provided the necessary reassurance sought and if I can be of any further assistance you should not hesitate to contact me directly.