NHS England
NHS / Health Body
Action Taken
The Forward Trust provides substance misuse services at HMP Lewes and has a protocol for opioid overdose, with staff trained in naloxone administration. NHS England has developed a quality assurance framework to ensure quality standards are met in secure estate establishments and discussed concerns at the HMP Lewes Quality Board. (AI summary)
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Dear Ms King,
Re: Regulation 28 Report to Prevent Future Deaths – Neville Lewis McNair (Date of Death 16th June 2018)
Thank you for your Regulation 28 Report dated 5th November 2019 concerning the death of Neville Lewis McNair on 16th June 2018. Firstly, I would like to express my deep condolences to Neville McNair’s family.
The regulation 28 report concludes Neville McNair’s death was a result of heroin toxicity with aspiration. Following the inquest, you raised concerns in your Regulation 28 Report to NHS England that the drug misuse and dependence: UK guidelines on clinical management “Orange Book” section 5.4.9.1 states that ‘all staff including non-healthcare staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone. Naloxone should be available in resuscitation kits and risk assessed areas in the prison so that it can be accessed and administered by clinical and non-clinical staff as per the local protocol’.
The Inquest was unable to establish that there was a local protocol and none of the prison staff were aware of the requirement. You were concerned that there is no Naloxone stored on the wings other than the healthcare wing and no prison officers appeared to have been trained in its use or know of its existence. You believed this may be a national issue and not limited to HMP Lewes and in these circumstances believed the report should be a concern for all prisons and NHS staff working in prisons nationally.
In response to the matters raised I can confirm that the Forward Trust who are commissioned to provide substance misuse services in HMP Lewes have a protocol in place in line with national clinical guidelines for the handling of suspected opioid overdose and they have assured us that Healthcare staff have access to and are trained in the administration of naloxone in the prison. Naloxone is available for the first line treatment of suspected opioid overdose contained within the accessible
National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH
10th January 2020
‘grab bags’ used by staff at HMP Lewes in the event of the sudden deterioration or collapse of a prisoner. NHS England and NHS Improvement Regional Health and Justice commissioners continue to work with Forward Trust and Sussex Partnership NHS Trust to ensure that the healthcare services delivered in HMP Lewes follow the national guidance as part of their quality assurance which is overseen via the Local Delivery Quality Board, Contract Review and Partnership Boards. I can confirm that your concerns were discussed at the HMP Lewes Quality Board on 27th November. The governor at HMP Lewes who is the chair for this meeting has agreed to review the protocol. This issue has also raised concerns for NHS England and Improvement at the National level. The National Quality & Lead Nurse and the National Pharmaceutical Adviser both for Health and Justice have developed a quality assurance framework which has been sent to all Regional Commissioning teams. This will be used to assure themselves that all the quality standards in the National Clinical Guidelines are being met in all secure estate establishments. Where these are not being met an action plan will be developed and monitored by the regional commissioners via contract management processes. The results will also be presented to the local governance structures in time to go to the May 2020 National Quality Assurance Group (NQAG) where any additional work will be planned, and completion monitored. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Re: Regulation 28 Report to Prevent Future Deaths – Neville Lewis McNair (Date of Death 16th June 2018)
Thank you for your Regulation 28 Report dated 5th November 2019 concerning the death of Neville Lewis McNair on 16th June 2018. Firstly, I would like to express my deep condolences to Neville McNair’s family.
The regulation 28 report concludes Neville McNair’s death was a result of heroin toxicity with aspiration. Following the inquest, you raised concerns in your Regulation 28 Report to NHS England that the drug misuse and dependence: UK guidelines on clinical management “Orange Book” section 5.4.9.1 states that ‘all staff including non-healthcare staff and operational/security staff should have training in recognising and responding to opiate overdose including using available Naloxone. Naloxone should be available in resuscitation kits and risk assessed areas in the prison so that it can be accessed and administered by clinical and non-clinical staff as per the local protocol’.
The Inquest was unable to establish that there was a local protocol and none of the prison staff were aware of the requirement. You were concerned that there is no Naloxone stored on the wings other than the healthcare wing and no prison officers appeared to have been trained in its use or know of its existence. You believed this may be a national issue and not limited to HMP Lewes and in these circumstances believed the report should be a concern for all prisons and NHS staff working in prisons nationally.
In response to the matters raised I can confirm that the Forward Trust who are commissioned to provide substance misuse services in HMP Lewes have a protocol in place in line with national clinical guidelines for the handling of suspected opioid overdose and they have assured us that Healthcare staff have access to and are trained in the administration of naloxone in the prison. Naloxone is available for the first line treatment of suspected opioid overdose contained within the accessible
National Medical Director NHS England & NHS Improvement Skipton House 80 London Road London SE1 6LH
10th January 2020
‘grab bags’ used by staff at HMP Lewes in the event of the sudden deterioration or collapse of a prisoner. NHS England and NHS Improvement Regional Health and Justice commissioners continue to work with Forward Trust and Sussex Partnership NHS Trust to ensure that the healthcare services delivered in HMP Lewes follow the national guidance as part of their quality assurance which is overseen via the Local Delivery Quality Board, Contract Review and Partnership Boards. I can confirm that your concerns were discussed at the HMP Lewes Quality Board on 27th November. The governor at HMP Lewes who is the chair for this meeting has agreed to review the protocol. This issue has also raised concerns for NHS England and Improvement at the National level. The National Quality & Lead Nurse and the National Pharmaceutical Adviser both for Health and Justice have developed a quality assurance framework which has been sent to all Regional Commissioning teams. This will be used to assure themselves that all the quality standards in the National Clinical Guidelines are being met in all secure estate establishments. Where these are not being met an action plan will be developed and monitored by the regional commissioners via contract management processes. The results will also be presented to the local governance structures in time to go to the May 2020 National Quality Assurance Group (NQAG) where any additional work will be planned, and completion monitored. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.