Source · Prevention of Future Deaths
Marcin Mazurek
Ref: 2017-0282
Date: 7 Oct 2017
Coroner: Nicholas Rheinberg
Area: Preston and West Lancashire
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted very poor quality medical record keeping and frequent instances where daily nursing and tri-weekly GP medical checks in segregation were either not recorded or did not take place.
Date
7 Oct 2017
56-day deadline
22 Jan 2018 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 1
Coroner's concerns
The coroner noted very poor quality medical record keeping and frequent instances where daily nursing and tri-weekly GP medical checks in segregation were either not recorded or did not take place.
View full coroner's concerns
(1) Medical record keeping was of very poor quality (2) The daily medical checks in segregation by members of the nursing team and the tri-weekly checks by the GP team, were frequently not recorded in the medical notes and / or did not take place.
Report sections
Investigation and inquest
On 7th September 2015 an investigation was commenced into the death of Marcin Miroslaw Mazurek aged 32. The investigation concluded at the end of the inquest on 4th October 2017. The conclusion of the inquest was that the deceased had died by hanging. The jury further found that the deceased had spent an inappropriately long time in segregation, that there had been a failure in the proper implementation of ACCT procedures, with no multidisciplinary working and no involvement of mental health and inadequate reporting by discipline and medical teams.
Circumstances of the death
The deceased had become mentally unwell which condition was exacerbated by a very long period in segregation. He began to self-harm and ultimately hanged himself.
Action should be taken
The medical notes of prisoners are often of a poor quality, particularly in the realms of mental health. Although it is the professional responsibility of doctors and nurses to make adequate entries in the medical records of prisoners, nevertheless you might wish to consider a universal system of training and audit across the prison estate in relation to medical note recording.
Similar PFD reports
Report details
- Reference
- 2017-0282
- Date of report
- 7 October 2017
- Coroner
- Nicholas Rheinberg
- Coroner area
- Preston and West Lancashire
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Jan 2018 (estimated from the Judiciary.uk publication date).
Sent to
- NHS England