Source · Prevention of Future Deaths
Ian Emsley
Date: 8 Sep 2015
Coroner: Elizabeth Earland
Area: Exeter and Great Devon
Responses identified: 0 / 2
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Inadequate formal guidance for healthcare staff on assessing re-offending and escape risk contributed to delays in compassionate release or transfer decisions for terminally ill prisoners.
Date
8 Sep 2015
56-day deadline
3 Nov 2015 est.
Responses identified
0 of 2
Coroner's concerns
Inadequate formal guidance for healthcare staff on assessing re-offending and escape risk contributed to delays in compassionate release or transfer decisions for terminally ill prisoners.
View full coroner's concerns
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During the Inquest into Mr Emsley's death from Natural Causes in the palliative care wing at HMP Exeter, the care at HMP Exeter was highly proactive in the last 9 weeks of his life The care given, in HMP YOI Portland was less so and subject to a number of resource based constraints in end of life care provision. The result being that transfer to HMP Exeter could have been much sooner: The Clinical Reviewer found that overall it might be helpful for healthcare staff to be given formal guidance or training to assist them in making decisions regarding the assessment of the requirement of restraints and the assessment and decision making of release on compassionate grounds at Multi-Disciplinary Team Meetings involving prison (security) staff and healthcare. With lack of formal guidancelor training on the subject healthcare staff were uncomfortable with making decisions on a prisoners risk of re-offending or escape: As a consequence there is a potential for in effecting transfer andlor compassionate release for prisoners who are terminally ill, Which could also impact on the family. When you have had an opportunity to review the current procedures require a substantive response within the statuary 56 days.
During the Inquest into Mr Emsley's death from Natural Causes in the palliative care wing at HMP Exeter, the care at HMP Exeter was highly proactive in the last 9 weeks of his life The care given, in HMP YOI Portland was less so and subject to a number of resource based constraints in end of life care provision. The result being that transfer to HMP Exeter could have been much sooner: The Clinical Reviewer found that overall it might be helpful for healthcare staff to be given formal guidance or training to assist them in making decisions regarding the assessment of the requirement of restraints and the assessment and decision making of release on compassionate grounds at Multi-Disciplinary Team Meetings involving prison (security) staff and healthcare. With lack of formal guidancelor training on the subject healthcare staff were uncomfortable with making decisions on a prisoners risk of re-offending or escape: As a consequence there is a potential for in effecting transfer andlor compassionate release for prisoners who are terminally ill, Which could also impact on the family. When you have had an opportunity to review the current procedures require a substantive response within the statuary 56 days.
Report sections
Investigation and inquest
On the 10h February 2015 commenced an investigation into the death of lan Paul Emsley, aged 50 years_ The investigation concluded at the end of the inquest on the 3rd September 2015. The conclusion of the inquest was Natural Causes_ The cause of death being: Ia Metastatic Renal Cell Carcinoma
Circumstances of the death
Metastatic renal cancer Prev IV use (on methadone) alcohol excess Diagnosed with terminal renal ca Sept 2013 whilst resident in HMP Dorchester. He was transferred to HMP YOI Portland on the 26l November 2013_ Moved to palliative care wing HMP Exeter Nov 2014 with life expectancy in terms of weeks Treatment consisted of steroids and analgesia, Mid Jan 2015 course of Radiotherapy to try and ease symptoms. 29/1/15 deterioration more pronounced and by 1/2/15 was unconscious for majority of the time. Family and Nursing staff were present at approx 1820hrs 1/2/15 when he stopped breathing: Prison Dr attended to confirm death 193Ohrs 1/2/15. Police attended no sus circs. An Investigation was opened on 1Oth February 2014
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action, please see what require Of you as listed below: 1a Assessment of the requirement of restraints 1b Assessment and decision making on compassionate grounds
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Report details
- Date of report
- 8 September 2015
- Coroner
- Elizabeth Earland
- Coroner area
- Exeter and Great Devon
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Nov 2015 (estimated).
Sent to
- HMP Exeter
- HMP Portland