Leicestershire Partnership NHS Trust
NHS / Health Body
Action Planned
An adapted version of the Track and Trigger system will be introduced, with staff trained in its use across the three Prison Healthcare Teams by October 2015. Staff will be reminded to access clinical information before seeing Prisoners. (AI summary)
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Dear Mrs Brown; Re_Derick James STANMORE Further to your report dated 01 May 2015,in accordance with paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, offer the following response. We have investigated the matters that you have raised relating t0 concerns about members of Leicestershire Partnership NHS Trust staff at HMYOI Glen Parva alleging issues ~surrounding observations and access t0 health records Leicestershire Partnership NHS Trust takes these matters very seriously and | hope that you and Mr Stanmore's family will be satisfied that we have taken the appropriate measures t0 prevent such an occurrence happening again; Service Manager for Prison Healthcare in response to the Regulation 28 has Fagreed t0 complete the following actions as this covers the scope of your matter of concern: Observations were taken on the morning of Mr. Stanmore' $ death by registered nurse: The observations were abnormal and required further action to be taken, but this was not recognised: A system similar to the hospital "Early Warning Score' (EWS) may assist the healthcare staff in recognising this and escalating care accordingly: The Healthcare Management Clinical Leadership Team will be introducing an adapted version of the Track and Trigger system as attached , Staff will need to be trained in the use of this tool across our three Prison Healthcare Teams and we anticipate that this will be in place by the October 2015 This will assist in ensuring that all healthcare staff are aware of the parameters of physical observations and be able to act swiftly in escalating any physical observations that present with potential concerns. This system iS used successfully within the Community Hospitals that are managed under the care of Leicestershire Partnership NHS Trust. Chair: Prolesor David Chiddick €BE Chiel Executive: Dr Peter Miller City willl Nout, ( 1 21548169
nurse attending Mr: Stanmore did not access his healthcare records that were available; and did not appear to have any information regarding the need for a healthcare assessment: He was therefore taking observations without the benefit of relevant clinical information in order to consider these in context Consideration should be given to ensuring all staff have appropriate access whenever possible to information before conducting examinations or observations of prisoners_ After review; can confirm that all staff are able t0 access clinical information prior t0 seeing Prisoners. Staff will be reminded that it is an expectation that when Prisoners are seen routinely, clinical notes should be accessed in order [0 make well informed clinical decision
nurse attending Mr: Stanmore did not access his healthcare records that were available; and did not appear to have any information regarding the need for a healthcare assessment: He was therefore taking observations without the benefit of relevant clinical information in order to consider these in context Consideration should be given to ensuring all staff have appropriate access whenever possible to information before conducting examinations or observations of prisoners_ After review; can confirm that all staff are able t0 access clinical information prior t0 seeing Prisoners. Staff will be reminded that it is an expectation that when Prisoners are seen routinely, clinical notes should be accessed in order [0 make well informed clinical decision