Redmond Johnson

In a person with the medical problems from which Mr Johnson suffered, there is always the risk of a sudden tragic cardiac event and death occurring so whether and, if s0, to what extent the failures that became apparent during this investigation contributed to this sad death could not be established in this individual situation,however,during due artery very the course of the inquest the evidence revealed matters giving rise t0 concern. In my opinion there is a risk that future deaths will occur unless action is taken: (1) Ifa detainee has a history of significant medical problems, healthcare professionals undertaking the initial reception assessment should request further information from the General Practitioner and, where necessary , hospital doctors normally involved in the detainee's care to enable appropriate care planning while that detainee is in the custody of the prison service.

(2) Reception healthcare should ask about any outstanding hospital or other healthcare appointments and rebook these if necessary: (3) Medication reviews should be conducted, with appropriate pharmacy input if required, if there are complex medication issues that need resolving or clarifying: (4) If medical tests or investigations are requested, there must be clear and adequate documentation to confirm that those investigations have actually been conducted and the results seen by a healthcare professional: (5) There must be a robust and clearly documented process in place when assessing a detainee's fitness to transfer; together with clear arrangements made in respect of any medication that the detainee needs to take while out of the prison'$ care.

(6) Information about which detainees are going to be transferred to court or other locations needs to be delivered to the individual prisons in enough time for a thorough assessment of the detainee's fitness to be transferred (including a face to face assessment if required) to be conducted.