Lee Curran

(1) The Prisons and Probation Ombudsman investigated Lee Terence Curran's death: At the conclusion of that investigation certain recommendations were made, two of which were as follows:
a. "The Head of Healthcare should ensure that healthcare staff take full account of family history when arranging clinical investigations for prisoners who report, or are observed to have possible signs of high cholesterol or hypertension; b "The Head of Healthcare should develop a protocol that is NICE compliant for investigating episodes of ioss of consciousness and should ensure that staff conduct clinical investigations of prisoners who experience such episodes Both of these recommendations were accepted . However the evidence given at the Inquest in relation to the implementation of recommendation was that all prisoners coming in to Forest Bank Prison undertake the reception screening process and any prisoner with any identified, or any Sign of, hypertension Is referred to the hypertension clinic: A full account of the prisoner's family history is then taken at that clinic_There was no _ the time, evidence that any action had been taken to address that part of the Ombudsman's recommendation that related to prisoners (such as Lee Terence Curran) who reported or showed signs of having high cholesterol. Likewise with recommendation b. The evidence given at the Inquest with regard to the implementation of that recommendation was that any individual who had a loss of consciousness would be automatically referred to a Doctor. That action does not encompass the whole of the Ombudsman's recommendation. Particularly it does not ensure that investigations of episodes of loss of consciousness are NICE compliant nor does it ensure that staff conduct clinical investigations of prisoners who experience such episodes: It should be remembered here that Doctors saw Lee Terence Curran on five occasions following episodes of loss of consciousness and the NICE guidelines were not followed at any time: (2) Evidence given at the Inquest revealed a potential need for the training of Prison staff as to the manner in which make entries in prisoners' medical notes. Expressly, incorrect; and potentially misleading, information had been entered in Lee Terence Curran's medical notes concerning the episodes of loss of consciousness that he experienced: For example a nurse described one such episode as a "petit mal seizure; whilst evidence at the Inquest made it clear that such could not have been the case: In addition those entering information did not make the basis upon which they were entering that information clear, that Is entered information that indicated that had witnessed an event when had not: (3) Evidence given at the Inquest also revealed a need for the training of Doctors working in prisons in that Doctors who provided general practice sessions at the prison (and in the community) gave evidence that they were unaware of the NICE Guidelines for Transient Loss of Consciousness Management in Adults and Young People despite such episodes being common in a prison environment: Additionally evidence was given by a Doctor that efforts were not made to investigate Lee Terence Curran's episodes of loss of consciousness because, the Doctor explained, it was common for prisoners to claim to have suffered losses of consciousness as a form of seeking behaviour;