Scotland: Fatal Accident Inquiry

Stephen Masson

Reference GLW-B830-21 Published 20 March 2023 Sheriff Sheriff Considine Sheriffdom Glasgow and Strathkelvin Date of death 6 December 2018 Location HM Prison Barlinnie, Glasgow Cause of death 1a Hanging. Section 28 responses identified 1 8-week deadline 15 May 2023

Recommendations

Recommendations (the sheriff's words)

The sheriff having considered the information presented at the Inquiry, in terms of section 26(1)(b) of the Act, in having regard to matters mentioned in section 26(4) of the Act recommends that: (1) A note of all ongoing prescriptions currently prescribed to a patient should be registered with the NHS regardless of the prescriber to allow healthcare professionals immediate access to details of a patient’s medication. (2) A clear and robust system should be put in place to ensure that all prescription medication is provided without delay to a prisoner once confirmation is received and a system should be in place before the end of each day where confirmation is awaited to confirm if a reply has been received to ensure that a prisoner is receiving the correct medication.

Under section 28 of the 2016 Act, each recipient of a recommendation must respond within 8 weeks. The 8-week window is counted from the publication date. See how we track responses. Go to the section 28 responses.

Section 28 responses 1

Overall status, as assessed by this site: Response(s) published

NHS Greater Glasgow & Clyde

NHS Trust · Source ↗

Response (the responding body's words)
SHERRIFDOM OF GLASGOW AND STRATHKELVIN AT GLASGOW
COURT REF: GLW-B830-21
Response
to the
Determination of Sheriff Gerard Considine Under THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC. (SCOTLAND) ACT 2016
IN THE
INQUIRY INTO THE DEATH OF STEPHEN MASSON
To:  the Scottish Courts and Tribunals Service
NHS Greater Glasgow and Clyde, being a person to whom recommendations under section 26(1)(b) was addressed, do respond as follows:
NHS Greater Glasgow and Clyde was a participant in the inquiry.
The recommendations were:
A note of all ongoing prescriptions currently prescribed to a patient should be registered with the NHS regardless of the prescriber to allow healthcare professionals immediate access to details of a patient’s medication
NHSGGC can advise that there is as yet no e-solution in place to allow this locally or nationally. Whilst work is ongoing regarding the development of Vision Anywhere to link patient data between Prison Healthcare and General Practice, this excludes information held by Police Custody Health Services. In the interim, there is national discussion taking place, involving the Scottish Government, about what further improvements can be made to Adastra, the current Police Custody system. Read-only access to Adastra following a systems upgrade is now possible, allowing for improved information sharing between Policy Custody and Prison Health care teams until a permanent cross-function e-solution can be delivered.
A clear and robust system should be put in place to ensure that all prescription medication is provided without delay to a prisoner once confirmation is received and a system should be in place before the end of each day where confirmation is awaited to confirm if a reply has been received to ensure that a prisoner is receiving the correct information.
NHSGGC is satisfied that a clear and robust system remains in place, noting that the delay in delivering medication was caused by very unusual and unfortunate circumstances which have not re-occurred since this incident.

About Fatal Accident Inquiries

Fatal Accident Inquiries are held under the 2016 Act before a sheriff. They are mandatory for deaths in custody and at work. The sheriff may make recommendations under s.26(1)(b); recipients must respond within 8 weeks under s.28. See the methodology page for detail.

Data: scotcourts.gov.uk.