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Independent investigation into the care and treatment of patient M – March 2017

East of England Published 01 Mar 2017

Patient M killed his cellmate in HMP Peterborough and was subsequently convicted of manslaughter on the grounds of diminished responsibility. The investigation was conducted jointly with the Prison and Probation Ombudsman (PPO) investigation into the death in custody of M’s cellmate.

Report PDF NHS England Source
Jump to 11 recommendations

Acceptance status

Per recommendation
No Response Published
11
Total recommendations
11
About this data

Acceptance status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.

Recommendations

11 total
100 the prison health care provider and services No Response Published
Recommendation
The educational endeavour should include positive reasons not to use, such as progressing towards personal developmental goals.
90 the prison health care provider and services No Response Published
Recommendation
It is difficult to be sure what has been used, so each situation must be managed according to the presenting problem. The most common adverse effects of NPS use – nausea, increased heart rate and agitation – will respond to … Read more
91 the prison health care provider and services No Response Published
Recommendation
If the person fails to respond, or their condition is deteriorating, they will need to be in an environment where their safety can be maintained. On assessment, this may be a place with heightened levels of observation within the prison, … Read more
92 the prison health care provider and services No Response Published
Recommendation
Prison services have considerable expertise in delivering clinical and psychosocial treatments to substance misusers. Users of NPS can be offered the same range of interventions.
93 the prison health care provider and services No Response Published
Recommendation
Prisoners who do not wish to stop using may benefit from motivational interviewing techniques to help them reflect on the part that substances are playing in their lives. Encouragement to explore the costs of using and the expected benefits of … Read more
94 the prison health care provider and services No Response Published
Recommendation
Once the person is accepting of the need for change, evidence-based interventions include an individual assessment of treatment need, and both educational and therapeutic groups. This can include group work led by prisoners. Other self-help initiatives are the establishment of … Read more
95 the prison health care provider and services No Response Published
Recommendation
Preparation for release should include specific advice about the risk of relapse, emphasizing that cannabis is a less risky choice than the synthetic cannabis in NPS.
96 the prison health care provider and services No Response Published
Recommendation
Education is the main preventative health intervention, especially in preventing the proportion of users who use NPS for the first time in prison. Topics include drug refusal skills, risks to physical and mental health, and the unpredictable effects of NPS … Read more
97 the prison health care provider and services No Response Published
Recommendation
Various methods of information sharing have been adopted, such as prison radio, poster campaigns and distributing leaflets and promotional materials. This should be a priority because prisoners report only patchy access to information, with particularly low levels of information on … Read more
98 the prison health care provider and services No Response Published
Recommendation
The prime time for conveying this information is at reception into the prison; partly for the prisoner’s safety but also to promote the culture that help with substance misuse issues is available. Specific vulnerabilities which may predispose to using in … Read more
99 the prison health care provider and services No Response Published
Recommendation
Interventions utilising a health model, for example, adopting a harm reduction approach and viewing substance misuse as a psychological disorder, are more likely to promote the alliance between prisoners and staff which is necessary for the prison community to address … Read more