Individual at Pentonville

INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING THE
DEATH OF A MAN IN HOSPITAL IN MARCH 2005 WHILST IN THE
CUSTODY OF HMP PENTONVILLE
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2007
This is the report of an investigation into the circumstances of the death of a man in
March 2005. He died in hospital whilst serving a sentence of imprisonment at HMP
Pentonville. He was 37 years of age.
The post mortem report concluded that the man died of a cerebral infarction (a
stroke). My colleagues and I would like to extend our sincere condolences to his
family and friends for their loss.
The investigation was conducted by one of my investigating officers assisted by
another officer A panel led carried out a clinical review on behalf of the Islington
Primary Care Trust (PCT). Following receipt of their report, our investigation was
supported by a registered clinician.
Following a pre-inquest hearing, the Coroner directed I undertake further
investigation into the circumstances of the man’s death. This further work has been
undertaken by my Deputy Ombudsman and by a registered clinician. They have
endorsed the view expressed in my initial investigation. I had clearly identified
systemic failures which, in turn, HMP Pentonville had accepted and sought to
address.
I am grateful to the Governor of Pentonville and his staff for their co-operation with
my investigation team. I regret that it has taken such a long time for this report to be
completed.
My report makes five recommendations and I also endorse the eight
recommendations made in the clinical review. I have concluded that, while in the
custody of Pentonville, the man received a standard of healthcare that was
unacceptable.
Stephen Shaw CBE
Prisons and Probation Ombudsman May 2007
2
Contents
Summary
Investigation Methodology
HMP Pentonville
Events prior to the man’s death
Clinical review
Family concerns
Findings and conclusions
Recommendations
3
Summary
The man died in hospital in March 2005, at the age of 37. He was serving a
sentence of three years and three months imprisonment at HMP Pentonville.
After complaining of pains down the right side of his body on 22 January 2005, he
was moved to the prison’s Healthcare Centre for observation. He was reviewed on
23 January, and admitted to hospital on 24 January suffering from a spontaneous
collapse of the lung (pneumothorax).
Following a short stay in hospital for treatment, the man returned to prison on 4
February. He was placed on normal location on D wing, despite the hospital
discharge sheet indicating he should go to the Healthcare Centre. There is no
record that medication prescribed for him at the hospital was administered, and he
received minimal pain relief and virtually no nursing care for his surgical wound.
He suffered a further lung collapse and was returned by ambulance to the hospital
on 9 February. He was moved to a specialist hospital on 15 February for an
operation. After the surgery, he regained consciousness for only a short time before
lapsing into a coma from which he sadly never emerged.
On 25 February, the man was released from custody on temporary licence. This
was reviewed on 2 March when it was extended until 8 March. However, after a
scan on the same day revealed no brain activity, he was pronounced dead. A post
mortem carried out on 4 March found the cause of death was cerebral infarction
(stroke).
Both my investigation and the clinical review panel found that the man received a
less than acceptable standard of healthcare while in the custody of Pentonville.
My report makes five recommendations in addition to the eight recommendations
made in the clinical review undertaken by the PCT.
Further to the issuing of my first draft report, Pentonville has made substantial
progress in improving practice in those areas identified to have systemic failures at
the time of the man’s imprisonment. I have received copies of new Clinical Nursing
Guidelines for the Management, Treatment and Disposal of Patients Requiring
Nursing Intervention within Pentonville Healthcare, a new Clinical Incident Reporting
and Investigating Procedure, a new Medicines Policy including a related training
policy for staff, and a report on progress in clinical governance. In addition, I have
received a report of an audit of compliance with Governor’s Order 41/2006 Correct
procedures for the transfer of inmates to and from hospital (a follow up to Governor’s
Order 10/2005 issued on 1 March 2005). The results of the initial audit were
disappointing but an action plan for improvement has been put in place.
4
Investigation Methodology
The investigation was begun on 14 March 2005. It was led by one of my former
investigators. He met with the Governor and with a representative of the local
Independent Monitoring Board (IMB), and with the prison’s chaplain. The local
branch representatives of the Prison Officers’ Association (POA) were not available
at this time but were subsequently briefed on the nature and scope of the
investigation. All relevant available documents and records were collected.
Prior to attending the prison, notices to staff and prisoners, terms of reference and
the Governor’s notification letter were sent for distribution and display. They
announced the investigation and invited staff and prisoners to submit to my
investigator any concerns or views they wished to express.
My investigator tried to contact two prisoners who shared a cell with the man while
he was in Pentonville. One has left the country following his release from custody.
The other has not replied to correspondence.
One of my family liaison officers telephoned the man’s mother, to arrange a visit
which took place on 5 April 2005 at the family home. This meeting was very
informative and allowed his family to raise their concerns over his treatment both in
prison and in the first hospital.
As part of my investigation process, the local Primary Care Trust (PCT) is required to
undertake a clinical review of the care afforded to the deceased person whilst in
prison. In this case Islington PCT appointed a doctor to lead a panel to review the
man’s care in Pentonville, and at the two hospitals where he was treated. The panel
concluded that the care and management that the man received at Pentonville was
of an “unacceptable standard”. Once their report was received by my office, a
number of Pentonville staff were interviewed by my initial investigators to explore
further some of the issues the clinical review had highlighted, as well as to obtain
more information about the man’s time in Pentonville. These interviews took place
on 20 September 2005.
On 28 September, my investigators discussed the clinical review with the Governor,
the Head of Healthcare at the time of the man’s death, and the In-patient
Development Manager.
A key purpose of my investigations is to identify learning opportunities, and good
practice if applicable, to prevent a further death in similar circumstances. It is not to
apportion blame or identify civil or criminal liability. In the case of this man, whilst
both the panel review and my investigator identified that the care he received was of
an unacceptable standard, these were due to systemic failures rather than any one
individual.
Following a pre-inquest hearing on 11 September 2006, the Coroner, directed I
undertake further investigation into the circumstances of the man’s death. This
further investigation was undertaken by my Deputy Ombudsman assisted by a
registered clinician. They decided there was little point in re-interviewing all those
who had spoken to the original investigators. Instead, they met with the new head of
5
healthcare on 23 October 2006, and with the pharmacist and one of the prison’s
doctors on 24 October. They also re-interviewed the in-patient development
manager and a prison officer. The aim of these discussions and interviews was to
gather more information about the man’s reception back into custody following a
period in hospital, and the circumstances of the apparent missing medication. (My
remit does not stretch outside the criminal justice system and I have no express
authority to interview staff beyond the prison, probation and immigration services.)
During their further investigation, it came to the attention of my deputy Ombudsman
and the registered clinician that there might have been a breach of the Code of
Professional Conduct issued by the Nursing and Midwifery Council (NMC). Whilst
this had no material bearing on the circumstances of the man’s death, it was
highlighted to the deputy governor and head of healthcare who immediately ordered
an investigation.
Following the pre-inquest hearing, I was made aware of a substantial number of
concerns raised by the family through their legal team. The vast majority of the
concerns relate to the role of the NHS and fall outside my terms of reference. Where
the concerns are properly within my remit, I have tried to address them within this
report.
6
HMP Pentonville
Pentonville is a Victorian prison. Its primary function is to serve the courts of North
London. The prison holds sentenced prisoners, together with those on remand for
all Magistrates’ Courts and Crown Courts within the area. Pentonville has a certified
normal accommodation of 897 and an operational capacity (maximum crowded
capacity) of 1,175.
There have been six other deaths at Pentonville since June 2004. None of these
raised issues similar to those arising from the man’s death.
The HM Chief Inspector of Prisons last inspected Pentonville in February 2005. Her
subsequent report said that:
“… there was a new and impressive inpatient facility. However, primary
healthcare was limited and prisoners did not have confidence in the system.
In our survey, 23% of prisoners rated the overall quality of healthcare as good
or very good, while 45% said it was bad or very bad. The care of newly
arrived prisoners was a concern. GPs were task-orientated; nursing plans
were poor; there was a lack of health promotion; and there were serious
deficiencies in primary mental healthcare. There was poor handling and
storage of medicines including controlled drugs; no clinical supervision, no
chronic disease work and poor management of waiting lists."
“The most recent health improvement plan was dated 2002, although we were
assured that this had been updated. Islington Primary Care Trust (PCT) now
commissioned healthcare services. The PCT understood the issues and was
striving for improvement: a multidisciplinary clinical governance committee
had been established.”
(In respect of a quite separate investigation, I have seen for myself how impressive
the new inpatient facility at Pentonville is.)
7
Events prior to the man’s death
The man was sentenced to three years and three months imprisonment in August
2004 for the offences of burglary, receiving stolen goods and going equipped for
burglary. He had been on remand at HMP Brixton and returned there after
sentencing. In late August 2004, he was transferred to HMP Hollesley Bay.
At the 7.30am roll check on 9 September, the man could not be found. He had
absconded and was unlawfully at large for eleven days. He was taken back into
police custody on 20 September 2004 and sent to Pentonville the next day.
The man was assessed by the prison medical team and referred to the substance
misuse and aftercare team for treatment of his drug and alcohol dependency. From
the age of 20, the man had been using heroin and crack cocaine regularly. He said
this was because of the financial, physical and psychological problems that he was
experiencing at that time. He said that he had been drinking a large amount of
alcohol since he was 16 years old. His family have clearly indicated that he was not
a heavy drinker; they think it is likely he said he drank large amounts of alcohol in
order to obtain a prescription of diazepam. They have also informed us that after his
death the man’s liver was transplanted so must have been healthy for this to have
taken place. His family feel that this shows he was not a heavy drinker as he had
stated.
He told the substance misuse and aftercare team that, after he absconded from
Hollesley Bay, he had used heroin and crack cocaine as well as drinking strong
alcohol. This was confirmed by a positive test result of his urine. He was placed on
a detoxification programme of diazepam and methadone together with
carbamazepine.1 There was no record of any methadone being administered. The
diazepam reduction was completed on 2 October and the carbamazepine was not
administered after 19 October. After that date, he did not come to the attention of
the healthcare staff until 22 January 2005.
On 22 January, a healthcare officer was called to see the man who was complaining
of a sudden onset of chest pains and tightness down the right side of his chest. He
was admitted to the prison’s Healthcare Centre. The man was examined by a duty
nurse. He told the nurse that he had suffered with heart problems since the 1990s
as a result of his ‘crack’ habit.2 He was prescribed atrovent, salbutamol and
flucloxacillin.3 Hourly observation and assessment of his condition was ordered but
there is no documentary record of these observations taking place.
The duty nurse noted that the man had completed the detoxification programme two
weeks earlier, but this was not borne out in the clinical records made available to my
investigators. His family told my investigators that the man achieved a number of
certificates for progress on a drug rehabilitation wing. They were concerned that,
1 Diazepam is a benzodiazepine widely used in detoxification in prisons. Methadone is an opioid
analgesic recommended for treatment of heroin addiction. Carbamazepine is an anti-epileptic drug
used to prevent or reduce seizures.
2 As his family has pointed out, the information the man gave is likely to have been incorrect as his
heart was offered and accepted for transplantation following his death.
3 Atrovent and salbutamol are each a different type of bronchodilator which treats breathlessness and
flucloxacillin is an antibiotic.
8
when he completed the programme, he moved to a different wing where he had
access to illicit drugs. The man told Healthcare staff on 22 January that he had been
using heroin on D wing for the previous two weeks, but this was not substantiated by
any recorded drug tests.
A review of his condition was carried out by the in-patient development manager on
23 January. He recommended continued monitoring and observations. These were
carried out, but the clinical review finds that the assessments were poor. The in-
patient development manager suggested a course of medication, but there is no
record that this was considered.
A prison doctor also carried out a review of the man’s case on 23 January. He
suggested that a chest x-ray should be carried out to rule out a pneumothorax
(collapsed lung). An x-ray was not taken until 24 hours later when it was discovered
that the man had in fact suffered a collapsed lung. At this point, the prison doctor
contacted the Medical Registrar on duty at the hospital, about a possible right-sided
pneumothorax. Subsequently, the man was admitted to hospital for treatment. A
chest drain was inserted to remove fluid from his lung and assist re-inflation. The
man was referred to a consultant thoracic surgeon, at a specialist hospital.
On 4 February, the man was discharged back to Pentonville from hospital to wait for
a bed to become available at another hospital for the surgical examination by the
consultant thoracic surgeon. A prison officer told my investigator that prior to leaving
the hospital the man had said that he did not want to go onto the Healthcare Centre
but would prefer to go back to his own cell on D wing. The officer said that he
discussed this with the consultant, who said that he had no problem with him going
onto the wing as long as he took things steadily. However, the first hospital
discharge sheet said the man was expected to be placed in the Healthcare Centre.
The prison officer told the man that, if the medical staff at the prison agreed, then he
would be taken back to his cell instead of to the Healthcare Centre.
The man was escorted back to Pentonville by two prison officers. On arrival, he was
taken to the reception area to see medical staff before being allocated a cell.
However, due to staff shortages, no medical staff had been detailed to work in the
reception area that afternoon and the man was taken back to his previous cell on D
wing. My investigator could find no documentary evidence that the man was seen by
any member of the medical or nursing team, even though the reception and
escorting staff say that he would have done so. There are no records of any
monitoring of his condition in the six day period that he was located in his cell on D
wing.
The man was discharged from the hospital with paracetamol tablets (one gram, four
times a day) and codeine phosphate tablets (30mg, four times a day). My
investigator could find no record of what happened to the medication with which he
left hospital, although the prison officer is sure he handed it to the reception staff.
There was no record of this medication in the man’s prison prescription sheet. It was
not until 7 February that he was prescribed 1g paracetamol twice daily. There are
four entries on his prescription chart indicating he received paracetamol on the
morning of 7 February, morning and afternoon on 8 February, and morning on 9
February. There are no entries in the clinical record referring to any reason for his
9
pain. The clinical review suggests that this level of pain control may have been
inadequate. It is therefore possible that the man could have been in pain throughout
this time.
My investigator interviewed the man’s landing officer who was on duty every day that
the man was there. She said that the man did not appear to be in pain. My
investigator also interviewed two nurses who are based on D Wing. They told him
that the man did not complain of any pain and was in high spirits. On the other hand,
his parents say that, on their visit to him on 8 February, he was in considerable pain.
When the man returned from the hospital, no clear instructions about wound care
were sent with him. This particular nursing problem therefore went unidentified,
primarily because of the lack of clinical assessment on his return to prison. The first
D wing nurse told my investigator that she had placed a dressing over the man’s
existing dressing whilst he was on the wing. There is no entry in his medical records
to verify this.
On 8 February, the man received a visit from his parents. They reported that he cut
the visit short because he felt unwell. They also raised concerns with a principal
officer (PO) about some of the man’s belongings that were missing from his cell
when he had returned from hospital. The PO agreed to make enquires to try to find
them. The man’s mother says that she also asked about her son’s medication
because he was in pain. She says that the PO told her that sometimes medication is
not given because it can cause an adverse effect on the prison drug testing
programme. My investigator discussed this with the PO who has no recollection of
saying this. He also said that this was not the case as prescribed medication is
always given.
At 8.40am on 9 February, the landing officer was called to the man’s cell by his
cellmate. She found the man sitting on the floor. She immediately called for the
nurses to attend. The two D wing nurses went straight to the cell to see him. He
appeared to them to have suffered a second spontaneous lung collapse. He was
taken immediately by ambulance to the first hospital, where he was admitted and
again referred to the specialist hospital.
On 15 February, the man was transferred to the specialist hospital under escort by
two prison officers. He underwent an operation on his right lung and had a chest
drain inserted on 17 February. Shortly after the operation, he spoke to his family and
complained of being in pain. The nurses said this was due to the operation. The
man then became unconscious and was moved to the Intensive Care Unit. He never
spoke with his family again. On 23 February, a prison manager visited the hospital
and said that the escort was being reduced to one officer from that evening. On 25
February, the man was released on a compassionate temporary licence, with a
review scheduled for 2 March when his temporary release was extended until 8
March. However, after a scan on 2 March revealed that there was no brain activity,
the man was pronounced dead. A post mortem carried out on 4 March 2005 found
the cause of death to be a cerebral infarction.
On 1 March 2005, a Governor’s Order (10/2005) was issued by the governor, giving
detailed instructions about the procedure when a prisoner returns to prison from
10
outside hospital. He wrote that, without Healthcare staff involvement, ‘a number of
prisoners’ had been placed on ordinary location rather than in the Healthcare Centre
after being in-patients at outside hospital. The Order requires that all prisoners
returning from outside hospital be referred to Healthcare staff for an assessment.
11
Clinical review
A clinical review into the care of the man who died was conducted in July 2005 by a
panel which met formally on 1 August to discuss its findings. This panel was led by
a clinical reviewer on behalf of the Islington Primary Care Trust. During the course
of their review, the panel had access to all the man’s prison medical records, as well
as his medical records from the two hospitals he was admitted to.
Their report concluded that the care and management that the man received at
Pentonville was of an “unacceptable standard”. Their main concern was that, when
the man returned from the first hospital with a discharge summary sheet saying that
he should be located in the prison’s healthcare department, this did not happen.
Instead he was returned to his cell on D wing. The report is also critical of the lack of
any record that his condition was monitored whilst on D wing.
The reviewers identified that the level of record keeping and the lack of robust local
procedures resulted in a sub-optimal level of care. There was no evidence of any
clinical reassessment once the man had returned to the prison. On the contrary,
there was evidence of poor pain relief and a lack of nursing care in relation to
observations and wound care.
The review panel said that these deficiencies contributed to a delay in accessing
timely specialist intervention, and denied him access to basic nursing care. They
said it was difficult to be conclusive as to whether or not the lack of nursing care was
directly linked to the cause of death without the opinion of a Consultant Chest
Physician.
The panel considered the care and management of the man at both hospitals to
have been of an acceptable standard.
12
Family concerns
My investigator and my family liaison officer attended a meeting with the man’s
family at their home on 5 April 2005. During this meeting, his parents raised
concerns about the treatment their son received both in prison and in the first
hospital. Most of the family’s concerns about the prison have been covered in this
report, but their remaining questions are set out below. My investigation has not
looked at the actions of the first hospital, although the clinical review has covered
some of the issues raised by the man’s parents.
1. The parents say that no one from the prison told them that their son had
been moved to the first hospital on the first occasion. The man instead had
to ask hospital staff to do this for him.
There is no policy in place at Pentonville to inform a prisoner’s family when they
are taken from the prison to outside hospital. If the prisoner is taken out as a
result of an emergency or their condition is considered life threatening, then the
family would be informed at the earliest possible time.
2. The parents say that the hospital gave antibiotics to their son to treat an
infection around his wound, and cream for a rash, to take back to the prison.
They say these were not given to him when he returned to the prison.
There is no evidence on the discharge sheet that the hospital discharged the man
with antibiotics or cream. This report has already commented on the fact that the
paracetamol and codeine phosphate, which were issued on discharge, were not
given to him at the prison. The man’s mother subsequently told her legal team
that what she had thought were antibiotics were codeine phosphate tablets, a
prescription only analgesic for moderate pain.
3. The parents say that, when their son was readmitted to the first hospital,
staff there said that another hospital had called the prison three times to
inform staff that a bed was available between 4 and 9 February, but this
information did not appear to have reached the Healthcare Centre.
My investigator can find no record of these calls from the hospital or at the prison.
I am therefore unable to take this matter any further. The man’s parents may wish
to consider taking this issue up directly with the first hospital using the hospital’s
complaints procedure.
4. The parents felt that the prison’s surveillance of their son in the outside
hospitals was heavy handed towards the end and could have been reduced
earlier. They gave as examples attempts by prison staff to handcuff him
following an operation and to enter the operating theatre. They also said
that he could have been released on compassionate licence earlier than he
was.
My investigator was given access to the bed watch logs and found the
surveillance and staffing levels to be of an acceptable level. Following a check at
the hospital by one of the prison managers, the necessary paperwork was
13
commenced to release the man on temporary licence. He was released on
temporary licence on 25 February 2005 and this was due to continue until at least
8 March. Prior to his operation on 15 February, he was still mobile and able to
walk around. With a history of absconding from another prison earlier in his
sentence, in my view it was not unreasonable to withhold temporary licence at
that stage. However, a more speedy decision on the granting of a
compassionate licence once the man was unconscious and sedated in the
Intensive Care Unit might have avoided some of the distress to his family.
5. Some of the man’s possessions went missing when he was moved to the
Healthcare Centre after he collapsed the first time. His parents collected his
possessions and a CD player was missing, but there were two radios that
did not belong to him. On 28 March, his parents wrote a letter to the prison
with the receipt in order to be reimbursed for the CD player.
My investigator has spoken to the prison and I understand that the man’s mother
received a cheque from the prison on 12 April 2005 to meet the cost of the CD
player, thereby resolving this matter. However, the prison should ensure that,
when a prisoner’s personal property is removed from their cell, a cell clearance
form should be completed and a copy of the form placed in the prisoner’s file.
6. The parents say that they were not given a named liaison officer or contact
telephone number at the prison. They also feel that the prison could have
done more by way of informing them that the prison could help with the cost
of the funeral.
My family liaison officer contacted the prison to enquire about the funeral costs
and the prison has now made a contribution. My view is that the prison should
have made sure that a family liaison officer had been identified to help and offer
support to the man’s family at this difficult time.
7. On a positive note, the man’s parents wished it to be noted in this report that
the care at the specialist hospital was ‘second to none’. They also said the
prison officers who were with their son in the outside hospital were good
and had kept up his morale.
In conjunction with the pre-inquest hearing on 11 September 2006, I became aware
of many other concerns raised by the family through their legal team. The majority of
these relate to the NHS and fall outside my terms of reference as Prisons and
Probation Ombudsman. Where the concerns are properly within my remit, I have
tried to address them within this report.
14
Findings and conclusions
Upon his return to prison from the first hospital, the man was not assessed by
Healthcare staff in reception. He was placed in normal living accommodation with no
arrangements in place for his healthcare. This was a serious failure on the part of
the prison. The Governor recognised the failure when, on 1 March 2005, he issued
an Order to make sure that it did not happen again. From the wording he used, it
seems other prisoners had experienced the same shortfalls in the reception process.
The hospital faxed a copy of the discharge summary to Pentonville. This clearly
documented his medication (codeine phosphate and paracetamol), but gave no
wound care advice. The discharge summary is in the medical record but there was
no evidence that it was acted upon.
According to his family and the discharge summary, the man returned to Pentonville
with medication prescribed by the hospital doctor. There was no record of what
happened to it. The loss of the medication is a serious matter. Not only did the man
not receive it, and there is no record of it arriving at the prison, codeine–based
medication could be used as illicit ‘currency’ by prisoners if not kept under proper
control.
There was no evidence that the man received appropriate pain relief. The codeine
phosphate and paracetamol were not prescribed immediately on his return to
Pentonville. The records show he was eventually prescribed paracetamol three days
after his return. Nursing staff on the wing said that the man did not complain of pain
while he was there. The landing officer supported this, but his parents said that
when they visited him he was in considerable pain. Given his physical condition,
there is a possibility that the man had experienced pain.
Not only was the man left without pain relief, but there is no record that his wound
was dressed in the six days he was on D wing. The first D wing nurse says that she
placed a dressing over the man’s existing dressing, but this could not be
corroborated. She made no entry in his records to that effect.
The clinical review points out that the lack of documentation meant it was not
possible to say how long the man was unwell before he was returned to hospital.
It is evident in the bed watch records for 21 February that the prospects for the man
regaining consciousness were bleak. On 23 February, the officer who carried out
the manager’s monitoring visit at the hospital on 22 February wrote to the duty
governor to update him on the man’s situation. He wrote that the ward sister in the
Intensive Care Unit had told him that the brain scans were showing considerable
swelling of the brain. Until it subsided, they could not estimate how much brain
damage the man had suffered. He was to have a further brain scan later on 22
February.
On 23 February, the prison manager (who had received the officer’s note) went to
the hospital and ordered that the bed watch be reduced from two officers to one. On
that same day, the process for considering release on temporary licence (ROTL) on
compassionate grounds was initiated. Unfortunately, due to the requirement to
15
consult quite widely, and giving due consideration to the risks posed by a prisoner
who had previously absconded and had significant past convictions, ROTL was not
granted until 25 February. For the parents, the delay from the time their son became
dangerously ill until his temporary release was granted must have been very
distressing.
The prison should at an early stage have ensured that a family liaison officer was
assigned to help the man’s parents. The failure to ensure that this happened only
caused more stress for them and made effective contact with the prison difficult.
It is clear from both my investigation and the clinical review that the man received a
less than acceptable standard of healthcare while in the custody of Pentonville.
The clinical review team are unable to say definitively whether or not the lack of
nursing care contributed to the man’s death. But it is a matter of great concern that
the possibility that his death was avoidable cannot be discounted.
16
Recommendations
It is imperative that steps are now taken to ensure that the failings in the care
provided to the man who is the subject of this report cannot happen again.
Operational
1. When prisoners are dangerously ill, assessment for release on temporary licence
should be initiated at the earliest possible opportunity.
Health
I recommend that the governor and the PCT work together to ensure that the
following recommendations are implemented:
2. There should be an audit of compliance to ensure the procedures for medical
care of prisoners returning to prison from outside hospital are adhered to.
3. All medication returning to the prison with escorting staff is handed over to the
healthcare department and signed for on the escort’s paperwork.
4. A training package should be developed to ensure that all healthcare staff are
fully trained in the correct procedures for records and record-keeping in
accordance with the requirements of their professional bodies.
5. A thorough system of management checks should be developed to audit the
standard of records and record keeping.
In addition I support the recommendations of the clinical review, namely that:
• There is a review of the educational needs of nursing staff, followed by
appropriate updates/professional development to ensure competent physical
assessment and diagnostic skills.
• Systems are developed to embed training and education into clinical practice
through clinical facilitation and audit.
• There is a review of policies and procedures around the handling of unwell
prisoners and the guidance around use of prison doctor services, use of prison
‘hospital’ and threshold for admission to external secondary care providers.
• A clinical assessment framework is established and implemented to support
clinical decision making.
• There is a review of policies and procedures around prescribing, dispensing and
administering of medications by nursing staff.
• There is a review of policies and procedures in the prison ‘hospital’ to support
nurses working beyond standard parameters of clinical practice. It is not clear
how care is provided or who is responsible.
17
• A pool of medical staff should be developed to provide expert clinical opinions for
use in prison investigations and reviews.
18