Individual at Manchester

Investigation into the circumstances surrounding the death
of a man at North Manchester General Hospital in November
2007 whilst in the custody of HMP Manchester
Report by the Prisons and Probation Ombudsman for
England and Wales
July 2008
This is the report of an investigation into the death of a man who died of
natural causes in November 2007, at North Manchester General Hospital,
whilst in the custody of HMP Manchester. He was 51 years old.
I would like to add my personal condolences to those already expressed to
the man’s family by one of my Family Liaison Officers.
This investigation was undertaken by one of my investigators. Both he and I
would like to thank the Governor and his staff for their participation in the
investigation. Manchester Primary Care Trust undertook a review of the
man’s clinical care, and I appreciate its assistance and report. However, the
clinical review into the man’s death was not received in my office until the
middle of June 2008 and this has resulted in the delay in my issuing this
report, for which I must apologise.
As is the case in many of my investigations following a death from natural
causes, I am heavily influenced by the findings of the clinical review. The
clinical reviewer finds that the man’s health deteriorated while in prison, and
he received prompt treatment of a good standard. There are some areas
where performance could be improved, but they did not make a material
difference to the man’s health and certainly did not cause or hasten his death.
There have been 19 deaths of prisoners of HMP Manchester since I took over
responsibility for investigating deaths in custody. This case is not comparable
to any of the others, but two of my previous reports included
recommendations about the use of individual nursing care plans. The clinical
reviewer for this report again makes such a recommendation. I am pleased to
see that the prison has since introduced an assessment tool to produce such
plans. This being the case, I do not make a recommendation and I hope that
the new tool is monitored to ensure that it is effective.
This report has been anonymised for publication on the website of the Prisons
and Probation Ombudsman.
Jane Webb
Deputy Prisons and Probation Ombudsman
July 2008
CONTENTS
Summary
The investigation process
HMP Manchester
Key findings
Issues
Clinical care
Conclusion
Recommendations
SUMMARY
The man who is the subject of this report was 51 years old when he died in
November 2007, in North Manchester General Hospital whilst in the custody
of HMP Manchester. He was received into custody in June 2007, when
arrested at Manchester Airport whilst entering the country. He was
subsequently convicted and sentenced to six years’ imprisonment.
On reception into prison it was noted that the man suffered from ill-health,
specifically diabetes which was controlled by tablets, and hypertension.
Between reception into prison and his death, healthcare services monitored
his known health problems and worked with outside health providers in North
Manchester General Hospital.
By late October, the man’s health had deteriorated and he was admitted into
North Manchester General Hospital. He remained in hospital for seven days,
the prison maintaining regular contact with the hospital in this time. The man
had not provided any details for next of kin or anyone to be contacted in an
emergency. As his condition was not thought to be imminently life-
threatening, no attempts were made to contact his family. He returned to
prison on 25 October.
On his return to prison the man was located as an in-patient in the healthcare
wing. He remained there until the morning of 6 November, when one of the
nurses, on checking patients, found him lying on the floor of his cell. An
ambulance was called, and he was taken to North Manchester General
Hospital. It was subsequently confirmed that he had suffered a stroke.
The man remained in hospital for a week, and appeared to be stable.
However, at approximately 5.40pm on the evening of 13 November, he
suffered a fit. Medical staff attended immediately, and attempted to revive
him. Escorting officers removed the restraints on the man, and a crash team
arrived and attempted to revive him. Sadly, they were unsuccessful, and at
6.00pm escorting officers were told that he had died.
The clinical review identified that broadly speaking, the man received good
medical care in prison. His known medical conditions were treated, and he
received regular monitoring and treatment as his health deteriorated. There is
a need to ensure that there is a system that identifies actions requiring follow-
up, but this did not materially affect the man’s death. I make four
recommendations.
THE INVESTIGATION PROCESS
1. My investigator visited the prison. He spoke to a number of staff there,
including the Governor, and was shown extensively around the prison.
He formally interviewed two members of staff. These interviews were
tape recorded and both interviewees signed a copy of their transcripts
confirming the accuracy of the record. Notices were posted to staff and
prisoners about the investigation, inviting contributions. No responses
were received. My investigator studied all available relevant prison
records relating to the man. These included his security record, medical
records and statements made by staff. Unfortunately, the man’s wing
history file could not be found and despite staff’s efforts to locate it, it
remains missing.
2. Manchester Primary Care Trust carried out a review of the man’s clinical
care. I am grateful to it for undertaking this review. My investigator
discussed aspects of the man’s treatment with both healthcare staff at
Manchester and the clinical reviewer.
3. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of my investigation and to request a copy of the Post
Mortem report. Upon completion, my report will be sent to the Coroner
to assist in his enquiries into the man’s death.
4. The man was Nigerian, and his family live in Nigeria. One of my Family
Liaison Officers contacted the representative of the man’s family in the
United Kingdom to offer the opportunity to raise any questions or
concerns for the investigation to consider. They were also offered the
opportunity to see my report at draft and final stages. The man’s family
said that he was a diabetic and suffered from high blood pressure
(hypertension), and asked if the investigation could ensure that he
received the appropriate care. They also wanted to know the exact
cause of the man’s death. I hope I have answered these questions to
their satisfaction in my report. My Family Liaison Officer gave contact
details for my office and advised them not to hesitate to contact us if
they had any further points they wished to raise. The family requested a
copy of my report when available.
HMP MANCHESTER
5. HMP Manchester was originally opened in 1868. It is a category A local
prison accommodating male adult prisoners. It holds those sent to
custody by courts in the Greater Manchester area (remanded, convicted
or sentenced) and allocates to training prisons if/when places are
available.
6. Major disturbances in 1990 led to the prison being rebuilt, and in 2003
Manchester became part of the high security estate. The prison consists
of two separate radial blocks, and its mix of single and double cells all
have power points and integral sanitation. As of October 2006 it had
capacity to hold 1,269 prisoners.
Healthcare
7. Healthcare is housed in a self-contained two-level block. Out-patient
provision is on the lower level, and in-patient facilities are on the upper
level. There are 38 beds for in-patients. Including medical and
discipline staff, there are approximately 70 members of staff who work in
the healthcare department.
8. Healthcare provides 24-hour nursing cover. Doctors are on site from
8.00am until 9.00pm at night on weekdays, from 10.30am until 3.00pm
on Saturdays, and for two hours on Sundays (the exact times are not
set). Beyond these hours, emergency cover is provided from outside by
the Primary Care Trust.
Foreign national prisoners
9. In November 2007, there were 194 prisoners in Manchester who were
foreign nationals. This included prisoners detained under immigration
legislation. This amounts to just under 16% of the prisoner population.
Of this number, 20 were of Nigerian origin.
10. There are no official support networks for foreign national prisoners, but
the prison are aware of the particular difficulties such prisoners can face.
The prison uses a telephone instant translation service for prisoners who
cannot speak English. Induction packs contain information for prisoners
who are foreign nationals, though this concentrates on immigration and
repatriation issues. As noted above, the man spoke and understood
English, and being a foreign national does not seem to have played a
part in his death.
Previous deaths in Manchester
11. There have been 19 deaths of prisoners at Manchester since I took over
responsibility for investigating deaths in custody. The death of the man
who is the subject of this report is not directly comparable to any of the
other deaths, so I will not list my previous recommendations here. But
two of my previous reports do include recommendations about ensuring
that patients are given nursing care plans. The clinical reviewer again
draws attention to this in the report for this investigation.
Her Majesty’s Inspectorate of Prisons (HMIP)
12. Her Majesty’s Inspectorate of Prisons last visited the prison in an
unannounced visit in May 2007. The report showed the prison as
improving from the time of the previous inspection. None of the issues
raised in the report are particularly relevant to this investigation.
Independent Monitoring Board (IMB) report covering the period 1 March
2005 – 26 February 2006
13. Each prison in England and Wales has an Independent Monitoring
Board responsible for monitoring day-to-day life in the prison and to
ensure that proper standards of care and decency are maintained. The
last report published by the IMB when the man arrived in Manchester
does not raise any issues which I consider need to be noted here.
KEY FINDINGS
14. The man was arrested at Manchester Airport in June 2007 and he was
remanded to HMP Birmingham. His reception notes show that he said
that he had no previous experience of prison, and the Police National
Computer confirms that he had no previous convictions in the UK. The
man confirmed that as well as speaking Yoruba, he spoke English. He
also confirmed that he took medication for diabetes. He did not provide
details for a family contact as next of kin. He gave details of a solicitor to
be contacted in the case of an emergency.
15. On 20 June, the man was transferred to HMP Forest Bank. His
reception notes confirm that he controlled his diabetes by tablet, and that
he needed to attend healthcare morning and afternoon for his
medication.
16. After attending the doctor’s clinic on 21 June, the man was admitted to
healthcare suffering from hypertension. While in healthcare he was
noted on one occasion to be having difficulty breathing, requiring oxygen
to be provided. He remained in healthcare until 8 July, and was treated
for a chest infection.
17. While in Forest Bank the man developed a facial nerve disorder and was
referred to hospital. An appointment was made at the Hope Hospital TIA
(Transient Ischaemic Attack) clinic but neither the man nor Forest Bank
appear to have received the appointment. As he did not attend the clinic
for his appointment he was discharged from the system.
18. The man was transferred to HMP Manchester on 17 July. His reception
medical screenings noted his diabetes, hypertension, and shortness of
breath. However, his outstanding referral to hospital was not identified
by anyone. An appointment was made to see the prison doctor on 19
July. The man was diagnosed with a chest infection and prescribed
medication. He was also prescribed medication for hypertension, as
well as continuing his usual medication. A further appointment was
made for one week’s time. It was also made clear that he should be
referred back to the doctor if he experienced any shortness of breath or
chest pain.
19. On 20 July, Nurse A was on duty in the healthcare centre when she
received a telephone call asking her to come to G wing to see the man.
He had become short of breath at lunchtime. The nurse examined him
and was satisfied that he was not suffering from a serious condition.
She did discover, however, that he did not have any of his prescribed
medications, which had been sent to A wing. The man was supposed to
hold his medications in his own possession (known as “in possession”
medication). Nurse A collected them, brought them to him, and
explained that it was up to him to ensure that he collected his
medication.
20. The man attended court and was convicted in July.
21. Medical records for him show that on 24 July, he saw one of the prison
doctors, as had been arranged the previous week. He was again noted
to be suffering from a chest infection, and was prescribed a salbutamol
inhaler (commonly used by asthmatics) to use if he suffered any further
breathlessness.
22. During the night of 18 August, Nurse B was on duty. He was called to
see the man, who had complained of shortness of breath, and pain in his
liver when he breathed in. The nurse examined the man and found that
he was not in any severe distress, and had his inhaler to use. He asked
discipline staff to observe him, and made an appointment for him to see
the prison doctor the following morning. Nurse B subsequently checked
with wing staff the following day and they reported that the man had had
no further problems. The nurse therefore cancelled the emergency
appointment, as the man had an appointment to see the doctor anyway
on 22 August. The man had a court appearance on 20 August and was
subsequently seen by Nurse A on his return to prison. No problems
were found. The man did not subsequently attend the scheduled
doctor’s appointment.
23. Nurse C was on duty on 23 August, and answered an emergency call to
the work area of the prison. She found that the man had collapsed and
was short of breath. She gave him oxygen before arranging for him to
be admitted to the healthcare centre. He was seen by a doctor, who
confirmed that he should remain in healthcare and receive oxygen by
way of a nebuliser. (A nebuliser is a machine which creates a mist of
whatever medicine is being applied, which makes it easier for the
medication to get into the patient’s lungs.) A care plan was put in place,
and the nebuliser treatment was discontinued on 28 August, when a
doctor reviewed the man. The doctor also set in place arrangements for
a review of the man’s asthma medication. There had been no previous
diagnosis of asthma, but as noted above he had been using a
salbutamol inhaler.
24. The man attended an appointment to see the prison doctor on 30
August. He noted the man’s medical history, including his diabetes,
hypertension, and recent difficulties in breathing. He diagnosed the man
with congestive cardiac failure (the presence of symptoms associated
with congestion of the tissues and organs). He recommended that the
man have an electrocardiogram (ECG, an electrical recording of the
heart used in the investigation of heart disease). The ECG was
completed the following day in the healthcare centre.
25. In September, the man was sentenced to six years’ imprisonment.
26. A follow-up appointment with the prison doctor took place on 7
September. The ECG had indicated that the man had left ventricular
failure, and he was prescribed medication to treat this. The prison
doctor wrote to North Manchester General Hospital on 13 September
asking for the man to see a cardiologist. The man was also scheduled
to have routine blood tests and to attend the diabetic clinic in healthcare.
None of the blood tests showed any abnormalities. He attended the
diabetic clinic on 20 September, and complained of breathlessness
despite taking his medication. One of the nurses therefore made an
appointment for him to see a prison doctor.
27. On 2 October, North Manchester General Hospital sent a letter
confirming an appointment with the cardiologist for 7 November. A
hand-written amendment on the letter shows that this was re-booked on
4 October for 5 December.
28. Following the appointment made subsequent to his visit to the diabetic
clinic, the man saw a doctor on 3 October, and told him that he was still
suffering from breathlessness. The doctor requested that the man have
a chest x-ray. However, the man’s records do not show that he was
referred to hospital for this.
29. The man again sought treatment in healthcare on 11 October, for feeling
short of breath. A healthcare officer advised him to rest and to use his
inhaler, and said he would arrange for the man to see the doctor the
following day. The man’s notes do not show whether this appointment
did in fact happen, but his scheduled appointment for 24 October, was
brought forward by a week.
30. When he saw the prison doctor on 17 October, the man said that he was
still short of breath and had pain in his chest. He had been ill since
before he came to the UK and had been in an area of Nigeria where
malaria was evident. The doctor thought it possible that the man might
have malaria. He arranged for him to be transferred to hospital. He was
taken to North Manchester General Hospital at 7.05pm that day.
31. A prisoner would usually be double-cuffed when attending hospital. This
means that they would be wearing handcuffs themselves, then have a
separate chain, known as an escorting chain, to a member of staff. This
is only altered if a risk assessment deems it unnecessary. At lunchtime
on 18 October, the man asked the officers escorting him to remove his
cuffs. His request was refused. When staff made an equipment check
that afternoon, they found that one of the inserts (an insert is a metal
attachment inside cuffs to ensure a proper fit) was missing from the
man’s cuffs.
32. At 1.25pm a hospital doctor informed staff that he could not be sure that
the man did not have tuberculosis (TB) and recommended that staff
were not constantly in the room with him. The escorting arrangements
were changed so that the two members of staff were located in a sterile
area and two more were outside, but none were actually in the room with
him. At this point, restraints were removed from the man. At 5.35pm
escort staff were told that he did not have TB. The escort was reduced
back to two prison officers, and the restraints were reapplied.
33. The following day, 19 October, doctors advised that further tests and
treatments would be required and that this might take “two or three
weeks”. The man needed to have a cannula (a drip) inserted into his
hand, so his cuffs were removed, leaving only an escorting chain. On 21
October he was transferred to E3 ward and the cannula was no longer
required. Double cuff arrangements were then reapplied.
34. Records show that on 23 October, the man was still receiving oxygen to
assist his breathing, but doctors told him that his heart was “fine”. A
governor from the prison visited him in hospital the next day and found
him to be in good spirits.
35. On 25 October, the man was told that he could be discharged. He did
not have malaria, but had been treated for excessive fluid in the
pericardium (the sac which surrounds the heart). He was diagnosed as
suffering from cardiomyopathy (disease of the heart muscle), which
needed ongoing out-patient treatment at the hospital. He was given an
ECG, and left hospital to return to prison at 2.20pm. In addition to
providing information in his discharge letter, staff at the hospital
telephoned the prison and explained what had happened with the man,
and that he would need follow-up care.
36. A care plan was put in place and the man saw a prison doctor the
following day. The doctor noted that the man had been diagnosed with
cardiomyopathy. North Manchester General Hospital sent the man’s
discharge letter to healthcare at the prison on 30 October. It noted his
enlarged heart.
37. The man saw a prison doctor on 4 November. He told the doctor that he
was feeling unwell, with pain in the right side of his abdomen. The
doctor advised that he would need to be reviewed and to be examined
for potential problems with his liver. An appointment was made to see
the prison doctor on 6 November.
38. However, early on the morning of 6 November, at approximately
6.30am, Nurse D was distributing medication when he found the man
lying on his cell floor. He had no control over his movement, was unable
to get up, his speech was slurred and he had right-sided weakness. It
was suspected that he had had a stroke, and an ambulance was called.
The man was taken to North Manchester General Hospital.
39. At the hospital it was confirmed that he had had a stroke. He was
partially paralysed down his right side, his speech was poor and he had
very little use of his right arm. The duty governor at the prison agreed
that the man did not need to be double-cuffed but only have an escorting
chain to one of the prison officers escorting him. Medical staff confirmed
that he would find it almost impossible to walk at that time.
40. The man was moved to F3 Ward on 7 November, and was visited by the
Head of Healthcare at HMP Manchester. The reason for the visit was
twofold. Firstly, it was to check on his welfare. Secondly, it was to
assess whether there were any areas of preparation the prison would
need to make for his return, should he need any adaptation to the
normal prison environment. This is good practice.
41. In the early hours of 8 November, the man became agitated and was
biting his handcuffs. He was struggling with speech, and through the
day appeared confused and incoherent, soiling his bed on a few
occasions.
42. Nurses informed escorting staff on 9 November, that the man would
have a brain scan the following week and would need to have his cuffs
removed. On 12 November, the man’s bedwatch log shows that a nurse
said a brain scan would not be required, but the log for the following day
shows that the scan results were clear. The prison medical record
shows regular contact between prison healthcare and the hospital during
this time.
43. At 2.00pm on 13 November, two officers began a shift of bedwatch duty
for the man. The bedwatch log shows that there were no problems
during the afternoon, with the man mainly sitting in his chair. He was
sometimes asleep but the escort staff noted movement. At
approximately 5.20pm one of the officers helped him to eat a meal then
helped him go to the toilet. As they returned, the man sat on the edge of
his bed, fell back onto his bed and began to suffer a fit. A nurse saw
what was happening and immediately came to the bed. She put the
man in the recovery position and tried to sedate him. She called a crash
team.
44. The officer uncuffed himself from the man and moved out of the room,
while maintaining a full view of what was happening. He informed the
duty governor at the prison. The medical team attempted to resuscitate
the man, but at approximately 6.00pm they told the escorting officers
that he had died.
45. One of the officers telephoned the prison and passed on the news of the
man’s death, and the procedures to be undertaken following the death of
a prisoner were begun. The two officers returned to the prison at
6.45pm. A debriefing meeting was held, and both officers were offered
support from Staff Care and Welfare Services and the Samaritans if they
felt they needed it.
46. The following day, 14 November, a Principal Officer sent a note round
the prison instructing that all prisoners subject to suicide and self-harm
monitoring were reviewed. On 16 November, notices to staff and
prisoners were posted around the prison informing them of the man’s
death.
Contacting family
47. The prison had difficulty tracing next of kin. The man had not provided
any details, and the prison enlisted the help of the police in contacting
his family. When the police did trace and speak to the man’s wife and
mother, language differences made this difficult. Eventually, they made
contact with a representative of the family in England and arranged and
paid for the man’s funeral. This was attended by the prison imam.
Post mortem report
48. The post mortem report showed the cause of death as:
1a. Pulmonary thromboembolism
1b. Deep vein thrombosis
1c. Immobility from cerebral infarction due to embolism from cardiac
mural thrombosis
2. Dilated cardiomyopathy
Systemic hypertension.
49. This is consistent with a death from natural causes.
ISSUES
Clinical care
50. Overall, it is the view of the clinical reviewer that the man received
proper medical treatment whilst in prison. His health worsened during
that time, but he was regularly monitored and his symptoms were
managed in a timely way.
51. There were several instances when treatment needs were not followed
up. The first relates to reception. When at Forest Bank, the man was
referred to a consultant who recommended that he should be given a
hospital appointment. There is no indication that the prison received the
subsequent appointment letter, but there should have been a system to
ensure that any further required treatment was followed up. This should
have been noticed on his arrival at Manchester but unfortunately it was
not.
The head of healthcare should consider systems to check whether
prisoners transferred to Manchester have outstanding medical
appointments or referrals.
52. The second relates to actions planned which were not followed up.
When at Manchester, the man saw a doctor on 3 October, and the
doctor wanted him to have a chest X-ray. However, there is no
indication that a referral was made. It may have been that the doctor,
who was a locum, did not fully understand the process required to obtain
an X-ray. I do not make a recommendation on this, but as a
housekeeping point the head of healthcare will want to ensure that
doctors working in the healthcare centre are aware of procedures which
need to be followed. Nevertheless, there should be a system which
would make it apparent that a recommendation had not been followed
up, and the clinical reviewer writes that it delayed the treatment of some
distressing symptoms. A third occasion was on 11 October, when the
man saw a member of staff in healthcare, complaining of shortness of
breath. This member of staff noted in the man’s medical record that he
would arrange a doctor’s appointment for the following day. There is no
indication that this happened but the man’s scheduled appointment to
see the doctor on 24 October was brought forward to 17 October.
The head of healthcare should ensure that all follow-up referrals
are made.
53. When the man was admitted to healthcare on 23 August, the doctor
made an assumption that he was asthmatic. There is no evidence of the
man having been diagnosed as having asthma.
54. It is the clinical reviewer’s opinion that neither healthcare in HMP
Manchester nor North Manchester General Hospital followed the
guidelines for someone with type two diabetes, specifically around the
prescription of medication. The National Institute for Health and Clinical
Excellence (NICE) guidance recommends prescription of a statin for the
management of type 2 diabetes. Manchester Primary Care Trust’s
guidance on the management of diabetes also recommends this. There
is no evidence in the man’s records that he was considered for such
treatment. While it is unlikely that there was any effect on him in this
instance, the head of healthcare will want to consider how the prison
uses the guidelines.
The head of healthcare should consider how the National Institute
for Health and Clinical Excellence Diabetes Guidelines are
followed.
55. On one occasion it was discovered that the man had not collected his
medication, as he was supposed to do. This only came to light when a
nurse answered an emergency call when the man suffered a bout of
breathlessness. Whilst it was the man’s responsibility to collect his
medication, healthcare should be aware of patients not doing so.
The head of healthcare should review monitoring arrangements for
patients who are supposed to collect “in possession” medication.
56. The clinical reviewer recommends that nursing assessments should be
developed and put in place, allowing robust person-centred care plans to
be developed. Problems with the provision and maintenance of care
plans also feature in two of my previous reports on investigations into
deaths in Manchester. I am pleased to see that since the death of the
man who is the subject of this report the prison have introduced a
computer-based physical assessment tool that identifies the physical
needs of anyone in healthcare. This being the case I do not repeat my
earlier recommendations. But I hope that the head of healthcare will
monitor the new assessment to ensure that it is meeting the need for
which it was intended.
57. The head of healthcare visited the man in hospital to ascertain whether
there were any adjustments that would be required when he returned to
prison. I consider this to be an example of good practice.
Contacting family
58. The man had not provided details for next of kin, family contacts, or
anyone to contact in an emergency. This led to a delay in his family
being informed of his death. This is a particularly traumatic time for
families, and they really should be informed and involved as soon as is
possible.
59. Prisoners may well, for a variety of reasons, not wish family to be
contacted by the prison. In general circumstances this should be
respected. But when the man was in hospital with a serious illness, it
might have been helpful for the prison to have discussed with him who
would be his primary family contact and in what circumstances he would
want them to be contacted.
60. The prison’s decision to ask for this information in such circumstances
would need to be assessed in each individual case. As such I do not
make a recommendation. But the Governor will wish to consider at what
point it might be prudent for such a discussion to occur.
CONCLUSION
61. The man had existing health problems when he arrived in prison, and his
health deteriorated whilst serving his sentence. His health problems
were treated whilst in prison, and he spent some time in and out of
hospital. In my view, he received good care whilst at Manchester
62. It is unfortunate that some actions and appointments fell by the wayside.
Although it appears that they did not make a material difference to the
man dying, prisoners are reliant upon healthcare services looking after
their welfare. The clinical reviewer says that the man suffered some
distressing symptoms which could have been treated earlier had he
been given the X-ray the prison doctor recommended on 3 October.
63. I am pleased to see that the prison have put in place what they feel is a
robust, computer-based physical assessment tool. This should identify
the physical needs of anyone housed in healthcare or who presents with
persistent medical issues. In line with the recommendation the clinical
reviewer makes concerning the need for nursing assessments, I hope
that the new system will be monitored to ensure that it is meeting its
purpose.
64. It is to be commended that the head of healthcare visited the man in
hospital with an eye to ensuring that if he needed any adjustments to the
environment on his return to prison they would be made in advance. It
did not transpire that it was necessary in this case, but it is an example
of good practice.
65. It is important to remember how difficult a time this is for a prisoner’s
family. Delays in informing families should be kept to an absolute
minimum. If a prisoner with failing health has not provided contact
details, consideration should be given to discussing the issue with the
prisoner.
RECOMMENDATIONS
The head of healthcare should:
1. consider systems to check whether prisoners transferred to
Manchester have outstanding medical appointments or referrals;
The Prison Service has accepted this recommendation. The Head of
Healthcare will review current procedures and ensure proper
arrangements are in place for monitoring and checking whether
prisoners transferred to Manchester have outstanding medical
appointments or referrals. The target date is 30 November 2008.
2. ensure that all follow-up referrals are made;
The Prison Service has accepted this recommendation. The Head of
Healthcare will put in place proper procedures and systems ensuring
that all follow up referrals are made. The target date is 30 November
2008.
3. consider how the National Institute for Health and Clinical
Excellence Diabetes Guidelines are followed;
The Prison Service has accepted this recommendation. The Head of
Healthcare will consult with Manchester PCT and consider the protocol
for following NICE guidance. The target date is 30 November 2008.
4. review monitoring arrangements for patients who are
supposed to collect “in possession” medication.
The Prison Service has accepted this recommendation. The Head of
Healthcare will in consultation with Manchester PCT review the
monitoring arrangements for the collection of in-possession medication.
The target date is 30 November 2008.