Individual at Norwich

Investigation into the circumstances surrounding the
death of a man in a hospital in May 2009,
whilst in the custody of
HMP Norwich
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2010
The man was admitted into a hospital on 26 May 2009 after being taken ill whilst a
prisoner. He died the following day aged 30. The cause of death was meningitis
secondary to sinusitis.
A senior investigator, family liaison officer, and I would like to offer our condolences
to the man’s family and friends for their sad loss.
I wish to thank the Governor for his assistance in making the necessary facilities and
information available to the investigator.
To assist the investigation, I asked for a clinical review to be carried out into the
medical care received by the man whilst he was in prison. I am grateful to NHS
Norfolk who appointed a reviewer to review the care the man received. They also
asked an independent consultant to oversee the review. I appreciate their
assistance.
This investigation has identified a number of issues relating to not only the man’s
medical care, but also that of a more general medical nature. Although the clinical
review recommendations made in this report relate directly to his care, I encourage
NHS Norfolk to read the clinical review report in full and consider the wider findings.
In addition to the medical findings, I make one recommendation regarding the
decision to appoint an untrained person to be the prison family liaison officer for the
man’s family.
Since taking over responsibility in April 2004 for the investigation of all deaths in
custody, there have been 17 deaths at the prison, including that of the man. In
nearly every case the Ombudsman has identified issues relating to healthcare. I am
aware that the PCT has developed its own action plan to deal with those
recommendations and those of its own internal auditing procedure. Additionally, the
PCT are aware of the clinical review findings in this case and have incorporated
them into their action plan.
Jane Webb
Acting Prisons and Probation Ombudsman October 2010
2
CONTENTS
Summary
The investigation process
HMP Norwich
Key findings
Issues
Conclusion
Recommendations
3
SUMMARY
The man was sentenced in June 2008 to four years nine months imprisonment.
He was taken to a prison and, during the routine reception procedure, told prison
staff that he was a regular user of drugs. He made it very clear in the early
stages of his imprisonment that he wanted to change his behaviour and so he
engaged with the support services to help break his habit.
As part of his commitment to changing his lifestyle, and wanting to help others,
the man became one of the prison Listeners. Listeners are selected and trained
by the Samaritans and offer an invaluable support to prison staff in helping keep
vulnerable prisoners safe.
Over the following months the man settled into prison life. He was well liked by
prisoners and staff and gave no cause for concern. It is for this reason that the
report concentrates in the main from the point when he first showed signs of
illness.
In April 2009, after a nurse noticed that he was not his usual self, the man spoke
to her and said he was experiencing headaches. His condition was assessed
and, as a precautionary measure, he underwent specialist assessment at
hospital’s Neurological Department. The tests did not find anything abnormal.
On 26 May, the man was found on his cell floor conscious but incoherent.
Following assessment by a prison doctor, he was admitted into the prison
healthcare for observation. It was whilst in healthcare that he became
unconscious and was transferred later that day as an emergency patient to
hospital. Sadly the man died the following day. I understand that the Coroner
has said that he died as a result of meningitis secondary to sinusitis.
The clinical reviewer has identified a number of issues relating to healthcare
procedures at the prison, although not all are directly linked to the man’s medical
care. I make one recommendation which relates to the decision to appoint an
untrained prison family liaison officer.
4
THE INVESTIGATION PROCESS
1. Once the Ombudsman had been notified of the man’s death, the investigation
was allocated to a Senior Investigator. A Family Liaison Officer (FLO) was also
appointed.
2. To assist the investigator, I asked NHS Norfolk to carry out a clinical review. A
reviewer was appointed to review the medical care. NHS Norfolk asked an
independent consultant, to oversee the review and ensure a proper level of
independence.
3. In the meantime, the FLO contacted the man’s family and invited them to
contribute to this investigation. His mother told the FLO that she wondered
whether her son had received the same level of healthcare as he would have
received in the community. She felt that her son would have received faster
treatment if he had been seen by his own doctor.
4. The mother also said that her son had not been prescribed antibiotics and, had
he done so, his meningitis may not have developed. Additionally, she said that
her son complained of headaches for several weeks and had been prescribed
pain killers, but the treatment had not been reviewed.
5. A further concern for the man’s mother was that her son had been to hospital for
a scan. She said this indicated that prison staff were aware that he had a
potentially serious condition. The mother questioned why it was over four hours
after her son was found “mumbling” in his cell, before he was taken to hospital.
The man’s family received a copy of my draft report. I am grateful to them for the
time they have taken to consider my findings. Some of the matters they raise are
for the Coroner to consider at the inquest. Those which are relevant to the
findings of my investigation are included and addressed within the issues section
of this report.
6. On 13 July, the investigator, clinical reviewer, and the FLO met the Governor at
the prison. The purpose of the meeting was to open the investigation and to
identify any key issues relating to the man’s care.
7. Following that meeting, the investigator and clinical reviewer began their
investigation and interviewed a number of staff. Two days later, they met the
Governor and gave their preliminary findings. Following that meeting, the
investigator wrote to the Governor outlining the feedback given, reminding him
that the case was still under investigation, and the initial findings were subject to
change.
8. On 31 July, at the invitation of NHS Norfolk, the investigator attended a clinical
review panel meeting. The purpose of the meeting was to discuss and review the
progress of the clinical review and identify any issues relating to the man’s
medical care. The meeting was chaired by the Chief Nurse for NHS Norfolk. In
addition the following people attended:
Commissioner for Prison Healthcare
5
Deputy Head of Prescribing and Medicines Management, NHS Norfolk
Head of Clinical Governance NHS Norfolk
Independent Monitoring Board HMP Wayland
Independent Consultant
Prison Liaison Officer represnting HMP Norwich
The Clinical Reviewer
9. The following month, on 11 August, the investigator and clinical reviewer returned
to the prison to continue the investigation. Over the next two days, they
interviewed healthcare staff and two prisoners. Before leaving the prison on 13
August, the investigator and clinical reviewer met the Governor to give additional
feedback. The Governor accepted the feedback and said he would discuss the
issues at a meeting the following day with the commissioning authority for
healthcare.
10. On 1 December, the investigator and clinical reviewer met the prison Head of
Healthcare, prison liaison officer representing the Governor and the Coroner’s
Officer. Unfortunately, the Healthcare’s Assistant Director of Quality was unable
to attend the meeting. The purpose of the meeting was to feedback the findings
from the clinical review and to allow the healthcare commissioning authority the
opportunity to incorporate the report within their ongoing action plan. It also
enabled the coroner’s officer to listen to the issues raised during this investigation
and to prepare a briefing report for the Coroner.
11. The Head of Healthcare told the meeting that a number of the issues were
already being dealt with, but that she recognised that they should be identified in
this report. Both she and the prison liaison officer accepted the findings and
recommendations. I wish to thank them, and the coroner’s officer, for their
assistance.
6
The Prison
12. HMP Norwich is a local training prison, with a separate young offender institution.
The adult side of the prison holds male sentenced and remand prisoners. It also
has an older prisoner unit.
Healthcare
13. Healthcare services are commissioned by NHS Norfolk and provided by Norfolk
Community Health and Care, Norfolk Waveney Mental Health Partnership NHS
Trust, Independent providers and East Anglia Ambulance Service. The
healthcare service provided at the prison consists of:
(cid:127) primary medical and nursing services
(cid:127) out of hours and 24 hour nursing cover
(cid:127) mental health in reach services
(cid:127) community services
(cid:127) dentistry
(cid:127) in patient care unit
(cid:127) life sentence prisoner inpatient unit.
14. Norwich prison healthcare use a computerised documentation system, known as
SystmOne.
Her Majesty’s Chief Inspector of Prisons
15. Her Majesty’s Chief Inspector of Prisons reports on all Prison Service
establishments. In November 2006, the Chief Inspector of Prisons carried out an
unannounced inspection at Norwich. In her report, published in March 2007, and
referring to a previous inspection, she said this inspection found that the prison
had tried with some success to grapple with some of the key problems identified,
but national population pressures had either undermined, or thrown off course,
much of the work being done. The Chief Inspector of Prisons went on to say that
previous criticisms of suicide and self harm procedures had been fully addressed.
Independent Monitoring Board
16. Each prison has an Independent Monitoring Board (IMB) and their role is to
monitor the prison and to report any concerns that they have regarding the
prison, or how prisoners are treated. Board members are able to visit any area of
the prison at any time and have direct access to any prisoner who they wish to
see, or who requests to see them. The Board holds regular meetings in the
prison, with the Governor attending for part of the meeting. The Chairperson of
the Board produces an annual report to the Secretary of State for Justice.
7
17. In their latest annual report, covering the period 1 March 2008 to 28 February
2009, the Board, when referring to healthcare, said:
“the continued absence of a dedicated GP service puts the proper
provision of healthcare, including mental health, within HMP Norwich
seriously at risk. Action should be taken to ensure that patients with
health, including mental health, needs receive treatment equivalent
to that given in the community in general.”
18. They went on to say:
“Although the provision of healthcare to the prison population has
improved since it has been financed by the NHS, there is still some
way to go before prisoners have the same access to healthcare as
those outside prison. There is an even greater distance to cover for
them to get access to healthcare that fully meets their needs.
“The most serious risk to the provision of healthcare within the prison
is that after a number of years, there is still no dedicated GP service.
The locum service has been shown to have serious deficiencies.
“Nurse practitioners have been introduced and are seeing an
increasing number of prisoners, thus taking some pressure off the
GP service. However, some prisoners are missing their
appointments because it is believed, of a lack of commitment to
escort them to clinics…”
19. The Board also said “clinical reviews of deaths in custody have identified the
need for the current provider to urgently undertake a skill mix review to reflect the
importance of reception screening by appropriately skilled staff”.
Prison Service Orders (PSO)
20. Prison Service Orders are long term instructions which are intended to last for an
indefinite period. Any mandatory instructions to Governors or Directors of
contracted prisons are written in italics. Each PSO is given a title and unique
reference number.
Prison family liaison officer (FLO)
21. Following any death in prison, the prison Governor is required to appoint a family
liaison officer to be the first contact in the prison for the deceased person’s family.
PSO 2710 contains advice and guidance that supplements the mandatory
instructions in the PSO.
Counselling, Assessment, Referral, Advice and Throughcare service
(CARATs)
22. CARATs teams are in place in each prison in England and Wales. The service
provides support and non-clinical treatment to prisoners with substance misuse
8
needs. CARATs offer a number of interventions for prisoners, including one to
one counselling and groupwork, and liaising with community services prior to
release.
Rehabilitation of Addicted Prisoner Trust (RAPT)
23. RAPT deliver drug and alcohol services in prisons and in the community, aimed
at helping people move away from addiction and crime. The services provides a
variety of support, including advice, counselling, group work and intensive
treatment. They also work with the families and carers of substance misusers, as
well as substance misusers themselves.
9
KEY FINDINGS
24. Imprisonment was not a new experience for the man. He had been in prison
in September 2001 after being sentence to two months imprisonment. He
was released the following month.
25. On 2 June 2008, the man was sentenced to four years and nine months
imprisonment. He was due to be released on 18 October 2010. Following
his appearance at court, the man was taken to HMP Norwich, which is where
he remained until he was admitted into hospital on 26 May 2009.
26. During the reception procedure, the man told prison staff that he had a daily
drug habit. He said that he had regularly used heroin and crack cocaine,
which he said he smoked. He hoped to use his sentence as an opportunity to
stop his drug use. As part of that commitment, the man was offered support
from the Counselling, Assessment, Referral, Advice and Through care
service (CARATs) team and, later on in his sentence, he joined the
Rehabilitation of Addicted Prisoner Trust (RAPT) programme.
27. In addition to telling reception staff about his drug habit, the man said he had
suffered from depression some years earlier. In her clinical review the clinical
reviewer said the man had, on that occasion, been prescribed Prozac. She
added that he recommenced treatment and continued to be treated for
depression throughout his sentence.
28. It appears from the prison records that the man settled down well into prison
life and, on 10 November 2008, he attended the first of a 12 session RAPT
programme.
29. At interview, a Focal Counsellor for RAPT said the man had asked to join the
programme because he wanted to change his life and because his drug use
had affected his family and relationships. The counsellor said when he first
joined the programme he was quiet and polite. She said after about two
weeks, he told her that he had taken drugs in the prison and been tested as
part of the prison drug test routine. The counsellor added that when the test
result came back it was negative.
30. The man continued to attend the RAPT programme and, according to the
counsellor, he became more positive and willing to express his views.
However, on 8 February 2009 during a routine drug test, he tested positive
for heroin. The counsellor said he was remorseful and regretted his actions.
She said it was a turning point in the man’s life as he recognised that he
needed to address his vulnerability.
31. The counsellor went on to say that the man had also become a Listener. She
said this was something he enjoyed doing as he “felt good at helping others”.
32. The man had been diagnosed as positive for hepatitis C prior to coming into
prison and had undergone further diagnostic tests to enable a treatment plan
to be provided for the remainder of his sentence. The clinical reviewer said
10
the ongoing investigations showed that, although this was rare, the level of
the virus was reducing. She said that discussions were taking place between
specialists to see whether his body was clearing the virus naturally.
33. As the man had hepatitis C, he was given support within the prison by a
Registered General Nurse (RGN), a specialist nurse. The RGN ran a group
meeting for prisoners with hepatitis and got to know the man well. She
described him as an articulate, intellectual and humorous man.
34. On 21 April, the RGN spoke to the man as she was concerned that he was
not his “normal self”, describing him as looking “off colour”. The nurse said
he told her that he had a headache, which he said had started some days
earlier. He also said that he might have hit his head about two weeks earlier
although the prison has no record of an injury. Concerned about the
continuing headache, the RGN arranged for the man to be assessed by a
prison doctor that day.
35. At about 4.15pm, the man was seen by a doctor. The clinical reviewer
explained to the investigator that the man’s medical notes show a ten day
history of headaches which started suddenly and became worse during
coughing and forward movement. In order to rule out any bleeding in the
brain, the doctor discussed the symptoms with a neurological registrar at the
hospital. Following their conversation and to enable further investigation,
arrangements were made to transfer the man as an emergency patient to
hospital. He was admitted the same day under the care of a Consultant
Neurologist.
36. While in hospital, the man underwent blood screening, lumbar puncture
investigation and a computerised tomography (CT) scan of his head. (A CT
scan uses computerised tomography, a combination of x rays and computer
software to see into the body.). There were no abnormal findings and
sinusitis was also ruled out.
37. Two days after being admitted, on 23 April, the man was discharged from
hospital and returned to the prison. The hospital doctor recommended that
he should continue to take mild pain relief and that no follow up action from
the neurological team was required. He was given a supply of pain relief and
anti inflammatory medication, and told to refer back to healthcare if the
headaches continued. The clinical reviewer notes that there is no record of
the man referring himself back to healthcare. However, when a nurse saw
him on 30 April, it was noted that there had been an improvement in his
condition.
38. On 19 May, the RGN met the man as part of her ongoing support for
prisoners with hepatitis. She said that he “was not himself” and told her he
had not renewed the pain killer prescription, as he had felt better. However
he also told the nurse that the headache had returned. The RGN said there
was no doctor available in the prison at the time and so she examined him.
Her examination revealed that he had a slightly enlarged pupil in his right
eye, which was the only thing which was abnormal. The nurse contacted the
11
neurological team at the hospital and spoke to another Neurological
Consultant. The clinical reviewer said the consultant did not consider it
necessary to see the man that day, but had said a neurological registrar
would return her call, once the records from his previous admission had been
reviewed.
39. The next day, a secretary from the neurological team telephoned the prison
to discuss arranging an out-patient appointment. At the end of the
conversation, the secretary wrote offering the man an appointment for
10.00am on 29 May. (The prison told my investigator that the letter was not
received at the prison until after the man returned to hospital.)
40. As part of this investigation, the investigator spoke to two prisoners. One of
them said that he had been into the man’s cell over the weekend of 23/24
May and had found him lying on the floor. He said that he told an officer who
told him that other officers were aware of the situation. The prisoner was
unable to remember who he had spoken to.
41. The other prisoner said that he too had spoken to prison staff about his
concerns for the man, but like the first prisoner, could not remember who the
officer was. He said that the man had been so ill that he had collected his
meals for him and taken them to the cell. Despite efforts to identify and
speak to the officers concerned, the investigator has not received any
response to his requests for information.
26 May
42. At about 9.00am, an officer unlocked the man’s cell to allow him to go to work
as a wing cleaner. At interview the officer said he spoke to the man who was
still in bed at that time. The officer said the man acknowledged him by
waving. He added that it was not unusual for him to still be in bed and that he
was not concerned about him.
43. About 90 minutes later, the officer returned to the man’s cell as he had not
started his cleaning duties. When he went into the cell he spoke to the man
but could not obtain a coherent response. Concerned about his welfare, the
officer left the cell to speak to a nurse. Initially, the officer had some difficulty
speaking to a nurse as they were busy. As he did not consider the man’s
condition to be serious, he said he did not ask for urgent medical assistance
at that time.
44. After making the telephone call, the officer returned to the man’s cell. When
he went into the cell he saw him lying on his back on the floor, with his feet on
the bed. He was waving his arms around and was incoherent. The officer
left the cell and telephoned the Day Centre where he was able to speak to a
nurse. He said that after telling the nurse he wanted someone to see the
man, a nurse arrived very quickly.
45. The officer said the nurse had a look around the man’s cell and found various
empty packets of medication. The empty packets were:
12
Mitrizipine 45mg, an antidepressant medication.
Diclofenac 75mg, an anti inflammatory medication.
Brufen 400mg, an anti inflammatory medication.
Co-Codomol 500mg, a pain relief medication.
46. The officer said the nurse thought that the man might have taken an
overdose of drugs. The officer said the nurse checked the man’s vital signs
and that she told him they were normal. The officer said that by this time the
man was beginning to grab at things and pulling items out of his locker.
47. In her evidence, the nurse said that when she arrived, she saw the man lying
on the cell floor, wearing just his underpants. She said examination was
difficult due to the way the man was kicking out and that the prison staff were
concerned that she might be hurt. The nurse said she had been able to
monitor his pulse rate, and found it to be within normal limits and regular.
Nevertheless she was concerned about his condition, and asked for the
prison doctor to be called urgently.
48. The duty doctor that day was asked to assess the man; he went straight to
the cell. When he arrived, he saw him lying on the cell floor, tapping the wall.
At interview the doctor said the cell was “disorderly” and, during his
examination, he saw a number of medication packets in the toilet bowl. He
said the man did not respond to his questions and was reluctant to have a
physical assessment. However, the doctor continued with his examination,
which he said revealed normal power to the limbs, equally reactive pupils and
a steady pulse.
49. There was another officer present at the same time. He told the investigator
that the man was lying underneath a table holding onto one of the table legs.
The officer said the man was shaking. He said the man had a small drink of
juice, but was incoherent.
50. After completing his examination, the doctor decided to refer him to the
mental health team, as he was unsure whether the condition was
psychological or organic. (This means the doctor was not certain if the
problem was a result of mental or physical health problems.)
51. The clinical reviewer said that a member of the mental health team arrived at
the man’s cell within about ten minutes, but was unable to assess his
condition properly. (The name of the team member who attended is not
recorded in the medical record.) A decision was made to transfer him to the
prison healthcare department, as it has an inpatient facility. Because
healthcare is located on the opposite side of the road to the main prison, it
meant he would have to be taken out of the main prison in a vehicle. The
journey required prison transport to be used and the transfer was given
priority. A number of prison officers helped and supported the man to the
vehicle and during the short journey, as he was unable to walk unaided. A
nurse also accompanied him in the vehicle.
13
52. Shortly before 1.00pm, the man arrived at the healthcare department. He
was unable to walk and was taken into healthcare in a wheelchair.
53. When he arrived in healthcare, the man was assisted into bed. The nurse
with him at that time said the man was unsteady, but was able to walk a few
paces with “considerable help”. She said there were no baseline clinical
observations taken of his temperature, pulse and blood pressure, as he was
a “good colour”. The nurse said she understood the plan for him was that he
would be reviewed later by a doctor.
54. A Senior Officer (SO) is the manager for the discipline staff employed in
healthcare and he was there when the man arrived. At interview he said that
the man was incoherent. Over the lunchtime period, the man pressed his
cell’s emergency call button on at least two occasions, possibly three. The
SO said he went to the cell each time, but could not understand what he was
saying.
55. At about 2.40pm, the SO went to the man’s cell as part of a routine check.
He looked inside the cell, through the door observation panel, and saw him
slumped over on his bed. The man did not respond to the SO. The SO said
that, although he could see him breathing, he immediately called for a nurse.
Having called for assistance, the SO went into the cell and noticed a
discharge from the man’s nose and that he had moved.
56. At interview, a nurse said when she went into the cell she saw that the man
had urinated and there was froth coming from his mouth. She placed him
into the recovery position and asked for an ambulance to be called.
Additionally, she asked another nurse to assist her by taking his clinical
observations.
57. A nurse said that when she went into the cell she carried out her own checks.
She said that the man’s right pupil was fixed and dilated and his right hand
was “spastic” (meaning that it was contorted and rigid). The nurse checked
his reflexes, but there were none. She also noticed that there was froth
around his mouth.
58. In her clinical review, the clinical reviewer said the man, for his own safety,
had been moved to the floor on his mattress. She said the paramedics’
record shows that when they arrived, they found him lying on the floor,
unconscious. The paramedics decided to transfer him as an emergency
patient to hospital. He was assessed by hospital staff and placed onto a
ventilator to assist his breathing. Additionally, he was given intravenous
antibiotic and antiviral drugs, as well as a CT scan. The CT scan results
were sent to Addenbrooke’s Hospital for a specialist medical opinion.
59. The man was later transferred to the hospital’s intensive care unit. His
brother, who was with him at the time, was told of his poor prognosis. His
parents, who at the time were on holiday, were contacted and they made
arrangements to fly home. His condition worsened over the next 24 hours.
At about 7.00pm on 27 May, his parents arrived at the hospital. Sadly he
14
died very soon after their arrival and at 7.15pm he was pronounced dead.
The cause of death has been recorded as “meningitis secondary to sinusitis”.
Following the man’s death
60. Following the man’s death, the Deputy Governor appointed the prison
Violence Reduction Coordinator as the prison family liaison officer (FLO)
even though she had not undergone the Prison Service FLO training.
Although five other staff were trained as FLOs, they were unavailable.
61. During an informal meeting with the liaison officer, she told the investigator
that both she and her line manager had expressed concern to the Deputy
Governor regarding his instructions that she was to act as FLO. The Deputy
Governor did not change his mind. The liaison officer said she had received
no training and was unhappy at being the family liaison officer, but carried out
the role to the best of her ability.
62. I understand that following the man’s death, those prisoners being monitored
as being at risk of suicide or self harm were spoken to by prison staff. This
was to ensure that his death had not adversely affected them and is in line
with proper procedure.
63. However, a number of staff interviewed as part of this investigation felt they
had not been given proper support by managers. The investigator has
already made the Governor aware.
64. An inquest was held into the man’s death in October 2010. The jury returned
the following narrative verdict:
“[The man] initially complained of headaches on the 21st April 2009.
After speaking to a doctor about this he was immediately sent to
hospital for further tests which showed no signs for concern and so
he was discharged on the 23rd April, 2 days later.
Between being discharged from hospital and up until the 23rd of May,
Prison staff and medical staff acted as would be expected; this
included a second referral to the hospital Neurology Department
given the symptoms [the man] was showing at that point in time.
[The man] was using prescribed painkillers to deal with the
headaches he was having.
On the 23rd May a significant change in [the man’s] condition was
apparent due to his spending the next few days in bed and not eating
and not interacting with fellow prisoners as was his normal character.
This did not seem to cause alarm with the prison officers although
fellow prisoners say they were concerned with his unusual condition.
His subdued condition over the weekend seemed no better on the
morning of the 26th May when at 9am his cell was opened for
cleaning duty by the duty officer. [The man] remained in bed and at
15
about 10.30am the duty officer checked on him to find him still in bed
but making incoherent noises. Seeing this, the duty officer attempted
to contact a nurse but none seemed available. Then, returning to the
cell about 15 minutes later, [the man] was found lying with his back
on the floor, feet still on the bed, making involuntary movements of
his limbs.
At this point concern for [the man’s] health grew and immediate
medical assistance was sought. A nurse arrived who quickly called
for a doctor who made some observations on his condition, but no
referral to hospital was made, however the nurse did request the
attendance of mental health nurses who arrived promptly.
Over the short period of time some observations were made by
medical staff although communication between them was lacking.
By around 11.30am it was decided [the man] should be transferred to
the Prison Healthcare Wing. He was helped by four officers to a
vehicle since he was unable to walk. On exit of the vehicle he was
put into a wheelchair. At this point still no decision was taken to get
[the man] to hospital yet his deteriorating condition was clear to see.
On arrival in Healthcare, [the man] was put in a cell and made as
comfortable as possible. However there were no immediate clinical
observations made, no nursing plan or assessments as nurses were
busy with other priorities.
Between 1300 and 1440 [the man’s] emergency cell alarm was
activated three times. An officer attended but no nurse was called.
At 1440 on routine patrol the Duty Officer checked on [the man] and
found him barely conscious, still breathing and it was obvious his
physical condition indicated a severe deterioration. At this point the
officer called for a nurse and at 2.55pm an ambulance was called to
take [the man] to hospital.
When [the man] arrived at hospital he was quickly moved to Critical
Care where blood tests and a CT scan were taken.
These tests showed damage and swelling to the brain and infection
within the blood. Treatment was given for suspected meningitis.
[The man] was declared dead at 7.15pm on the 27th May 2009 at the
Norfolk and Norwich University Hospital.
The death being by meningitis due to sinusitis and therefore of
natural causes.”
16
ISSUES
Clinical care
65. In her clinical review, the clinical reviewer makes a number of recommendations
relating to her findings. For ease, they are broken down between the healthcare
provider and commissioner.
Reception health screening
66. The clinical reviewer said there appears to have been some confusion during the
reception health screening process regarding drug detoxification medication,
which the man said he was prescribed whilst in the custody of Great Yarmouth
Police. She said a nurse from the prison telephoned the custody sergeant at the
police station to clarify what the man had been prescribed. Unfortunately, the
doctor who saw him at the police station had not recorded the visit or treatment.
67. There is no evidence of a substance misuse assessment being carried out during
the reception health screening process and no plan recorded for detoxification.
The clinical reviewer said that the nurse decided that the man did not appear to
be suffering from withdrawal symptoms, and did not refer him to a proper
assessment process. The nurse had said the man was to be prescribed
Lofexidine, which is a drug used to assist with opiate withdrawal. The clinical
reviewer adds that doses are meant to be administered in a stepped approach
and should be recorded to show how they have progressed to the optimal dose.
However the actual doses administered were not recorded in this fashion.
68. In addition to the question of withdrawal, the clinical reviewer said it was noted
during the reception health screening that the man reported previous symptoms
of depression. She said that a mental health assessment was not carried out and
neither was his risk of self harm assessed or mitigated. At the time of her clinical
review, there were no systems to support a robust mental health screening.
However, she added that a system has since been put in place to ensure that all
prisoners are risk assessed during the reception health screening process.
69. The clinical reviewer also noted that, despite the man giving his permission on 3
June for his community medical records to be obtained, this was not done. She
said there was no consistent system at that time to ensure that community
records are requested. The clinical reviewer makes the following
recommendations concerning the reception health screening process, which I
endorse:
The provider [that is prison healthcare] should ensure that only
experienced staff with the appropriate skills and training should
undertake reception screening. Those staff would require specific
training in relation to the various elements of the screening programme
which includes substance misuse and mental health assessment where
appropriate.
17
The provider should ensure that the local guidelines for reception
screening (June 2005) are reviewed and updated to meet the national
standards.
The provider should put in place a regular audit programme which
ensures that all areas of the screening assessment are competently
completed and correct care pathways are followed.
Mental health and substance misuse assessment and management
70. The clinical reviewer said the treatment for the man’s depression over the
following weeks was erratic. There is conflicting documentation regarding the
timeframe for his previous period of depression and the drug regime used for its
treatment prior to his arrest. She went on to say that access to the man’s own
doctor’s records might have provided information of his history and treatment of
depression and enabled a more coordinated approach to his care.
71. In her clinical review, the clinical reviewer said that the prescribed detoxification
regime did not appear to ease the man’s symptoms adequately. He presented
on three further occasions over the next three weeks with symptoms of opiate
withdrawal. She considers that he was just given more medication rather than
being given a planned and coordinated regime.
72. In their response to the draft report, the man’s family asked why it had taken from
10 May, when the man first requested mitrazapine which had worked well for him
in the community, until 14 May for it to be prescribed. In her response to the
family’s comments to the Coroner, the former Assistant Director for Primary Care,
NHS Norfolk, said:
“ … we can offer a possible explanation for this. In accordance with
NICE guidance, mirtazapine is recommended where first line
medication is not effective. We suggest that the GP therefore started
the man on Atalopran as a first line medication and then progressed
onto mitrazipine. In addition he was seen by different GPs on each
occasion which may account for the differences in prescribing.”
73. The clinical reviewer said when the man came into prison in June 2008, that
prison healthcare was not following the nationally recommended regime for the
administration of Lofexidine. However, she noted that since then, a new policy
was implemented in May 2009, which outlined best practice for the administration
and monitoring of patients undergoing withdrawal of opiates using Lofexidine.
The clinical reviewer makes the following recommendations to address the
management of mental health and substance misuse:
The provider should ensure that all healthcare staff are trained to
undertake mental health assessments and the management of
substance misuse, to ensure that the care provided offers the most
appropriate treatment regimes for the conditions of prisoners and
maintains their safety.
18
The provider should ensure that treatment plans and the rationale for
decisions made are clearly documented within SystmOne clinical
records to enable continuity of care.
The provider should ensure that requests for community medical
records are routinely made as soon as possible in order to inform
better healthcare assessments and outline current needs. There should
be an administrative process in place to facilitate this, and regular audit
process to monitor effectiveness and response.
The provider should ensure there is clear guidance on drug
detoxification available and followed, with appropriate and timely
prescribing in order to palliate the wide range of withdrawal symptoms
prisoners’ experience. They should ensure that all healthcare staff are
competent to assess and respond to this.
Events of 26 May
74. The clinical reviewer said that insufficient clinical, analytical and assessment
skills were used in the care of the man that morning, with little consideration
given to his previous medical history or normal behaviour. She said that despite
prison officers telling healthcare staff that the man had not exhibited behavioural
problems, made undue fuss, complained or feigned ill-health, this information
was not considered as part of a holistic assessment.
75. In addition, she said that a link was not made between the man’s history of
headaches, the request for a further neurological review six days earlier and this
episode. She commented that no consideration was given as to whether it was
necessary to contact the neurological team for further advice or whether what
occurred on 26 May was a related problem.
76. In her clinical review, she wrote that when the man was admitted into healthcare
as an in patient, the doctor and nurse who attended him on the wing said that it
was to enable further observation to take place. However, nothing was
documented to say what information was communicated to healthcare staff, the
intended care pathway or the timeframe for a further review.
77. The clinical reviewer said that, despite a nurse being present when the man was
admitted into healthcare at 12.56am, neither a health assessment nor clinical
observations were recorded until he was found unconscious at 2.40pm. She said
there was no criterion for admission into healthcare, nor any evidence that there
is a requirement of a minimum level of baseline medical care or observations for
patients entering the facility. Healthcare staff were unable to determine what was
wrong with him. Despite his behaviour and presentation being so significantly
different to his usual conduct, no one considered that the man should have been
sent to an external hospital for further medical review.
78. The clinical reviewer said the prison’s healthcare facility offers a minimal level of
qualified nursing intervention with only one member of nursing staff being on duty
on the upper level, where the man was taken. The member of staff on duty is
19
also required to cover for meal breaks and evening drug administration for
colleagues working on the ground floor. This means that the unit can be left
without clinically trained staff for periods of time. The clinical reviewer said that
this was the case during the man’s admission, because the nurse was away from
the unit visiting the pharmacy which is on the main prison site when he was found
to have collapsed. The clinical reviewer makes the following recommendations:
The provider should ensure that healthcare staff have all the necessary
information available to them at the earliest opportunity, changes
should be made to the SystmOne template to allow ease of access to all
categories of information held and support improved communication
through documentation.
The provider should ensure that healthcare staff work to a clear criteria
and assessment process to establish when the needs of a prisoner can
safely and usefully be met in the healthcare centre or when it is more
appropriate for care to be provided in other healthcare settings. They
should ensure that they are acting in the prisoner’s best interest.
The provider should ensure a basic expected level of assessment is
made by healthcare staff when prisoners are admitted to healthcare,
with documentation of immediate care needs, treatment or referral
plans, and longer term interventions. A programme of audit should be
established to ensure this is in place.
The provider should ensure that all pertinent details regarding a
prisoner’s medical status are documented and shared so that relevant
information is passed to outside agencies.
General medical issues
79. Commenting on the empty medication packs found in the man’s cell, the reviewer
said there was no documented risk assessment made in relation to him
continuing to hold his medication in his own possession. This is contrary to the
recommended practice in the “Pharmacy for prisoners”, Department of Health
2003 policy.
80. The clinical reviewer went on to say that it became apparent to her during
interviews that there were a number of teams and individual professionals
involved with the continuing health and social care of the man. However, she
added there did not appear to be an integrated approach to using information,
and she considers that the services were working in a separate and disjointed
way. No support was offered to the healthcare staff involved and a root cause
analysis was not carried out which would have examined the processes and
identified learning opportunities or changes.
81. The clinical reviewer makes several recommendations in her clinical review to the
commissioners of healthcare services at the prison. Some of these relate to the
matters covered above. While I do not repeat these recommendations here, I
suggest that all involved in healthcare at the prison read the clinical review and
ensure that they are aware of the issues raised.
20
The man’s prognosis
82. As part of her clinical review, the clinical reviewer wrote to the neurological
department at the hospital asking for an opinion about whether admission into
hospital four or five hours earlier on 26 May would have made any difference to
the outcome. In response to her question, a Consultant Neurologist wrote back
saying:
“it would be speculation to address this question, but it is certainly
true to say that the earlier treatment for intracranial infection is
commenced, the more likely a positive outcome will result. I am
unable to give any specific opinion in this case”.
The doctor concluded by saying,
“Overall, it seems to me that his medical care was appropriate. Had
he lived alone, he may not have come to medical attention as quickly
as he did when his severe symptoms occurred and so I suspect that
things were recognised and acted upon promptly while in prison,
from what I have seen documented in the NNUH medical notes.”
Good practice
83. The clinical reviewer said there appears to be excellent provision for specialist
nursing support for those with hepatitis C. She described the service within the
prison for the treatment for hepatitis C as a gold standard service, possibly better
than that offered within the community. She said it was evident to her that the
relationships between the specialist nurse and her patients were very supportive
and interactive. It was due to the intervention of the specialist nurse that the man
received medical reviews in relation to his headaches. (However, she does add
that the same level of service may not be provided for prisoners with other blood
borne viruses.)
84. Regarding the healthcare documentation relating to the treatment of the man’s
hepatitis C, the clinical reviewer said it was clear and comprehensive. She added
that there were clear pathways in place for accessing appropriate medical
professionals for support.
85. The clinical reviewer said that when the man was assessed on 21 April, following
his first presentation with headaches, the relevant advice was sought by the
doctor and speedy and appropriate action taken to respond to his symptoms.
Prison Family Liaison
86. Contained within the supplementary guidance of PSO 2710 “Follow up to death in
custody” is the following statement:
“Family Liaison Officers should be carefully selected volunteers who
have the appropriate qualities and skills. They must understand the
bereavement process resulting from a death occurring in prison. It is
21
recommended that Family Liaison Officers attend a Family Liaison
Officer training course before being deployed to support a family.”
87. It is clear from the prison’s family liaison officer that both she and her line
manager objected to the Deputy Governor’s decision that she should be the
prison FLO. Although there were, I understand, five trained staff at the prison, it
would appear that they were not available, hence his decision. The role of FLO is
a specialised task and should only be carried out by those who volunteer and are
trained to deal with the work. It is not a task that can be given out to anyone and
nor should it be.
88. The liaison officer told the investigator that she did not think that her visit to see
the man’s family went well and she had felt out of her depth. It is also clear that
she felt that his family were frustrated and angry at her because she was unable
to tell them what had happened.
89. At a time when families are grieving and confused, they expect to be supported
properly and decently. It disappoints me that in this case they were not. I
consider that the Deputy Governor’s decision to appoint the Violence Reduction
Coordinator Officer was wrong. My comments are no reflection on what she did
as I am sure she did her best in the circumstances. I see many cases where the
work of the prison FLO has produced first class evidence of support and trust.
Sadly the same cannot be said in this case.
The Governor must ensure that prison family liaison officers at the
prison are properly trained volunteers in line with the guidance
contained within PSO 2710.
Family response to the draft report
90. The man’s family provided detailed feedback to the draft report into his death.
Some of these issues are matters that should be properly raised at inquest. A
couple of others have already been noted in paragraphs 51 and 71 above and I
will cover those that I am not able to provide a response to in a separate letter to
the family. There remain, however, several other issues which were raised by
the family and which I have asked NHS Norfolk to comment on. They have done
so by means of a management letter which the Coroner has kindly shared with
me. Below, I list the questions raised by the family and the responses from NHS
Norfolk.
91. The first matter they have raised concerns the management of the man’s opiate
withdrawal. The family have asked whether the system has now been changed.
In response, NHS Norfolk have replied:
“The treatment of drug misuse has changed dramatically at HMP
Norwich with the introduction of the Integrated Drug Treatment
System (IDTS). Following the receipt of government funding, the
IDTS was implemented which increased the range of available
treatment options in line with National Guidance. In particular this
programme supports substitute prescribing to enable stabilisation,
22
maintenance and detoxification from opiates within a safe
environment. All prisoners with an active substance misuse history
are now located on the new A wing where healthcare staff are all
appropriately trained and experienced in the management of
substance misuse. A registered nurse is available 24 hours a day
and GPS now have extended hours until 8pm Monday to Friday and
until 4pm on Saturdays. The nurses are also able to provide
immediate symptom relief for opiate withdrawal without the need for
a GP prescription by using the Patient Group Directions.”
92. The man’s family also asked about the clinical governance structure for the
healthcare staff at the prison and has there been any subsequent improvement
following his death.
93. NHS Norfolk replied:
“In November 2008, NCH&C [Norfolk Community Health and Care]
commissioned an external Clinical Governance Review. The review
contained a series of recommendations. Following receipt of the
review an action plan was developed, implemented and is now
complete. This resulted in a robust Clinical Governance system with
a strengthened management structure and improved clinical
supervision. Three Band 7 nurses were recruited to act as team
leaders and mentors to junior staff who now have clear lines of
accountability and regular supervision to ensure good practice is
followed and any training needs are identified. Clinical Governance
is a standing agenda item at team meetings which are an opportunity
to discuss issues that have arisen and to introduce and/or reinforce
current policy. These meetings ensure two way communications with
staff and shared learning.
“As a result of the review prison healthcare became fully integrated
into the wider NCH&C governance framework. This allows for better
joint working with the prison. There is also a new information sharing
protocol which enhances communication between healthcare and
prison staff. A Healthcare Integrated Governance Group was also
set up to bring healthcare and prison staff together to improve patient
care where joint working is particularly important. This group reports
to the Prison Health Operational Forum and from there to the Prison
Health Partnership Board, the membership of which includes three
Prison Governors, a Director of NHS Norfolk, the Director of Clinical
Governance (NCH&C) and the Independent Monitoring Board.”
94. Next, the family pointed out that “the report refers in detail to the lack of
opportunity to learn from or do a root cause analysis of this incident”. They asked
whether this had now been addressed.
95. NHS Norfolk replied:
23
“NCH&C has taken on board all the recommendations of the Clinical
Reviewer and addressed each point, as shown in the action plan
attached. The Serious Untoward Incident Policy was revised and re-
issued in December 2009. The new policy provides clear structures
for the reporting and investigation of incidents, ensures appropriate
support for staff and stresses the importance of lessons learnt.”
96. The family then asked why the man was sent to the inpatient healthcare wing
when there appears to be no criteria for referral and no treatment pathways in
place.
97. NHS Norfolk replied:
“We understand from the PPO interviews that the man was sent to
the inpatient healthcare wing to be observed and assessed by the
mental health although this is subject to the evidence of the relevant
witnesses at the Inquest. Since this incident the Healthcare Bed
Admission/Discharge Policy has been introduced. This provides
clear guidelines for the management of patients admitted to the
inpatient healthcare unit. In particular an initial nursing assessment
and management plan will be documented within one hour of
admission.”
98. The next question the man’s family asked was whether Prison Officers have the
ability to override a healthcare decision if they felt is was inappropriate. NHS
Norfolk replied that Prison Officers can inform the Head of Healthcare if they are
unhappy. The Head of Healthcare is able to override a nursing decision.
99. The man’s family then asked why empty packets of diclofenac and co-codamol
were found in his cell when the last prescription showed that these should have
been issued as “Not in possession” medication. They also asked why brufen had
been found, when this had not been prescribed at all, and whether risk
assessments were now in place to ensure that this situation did not arise again.
100. NHS Norfolk replied:
“The diclofenac and co-codamol were prescribed as daily “in
possession”. At this time it was standard practice to use the “not in
possession” part of the medicines chart also for daily “in
possessions.” Medications which were strictly “not in possession”
would have been documented as “in sight” meaning that they had to
be given under observation of a nurse and a prison officer. A new
procedure is now in place. The medication chart has been amended
and “in possession” risk assessments are now undertaken as part of
the secondary screening process.
“Unfortunately we are unable to confirm how brufen came to be in his
cell. The man was prescribed Ibuprofen 400mg on 23 September
2008 and held this “in possession” so the packaging found in his cell
could be from that occasion.
24
“The Medication In Possession Policy was updated in August 2009.
The updated policy provides that a risk assessment must be
completed before medication is given in possession.”
101. The man’s family also wanted to know why, if staff were unable to
accurately take his vital signs, “the default position” was to send him to
healthcare and not to hospital. They also asked whether prison officers
should have used restraint techniques to help healthcare staff make further
clinical observations. (These events are referred to in paragraph 51
above.)
102. NHS Norfolk replied:
“At the time of the incident it was not the default position that
prisoners would be taken to the inpatient healthcare unit rather than
a hospital. This was a decision for the assessing clinicians and
therefore this is a question for the relevant witnesses at the inquest.
… it would not be normal practice to restrain a patient so that
observations could be taken. NCH&C has received funding to
provide advanced clinical assessment skills training to nursing staff.
The training will emphasise the importance of establishing capacity to
consent to treatment and the importance of acting in the patient’s
best interest where the patient lacks capacity.”
103. The family then asked “will there be any insistence on retraining of certain
individuals?”. NHS Norfolk replied:
“Any individual training needs are identified as part of the
performance review process. The Head of Healthcare will attend the
inquest and will, if need be, feedback to line managers if it appears
that additional training is needed.”
104. The next question put by the family was:
“If nursing staff have no medical concept of one of the most basic
skills ie medical/nursing observation then there is a definite
requirement for retraining, would it be better to employ less qualified
staff and rename this facility so that anybody with genuine or
suspected health care needs are looked after in a more appropriate
environment for those needs?”
105. NHS Norfolk replied:
“We accept that baseline observations should have been taken when
the man was brought into the inpatient healthcare unit. The
importance of this has been fed back to staff and addressed by the
introduction of the Healthcare Bed Admission/Discharge Policy as
detailed above. The … Policy will be subject to audit in 2010/11 and
compliance with the policy will form part of the staff performance
review process. The Healthcare facility has also been subject to a
25
comprehensive data collection by NHS Norfolk with a view to
reviewing the service as a whole in due course”.
106. The family asked why the appointment letter for the CT scan on 29 May
was not included in the medical records. NHS Norfolk were unable to
explain this, although they did suggest that it was possible that the
appointment letter was received after the man’s death when the clinical
record was sealed.
107. As mentioned in the clinical review produced as part of this investigation,
“importance should be placed upon ruling out any organic cause which is
more urgent to deal with before settling upon alternative causes”. The
man’s family asked how this was being dealt with at HMP Norwich.
108. NHS Norfolk replied:
“As diagnosis is primarily a medical responsibility, NHS Norfolk has
sought to improve the care for prisoners by putting in a place a new
prison healthcare contract which will provide dedicated GPs within
the prison. This will reduce the need for locums and provide for
continuity of care. Also … additional funding has been allocated to
provide advanced assessment skills training to nurses.”
109. Finally, the man’s family asked what thermometer equipment was held at
HMP Norwich. NHS Norfolk replied that tympanic (ear) thermometers were
available in the inpatient healthcare facility, and digital thermometers were
in every emergency bag located around the prison.
26
CONCLUSION
110. It is clear to me that when the man arrived into the prison he was committed to
changing his lifestyle. He engaged with those able to help him with his drug
addiction and appears to have been determined to change. He in turn wanted to
give something back and so became one of the prison Listeners, something he
valued and enjoyed.
111. He began to complain of headaches and, despite a number of medical
examinations, his condition remained undetected. Sadly, on 26 May, his health
worsened and, as he was behaving oddly, medical assistance was sought. He
was later discovered on the floor of his cell, conscious but incoherent which
resulted in urgent medical assistance being requested. I am satisfied that prison
staff recognised his distress and summoned medical assistance.
112. Having assessed him, the nurse asked for a doctor and he arranged for the man
to be admitted into the prison’s healthcare department. Healthcare and the
prison wings are in different buildings and he was moved in a vehicle. After being
admitted, I endorse the clinical reviewer’s opinion that his medical care was not
well managed, with a number of fundamental gaps identified in my report.
113. A consultant neurologist said that it would be true that the earlier someone with
intracranial infection is admitted into hospital, the more likely it was to have a
positive outcome. I have considered the doctor’s comment carefully. Whether
the outcome for the man would have been any different cannot be known but, it
has to be the case, it might well have been. His death is tragic. There are a
number of concerns about the healthcare he received, and the evidence is that,
despite specialist medical examinations, healthcare staff did not identify the
seriousness of his condition.
27
RECOMMENDATIONS
1. The Governor must ensure that prison family liaison officers at Norwich are
properly trained volunteers in line with the guidance contained within PSO
2710.
The Prison Service has accepted the recommendation and commented:
It is not a mandatory requirement within PSO 2710 for Family Liaison
Officers to attend the training course. Locally, at Norwich, no untrained
Family Liaison Officer will be asked to carry out these duties”
For healthcare provider and commissioner
2. The provider should ensure that only experienced staff with the appropriate
skills and training should undertake reception screening. Those staff would
require specific training in relation to the various elements of the screening
programme which includes substance misuse and mental health
assessment where appropriate.
NHS Norfolk has responded:
“The Primary care team responsible for reception screening have received
additional training in the competencies listed within the Reception
Screening Policy. Also, all new staff receive Reception Training as part of
their induction.
“The reception screening assessment template has also been improved.
See answer 3 below.”
3. The provider should ensure that the local guidelines for reception
screening (June 2005) are reviewed and updated to meet the national
standards.
NHS Norfolk has responded:
“The reception Screening Policy was updated in October 2009 to meet
national standards.
“To improve the reception process we have also made significant
improvements to the Clinical information System (SystmOne)
“Between August 2009 and March 2010 Suffolk Support Services
contracted to undertake a complete review of SystmOne (the Clinical
Information System). This project included the complete reconfiguration of
the system with the development of safe and effective assessment
templates, retraining of all staff including Super-users (who receive
additional training) to support less experienced staff, and improved
reporting.
28
“The system now includes the National Reception Screening Tool, the
Depression and anxiety assessment templates which are used by GPs in
the community, the Opiate withdrawal screening tool, the alcohol screening
tool and the threshold assessment grid (TAG) risk assessment tool which
identifies the risk of suicide and self-harm.
It is also standard practice to seek the consent of prisoners to the release
of their medical records from their GP as part of the reception process.”
4. The provider should put in place a regular audit programme which ensures
that all areas of the screening assessment are competently completed and
correct care pathways are followed.
NHS Norfolk has responded:
“We have completed a number of audits:
“Record Keeping Audit September 2009
“Reception Screening Process Audit November 2009
“Alcohol Screening and Intervention Audit March 2010
“Consent Audit (see answer to point 7 below) September 2009
“The audit programme 2009/10 demonstrated a high level of compliance
with the policies.”
5. The provider should ensure training for all healthcare staff be undertaken
around mental health assessment and the management of substance
misuse, to ensure that care provided offers the most appropriate treatment
regimes for the conditions of patients and maintains their safety.
NHS Norfolk has responded:
“We have met this recommendation through both formal training and also
effective clinical supervision of staff.
“There are now Band 7 clinical leads in place for Primary Care, IDTS and
Inpatients. The band 7 clinical leads act as mentors or delegate this
responsibility to other senior nurses. Mentors for new staff are identified
on the induction checklist.
Group supervision bimonthly and informal supervision is established. Staff
have the option of additional individual supervision and this can be made
mandatory at line manager discretion.
“Specific to mental health – A mental health rota ensures that there is
always support available from an RMN. Additional funding has now been
29
allocated to provide mental health awareness training for all healthcare
staff.
“Specific to substance misuse, the staff were initially trained by TADS
(Trust Alcohol and Drug Service, part of NWMHFT). Now that IDTS is fully
implemented, the training for staff on the new A wing is provided in a
number of ways including attendance at courses, supervision by the IDTS
lead, shadowing opportunities and ongoing appraisal and continuous
professional development.”
6. The provider should ensure that treatment plans and the rationale for
decisions made are clearly documented within SystmOne clinical records
to enable continuity of care.
NHS Norfolk has responded:
“There is now a care plan template within SystmOne which ensures that all
prisoners with complex health needs have a clear care plan. The
Continuity of care Audit undertaken within Healthcare in March 2010
demonstrated a high level of compliance. The NCH&C audit facilitator
reported “Overall the results at HMP Norwich were exemplary””.
7. The provider should ensure that requests for community medical records
are routinely made as soon as possible in order to inform better healthcare
assessments and outline current needs. There should be an
administrative process in place to facilitate this, and regular audit process
to monitor effectiveness and response.
NHS Norfolk has responded:
“The Reception Screening Policy states that the member of staff
undertaking the reception screen will send a written request to any relevant
healthcare providers for past medical history, having gained patient
consent to do so.
“A Consent Audit was completed in September 2009. This demonstrated a
high level of compliance with this aspect of the policy. Of the 66 patients
that had a GP that could be contacted, 65 of them (98%) had given the
prison consent to contact their GP.”
8. The provider should ensure there is clear guidance on drug detoxification
available and followed, with appropriate and timely prescribing in order to
palliate the wide range of withdrawal symptoms patients’ experience. They
should ensure that all healthcare staff are competent to asses and respond
to this.
NHS Norfolk has responded:
“The Integrated Drug Treatment System (IDTS) has now been
implemented in line with National Guidance. This increases the range of
30
available treatment options, and in particular supports substitute
prescribing to enable stabilisation, maintenance and detoxification from
opiates within a safe environment. Specifically, methadone may now be
prescribed from reception into the prison, where this is indicated by clinical
need.
“All prisoners with an active substance misuse history are located on the
new A wing where the healthcare staff are all appropriately trained and
experienced in the management of substance misuse. The staff are able
to provide immediate symptom relief through the use of Patient Group
Directions (PGDs). The nursing staff are supported by GPs working until
8pm Monday-Friday and 4pm on Saturdays which allows for substitute
prescribing on the first night of custody, supported by the availability of an
emergency stock of medication.”
9. The commissioners should seek assurances from the providers that all
relevant staff are aware of the local Lofexidine management policy and
guidance, and that they comply with the policy. Additionally, there should
be a regular audit carried out to ensure compliance.
NHS Norfolk has responded:
“A revised protocol for the Clinical Management of Patients Administered
Lofexidine was published in May 2009. Following an audit in July 2009 an
action plan was developed and implemented. Re-audit in November 2009
demonstrated significant improvement. In 100% of cases the Substance
Misuse Screening Tool had been used, baseline observations (including
urine screening) were recorded, and prescribing, administration and
ongoing care were in line with policy.”
10. The commissioners should seek assurances from the provider that all
those carrying out reception health screening, substance misuse
management and mental health screening have received proper training.
Additionally, they should ensure appropriate services have been put into
place to safeguard patients via these assessments, with regular audit
embedded to monitor standards.
NHS Norfolk has responded:
“The Commissioner has requested and received copies of the relevant
training logs and audit reports.
“The review of action plans now forms part of the contract monitoring
process undertaken by NHS Norfolk of its providers.”
11. The commissioner should ensure there is a clear criteria for admission to
the healthcare centre and expectations around a minimum level of
baseline clinical assessment should be developed and made available for
providers to implement. Additionally, the commissioner should seek
assurances and evidence that the criteria is being followed.
31
NHS Norfolk has responded:
“Please see 10.3.2 and 10.3.3 below [these relate to recommendations
made in the clinical review – “10.3.2 - The healthcare Bed Admission and
Discharge Policy, April 2010 clarifies admission and exclusion criteria,
admission procedures (including the requirement for observations), and
procedures for transfer to secondary care. This will be the subject of audit
during 2010/11. 10.3.3 – Section 3.5 of the Healthcare Bed Admission and
Discharge Policy, April 2010, specifies the admission procedure which
includes an initial nursing assessment and management plan which must
be documented within 1 hour of admission. This will be the subject of audit
during 2010/11].
“A new policy is now in place and this will be subject to audit in due course.
“NHS Norfolk are also in the process of gathering data on the healthcare
unit to allow for an evaluation of the service.”
12. The commissioner should ensure that the services for specialist nursing for
those prisoners with blood borne virus (hepatitis B & C, HIV) is reviewed to
reflect best practice in the community and meets the needs of prisoners.
NHS Norfolk has responded:
“A new provider of healthcare will take over at HMP Norwich from 1
October 2010. The provision of specialist nursing for prisoners with blood
borne viruses is a key performance indicator for the new provider and we
expect a competency review to be undertaken as part of the
implementation plan.”
32