Individual at Gartree

Investigation into the circumstances surrounding the
death of a prisoner at HMP Gartree
in February 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2008
This is a report into the circumstances surrounding the death of a prisoner who died
at HMP Gartree in February 2007, having been taken ill earlier in the day whilst his
partner was visiting him. He was subsequently admitted to the health care in-patient
centre and that evening was discovered dead from a heart attack. The man was 40
years of age.
I wish to extend my condolences to the man’s long-term partner, together with his
other friends and family. To lose a loved one at any time is difficult, but especially so
when they are relatively young, die suddenly and are in custody.
This investigation was carried out by one of my colleagues. A clinical review was
undertaken by a doctor from the local Primary Care Trust (PCT) for which I am most
grateful. I included the clinical review as an annex to earlier versions of this report
and I would urge the PCT to consider its findings as well as my own
recommendations.
I am indebted to the Governor of Gartree for her support and attention to my
investigator’s early concerns regarding clinical practice at the prison. It is rare that I
feel the need to be critical of an individual staff member’s practice, but in this
instance I have felt it necessary. It is evident from my investigation and from the
clinical review that, had this man received more appropriate treatment (referral to
outside hospital), he would have stood a much better chance of being alive today.
I make nine recommendations and one point of good practice in this report.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2008
2
CONTENTS
Summary 4
The Investigation Process 5
HMP Gartree 6
Key Findings 7
Issues 10
Recommendations 15
Good Practice 16
3
SUMMARY
The man died in February 2007 at HMP Gartree.
The man was convicted of murder at Crown Court on 5 December 2005, and
received a life sentence. He was transferred to HMP Gartree on 13 July 2006
from HMP Woodhill.
During the man’s early days at HMP Gartree, the priority for both him and staff at
the prison was to assess and manage his mental health. The man was
diagnosed, not with a mental illness, but with an ‘emotionally unstable personality
disorder’. The treatment was to be cognitive support, counselling and an
adjustment of his medication.
There were times of emotional distress for the man, and he was assisted through
these crises by prison staff, the Assessment, Care in Custody and Teamwork
(ACCT) process, and by mental health in-reach staff.
On an afternoon in February, 2007, the man went to the visits area in the prison to
meet his partner and a friend. During this visit, the man felt unwell and was
suffering from chest pain. Healthcare staff were called to assess and treat him.
The nurse who saw the man believed him to be suffering from stress and anxiety
as the following day was an anniversary date of some significance for him. The
man was reassured and continued his visit.
After his visit, the man returned to his residential unit. He again felt unwell and
nursing staff were called to see him. Once more he was experiencing chest
pains, but nursing staff continued to believe this was due to anxiety and
indigestion. However, he was admitted to the healthcare unit in order for his
condition to be monitored.
At approximately 8.45pm, when the night staff for the healthcare unit arrived, the
man was discovered dead from a heart attack.
4
THE INVESTIGATION PROCESS
1. One of my investigators made initial contact with HMP Gartree to ensure that
Notices to Staff and Prisoners were issued for display. My investigator also
made arrangements for prison papers to be sent to this office and made
contact with the prison’s liaison officer and family liaison officer.
2. Another of my investigators visited HMP Gartree on 30 March 2007. He met
the Governor, members of the healthcare team, the family liaison officer and
the prison liaison officer. My investigator was shown around the prison and
saw the healthcare centre where the man died, together with the visits area
and residential accommodation where the man had been unwell on the day
he died. My investigator was also introduced to members of the local branch
of the Prison Officers’ Association, but no members of the Independent
Monitoring Board (IMB) were available on this occasion. I am grateful to the
Governor and her staff for the consideration and assistance given to my
investigators throughout this investigation.
3. The local Primary Care Trust (PCT) was asked to undertake a clinical review of
the care the man received while in custody. A doctor who works as a GP
undertook this review on behalf of the PCT. The doctor was asked to look at
the entries in the man’s clinical record and the quality of such entries. The
doctor was also invited to judge whether the care the man received while at
Gartree was appropriate and of equal standard to that that he might have
expected had he been at liberty. In particular, the doctor was asked to
consider the response of healthcare staff to the man’s three presentations of
chest pain on the day he died.
4. On various dates between June and August 2007, my investigator and the
doctor undertook interviews of staff at HMP Gartree. The doctor also spoke
with the man’s next of kin, to gain information about his visit to the man that
took place on the day the man died.
5. On 5 March 2007, one of my own Family Liaison Officers, spoke with the
man’s partner on the telephone. She explained the investigation procedure
and invited him to raise any questions. He raised a number of issues of
concern. Chief amongst these was the man’s care under the mental health
services whilst at HMP Gartree, a matter dealt with in the clinical review. The
man’s partner also asked why the healthcare team had not been able to
identify the seriousness of his partner’s condition on the day he died. I hope
this report goes some way to addressing these concerns.
5
HMP GARTREE
6. HMP Gartree is located three miles north of Market Harborough in
Leicestershire. It opened in 1966 as a category C prison. It was upgraded to
form part of the high security group of prisons in the 1980s, but in the early
1990s it was re-graded to a category B training prison for adult males. It
holds life sentenced prisoners in the first and second stages of their sentence.
Gartree has an operational capacity of 577 prisoners. Two new units were
added in November 2006.
7. Ms Anne Owers, Her Majesty’s Chief Inspector of Prisons, last reported on
Gartree in May 2005 when she found the prison wanting in its delivery of lifer
services. She described Gartree as ‘showing all the signs of a prison that had
been drifting …’ She described healthcare services as giving her cause for
serious concern. She was particularly worried that staff shortages, coupled
with inappropriate use of healthcare staff for discipline roles, were leading to
poor service delivery. There were 14 beds within the healthcare centre, but
only two of these beds were allocated to clinical need. This meant that
healthcare staff were used to supervise non-patient prisoners, thereby
detracting from their clinical duties. This situation continues to date.
8. One of the other serious failings identified by the Chief Inspector was the use
of nurse triage without any formal training – a feature in this man’s death.
However, I am pleased to report that there have been significant steps
forward at HMP Gartree from the time of the Chief Inspector’s report and the
man’s death. There are now some 15 members of the healthcare team (a
Band 8a leader, with two Band 7s – one for primary care one for mental
health care; six RMN Band 5s including two HCOs with mental health
qualifications; three RGN band 5’s plus two HCO’s without qualifications)
leaving just one post currently vacant. The action plan from the 2005
Inspection report has largely been implemented with just the one major area
of concern outstanding. This is tied up with the number of places Gartree can
offer to the Prison Service and means that, for the time being, the inpatient
unit has to continue to provide cell spaces for non-patient care.
9. This man’s death was one of eight deaths that have occurred at Gartree since
I began investigating all deaths in custody in April 2004. In one of my earlier
investigations (2006), I made similar recommendations to those contained in
this report. Although Gartree has only had two months to implement those
recommendations, I am told they have already done so. I hope this will leave
the prison better able to deliver healthcare to the prisoner patient population.
6
KEY FINDINGS
10. The man arrived at HMP Gartree on 13 July 2006. He appears to have
settled in quite well, although he liked to largely keep himself to himself. He
struck up good relationships with some staff, particularly his personal officer
and one of the chaplaincy team. He also underwent some psychological and
mental health nursing interventions to help him with his coping skills.
11. The man had a number of episodes of self harm or cause for concern from
staff such that he was put onto an ACCT document. (ACCT is a flexible,
prisoner centred assessment and care planning system, which aims to identify
individual needs and offer personalised care and support before, during and
after crisis, in a safe and caring environment.)
12. During the man’s relatively short time at Gartree, he engaged with the
healthcare team and the psychology department, in respect of issues relating
to his offence and his continued personality disorder. He worked on a one to
one basis and had considered asking for a trial at HMP Grendon (which
operates as a therapeutic community). It was agreed in one of his sessions
that he should find out more for himself about Grendon, and then apply to go
there when he felt ready. At the time of his death, he had not made a formal
application to transfer.
13. The man had contact with his outside probation officers and regular visits from
his partner and friends throughout his time in prison. In fact, it was on one of
these visits, in Sunday February 2007, that the man first felt unwell in the
episode that led to his death.
14. That afternoon the man was being visited by his partner and their friend. The
man arrived at the visits hall with chest pain and his visitors noted that he was
clammy to the touch when they hugged him. Nevertheless, he wanted to
proceed with his visit. After approximately half an hour of feeling
uncomfortable with his chest pain and having restless arms, the pain
intensified to such an extent that the man had to stop his visit and request the
assistance of staff.
15. Discipline staff on duty at the time summoned the assistance of healthcare
staff. A male nurse arrived and, according to his interview, started to make an
assessment of the man in the privacy of a back room off the main visits room.
The nurse (who is general nurse qualified) made an assessment and took a
clinical history from the man. The nurse felt certain that the man was having
an anxiety attack because the man seemed pre-occupied with the fact that the
following day was an anniversary date of his index offence. According to the
nurse, most of what the man was talking about was this forthcoming
anniversary. The nurse was keen to reassure the man and suggested that he
use the coping skills he had acquired to distract him from self harming
behaviour and as a means of relieving stress.
16. The man resumed his visit, apparently having declined any medication
(according to the nurse he had offered him some relief from his pain which the
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nurse thought may have been related to indigestion). The man’s visitors left
at their due time without further interruption to the visit.
17. When the man returned to his living unit (G Wing) at approximately 4.15pm,
the female officer who supervised his entry to the unit recalls seeing and
speaking to him. She asked the man if he had had a good visit. He replied
‘yes but I had a panic attack and they came over from healthcare and they
gave me some indigestion tablets’. The officer reports that he then said, ‘but
I’ve still got the pain here’ and patted his chest and told her that he was
sweaty. When asked in interview if the man appeared sweaty or distressed,
the officer said that he did not, but he was wearing a thick jumper and was his
usual pale complexion.
18. The man then made his own way back to his cell after being advised by the
officer to rest in his cell and see if he felt better. The officer felt that the man
had accepted and agreed with the healthcare team that he was suffering from
anxiety.
19. Later that evening, at approximately 6.15pm, the man rang his cell call bell for
assistance. A different female officer was in charge of the unit, and she
attended and discovered the man gripping his chest and complaining of chest
pains and pains in his elbows. This officer had only ten minutes earlier looked
in on the man (as part of his ACCT observations) and found him to be fine
and sitting on his bed. She was concerned for the man because she was
aware he had had problems earlier on his visit. In her opinion, he was in a lot
of pain and very distressed. The officer immediately contacted the duty senior
manager and healthcare using her radio, and stayed talking to the man to
offer reassurance.
20. There was a ten minute delay before the duty senior manager and nurse
arrived due to the fact that they had been dealing with another incident
elsewhere in the prison. The man remained under constant observation by
this second supervising officer during this time.
21. When staff arrived, the nurse (a female nurse who is qualified as both a
general nurse and a mental health nurse) calmed the man down and took his
blood pressure. According to the female officer who had been watching over
him, the man did calm down somewhat and the female nurse gave him some
liquid indigestion medication. The officer believes that, although he calmed
down, the man remained in pain throughout the assessment by the nurse.
The man described it as being a crushing pain and complained that he had
pain in his elbow too.
22. The female nurse decided to admit the man to healthcare in order to further
assess him and monitor him overnight. The duty senior manager, his assist
(a male officer), and the female nurse then left, escorting the man to
healthcare together.
23. Both the male officer and the duty senior manager said in interview that the
man, on being escorted to healthcare, was clutching his chest and walking
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very slowly, as though he was having some difficulty. They both recall he
needed to stop at least once en route in order to sit down.
24. The man eventually arrived at the healthcare centre (it is a walk of some 600
yards from G wing) and he was admitted to a cell there. He was then
examined by a Healthcare Officer (HCO) who took his pulse and blood
pressure. The HCO undertook further questioning and assessment of the
man and admitted him for further observation.
25. Over the next hour or so, the HCO looked in on the man two or three times,
noting that he was lying on his bed and appeared to be sleeping. The HCO
prepared to hand over to the night patrol at about 8.45pm (a fellow healthcare
officer with a Registered General Nurse qualification). The day HCO tried to
rouse the man. Due to the fact they could not wake him, they went into the
man’s cell and discovered he was not breathing. They immediately started
cardio pulmonary resuscitation (CPR) and used the emergency radio system
to call for an ambulance. The night HCO and the day HCO both used the
heart start machine but it indicated no signs of life. They continued CPR until
the ambulance team arrived.
26. Despite further attempts at resuscitation by the paramedic team, the man was
pronounced dead at 9.15pm.
27. The man’s partner was informed by the police at 3.00am the next morning
that he had died. He was told to contact the prison in the morning for further
details. According to the man’s partner, it was at the insistence of the prison
that the police broke the news of the man’s death immediately and in this
manner. The prison however, is quite clear that they did not request the news
be broken immediately, but merely requested the police do so on their behalf.
The Deputy Governor was, in fact, quite unhappy overall with the way the
police handled matters relating to the man’s death – a matter she thought
would benefit from some joint training locally in the future.
28. The man’s funeral expenses were partially met by the prison. However, the
prison ‘offset’ part of these costs by utilising funds from the man’s personal
account at the prison.
9
ISSUES
29. The clinical review was undertaken by a doctor who was appointed by the
local Primary Care Trust. In his review, the doctor deals with each
presentation of the man’s medical emergency in February 2007. There were
no less than three opportunities for healthcare staff to have referred this man
to local NHS services. Had they done so, the doctor says there would be an
80 per cent likelihood that the man would be alive today.
30. At the Coroner’s inquest held in July 2008 the Coroner had asked for a report
from a consultant cardiologist. The cardiologist (a professor) provided a
report which I attached as a new appendix to the final version of this report.
The professor was asked to comment on the likely outcome for this man,
given the severe narrowing of his anterior descending artery (a main blood
vessel of the heart). His report says:
On the basis of information available to me, I do not think that it was
possible to prevent the myocardial infarction [the heart attack]. Once it
occurred, the risk of death was high because of the location of the
occlusion of the anterior descending artery.
The sudden occlusion of the anterior descending artery in young men
carries a high risk of sudden death, particularly as it often presents with
no typical angina.
Conclusion. On the balance of probabilities I believe that even if the
anterior myocardial infarction (had) been identified, the outcome would
have been the same.
31. This is quite at variance with the clinical reviewing doctor’s position. My
investigator therefore spoke with both the doctor and the professor. The
doctor feels that his use of statistics to say that this man would have had an
80 per cent likelihood of being alive today if healthcare staff at Gartree had
referred him to hospital sooner was ‘a little clumsy’. He stands by his point
that if the man had been referred to local NHS services at any time after his
first presentation of chest pain at approximately 2.30pm, he would have stood
a better chance of survival. The professor agrees with this point – and both
doctors say that early diagnosis and start of treatment for people with chest
pain is imperative. There was much more each doctor could have said about
the early treatment and referral processes, but the underlying points within
this report remain unchanged.
32. In respect of the first of these opportunities (the man’s examination by the
male nurse during his afternoon visit), the doctor’s opinion is that, the man
‘presented with, if not classical symptoms, then symptoms highly suggestive
of acute cardiac pain.’ The fact that the nurse failed to recognise this
highlights inadequate training, errors of judgement in respect of heart attacks,
inadequate knowledge of the correct management of undiagnosed chest pain
and, says the doctor, a pre-judged acceptance that the man’s problem was
attributed to anxiety.
10
33. The doctor says the management of chest pain of uncertain origin should
result in immediate transfer to an emergency department for a more in-depth
assessment using blood tests and electrocardiograph (ECG) monitoring (a
tracing of the electrical output of the heart). Delays in such referrals, even by
an hour, increase the chances of a patient’s death, or further damage to their
heart.
The local PCT should assist the Governor in developing chest pain
guidelines to ensure it provides appropriate guidance for staff who are
assessing patients presenting with severe chest pain symptoms.
Untrained (without formal minor illness training) nursing staff should
not take clinical decisions in isolation and should be supported in their
assessment of medical problems either by appropriately trained staff in
the day, or the out of hours triage service at night.
34. When the man was seen at about 6.30pm by the female nurse (the second
opportunity for transfer to a hospital), she also seems to have assumed that
the man was suffering from anxiety. It is evident from her interview that, in
her assessment of this man’s presentation, she was preoccupied with the
psychological distress he was apparently suffering rather than the
physiological symptoms of acute chest pain. In interview, this nurse declared
that it was difficult to obtain a good history from the man because he was in
such distress. She did give medication for indigestion but failed to check if the
man had ever suffered from such acute gastric pain before, or whether the
medication was effective.
35. The female nurse Murphy to admit the man to healthcare so that another
member of the healthcare team could continue observation of him.
Unfortunately, the nurse made inadequate written records of her findings and
administration of medicines. She gave an inadequate handover to an
unqualified member of staff, and appears to have misjudged significantly the
degree of pain the man was experiencing at the time she reviewed him. The
nurse accompanied the man on his movement to healthcare. This took a long
time because the man had to stop several times. He apparently clutched his
chest throughout the move and complained of pains in his arms. These are
classic signs of someone in acute cardiac distress.
36. The doctor says that the female nurse clearly breached her professional
duties by working beyond her scope of practice. She failed to record matters
adequately in the medical notes. She administered medicines without
adequate training or the support of a local prescribing protocol. She
delegated a task to a lesser qualified healthcare worker without an adequate
handover.
The Governor, in conjunction with the local PCT, should consider
whether this nurses conduct should be referred to the Nursing and
Midwifery Council (NMC).
11
The medicines management committee should ensure there are
sufficient and appropriate Patient Group Directives to allow the
administration of simple medicine remedies for patient care at HMP
Gartree. There should be appropriate staff training in their use.
37. More generally, the medicines management issues caused the doctor to have
very serious concerns which he raises in his clinical review. In interview, the
day HCO stated that he would be happy to admit an asthmatic patient to the
in-patient unit, administer medication and continue to monitor the patient
overnight, even though there was no working policy to cover such
eventualities at that time. Nowhere within the NHS would such clinical
freedom be afforded (or expected) of an unqualified member of staff. The
doctor says, ‘Such a worker would be expected to be supported by robust
clinical guidelines and narrow protocols, always with access to a qualified
member of staff to support and guide decision making.’
38. Once the man arrived in healthcare, the day HCO reassessed his signs and
symptoms and came to the same erroneous conclusion that he was suffering
from anxiety. This was the third opportunity healthcare staff had to identify
the seriousness of the man’s condition. In interview, the day HCO described
how someone would present with anxiety correctly, and recognised that these
were not the signs and symptoms that this man was displaying. He was also
able to describe to some degree the typical signs and symptoms of someone
experiencing a heart attack, but he mistakenly believed that these would
always present as a band of pain across the chest. It is likely, according to
the clinical reviewer, that this inexperience is attributable to lack of formal
qualifications and training in recognising the full range of signs and symptoms
for heart conditions. I am particularly concerned by this HCO’s assumption (to
which the clinical reviewer refers) that the man’s elbow pain might have been
attributable to arthritis.
A full training needs analysis for staff working in healthcare should be
undertaken by the PCT to incorporate an urgent review of the nursing
roles at HMP Gartree.
39. The day HCO is not a qualified nurse (he has an NVQ level Three in Care
which is akin to a Health Care Assistant), yet he was put in sole charge of an
in-patient area over a prolonged period of time. The female nurse had clinical
accountability for her patient, yet she felt able to discharge that responsibility
to a non-nurse qualified member of the team and gave an inadequate
handover. She failed to inform the HCO fully of what she expected of him and
did not mention (or record properly) the medication she had given the man.
Indeed, the HCO thought that the man had been given paracetamol by the
nurse, and was unaware that she had given him indigestion medication which
he ought to have been monitoring for effect.
Staff who are not qualified and registered should not take sole
responsibility for delivering healthcare. Their practice should always be
under the supervision of a qualified member of the healthcare team.
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40. The doctor’s review states that the current arrangements for the provision of
healthcare at HMP Gartree are less than satisfactory. He says the, ‘Primary
Care Trust commission HMP Gartree to provide a healthcare service
(essentially the nurses employed by the prison). The prison as the provider is
responsible for the quality and governance issues of this service. I believe the
necessary skills for the proper provision of this service is not currently
available at the prison. There has not been sufficient engagement between
the PCT and the prison to ensure that suitable systems are in place to ensure
the quality of health provision and its development.’
41. When commissioning arrangements changed in April 2005, it was envisaged
that there would be an improvement in systems to ensure the quality of health
provision and its development at Gartree. Whilst there have undoubtedly
been some improvements (as highlighted in the clinical review) in provision at
Gartree, events surrounding this man’s death suggest that the skills and
competencies required to run a health service of this complexity are not
sufficiently present at the moment.
42. The doctor also questions the healthcare service facilities, in particular the
function of the in-patient unit: ‘I would further question the role of the
healthcare wing. Only two of the fourteen cells are reserved for healthcare
and nursing staff have penal duties for all the cells. I struggle to see the
medical value of an admission to these cells given the capability of the staff
and the restrictions on access to the patients. The majority of prisoners
housed on the unit are requiring sanctuary from bullying and could be
managed elsewhere. Similarly increased vigilance for psychological distress
could be managed more closely on the wings.’ This echoes concerns raised
by Ms Anne Owers’ report (Ms Owers said, ‘Prisoners should be located in
the healthcare centre only if clinically indicated.’)
The PCT should review current arrangements to ensure that an effective
healthcare service is being delivered at HMP Gartree. Consideration
should be given to better use of the provider skills of the GPs during the
current tender period, in particular to underpin clinical responsibility for
the current service.
43. There was an apparent reluctance to seek additional advice or guidance from
outside the prison during out of hours periods. The day HCO seemed to
believe that he had two main options if he felt unduly concerned about a
patient. He said in interview, ‘But at night-time the only referral you’ve got is
either get the doctor in or send them out.’ Similarly, the female nurse did not
consider calling for any additional help or guidance from outside services in
respect of the man’s chest pain because she was so convinced that his
condition was that of anxiety and indigestion. If any of the three staff who saw
this man on this day had sought outside guidance, there is no doubt in the
reviewing doctor’s mind that they would have recommended that he should be
sent to hospital immediately.
13
44. The doctor believes that there are inappropriate attitudes to the value of an
out of hours service, and these attitudes stood in the way of staff seeking help
and guidance from outside the prison.
The PCT should ensure that closer working relationships are
established with the medical lead of the out of hours service to develop
protocols for referral, advice and requests for visits from them.
45. When the man was admitted to the in-patient unit, the prison was on ‘patrol
state’. This means that, except in extreme emergencies, prisoners’ doors can
not be opened unless there are sufficient staff present (which would usually
mean at least three members of staff). If this man was admitted for further
observation (as indicated by the female nurse and day HCO), his room would
have had to be unlocked with additional staff having been summoned to
facilitate this. There does not appear to have been any attempt by the day
HCO to request attendance of any additional staff for this purpose. I believe
the observations and monitoring that should have been expected for this man
should have amounted to more than a verbal check from the doorway that he
was alright.
The Governor should develop a protocol for managing patients who
require observations, monitoring and administration of medicines or
treatments during patrol state times.
46. As the clinical review makes clear, there have been some significant
improvements in the care provided at Gartree over recent years. My previous
reports contained relevant recommendations for further improvements, but
unfortunately they would not have had time to have become established by
the time of this man’s death. I am confident that if the PCT and prison work
together in partnership and act on the recommendations within this report and
others, they will improve still further and provide a much enhanced service to
their prisoner patients.
47. Prison Service Order (PSO) 2710 gives guidance and instruction to prisons on
matters related to deaths in custody. In respect of notification of a death to
the deceased’s next of kin, it makes clear that this should be done ‘in a
suitable manner’. Supplementary guidance to this PSO makes it clear that,
where possible, this notification should be face to face by staff from the Prison
Service. In this instance, the prison asked the local police to break the news
of the man’s death (a practice that is reasonable given the circumstances of
distance from the prison). However, I was disappointed to learn that the
man’s partner was informed in the manner in which he was and hope that the
prison can learn from this for the future. The man’s partner has made no
complaint on this matter, although he has mentioned it to my Family Liaison
Officer.
48. Similarly PSO 2710, in its supplementary guidance, says that the prison
should ‘offer to pay reasonable funeral expenses’. The guide for ‘reasonable’
is seen to be in the region of £3,000. This man’s funeral expenses were
£3,210.50 (after deduction of costs for floral tributes). The prison initially
14
chose to reduce their contribution towards the funeral costs by deducting the
man’s prison cash account balance and paying 70 per cent of the remaining
bill. This course of action is not in the spirit of the PSO which advises prisons
not to quibble over small sums. Gartree has since returned the man’s prison
account money to his partner.
The Governor should review the contribution the prison has made to the
man’s funeral expenses.
49. In contrast, the prison were very supportive to the man’s partner in many
other ways. Gartree should be commended for this.
15
RECOMMENDATIONS
To the Primary Care Trust
The medicines management committee should ensure there are sufficient and
appropriate Patient Group Directives to allow the administration of simple
medicine remedies for patient care at HMP Gartree. There should be appropriate
staff training in their use.
A full training needs analysis should be undertaken by the PCT to incorporate an
urgent review of the nursing roles at HMP Gartree.
The PCT should review current arrangements to ensure that an effective
healthcare service is being delivered at HMP Gartree. Consideration should be
given to better use of the provider skills of the GPs during the current tender
period, in particular to underpin clinical responsibility for the current service.
The PCT should ensure that closer working relationships are established with the
medical lead of the out of hours service to develop protocols for referral, advice
and requests for visits from them.
To the Governor and Primary Care Trust
The Governor, in conjunction with the local PCT, should consider whether the
nurses conduct should be referred to the Nursing and Midwifery Council (NMC).
The local PCT should assist the Governor in developing chest pain guidelines to
ensure it provides appropriate guidance for staff who are assessing patients
presenting with severe chest pain symptoms.
Untrained (without formal minor illness training) nursing staff should not take
clinical decisions in isolation and should be supported in their assessment of
medical problems either by appropriately trained staff in the day, or the out of
hours triage service at night.
Staff who are not qualified and registered should not take sole responsibility for
delivering healthcare. Their practice should always be under the supervision of a
qualified member of the healthcare team.
To the Governor
The Governor should develop a protocol for managing patients who require
observations, monitoring and administration of medicines or treatments during
patrol state times.
The Governor should review the contribution the prison has made to the man’s
funeral expenses.
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Good Practice
I am pleased to note that Gartree dealt sensitively and compassionately with a
number of matters relating to supporting the man’s partner. Gartree’s Chaplain
presided over the funeral of the man in accordance with the wishes of his partner.
17