Individual at Dovegate

Investigation into the circumstances surrounding the
death of a man
at HMP Dovegate in July 2009
Report by the Prisons and Probation Ombudsman for
England and Wales
August 2011
This report considers the circumstances surrounding the death of the man at HMP
Dovegate in July 2009. He was found in his cell when it was unlocked that morning.
He was 48 years old.
I offer my sincere condolences to all those who knew him. I apologise for the very
long time taken to issue this report, and any further distress that this may have
caused.
The investigation was conducted by my investigator on my behalf. I would like to
thank the Director and his staff for their co-operation. I also thank the clinical
reviewer who conducted a review of his clinical care. She was appointed by the
local Primary Care Trust. The final version of her review was sent to my office in
June 2011.
The man received a sentence of imprisonment for life in 1999. He had a history of
harming himself and attempting suicide. Whilst in prison but before his transfer to
HMP Dovegate, he attempted suicide on two occasions, and harmed himself by
cutting his arms a number of times. He was also diagnosed with personality
disorders. When transferred to Dovegate in September 2008, he said he felt like
harming himself. He did so in November 2008, using a piece of broken glass to cut
his arm.
He was prescribed anti-depressant and anti-psychotic medication. He was assessed
by a community psychiatric nurse (CPN) but was not offered ongoing support from
mental health services.
On 19 June 2009, he moved to Dovegate’s therapeutic community. This is separate
from the main prison and offers an intensive group therapy setting for serious
offenders. On the morning of 9 July, he was found dead in his cell. The cause of his
death was not immediately apparent. A post-mortem examination found that he died
from aspiration of gastric content caused by quetiapine (an anti-psychotic medication
that he was not prescribed) and fluoextine poisoning. I have considered both the
possibility that he intended to take his own life, and the possibility that his death was
accidental. Unfortunately, I am unable to speak with any certainty about his
intentions.
I endorse seven recommendations made by the clinical reviewer, which cover a
number of aspects of clinical care including access to mental health services, pain
assessment and management, and record keeping.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Thea Walton
Acting Deputy Ombudsman August 2011
2
CONTENTS
Summary
The investigation process
HMP Dovegate
Key events
Issues
Conclusion
Recommendations
3
SUMMARY
1. The man was sentenced to life imprisonment in 1999. He had a history of
convictions for violent offences, and had served a number of previous prison
sentences.
2. Before his transfer to HMP Dovegate in September 2008, he spent time in a
number of other prisons. He had complex mental health needs over a
considerable period of time. He had attempted suicide on a number of
occasions before he was imprisoned, both by overdose and by hanging. In
2003 and 2004, he attempted to hang himself whilst at HMP Frankland. He
also harmed himself on a number of occasions by cutting his arms.
3. He was assessed in February 2008 for Broadmoor’s Dangerous and Severe
Personality Disorder (DSPD) unit. The assessment commented on his self-
harm and suicide attempts, violent altercations whilst in prison, and his
tendency to seek out psychotropic medication. Whilst the assessment
concluded that he had antisocial and emotionally unstable personality
disorders, he was not considered suitable for admission. This was due to his
acts of self-harm, his manipulation of staff to gain access to medication, and
his unwillingness to describe his internal world.
4. On 20 August 2008, he harmed himself whilst at HMP Long Lartin by cutting
his left arm with a razor. An Assessment Care in Custody and Teamwork
(ACCT) was opened to monitor him and offer him additional support. This
was closed on 17 September, and he moved to Dovegate the following day.
When he arrived, he described himself as worried, distressed, depressed, and
thinking about suicide and self-harm. An ACCT was opened and he was
admitted to the healthcare unit. He remained in the healthcare unit until 23
October, and on the ACCT until 3 November. He did not harm himself during
this period. However, he told members of staff that he heard voices at night
telling him to harm himself.
5. He was prescribed fluoxetine, an anti-depressant, and olanzapine, an anti-
psychotic medication, when he arrived at Dovegate. He had been taking
fluoxetine for a number of years, and olanzapine for around a year. He was
reviewed by a community psychiatric nurse (CPN), and an appointment with a
psychiatrist was arranged.
6. Although his ACCT was closed on 3 November, he cut his arm using a piece
of broken glass later that evening. A new ACCT Plan was opened, and he
moved to the healthcare unit. He said he was being bullied and felt his only
way out of the situation was to harm himself. The ACCT was closed on 18
November, and he was advised to speak to members of staff on the unit if he
had any issues or concerns. During the same period, he was discharged from
the psychiatrist’s clinic without being assessed, after failing to attend his
appointment.
7. He did not harm himself again. Towards the end of 2008, he seemed to mix
well with other prisoners when he was on the wing. He was polite to
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members of staff and attended education classes. During the first four
months of 2009, regular entries were made in his wing history record. There
were no major concerns about him, although several references were made to
the fact that he spent much of his time in his cell. He did not socialise very
much with other prisoners.
8. During May and June, further entries were made in the wing history record.
One entry noted that he “rarely leaves his cell other than to collect food”.
There were no recorded concerns specifically about his well-being, but it
seems that he remained reluctant to socialise with other prisoners.
9. On 19 June, he transferred to Dovegate’s therapeutic community. This is
separate from the main prison, offering a group therapy model for serious
offenders. There were few entries in his records following this move. An
entry in his wing history record on 5 July noted that he had experienced “a bit
of a tough week”.
10. There were no further recorded concerns about him. He was found dead in
his cell. The cause of his death was not readily apparent. A post-mortem
report concluded that he died from aspiration of gastric content caused by
quetiapine (an anti-psychotic medication that he was not prescribed) and
fluoxetine.
11. The clinical reviewer highlighted a number of issues relating to mental health
services, pain management, and information security. I endorse seven
recommendations in these areas.
5
THE INVESTIGATION PROCESS
12. One of my senior investigators was appointed to conduct the investigation on
my behalf. Notices of the investigation were sent to the prison for distribution
and display, giving staff and prisoners the opportunity to contact him with any
relevant information. Nobody came forward as a result.
13. He visited HMP Dovegate to open the investigation on 5 August 2009. He
met a number of members of staff and collected paperwork relating to the
man’s time in custody. This paperwork was considered when conducting the
investigation.
14. The local Primary Care Trust asked the clinical reviewer to conduct a review
of the man’s care whilst in custody. The purpose of a clinical review is to
examine the medical care that a prisoner received in custody, which should
be an equivalent standard to what might have been expected in the
community. She consulted his extensive medical records to inform her
review. She wrote in detail about some of the problems experienced in
obtaining paperwork, and noted that her review was made very difficult as a
result of poor record keeping. The final version of her clinical review was
received by my office in June 2011.
15. Members of staff from HMP Dovegate asked Staffordshire Police to assist
them in tracing any living relatives of the man. Their efforts proved fruitless.
16. My investigator contacted Her Majesty’s Coroner for South Staffordshire to
inform him of the nature and scope of the investigation and request a copy of
the post-mortem report. My report will be sent to the coroner to assist his
enquiries into his death.
6
HMP DOVEGATE
17. Dovegate is located in Uttoxeter, Staffordshire. It is managed by Serco, a
private company, under contract to the National Offender Management
Service (NOMS). It holds up to 860 adult male offenders in the main prison.
A further 200 are accommodated in the therapeutic community, an intensive
group therapy environment for those convicted of serious offences and
assessed as suitable for inclusion.
Performance
18. HM Chief Inspector of Prisons last reported on Dovegate following an
announced inspection in October 2008. She said that:
“On our last two visits to the main prison, we noted serious weaknesses in
safety and control and a lack of progress between inspections. To the
credit of the Director and his staff, this full announced inspection found a
safer and more controlled prison with reasonable purposeful activity,
although resettlement remained weak.
“The establishment was now much better ordered and considerable efforts
had been made to tackle bullying. A strong emphasis had been placed on
security, and this was not disproportionately affecting the regime for
prisoners. Staff appeared more confident and there had been a
substantial reduction in the use of force.”
19. She made the following comment about healthcare services at Dovegate:
“Primary health services were reasonable, but were compromised by
shortages of staff and accommodation, which needed a substantial
increase in funding for healthcare to move forward. Chronic disease
management was maintained despite staff shortages, but staff needed
more time to give a quality service to prisoners. Many NHS appointments
were cancelled or rearranged, and pharmacy services needed further
development. Nursing staff administered medications on their own, which
was unsafe. Mental health services were good and developing, and
prisoners were well supported by the primary and secondary services.”
20. The therapeutic community was inspected separately in June 2008. She
reported that:
“The TC was … a generally safe place. It remained a struggle to ensure
sufficient applicants to the TC, but once at Dovegate, assessment and
induction were thorough. Levels of self-harm were low, although the TC
had recently suffered its first apparently self-inflicted death. Bullying did
not appear to be a major issue, but there was evidence of an increase in
the use and availability of drugs.”
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Previous deaths at HMP Dovegate
21. This was the ninth death to have occurred at Dovegate since April 2004, when
the Ombudsman began investigating all deaths in prison custody in England
and Wales. Since the man’s death, there have been four further deaths at
Dovegate. Following the death of a prisoner in March 2009, I made a
recommendation aimed at improving the standard of clinical record keeping. I
return to the same issue as part of this report.
8
KEY EVENTS
22. The man was sentenced to life imprisonment for murder in 1999. He had a
history of violent convictions and had served previous prison sentences.
23. Before his transfer to Dovegate in September 2008, he spent time in a
number of other prisons. In her review of his clinical care, the clinical reviewer
summarised his contact with mental health services. She described him as
having “complex health related needs over a considerable period of time”.
She examined his medical records and found that he had attempted suicide
by overdose on two occasions prior to his imprisonment. He had also
attempted to hang himself on three occasions, once before his imprisonment,
and twice more in 2003 and 2004 whilst at HMP Frankland. He also harmed
himself on numerous occasions whilst in custody by cutting his arms.
24. In February 2008, his suitability for Broadmoor’s Dangerous and Severe
Personality Disorder (DSPD) unit was assessed. She noted in her clinical
review that the assessment referred to the considerable period of time that he
had spent in custody, his history of self-harm and attempted suicide, and the
various types of psychotropic medication that he had sought out and had
subsequently found it difficult to withdraw from. The assessment also
commented on his history of violence, including a premeditated assault in
custody in 2000, during which he stabbed another prisoner with a pair of
scissors. He was diagnosed with antisocial and emotionally unstable
personality disorders, with features of a paranoid personality. However, he
was not considered suitable for admission. The assessors wrote:
“While we agree that the man suffers from at least two personality
disorders which are clearly linked to his violent and offending behaviour
and he is at risk of re-offending, we also had some concerns about his
suitability for the DSPD service at Broadmoor. These relate to: his
recurrent acts and threats of self-harm; his manipulation of staff to obtain
medication to alleviate his negative emotions; his potential capacity to split
staff and other patients and his unwillingness/inability to access and
describe his internal world.”
25. He therefore remained in the prison system. On 20 August 2008, whilst at
HMP Long Lartin, he harmed himself by cutting his left arm with a razor. As a
result, the Assessment, Care in Custody and Teamwork (ACCT) was started.
The purpose of an ACCT is to ensure the safety of prisoners at risk of self-
harm or suicide, and often involves additional support and monitoring. The
process also includes regular reviews. During his time on the ACCT, he did
not harm himself. During a review on 16 September, he was described as
“upbeat about a proposed move to Dovegate”. The next day, his ACCT was
closed.
26. He transferred to Dovegate on 18 September 2008. Whilst at Long Lartin, he
had been seen by the Worcestershire mental health in-reach team and the
clinical manager had identified him as having complex needs, a history of self-
harming behaviour, and self-reported auditory hallucinations. This
9
information, along with care plans, was sent to the Mental Health Foundation
Trust at the time of his transfer to Dovegate.
27. When he arrived at Dovegate, he said he felt worried, distressed and
depressed and had thoughts of suicide and self-harm. An ACCT Plan was
opened and he was admitted to the healthcare unit. He remained in the
healthcare unit until 23 October, and on the ACCT Plan until 3 November. He
did not harm himself during this time. Seven reviews of the plan were
conducted, and he appeared to become more settled as time passed.
However, he continued to tell members of staff that he heard voices at night
telling him to harm himself.
28. The clinical reviewer reviewed medical interventions for him following his
transfer to Dovegate. She noted that he was prescribed olanzapine, an anti-
psychotic medication, and fluoxetine, an anti-depressant. He had been
prescribed these medications for a number of years. Although the medical
notes were incomplete, it appeared that he began taking fluoxetine in May
2003, and olanzapine in October 2007. The healthcare team agreed that he
would be reviewed monthly by a community psychiatric nurse (CPN) and
referred to a psychiatrist for assessment. After assessing him on 17 October,
the CPN concluded that he did not have an enduring mental illness, but
recognised that he had long been prescribed anti-psychotic and anti-
depressant medication due to a history of depression and self-harming
behaviour. He was reviewed by the CPN on 23 October. The possibility of
discharge from the in-reach team was discussed by the multi-disciplinary
panel. An appointment with a psychiatrist was arranged for early November.
29. Although his ACCT was closed on 3 November, he cut his arm using glass
from a broken coffee jar later the same evening. A new ACCT was opened
and he moved to the healthcare unit. He said he was being bullied and felt
his only way out of the situation was to harm himself. After reviews on 4
November, 11 November and 18 November, the ACCT was closed. He had
moved to a different unit and said he was settling well, with no thoughts of
self-harm. He was advised to speak to members of unit staff if he had any
issues or concerns.
30. During the same period, he was discharged from the psychiatrist’s clinic
without being assessed, after failing to attend his appointment. The clinical
reviewer wrote in her clinical review that he had refused to attend for the
planned assessment on 11 November. He was discharged from the mental
health in-reach team on 28 November.
31. There were no further recorded incidents of him harming himself between
November 2008 and July 2009. After the closure of his ACCT in November,
there was little of note recorded for the remainder of the year in terms of
concerns about his well-being. Regular entries were made in his wing history
record which suggested that he was polite to members of staff, mixed well
with other prisoners, and was participating in education.
10
32. On 7 January 2009, he moved to the healthcare unit after complaining that he
was being bullied on the unit. He remained in the healthcare unit until 9
February. During this period, members of staff noted in the wing history
record that he spoke to them only when he wanted something, and was
reluctant to mix with other prisoners.
33. He moved to a new unit on 9 February. Regular entries were made in his
wing history record throughout February, March and April. Officers reported
that he was polite, but did not tend to socialise with other prisoners and spent
much of his time in his cell. However, there were no major concerns about his
well-being. On 29 April, he again moved units.
34. During May and early June, a number of entries were made in his wing history
record. One such entry noted that “he rarely leaves his cell other than to
collect food”. Although there were no major concerns about his well-being, he
remained reluctant to socialise.
35. Throughout this time, he had been receiving his prescribed medication. It was
given to him daily, and he did not keep it in his possession. The last entry in
his clinical record was on 3 June, and indicated that he had not collected his
medication that afternoon. There was no indication that this was an ongoing
problem, although the clinical reviewer noted in her clinical review that there
were some gaps in the documentation of the administration of his medication.
36. On 19 June, he was transferred to Dovegate’s therapeutic community for
assessment. The therapeutic community is separate to the main prison,
taking serious offenders and offering a group therapy treatment model. The
community challenges entrenched attitudes to offending, exposes the
suffering of victims and works towards change. The group therapy is
intensive and prisoners are assessed for suitability.
37. There is limited information in his prison records about his time in Dovegate’s
therapeutic community during late June and early July. Information about
things like, for example, his level of interaction with staff and other prisoners,
was not recorded as frequently as it had been before the move.
38. A probation officer at Dovegate wrote a sentence planning and review report
on 25 June. She wrote:
“Now that the man is located in the [therapeutic community] and is being
assessed, future targets will depend on the outcome of this assessment,
and whether he is suitable for therapy. Having interviewed him, he would
appear to be a likely candidate for therapy and in my view he would gain
considerably from this.”
39. Following his move to the therapeutic community, a single entry was made in
his wing history record on 5 July. This stated that he had experienced “a bit of
a tough week” and had not attended all the groups that he was meant to, but
that he remained polite and respectful towards members of staff.
11
40. No further concerns were recorded about him in his wing history record or his
clinical record.
41. One morning his cell was opened at around 7.45am along with the others on
the wing. A Prisoner Custody Officer (PCO) found him lying on the floor of the
cell. He was unresponsive. She and her colleagues began cardio pulmonary
resuscitation, and this was continued by paramedics when they arrived at
8.00am. The attempts at resuscitation were unsuccessful, and the
paramedics declared at 8.25am that he had died.
42. The cause of his death was not immediately obvious. A post-mortem report
was completed and concluding that he died from aspiration of gastric content
caused by quetiapine and fluoxetine poisoning. Quetiapine is an anti-
psychotic medication which was not prescribed for him. This issue is
discussed in the following section.
43. The prison and Staffordshire Police attempted to find surviving relatives of his
but were unsuccessful. The funeral was therefore organised by the prison
and took place on 27 July 2009.
12
ISSUES
Clinical care
44. The clinical reviewer, from the local Primary Care Trust (PCT), conducted a
review of the man’s clinical care whilst in custody. I refer to her findings in this
section.
Provision of mental health services
45. There is evidence that he had input from mental health services over a
significant period of time. In February 2008 he was assessed by the
admission team at Broadmoor hospital and was diagnosed with two
personality disorders. He worked with the mental health in-reach team from
the Mental Health Trust and, when transferred to Dovegate, with the Health
Foundation Trust.
46. He arrived at Dovegate on 18 September. By the end of November, he had
been discharged from the in-reach team’s caseload, having been assessed by
a CPN and refusing to attend an appointment with a psychiatrist. He had
been on an open ACCT almost continuously since his arrival at Dovegate,
had reported hearing voices, and had harmed himself using a piece of broken
glass. By early January 2009, he was discharged from the prison’s primary
mental health services and so received no mental health support other than
his regular medication. Given the relatively short period of time that he had
been at Dovegate and his obvious needs, she thought that discharge from
mental health services may have been premature. However, there were no
further recorded incidents of self-harm between November 2008 and July
2009.
47. In her clinical review, she notes that patients in the community would usually
be offered a further appointment with a psychiatrist before being discharged
from the clinic.
48. I endorse the following recommendation made by the clinical reviewer.
The mental health in-reach provider should consider reviewing existing
standards relating to ‘did not attend’ and discharge from the caseload,
to ensure equity of access to services for those in prison. These
standards should be clarified with Dovegate as part of an agreed
protocol.
Medication
49. When he arrived at Dovegate, he was taking fluoxetine and olanzapine,
having been prescribed these medications for a number of years. He
continued to receive both medications on prescription until the time of his
death.
13
50. The clinical reviewer noted that he was diagnosed with personality disorders
but not with depression. She therefore questioned the rationale behind him
being prescribed anti-depressants, particularly at the highest recommended
therapeutic dosage. She further commented that patients in the community
prescribed such a level of fluoxetine would ordinarily be reviewed by their GP
every month or every two months. For him, such reviews were infrequent and
coincided with him seeing a doctor for other reasons. The last medication
review was dated 15 September 2008, meaning that no reviews took place at
Dovegate, other than when he was first transferred there. This was,
therefore, not equitable with the level of care that would be expected in the
community. I endorse the following recommendations.
The Head of Healthcare should consider devising a process to facilitate
and/or trigger regular review of those being treated for depression
and/or on regular medication.
The Head of Healthcare should, in conjunction with the commissioner of
healthcare services, consider reviewing procedures for the application
of guidance relating to managing depression.
51. The clinical reviewer found no documented reason for the repeat prescribing
and administration of olanzapine to him. He had been prescribed olanzapine
since October 2007 and, during his assessment for Broadmoor hospital, said
he got considerable benefit from the medication as he believed that it calmed
him down. However, there were no apparent reviews of the suitability of this
medication following his transfer to Dovegate, and no stated reason in the
clinical record of why he continued to have it prescribed.
52. In addition to his anti-depressant and anti-psychotic medications, he had a
long history of seeking out opiate analgesia (pain relief) for various aches and
pains. He had a repeat prescription for co-codamol, which is composed of
codeine and paracetamol. The clinical reviewer found no evidence of specific
pain assessments during his entire history of imprisonment, despite
healthcare staff repeatedly prescribing pain relief medication. I endorse her
recommendation in this area.
The Head of Healthcare should consider introducing simple pain
assessment (and accompanying training) as standard, to be utilised
within consultations where pain is presented.
53. Regarding administration of his medication, the clinical reviewer found gaps in
the documentation. It was, therefore, unclear if his medication had been
administered. There were spells during which administration of medication
was not documented, as well as other sporadic instances.
54. I endorse the following recommendation made by the clinical reviewer with
regard to medication.
The Head of Healthcare should ensure that robust standard operating
procedures are in place, to provide assurance that medication is
14
managed safely. These operating procedures should cover the
prescribing, procuring, record keeping, administration and disposal of
all medication.
Record keeping
55. The clinical reviewer wrote in her clinical review that the standard of record
keeping was a source of concern. In particular, this related to handwritten
notes and records of management practices at both a clinical and
organisational level. It was not possible to coherently read significant sections
of the original records. Whilst handwritten notes were dated, they were not
signed clearly or legibly in some cases, and times were frequently omitted.
Treatment sheets deviated from the accepted standards of the Medicine
Administration and Documentation Code.
56. When she received his clinical record, it was incomplete. The entire record
accounting for the period February to July 2009 was missing. This was later
provided, though no explanation was given for its loss and eventual recovery.
Her documents were a copy of the clinical record. When she asked to see the
original, she was told that its whereabouts were not known. In her clinical
review, she said she had concerns about the way in which the clinical record
had been handled following the man’s death. I endorse her recommendations
in this area.
The Head of Healthcare should undertake an audit of documentation
standards to ensure that record keeping is in line with the guidance set
out by the Nursing and Midwifery Council.
The Director and Head of Healthcare should review existing procedures
and protocols for the security and effective management of records
following a death.
Issues arising from the post-mortem report
57. The man died as a result of aspiration of gastric content, caused by fluoxetine
and quetiapine poisoning. Whilst he had been prescribed fluoxetine for a
number of years, he had not been prescribed quetiapine, an anti-psychotic
medication.
58. He received his medication on a daily basis and was not permitted to retain
stocks of it in his cell. The clinical reviewer noted in her clinical review that
quetiapine was stocked by the prison, but was not given to prisoners to keep
in their cells. Quetiapine would be given to prisoners with a prescription on a
day by day basis, in the same way as he received his prescribed medication.
The clinical review reported that a small number of prisoners were prescribed
quetiapine between September 2008 and July 2009.
59. It is unclear how he came to be in possession of quetiapine. She found that
the prison was keeping a “relatively high level” of the medication and said that
whilst some medications were kept ‘in stock’ to allow rapid access, they
15
should be kept to a minimum and used only in urgent situations. She
mentioned in her clinical review that the situation might be improved by a
review of the pharmacy arrangements and the provision of an on-site
pharmacist.
The man’s cause of death
60. Although I have considered the issue of whether he intended to take his own
life, I cannot say with any certainty if this was the case. He had attempted
suicide on more than one occasion, though these attempts were made some
years earlier. Two attempts were by overdose, but were more than ten years
prior to his death. Additionally, he had harmed himself, usually by making
cuts to his arms. When he arrived at Dovegate, he said he felt worried,
distressed and depressed, and had thoughts of suicide and self-harm. He
also said he heard voices at night. On 3 November 2008, he cut his arm
using a piece of broken glass. However, he did not harm himself again after
that occasion.
61. The clinical reviewer noted in her clinical review that he had a history of
seeking out medication, usually opiate pain relief. It is unclear how he came
to possess quetiapine, an anti-psychotic medication. He had been taking a
relatively high dosage of fluoextine for a number of years.
62. He may have taken this combination of medications in an attempt to end his
life, though the possibility exists that he did not anticipate the adverse effects
and that his death was accidental.
16
CONCLUSION
63. The man was serving a sentence of imprisonment for life, and had been in
custody for ten years at the time of his death. He had a history of self-harm
and attempting suicide. In addition, he was known to seek out prescription
medications, particularly opiate-based pain relief. He had a long history of
mental health issues, and had been diagnosed with personality disorders.
64. At the time of his death, he was prescribed anti-depressant and anti-psychotic
medication. He had recently moved to the therapeutic community. He was
found collapsed in his cell in July 2009. Resuscitation attempts were
unsuccessful.
65. A post-mortem examination found that he died from aspiration of gastric
content caused by quetiapine and fluoxetine poisoning. Quetiapine is an anti-
psychotic medication that was not prescribed to him. He was prescribed
fluoxetine, an anti-depressant. It is not possible to say with any certainty
whether he intended to take his own life, or whether his death was accidental.
I am sure the inquest will consider this matter further.
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RECOMMENDATIONS
1. The mental health in-reach provider should consider reviewing existing
standards relating to ‘did not attend’ and discharge from the caseload, to
ensure equity of access to services for those in prison. These standards
should be clarified with Dovegate as part of an agreed protocol.
The recommendation was partially accepted. In-reach services are compliant
with their own Foundation Trust protocol. The first ‘did not attend’ is followed
up, with reasons established. A second ‘did not attend’ results in a referral
back to primary care. HMP Dovegate should ensure that they comply with
their own Trust protocol.
2. The Head of Healthcare should consider devising a process to facilitate
and/or trigger regular review of those being treated for depression and/or on
regular medication.
The recommendation was accepted. The service specification for mental
health will be reviewed and will incorporate a list of agreed interventions
according to health need and nurse capability. This will include a whole team
and integrated approach with primary care GP services.
3. The Head of Healthcare should, in conjunction with the commissioner of
healthcare services, consider reviewing procedures for the application of
guidance relating to managing depression.
The recommendation was accepted. The service specification for mental
health will be reviewed and will incorporate a list of agreed interventions
according to health need and nurse capability.
4. The Head of Healthcare should consider introducing simple pain assessment
(and accompanying training) as standard, to be utilised within consultations
where pain is presented.
The recommendation was accepted. The primary care lead will source an
appropriate and evidence-based tool and ensure that all members of staff are
instructed in its use. Pain management clinics will be evident as part of
chronic disease management.
5. The Head of Healthcare should ensure that robust standard operating
procedures are in place, to provide assurance that medication is managed
safely. These operating procedures should cover the prescribing, procuring,
record keeping, administration and disposal of all medication.
The recommendation was accepted. Medicines management will be
implemented by the deputy healthcare manager by September 2011, and will
include all key stakeholders. The process of prescribing, dispensing and
administering medications will be fully reviewed.
18
6. The Head of Healthcare should undertake an audit of documentation
standards to ensure that record keeping is in line with the guidance set out by
the Nursing and Midwifery Council.
The recommendation was accepted. An electronic clinical records system
has now been implemented.
7. The Director and Head of Healthcare should review existing procedures and
protocols for the security and effective management of records following a
death.
The recommendation was accepted. The policy will be reviewed in the
context of a new electronic clinical records system having been implemented.
19