John Delahaye
18 Dec 2018 · Coroner Emma Brown · Birmingham and Solihull
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. incorrect medication authorisation due to unclear risk assessment question
“Have you had problems in the last 6 months with not taking, or not remembering to take your medicines as prescribed?”
2. unreliable medical condition identification
“the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct 'read code'”
3. healthcare absence from ACCT reviews
“No member of the healthcare team was present at any of Mr. [name redacted] ACCT reviews”
4. failure to conduct welfare check on unlock
“Mr. [name redacted] cell had been unlocked at approximately 07:50.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“The evidence presented at the inquest confirmed that at night the healthcare wards are staffed by 1 nurse per ward and 1 prison officer who is shared between both wards.”
This report
“No member of the healthcare team was present at any of Mr. [name redacted] ACCT reviews.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“some staff were working without having received any training and some either had not had sufficient training or had forgotten it or were not applying it with”
This report
“No member of the healthcare team was present at any of Mr. [name redacted] ACCT reviews.”
Closely relatedConfidence 0.80 · moderate
This report
“No member of the healthcare team was present at any of Mr. [name redacted] ACCT reviews.”
Later report
“question now operates a local policy to ensure someone from the mental health team attends all ACCT reviews irrespective of other disciplines attending.”
Responses
2018-0388-Responses.pdf ↗· Birmingham Community NHS Trust
Stated action · 1% February 2019
“The Head of:Healthcare.at HMP Birmingham will remind all clinical staff (including those working within BCHT) that when reviewing a patient's records for previous medical conditions that the following most be followed: ; ; "4. The clinician will check the 'summary and family history' section of System 2. The clinician will check the 'quick glance' section of System1 3, The clinician will use the 'search function' to check for the medical conditions » relevant to the. clinical intervention they”