Justin Gallagher
16 Aug 2019 · Coroner Alan Craze · East Sussex
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of coordinated healthcare
“The prison never obtained his previous medical history. No proper care plan was drafted for him and there was no single clinician responsible for his care.”
2. cancellation of external hospital appointments
“A number of external hospital appointments were cancelled at short notice because of lack of resources (no available escorts etc.) and there was no system available for arranging such visits.”
3. missed cancer diagnosis
“The deceased died of cancer but this had never been diagnosed and opportunities to have discovered his condition were missed.”
4. lack of family involvement
“There was no involvement of the family and so a source of important information was missed.”
5. fragmented healthcare responsibility
“The underlying problem was that healthcare in the prison was the responsibility of three different organisations, namely the prison service, the local mental health NHS Trust (who were given the responsibility of dealing with all physical health matters and running the healthcare centre), and a separate organisation who supplied GPs. These three organisations had entirely separate database systems.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“The family gave evidence to the extent that having better contact with [the deceased] and more input into her care may have brought about a different outcome”
This report
“There was no involvement of the family and so a source of important information was missed.”
Closely relatedConfidence 0.90 · high
Earlier report
“The meaningful involvement of families in the ACCT process, including by ensuring the formal recording, and communication of concerns raised by a prisoner's family.”
This report
“There was no involvement of the family and so a source of important information was missed.”
Identical hazardConfidence 0.90 · high
This report
“A number of external hospital appointments were cancelled at short notice because of lack of resources (no available escorts etc.) and there was no system available for arranging such visits.”
Later report
“Cancelled hospital appointments putting vulnerable prisoners at risk. As the commissioning body you are asked to investigate the possibility of organising special prison clinics for visiting hospital consultants.”
Responses
2019-0491-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2019-0491-Response-by-HM-Prison-and-Probation-Service.pdf ↗· Department of Health and Social Care
Stated action
“The Governor of HMP Lewes is committed to providing resources for external escorts to medical appointments. Currently, sufficient escorting staff are made available for three external hospital escorts each weekday, and appointments are prioritised by the healthcare team. In the event that there are inadequate resources because of other operational pressures and it is necessary to consider the cancellation of an external appointment, the Duty Governor contacts the healthcare team for advice on”
2019-0491-Response-by-NHS-England.pdf ↗· NHS England
Stated action · end of December 2019
“a more robust administrative process which ensures that community medical records for newly arrived prisoners are requested within a week in line with NICE Guidelines 57, PSO 3050; : . an audit of healthcare record requests in March 2017 to ensure the process was effective and efficient. As a result of your report | can confirm commissioners have asked SPFT to undertake a further audit which was completed in November with the outcome due to be shared by the end of December 2019”
Stated action · monthly Contract Review Meetings (CRM)
“a clinical review of any appointments which are postponed. This includes a review by the GP to assess Clinical need and risk. Where the demand for external escorts exceeds availability, the GP will prioritise appointment attendance based on clinical need and any appointment cancelled is to be automatically re-booked with the hospital trust. This revised process including clinical review will suitably prioritise and prevent future failings to re-arrange cancelled appointments. The monitoring of this”
Stated action · ongoing
“the running of a regular report via SystmOne to ensure that healthcare records have been requested; and e © anominated member of staff checking that all newly arrived prisoners have been offered a full general health assessment to include the drafting of a care plan within 7 days of arrival. The checks to be noted on an internal document which is shared with all healthcare staff”
Stated action · ongoing
“New prisoners with chronic conditions are assigned to a named clinician. Depending upon the condition this may be a GP, [name redacted] or Primary Care Nurse”
Stated action · end of December 2019
“a more robust administrative process which ensures that community medical records for newly arrived prisoners are requested within a week in line with NICE Guidelines 57, PSO 3050; : . an audit of healthcare record requests in March 2017 to ensure the process was effective and efficient. As a result of your report | can confirm commissioners have asked SPFT to undertake a further audit which was completed in November with the outcome due to be shared by the end of December 2019”