Martin Haines
16 Aug 2019 · Coroner Alan Craze · East Sussex
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. unauthorised alcohol production
“The fact that the deceased was able to brew or distil his own alcohol”
2. missed diabetes monitoring and cardiovascular disease confirmation
“The failure to carry out diagnostic testing and monitoring for his diabetes and to confirm his considerable cardiovascular disease”
3. substandard prison healthcare
“The standard of care appears to have fallen well below that which he could have received in the community”
4. absence of response protocols for unresponsive inmates
“There were no protocols or agreements between healthcare staff and the prison service as to how best to respond to an unresponsive body”
5. fragmented healthcare responsibility and communication breakdown
“In my opinion, the underlying problems were due to the fact that responsibility for healthcare in the prison was split between the prison service, Sussex Partnership Foundation Trust (which is a mental health provider but was also contracted to run all healthcare, both physical and mental within the prison), Medco Ltd who provided the GPs and Forward Trust who were contracted to treat alcohol and substance misuse in the prison. There was insufficient communication between these bodies and they had”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“There were no protocols or agreements between healthcare staff and the prison service as to how best to respond to an unresponsive body.”
Later report
“There is no system to ensure that important healthcare information including recent administration of medicines and the results of physical observations is passed between separate providers of healthcare”
Responses
2019-0486-Response-from-HM-Prison-and-Probation-Service.pdf ↗· His Majesty's Prison and Probation Service
2019-0486-Response-from-NHS-England.pdf ↗· NHS England
Stated action
“The Ministry of Justice will respond directly to the Coroner on this.”
Stated action · end of 2018
“Partnership NHS Foundation Trust (SPFT) undertook a Root Cause Analysis Investigation following Mr [name redacted] death and three recommendations were made: a. healthcare staff should be trained in how to detect diabetes and hypertension; b. long term conditions such as diabetes and hypertension are managed in line with National Institute for Care Excellence (NICE) guidelines; and c. reviews of repeat medication comply with NICE”
Stated action · 31 March 2020
“An on-going action plan remains in place and will continue to be monitored closely for the remainder of the trust's contract which ends on 31 March 2020. To support · this, and ensure a reduction in any risk to patients, commissioners have appointed a clinical reviewer (previously Director of Nursing”
Stated action
“The Prison and Healthcare providers have reminded staff of the protocols in relation to responding to an unresponsive body, including the need for prison staff to elicit a verbal or non-verbal response from each prisoner when cells are unlocked. Further reminders have been issued on the need to immediately call an ambulance when a Code RED or Code BLUE is called, including a new poster in the control room.”
Stated action
“Electronic Patient Records All healthcare providers are given access to electronic healthcare software, SystmOne. Substance misuse services have their own database which records performance and on which payment is based. Clinical information is recorded on SystmOne.”
2019-0486-Response-by-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care