Tedros Kahssay
6 Dec 2016 · Coroner ME Hassell · London Inner (North)
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. person escort record and forensic medical examiner report not accompanying prisoner to reception screening
“The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr [name redacted] to HMP Pentonville did not accompany him to nurse reception screening”
2. index offence circumstances not recorded in healthcare system
“The index offence is recorded on the PER (and inputted onto the prison computer system NOMIS, though not the healthcare computer system SystmOne), but not the circumstances”
3. general practitioner records not obtained despite system
“The general practitioner records were never obtained (an issue that I have raised in the past), despite there being a system in place for Pentonville healthcare administrative staff to do this”
4. ambiguous reception screening questions
“The first reception screen template contained questions that carried an inherent ambiguity, in that they related to a change in personal and family circumstances, which must always be the case when a person is incarcerated and therefore does not assist in determining which prisoners are at an increased risk”
5. reception screening lacking objective analysis
“Both nurses conducting reception screening talked often in evidence about not being able to do anything other than accept the answers given by the prisoner. They did not seem to bring any objective analysis to the screening. The process of nurse screening appeared at times to be a tick box exercise”
6. failure to explore depression history during screening
“The second reception (well man) screening nurse did not explore the history of depression recorded, he said because the prison general practitioner had not prescribed any medication for depression. On reflection, the nurse thought that he should have asked about it”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“That there is a need for the Prisoner Escort Record to be reviewed and redesigned”
This report
“The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr [name redacted] to HMP Pentonville did not accompany him to nurse reception screening.”
Closely relatedConfidence 0.90 · high
Earlier report
“There is no record from that meeting or any other time, of any consideration of or management plan for Mr [name redacted] depression.”
This report
“The second reception (well man) screening nurse did not explore the history of depression recorded”
Identical hazardConfidence 0.95 · high
This report
“The person escort record (PER) and appended report of the forensic medical examiner (FME) that accompanied Mr [name redacted] to HMP Pentonville did not accompany him to nurse reception screening.”
Later report
“During the course of the inquest into the death of [name redacted] (Ned) O'Donnell it was apparent that a nurse carrying out the first health reception screening was not given access to the PER (Prisoner Escort Report) which had accompanied the prisoner from another prison establishment.”
Responses
2016-0437-Response-by-Care-UK.pdf ↗· Care UK
Stated action · early December 2016
“The change that has been implemented is a control question in the first reception screen which is a mandatory field so the nurse needs to stop and answer the question. It asks if the nurse has seen the PER. All nursing staff have been instructed and are aware that they are not to screen any prisoner without a CSRA and PER as minimum requirement to aid screening.”
Stated action · now
“consent for the obtaining of general practitioner records is now sought as part of the reception screen and it is also a mandatory field that needs to be completed by the member of healthcare prior to finishing the screen. When consent is taken, the screening tool requires a task be sent to the Administrative staff to make them aware that Care UK Clinical Services Limited - Registered in England No 03462881 Registered Office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester”
Stated action · early December 2016
“The first reception screen template contained questions that carried an inherent ambiguity, in that they related to a change in personal and family circumstances, which must always be the case when a person is incarcerated and therefore does not assist in determining which prisoners are at an increased risk.”
Stated action · in development
“The scoring system in relation to the risk of self-harm and or suicide has now gone as this was found to be too prescriptive. The focus is now placed on the member of healthcare who is screening the patient to explore the presentation and look into factors that may be relevant to suicide and or self-harm. To support this, a new risk assessment is currently in development by the national team and is based on learning from previous deaths in custody, concerns raised by the Learned Coroner,”
Stated action · end of March 2017
“We accept that the nurse could have explored the history of depression in greater detail. Our secondary reception screening process provides more time for this and we are in process of rolling out our wellbeing wheel assessment to support this assessment. The wellbeing wheel provides a structure for clinical staff to explore mental health issues in more depth alongside their physical health and substance misuse issues. Training, both online and face to face, has been developed to support the use”
Stated action · December 2016
“The use and meaning of Code Red and Code Blue has again been strongly reinforced to the nursing staff. Training sessions have taken place for all the staff and attendance sheets have been collected. Posters re-affirming the criteria of Code Red and Code Blue were displayed in clinical areas in December 2016. Furthermore, Safer Custody have been requested to re-order 250 of the aide-memoire cards for distribution across the establishment”