Recurance · prevention of future deaths reports
Pre-inquest brief
Cancellation of hospital appointments for prisoners
The earlier warning
Justin Gallagher · 16 Aug 2019 · Alan Craze, East Sussex
“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.”
judiciary.uk/prevention-of-future-death-reports/justin-gallagher
What was promised
Stated action 1 · response to Justin Gallagher (16 Aug 2019) · stated timescale: 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 2 · response to Justin Gallagher (16 Aug 2019) · stated timescale: 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 3 · response to Justin Gallagher (16 Aug 2019) · stated timescale: 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”
3 further stated actions are listed on the full chain page.
What recurred
- 4 Apr 2021 · Imre Thomas · Nicholas Rheinberg · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Justin Gallagher · 16 Aug 2019
“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 · Imre Thomas · 4 Apr 2021
“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.”
What happened next
No web check of the stated actions has been published for this chain.