Alan Davies
21 Mar 2024 · Coroner David Regan · South Wales Central
The coroner's concerns
1. limited communication between Caswell clinic and HMP Cardiff
“limited communication between the Caswell clinic and HMP Cardiff following the s 117 meeting until Mr [name redacted]' discharge”
2. discharge information not provided in clear format
“Discharge information and assessment was not provided to HMP Cardiff in a clear and easily understandable format”
3. transfer without clinical escort
“Mr [name redacted] was transferred to prison without being accompanied by a member of Caswell Clinic staff”
4. complex needs unmet
“Insufficient consideration was given to whether Mr [name redacted]' needs were too complex to be met by HMP Cardiff”
5. premature transfer without stable care
“Mr [name redacted] was transferred to HMP Cardiff with the intention that he be transferred again within a short time to HMP Parc”
6. lack of engagement plan
“No clear plan to promote Mr [name redacted]' engagement with prison medical services”
Responses
2024-0138-Response-from-Department-of-Health-and-Social-Care-1.pdf ↗· Cardiff and Vale University Health Board
Stated action
“We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.”
2024-0160-Response-from-HM-Prison-and-Probation-Service-2.pdf ↗· Swansea Bay University Health Board
Stated action
“The Governing Governor is also committed to encouraging an environment in which all staff, including those who are not directly employed by HMPPS, feel able to raise concerns about an individual's management and will discuss with the Head of Healthcare how healthcare staff can be empowered to do so in accordance with Prison Service Instruction 16/2015 Adult Safeguarding in Prison.”
2024-0160-Response-from-Swansea-Bay-University-Health-Board-2-2.pdf ↗· Swansea Bay University Health Board
Stated action
“The protocol also provides guidance as to what should be considered in deciding where a person should be placed post hospital treatment i.e. whether they should be returned to the HMP from whence they were originally referred or whether a temporary placement in a local remand facility is required as an interim step.”