Alexander Braund
20 Dec 2022 · Coroner Laurinder Bower · Nottingham City and Nottinghamshire
The coroner's concerns
1. inadequate healthcare provision
“continuous failures to provide adequate healthcare, which probably more than minimally contributed to his death”
2. lack of coordinated care between prison staff and healthcare staff
“absence of a safe joint system of care (between discipline and healthcare staff) for supporting and managing acutely unwell patients who remain in the prison setting”
3. misunderstanding of emergency response protocols
“There continues to be a misunderstanding across discipline staff as to what constitutes a CODE BLUE/CODE RED situation, and in what circumstances a cell can be entered by a prison officer for the purpose of preserving life”
4. unverifiable medical record amendments
“Amendment of Medical Records without clear evidence of such amendment on the face of the SystmOne patient summary”
Responses
2022-0407-Response-from-HM-Prison-and-Probation-Service.pdf ↗· HMP Nottingham
Stated action · 2022
“An annual training plan for staff has been introduced, and this includes training on the role of staff during a medical emergency, including the specific issues of the correct use of the emergency codes and the expectations about when staff should enter a cell during a patrol state. Staff received this training in May and September 2022 and it will be repeated at least twice yearly.”
2022-0407-Response-from-Nottingham-Healthcare-NHS-Foundation-Trust.pdf ↗· Forensic Services Nottinghamshire Healthcare NHS Foundation Trust and TTP-UK
2022-0407-Response-from-TPP.pdf ↗· HMP Nottingham
Stated action
“I will demonstrate how the audit trail is shown within SystmOne below”