Garry Gilbey

1. 1. lack of ambulance policy

   “The Prison did not have a set policy about when an ambulance should be called”

2. 2. inadequate training for night staff

   “In turn this raises concern about the adequacy of training and clarity of what amounts to a medical emergency for those night time prison staff involved in having to make dynamic risk assessment especially for those prisoners who are at higher tisk of a chronic condition developing into an acute episode e.g. during the referral period to a hospital especially when a very serious underlying condition is suspected such as lung cancer that has the capacity to affect breathing suddenly even though a”

3. 3. inconsistent healthcare event flagging

   “There was no clear or consistent system to flag key healthcare events during the day and there seemed to be a variable practice/policy in place that not all healthcare staff seemed to be familiar with or followed so that less relevant information was recorded such as an additional pillow being supplied yet important information such as nebuliser treatment or having a low threshold for medical review if symptoms reoccur or worsen was not consistently recorded in a way that would enable daytime”

4. 4. inadequate specialist investigation tracking

   “There were also worrying aspects to prison health care systems including checking that all necessary specialist investigations are fully recorded and carried out as well as results properly checked when they return”

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