Jason Lawson
9 Jan 2015 · Coroner Robert Chapman · Rutland & North Leicestershire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. death not detected during welfare checks
“The welfare check did not ascertain that he had died. He was certainly dead at the time of the check at 7.30am and 8.20am on the 17'”
2. delayed medical access
“On some wings there is still some distance to walk to the medical centre and the time to wait mitigates against prisoners bothering to do attend”
3. lack of automated attendance alerts
“The current system relies on healthcare staff/pharmacy staff recognising that prisoners have not attended to collect their prescription, without having a computer driven system to flag up non-attendance”
4. unflagged prescription lapses
“The current system relies on healthcare staff/pharmacy staff recognising that prescriptions have lapsed without having a computer driven system to flag it up”
5. absence of 24-hour observation policy
“There is no specific policy to deal with the situation where a prisoner needs 24 hour observation from medical staff where the prison is not equipped for constant medical supervision”
Linked reports
Identical hazardConfidence 0.92 · high
This report
“The current system relies on healthcare staff/pharmacy staff recognising that prisoners have not attended to collect their prescription, without having a computer driven system to flag up non-attendance.”
Later report
“An automated flag alert via the system upon the failure to dispense or collect medication by a prisoner would be a far more efficient and effective way in which prisoners failing to comply with medications could be identified and actioned quickly and in which future deaths could be prevented.”
Responses
No published response was found on judiciary.uk.