Clinical review following a death in custody investigated by the prisons and probation ombudsman
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Clinical review template – Foreseeable Death CLINICAL REVIEW FOLLOWING A DEATH IN CUSTODY INVESTIGATED BY THE PRISONS AND PROBATION OMBUDSMAN PART 2 - GUIDANCE FOR CLINICAL REVIEWERS Updated September 2014 Clinical review template – Foreseeable Death 1. INTRODUCTION
You have been commissioned by the NHS Area Team (or equivalent body) to carry out or lead a clinical review relating to the death of a person in the custody (or released on temporary licence) of a:
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- Young Offender Institution -
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sentenced into custody) -
This review forms part of the Prisons and Probation Ombudsman’s (PPO) investigation into the circumstances surrounding the death. The PPO is remitted to investigate all deaths that occur in the above listed premises.
The commissioning Area Team (or equivalent) will have provided you with contact details of the PPO investigator in this case. You will need to make early contact to agree the parameters of the investigation and what, if any, interviews need to be carried out.
It is important that the clinical reviewer and PPO investigator work in partnership to ensure a proportionate but full investigation of the circumstances surrounding the death. The clinical reviewer should inform the Area Team within 72 hours of being commissioned if there are any immediate concerns regarding the healthcare provided.
Prior to the review commencing the reviewer and the PPO investigator will have agreed on a level 1, 2 or 3 review, and this will be agreed by the commissioning Area Team:
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report -
healthcare staff at the establishment and report -
with healthcare staff and others as appropriate – complex case with multi- disciplinary input.
In the case of a foreseeable death, the PPO investigator will also decide whether this will be an issues led investigation, in which case the clinical review will need to use the issue based template (Annex A).
This document has been prepared to provide a consistent and clear approach to the review and subsequent report, including clear timescales and quality assurance. Clinical review template – Foreseeable Death 2. AIMS OF THE CLINICAL REVIEW The aim of the review is to consider the clinical care the deceased received while in prison custody.
An approach of how and why should be adopted. Not who was to blame. The following key questions should be covered:
- How and when did the prisoner die? - Is there any root cause(s) of the death? - Was the clinical care equivalent to what might have been expected in the wider community? - Are there any learning opportunities? - Were local and national policies and procedures (both prison and NHS) followed? - Is there an opportunity to prevent future deaths in similar circumstances? - Are there any examples of good practice?
The review should: - Examine the provision of clinical care and treatment, including risk assessment and risk management. - Examine any secondary care provided (to the extent necessary for the review) - Provide a chronology of the health and social care events leading up to the incident. - Identify any care or service delivery failures along with the factors that contributed to these problems. - Examine policy and practice. - Identify any root causes(s) that inform the identification of learning opportunities. - Make timely, clear and sustainable recommendations for the health community and service. - Provide explanations and insight for the relatives of the deceased. Information available to support the clinical review This is not an exhaustive list, but provides some guidance:
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custody (PSO 2710) provides more information about the types of records a prisoner may have.
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- Prison records (including ACCT documents if relevant) - Police and prison statements - GP records - Acute NHS trust records - Mental health Trust records - Post-mortem results and toxicology - Local policies and procedures (both prison and NHS) - Prison Service standards For the purpose of investigations the PPO has unfettered access to information, documents, establishments and individuals, including material and information
Clinical review template – Foreseeable Death provided to the services (in remit) by other organisations. This includes the prison’s clinical records (both paper and electronic). The relevant NHS Area team will arrange for the prison healthcare records to be provided to the clinical reviewer. The PPO investigator will arrange for copies of any other relevant service held records to be made available to the clinical reviewer.
NHS records outside of the prison context should be obtained by the Area Team (or equivalent body).
Prior to the review commencing, the commissioning organisation, the reviewer and the PPO investigator will have agreed on a level 1, 2 or 3 review:
- Level 1 will not require any interviews by the clinical reviewer. - Levels 2 and 3 will require interviews. Healthcare staff who have had significant dealings with the deceased should be interviewed. The clinical reviewer and PPO investigator should conduct such
interviews jointly, with the clinical reviewer leading. The PPO has a preference for joint interviews, which give a greater understanding and clearer picture of the care received across disciplines. Joint interviews will be recorded and transcripts (signed and agreed by the interviewee) will be annexed to the PPO report. Coroners require that any interview carried out in relation to the investigation is appropriately recorded (either through a recording device and transcript or by clear notes of interview). The PPO recording devices are accepted by the prison service.
There is no expectation the clinical reviewer attends any non-healthcare interviews. However, on occasions the investigator may ask for the clinical reviewer to attend relevant interviews (for example where a member of prison staff has attempted resuscitation).
Clinical review template – Foreseeable Death 3. SUGGESTED AREAS FOR CONSIDERATION The majority of PPO investigations are into deaths that occur in a prison setting. While this is not an exhaustive list, it has been prepared using learning opportunities and findings from previous investigations (mainly prison). The clinical reviewer or panel should consider involving specialists to contribute as required. When carrying out a desk-based clinical review, a proportionate approach should be taken.
Care should be taken to respect the privacy and dignity of the deceased, who may have withheld information from their family. It will be necessary to consider information which is relevant to the circumstances of the death, but other information should not be disclosed.
Ensure that due consideration is given to any clinical issues raised by the family (which will be provided by the PPO investigator) Were arrangements for notifying the family of a serious illness timely? Were links with the family appropriately considered and maintained by healthcare staff?
ii) Records and record keeping
This is an integral part of the care process and is a tool of professional practice. It should not be seen as an optional extra to be fitted in as and when. The quality of records and record keeping should be considered against the standards laid down by the relevant professional bodies.
Are there regular documented audits of the standards of records keeping as required by the NMC/HPC and GMC?
Is the documentation and records keeping adequate and appropriate? Are the records factual, consistent and accurate? Have they been completed as soon as possible after the event, providing current information on the care and condition of the patient or client? Are they written clearly and in a way that ensures the text cannot be erased? Are they accurately dated, timed and signed – with the name and designation printed alongside the first entry? Do they include abbreviations, jargon, meaningless phrases, irrelevant speculation or offensive subjective statements? Are the entries respectful to the patient or client? Are they consecutive? Do they identify problems that have arisen and the action taken to rectify them? Do they provide clear evidence of the care planned, the decisions made, the care delivered and the information shared? Is SysmOne used effectively?
Was the appropriate screen completed? First health screen on the first night into reception Second health screen completed within 5 days of arrival into establishment Was the screening process effective to establish the prisoner’s past and current mental and physical history? Clinical review template – Foreseeable Death Did the screening process establish the nature and extent of any substance misuse?
iv) Mental health
Did the prisoner have a mental health history? Were attempts made to obtain their previous records (both prison and NHS)? Was the correct mental health diagnosis made in custody? Were they referred to local mental health services? Were they receiving appropriate mental health care to meet their needs? Were relevant NICE/NHS guidelines followed?
Was an appropriate physical health history taken? Was the correct physical health diagnosis made in custody? Was the prisoner referred to secondary care services in a timely manner? Did the prisoner receive care appropriate to their need? If the prisoner was disabled, did they have full access to healthcare services and facilities? Were attempts made to obtain previous records from their community GP or other specialist health provider? If a terminal illness had been diagnosed, was appropriate palliative care provided using accepted pathways. If a terminal illness had been diagnosed was Release on Temporary Licence or Compassionate Release appropriately recommended to the prison authorities? If not, why not? Were relevant NICE/NHS guidelines followed?
Was the care the prisoner received equal to that they could have expected to receive in the community? Was the care consistent with National Health Service Frameworks? Were external agencies involved in the care of the prisoner if considered necessary? Were appointments (both internal and external to the prison) attended regularly? If not, were they cancelled by the prison or external agencies? Why? vii) Substance misuse Was a full history of any drug and/or alcohol use obtained? Was the prisoner referred to specialist clinical drug services? Were they referred to other drug and/or alcohol support services? Was the detoxification or maintenance regime appropriate? Was the care they received appropriate to meet their needs? Was the prisoner provided with appropriate discharge information and advice prior to release? Is there evidence that CARATs and healthcare transferred appropriate and timely information to allow community services to provide ongoing care?
Were there any key clinical suicide or self-harm indicators identified? Were these acted upon and managed appropriately? Clinical review template – Foreseeable Death Was the prisoner on a suicide and/or self-harm support plan (Assessment, Care in Custody and Teamwork – ACCT)? Was the ACCT plan referred to in the clinical care plan? Was the prisoner referred to local mental health services? Were there any delays or disagreements in providing mental health assessment? Were there any delays in transferring out to external mental health facilities? Was there appropriate healthcare input into the prisoners ACCT plan (both CAREMAP and review meetings)? Were relevant NICE guidelines followed?
ix) Policies and procedures
Are there local policies and procedures in place that meet with relevant NICE/NHS guidelines? Do these also meet Department of Health and Prison Service standards? Have these been agreed with the local health and social care partnerships involved in the delivery of local prison healthcare? x) Incident/emergency response Was the clinical response to symptoms presented reasonable and appropriate? Were there any delays or equipment shortages/failures? Would any different care or treatment at any stage, led to a different outcome? Are there any lessons to be learned? Were the clinical governance arrangements satisfactory? Was the clinical emergency response appropriate? Was any resuscitation used appropriately? (please include when resuscitation was not appropriate eg: when someone is clearly dead)
Is the physical environment in which primary health care is delivered fit for purpose? Are there adapted cells available to meet the physical needs of patients? Do the consultation rooms enable appropriate levels of confidentiality without compromising security? Is the in-patient unit fit for purpose, ensuring decent and humane conditions for the prisoner?
Did the healthcare staff involved in the incident receive appropriate support, both in terms of clinical supervision and psychological support? Did healthcare professionals participate in a post incident debrief?
Are pharmacy services equivalent to that in the community, including direct access to advice by appropriately trained pharmacy staff, information about the benefits and risks of medications and the self administration of medication? Did the prisoner have access to their long term medications without gaps or delays?
Was the prescribing of medications appropriate to meet the patient’s clinical need?
Clinical review template – Foreseeable Death xiv) Training and Staff development Do the staffing levels and skills mix include appropriately trained medical, nursing, reception, administrative, discipline and other ancillary or specialist staff to reflect prisoners’ needs? Have staff received appropriate training and development to meet the health needs of the prisoners they are caring for? Are staff aware of how to access and use emergency medical equipment including the resuscitation kit? Does the healthcare team have regular team practice sessions on the use of their emergency procedures?
Did the prisoner receive health services that were not unnecessarily restricted by security procedures? Was timely consideration given to temporary or compassionate release, if appropriate?
Clinical review template – Foreseeable Death 4. STRUCTURE OF THE CLINICAL REVIEW REPORT Plain English should be used and technical terms should be explained (remember the review will be read by a wide audience, including the family of the deceased). Please use the relevant template – Annex A for foreseeable deaths (issues led format) and Annex B for other deaths (standard format).
Any recommendations made should be based on the guidance at Annex C. It is not necessary to remove names of prisoners or staff – the clinical review will be annexed to the PPO report, which will include names of relevant persons involved. The PPO report is sent to the family, the Coroner, the service and any other properly interested person. The clinical review is not made public. After inquest, the PPO report is anonymised and put on the PPO website, at this stage the clinical review has been removed, along with other appendices.
5. TIMESCALES AND PPO ESCALATION PROCESS The Area Team (or equivalent) should provide the clinical reviewer with the time and resources, including administrative support, necessary to enable them to carry out and complete the review within the agreed timetable.
The PPO has a target to issue the draft report of a death due to natural causes within 100 working days (20 weeks) and the draft report of any other death within 130 working days (26 weeks). To allow clinical matters to be fully integrated into the PPO report, the finalised clinical review report should be with the PPO investigator within
weeks) for any other death, of the initial correspondence from the PPO.
A draft report should be submitted by the clinical reviewer to the Area Team (or equivalent) for quality assurance with 35 working days (7 weeks) for a natural causes death and 45 working days (9 weeks) for any other death. At the same time it should be sent to the PPO investigator to check it meets the needs of the investigation.
The Area Team (or equivalent) quality assured draft and comments will be returned to the clinical reviewer within 10 working days to allow any changes to be made prior to sending the final report to the PPO investigator.
The PPO investigator may, from time to time, need to contact the clinical reviewer if there are matters which require further exploration, clarification or correction. Ideally this will be within 30 working days of receipt of the final clinical review report. However Area Teams (or equivalent) and reviewers should note that issues of clarification sometimes arise following the consultation period (6.1 d).
If there are good reasons to do so, an extension to the time limit can be agreed with the PPO investigator (in consultation with the Assistant Ombudsman). Any extension should be confirmed in writing. The timeliness of the clinical review report is important and when late, can adversely impact on the delivery of the Ombudsman’s investigation report. As a result a robust escalation process has been introduced.
Clinical review template – Foreseeable Death The PPO escalation process for the late delivery of final clinical review reports is as follows:
A final agreed copy of the clinical review report should be received by the investigator within 50/60 working days of the original commissioning letter,
An extension to the time limit may be agreed if there are good reasons to do so, and with the Assistant Ombudsman’s approval. An agreed extension should be documented.
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