Foreseeable and non-foreseeable deaths

1. Summary

• A summary of findings and recommendations included at the start of the report; a snapshot for the reader without having to scroll through the narrative.

2. Methodology

• Report on quality of records management in line with:
• The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates – The Nursing and Midwifery Council
• Good medical practice – professional standards – GMC, Standards of conduct, performance and ethicsb – Health and Care Professions Council.

3. Clinical reviewer

• Name, qualifications, professional experience and professional registration details; should be succinct, to the point.
• Experience relating to the type/cause of death and all relevant training, including root cause analysis and investigative training.
• Frequency of clinical reviewer training to remain up to date; reviewer equipped to produce a good standard report.

4. Conflict of interest statement

• Circumstances by which a reasonable person would consider an individual’s ability to apply judgement or act could be impaired or influenced by another interest they hold (in the context of delivering, commissioning or assuring taxpayer funded health/care services).
• Consider the following:
  • financial interest (shares, holdings, etc)
  • financial/personal interest in the healthcare provider of this review
  • employed by/providing services to the healthcare provider/establishment of this review
  • receipt of any monetary/non-monetary payment/incentive (including hospitality/commercial sponsorship) from the healthcare provider of this review
  • canvassing/negotiating with any person entering into the arrangements outlined above
  • having a close family member (current/historically) with the healthcare provider/establishment of this review.

Note: This is not an exhaustive list. It is the clinical reviewer’s responsibility to ensure potential conflicts, whether listed here or not, are disclosed in writing to the commissioners of the review.

5. Clinical care

• The review should consider and refer only to the clinical care the deceased received while in custody; that is, pertinent to the death or considered a key factor in the circumstances surrounding the death.
• Avoid apportioning blame; a what, how, why approach should be adopted.
• Include details of any significant conditions; date of diagnosis/onset.
• Include details of any minor conditions.
• Consider whether appropriate care was provided; health assessment considering factors pertinent to the death.
• Detail regular medication; include generic and brand names where possible.
• Include details of any other services/clinicians the deceased was receiving care from (hospital, consultant, doctor).
• Consider SystmOne records; do they confirm reception screen was undertaken (not necessary for longer serving prisoners, consider whether pertinent to death).
• For terminal diagnosis/conditions consider medication, symptom control, pain management.
• Was any assessment undertaken to assess the patient’s mental capacity (Mental Capacity Act); when, by whom (if relevant)?
• Advanced care planning, DNACPR; was this in place, when was it discussed, when was it signed, by whom, does it comply with legislation, was the decision communicated across the whole prison and understood, were custodial staff aware not to call 999?
• For ACCT/ACDT comment is not required about custodial management; focus on healthcare role and input.
• Other vulnerabilities to consider:
  • assessment of learning disabilities (consider LeDeR categories)
  • language barriers
  • mobility difficulties requiring reasonable adjustments
  • other issues requiring reasonable adjustments; what was delivered to appropriately meet these needs
  • transgendered; receiving appropriate support or not
  • were any safeguarding concerns identified?
• Was the environment suitable for the patient’s needs; location?
• Include reception screen summary if relevant/pertinent to the death.
• Consider if staff managing the cases were appropriately trained and supported.
• If restraints were used, comment on whether there was appropriate healthcare input into risk assessments for their use; was a risk assessment undertaken, was it documented appropriately? (The Graham Judgement, High Court, 2007: There should be appropriate healthcare input into risk assessments for the use of restraints. Healthcare staff should not merely state “no objection to the use of restraints”. They should give a clear account of the prisoners’ condition and how it impacts on their escape risk.)

6. Custodial management and partnership working

• This section must be led by the PPO investigator.
• If required, capture if any custodial or detention management processes impacted on healthcare delivery; how many
• How did healthcare input into any security risk assessments carried out?
• Remember this section will mainly be measured against PSIs, PSOs, DSOs (IRC death).
• Information sharing; evidence of appropriate and timely sharing of information with multidisciplinary team.
• Establishment regime and escorts to internal clinics; include commentary and evidence of impact establishment regime had on the delivery of and access to healthcare and/or delivery of medicines as prescribed.
• Escort and bed watch; impact on timely attendance to external healthcare appointments; secondary care, specialist care, etc.
• Clinical/medical holds; evidence where staff have documented any decisions relating to requests for clinical/medical hold made to custodial.
• Emergency response (ER):
  • What code was used; was it correct for the emergency?
  • Was the response timely and appropriate (first responders, healthcare, ambulance services, refer to PSI 03/2013 and resuscitation guidelines)?
• Evidence of skills and training of healthcare staff involved in ER.
• Provider process for mandatory training.
• Comment on emergency equipment; availability, checking and maintenance logs.
• Include information on any post incident debriefing and support.

7. Key findings and areas of concern

• Include a sub-heading for each area of concern.
• Refer to NHS England/NICE guidelines and relevant prison/IRC policies and reference fully.
• Cover all relevant treatment pertinent to the cause of death; consider the following (not an exhaustive list):
  • identification
  • referrals
  • treatment
  • integrated working
  • symptom management for an expected death.
• For an unexpected death think about:
  • substance misuse service
  • mental health treatment and appropriate medication
  • physical health and appropriate treatment
  • emergency response and appropriateness of resuscitation attempt.

8. Conclusion on Equivalence

• Consider whether the clinical care extended to the patient was of a reasonable/good standard and at least equivalent to that which would have been received in the wider community
• Equivalence can be measured based on the delivery of evidence based and clinically effective interventions and pathways.

9. Recommendations

• Clear, specific recommendations.
• Direct recommendations to the relevant stakeholders (governor, director, centre manager, head of healthcare or commissioners).
• Keep recommendations SMART:
  • specific
  • measurable
  • achievable
  • realistic
  • timely
• Recommendations should be short and to the point.
• Ensure recommendations made relate to the clinical care.

10. Other findings for the attention of the NHS England healthcare commissioners

• Anything identified relating to the healthcare provider at the establishment such as:
  • good practice or best practice
  • recommendations for staff; individually or collectively.

11. Other recommendations

• Recommendations that may relate to the wider system, not specifically pertinent to the death.
• Direct recommendations should be made to the relevant stakeholders (governor, director, centre manager, head of healthcare or commissioners).
• Keep direct recommendations SMART:
  • specific
  • measurable
  • achievable
  • realistic
  • timely 
• Recommendations should be short and to the point.
• Ensure recommendations made relate to the clinical care.
• Where an ‘other’ recommendation is made that is not specifically pertinent to the death, ensure the rationale for this is clear.

12. Conclusion

• Overall conclusion about the clinical care the deceased received.
• Was the clinical care equivalent to what the deceased could have expected to receive in the community as defined by the Royal College of General Practitioners (RCGP)?
• Select the relevant statement on the template; qualify the statement of equivalence and explain if there are some areas where equivalence was demonstrated others where was not.

Appendix A

• List of documentary evidence that has been considered for this report (document name, source, date).

Appendix B

• Chronology of pertinent clinical events leading up to death.
• Not necessary for this to be a complete history of the deceased’s time in prison.
• Consider relevance.

Appendix C

• Attach relevant terms of reference for the investigation as Appendix C.

Post-release deaths

1. Summary

• A summary of findings and recommendations included at the start of the report; a snapshot for the reader without having to scroll through the narrative.

2. Methodology

• Report on quality of records management relating to the care provided leading up to release, in line with relevant guidelines/policies. Consider:
  • NMC code of conduct
  • GMC good medical practice guidelines, Healthcare Professional Council (HCPC) standards of conduct, performance and ethics.
• Most PRDs will be categorised as level 1, but may change throughout the investigation (see table):

3. Clinical reviewer

• Name, qualifications, professional experience and professional registration details; should be succinct, to the point.
• Experience relating to the type/cause of death and all relevant training including root cause analysis and investigative training.
• Frequency of clinical reviewer training to remain up to date; reviewer equipped to produce a good standard of report.

4. Conflict of interest

• Circumstances by which a reasonable person would consider an individual’s ability to apply judgement or act could be impaired or influenced by another interest they hold (in the context of delivering, commissioning or assuring taxpayer funded health/care services).
• Consider the following:
  • financial interest (shares, holdings, etc)
  • financial/personal interest in the healthcare provider of this review
  • employed by/providing services to the healthcare provider/establishment of this review
  • receipt of any monetary/non-monetary payment/incentive (including hospitality/commercial sponsorship) from the healthcare provider of this review
  • canvassing/negotiating with any person entering into the arrangements outlined above
  • having a close family member (current/historically) with the healthcare provider/establishment of this review.

Note: This is not an exhaustive list. It is the clinical reviewer’s responsibility to ensure potential conflicts, whether listed here or not, are disclosed in writing to the commissioners of the review.

5. Clinical care

• The review should consider and refer only to the clinical care the deceased received leading up to release from custody.
• Avoid apportioning blame; a what, how, why approach should be adopted.
• Include details of any significant conditions; date of diagnosis/onset.
• Include details of any minor conditions.
• Consider whether appropriate care was provided leading up to release.
• Detail regular medication; include generic and brand names where possible.
• Include details of any other services/clinicians the deceased was receiving care from (hospital, consultant, doctor).
• Consider SystmOne records; are there details of referrals/handovers or notes relating to release planning?
• Was there a terminal diagnosis/condition; were medication needs met?
• Advanced care planning, DNACPR; was this in place, was it communicated/
  information shared?
• Look at referrals, handover, RECONNECT.

6. Key findings and areas of concern

• Include a sub-heading for each area of concern.
• Refer to any relevant guidelines and policies and reference fully.
• Cover all relevant treatment/care leading up to release.
• Was this an expected or unexpected death?; think about:
  • substance misuse service and appropriate medication
  • physical health.

7. Recommendations

• Clear, specific recommendations.
• Direct recommendations to the relevant stakeholders (governor, director, centre manager, head of healthcare or commissioners).
• Keep recommendations SMART:
  • specific
  • measurable
  • achievable
  • realistic
  • timely
• Recommendations should be short and to the point.
• Ensure recommendations made relate to the clinical care provided leading up to release.

8. Other findings for the attention of the NHS England healthcare commissioners

• Anything identified relating to the healthcare provider at the establishment such as:
  • good practice or best practice
  • recommendations for staff; individually or collectively.

9. Other recommendations

• Clear, specific recommendations.
• Direct recommendations to the relevant stakeholders (governor, director, centre manager, head of healthcare or commissioners).
• Keep recommendations SMART:
  • specific
  • measurable
  • achievable
  • realistic
  • timely
• Recommendations should be short and to the point.
• Ensure recommendations made relate to the clinical care provided up to release.

10. Conclusion

• Overall conclusion about the clinical care the deceased received leading up to release.
• Was the clinical care leading up to release equivalent to what the deceased could have expected to receive in the community as defined by the Royal College of General Practitioners (RCGP)?
• Select the relevant statement on the template; qualify the statement of equivalence and explain if there are some areas where equivalence was demonstrated but others where this was not the case.
• Consider the release planning; was this satisfactory/appropriate?

Appendix A

• List of documentary evidence that has been considered for this report (document name, source, date).

Appendix B

• Chronology of pertinent clinical events leading up to release.
• This should not be a complete history of the deceased’s time in prison.
• Consider relevance.

Appendix C

• Attach the relevant terms of reference for the investigation as Appendix C.

Publication reference: PRN00228