Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0248, written 3 Oct 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Oct 2013 |
|---|---|
| Reference | 2013-0248 |
| Deceased | Ishmail Kubilay |
| Coroner | Edward Thomas |
| Coroner area | Hertfordshire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
Gs CORONER’S OFFICE AREA OF HERTFORDSHIRE The Old Courthouse, St Albans Road East, Hatfield, Hertfordshire, AL10 OES DX: 100702 Hatfield Tel: 01707 292780 Fax: 01707 897399 E-mail:coroner.service@hertfordshire.gov.uk MR EDWARD THOMAS Senior Coroner MR GRAHAM DANBURY Dr FRANCES CRANFIELD, ALISON GRIEF, EDWARD SOLOMONS Assistant Coroners 3" October 2013 Rt Hon Mr Jeremy Hunt MP Secretary of State for Health Department of Health Richmond House 79 Whitehall London SW1A 2NS Your Ref: to be advised Our. Ref: 01321-2010 Dear Mr Hunt, Re: Ishmail KUBILAY, deceased | am writing to you under the provisions of Schedule 5 (paragraph 7) of the Coroners and Justice Act 2009 which came into force in July of this year. This re-enacted the provisions of the old Rule 43 of the Coroner's Rules 1984. Attached to this letter is information concerning the new Rule, from which you will see, requires a written response and for copies of this letter and the response received in due course from you to be forwarded to the other properly identified interested persons identified at the Inquest in accordance with the list attached. In addition | am sending a copy of this letter to the Ministry of Justice as they, of course, have the responsibility for prisons. | am writing to you direct because | understood from evidence received not only from the nursing at HM Prison but also from NHS England (East Anglia Division) that although, of course, prisoners are the responsibility of the Ministry of Justice whilst serving their sentence, their healthcare needs are dealt with through NHS England and the various Trusts who have successfully tendered to provide services for the care and treatment of persons in custody. On 26" September 2013 | concluded an Inquest into the tragic death of Ishmail Kubilay and | attach a copy of the Inquisition from which you will note that Mr Kubilay died of:- da. Metastatic Lung Carcinoma | recorded in some detail the circumstances in which he came by his death. You will note that he died of Metastatic Lung Carcinoma which was first diagnosed when he was admitted to hospital on 9" May 2010 after a chest x-ray on admission had shown shadowing which was Cont'd/2 ... -2- confirmed by CT scan to be a lung cancer stage 4 as metastasis had developed. Mr Kubilay was too ill for a bronchoscopy for tissue analysis to be undertaken and the death was not reported to the Coroner Service until well after Mr Kubilay was buried. Therefore there was no histology on the type of lung cancer from which he suffered. Mr Kubilay had two chronic conditions. He had asthma which was exacerbated by the fact that he was a long-term smoker and he suffered regular chest infections not only at the Mount Prison, but | was also able to see from perusing medical records, from other prison establishments as well. In addition he had suffered a back injury before he had been sent to prison and was in receipt of dihydrocodeine but pain relief appears to have been a constant problem for him to the extent that in 2006 whilst at HM Prison Whitemoor he was seen by a pain management consultant on the question of appropriate pain relief. You will note from the Inquisition that his pain relief was adjusted because it was not effective. He was in due course referred to a rheumatologist when certain blood test results were of concern. The Prison Ombudsman obtained a clinic review which helpfully made a number of recommendations concerning healthcare not only at the Mount but also nationally. The national recommendations which had implications nationally were:- “ A review of end of life care in prisons should be undertaken to produce guidance for healthcare commissioning organizations to ensure that there are appropriate pathways and resources for end of life care for prisoners in category C prisons. “ National guidance should be agreed and developed to facilitate the assessment of the social care and needs of prisoners and provide care to meet the needs. | was informed by both the NHS England (East Anglia) and the Mount Prison that these recommendations have been implemented locally as far as possible but | draw these to your attention just in case there are implications for other areas of the country that may not have implemented these recommendations. | would be grateful for your confirmation that these have been considered for national implementation. However, in the discussion at the Inquest relating to palliative care it was clear that good links have now been established within Hertfordshire but this raised a further discussion at the Inquest relating to pain management. | heard evidence both from the Healthcare Manager at the Mount and also from fF who was the Director of Nursing and Quality at East Anglia for NHS England who has the responsibility for the medical services in prison undertaking clinical reviews where deaths occur in prisons, that outside support for medical teams in hospital in relation to pain management would be useful. | was informed that many of those who are in custody suffer from pain usually in their backs and that pain relief can sometimes be difficult to manage as in the community. This is why patients are often referred to specialist pain management clinics when you know the cause of the pain. Medication for pain relief in prisons also has it own problems. | heard for instance at this Inquest that dihydrocodeine which was prescribed for Mr Kubilay was to be administered on a daily basis under supervision in view of its opiate qualities. The impression | got from the Healthcare Manager and from the NHS England (East Anglia) was that they would both welcome the establishment of similar links that are now being established with palliative care and social care and would also be available in relation to pain management. | am wondering whether this could be considered and recommendations made for the provision of such links Cont'd/3 ... -3- maybe with pain management specialists accessing prisons as | am aware that outside appointments have implications for prison management personnel and assessments of risk. | am writing to you on this issue because it was not covered in the clinical review of the prison and probation ombudsman but it was clear from hearing the evidence that this was something | felt | should draw your attention to. | appreciate your interest in this matter and look forward to hearing from you in due course. The rules require a response within 56 days, which | calculate is 28" November 2013. Please do not hesitate to contact me if you have any difficulty in complying with this date as | would be happy to extend the time with good reasons. Many thanks for your anticipated assistance in this matter. Yours sincerely Edward G Senior Co ¥,
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