Edward Devlin

Date of report	22 Jul 2014
Reference	2014-0335
Deceased	Edward Devlin
Coroner	Crispin Oliver
Coroner area	County Durham & Darlington
Category	State Custody related deaths
Source	judiciary.uk record · original PDF
Responses published	1

The report

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.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

Michael Spurr, Chief Executive, National Offender Management Service,
Clive House, 70 Petty France, London SW1H 9EX.

Mike Parrish, Chief Executive Care UK, Connaught House, 850 The
Crescent, Colchester Business Park, Colchester, Essex CO4 99B

Tim Allen, Governing Governor of HMP Durham, 19b Old Elvet, Durham,
County Durham DH1 3HU

Martin Barkley, Chief Executive, Tees Esk Wear Valley NHS Foundation
Trust, West Park Hospital, Edward Pease Way, Darlington, County Durham

CORONER

lam Crispin Oliver, Assistant Coroner, for the coroner area of County Durham and
Darlington.

CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

(see attached sheet)

INVESTIGATION and INQUEST

Following his death | commenced an investigation into the death of Edward John Devlin.

The investigation concluded at the end of the inquest on 24" June 2014. The findings
were that Mr Devlin was found dead at HMP Durham at 06.25 on 17" July 2011, that his
physical condition by 22.45 on 16" July 2011, when prison officers and nurse attended
him, warranted a medical examination/assessment and that no such assessment was
carried out. He died as a result of the effects of dihydrocodeine. The conclusion of Jury
was “misadventure”.

CIRCUMSTANCES OF THE DEATH

1) Edward Devlin was born on 16" May 1955 and was 54 years old when he was
remanded in custody to HMP Durham on 26" July 2010.

2) Mr Devlin had a detailed medical history of Chronic Obstructive Pulmonary
Disease (COPD). He had a consultant respiratory specialist. He took regular
medication to manage his condition: inhalers, Aspirin, Omerprazole and
Simvastatin, Carbocistine, Theophitine; also for pain management, a controlled
drug MST (Morphine Sulphate) and oramorph. On the 24" July 2010 prior to
arrival at HMP Durham, while in police custody, he had attempted self-harm by
taking an overdose of MST and was taken to A & E at West Cumberland
Hospital in Whitehaven. On reception at HMP Durham an ACCT was opened.
This was closed on 27" July 2010. In prison the MST was dispensed to him
“Not In Possession” (that is, the tablets were dispensed to him and taken by him
under the supervision of nursing staff, whether registered general nurses or
mental health nurses with a prescription card being signed to say the patient
had been given the medication). During the day, this was at the wing clinic
through a dispensing gate or hatch at which the prisoner patient attended. At
other times of the day or when prisoners were locked in their cells, this would be
in the course of a medication dispensing round conducted by general or mental
health nurses accompanied by discipline staff.

3) On2™ August 2010 Mr Deviin was discovered by a mental health nurse, and
discipline staff, to have hidden MST 1 x 30 mgms and 2 x 20 mgms that he had
just been dispensed to him and which he had appeared to have taken. This led
to an adjudication on 3” August 2010, at which his defence was that the
dispensing of Not in Possession medication during night state in the prison had
not been at regular times and had disrupted his sleep.

4) On 17" August 2010 his prescription of pain relief medication was changed from
MST to a) dihydrocodeine Modified Release 120mg two tablets every 12 hours
and b) dihydrocodeine (normal) 30 mg twice a day. These were dispensed to
him “In Possession”, that is, without the requirement that he be supervised
actually taking the medication: he would have discretion as to when he took it
and in what quantity. This prescription, in terms of the amount of
dihydrocodeine and type of tablet, was repeated every few weeks up to 14"° July
2011 (the last prescription before Mr Devlin’s death). Save for when Mr Devlin
was a patient in either University of North Durham Hospital, or on the Healthcare
Wing of HMP Durham, when it was “Not in Possession”, it was always “In
Possession”. He would be dispensed a week’s (7 days) supply at a time. The
dispensing nurse and patient each would initial and sign/counter sign the back
of the prescription card known as the “Kardex’.

5) From the 27" September 2010 until 20" December 2010 Mr Devlin was
assigned to cells in F Wing of Durham Prison. On 20" December 2010 he was
admitted to University Hospital North Durham. He was discharged on 3
January 2011. During his stay as a patient in University Hospital North Durham
it was reported by hospital nursing staff to HMP Durham that Mr Devlin had
been found hiding medication.

6) On reception back into HMP Durham Mr Devlin was admitted into the
Healthcare Wing: this contained a medical centre, a pharmacy and some cell
accommodation for patients. He was discharged from the Healthcare Win on
12"" January 2011 and assigned to cells on F Wing until 24" June 2011. While
on F Wing, as mentioned above, he was dispensed his dihydrocodeine “In
Possession” under prescriptions which in terms of pain relief medication
repeated the terms of that of 17" August 2010, receiving a week's (7 days)
supply at a time.

7) On23™ June 2011 Mr Devlin was sentenced to 12 years in prison. On 24” June
2011 Mr Devlin was admitted again into Healthcare Wing as a patient. The
Deputy Health Care Manager gave evidence that judging from the prescription
documentation, which showed a signature where medication was dispensed, in
theory he would have run out of dihydrocodeine by the time he was admitted to
the Healthcare Wing. She also gave evidence that on admission to the
Healthcare Wing he would have been searched and any medication in his
possession taken from him. Further she gave evidence that while a patient in
the Healthcare Wing his medication was prescribed and dispensed to him ona
“Not in Possession” basis: he was supervised while taking it. His prescription “In
Possession” was stopped on 24" June 2011, and a new prescription for “Not in
Possession” provided on 27" June 2011. His last recorded dose of
dihydrocodeine was two 120 mg tablet dispensed at night by a nurse on 12"
July 2011. |

8) On 13" July 2011 at 17.54, Mr Devlin was discharged from the Healthcare Wing
to E Wing cell E1-005. He was still being dispensed medication "Not in
Possession” as per the prescription for him while on the Healthcare wing of 27"
June 2011, pending a new prescription being provided.

9) On 13" July 2011 at 22.37 hours a nurse noted Mr Devlin refused his
medication: Simvastatin 40 mgms, dihydrocodeine 120 mgms x 2 and 30
mgsms tablets, Carbocisteine 375 mgms x 2 caps, Uniphyllin continuous 400
mgsms x 1 tab. Mr Devlin stated he did not need them.

10) At 08.31 hours on 14" July 2011 Mr Devlin refused to go to get his medication.
AT 09.56 hours a doctor noted that Mr Devlin moved to the wing from
Healthcare and providing a new prescription for the drugs to be dispensed “In
Possession”. It was established that no medication was apparently dispensed
under this prescription however before Mr Devlin died, as the prescription card

(Kardex) did not bear the relevant signatures. At 19.03 hours a nurse saw Mr
Devlin. Mr Devlin had not attended clinic for his evening medication. The nurse
recorded that when she asked him if he was given his medication in his
possession would he take them he said no as he would not eat or take his
medication until he was moved to HMP Frankland or died in HMP Durham. He
denied suicidal ideation but wanted to be “off E Wing”.

11) At 06.04 hours on 15" July 2011 a nurse noted that Mr Devlin had refused his
night time medication. At 14.41 on 16" July 2011, Mr Devlin was moved to B
wing, cell B2-001. At 22.34 hours on 16" July 2011, a nurse recorded that Mr
Devlin refused his medication again. At 23.08 Mr Devlin was moved to E Wing
cell E1-009. At approximately 06.25 hours on 17" July 2011, Mr Devlin was
found dead in that cell.

12) The initial post mortem report concluded that his was a death from natural
causes as Mr Devlin had:-

1a Ischaemic Heart Disease
1b Coronary Artery Atheroma
2 Severe Pulmonary Emphysema

13) However, the forensic toxicology report showed an abnormally high level of
dihydrocodeine in the blood (14.9 mg/l) enough to be fatal and consistent with a
recent large overdose of the drug prior to death. The pathologist changed his

ee to effects of dihydrocodeine.
14) consultant physician, clinical toxicologist and pharmacologist gave

evidence during the Inquest to the effect that it was not possible to conclude on
a balance of probabilities when, or over what period of time, the dose had been
taken, or at what point it became fatal. Further, that it was not possible to
conclude which type of tablet, normal or modified release, had been used.

15) What could be said with certainty was that Mr Devlin had been able to obtain
and take enough dihydrocodeine tablets to cause his death. This was against a
background whereby: he would have been searched on being admitted onto the
Healthcare Wing, from F wing, as a patient on 24" June 2011; his prescription of
27" June 2011 was for medication to be dispensed to him “Not in Possession”
while on the Healthcare Wing; this was the operative prescription when he was
discharged from the Healthcare Wing on 13" July 2011, onto E Wing; that his
medication was to be dispensed to him on a “Not in Possession” basis on 13",
14", 15" and 16" July 2011, when he refused it; that in the event apparently no
drugs had been dispensed under the “In Possession” prescription of 14" July
2011. So it was available to conclude that Mr Devlin had possibly or probably
obtained them from other prisoners, rather than by accumulating them out of
drugs that had been dispensed to him “In Possession’.

16) With this in mind, it is significant that one of the nurses who was responsible for
attempting to dispense medication to him from his discharge from the
Healthcare Wing onto E Wing on 13" July 2011 until his death on 17" July 2011
stated that it had been his practice in the case of Mr Devlin when previously on
F Wing to slide his medication, including dihydrocodeine, under his cell door.
He described how he would take it out of its packaging, fold the strips over, and
slide it under the door. He said that his happened in the case of other patients
too. He said that no thought would be given as to whether the medication end
up in the possession of the intended patient. He said that this was a common
practice amongst nursing staff. He did not distinguish between general nursing
staff and mental health staff.

17) It should be added that when other discipline and health staff and healthcare
manager witnesses were questioned as to whether this ever happened they
expressly denied that it did.

Pe CORONER'S CONCERNS

During the course of the investigation my inquiries revealed matters giving rise to
concern. In my opinion there is a risk that future deaths will occur unless action is taken.
| In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

| (1) It was stated by a nurse that he had, while dispensing medication to Mr Devlin and
other patients on F Wing, slid strips of medication including dihydrocodeine under
locked cell doors instead of handing it to the patient.

(2) He claimed this was his own common practice and was also common practice
amongst nursing staff on F Wing. This was in relation to potentially dangerous
and/or tradable drugs like dihydrocodeine.

(3) If this were the case, no one would know whether a patient is taking the medication
intended for him.

(4) Further, other healthcare professionals, assuming that medication was being taken
by the patient, could base a future diagnosis upon this which would be potentially
flawed.

(5) Assessing any other patient would become fraught with uncertainty as healthcare
professionals could never know for certain what medication had been taken by him.

(6) The concomitant concem with 3, 4 and 5 above would be that the system whereby
the dispensing of drugs is recorded by signatures of nurse and patient is either
being ignored or subject to forgery.

(7) Further, no one would know whether somebody else was appropriating that
patient's medication.

(8) Depending on the type of medication, this may be traded within the establishment
raising security concerns.

(9) The drugs could be stockpiled with a view to creating a potentially lethal overdose.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you have the
power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 16" September 2014. |, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and | have also sent it to the
following Interested Re oes AS Lace Mawer, Park Row
House, 19-20 Park Row, Leeds, LS1 5JF; Solicitor, Litigation and
Employment Team A1, Treasury Solicitors Department, One Kemble Street, London,
WC2B 4TS Lester Morrill incorporating Davies Gore Lomax, 27 Park
Square West, Leeds, LS1 2PL; a 21 Officer and Solicitor, Northern
Region, Royal College of Nursing, legal Services, ff St Catherine’s Court,

Sunderland Enterprise Park, Sunderland SR5 3XH Ward Hadaway Lawe
Firm, Sandgate House, 102 Quayside, Newcastle Upon Tyne, NE1 3DX.

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.

Signed by Cab ohn th Ae 4 eeeseee

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Care UK (PDF)

Prison Health Department
HMP Durham
Old Elvet
Durham
DH13HU

care gg

HM Assistant Coroner Crispin Oliver
HM Coroners Office
PO Box 282
Bishop Auckland
County Durham
DL 14 4FY

Dear Sir,

RE: The inquest touching the death of Edward Devlin Deceased
Response to Regulation 28 Report to Prevent Future Deaths

I am writing in reply to you letter dated 22nd July 2014 containing the Regulation 28
Report to Prevent Future Deaths ("PFD Report") following the conclusion of the inquest
touching the death of Edward Devlin Deceased which was heard before you, sitting with a
jury, at the Coroner's Court, Crook commencing on Monday 16th June and concluding on
24th June 2014.

You have requested a response by 16th September 2014 and I am able to respond now.
When this issue was raised at the inquest an investigation was commenced prior to
receipt of your letter.

In hearing evidence at Mr Devlin's inquest you have identified matters of concern as
follows:

1. It was stated by a nurse that he had, whilst dispensing medication to Mr Devlin and
other patients on F wing, slid strips of medication including dihydrocodeine under
locked cell doors instead of handing it to the patient

2. He claimed this was common practice amongst nursing staff on F wing This was in

relation to potentially dangerous and/or tradeable drugs like dihydrocodeine.

3. If this were the case, no one would know whether a patient is taking the medication

intended for him.

4. Further. Other healthcare professionals, assuming that medication was being
taken by the patient, could base a future diagnosis upon this which would be
potentially flawed.

5. Assessing any other patient would become fraught with uncertainty as healthcare
professionals could never know for certain what medication had been taken by
him.

6. The concomitant concern with 3, 4 and 5 above would be that the system whereby
the dispensing of drugs is recorded by signatures of nurse and patient is either
ignored or subject to forgery.

7. Further, no one would know whether somebody else was appropriating that

patient's medication.

8. Depending on the type of medication, this may be traded within the establishment

raising security concerns.

9. The drugs could be stockpiled with a view to creating a potentially lethal overdose

Firstly at Box 4 paragraph 16 in recalling the evidence you have said that it was the
practice of the Nurse in the case of Mr Devlin when he was on F wing to slide his
medication, including dihydrocodeine, under his cell door. That he described how he
would take it out of its packaging, fold the strips over, and slide it under the door. He said
that this happened in the case of other patients too. He said that no thought would be
given as to whether the medication would end up in the possession of the intended
patient. He said that this was common practice among nursing staff (general and mental
health).

It is not our recollection that the Nurse referred to having placed dihydrocodeine under the
cell but that it was In possession medication.

At box 4, paragraph 17 you have confirmed that when other discipline staff and
healthcare staff were question as to whether the practice had ever happened , they
expressly denied it. This evidence was heard during the course of the inquest.

You will also recall that disciplined staff were asked what they would do if they saw this
practice. They all confirmed if they had seen that practice then they would have reported
it.

At the inquest you heard evidence regarding In possession and Not In Possession
medication. In order to assist you and dealing with your matters of concern, I consider it
would be helpful if I could expand on the management and administration of medication in
prison.

With In possession medication (IP), following the generation of a valid prescription and
the supply being issued by pharmacy, medication is issued to the patient from the hatch
located on the wing and signed for by the patient. The volume issued may vary from one
week's supply to eight weeks and is dependent on the medication. The patient is then
expected to take the medication as directed with no healthcare supervision.

With Not In Possession (NIP) medication the patient is required to attend the medication
administration hatch located on the relevant wing where one dose of the prescribed
medication would be administrated and taken under direct supervision of the nurse. Once
administrated , the prescription/administration drug kardex is initialled by the trained nurse
administering the drug ; there is no requirement for a signature from the prisoner.

Following the transfer of the responsibility of healthcare delivery to the NHS in 2004 it was
identified that nursing staff were required to administer NIP medication by sliding it under

the cell door. This was limited to night time medication rounds as the requirement to open
a cell door when in patrol state requires a senior prison officer to be present and the
working arrangements at the time did not always allow this. At the time this was
highlighted as a clinical risk and not appropriate. Procedures were therefore put in place
to ensure this practice ceased .

As in a community setting the patient has a responsibility to order and collect any IP
medication. In the event of the patient not collecting medication it is expected that an
assessment be carried out by healthcare staff as to the continued need for the
medication. This may include seeking out the patient and enquiring of his rationale for not
collecting which in turn may result in the acceptance of his rationale or an attempt to
educate the patient as to its importance. In the event of the continued refusal the
prescriber and/or relevant professional would be informed.

Under no circumstances would there be an expectation for IP medication to be delivered
by nursing staff by sliding it under the door of a cell and therefore limit the required level
of interaction needed to establish if it is appropriate to continue the medication.

I have investigated the claim that was made by the Nurse and interviewed healthcare
staff. Other than the claim made by the Nurse there are no recorded incidents of IP
medication being issued "under the door".

There are a number of practical difficulties nursing staff would face if this was a method
used as follows:

• The medication would have to be unpacked and individual strips 'inserted along

with the packaging.

• A signature would have to be obtained either before or after the medication was

inserted under the door.

In the majority of situations the medication is wanted by the patient and the patient would
make efforts to obtain his supply by attending the collection point. In most situations when
a decision not to collect the medication is made it is one of patient choice, with the
medication being returned to pharmacy and no further intervention. In the event that there
is a clinical concern that the patient has not collected the medication, nursing staff have a
procedure to follow. Which is an assessment be carried out by healthcare staff as to the
continued need for the medication. This may include seeking out the patient and
enquiring of his rationale for not collecting which in turn may result in the acceptance of
his rationale or an attempt to educate the patient as to its importance. In the event of the
continued refusal the prescriber and/or relevant professional would be informed.

That procedure to make a special effort to attend the cell and then pass all the IP
medication under the door when the patient may have made no effort to collect the
medication himself and the assessment of the medication indicates it is not essential does
not appear to create any advantage or benefit for nursing staff.

A number of Healthcare and Prison service staff have been approached and asked
directly if they had witnessed or carried out the process of administering NIP medication
under a cell door.

A staff meeting was held on 1st July 2014 and staff were informed of the claim made by
the Nurse. Healthcare staff were asked if they had ever witnessed or performed such
actions. While it was acknowledged by the trained nurses who attended the meeting that
the issue of putting night time NIP had been raised in the past, no one indicated that IP
medication was ever administrated this way.

As part of investigation in the event of nursing staff not being able to administer NIP
medication to a prisoner by opening the cell door, for example; the threat of violence from
the individual or industrial action, I have identified that a formal policy should be
developed and approved by Care UK clinical governance detailing the action required by
nursing staff.

There is no evidence to suggest that putting IP medication under the cell doors is
common practice in HMP Durham.

If you require any further information, please do not hesitate to contact me.

Head of Healthcare
HMP Durham

The report

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