Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0533, written 10 Dec 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Dec 2014 |
|---|---|
| Reference | 2014-0533 |
| Deceased | Garry Gilbey |
| Coroner | Karen Harrold |
| Coroner area | Portsmouth & South East Hampshire |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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 THIS REPORT IS BEING SENT TO: 1. Mr Andrew Selous MP, Parliamentary Under-Secretary of State, Minister for Prisons, Probation and Rehabilitation, Ministry of Justice, 102 Petty France, London SW1H 9AJ. 2. The Rt Hon Norman Lamb MP, Minister for Care and Support (Prison Services), Department of Health, Richmond House, 79 Whitehall, London SW1A 2NS CORONER | am Karen Harrold, Assistant Coroner, for the coroner area of Portsmouth & South East Hampshire. 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. INVESTIGATION and INQUEST On 11°" July 2012 an investigation into the death of GARRY GILBEY was commenced. The investigation concluded at the end of the inquest on 4" August 2014. The conclusion of the inquest was recorded as a narrative conclusion as follows: Mr Garry Victor Gilbey was admitted to hospital from HMP Kingston on 25th June 2012 with a productive cough, weight loss and breathlessness. On admission a chest X-ray showed signs of collapse of the upper lobe of the left lung and later tests diagnosed he was suffering from lung cancer. Despite treatment he died at 08.30 on 3rd July 2012. There were a number of missed opportunities in Mr Gilbey’s care and treatment in the preceding months but it cannot be said on the balance of probabilities that Mr Gilbey would have survived or his life would have been prolonged if any or all of the opportunities had been taken. CIRCUMSTANCES OF THE DEATH In 2002, Mr Garry Gilbey was imprisoned for serious offences and was first taken to HMP Manchester. At this time, he told healthcare staff that he had a long standing injury to a nerve in his left arm for which he took pain relief medication. He continued to receive prescribed medication in prison and was also referred for physiotherapy. Mr Gilbey transferred to HMP Kingston in July 2010. Healthcare staff noted his existing health problems and also that he smoked between 20-40 cigarettes a day but he tried to give up smoking in February 2011. In December 2011, Mr Gilbey complained of pain in his upper left arm and was initially prescribed additional pain relief medication. He continued to experience arm pain over the following weeks and saw another doctor. He was prescribed a variety of medication in an attempt to manage the pain. By February 2012, Mr Gilbey told a prison doctor that he had a cough and pain in his left shoulder and back. The doctor who examined him was not sure what was causing the symptoms but indicated he would do some research to see if the symptoms were connected and told Mr Gilbey he would be reviewed again once this was complete. By March 2012, the same doctor spoke to a hospital neurologist and he concluded the most likely cause of the arm pain was carpal tunnel syndrome. However, to rule out the possibility of a rare form of lung cancer he decided Mr Gilbey should have a chest X-ray. However this was never arranged and no one in the prison health care department identified that the required chest X-ray had not been performed. On 20 March, Mr Gilbey's shoulder was X-rayed, after a referral by the Modern Matron who as a nurse practitioner wanted a further test to explore whether a bony injury could be causing the ongoing back and shoulder pains. This referral was unrelated to the doctor's intention that Mr Gilbey should have a chest X-ray and therefore purely coincidental. The hospital consultant radiologist who reviewed the shoulder X-ray concluded that it was normal. However, he missed the fact that the plain X-ray did in fact show some changes in the left lung apex which were indicative of upper lobe collapse. In early June, Mr Gilbey reported chest pains and breathlessness, which he said he had been experiencing for several months. His heart was checked and was normal. Mr Gilbey was diagnosed with acid reflux and prescribed medication by the Modern Matron. On 18 June, a prison doctor who examined him considered that his symptoms were highly suggestive of lung cancer. Mr Gilbey was referred to the hospital for further tests and an X-ray appointment was booked for 25 June. Until then, Mr Gilbey was seen most days by health care staff because of his cough and breathlessness. On 22 June he was seen by a nurse consultant during the day short of breath and struggling to get out of bed. Nebuliser treatment was prescribed which eased the symptoms and staff were told to have a low threshold for a medical review if the symptoms should reoccur or worsen. He was seen on 23 June during the day by a nurse due to shortness of breath and an out of hours doctor was called who diagnosed a chest infection and prescribed antibiotics. He attended the clinic on 24 June and requested nebuliser treatment but this was refused. Later the same morning a different nurse attended Mr Gilbey’s cell due to coughing and breathlessness and he was nebulised. Details of the nebulising treatment given over the days immediately before admission to hospital were not recorded in the wing log book to alert prison officers to prisoner medical issues. Overnight 24/25" June, two officers attended Mr Gilbey’s cell as he was requesting an ambulance because of breathing difficulties. One officer was first aid trained. They did not enter his cell and because he could talk they decided it was not a medical emergency. Finally on the morning of admission to hospital on 25 June Mr Gilbey was given more nebuliser treatment by prison staff. Mr Gilbey had a chest X-ray at hospital later the same day and was admitted as an inpatient that day due to suspected lung cancer. On 27 June, he was told that he had inoperable lung cancer and that he might live for up to 12 months if he received chemotherapy and radiotherapy and two months if he did not. However, Mr Gilbey's health deteriorated much more quickly than anticipated and he died the following week at 8.30am on 3 July. CORONER’S CONCERNS During the course of the inquest the evidence 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. The Prison did not have a set policy about when an ambulance should be called. This was left to the judgment of the prison officer(s) making an assessment of the prisoner from outside the cell and whether what they observed amounted to a medical emergency. In addition, it was not clear what amounted to a medical emergency and that the threshold was high. This raises genuine concern in relation to those prisons who do not have 24/7 medically trained staff available to make emergency assessments of prisoners during the night. 2. Inturn this raises concern about the adequacy of training and clarity of what amounts to a medical emergency for those night time prison staff involved in having to make dynamic risk assessment especially for those prisoners who are at higher tisk of a chronic condition developing into an acute episode e.g. during the referral period to a hospital especially when a very serious underlying condition is suspected such as lung cancer that has the capacity to affect breathing suddenly even though a prisoner may initially appear to be able to speak. 3. There was no clear or consistent system to flag key healthcare events during the day and there seemed to be a variable practice/policy in place that not all healthcare staff seemed to be familiar with or followed so that less relevant information was recorded such as an additional pillow being supplied yet important information such as nebuliser treatment or having a low threshold for medical review if symptoms reoccur or worsen was not consistently recorded in a way that would enable daytime medical staff to flag prisoner healthcare concerns to night-time prison staff. 4. There were also worrying aspects to prison health care systems including checking that all necessary specialist investigations are fully recorded and carried out as well as results properly checked when they return. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you as Ministers responsible for prisons and healthcare provision in prison have the power to take such action. Although, HMP Kingston closed on 28 March 2013, | heard evidence to suggest that there are other prisons across the country where healthcare staff are not present on prison premises on a 24/7 basis resulting in prison officers having to carry out dynamic risk assessments at night and similar issues could well arise as in this case. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 4" February 2015. |, 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 to the following Interested Persons: 1. Fe Garry Gilbey's son; 2, EEE Hodge Jones & Allen LLP, solicitor fo 3. for the Treasury Solicitor's Department on behalf of HM Prison Service; Beachcroft LLP on behalf of Solent NHS Trust; Goodrich on behalf of the Practice FY Le | have also sent it to Ursula Ward, Chief Executive of Portsmouth Hospitals NHS Trust who may find it useful or of interest. | 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. DATE: 10"December 2014 SIGNED:
2 responses 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.
2 nN MR From Norman Lamb MP Minister of State for Care and Support Department of Health Richmond House 79 Whitehall London SWIA 2NS Karen Harrold Tel: 020 7210 4850 HM Assistant Coroner Coroner’s Office : ECEIVED The Guildhall ae Guildhall Square FEB 2015 Portsmouth BY H.M CORONER PO! 2AB 2.5 FEB 2015 Thank you for your letter about the death of Garry Gilbey. Please extend my condolences to Mr Gilbey’s family. Your report details events prior to Mr Gilbey’s death, focussing on the conduct of the prison staff and the care provided. You also noted a number of concerns about operational practice in the prison at that time. You were concemed that prisons do not always have 24 hour a day, medically trained staff available to make emergency assessments of prisoners and that the prison in question did not have a set policy about when an ambulance should be called, instead leaving it to the judgment of the prison staff. You were also concerned about the adequacy of training for night time prison staff and the handover of medical information between day/night staff. 1 am aware that you have also sent a copy of your report to the Ministry of Justice, which oversees the National Offender Management Service (NOMS), which will be able to address prison-related issues such as training for non-medical prison staff. Healthcare contracts for prisons are performance managed by NHS England’s Area Teams at a local level, who have not alerted DH Offender Health or the NHS England Health and Justice central team to any particular problems. Guidance was issued by DH and NOMS in 2011 (’Emergency access to establishments for ambulance services”) to all prisons in England, NHS commissioners and NHS ambulance trusts. This sets out when an ambulance should be called to take a prisoner to hospital in life-threatening circumstances. The guidance covers day and night emergencies and makes the following main points: e The most important aspect of emergency care is that an ambulance is called in all cases where there are grave concerns about the immediate health of a prisoner. Examples of where an ambulance would always need to be called to a prison include suicide attempts or cardiac arrest. e Prisons need to minimise the delays that can be encountered in getting an emergency response to prisoners. There are set standards for the time it should take for an ambulance to respond to emergency calls. e Itis the responsibility of the Governing Governor/Director to ensure that a protocol exists at each prison (regardless of security status) to facilitate immediate access for the ambulance service to both the prison and the individual prisoner when required. As not all prisons in England have 24 hour provision as part of their healthcare contract, the absence of medical cover (e.g. a duty nurse on-call outside normal healthcare centre hours) does not necessarily indicate a service provision problem: the 2011 guidance above applies in emergencies outside normal health centre opening hours. The bodies regulating medical professionals have published comprehensive guidance for clinicians within the prison service, including communicating with non-clinical prison staff. The Nursing and Midwifery Council (NMC) has published “The code: Standards of conduct, performance and ethics for nurses and midwives”. This includes a requirement that nurses must keep clear and accurate records. Records should be made as soon as possible after an event has occurred — for example recording the results of an observation as soon as it has occurred, rather than at the end of a shift. The GMC code of practice, “Good Medical Practice” contains a section covering the continuity and coordination of patient care which makes clear that all relevant information should be shared with colleagues involved in a patient’s care. I hope that this information is helpful and I thank you for bringing the circumstances of Mr Gilbey’s death to our attention. - —_ tree, , NORMAN IANLAMB ~
RECEIVED 09 FEB 2015 BY HM CORONER we Equality, Rights and Decency National Offender Group offender «seni 7 ational lenaer Management service Management Service 4th Floor, Clive House, 70 Petty France, London, SW1H 9HD Assistant Coroner Karen Harrold Portsmouth & South East Hampshire Coroner's Office, The Guildhall Guildhall Square Portsmouth PO1 2AB Dear Coroner, RE: the death of Garry Gilbey on 3 July 2012 whilst in HMP Kingston. Thank you for your letter to Andrew Selous, Minister for Prisons dated 10 December, concerning the inquest into the death of Garry Gilbey, who died at HMP Kingston on 3 July 2012. | am replying as Equality, Rights and Decency Group (ERD) part of National Offender Management Service (NOMS) has ownership of suicide prevention and self-harm management policy in prisons and for sharing learning from deaths in custody. As you know HMP Kingston is now closed. This response includes the contribution provided from NHS England. | have dealt with the points in the order that you raise them: Calling ambulances Since Mr Gilbey’s death Prison Service Instruction 2013/03 Emergency Response Codes has been issued. The PSI reminds staff who can call a medical emergency, and provides guidance on the use of the correct medical emergency codes, and what information should be communicated to the control room from the scene of the incident. It also states that all Governors must have a Medical Emergency Response Code protocol in place that is based on the PSI and that all prison staff must be made aware of and understand the instruction and their responsibilities during medical emergencies. | have attached a copy of the PSI for your information. Training and clarity on medical emergencies for night time prison staff PSI 24/2011 National Security Framework Nights Function Management and Security of Night State requires that all prisoners must be locked up during the night state and that Local Security Strategies (LSS) must state clearly the procedures staff should follow if faced with a potentially life-threatening situation. Staff must have access to the LSS and be aware of the implications of this for their role in maintaining security during the night state. There are many incidents that may occur at night and it is difficult to be prescriptive about what actions to take in each particular case. Under normal circumstances, authority to unlock a cell at night must be given by the Night Orderly Officer (NOO). No cell will be opened unless a minimum of two/three (subject to local risk assessment procedures) members of staff are present one of whom should be the NOO. All staff have a duty of care to prisoners, to themselves and to other staff and the preservation of life must take precedence over other directions. Where there is, or appears to be, an immediate danger to life, then cells may be unlocked without the authority of the NOO and an individual member of staff may enter the cell on their own. However, night staff should not take action that they feel would put themselves or others in unnecessary danger. Before entering a cell: a) Every effort should be made to gain a verbal response from the prisoner. b) This, together with what the member of staff can observe through the panel and any knowledge of the occupant(s), should inform a rapid dynamic risk assessment of the situation and a decision on whether to enter immediately or wait for assistance. c) The Communications Room/Control Room must be informed before entering the cell stating the location of the cell and describing the circumstances that require intervention. Cells should only be entered using the sealed pouches. There must also be clear instructions about the unhindered admission of the emergency services during the night state. Flagging healthcare events to night staff and healthcare systems for checking that all necessary specialist investigations are fully recorded and carried out as well as results properly checked when they return. Under the Health and Social Care Act, NHS England has responsibility for commissioning and quality assuring an equivalent health service for prisoners to those who are in the community and as such NHS England believe they have commissioned an equivalent service. Service specifications are reviewed on a regular basis and changed in line with new national guidance from NICE or as a result of lessons learnt from previous deaths in custody or serious untoward events. All establishments have access to the same level of service that they would receive in the community which is an in-house healthcare service and access to Out of Hours urgent care to an equivalence of the community. As such 24/7 healthcare would not always be provided in- house as this would not be an efficient use of limited resources. Some establishments where there is an in-patient unit will have 24/7 in house healthcare although for the majority of establishments this is not a requirement. Within the new specifications for prison healthcare services there is a contractual requirement for the management of appointments and referrals including those that Did Not Attend (DNA) having an automatic referral to secondary care services. There is a requirement that systems must be in place to ensure that patients can attend medical appointments outside the establishment. Appropriateness of referrals must be subject to regular peer review. They must keep and maintain a detailed database which includes the planning of appointments and follow up requirements. NHS England are happy to work with NOMS to review pathways and protocols both at a national and local level to see if there are further lessons that we can learn as a result of this tragic incident | hope that you find this response helpful and reassuring. Yours sincerely, Pe NOMS Equality, Rights and Decency Group
See every Prevention of Future Deaths report matching State Custody related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.