Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0225, written 8 Jun 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Jun 2016 |
|---|---|
| Reference | 2016-0225 |
| Deceased | Anthony Fraser |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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Nicola Jane Mundy Senior Coroner for South Yorkshire (East District) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: EE Governor HMP Lindholme, Bawtry Road, Hatfield Woodhouse Doncaster DN7 6EE CORONER !am Nicola Jane Mundy, Senior Coroner for South Yorkshire (East District) 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 30 September 2015 | commenced an investigation into the death of Anthony Benjamin Patrick Fraser, 62 . The investigation concluded at the end of the inquest on 8 June 2016. The conclusion of the inquest was Natural causes. The cause of death was 1a. Relapsed Multiple Myeloma 2. Paraplegia, Diabetes, Epilepsy. CIRCUMSTANCES OF THE DEATH Mr Fraser was diagnosed as suffering from multiple myeloma in 2012 whilst an inmate at HMP Lindholme. He received treatment in hospitals in South Yorkshire for this terminal cancer and was kept under regular review of the haematologist from then until the time of his death on the 24" September 2015. In August 2015 his mobility became significantly compromised leading to referral to the hospital where investigations revealed that the disease process had significantly progressed and after investigations and MDDT discussions a decision was made that he was for palliative care only and he passed away in the Doncaster Royal Infirmary on the 24" September. 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. — | heard evidence that the medical records on the electronic System One contain a summary overview of a person’s medical status which should be sent to A&E Departments where patients have been referred. This information is readily accessible but in Mr Fraser's case when he was referred to A&E on 15" August 2015, this information was not conveyed by them to the receiving hospital. | also heard in evidence that there is no system for ensuring that such information is sent and therefore is “hit and miss” as to whether or not it is sent. Whilst | concluded that in Mr Fraser's case this did not affect the ultimate outcome due to him re-attending four days later and given the very aggressive nature of the cancer from which he was suffering, it is clear that for other inmates with different conditions, failure to provide such information may well delay diagnosis or make it extremely difficult to reach diagnosis. Accordingly consideration needs to be given to implementing a system where such information is conveyed for every such inmate in a timely fashion. Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DNI 3HS Tel 01302 737135 | Fax 01302 736365 Summary of concerns:- 1. Absence of a robust system for conveying summary medical information to receiving A&E departments when inmates are transferred with an acute illness. . ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you Governor, 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 Wednesday 3 August 2016. I, 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 Mills & Reeve, (Notts Healthcare rust), overnment Legal Department J, Lindholme Prison). | 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. Dated 8 June 201 Signature Senior Coroner f ith Yorkshire (East District) Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS Tel 01302 737135 | Fax 01302 736365
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.
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26 July 2016
Strictly Private and Confidential
Ms Mundy
Coroner’s Court and Office
Crown Court
College Road
Doncaster
DN1 3HS
Dear Ms Mundy
Report to prevent future deaths following the inquest into the death of Mr Anthony
Fraser
| write in response to your Prevention of Future Deaths (PFD) report dated 8th June 2016 in
order to provide you with the information you have requested. This report was issued
subsequent to the inquest into the death of Mr Fraser who died whilst a Prisoner at HMP
Lindholme, where this Trust provides healthcare services.
The Trust welcomes any chance to improve the quality of its services and we have
considered the concerns you raise in your report with care.
As you will be aware, the Trust commissions internal investigations whenever Serious
Incidents (SIs) occur. The purpose of these SI reports is to look at the whole circumstances
of the incident, set against best practice, and to identify opportunities for learning and
improvement. In the context of any death in a prison setting, the circumstances are always
investigated by the Prisons and Probation Ombudsman (PPO). If there has been any
healthcare involvement, the Ombudsman is assisted by a clinician, appointed by NHS
England, who carries out an independent clinical review. This ensures that whenever there is
a fatality involving a patient of the Trust who is held in a prison setting, there is both an
internal and an external investigation.
Where considered appropriate by the investigators, each of those investigations can make
formal recommendations for changes in, or reviews of, clinical practice and management.
ONG,
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 2 f § it] Sve ©) INVESTORS
Chair: Dean Fathers, Chief Executive: Ruth Hawkins SS ae IN PEOPLE
Woe
Silver
An external investigation was conducted regarding Mr Fraser’s death. The Trust took action
in response to the recommendation made by the PPO report prior to the inquest taking place.
The actions taken by the Trust in response to the recommendation was set out in the Head of
— oral evidence at the inquest.
Coroner’s Concerns
Absence of a robust system for conveying summary medical information to receiving
A&E departments when inmates are transferred with an acute illness.
Following the receipt of the Re i a collaborative meeting took place with the
Governor of HMP Lindholme, and the Associate Director for Offender
Health, and the Head of Healthcare_at_HMP Lindholme, iii
and the Head of Security at HMP Lindholme, [EEE The purpose of the
meeting was to develop a shared system to address the concerns you have raised in the
Preventing Future Deaths report.
A procedure was co-authored by the group, clearly identifying the roles and responsibilities of
both Custodial and Healthcare staff. A copy of the procedure has been included with this
letter. The procedure has been issued to staff and is now in operation. A review of
compliance will be undertaken by the Head of Healthcare within the coming month, to ensure
we have achieved full implementation for a robust system of conveying summary medical
information to A&E depts.
A copy of the procedure will be shared at the Offender Health Learning the Lessons Forum on
the 9th of September 2016, to ensure colleagues in other establishments also have a system
in place for the transfer of medical information, thereby avoiding future deaths.
Please do not hesitate to contact me should you require further information.
Yours sincerely
Lite foe
Ruth Hawkins
Chief Executive
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