Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0261, written 22 Jul 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jul 2016 |
|---|---|
| Reference | 2016-0261 |
| Deceased | Alan Stead |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (South) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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. Care UK, Hawker House, 5-6 Napier Court, Napier Road, Reading, Berkshire RG1 8BW CORONER | am Mr Andrew Haigh senior coroner for the coroner area of Staffordshire South 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 22 January 2016 | commenced an investigation into the death of Alan George Stead aged 49 years. The investigation concluded at the end of the inquest on 20 July 2016. The conclusion of the inquest was natural causes with the cause of death being given as la Haemopericardium Ib Thoracic aortic dissection lc Ruptured atheromatous plaque. | CIRCUMSTANCES OF THE DEATH Mr Stead was a serving prisoner at HMP Dovegate who was taken ill in his cell late evening on 20 January 2016. He was taken to Queens Hospital Burton shortly after midnight but was certified dead there soon after arrival. Death resulted from bleeding from a major vessel near his heart. 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 medical review has identified delays with the taking and testing of blood samples from prisoners at HMP Dovegate. This was not something included in a recommendation in the PPO report but was expressed as a concern by the family at the Inquest. This could have serious consequences in some cases. | wonder if you have looked at this and have done or can do anything to improve the situation with this at HMP Dovegate and indeed at any other prisons where you provide healthcare if this is an issue. for) ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. 7 | 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 2016. |, 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: Mr Stead’s family, DWF Solicitors, the PPO and the IMB at HMP Dovegate. | 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 caroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. DATE 22 July 2016 SIGNED BY CORONER haa. | Ke Andrew A Haigh HM Senior Coroner Staffordshire (South) Coroner's Office No 1 Staffordshire Place Stafford ST16 2LP Tel No: 01785 276127 Fax No: 01785 276128 www.staffordshire.gov.uk sscor@staffordshire.gov.uk
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.
Cofe Care UK Hawker House 5-6 Napier Court Napier Road F . Reading HM Senior Coroner Andrew Haigh Berkshire RG18BW Staffordshire (South) Coroner’s Office No 1 Staffordshire Place Stafford www.careuk.com ST16 2LP T 0333 999 2570 F 0333 200 4063 09 September 2016 Dear Sir, Regulation 28: Prevention of Future Deaths report, Alan George STEAD Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Care UK following the inquest into the death of Alan George Stead Deceased. Care UK would like to express its condolences to Mr Stead’s family and friends. Care UK is the provider of healthcare services at HMP Dovegate and has been since October 2014. Care UK provide a 24 hour healthcare service at HMP Dovegate. Our response to your matter of concern, and action taken, is set out below. Matter of Concern: The medical review has identified delays with the taking and testing of blood samples of prisoners at HMP Dovegate. This was not something included in a recommendation in the PPO report but was expressed as a concern by the family at the inquest. This could have serious consequences in some cases. | wonder if you have looked at this and have done or can do anything to improve the situation with this at HMP Dovegate and indeed at any other prisons where you provide healthcare if this is an issue. Response: On Tuesday 8 December 2015 Mr Stead was seen by an advanced nurse practitioner, having reported that he had occasionally been experiencing palpitations in his chest and a dull, left- sided pain when breathing. The nurse examined Mr Stead thoroughly, took his observations and checked his chest. As everything was clear, she decided to carry out an ECG, as well as Mr Stead’s blood pressure, pulse rate and rhythm and respiration rate to see if this would establish the cause of the palpitations. A prison GP reviewed the results of the ECG but found nothing significant. The nurse also referred Mr Stead for blood tests to check his thyroid function, vitamin B12 levels and his ferritin level to rule out anaemia. Healthcare staff were unable to obtain a suitable blood sample due to Mr Stead having poor veins, and so they booked an appointment for Mr Stead to see a healthcare member of staff trained in Phlebotomy on Friday 11 December. Mr Stead was told to contact healthcare staff if he experienced any further symptoms in the meantime. Care UK Limited. Registered in England No 1668247 Registered Office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex CO4 90B The appointment on Friday 11 December did not take place. Healthcare records show that this was a “No Access’ visit which means that the prison were unable to move Mr Stead to the healthcare centre. However, the appointment was rescheduled for the next available blood testing appointment which was on Wednesday 13 January 2016. At the time there were not as many staff in the Healthcare Team at HMP Dovegate trained to undertake blood samples. Although this was a gap of over a month, the blood test was considered routine. Had the test been considered urgent, another Healthcare professional, usually a Doctor, would have taken the blood sample. Mr Stead attended the appointment and the results of his blood test were received by healthcare on 14 January 2016. The Doctor reviewed the results that day and his view was that they did not warrant treatment or referral to a specialist. However, Mr Stead was advised to speak to healthcare staff if there was a recurrence of his symptoms. As noted by the independent clinical reviewer, this blood test would not have had an impact on Mr Stead’s death on 21 January and an earlier test would not have resulted in Mr Stead receiving any different treatment. Care UK Action: On 14 December 2015 a programme was introduced at HMP Dovegate for all nurses and HCAs to be trained in phlebotomy. This programme was completed and all of the staff were deemed competent and signed off in March 2016. Now, blood tests are conducted as soon as required and on the same day whenever possible or if flagged urgent. If they are not performed on the day, patients are added onto a waiting list of a few days. Blood samples are sent to the hospital laboratory daily each afternoon. More widely, the Governance team have shared the events and learning from Mr Stead’s death as part of the National Quality and Improvement Meeting for all Regional Managers. Healthcare Commissioning at HMP Dovegate During the inquest, when giving evidence, FO Assistant Director of Serco was asked if Serco commissioned the healthcare service that Care UK provide within HMP Dovegat al responded “yes” and | am informed that this was reflected in your summing up. | would respectfully like to take this opportunity to clarify the position as this is incorrect. NHS England commission health services within Health and Justice and Care UK has a contract with NHS England to provide healthcare services within HMP Dovegate. NHS England is thus the Commissioner and Care UK the health service provider. Serco do not feature anywhere in this contract. Care UK is committed to providing a high quality healthcare service at HMP Dovegate and across all of our services and | trust that the above response provides the information that you require. However, please do not hesitate to contact me if | can be of any further assistance. Yours faithfully Company Solicitor Care UK Page 2 of 2
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