Justin Gallagher

Phil Copple 
Director General Prisons 
HM Prison and Probation Service 
8th Floor Ministry of Justice 
102 Petty France 
London SW1H 9AJ 

Email:DirectorGeneralPrisons@justice.gov.uk  

Mr Alan R Craze 
HM Senior Coroner for East Sussex 
East Sussex Coroner’s Office 
Unit 56, Innovation Centre 
Highfield Drive 
St Leonards-On-Sea 
East Sussex TN38 9UH 

24 October 2019 

Dear Mr Craze 

Thank you for your Regulation 28 Report of 16 August 2019 following the inquest into the 
death of Justin Peter Gallagher at HMP Lewes on 17 June 2016. I am responding on behalf 
of Her Majesty’s Prison and Probation Service (HMPPS). 

I know that you will share a copy of this response with Mr Gallagher’s family, and I would 
like first to express my condolences for their loss. The safety of those in our care is my 
absolute priority, and every death in custody is a tragedy. 

As you know, the commissioning of health care in English prisons is the responsibility of 
NHS England and NHS Improvement, (NHSE/I), and HMPPS ensures access to healthcare 
services within establishments and, where required, at external healthcare facilities. I 
understand that NHSE/I is providing a separate response, and I will address matters (2) and 
(5) in your report, as these are within the responsibility of HMPPS. 

The Governor of HMP Lewes is committed to providing resources for external escorts to 
medical appointments. Currently, sufficient escorting staff are made available for three 
external hospital escorts each weekday, and appointments are prioritised by the healthcare 
team. In the event that there are inadequate resources because of other operational 
pressures and it is necessary to consider the cancellation of an external appointment, the 
Duty Governor contacts the healthcare team for advice on the potential medical impact. If 
this results in a decision to cancel an escort, the healthcare team cancels and rearranges 
the appointment. Where possible, emergency escorts are facilitated in addition to scheduled 
appointments, but where this is not possible healthcare staff are asked to consider the 
priority with which the scheduled appointments are required and one is postponed to a later 
date. 

With regard to the sharing of information between the organisations involved in the 
management and care of prisoners, you will appreciate that it is not appropriate for prison 
staff to have access to clinical records on SystmOne. At HMP Lewes, there is a daily 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 meeting between prison and healthcare staff at which important information is shared. Each 
staff team then ensures that their respective databases are updated.  

I understand that a new database is being created by NHSE/I which will supersede the 
current clinical system. The plan is for this to have some inter-operability with the NOMIS 
database used by prison staff, and this will enable better sharing of information between 
prison and healthcare staff. 

Thank you again for bringing your concerns to my attention. I hope this provides 
reassurance that they are being addressed. 

Yours sincerely, 

PHIL COPPLE   

Director General for Prisons

NHS’

Professor Stephen Powis
National Medical Director
Skipton House
80 London Road
SE1 6LH
Mr Alan Romilly Craze, Senior Coroner for the
area of East Sussex
Unit 56
Innovation Centre -
Highfield Drive
St Leonards on Sea

East Sussex .
TN38 9UH Via December 2019

Dear Mr Craze,

Re: Regulation 28 Report to Prevent Future Deaths —
Mr Justin Peter GALLAGHER, who died in HMP Lewes 17" June 2016.

Thank you for your Regulation 28 Report (hereinafter the ‘report') dated 16 August 2019
concerning the death of Justin Peter Gallagher on 17 June 2016. Firstly, | would like to
express my deep condolences to Mr Gallagher's family.

| note that your recent inquest concluded Mr Gallagher’s death was as a result of Hypoxic
brain injury caused by a heart attack brought on by laryngeal cancer.

Following the inquest, you now raise concerns in your report to NHS England regarding:

1. The prison never obtained his previous medical history. No proper care plan was
drafted for him and there was no single clinician responsible for his care.

2. Anumber of external hospital appointments were cancelled at short notice because
of lack of resources (no available escorts etc.) and there was no system available
for rearranging such visits.

3. The deceased died of cancer but this had never been diagnosed and opportunities
to have discovered his condition were missed.

4. There was no involvement of the. family and so a source of important information
was missed

5. The underlying problem was that healthcare in the prison was the responsibility of
three different organisations, namely the prison service, the local mental health
NHS trust (who were given the responsibility for dealing with all the physical health
matters and running the healthcare centre), and a separate organisation who
supplied GPs. These three organisations had entirely separate database systems.

Firstly, | would like to advise you that following Mr Gallagher’s death in June 2016, in line
with the Prisons and Probation Ombudsman’s requirements, NHS England commissioned
an independent clinical review into the care received by Mr Gallagher whilst a prisoner in
HMP Lewes to consider whether it was equivalent to that he could have expected to
receive in the community. The clinical reviewer was required to identify any improvements
that could be made and make appropriate recommendations.

NHS England and NHS improvement

The review made a number of recommendations and an action plan was agreed with
providers of healthcare at HMP Lewes, which was completed by 1 April 2017. A copy of
this action plan is attached as annex A. :

Further joint inspections by Her Majesty's Inspectorate of Prisons (HMIP) and The Care
Quality Commission (CQC), and specific quality visits carried out-by the commissioners,
have resulted in a number of the recommendations being repeated to ensure that the
changes were embedded. In addition, a further Service Development Improvement Plan
was agreed in April 2018, and | can advise this was last updated in July 2019. The relevant
actions within the plan are listed below in response to your individual concerns which | look
to respond to in turn. When responding | am also mindful of the similar concerns raised in
the report following the more recent death of Mr Martin Leslie Haines who also sadly died
whilst detained at HMP Lewes in March 2018:

1. The prison never obtained his previous medical history. No proper care plan
was drafted for him and there was no single clinician responsible for his care.

All providers are contracted using the NHS Standard Contract. Service Specifications
within the contract set out clear expectations in relation to service delivery. In this instance,
the Primary Care Service Specification sets out a requirement for the provider to carry out
“an in-depth assessment of health needs within 72 hours of arrival...... accurate clinical
care must be maintained and any referrals for follow up and further assessment or
intervention must be discussed and undertaken. Reasonable efforts should be made to
source clinical history, GP etc.”

NICE Guidelines 57: Physical health of people in prison (November 2016)' covers
assessing, diagnosing and managing physical health problems of people in prison and
includes the following recommendations:
e A first health assessment on reception into prison;
e Arrange for the person’s medical records to be transferred from primary and
secondary care to the prison healthcare team on entry to prison; and
e A healthcare profession should carry out a second-stage health assessment for
very person in prison.
Mr Gallagher arrived at HMP Lewes on 29" March 2016 and underwent a first screen on
that day. A copy of his summary care record was obtained via the NHS Spine portal the
following day, along with a medication summary, but attempts to obtain a more detailed
history from GP/Consultants were unfortunately not followed up. :

The Clinical Reviewer recommended that the Head of Healthcare at HMP Lewes should
ensure that the past medical history is obtained for new prisoners with chronic conditions,
and that their care should be assigned to a name clinician. | can confirm an action plan
was implemented with all actions achieved by 1 April 2017 which included:

. implementation of a more robust administrative process which ensures that
community medical records for newly arrived prisoners are requested within a week in
line with NICE Guidelines 57, PSO 3050; .

. an audit of healthcare record requests in March 2017 to ensure the process was
effective and efficient. As a result of your report | can confirm commissioners have
asked SPFT to undertake a further audit which was completed in November with the
outcome due to be shared by the end of December 2019. A CQC focus visit took
place on 21 and 22 October 2019 and it was reported to the commissioners that
record keeping and care planning in particular had significantly improved with the
input of additional. resources to support this process;

4 https://www.nice.org.uk/guida nee/ng57/chapter/recommendationsi#on-entry-into-prison

NHS England and NHS improvement

. the running of a regular report via SystmOne to ensure that healthcare records
have been requested; and

e © anominated member of staff checking that all newly arrived prisoners have been
offered a full general health assessment to include the drafting of a care plan within 7
days of arrival. The checks to be noted on an internal document which is shared with
all healthcare staff.

. New prisoners with chronic conditions are assigned to a named clinician.
Depending upon the condition this may be a GP, Specialist Nurse or Primary Care
Nurse.

2. A number of external hospital appointments were cancelled at short notice
because of lack of resources (no available escorts, etc) and there was no system
available for rearranging such visits.

Regional commissioners are aware that there is an ongoing shortage of trained officers at
HMP Lewes which can result in a restricted regime resulting in less access to healthcare
and attendance at external hospital appointments. There also continues to be issues with
the re-booking of appointments and commissioners are working with Sussex Partnership
Foundation Trust (SPFT) to resolve this. .

| can confirm SPFT have implemented a revised process to ensure there is a clinical
review of any appointments which are postponed. This includes a review by the GP to
assess Clinical need and risk. Where the demand for external escorts exceeds availability,
the GP will prioritise appointment attendance based on clinical need and any appointment
cancelled is to be automatically re-booked with the hospital trust. This revised process
including clinical review will suitably prioritise and prevent future failings to re-arrange
cancelled appointments. The monitoring of this by the commissioners will take place at
monthly Contract Review Meetings (CRM). and any concerns will be reported to the
monthly Partnership Board (PB) and if further escalation is required it will be dealt with at
the monthly Local Delivery and Quality Board (LDQB).

3.’ The deceased died of cancer but this had never been diagnosed and
opportunities to have discovered his condition were missed

The Clinical Reviewer's report states that Mr Gallagher had been diagnosed with laryngeal
cancer 2 years prior to reception at HMP Lewes, and that Mr Gallagher died from events
caused by the recurrence of a laryngeal tumour that had been treated the previous year
with radiotherapy. .

It is however apparent from the Clinical Reviewer’s report that thefe were several factors
that may have hindered .the diagnosis of this recurrence not least because of Mr
Gallagher's complex medical history, including: .

a) Limited knowledge of past history;
b) Deferred outpatient appointments;
c) Continuity of care; and

d) Mental health.

Commissioners agreed a Service Development Plan with the healthcare providers (SPFT
and Medco), which inciuded the introduction of a named clinician for all patients with
chronic illnesses; reinforcement of the requirement for a clinician to be involved in any
decision to postpone out-patient appointments; and a work plan to reduce the number of
cancelled appointments. Commissioners recognised the need for improved clinical
oversight and scrutiny and this takes place via the local governance arrangements. The
process is that SPFT and Medco revisit the findings of Mr Haines Clinical Review and

NHS Engiand and NHS Improvement

ensure all lessons learned have been implemented and identify any further training
requirements for staff. This will include GPs discussing the case with their RO.
Commissioners now also make it a requirement that cancelled appointments are reviewed
at a multi-disciplinary team meeting and a risk assessment completed for each prisoner.
Provider(s) will be required to submit a report to contract meetings to ensure full oversight
by the prison governor and commissioners. In addition, in 2018 Commissioners

- introduced enhanced quality surveillance and support for providers. This was achieved
through newly created Health and Justice Quality and Safety Manager posts in South East
Region. These posts are clinical roles that bring additional oversight and support to the
quality of healthcare delivery.

Commissioners have monitored the implementation of these recommendations and since
2017, have served Contract Notices: in June 2018 and November 2018 to SPFT relating
to poor performance. These notices have included: the potential for financial penalties if
action plans were not completed satisfactorily but were not required on either occasion.

4, There was no involvement of the family and so a source of important
information was missed.

Providers do not routinely link with family members but where it is considered appropriate
or necessary they will look to obtain the permission of the patient to do so. In this case, Mr
Gallagher's father had provided a letter outlining the importance of his out-patient follow,
ups and compliance in taking his Hydrocortisone for adrenal insufficiency. Unfortunately
the re-booking of appointments for Mr Gallagher was not based on clinical need but on
availability of out-patient appointments, in hindsight it is acknowledged that the clinician
(GP) could have been informed of the new dates so that a decision on clinical
appropriateness of timings could be considered. As above | am happy to report that these
additional measures are now in place.

5. The underlying problem was that healthcare in the prison was the
responsibility of three different organisations, namely the prison service, the
local mental health NHS trust (who were given the responsibility for dealing with
all the physical health matters and running the healthcare centre), and a separate
organisation who supplied GPs. These three organisations had entirely different
database systems.

In 2017, NHS England (NHSE) reviewed the model of commissioning in Kent, Surrey and
Sussex as it was becoming increasingly apparent that the model was not delivering the
benefits anticipated and services were not integrating effectively. In line with other prison
groups in England, NHSE made the decision to commission services using a Prime
Provider model. | can confirm that this model ensures a single contract and provider, and
therefore better accountability for the delivery of integrated healthcare in a prison (or group
of prisons). This will negate any communication issues and the single provider will use one
database system only.

This model has been found to be more effective in management of services, and the
development and delivery of integrated pathways between the different healthcare teams
within a prison. Commissioners have worked closely with Governors to ensure that they
are able to provide officer support (enablement) to increase healthcare access to prisoners
including supervision of medications, movement of prisoners to and from appointments and
out of hours access where required. : : , .

NHS England and NHS Improvement

The current healthcare contracts with existing providers end in March 2020 (SPFT and
Medco) and October 2020 (Forward Trust) respectively. NHSE have undertaken a
procurement process for the provision of these services after those dates. .

NHSE awarded the contract to Care UK in October 2019 and the services are currently
being mobilised for a delivery start date of April 2020. Monthly Mobilisation Boards have
been established and include all incumbent providers, the prison, social care and the new
provider. These Boards are overseen by NHSE Commissioners.

Once the contract starts the NHSE governance process will have oversight via Contract
- Review Meetings, Partnership Boards and Local Delivery Quality Boards.

Thank you for bringing these important patient safety issues to my attention. | hope the
information in this response, alongside the associated response regarding the death of Mr
Haines, provides you with the detailed context of the steps and measures being
implemented at HMP Lewes in order to improve the healthcare in the prison to prevent
future deaths. However should you require any further information please do not hesitate to
contact me.

Yours sincerely,

Professor Stephen Powis
National Medical Director
‘NHS England and NHS Improvement

NHS England and NHS Improvement °

NHS England and NHS tmprovement

• 

Department 
of Health & 
Social Care 

From Nadine Dorries MP 
Parliamentary Under Secretary of State for Mental Health,
Suicide Prevention and Patient Safety 

39 Victoria Street
London 
SW1H0EU 

020 72104850 

Mr Alan Craze 
HM Senior Coroner, East Sussex 
East Sussex Coroner's Office 
Unit 56, Innovation Centre 
Highfield Drive 
St.-Leonards-On-Sea TN38 9UH 

9l~  January 2020 

Thank you for your correspondence of 16 August 2019 to Matt Hancock about the 
death ofMr Justin Peter Gallagher.  I am replying as Minister with responsibility for 
prison health services and I am grateful to you for the additional time in which to 
issue this response. 

Firstly, I would like to extend my sympathies to the family and loved ones of Mr 
Gallagher.  We know that more can be done to better meet the healthcare needs of 
people within our prison system and I am grateful to you for bringing these matters to 
my attention. 

Providers of healthcare services are responsible for the quality and safety ofthe care 
they provide.  I expect the healthcare providers at HMP Lewes to look into the care 
provided to Mr Gallagher and to consider where improvements can be made.  This 
includes how they work with the prison authorities and other relevant organisations, 
including NHS England which is responsible for commissioning healthcare services 
for prisoners.  Given its role in monitoring, inspecting and regulating the providers of 
health and social care in prisons, my officials have brought your reports to the 
attention ofthe Care Quality Commission (CQC). 

 
 
 At a national level, the National Audit Office report into Mental Health in Prisons 1
, 
published in June 2017, made a recommendation in relation to the way that NHS 
England, Her Majesty's Prison and Probation Service and Public Health England 
manage their joint working on prison healthcare. 

As a result, the original tri-partite partnership agreement (developed and signed in 
autumn 2013) was revised to include the Department of Health and Social Care and 
the Ministry ofJustice as partners to bring additional oversight and accountability to 
the commissioning and delivery of healthcare services in prison. 

The National Partnership Agreement for Prison Healthcare in England 2018-21 2, 
published in April 2018, acknowledges the need for health and justice partners to 
work together to ensure "safe, legal, decent and effective care that improves health 
outcomesfor prisoners, reduces health inequalities (particularly for those with 
protected characteristics), protects the public and reduces reoffending". 

The Agreement sets out a joined-up, strategic approach to meet the complex nature of 
offender health care needs and provides the partnership members with an overarching 
framework for collaborative working at all levels.  The Agreement has three shared 
core objectives to be delivered through ten high level priorities.  These priorities are 
underpinned by the Agreement's 2018 Workplan, which includes a commitment to 
deliver on three key issues that relate to the responsibilities of all organisations 
involved in prison care.  These commitments are to: 

• 

• 

Improve the quality of data and intelligence collection and enable better data-
sharing between partners.  This includes improving the sharing of information 
before, during and after incarceration to support continuity of care; 
Input into the development ofpolicy amongst the health and justice partners, 
and across Government, to ensure that the potential impact on prisoners' health 
and social care needs are properly considered and that shared objectives are 
maintained; and, 

•  Review and improve commissioning between health and justice partners and 

links with local authorities, probation services and health commissioning in the 
community, so that health and social care services are aligned for better and 
more consistent provision before, during and after custody. 

1 www.nao.org.uk/wp-content/up loads/20 I 7 /06/Mental-health-in-prisons.pdf 
z 

ht1ps://ass~  publishing.service.gov.uk/~overnment/upJoadsLsY11tem/uploads/auachment  data/filef767832/6.4289  MoJ 
National  health  partnership  A4-L  vlO  web.pdf 

 Effective delivery ofthe ten objectives will be observed by existing scrutiny bodies, 
including HM Inspector of Prisons, Independent Monitoring Boards, the CQC and 
Health watch. 

The National Prison Healthcare Board has responsibility for the oversight and on-
going management of the Agreement and delivery of the shared objectives. 

You may be aware that the Health and Social Care Select Committee conducted an 
inquiry into prison health that reported in November 20183
response, published in January 20194, outlined a range of actions, including those in 
the National Partnership Agreement, that will be taken to support· the delivery of 
high-quality health services in prisons.  We remain committed to working 
collaboratively across Government to achieve those aims.  For example, in response 
to one ofthe recommendations, the National Prison Partnership Board published a 
Principle of Equivalence in October 2019.  This states that the co-chairs of the 
National Prison Healthcare Board affirm that: 

•  The Government's 

'Equivalence' is the principle which informs the decisions ofthe National Prison 
Healthcare Board so that member agencies' statutory and strategic objectives and 
responsibilities to arrange services are met, with the aim ofensuring that people 
detained in prisons in England are afforded provision ofand access to appropriate 
services or treatment (based on assessed population need and in line with current 
national or evidence-based guidelines) and that this is considered to be at least 
consistent in range and quality (availability,  accessibility and acceptability) with 
that available to the wider community, in order to achieve equitable health 
outcomes and to reduce health inequalities between people in prison and in the 
wider community. 

The Board is working with analysts and scrutiny bodies to understand the extent to 
which available indicators could help evidence the achievement of equivalence of 
care and what would be both useful and feasible. 

Finally, I am aware that NHS England and NHS Improvement, as the commissioner 
of healthcare services for people in prison, has responded to your report providing 
detail on the actions taken to support healthcare services at HMP Lewes.  You will 
therefore know that this includes the procurement of a single provider ofhealthcare 
services at HMP Lewes to deliver better integrated services.  In addition, NHS 

3  https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/963/963.pdf 
4 www.parliament.uk/documents/commons-committees/Health/Correspondence/2017-19/Govemment-Response-to-
twelfth-report-into-prison-health-cp4.pdf 

 England and NHS Improvement have taken steps to review and strengthen its quality 
assurance and contract performance systems. 

I hope this response is helpful.