Gary McDonald

Practice Plus Group 
Hawker House 
5-6 Napier Court 
Napier Road 
Reading 
Berkshire 
RG1 8BW 

practiceplusgroup.com 

HM Senior Coroner for Worcestershire 
David Reid 

BY EMAIL 

14 November 2022 

Dear Sir 

The Inquest touching upon the death of Mr Gary McDonald 

Thank you for your Report to Prevent Future Deaths issued pursuant to Regulation 28 Coroners 
(Investigations) Regulations 2013 dated 20 September 2022 and following the inquest touching 
upon the death of Mr Gary McDonald, who sadly passed away on 21 July 2021 whilst residing 
at HMP Hewell.   

I  would  like  to  take  the  opportunity  on  behalf  of  Practice  Plus  Group  to  offer  my  sincere 
condolences to Mr McDonald’s family and friends for their loss.  

This letter addresses the matters of concern insofar as they relate to Practice Plus Group.  

Matter of Concern  

Below are the concerns quoted in the PFD report: 

1)  During his initial healthcare screening appointment on the evening he arrived at HMP 
Hewell  (25  March.2021)  and  his  secondary  healthcare  screening  appointment  the 
following day, Mr. McDonald denied any mental health issues, and denied any current 
thoughts of suicide or self-harm. His community GP records were requested and were 
received  by  the  prison  on  30  March  2021;  these  showed  a  previous  history  of 
depression, and two previous drug overdoses, the most recent of which had been only 
7 months earlier;  

2)  Despite this history, no appointment was made with Mr. McDonald by the healthcare or 
mental healthcare teams to follow this up with him, and discuss his mental health in more 
depth;  

3)  In his evidence to the inquest, the current Head of Healthcare at the prison conceded 
that it might have been appropriate for someone to have visited Mr. McDonald, raised 
with him what the GP summary had shown, and asked him if he would like any help, but 

Practice Plus Group Health and Rehabilitation Services Limited. Registered in England No 10498997 
Registered Office: Hawker House, 5-6 Napier Court, Napier Road, Reading, Berkshire RG1 8BW 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 that  he  would  only  have  expected  any  such  follow  up  if  there  had  been  any  current 
concerns about his mental health. He further confirmed that there would have been no 
automatic  follow-up  about  this,  even  if  staff  believed  that  Mr.  McDonald  may  have 
deliberately misled them about his mental health history during his healthcare screening 
appointments;  

4)  In subsequent correspondence to my office, the Head of Healthcare has suggested that 
it  might  be  appropriate  to  delay  a  prisoner’s  secondary  healthcare  screening 
appointment until his GP records have been obtained and scrutinised, so that concerns 
about any history set out in those records can be raised with the prisoner. That proposal 
is due to be raised at the prison’s next Local Quality Assurance Meeting;  

5)  I am concerned that there is currently no system in place at HMP Hewell to follow up 
with  a  prisoner  any  discrepancy  between  the  mental  health  history  which  he  has 
disclosed  on  arrival  at  the  prison,  and  that  revealed  in  his  community  GP  records. 
Experience  suggests  that  a  prisoner  with  a  recorded  history  of  mental  health  issues, 
particularly  one  which  includes  a  recent  episode  of  attempted  suicide  or  self-harm 
through overdose, may be at his most vulnerable during his first days and weeks at a 
prison,  and  having  been  reluctant to  disclose  such  issues for  any  number  of  reasons 
(e.g.  fear,  embarrassment),  may  be  reassured  to  be  told  that  healthcare  staff  at  the 
prison are aware of that history and can provide confidential support. In my view, without 
routine follow-up in such cases, there remains a significant risk that a prisoner’s recent 
significant  history  of  suicide  or  self-harm  may  be  overlooked  in  those  important  early 
days and weeks in prison, and that such prisoners will therefore be at an increased risk 
of further episodes of attempted suicide during that period. 

Response 

In providing a detailed response to the concern raised we consider that it is important to outline 
the  current  process  in  place  for  new  prisoners  coming  into  HMP  Hewell.  This  is  important 
because the arrangements and processes have changed since Mr McDonald’s death. 

Changes since July 2021 

When  a  patient  is  received  into  the  prison  he  is  immediately  located  onto  the  Early  Days  in 
Custody  (EDiC)  unit.  This  EDiC  unit  was  opened  by  HMPPS  colleagues  and  has  been  in 
operation since November 2021 and is based on House Block (HB)2. What this provides is a 
comprehensive induction period for up to 14 days for all new arrivals. Healthcare services form 
a  part  of  this  induction  programme  and  are  also  based  on  HB2.  As  part  of  this  ongoing 
development since its launch, the current pathway means that the patient undergoes a number 
of  key  assessments.  As  well  as  the  assessments,  day-to-day  interventions  are  provided  in 
accordance with any identified healthcare need and subsequent care planning.  

As part of a national NHS England rollout programme since April 2022, the Healthcare team 
and  patients  alike  at  HMP  Hewell  have  benefitted  from  the  introduction  of  the  SystmOne 
upgrades commonly referred to as GP2GP. GP2GP is a process whereby the entire patient’s 
record from the community GP is transferred into HMP Hewell, where in effect the Healthcare 
team  becomes  the  patient’s  registered  GP  practice.  The  GP2GP  functionality  supports  a 
number of benefits including: 

• 
Improved quality of care 
•  Access to the full GP records 
•  Continuity  of  care;  past  medical  history  available 

immunisations and vaccinations   

including  drugs,  allergies, 

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 Improved clinical safety  

• 
•  Clinical time saving  
•  Administrative time saving  
•  Reduced time to summarise 
•  QOF information readily available 
•  Reduced risk of transcription errors 

The  GP2GP  no  longer  requires  the  need  for  a  GP  summary  of  the  patient’s  previous  GP 
healthcare  record.  GP2GP  is  the  patient’s  healthcare  record  which  includes  all  read  coded 
entries for reporting and key word search functionality. There is no longer the need for trained 
back-office staff to enter the read codes from the GP summary into SystmOne, it is an automatic 
process.  

Following the Inquest of Mr McDonald 

Since the Inquest, the Head of Healthcare has consulted with other stakeholders within the team 
about  the  concern  raised  and  have  considered  ways  this  concern  can  be  alleviated.  The 
healthcare team have introduced an updated version (V4) of the EDiC pathway and passport. 
This  “passport”  is  a  document  that  serves  as  a  checklist  to  be  completed  by  the  healthcare 
induction team. By working through such a checklist in a systematic way, assurance is gained 
that all identified needs are being met for all patients, and to a consistent standard.  

The key change between the previous version and Version 4 of this EDiC pathway is the timing 
of the Initial Management Review. It has been moved from Day 3 to Day 5 and now includes 
key  word  searches for  suicide/self-harm  references  and  will  be  undertaken  after  the GP2GP 
transition  process  has  been  completed.  This  key  word  search  of  the  GP  records  has  been 
implemented to identify any discrepancies in the information the patient has disclosed during 
the reception screenings. If a patient was to deny a history of mental health illness during the 
reception screenings, the key word search would pick this history up in his GP records. 

The adoption of version 4 of this pathway continues to provide management reviews of every 
patient’s  GP  record  during  the  first  2  weeks  in  custody.  These  management  reviews  are 
undertaken by a Senior Nurse, who provides a quality and assurance check that all actions have 
been  completed.  In  summary,  the  new  pathway  within  v4  means  that  the  patient  will  now 
undergo the following key assessments: 

•  Day 1 – Initial Reception Healthcare Screen completed, including appropriate referrals 

and actions. 

•  Day 2 – Medication Reconciliation completed (including face-to-face consultation with 

the patient) 

•  Day 2 to 3 - Second Screen completed, including a holistic Wellbeing Assessment. 
•  Day 2 to 3 – Substance Misuse Assessment (ISMS)  
•  Day 3 to 4 – GP2GP record transition completed (assuming patient consent). 
•  Day 5 – Initial Management Review and key word search undertaken by a Senior Nurse 
•  Day 10 – Final Management Review undertaken by a Senior Nurse 

In addition to these key assessments, day-to-day interventions are provided in accordance with 
those identified healthcare needs and subsequent care planning.  

At the point where the Day 5 management check has been completed, we have introduced new 
measures  such  as  the  key  word  search  that  address  those  specific  concerns  raised  by  the 
Coroner.  These  measures  enable  identification  of  previously  undisclosed  information  and 
discrepancies about previous suicidal ideation and/or self-harm (irrespective of when). If any 
discrepancy is identified a member of the EDiC team (either a nurse or HCA) will return to meet 
the patient, informing him of our findings and then proceed to ask him 2 specific questions: 

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 •  Question 1: “Does the patient have any current thoughts of suicide or self-harm?”  
       If Yes, we will then open an ACCT and complete a TAG referral to the MH team.  
       If No, we then proceed to Q2.  

•  Question 2: “Does the patient currently require any input or support from the MH team?”  
• 
• 

If Yes, we complete a TAG referral to MH.  
If No, then no further action is taken.  

These questions serve as a prompt for further discussion and for nursing staff to then evaluate 
and assess a patient where any disclosure is made/discovered. For both questions, the EDiC 
passport  is  then  updated  accordingly  and  a  corresponding  entry  is  made  onto  the  patients 
SystmOne record, along with any further action taken. 

These improvements have been developed as a result of a systematic process of consultation 
and  engagement  with  those  key  stakeholders,  particularly  the  EDiC  and  MH  teams.  The 
changes  now  ensure  that  any  discrepancies  are  identified  and  the  patient  is  provided  with 
another opportunity to discuss their current position with a member of the healthcare team. It 
also  ensures  that  healthcare  are  aware  of  the  patient’s  history  and  can  factor  this  into  any 
subsequent assessments. 

We have also recently undertaken a pilot exercise for mental health triage screening of every 
new reception, and that typically was being undertaken on day 2. This pilot exercise took place 
during May - July 2022. The results of this pilot exercise were positive from both the patients 
and  team/clinicians  perspectives.  On  this  basis,  the  introduction  of  the  MH  triage  on  a 
permanent basis is now subject to contractual discussions between Practice Plus Group and 
Midlands Partnership Foundation Trust (MPFT) as our sub-contracted mental health provider.  

As always, we continue to receive large numbers of new prisoners each week and therefore 
regular reviews of our EDiC pathway and processes are important to us and our service. Whilst 
we are happy that the clinical review found good and equivalence of care in this case, we are 
always looking for ways to improve and thank the Coroner for raising his concern with us. 

I hope that the above information provides you with reassurance that the concerns expressed 
have been addressed. Practice Plus Group is committed to ensuring the high quality provision 
of healthcare services to all prisoners at HMP Hewell and Early Days in Custody is something 
that is regularly reviewed for improvement and a formal review of the EDiC Passport v4 will take 
place by end of December 2022. We will also ensure that any lessons learnt as a result of this 
inquest are shared across all of Practice Plus Group’s services.  

If I can be of any further assistance you should not hesitate to contact me directly. 

Yours sincerely 

National Medical Director, Health in Justice, Practice Plus Group 

Enc. 

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