Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0019, written 19 Jan 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Jan 2023 |
|---|---|
| Reference | 2023-0019 |
| Deceased | Joseph Price |
| Coroner | Crispin Oliver |
| Coroner area | County Durham and Darlington |
| Category | Other related deaths · State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Director of Health and Justice, Armed Forces and Sexual Assault Referral Centres for NHS England 2 Chief CORONER CC OFFICE 1 CORONER I am Crispin Oliver, assistant coroner for the coronial ares of County Durham and Darlington. 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST On 24 September 2020 I commenced an investigation into the death of Joseph Andrew PRICE aged 28. The investigation concluded at the end of the inquest on 18 January 2023. The conclusion of the inquest was that the death was from Natural Causes. 4 CIRCUMSTANCES OF THE DEATH On 20 September 2020 Joseph Andrew Price (Andrew), born 05 December 1991, was found dead in his cell on A Wing at HMP Durham. The opinion initially provided by the pathologist was that the cause of death was unascertained. However, having heard evidence at the Inquest of a paternal family history of pre-mature cardiac related deaths, she changed this to Sudden Cardiac Death. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Mr Price (Andrew) was remanded to HMP Durham on 10 September 2020. He died there, aged 28 years, on 20 September 2020. The evidence of the pathologist at the Inquest was that the medical cause of death was Sudden Cardiac Death (this was an amendment from her original opinion that the cause of death was un-ascertained). The pathologist explained that this death would have followed sudden arrhythmia. She concluded thus after hearing evidence of a paternal family history of premature cardiac related deaths. Clearly this is a comparatively rare condition and one where diagnosis is extremely difficult: it occurs in people who are young and physically fit; there can be an absence of clear symptoms before hand. In Andrew’s case this was complicated further because he was suffering from what are sadly common problems for prison inmates - he had serious mental health and Regulation 28 – After Inquest Document Template Updated 30/07/2021 personality disorder issues and was an established abuser of substances - illicit and otherwise. Such symptoms as there might have been (breathlessness and reported chest pains) in the days and hours leading up to his unexpected death were readily confusable and could have been associated with drug withdrawal (he was subject to a methadone care plan) and mental and emotional distress (he was reported to be suffering from extreme anxiety and paranoia). The best, in some cases the only, way to predict a pre-disposition to a death of this nature is by reference it to family medical history of such, or similar, occurrences. Once this is known, the person can then be referred for genetic screening. Sadly, in Andrew`s case no one in healthcare, some of whom had been familiar with him for years from previous terms of imprisonment, had any knowledge of the family history, as it did not feature on system one, and Andrew had never volunteered it. Equally, he had never been asked about it. This is not a criticism, simply a statement of fact made starkly relevant by the circumstances, unusual though they are. The head of healthcare at HMP Durham gave evidence, when asked directly by me, that provision for a question in the reception health screen template about any family history of sudden cardiac death could help to prevent deaths of this kind reccurring at the prison. She, with the health care provider for HMP Durham (Spectrum Community Health), has helpfully and very pro-actively put this into immediate effect locally (at HMP Durham and those other prisons covered by the health care provider). Specifically, the second health screen template (see attached - at pages 7 and 8) now shows that a question with regards family history (FH) of a ‘FH: Cardiac Disorder (incl. Sudden Cardiac Death)’ has been added to the second reception screen. The updating of the first reception health screen template is currently in hand. Additionally, the health care provider proposed the introduction of a read code specifically for ‘FH: Sudden Cardiac Death’ in the SystmOne template. This read code does not currently exist in SystmOne and so locally, the health care provider has now added it as a prompt in the read code for ‘FH: Cardiac Disorder (XM1Jv)’ and add to this ‘(incl. Sudden Cardiac Death)’. By adding ‘FH: Sudden Cardiac Death’ as a read code in its own right, it will make it easier to search for and flag on the SystmOne records of prisoners so staff can clearly see and be aware of this previous family history. The purpose of this report to you is that you might take appropriate similar steps nationally. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have 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 March 16, 2023. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to Regulation 28 – After Inquest Document Template Updated 30/07/2021 who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. 9 Dated: 19/01/2023 Crispin OLIVER Assistant Coroner for County Durham and Darlington Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Crispin Oliver
Assistant Coroner
County Durham and Darlington Coroner’s Court
P.O. Box 282
Bishop Auckland
Co. Durham
DL14 4FY
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
15 March 2023
Dear Mr Oliver
Re: Regulation 28 Report to Prevent Future Deaths – Joseph Andrew Price
(Andrew), D.O.B 05 December 1991.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 19
January 2023 concerning the death of Andrew Price on 20 September 2020 at HMP
Durham. In advance of responding to the specific concerns raised in your Report, I
would like to express my deep condolences to Andrew’s family and loved ones. NHS
England is keen to assure the family and the Coroner that the concerns raised about
Andrew’s care have been listened to and reflected upon.
Following the inquest, you raised concerns in your Report regarding:
1. Lack of a specific question relating to family history of sudden cardiac death
in the reception health and secondary health screen templates.
2. Lack of an appropriate way of recording family history of sudden cardiac
death within the SystmOne template, and lack of an appropriate ‘read code’
for this meaning staff are not easily able to identify when this information is
recorded.
It should be noted that the UK National Screening committee does not recommend
that screening is undertaken for younger individuals, namely those aged 12-39 years,
as there is not enough evidence to support the screening. This is because:
• There is uncertainty about how many young people each year are affected by
•
sudden cardiac death.
It is unclear whether the tests could accurately detect heart conditions in young
people not displaying any symptom.
• There is no research evidence that testing young people has reduced or is likely
to reduce the chance of a sudden cardiac death.
More information regarding the research undertaken by the UK National Screening
Committee can be found at Sudden cardiac death - UK National Screening Committee
(UK NSC) - GOV.UK (view-health-screening-recommendations.service.gov.uk).
Andrew was 28 years old at the time of his death meaning he fell within the age range
for which screening is not recommended.
With regard to your concern regarding the lack of a specific question relating to family
history of sudden cardiac death in the reception health and secondary health screen
templates, I understand that as an immediate response to your report, the prison
healthcare provider responsible for ten prisons across the North East and Yorkshire
region (including HMP Durham), has added an additional question to the secondary
screening templates relating to family history of sudden cardiac death.
At a national level, the second health assessment, which should be undertaken within
seven days of the reception screen and should act as a prompt to ask relevant
questions relating to family history, is carried out in line with guidelines from the
National Institute for Health and Care Excellence (NICE). It includes a question
specifically relating to any history of serious illness in the person’s family, for example
heart disease.
These guidelines also point out the need to have a system and processes in place to
carry out other assessment and highlight action to take in terms of referring a person
to a General Practitioner (GP) or relevant clinic if further assessment is needed, for
example upon identification of cardiovascular disease. More information can be found
at Recommendations | Physical health of people in prison | Guidance | NICE
In relation to your concern raised over a lack of appropriate read code for sudden
cardiac death, there is no specific read code for sudden death syndrome on any clinical
system, which is likely due to the fact there is no evidence to screen for it. NHS
England is however refreshing the secondary health screening template to include a
specific prompt for users to ask relevant questions relating to family history.
I would like to provide further assurances on the national NHS England work taking
place around the Reports to Prevent Future Deaths. All reports received are discussed
by the Regulation 28 Working Group, comprising Regional Medical Directors and other
clinical and quality colleagues from across the regions. This ensures that key learnings
and insights around events, such as the sad death of Andrew are shared across the
NHS at both a national and regional level and helps us to pay close attention to any
emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
NHS England
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