Jonathan McCarthy

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

practiceplusgroup.com 

Assistant Coroner Hassan Shah  
Northampton Coroner’s service 

15 December 2023 

Dear Sir 

The Inquest touching upon the death of Mr Jonathan McCarthy 

We  write  further  to  your  Report  to  Prevent  Future  Deaths  issued  pursuant  to  Regulation  28 
Coroners (Investigations) Regulations 2013 dated 12 October 2023 and following the inquest 
touching upon the death of Mr McCarthy, who sadly passed away on 12 August 2018 whilst 
residing at HMP Onley.   

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

This letter addresses the matters of concern insofar as they relate to Practice Plus Group (PPG). 
As you are aware, PPG were not the healthcare provider at the time of Mr McCarthy’s death at 
either HMP Thameside or HMP Onley, however PPG have since started providing healthcare 
at both these sites. 

Matter of Concern  

We note that you have the following concerns: 

Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an 
outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps 
to verify this appointment.   

Mr McCarthy was transferred to HMP Thameside on 7 May 2018.  It is recorded that he had an 
appointment  to  see  the cardiologist  at Whittington  Hospital  on  13  June  2018.  There  was  no 
evidence that HMP Thameside took any steps to verify this appointment. He was transferred 
from the prison on the next day, 14th June 2018. 

It  was  suggested  in  evidence  that  HMP  Thameside  automatically  re-arrange  all  community 
medical appointments for security reasons. It was clarified that the prison would only try to get 
a new appointment if there was a specific security concern. 

There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either 

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 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 HMP Altcourse or HMP Thameside. 

In light of these matters, you consider that a Regulation 28 report is required in relation to the 
policies and procedures for: - 

1.  verifying a prisoner’s pre-existing community hospital appointments. 

2.  determining  the  clinical  importance/urgency  of  pre-existing  community  hospital 

appointments and the impact of security issues upon this assessment. 

3.  assessing fitness to transfer and determining medical hold. 

Response 

Pre-Existing Appointments 

When a patient arrives into the prison a healthcare practitioner undertakes a first night screen, 
this consists of a face to face assessment of the patient establishing all pre-existing medical 
conditions and current risk. SystmOne is used to help inform this assessment. This assessment 
is known as the initial reception screening and forms part of the process for all new admissions. 

As part of this reception process, any pre-existing external appointments are identified on arrival 
into  the  prison.  This  is  identified  through  either  checking  the  patients’  medical  records, 
information  from  the  sending  prison  or  confirmation  from  the  patient  himself.  Once  an 
appointment is identified the healthcare practitioner will alert the administration team that there 
are outstanding hospital appointments. The administration team will then make contact with the 
hospital, or other external agency, to ascertain details of the appointment if this is not already 
available.  

If the patient has transferred in from another prison establishment then they would not be aware 
of the date of any external appointments. As noted at the Inquest, this is for security reasons. 
In  such  circumstances  it  is  much  easier  for  the  appointment  to  be  kept  and  it  would  not  be 
cancelled  for  any  security  reason.  Contact  would  still  be  made  with  the  external  provider  to 
ensure that the appointment is still scheduled and then the prison would be informed accordingly 
so that escorts can be arranged. Escorts to external appointments fall to the prison and is not 
the responsibility of healthcare. 

If  the  patient  has  transferred  from  another  prison  but the  hospital  is too far to  travel for then 
these appointments are cancelled by the admin team and a task sent to the GP to inform them 
that the patient needs referring to the local hospital. Where new appointments are scheduled, 
the  patient  is  not  informed  until the  day  of the  appointment.  This  is standard  practice  due to 
security. 

Where a patient is admitted into prison from the community they will often already be aware of 
any  outstanding  appointments.  In  this  case,  the  external  provider  will  be  contacted  to  see 
whether the appointment can be carried out over the phone or via video link. This ensures that 
the appointment goes ahead as scheduled without the security risks of being escorted in person. 
If this is not possible for any reason then the appointment will be rescheduled. However, patients 
with external appointments are highlighted to the GP/ANP or senior nurse to clinically triage to 
ensure that nothing is missed and that their needs are met. If the appointment can be serviced 
within the prison then this will be carried out. Any urgent appointments will be discussed with 
the hospital and an urgent re-referral completed. 

All appointments are recorded on SystmOne by the admin team when they are made so that all 
staff can see the appointments. The prison are informed in advance of external escorts that are 

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 needed where, when and type of transport required. Prison staff are given as much notice as 
possible.  

HMP Thameside have developed a Transfer of Care LOP regarding the transfer in and out of 
patients. Included in this is details regarding external appointments.  

Determining Clinical Importance 

As  part  of  the  LOP  noted  above,  HMP  Thameside  have  put  in  place  a  process  in  which  all 
patients who arrive with external appointments are highlighted to the GP/ANP or senior nurse 
to clinically triage. When considering the urgency of the appointment, multiple factors are taken 
into  consideration.  This  includes  what  the  appointment  is for,  whether  it  can  be  delivered  on 
site, and if it needs transferring to a local hospital. Once a priority category has been has been 
allocated,  admin  are  informed  whether  the  appointment  needs  to  be  kept,  can  be  moved  to 
remote or can be cancelled and re-referred. The priority categories are urgent, routine and non-
urgent or follow up.  

If  an  urgent  appointment  has  to  be  cancelled,  this  would  be  recorded  on  SystmOne  and  an 
urgent task sent through SystmOne to the senior clinician to follow this up. The hospital would 
be  contacted  to  discuss  and  an  urgent  re-referral  completed.  The  prison  are  advised  of  all 
escorts that cannot be cancelled. All escorts are discussed as part of the daily briefing which is 
a joint meeting which all staff attend. The cancellation of appointments is not undertaken without 
clinical consultation, and as previously noted, all patients affected will be seen by a GP/ANP or 
senior nurse to ensure their needs are met.  

Those undergoing treatment at a local hospital would be placed on “Medical Hold” in order for 
the treatment to be completed. If a patient has to be transferred, a Transfer of Care letter is sent 
with  them  to their  new  establishment  which  includes  all  appointments  and  reasons  for them. 
This process is documented in the Transfer of Care LOP, which all staff have been made aware 
of. Our transfer process is detailed further below.  

If an appointment has to be re-booked, this is followed up by the admin team any concerns are 
escalated to the clinician who referred. In January 2024 HMP Thameside will be using the NHS’ 
Electronic Referral System that will ensure all referrals are logged. The admin team will then be 
able to track these more easily.  

Assessment Fitness to Transfer 

All  patients  will  have  a  fitness  to  transfer  assessment  undertaken  prior  to  transfer  to  any 
establishment or court, this is recorded on SystmOne and forms part of the transfer process. 
Healthcare are generally notified 24 hours prior to release or transfer of a patient. This can vary 
depending on external factors such as Court listings and timings.   

All patients transferred from HMP Thameside will have a transfer document sent with them to 
the receiving prison, which will include future external appointments. This has been launched 
as part of the new transfer process implemented by PPG in November 2023. This new process 
has  been  implemented  to  ensure  that  the  transfer  of  patients  is  safe  and  that  all  relevant 
information  is  easily  accessible  to  the  new  establishment.  The  transfer  assessment  is 
undertaken face to face and the document is partially completed prior to the consultation using 
the information from SystmOne. As noted above and during the inquest, “Medical Hold” will be 
utilised to ensure that those patients booked for urgent or specialised treatments/appointments 
are  not  transferred  until  such  time  as  the  treatment  or  appointment  has  taken  place.  For 
example, those having cancer care at specialised hospitals would be placed on Medical Hold. 

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 Medical Holds are communicated directly with the prison and reviewed on a regular basis by 
healthcare. 

Practice Plus Group is committed to ensuring the high quality provision of healthcare services 
to all prisoners at HMP Thameside. We will also ensure that the lessons learnt as a result of 
this inquest are shared across all of Practice Plus Group’s services. We can confirm that this 
has  specifically  been  shared  with the  Heads  of Healthcare  at  both  HMP  Altcourse  and  HMP 
Onley to ensure that similar processes and lessons can be learned. 

I  do  hope  that  this  letter  provided  the  necessary  reassurance  sought  and  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 

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