Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0534, written 7 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Oct 2024 |
|---|---|
| Reference | 2024-0534 |
| Deceased | John Eyre |
| Coroner | Ian Brownhill |
| Coroner area | Mid Kent and Medway |
| Category | State Custody related deaths · Hospital Death (Clinical Procedures and medical management) 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.
Mid Kent and Medway Coroners' Service Oakwood House Oakwood Park Maidstone Kent ME16 8AE Telephone: Email: Date: 7 October 2024 Case: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State for Health and Social Care 1. CORONER I am Ian Brownhill, HM Assistant Coroner for Kent. 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 30 November 2022 I commenced an investigation into the death of John Raymond EYRE. The investigation concluded at the end of the inquest . The conclusion of the inquest was Natural causes 1a Pneumonia 1b Liver Disease 1c 1d II 4. CIRCUMSTANCES OF THE DEATH The deceased was a serving prisoner at HMP Swaleside and had been experiencing a deterioration in his health in the latter part of his life. It was described at the inquest that there was a sudden deterioration in Mr Eyre’s presentation in spring 2022 and mention of a possible lymphoma. It was clear from all of the medical evidence that the clinicians who were treating Mr Eyre thought that lymphoma was the most likely cause of the deterioration in his health. It appears that potential diagnosis was only excluded shortly before his death. During Mr Eyre’s deterioration it is apparent that tests were missed. It is also apparent that he had neutropenic sepsis on more than one occasion. The inquest was not able to come to a conclusion as to what was causing the neutropenic sepsis. As a result of Mr Eyre's condition, he spent time as an inpatient at Medway Maritime Hospital. In October 2022, Mr Eyre was due to be discharged from hospital again to return to a custodial setting. The prison healthcare provider was adamant that his needs could not be met in the custodial setting and was concerned that there were outstanding investigations to be completed. A healthcare professional from the prison shared her concerns with staff in the acute hospital. A junior doctor indicated that the concerns would be escalated to a Consultant prior to discharge. That did not happen, instead, there was a telephone conference in which the prison healthcare staff were challenged as to their approach. The responsible Consultant gave evidence at the inquest that she had not been made aware of the concerns of the prison healthcare provider. Mr Eyre was returned to prison. Shortly thereafter, he was readmitted to hospital by ambulance having been found on the floor. In hospital, Mr Eyre's health deteriorated and despite efforts at treatment, he died there on 20 November 2022. The record of inquest states: John Eyre was serving a custodial sentence at the time of his death, his health deteriorated in 2022 and he was treated for recurrent sepsis. The root cause of the sepsis was not identified. On 31 October 2022, John was readmitted back to Medway Maritime Hospital as his health had deteriorated. Despite efforts as to ongoing investigations and treatment, John died at Medway Maritime Hospital of pneumonia on 20 November 2022. At the time of John’s death he had liver disease which had not been identified. The conclusion was a death by natural causes. 5. 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) There was no concrete escalation route when prison healthcare staff challenged the appropriateness and sustainability of discharge from the acute setting. (2) There was no national guidance document, or national policy in place, which outlined whether a prisoner should be returned to a custodial setting in the absence of the prison healthcare provider's concerns being considered by the patient's consultant. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you as the Secretary of State for Health and Social Care 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 2 December 2024 . 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 Interested Persons in the inquest. I have also sent it to the Prison and Probation Ombudsman who may find it useful or of interest. I 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 coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 7 October 2024 Ian Brownhill Assistant Coroner for Mid Kent and Medway
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.
From Minister of State for Care 39 Victoria Street London SW1H 0EU 17 January 2025 Our ref: HM Coroner Ian Brownhill Mid Kent and Medway Coroner’s Service Oakwood House Oakwood Park Maidstone Kent ME16 8AE By email: Dear Mr Brownhill, Thank you for the Regulation 28 report of 7 October 2024 sent to the Department of Health and Social Care about the death of John Eyre. I am replying as the Minister with responsibility for hospital discharge. First, I would like to say how saddened I was to read of the circumstances of John Eyre’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report highlights concerns about the lack of a clear escalation route and national guidance for prison healthcare staff to address issues with discharging a serving prisoner from an acute hospital setting. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. As the Minister responsible for hospital discharge, I recognise the importance of ensuring that people are discharged from hospital when they are clinically ready, and to an appropriate setting where they will have the right care and support in place. Doing so will help to ensure that people are able to recover in a safe and timely way. As set out in the Hospital Discharge and Community Support Guidance (January 2024), NHS bodies should work closely with care providers and other partners to ensure people’s care is timely, optimal and co-ordinated, while also practising active risk management to reach a reasonable balance between safety and minimising delays when patients are ready to be discharged. I will ask my officials to consider whether an amendment to the hospital discharge guidance is required to make more explicit the obligation to consider concerns raised by care providers before the discharge of patients to custodial settings. Furthermore, as required and described in the Health and Social Care Act 2012, patients within secure settings should receive the same quality and access of healthcare as the rest of the population, both in terms of the range of interventions to meet their needs, and the quality and standards of those interventions. As signatories to the National Partnership Agreement for Health and Social Care for England, the Department of Health and Social Care, HM Prison and Probation Service, the Ministry of Justice, NHS England, and the United Kingdom Health Security Agency have a shared understanding of, and commitment to, how we work together to support the commissioning and delivery of healthcare in English prisons. Relevant NHS bodies and local authorities have legal obligations to ensure that appropriate arrangements are put in place in order to ensure a safe discharge from an acute hospital setting. These obligations are set out in the Care Act 2014 and ensure that prisoners are entitled to the same equivalent care provision as someone in the community. Therefore, maintaining effective continuity of care between acute and custodial settings is essential to ensuring that people in prison receive good and safe care. The Health Services Safety Investigations Body is currently conducting a series of investigations into healthcare provision in prisons, examining emergency care, continuity of care and data sharing and IT. Reports on the first two topics have been published, with the data-sharing and IT report not yet released. You can find out more about the investigation here: Healthcare provision in prisons (hssib.org.uk). Your report also highlights the lack of an escalation route through which healthcare staff in prisons can raise their concerns to hospital staff. I am grateful for NHS England for advising that, since the inquest, Medway Maritime Hospital have been working with their system partners – including providers of healthcare services at Sheppey prisons - to co-create a written document setting out the process for effective and safe discharges of Trust patients who are serving prisoners. The hospital is hoping to ratify the document with relevant governance committees in the near future, and the document will seek to action the concerns raised by your report. The Trust has also implemented twice-daily board rounds, where the status of all patients is discussed by a multidisciplinary team. The team use an electronic bed management system called TeleTracking that enables them to update patient records in real time, including any concerns raised about the safety or appropriateness of their discharge. Consultants are responsible for ensuring any concerns are addressed before they confirm that the discharge can safely proceed. Such actions will strengthen the discharge process in similar cases within the Trust, ensuring they meet the obligations set out in legislation. NHS England’s National Regulation 28 Working Group’s seven regional leads will be asked to share the Trust’s learnings, including the collaborative development of standard operating procedures, from this incident with their systems. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR CARE
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