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Content ArticleOn 27 February 2024, NHS Resolution's Safety and Learning team delivered a virtual forum on delivering health in the prison and justice system. The aim of the session was to discuss the realities, best practice, challenges and recommendations around collaborating to support healthcare delivery in the justice system.
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Event
Behind bars-perspectives on delivering health in prison
Sam posted an event in Community Calendar
NHS Resolution’s Safety and Learning team, are hosting a virtual forum on perspectives on delivering health in the prison and justice system. The purpose is to raise awareness of the cost and scale of harm, discuss the realities, best practice, challenges and recommendations around collaborating to support healthcare delivery in the justice system. The format is interactive, with presentations followed by questions and panel discussion. Event programme: Learning from prison claims – NHS Resolution The realities of delivering healthcare in prison – Practice Plus Group The medico-legal aspect of prison health claims – Bevan Brittan Q&A panel discussion Contributors: Natalie Miller – Deputy Regional Manager for West Midland Prisons (Practice Plus Group) Ruth Kavanagh – Clinical Quality and Patient Safety Lead (NHS England) Michelle Hodgkinson – Lead Commissioner (NHS England) Jo Easterbrook – Partner (Bevan Brittan) Julie Charlton – Partner (Bevan Brittan) Samantha Thomas – National Safety and Learning Lead for General Practice (NHS Resolution) Dr Anwar Khan – Senior Clinical Advisor for General Practice (NHS Resolution) Register -
News ArticleA Mississippi prison denied medical treatment to an incarcerated woman with breast cancer, allowing her condition to go undiagnosed for years until it spread to other parts of her body and became terminal, according to a lawsuit filed on Wednesday. Susie Balfour, 62, alleges that Mississippi department of corrections (MDOC) medical officials were aware she might have cancer as early as May 2018, but did not conduct a biopsy until November 2021, one month before she was released from prison. It was not until January 2022, after she left an MDOC facility, that a University of Mississippi Medical Center doctor diagnosed her with stage four breast cancer, according to her federal complaint. Her lawsuit and medical records paint a picture of a prison healthcare system that deliberately delayed life-saving healthcare and for years repeatedly failed to conduct follow-up appointments that the MDOC’s contracted clinicians recommended. Read full story Source: The Guardian, 14 February 2024
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Content ArticlePrisoners have a right to the same standards of healthcare available to people in the community, and although we might suspect that people in prisons don't always receive the care they need, this is a difficult issue to get at through research. So how can we meaningfully compare hospital use between those in prison and those who are not? Miranda Davies and Eilís Keeble used a novel matched control methodology to show that prisoners use services less than people with similar health characteristics who are not incarcerated.
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EventuntilNHS Resolution’s Safety and Learning team, are hosting a virtual forum on perspectives on delivering health in the prison and justice system. The purpose is to raise awareness of the cost and scale of harm, discuss the realities, best practice, challenges and recommendations around collaborating to support healthcare delivery in the justice system. We will hear from a diverse range of experts in the field. The format is interactive, with presentations followed by questions and panel discussion. Event programme: Learning from prison claims - NHS Resolution The realities of delivering healthcare in prison - Practice Plus Group Good practice and themes from inspections - HM Inspectorate of Prisons The medico-legal aspect of prison health claims - Bevan Brittan Q&A panel discussion. Register
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Content ArticleThis report makes several recommendations to unlock the preventative potential of Prevention of Future Deaths (PFD) Reports. These reports should be viewed as an opportunity for organisations to improve, share good practice, and ultimately prevent custodial deaths – not as criticism to be avoided at all costs. PFD reports have an integral function in ensuring compliance with the state’s duties under Article 2 of the European Convention of Human Rights (ECHR), the right to life, both locally and nationally. This, as well as their immense importance to bereaved families, must be borne firmly in mind.
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News Article
‘Serious failings’ contributed to baby’s death in 12-hour lone prison birth
Patient Safety Learning posted a news article in News
Serious systemic failings contributed to the death of a newborn baby in a cell at Europe’s largest women’s prison, a coroner has concluded. Rianna Cleary, who was 18 at the time, gave birth to her daughter Aisha alone in her prison cell at HMP Bronzefield, in Surrey, on the night of 26 September 2019. The care-leaver was on remand awaiting sentence after pleading guilty to a robbery charge. The inquest into the baby’s death heard that Cleary’s calls for help when she was in labour were ignored, she was left alone in her cell for 12 hours and bit through the umbilical cord to cut it. In a devastating witness statement read to the court, Cleary described going into labour alone as “the worst and most terrifying and degrading experience of my life”. She said: “I didn’t know when I was due to give birth. I was in really serious pain. I went to the buzzer and asked for a nurse or an ambulance twice.” Cleary passed out and when she woke up she had given birth. The senior coroner for Surrey, Richard Travers, said Aisha “arrived into the world in the most harrowing of circumstances”. He concluded it was “unascertained” whether she was born alive and died shortly after or was stillborn. Read full story Source: The Guardian, 28 July 2023 -
Content ArticleReducing avoidable healthcare-associated harm is a global health priority. Progress in evaluating the burden and aetiology of avoidable harm in prisons is limited compared with other healthcare sectors. To address this gap, this study, published in PLOS ONE, aimed to develop a definition of avoidable harm to facilitate future epidemiological studies in prisons. Authors conclude: "We have developed a working definition of avoidable harm in prison health care that enables consideration of caveats associated with prison environments and systems. Our definition enables future studies of the safety of prison healthcare to standardise outcome measurement."
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News Article
WHO reveals one-third of prisoners in Europe suffer mental health disorders
Patient Safety Learning posted a news article in News
One in three prisoners in Europe suffer from mental health disorders, the World Health Organization (WHO) has said in a new report. While European prisons managed adequate COVID-19 pandemic responses for inmates, concerns remain about poor mental health services, overcrowding and suicide rates, the report stated. “Prisons are embedded in communities and investments made in the health of people in prison becomes a community dividend,” said Dr. Hans Henri P. Kluge, regional director of the WHO regional office for Europe. “Incarceration should never become a sentence to poorer health. All citizens are entitled to good-quality health care regardless of their legal status.” The second status report on prison health in the WHO European region provides an overview of the performance of prisons in the region based on survey data from 36 countries, where more than 600,000 people are incarcerated. Findings showed that the most prevalent condition among people in prison was mental health disorders, affecting 32.8% of the prison population. The report drew attention to several areas of concern, including overcrowding and a lack of services for mental health, which represents the greatest health need among people in prison across the region. The most common cause of death in prisons was suicide, with a much higher rate than in the wider community, the report found. Read full story Source: United Nations, 14 February 2023 -
News Article
Parents of man left to die in prison say care failures will haunt them for ever
Patient Safety Learning posted a news article in News
The parents of a 25-year-old man left to die in a cell by a negligent prison nurse given responsibility for 800 inmates have told how the conditions in which their son died will haunt them for ever. The case – the 27th death in just five years at HMP Nottingham – was said to illustrate the desperate state of Britain’s understaffed and increasingly dangerous prison system. Alex Braund was being held on remand awaiting trial when he fell ill in his cell with the first signs of pneumonia on 6 March 2020. Four days later, on the morning of 10 March, after a series of ill-fated attempts by Braund’s cellmate to get prison staff to take the situation seriously, the young man collapsed. Prison staff responded to an emergency bell rung by Braund’s cellmate at 6.55am, but they initially only looked through the cell hatch, taking five minutes to enter the cell in order to give CPR. Braund was subsequently taken to Queen’s medical centre in Nottingham, where he was pronounced dead at 11.44am of cardiac arrest caused by pneumonia. The jury at an inquest at Nottinghamshire coroner’s court found there had been a “continuous failure to provide adequate healthcare”, with a prison officer told by a nurse a few hours before Braund’s death that there was “nothing to be done at this time of night”. Questioning during the hearing revealed that the nurse, who has since lost her job and been reported to the nursing and midwifery council, had amended her records on the morning of Braund’s death. Read full story Source: The Guardian, 6 December 2022 -
Content ArticleAn open letter to Brandon Lewis, the justice secretary, and the Sentencing Council for England and Wales warns that pregnant women in jail suffer severe stress and highlights evidence suggesting they are more likely to have a stillbirth. The signatories include the Royal College of Midwives and Liberty.
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Content ArticleIs good-quality health care being provided for women in prison? As the government proceeds with plans to build 500 more prison places for women, this new Nuffield Trust analysis uses HES data to look at women prisoners' use of hospital services, finding that they face a series of challenges and risks in prison because of barriers to accessing health and care services.
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News Article
Trust failed for months to give vital medication to vulnerable inmate
Patient Safety Learning posted a news article in News
A troubled NHS trust failed for months to give vital medication to a prison inmate who had a long-standing diagnosis of HIV, an inquest has found. A jury at Essex Coroner’s Court concluded that a series of failures and neglect by Essex Partnership University Trust (EPUT) contributed to the death of Thokozani Shiri in April 2019. The 21-year-old spent two spells as a prisoner at HMP Chelmsford, where EPUT provided some services at the time. He was considered vulnerable due to a long-standing diagnosis of HIV for which he was receiving treatment before he went to prison, and the trust was aware he had HIV throughout both stays, the inquest heard. The inquest jury identified that five separate failings had “probably caused” Mr Shiri’s death. These included: a failure to provide antiretroviral medication to Mr Shiri during both periods of imprisonment; a failure to refer him to an HIV clinic; the absence of an appropriate care plan and engagement with a multidisciplinary team; and inadequate management of records. Each failing on behalf of the trust was considered by the jury to have amounted to neglect. Read full story (paywalled) Source: HSJ, 9 June 2022 -
News Article
Hundreds of mentally ill prisoners denied urgent treatment in England
Patient Safety Learning posted a news article in News
Hundreds of severely mentally ill prisoners in urgent need of hospital treatment are being left in prison cells due to bed shortages in secure NHS psychiatric units, an investigation has discovered. Freedom of information (FoI) responses from 22 NHS trusts reveal for the first time that just over half of the 5,403 prisoners in England assessed by prison-based psychiatrists to require hospitalisation were not transferred between 2016 and 2021 – an 81% increase on the number of prisoners denied a transfer in the previous five years. In some areas, the majority of mentally ill prisoners were not admitted, which could be the result of long delays or a trust refusing to take certain patients. Norfolk and Suffolk NHS foundation trust, which was rated inadequate by the Care Quality Commission last month, only admitted 16 of 41 prisoners referred in 2021. Essex Partnership University NHS foundation trust only admitted 24 of 57 prisoners referred in 2021. Lancashire and South Cumbria NHS foundation trust only accepted 18 of the 38 prisoners referred in 2021. Peter Dawson, the director of the Prison Reform Trust, said the figures unearthed by the investigation suggested hundreds of very ill people were being denied the treatment they needed. “It is shocking that a growing number of people are not getting the transfer to hospital that clinicians say is essential for their mental health,” he said. “Instead they are languishing in often overcrowded and dilapidated prisons. It is cruel and guarantees people will leave prison in a worse state than when they came in, with every likelihood that the behaviour that originally led to their arrest and conviction will continue.” Read full story Source: The Guardian, 10 May 2022 -
Content ArticleJail can never be a safe place to be pregnant but the flouting of rules makes things worse. No woman should suffer as I did, writes Anna Harley in this Guardian article.
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News ArticleRaDonda Vaught, a former nurse criminally prosecuted for a fatal drug error in 2017, was convicted of gross neglect of an impaired adult and negligent homicide on Friday after a three-day trial in Nashville, Tenn., that gripped nurses across the country. Vaught faces three to six years in prison for neglect and one to two years for negligent homicide as a defendant with no prior convictions, according to sentencing guidelines provided by the Nashville district attorney's office. Vaught is scheduled to be sentenced 13, and her sentences are likely to run concurrently, said the district attorney's spokesperson, Steve Hayslip. Vaught was acquitted of reckless homicide. Criminally negligent homicide was a lesser charge included under reckless homicide. Vaught's trial has been closely watched by nurses and medical professionals across the U.S., many of whom worry it could set a precedent of criminalising medical mistakes. Medical errors are generally handled by professional licensing boards or civil courts, and criminal prosecutions like Vaught's case are exceedingly rare. Read full story Source: OPB, 26 March 2022 See also: As a nurse in the US faces prison for a deadly error, her colleagues worry: Could I be next?
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News ArticleFour years ago, inside the most prestigious hospital in Tennessee, nurse RaDonda Vaught withdrew a vial from an electronic medication cabinet, administered the drug to a patient, and somehow overlooked signs of a terrible and deadly mistake. The patient was supposed to get Versed, a sedative intended to calm her before being scanned in a large, MRI-like machine. But Vaught accidentally grabbed vecuronium, a powerful paralyser, which stopped the patient’s breathing and left her brain-dead before the error was discovered. Vaught, 38, admitted her mistake at a Tennessee Board of Nursing hearing last year, saying she became “complacent” in her job and “distracted” by a trainee while operating the computerized medication cabinet. She did not shirk responsibility for the error, but she said the blame was not hers alone. “I know the reason this patient is no longer here is because of me,” Vaught said, starting to cry. “There won’t ever be a day that goes by that I don’t think about what I did.” If Vaught’s story followed the path of most medical errors, it would have been over hours later, when the Board of Nursing revoked her RN license and almost certainly ended her nursing career. But Vaught’s case is different: This week she goes on trial in Nashville on criminal charges of reckless homicide and felony abuse of an impaired adult for the killing of Charlene Murphey, a 75-year-old patient who died at Vanderbilt University Medical Center on the 27 December 2017. Prosecutors do not allege in their court filings that Vaught intended to hurt Murphey or was impaired by any substance when she made the mistake, so her prosecution is a rare example of a health care worker facing years in prison for a medical error. Fatal errors are generally handled by licensing boards and civil courts. And experts say prosecutions like Vaught’s loom large for a profession terrified of the criminalization of such mistakes — especially because her case hinges on an automated system for dispensing drugs that many nurses use every day. Read full story Source: Kaiser Health News, 22 March 2022
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News Article
‘Serious failings’ contributed to death of patient at Broadmoor hospital
Patient Safety Learning posted a news article in News
Serious failings by healthcare staff at Broadmoor Hospital were likely to have contributed to the death of a patient from self-asphyxiation, a jury has found. Following a two-week inquest at Reading Coroner’s Court, a jury found staff failed to recognise and reduce the risks that acutely unwell patient Aaron Clamp presented to himself in the minutes leading to his death. Mr Clamp died on 4 January 2021 after choking in his room at the NHS-run high secure mental health hospital Broadmoor. In the weeks prior to his death, Mr Clamp’s mental health had deteriorated. He was transferred into a “psychiatric intensive care” ward at Broadmoor Hospital and placed in long-term segregation. A summary of the jury’s findings shared with The Independent has found there was “a serious failure in the timely manner to recognise and reduce the level of risk, and a serious failure to recognise and execute the steps to remove the item of fabric” that Mr Clamp choked on. “This omission probably contributed to the death,” the jury said. It was also found there was “insufficient” recording by the trust of previous incidents of self-asphyxiation by Mr Clamp when he died. Jurors said the plan for staff to carry out constant eyesight observations was appropriate, but not all aspects of the plan were adequately followed by staff members. Read full story Source: The Independent, 7 March 2022 -
News Article
Patient at Broadmoor Hospital died after suffocating, inquest hears
Patient Safety Learning posted a news article in News
A patient at Broadmoor Hospital has died after suffocating while staff were chatting outside of his room, an inquest has heard. Aaron Clamp, a patient at the notorious high security mental health hospital Broadmoor, died on 4 January 2021 after asphyxiating whilst in his room. The Independent understands Mr Clamp’s death may have been the first “non-natural” death since the new Broadmoor Hospital, run by West London Trust, opened in December 2019. According to evidence heard at the inquest, staff who were meant to be carrying out continuous “eyesight” observations on Mr Clamp, were having a conversation without direct sight into his room. Mr Clamp’s father told The Independent he was “tormented” by the criminal justice and mental health system which resulted in his “indefinite incarceration.” “Diagnosed with a mental illness, schizoaffective disorder, the purpose of treatment was rehabilitation. Psychiatric treatment is conventionally centred on medication to manage symptoms and risk," his father said. He acknowledged there is a balance to be struck between managing risks and restricting patients, but closer attention of holistic compassionate care should be given. Read full story Source: The Independent, 3 March 2022 -
News Article
Record levels of self-harm found at Derbyshire women’s prison
Patient Safety Learning posted a news article in News
Inmates held in a women’s prison are making 1,000 calls a month to Samaritans amid record levels of self-harm, increased violence and low safety levels usually only seen in men’s facilities, a damning report has found. Nearly a third of women held at Foston Hall in Derbyshire, which holds 272 residents, told inspectors they felt unsafe, while the use of force in the prison has doubled over nearly three years and is the highest on the women’s prison’s estate. The women’s prison and youth offender institute is the first to be given a score of “poor” – the lowest – for the safety of female prisoners, since HM Inspectorate of Prisons developed its current framework more than a decade ago. Charlie Taylor, HM chief inspector of prisons, said the rating of “poor” for safety levels was a “rare and unexpected finding” in a women’s prison. Recorded levels of self-harm were also the highest in the women’s estate and two prisoners had taken their own lives since the last official inspection in February 2019, he said. “As an indicator of the level of distress, women were making 1,000 calls a month to Samaritans. The prison had no strategy to reduce self-harm or improve the care for those in crisis,” Taylor said. The response to women in crisis was too reactive, uncaring and often punitive, Taylor observed. “This, taken with other safety metrics and observation, meant it was no surprise that in our survey nearly a third of women told us they felt unsafe,” he said. The report also found that the majority of women who harmed themselves did not have enough support or activity and faced daily frustration in getting the help they needed. Read full story Source: The Guardian, 9 February 2022 -
Content ArticlePrisons and Probation Ombudsman (PPO) Sue McAllister has published the independent investigation into the death of a baby (Baby B) at HMP Styal on 18 June 2020. The PPO was concerned that there were missed opportunities to identify the urgent clinical attention that Ms B, the baby’s mother, needed during that evening. The investigation found gaps in prison nurse training about reproductive health, long-acting reversible contraception and recognition of early labour, and the PPO has made recommendations to remedy these issues in all women’s prisons. View the report
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News Article
UK inmate gave birth to stillborn in prison toilets, inquiry finds
Patient Safety Learning posted a news article in News
An inmate gave birth to a stillborn baby in shocking circumstances in a prison toilet without specialist medical assistance or pain relief, an investigation by the Prisons and Probation Ombudsman (PPO) has found. A prison nurse who did not respond to three emergency calls from a prison officer to come to the woman’s aid when she developed agonising stomach cramps has been referred to the Nursing and Midwifery Council. Louise Powell, 31, was unaware that she was pregnant. She gave birth on a prison toilet on 18 June 2020 at HMP & YOI Styal in Cheshire. She previously said she believed her baby girl could have survived had she had more timely and appropriate medical intervention. Her lawyer said they had obtained expert evidence that also suggested that the baby, who Powell named Brooke, may have survived had things been handled differently. The report is the second by the PPO in six months to investigate the death of a baby in prison. While Tuesday’s report found that there had not been failures before the day Powell gave birth, the ombudsman, Sue McAllister, found there were missed opportunities to establish that she needed urgent clinical attention in the hours beforehand. “It’s not safe to have pregnant women in prison, we are just treated like a number,” Powell told the Guardian in a previous interview. “I can’t grieve for my baby yet because there are still things I don’t know, like why an ambulance wasn’t called. I want to get justice for Brooke and I decided to go public in the hope that things will change and pregnant women will stop being imprisoned.” Read full story Source: The Guardian, 11 January 2022 -
News Article
Jailed women in UK five times more likely to suffer stillbirths, data shows
Patient Safety Learning posted a news article in News
Women in prison are five times more likely to have a stillbirth and twice as likely to give birth to a premature baby that needs special care, new data collected by the Observer shows. Following two baby deaths in prisons since 2019 there have been increasing concerns about safety for pregnant women and their babies. Figures obtained through freedom of information requests made to 11 NHS trusts serving women’s prisons in England show 28% of the babies born to women serving a custodial sentence between 2015 and 2019 were admitted to a neonatal unit afterwards – double the national figure, according to data from the National Neonatal Research Database. The findings come as the House of Lords prepares to vote this week on proposed changes to bail and sentencing laws that would improve the rights of pregnant women and mothers facing criminal charges. A report published in September examined the circumstances of a baby’s death at Bronzefield prison in Surrey where an 18-year-old was left to give birth alone in her cell. When Anita rang her cell bell at 5.30am when she went into labour the guards said they would send somebody. It was only during the morning rounds at 7.30am that a nurse was called. She was transferred to hospital at 10.30am. Anita said: “Despite being in active labour the guards would not remove my handcuffs and ignored me when I asked them to call the baby’s father and my mum – who were eventually contacted by a doctor.” Read full story Source: The Guardian, 5 December 2021 -
News Article
Acutely unwell prisoners left in ‘limbo’ due to lack of mental health beds
Patient Safety Learning posted a news article in News
People needing acute mental health treatment are being left in prison for extended periods, HSJ can reveal. Figures HSJ obtained under the Freedom of Information Act show that 3,111 patients were transferred from prisons to mental health facilities between 2018-19 and 2020-21. A total of 481 (15%) of the transfer took more than 14 days from the date the mental health casework section received an application for transfer to the date the transfer took place. Across these three years, 167 transfers (5%) took more than 28 days. The longest wait for transfer was 161 days, which happened in 2018-19. However, the average number of days taken to transfer a patient has remained consistent at between 10 and 11 days. Until the summer, NHS England’s guidance recommended a 14-day time limit for transfers of patients from prisons to mental health facilities. In June 2021, NHSE published new guidance which recommended a 28-day time limit between a person first being referred for inpatient assessment and being admitted to a mental health facility. The timeline, which consists of two sequential 14-day periods, says medical reports should be “completed to be sent to the [MHCS]” between days 15 and 25, while the MCHS should approve and issue a warrant and admission should take place before day 28. Sophie Corlett, of mental health charity Mind, said: “Nobody who has been assessed as needing specialist inpatient care should be left for extended periods of time in prison, as it’s a completely inappropriate setting for anyone in crisis… When people are a risk to themselves, it’s crucial there are enough staff and beds available to make sure they are cared for in a safe and therapeutic environment.” Bethan Roberts, British Medical Association forensic and secure environments committee interim chair, said: “A prisoner who is mentally unwell and cannot be adequately cared for in a prison should… be transferred to a forensic mental health unit as soon as possible." Read full story (paywalled) Source: HSJ, 1 December 2021 -
Content ArticleThis study in the British Journal of Clinical Pharmacology involved searching electronic health records to uncover how many people in prisons have been affected by a potential problem related to their prescribed medication. Researchers looked at published studies and worked with prison healthcare staff to develop and implement prescribing safety indicators (PSIs) for prison electronic health records. The authors found that PSIs provide a significant opportunity to measure and improve medication safety for people in prisons and that more patients were affected by some PSIs than others. The study also investigated how the searches could be used more widely in prisons and interviewed 20 prison health care staff to explore this topic. The staff they spoke to said that it was important to have people who can take on leadership of the searches and to promote team-based responses to them.
