Clinical review following a death in custody investigated by the prisons and probation ombudsman
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Escalation - if an extension had not been agreed and the report is not received by the 50/60 working day deadline – the investigator will contact the reviewer to ascertain an expected date of delivery. The Assistant Ombudsman will inform the Commissioning Officer that the review is now overdue.
the Assistant Ombudsman will contact the reviewer reminding them of the agreed timescales and extensions. The Assistant Ombudsman will also write to the Commissioning Officer informing them of the late review.
In each case, when a review is received outside of the agreed timescales, the Deputy Ombudsman will inform the National Commissioning Board.
Clinical review template – Foreseeable Death 6. STAGES FOLLOWING THE PPO INVESTIGATION AND CLINICAL REVIEW
There are a number of stages following the investigation and clinical review that the reviewer should be aware of, as follows:
- The PPO investigator writes a draft report including the clinical issues and relevant recommendations. - The draft report is issued to the family (who have up to 8 weeks to feed back) and the service (who have 4 weeks to feed back). Copies will be sent to the NHS Area team and clinical reviewer for factual accuracy checking. - The service and healthcare provider are asked to provide an action plan in response to any recommendations. -
for further investigation to take place, which may include clinical matters. - The report is finalised, including the response to any recommendations, and is used by the Coroner to prepare for the inquest. - Inquest - both the PPO investigator and clinical reviewer may be called to give evidence at the inquest. - After the inquest, the annexes (including the clinical review report) are removed from the PPO report – the report is anonymised and published on the PPO website.
individual member of staff is criticised.
If the final report (e) goes on to make serious criticisms of a member of staff, it will recommend that the appropriate disciplinary procedures are implemented, and may in extreme cases, recommend referral to the appropriate regulatory body. The Area Team (or equivalent) should undertake such a referral.
Both the PPO investigator and the clinical reviewer may be called to give evidence at inquest. Although the inquest should not be an adversarial process, the interested parties (which include the bereaved family and specific members of staff from the service concerned) may have different perspectives of the individual’s care and management than that identified by the PPO investigation and/or clinical review. Each interested party may have their own legal representation and each may require the PPO investigator and the clinical reviewer to give evidence.
Clinical review template – Foreseeable Death ANNEX A – Foreseeable deaths template
Clinical Review for [Name] [Date of death] [Establishment]
Carried out by [name of reviewer] Date of final clinical review report: [date]
Clinical review template – Foreseeable Death
The aim of the review is to consider the clinical care the deceased received in relation to his/her cause of death while in prison custody.
The approach of how and why should be adopted, not who was to blame. The following key questions should be covered in relation to the death:
- How and when did the prisoner die? - Is there any root cause(s) of the death? - Was the clinical care equal to that which could have been expected in the community? - Are there any learning opportunities? - Were local and national policies and procedures (both prison and NHS) followed? - Is there an opportunity to prevent future deaths in similar circumstances? - Are there any examples of good practice?
The review should: - Examine the provision of clinical care and treatment, including both risk assessment and risk management. - Examine any secondary care provided (to the extent necessary for the review) - Provide a chronology of the health and social care events leading up to the incident. - Identify any care or service delivery failings along with the factors that contributed to these problems. - Examine policy and practice. - Identify any root causes(s) that inform the identification of learning opportunities. - Make timely, clear and sustainable recommendations for the prison health care provider and service. - Provide explanations and insight for the relatives of the deceased.
This is a Level 1 review - healthcare and other relevant records have been reviewed and the report written based on documentary evidence and discussion with the PPO investigator.
Clinical review template – Foreseeable Death
dates, times and names of staff.
Details of the clinical reviewer, qualifications, area(s) of specialism etc. 4. Conflict of interest statement
conflicts of interest. This has be to declared this in this paragraph of the report.
Having a financial interest (e.g. holding shares, options or partnership agreements) in the healthcare provider of this clinical review Having a financial or any other personal interest in the healthcare provider of this clinical review If you are employed by, or providing services to, the healthcare provider/establishment of this clinical review Receiving any kind of monetary or non-monetary payment or incentive (including hospitality or commercial sponsorship) from the healthcare provider of this clinical review Canvassing, or negotiating with, any person with a view to entering into any of the arrangements outlined above; Having a close family member (which includes unmarried partners) who fall into any of the categories outlined above; and Having any other close relationship (current or historical) with the healthcare provider/establishment
responsibility to ensure that any and all potential conflicts – whether or not of the type listed above – are disclosed in writing to the commissioners of the review.
5. The diagnosis of [prisoners name] terminal illness and informing him of his condition This section should contain anything relevant up to and including the diagnosis. Please include whether referrals were made appropriately and in line with NHS/NICE guidelines (eg: two week referral for suspected cancer) Clinical review template – Foreseeable Death The clinical reviewer should conclude whether referrals and diagnosis was timely, and the prisoner was appropriately informed. (Examples of issues to include in this section): Was a referral to specialist secondary health service made at onset of symptoms? If cancer suspected, was the referral made within the two week rule? Was the appropriate information recorded in the medical record? Was the prisoner given full information on the reason for the referral? Following a diagnosis of terminal illness, was the patient informed in a timely manner? Were they offered sufficient support? Were they kept informed about ongoing appointments, treatments and prognosis? 6. [Prisoner’s name] clinical care This section should contain all relevant clinical input relating to medical treatment and nursing care after diagnosis. This should include palliative and end of life care eg: pain and symptom control, holistic assessment, advance care planning (including the appropriateness of DNACPR), with reference to appropriate NHS/NICE guidelines. The clinical reviewer should conclude whether medical treatment was appropriate and comment on any delays in receiving treatment. (Examples of issues to include in this section): Was the deceased able to attend hospital appointments etc without difficulty? On return to prison following appointments and treatments, were appropriate clinical and nursing checks carried out? Was there good communication between outside providers and prison healthcare? Was appropriate pain relief given at the appropriate times? Were decisions about whether medication is held in possession or not recorded in the file? Were any security related decisions, e.g. the use of a syringe driver noted in the file? Were appropriate comfort aids supplied e.g. mattresses, chairs, modified cell? Were palliative care agencies contacted? Were treatment care plans in place and agreed with the prisoner? 7. [Prisoner’s name] location From a clinical perspective only, whether the location of the prisoner was appropriate and did not impede clinical care. (Examples of issues to include in this section): Was the prisoner able to stay in their cell until their condition dictated otherwise? Was the prison disability officer informed and an assessment of need carried out if appropriate? Clinical review template – Foreseeable Death Was the prison equipped to care for prisoners with terminal illnesses or was transfer to such a prison considered/facilitated? Was consideration given to transfer the prisoner to a hospice or to hospital inpatients, taking into account security issues and accessibility to the family? 8. Restraints, security and escorts – healthcare input into risk assessments The Graham Judgement, High Court 2007 – made it clear that there should be appropriate healthcare input into risk assessments for the use of restraints. Healthcare should not merely state ‘no objection to the use of restraints’ they should give a clear account of the prisoner’s condition and how this impacts on their risk of escape. Clinical reviewers should comment on this aspect of the risk assessments only. 9. Compassionate release – healthcare input into application process Prisoners can be released from custody before their sentence has expired on compassionate grounds for medical reasons. This is usually when they are suffering from a terminal illness and have a life expectancy of less than three months. Clinical reviewers should comment on the healthcare input into compassionate release applications, particularly in relation to life expectancy. 10. Conclusion Clinical reviewers overall conclusion about the clinical care the prisoner received including whether it was equivalent to that they could have expected in the community 11. Recommendations Clear recommendations to relevant parties (head of healthcare or commissioners). Recommendations should be specific, short and to the point and relate to the clinical care in respect of the terminal condition.
Other findings to bring to the attention of the NHS Area Team (healthcare commissioners) Anything uncovered by the clinical reviewer in relation to the healthcare provider at the establishment – that may not necessarily relate to the care of the prisoner concerned, or to the treatment of their terminal illness. Other recommendations That relate to the above paragraph Annex A – Chronology of relevant events Date Time Event Location Name Source (eg IMR)
Clinical review template – Non-foreseeable Death
Clinical Review for [Name] [Date of death] [Establishment]
Carried out by [name of reviewer] Date of final clinical review report: [date]
Clinical review template – Non-foreseeable Death 1. Terms of Reference
The aim of the review is to consider the clinical care the deceased received in relation to his/her cause of death while in prison custody.
The approach of how and why should be adopted, not who was to blame. The following key questions should be covered in relation to the death:
- How and when did the prisoner die? - Is there any root cause(s) of the death? - Was the clinical care equal to that which could have been expected in the community? - Are there any learning opportunities? - Were local and national policies and procedures (both prison and NHS) followed? - Is there an opportunity to prevent future deaths in similar circumstances? - Are there any examples of good practice?
The review should: - Examine the provision of clinical care and treatment, including both risk assessment and risk management. - Examine any secondary care provided (to the extent necessary for the review) - Provide a chronology of the health and social care events leading up to the incident. - Identify any care or service delivery failings along with the factors that contributed to these problems. - Examine policy and practice. - Identify any root causes(s) that inform the identification of learning opportunities. - Make timely, clear and sustainable recommendations for the prison health care provider and service. - Provide explanations and insight for the relatives of the deceased.
This is a [Level 2 or 3 review – delete as appropriate]
healthcare staff at the establishment carried out jointly with the PPO investigator and report Level 3 – Panel review with lead reviewer – Review of records, interviews with healthcare staff and others as appropriate carried out jointly with the PPO investigator.
considered when appropriate: Clinical review template – Non-foreseeable Death PSI 03/2013 – Emergency response PSI 64/2011 – Safer custody PSO 3050 – Continuity of healthcare PSO 45/2010 – IDTS PSO 1700 – Segregation PSO 1600 – Use of Force PSI 74/2011 – Early days in custody Appendix A – chronology of clinical events leading up to death. Include dates, times and full names of staff.
Details of the clinical reviewer, qualifications, area(s) of specialism etc. 4. Conflict of interest statement
conflicts of interest. This has be to declared this in this paragraph of the report.
Having a financial interest (e.g. holding shares, options or partnership agreements) in the healthcare provider of this clinical review Having a financial or any other personal interest in the healthcare provider of this clinical review If you are employed by, or providing services to, the healthcare provider/establishment of this clinical review Receiving any kind of monetary or non-monetary payment or incentive (including hospitality or commercial sponsorship) from the healthcare provider of this clinical review Canvassing, or negotiating with, any person with a view to entering into any of the arrangements outlined above; Having a close family member (which includes unmarried partners) who fall into any of the categories outlined above; and Having any other close relationship (current or historical) with the healthcare provider/establishment
responsibility to ensure that any and all potential conflicts – whether or not of the type listed above – are disclosed in writing to the commissioners of the review.
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