Recurring concern

Unreliable management of prisoners’ outstanding hospital appointments

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First reported 20 Jun 2014•Latest report 12 Oct 2023

Definition

What this concern includes

Includes prison healthcare or custody processes for identifying outstanding hospital or other external healthcare appointments, verifying their status, assessing clinical urgency, accounting for transfer or security issues, maintaining appointments and arranging timely replacements when needed.

Not included

Excludes general hospital appointment delays or cancellations where no prison healthcare or custody responsibility for maintaining the appointment is identified.
Excludes routine prison healthcare appointments arranged and delivered entirely within the prison unless they are explicitly part of managing an external hospital appointment.
Excludes generic prisoner-transfer, reception, staffing or communication deficiencies unless they directly impair management of an outstanding hospital appointment.
Excludes failures in clinical assessment or treatment after the prisoner has attended the hospital appointment.
Excludes generic appointment-access concerns for non-prisoners and the existing broader concern about vulnerable-patient clinically directed appointments where no prison-specific appointment-management condition is supported.

Reports: 3
Individual concerns: 5
Date range: 2014–2023
Stated actions: 4

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Ministry of Justice3

NHS England3

Department of Health and Social Care1

Practice Plus Group1

Thameside Prison1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

12 Oct2023
Northamptonshire
Concerns raised2
1. Failure to determine the clinical importance and urgency of pre-existing community hospital appointments in light of security issues
2. Failure to verify prisoners’ pre-existing community hospital appointments
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Clinically triage patients arriving with external appointments and assign urgency categories to determine whether appointments are kept, delivered remotely, cancelled, or re-referred.
  Stated by Practice Plus GroupStated completed
2. Action
  Place patients receiving local-hospital treatment or urgent or specialised appointments on medical hold until treatment or appointments are completed.
  Stated by Practice Plus GroupStated completed
Respondent positions 1
1. Position
  Responsibility for arranging escorts to external appointments lies with the prison, not healthcare.
  Stated by Practice Plus GroupRedirects responsibility
AI-generated summary

Mr Jonathan Michael McCarthy · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr Jonathan Michael McCarthy died on 12 August 2018 at University Hospital Coventry and Warwickshire from a cardiac arrhythmia associated with scarring of the heart, while at HMP Onley. Concerns included failures to verify and assess the clinical importance of pre-existing community hospital appointments, the impact of security issues on those appointments, and whether he was fit to transfer or should have been placed on medical hold.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to determine the clinical importance and urgency of pre-existing community hospital appointments in light of security issues
Wider context from the report
“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 HMP Altcourse or HMP Thameside. 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. ”
Source location
Mr Jonathan Michael McCarthy · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to verify prisoners’ pre-existing community hospital appointments
Wider context from the report
“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 HMP Altcourse or HMP Thameside. 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. ”
Source location
Mr Jonathan Michael McCarthy · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Clinically triage patients arriving with external appointments and assign urgency categories to determine whether appointments are kept, delivered remotely, cancelled, or re-referred.

Verbatim wording from the response
“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.”

Source location
Response from Practice Plus Group
Page 3 · response
Published 1 November 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Place patients receiving local-hospital treatment or urgent or specialised appointments on medical hold until treatment or appointments are completed.

Verbatim wording from the response
“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.”

Source location
Response from Practice Plus Group
Page 3 · response
Published 1 November 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Responsibility for arranging escorts to external appointments lies with the prison, not healthcare.

Verbatim wording from the response
“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 unless for a 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.”

Source location
Response from Practice Plus Group
Page 2 · response
Published 1 November 2023
Open published response
16 Aug2019
East Sussex
Concerns raised2
1. Lack of a system for arranging external hospital visits
2. Lack of resources for attending external hospital appointments
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review postponed hospital appointments clinically, prioritise attendance by need and risk, and automatically rebook cancellations with hospital trusts.
  Stated by NHS EnglandStated completed
2. Action
  Provide resources for three external hospital escorts each weekday.
  Stated by HM Prison and Probation ServiceStated planned
Respondent positions 2
1. Position
  Existing escort staffing, appointment prioritisation and cancellation procedures are considered sufficient to manage external medical appointments.
  Stated by HM Prison and Probation ServiceExisting arrangements considered sufficient
1. Position
  Healthcare providers are responsible for the quality and safety of care provided at HMP Lewes.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Justin Peter Gallagher · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Justin Peter Gallagher was received at HMP Lewes on 20 March 2016 and was later found collapsed in his segregation-block cell on 24 May 2016. He was taken to hospital, where he died on 17 June 2016; the post-mortem recorded hypoxic brain injury, cardiac arrest and laryngeal carcinoma with upper airway obstruction among the causes. Concerns included the absence of his previous medical history, a proper care plan and a single clinician responsible for his care, cancelled hospital appointments, missed opportunities to diagnose his cancer, lack of family involvement, and separate healthcare organisations using unconnected database systems.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a system for arranging external hospital visits
Wider context from the report
“(2) A number of external hospital appointments were cancelled at short notice because of lack of resources (no available escorts etc.) and there was no system available for arranging such visits. ”
Source location
Justin Peter Gallagher · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of resources for attending external hospital appointments
Wider context from the report
“(2) A number of external hospital appointments were cancelled at short notice because of lack of resources (no available escorts etc.) and there was no system available for arranging such visits. ”
Source location
Justin Peter Gallagher · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review postponed hospital appointments clinically, prioritise attendance by need and risk, and automatically rebook cancellations with hospital trusts.

Verbatim wording from the response
“Regional commissioners are aware that there is an ongoing shortage of trained officers at HMP Lewes which can result in a restricted regime resulting in less access to healthcare and attendance at external hospital appointments. There also continues to be issues with the re-booking of appointments and commissioners are working with Sussex Partnership Foundation Trust (SPFT) to resolve this.”

Source location
2019-0491-Response-by-NHS-England
Page 3 · response
Published 16 August 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide resources for three external hospital escorts each weekday.

Verbatim wording from the response
“The Governor of HMP Lewes is committed to providing resources for external escorts to medical appointments. Currently, sufficient escorting staff are made available for three external hospital escorts each weekday, and appointments are prioritised by the healthcare team. In the event that there are inadequate resources because of other operational pressures and it is necessary to consider the cancellation of an external appointment, the Duty Governor contacts the healthcare team for advice on the potential medical impact. If this results in a decision to cancel an escort, the healthcare team cancels and rearranges the appointment. Where possible, emergency escorts are facilitated in addition to scheduled appointments, but where this is not possible healthcare staff are asked to consider the priority with which the scheduled appointments are required and one is proposed to a later date.”

Source location
2019-0491-Response-by-HM-Prison-and-Probation-Service
Page 1 · response
Published 16 August 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing escort staffing, appointment prioritisation and cancellation procedures are considered sufficient to manage external medical appointments.

Verbatim wording from the response
“The Governor of HMP Lewes is committed to providing resources for external escorts to medical appointments. Currently, sufficient escorting staff are made available for three external hospital escorts each weekday, and appointments are prioritised by the healthcare team. In the event that there are inadequate resources because of other operational pressures and it is necessary to consider the cancellation of an external appointment, the Duty Governor contacts the healthcare team for advice on the potential medical impact. If this results in a decision to cancel an escort, the healthcare team cancels and rearranges the appointment. Where possible, emergency escorts are facilitated in addition to scheduled appointments, but where this is not possible healthcare staff are asked to consider the priority with which the scheduled appointments are required and one is proposed to a later date.”

Source location
2019-0491-Response-by-HM-Prison-and-Probation-Service
Page 1 · response
Published 16 August 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Healthcare providers are responsible for the quality and safety of care provided at HMP Lewes.

Verbatim wording from the response
“Providers of healthcare services are responsible for the quality and safety of the care they provide. I expect the healthcare providers at HMP Lewes to look into the care provided to Mr Gallagher and to consider where improvements can be made. This includes how they work with the prison authorities and other relevant organisations, including NHS England which is responsible for commissioning healthcare services for prisoners. Given its role in monitoring, inspecting and regulating the providers of health and social care in prisons, my officials have brought your reports to the attention of the Care Quality Commission (CQC).”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 16 August 2019
Open published response
20 Jun2014
Suffolk
Concerns raised1
1. Failure to identify and rebook outstanding healthcare appointments
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Redmond Johnson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Redmond Johnson, aged 67, suffered a cardio-respiratory arrest while being transferred to Ipswich Crown Court on 25 November 2011 and died after transfer to Ipswich Hospital. The report identified concerns about the assessment of his fitness for transfer, including a record stating that he had no known medical risks despite the healthcare professional not having seen him. It also identified concerns about the management and documentation of his complex healthcare needs in custody, including liaison with community providers, specialist appointments, investigations, medication and care monitoring.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to identify and rebook outstanding healthcare appointments
Wider context from the report
“(2) Reception healthcare should ask about any outstanding hospital or other healthcare appointments and rebook those if necessary. ”
Source location
Redmond Johnson · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to determine the clinical importance and urgency of pre-existing community hospital appointments in light of security issues

Failure to verify prisoners’ pre-existing community hospital appointments

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Lack of a system for arranging external hospital visits

Lack of resources for attending external hospital appointments

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to identify and rebook outstanding healthcare appointments

Actions described in response 2

Respondent positions 1

Actions described in response 2

Respondent positions 2