Mr Thomas Patrick McAuley · Prevention of Future Deaths report

On 29th August 2017, I opened an investigation and on 8th September 2017 an inquest into the death of Mr Thomas Patrick McAuley (02314-17 PF), who was found dead in his prison cell on 23rd August 2017
The medical cause of death given at autopsy was
I a Bronchopneumonia
II Chronic Bronchitis. Alcohol and Drug Dependence

The inquest concluded on 18th September 2018, before a jury, who delivered a narrative conclusion, by answering a questionnaire. The conclusion as to the death was natural causes, contributed to by two failures:

1. There was a failure not to have ensured that the clinical information on the police custody medical form was available to all clinical staff in the prison, which probably contributed to his death.
2. There was a failure not to have conducted clinical observations in the first five days of Methadone treatment, which probably contributed to the death.

The deceased was in police custody from 5th to 7th. The narrative demonstrated that death was probably preventable (“pneumonia can generally be treated successfully”) and the jury highlighted that:

1. “Dr L said that had he known about the report of current pneumonia in the police station, he would have taken a history and made more enquiries. He might examine the chest.... or repeat a chest X-Ray.” (There was evidence that there was a past history of pneumonia and from police that he was seeking medication, possibly for pneumonia, but no diagnosis had been made).

2. “Nurses and doctors all agree that [the Detained Persons Medical Form DPMF] would have been useful to them. It was not available to health care staff on the wings unless its contents had been transcribed onto System One Records.”

3. “This is significant because there were multiple missed opportunities for detection, monitoring and treatment”

1. The reception nurse said that she would have had access to DPMFs but does not always have time to look at these. The DPMF was not available in the wings.
2. A manager of the drug addiction services in the prison said that health care staff were not always given the DPMF.
3. An Oxleas manager said that the case history notes from the prison were uploaded onto PNomis, but a prison doctor did not think he had access to this.
4. A representative of Oxleas HC reported that a new process required a nurse to tick a box when the DPMF was uploaded onto the medical records, but there was no evidence that the DPMF is universally available to health care staff.
5. There was no evidence that police doctors communicated directly with health care staff in prison, or arranged for transfer of medical information between doctors. (The police doctors were not called).
6. In conclusion, there is no assurance that doctors attending in custody, the prison service and those providing health care in prisons have established a fail-safe mechanism of ensuring that medical assessments on vulnerable individuals and records from custody are seen and considered by medical staff in prison.