PFD report

James Paul COLTON · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 20 Mar 2015•Worcestershire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
7

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
13

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised7

  1. Failure to provide prescribed analgesia when required
    Part of recurring concern: Failure to provide required medication promptly when clinically needed
  2. Inadequate communication between healthcare nurses and doctors
    Part of recurring concern: Unreliable communication of patient-care information between clinical staff
  3. Failure to appropriately review care and treatment
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.8

  1. Action

    Assign named nurses to inpatient patients and two nurses to each normal-location wing to improve continuity of care.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2015.
  2. Action

    Hold staff study sessions to discuss case learning and encourage curiosity in clinical situations.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2015.
  3. Action

    Provide weekly opportunities for prison sessional GPs to discuss cases and share good practice.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2015.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide prescribed analgesia when required

Wider context from the report

“(2) The procedure and processes for providing Mr Colton with adequate analgesia were defective and there were occasions when Mr Colton did not receive Tramadol to control his pain. This meant that his last days in prison were distressing and increasingly painful for him to the extent that he was at times unable to get off his bed to receive medication. ”

Is this part of a recurring concern?

Yes — Failure to provide required medication promptly when clinically needed.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate communication between healthcare nurses and doctors

Wider context from the report

“(3) There appeared to be no continuity of care for Mr Colton, little or no adequate communication as between Healthcare nurses and doctors, and no coherent plan for his care. There appeared to be no appropriate review of Mr Colton's care or treatment. ”

Is this part of a recurring concern?

Yes — Unreliable communication of patient-care information between clinical staff.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to appropriately review care and treatment

Wider context from the report

“(3) There appeared to be no continuity of care for Mr Colton, little or no adequate communication as between Healthcare nurses and doctors, and no coherent plan for his care. There appeared to be no appropriate review of Mr Colton's care or treatment. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to reassess diagnoses and escalate treatment despite continuing clinical decline

Wider context from the report

“(1) The doctors and nurses at the prison failed to properly diagnose, treat and care for Mr Colton in that they assumed that the diagnosis of mechanical back pain was accurate and took no steps to revisit the diagnosis or to escalate his treatment despite his obvious continuing decline. The failure to consider alternate diagnosis led to him missing his developing cancer and which may, therefore, have contributed to his early death. ”

Is this part of a recurring concern?

Yes — Failure to consider or reconsider serious alternative diagnoses; Failure to reassess treatment options when clinically indicated; Failure to reliably recognise and respond to acute clinical deterioration; Inadequate medical assessment and escalation for unwell prisoners.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate healthcare workload capacity for required clinical work and reviews

Wider context from the report

“(4) The evidence given was that there was an extremely heavy workload which meant (to quote one of the GP's who gave evidence) that he was unable to get on top of the work that was required of him and that reviewing prisoners in Healthcare was not a priority. ”

Is this part of a recurring concern?

Yes — Insufficient clinical workload capacity for completing important patient-care tasks.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain a coherent care plan

Wider context from the report

“(3) There appeared to be no continuity of care for Mr Colton, little or no adequate communication as between Healthcare nurses and doctors, and no coherent plan for his care. There appeared to be no appropriate review of Mr Colton's care or treatment. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of continuity of care

Wider context from the report

“(3) There appeared to be no continuity of care for Mr Colton, little or no adequate communication as between Healthcare nurses and doctors, and no coherent plan for his care. There appeared to be no appropriate review of Mr Colton's care or treatment. ”

Is this part of a recurring concern?

Yes — Failure to provide continuity of patient care.

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

Assign named nurses to inpatient patients and two nurses to each normal-location wing to improve continuity of care.

Verbatim wording from the response

“I recognise that in Mr Colton’s case there was a lack of continuity of care and I am able to notify you that every patient who is on the inpatient facility has a named nurse and this is identified on each cell door so that the discipline officers are also aware of the identity of the named nurse. For those individuals who are on normal location, there are two nurses assigned to each wing so that there is a greater continuity of care for all prisoners. There are also now regular nursing meetings to discuss individual patients that take place both in respect of physical and mental health patients.”

Source location

2015-0021-Response-by-Worcestershire-Health-Care-NHS
Page 2 · response
Published 21 January 2015

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

Hold staff study sessions to discuss case learning and encourage curiosity in clinical situations.

Verbatim wording from the response

“Importantly, a couple of study sessions were held in which staff were taken through the case notes of Mr Colton and had an opportunity to discuss learning identified and how they may act in future situations. Whilst there are a number of learning objectives for the day, principally, staff were asked to be open and to be curious in clinical situations. I understand from my Deputy Head of Healthcare at HMP Long Lartin that staff still talk about the learning generated from this case and in the last week there has been an example of staff raising an issue and being encouraged to consider alternative options.”

Source location

2015-0021-Response-by-Worcestershire-Health-Care-NHS
Page 1 · response
Published 21 January 2015

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 weekly opportunities for prison sessional GPs to discuss cases and share good practice.

Verbatim wording from the response

“At HMP Long Lartin, the GPs who provide sessional cover do have a weekly opportunity when they are both in the prison at the same time to discuss individual cases and share good practice. I consider that this is a positive move as well as formalising the new process for the obtaining of clinical supervision, which I anticipate will be through the South Worcestershire Federation. I consider that this provides adequate support for any individual clinician. Overall, I do consider that it is entirely appropriate for a clinical director from a different specialism (psychiatry) to manage other doctors from other specialties. If this was not appropriate we would inevitably have a position where we had to have lead clinicians for every type of professional within the organisation and I think that this would neither be desirable nor an appropriate use of scarce public funds.”

Source location

2015-0021-Response-by-Worcestershire-Health-Care-NHS
Page 3 · response
Published 21 January 2015

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

Discuss introducing further care-planning training and adapting SystmOne to support improved practice.

Verbatim wording from the response

“I understand that you have been made aware as part of the action plan of an audit that took place in respect of care planning in January 2014 which showed an improvement in previous performance. However, I am not complacent about the need to ensure effective care planning and would confirm that the Trust has now appointed a quality and safety lead for offender healthcare as well as a new lead for SystmOne, our prison patient record, both of whom will work across the three prisons that this Trust provides healthcare in respect of and ensure best practice in areas such as care planning audits, improving our functionality and training on the patient records system. Discussions are taking place in the Trust as to introducing some further training on care planning and how SystmOne may be adapted to support improved practice in this area.”

Source location

2015-0021-Response-by-Worcestershire-Health-Care-NHS
Page 2 · response
Published 21 January 2015

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

Conduct a new inpatient-prisoner standard operating process with reviews of previous entries, tests, and patient care.

Verbatim wording from the response

“As part of our continuing efforts to provide safe, high quality care in all of our services, I was keen to share with you some recent initiatives. A new standard operating system for inpatient prisoners is being conducted, at which time a review of previous entries is conducted. This is an additional review aimed at ensuring that no significant issues or tests are missed, as well as reviewing patient care. Further, the Deputy Head of Healthcare has identified an opportunity to accompany the Prison’s Disability Liaison Officer when undertaking her activities, to raise awareness of the healthcare function, especially for hard to reach groups, as well as identifying any issues being raised about the healthcare provision.”

Source location

2015-0021-Response-by-Worcestershire-Health-Care-NHS
Page 2 · response
Published 21 January 2015

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

Appoint quality and safety and SystmOne leads to support care-planning audits, record-system functionality, and staff training across three prisons.

Verbatim wording from the response

“I understand that you have been made aware as part of the action plan of an audit that took place in respect of care planning in January 2014 which showed an improvement in previous performance. However, I am not complacent about the need to ensure effective care planning and would confirm that the Trust has now appointed a quality and safety lead for offender healthcare as well as a new lead for SystmOne, our prison patient record, both of whom will work across the three prisons that this Trust provides healthcare in respect of and ensure best practice in areas such as care planning audits, improving our functionality and training on the patient records system. Discussions are taking place in the Trust as to introducing some further training on care planning and how SystmOne may be adapted to support improved practice in this area.”

Source location

2015-0021-Response-by-Worcestershire-Health-Care-NHS
Page 2 · response
Published 21 January 2015

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

Assess offender-healthcare nursing numbers against workload and headcount.

Verbatim wording from the response

“In respect of the workload of clinicians at the prisons, there is no national guidance as to staffing levels within prison environments. You may be aware that for other inpatient areas there is a NICE accredited tool entitled Safer Nurse Care Tool (SNCT) which provides a framework for assessing the number of qualified and unqualified staff on a particular ward. As a result of having no national guidance for identifying the establishment, the Trust is undertaking an assessment of nursing numbers in offender healthcare based upon the range of task undertaken and the headcount. The Trust is also having discussions about the assessment of our other medical inputs involving our commissioners.”

Source location

2015-0021-Response-by-Worcestershire-Health-Care-NHS
Page 2 · response
Published 21 January 2015

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

Minute daily multidisciplinary lunchtime meetings, allocate actions, and record them in patient records.

Verbatim wording from the response

“Additionally, the daily lunchtime meeting at HMP Long Lartin is now properly minuted with actions being allocated and recorded in patient records. This meeting is attended by a range of staff and encourages greater discussion about the care of particular individuals. As a result of some of the issues raised in Mr Colton’s case, there have been changes to practices such as nurses undertaking pain scores. I am aware that individual nursing staff are more frequently recording pain scores in order to allow a judgment to be made as to whether a problem is persisting or becoming increasingly painful or resolving itself.”

Source location

2015-0021-Response-by-Worcestershire-Health-Care-NHS
Page 1 · response
Published 21 January 2015

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. 1

    Establish dedicated prison GPs following concluded agreement, pending staff security clearances.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 January 2015.
  2. 2

    Record patient pain scores more frequently to identify whether problems persist, worsen, or resolve.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2015.
  3. 3

    Hold regular nursing meetings to discuss individual physical and mental health patients.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2015.
  4. 4

    Discuss assessing other medical inputs with healthcare commissioners.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 January 2015.
  5. 5

    Formalise clinical supervision for prison GPs through the South Worcestershire Federation.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 January 2015.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.3

  1. 1

    Management supervision need not be provided by a professional of the same discipline or specialism as the supervised clinician.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    Weekly case discussions and planned clinical supervision provide adequate support for individual prison clinicians.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  3. 3

    Appointing lead clinicians for every professional type is considered an undesirable and inappropriate use of scarce public funds.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Establish dedicated prison GPs following concluded agreement, pending staff security clearances.

Verbatim wording from the response

“The Trust has been involved in discussions for some time with the South Worcestershire Federation to seek agreement for having dedicated GPs in place in the prison and I am pleased to report that this agreement has been concluded and we are now just awaiting the security clearances for the staff to be physically working at HMP Long Lartin. Discussions are underway with the senior GP from the Federation to arrange for clinical supervision for the general practitioners at the prison to be provided through this mechanism. However, I do need to also raise the issue as to whether it is appropriate for a consultant psychiatrist to be the responsible individual to monitor the standard of work for GPs at the health centre. The Trust has a management structure in which there are clinical directors for a number of different areas of specialism including a clinical director for offender healthcare.”

Source location

2015-0021-Response-by-Worcestershire-Health-Care-NHS
Page 2 · response
Published 21 January 2015

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

Record patient pain scores more frequently to identify whether problems persist, worsen, or resolve.

Verbatim wording from the response

“Additionally, the daily lunchtime meeting at HMP Long Lartin is now properly minuted with actions being allocated and recorded in patient records. This meeting is attended by a range of staff and encourages greater discussion about the care of particular individuals. As a result of some of the issues raised in Mr Colton’s case, there have been changes to practices such as nurses undertaking pain scores. I am aware that individual nursing staff are more frequently recording pain scores in order to allow a judgment to be made as to whether a problem is persisting or becoming increasingly painful or resolving itself.”

Source location

2015-0021-Response-by-Worcestershire-Health-Care-NHS
Page 1 · response
Published 21 January 2015

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

Hold regular nursing meetings to discuss individual physical and mental health patients.

Verbatim wording from the response

“I recognise that in Mr Colton’s case there was a lack of continuity of care and I am able to notify you that every patient who is on the inpatient facility has a named nurse and this is identified on each cell door so that the discipline officers are also aware of the identity of the named nurse. For those individuals who are on normal location, there are two nurses assigned to each wing so that there is a greater continuity of care for all prisoners. There are also now regular nursing meetings to discuss individual patients that take place both in respect of physical and mental health patients.”

Source location

2015-0021-Response-by-Worcestershire-Health-Care-NHS
Page 2 · response
Published 21 January 2015

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

Discuss assessing other medical inputs with healthcare commissioners.

Verbatim wording from the response

“In respect of the workload of clinicians at the prisons, there is no national guidance as to staffing levels within prison environments. You may be aware that for other inpatient areas there is a NICE accredited tool entitled Safer Nurse Care Tool (SNCT) which provides a framework for assessing the number of qualified and unqualified staff on a particular ward. As a result of having no national guidance for identifying the establishment, the Trust is undertaking an assessment of nursing numbers in offender healthcare based upon the range of task undertaken and the headcount. The Trust is also having discussions about the assessment of our other medical inputs involving our commissioners.”

Source location

2015-0021-Response-by-Worcestershire-Health-Care-NHS
Page 2 · response
Published 21 January 2015

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

Formalise clinical supervision for prison GPs through the South Worcestershire Federation.

Verbatim wording from the response

“The Trust has been involved in discussions for some time with the South Worcestershire Federation to seek agreement for having dedicated GPs in place in the prison and I am pleased to report that this agreement has been concluded and we are now just awaiting the security clearances for the staff to be physically working at HMP Long Lartin. Discussions are underway with the senior GP from the Federation to arrange for clinical supervision for the general practitioners at the prison to be provided through this mechanism. However, I do need to also raise the issue as to whether it is appropriate for a consultant psychiatrist to be the responsible individual to monitor the standard of work for GPs at the health centre. The Trust has a management structure in which there are clinical directors for a number of different areas of specialism including a clinical director for offender healthcare.”

Source location

2015-0021-Response-by-Worcestershire-Health-Care-NHS
Page 2 · response
Published 21 January 2015

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

Management supervision need not be provided by a professional of the same discipline or specialism as the supervised clinician.

Verbatim wording from the response

“The role of the clinical director is to provide assurance and clinical leadership for the care delivered within the service delivery unit. Whilst I note there may be concerns about appropriate clinical supervision of an individual clinician, I do not agree that it is not appropriate for management supervision to be provided by either a different professional or a professional of the same nature but of a different specialism. Whilst I agree that clinical supervision should be provided by somebody appropriate skills and experience I do not think it is necessary for there to be management supervision similarly so provided.”

Source location

2015-0021-Response-by-Worcestershire-Health-Care-NHS
Page 2 · response
Published 21 January 2015

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

Weekly case discussions and planned clinical supervision provide adequate support for individual prison clinicians.

Verbatim wording from the response

“At HMP Long Lartin, the GPs who provide sessional cover do have a weekly opportunity when they are both in the prison at the same time to discuss individual cases and share good practice. I consider that this is a positive move as well as formalising the new process for the obtaining of clinical supervision, which I anticipate will be through the South Worcestershire Federation. I consider that this provides adequate support for any individual clinician. Overall, I do consider that it is entirely appropriate for a clinical director from a different specialism (psychiatry) to manage other doctors from other specialties. If this was not appropriate we would inevitably have a position where we had to have lead clinicians for every type of professional within the organisation and I think that this would neither be desirable nor an appropriate use of scarce public funds.”

Source location

2015-0021-Response-by-Worcestershire-Health-Care-NHS
Page 3 · response
Published 21 January 2015

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

Appointing lead clinicians for every professional type is considered an undesirable and inappropriate use of scarce public funds.

Verbatim wording from the response

“At HMP Long Lartin, the GPs who provide sessional cover do have a weekly opportunity when they are both in the prison at the same time to discuss individual cases and share good practice. I consider that this is a positive move as well as formalising the new process for the obtaining of clinical supervision, which I anticipate will be through the South Worcestershire Federation. I consider that this provides adequate support for any individual clinician. Overall, I do consider that it is entirely appropriate for a clinical director from a different specialism (psychiatry) to manage other doctors from other specialties. If this was not appropriate we would inevitably have a position where we had to have lead clinicians for every type of professional within the organisation and I think that this would neither be desirable nor an appropriate use of scarce public funds.”

Source location

2015-0021-Response-by-Worcestershire-Health-Care-NHS
Page 3 · response
Published 21 January 2015

Open published response
Back to top

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026