This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.
On 21st March 2018 I commenced an investigation into the death of Martin Leslie Haines, aged 60, who died at Lewes Prison on 18th March 2018. The investigation concluded at the end of the inquest on 6th April 2019. The conclusion of the inquest found by the jury was a narrative conclusion: Cardiac arrest in the presence of Venlafaxine, Amitriptyline and alcohol.
Circumstances of the death
The deceased was detained in Lewes Prison and was seen on numerous occasions by primary healthcare staff for, amongst other conditions, a wound on his toe which caused a lot of pain and discomfort. He was diagnosed with Type II Diabetes but there were warning signs which could have led to a diagnosis of cerebrovascular disease and the appropriate diagnostic tests were not carried out. On 18th March 2018 he was found dead in his cell. There was confusion and delay in responding to the discovery of his body, but in fact rigor mortis had set in so this did not contribute to the causation of his death. The subsequent post-mortem examination led to the discovery of alcohol, Venlafaxine and Amitriptyline in his system and the pathologist considered these had contributed to his death.
Coroner’s concerns
(1) The fact that the deceased was able to brew or distil his own alcohol.
(2) The failure to carry out diagnostic testing and monitoring for his diabetes and to confirm his considerable cardiovascular disease.
(3) The standard of care appears to have fallen well below that which he could have received in the community.
(4) There were no protocols or agreements between healthcare staff and the prison service as to how best to respond to an unresponsive body.
(5) In my opinion, the underlying problems were due to the fact that responsibility for healthcare in the prison was split between the prison service, Sussex Partnership Foundation Trust (which is a mental health provider but was also contracted to run all healthcare, both physical and mental within the prison), Medco Ltd who provided the GPs and Forward Trust who were contracted to treat alcohol and substance misuse in the prison. There was insufficient communication between these bodies and they had separate IT databases.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised7
Failure to carry out diagnostic testing and monitoring for diabetes
Each statement is shown once, whether or not it is linked to an individual 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.24
Action
Mobilise the integrated Care UK healthcare contract through monthly boards involving incumbent providers, the prison, social care and the new provider.
Stated byNHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 16 August 2019.
Action
Appoint a dedicated Quality Assurance Team comprising senior quality and quality-and-safety managers for Kent, Surrey and Sussex.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
Action
Review providers’ use of SystmOne tasks in response to concerns about communication and messages going astray.
Stated byNHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 16 August 2019.
Action
Implement a more rigorous approach to healthcare contract management, procurement and service mobilisation.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
Action
Agree and monitor a Service Development Improvement Plan addressing provider performance and embedding required care improvements.
Stated byNHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 16 August 2019.
Action
Establish a revised governance and reporting structure, including a Quality Board and Serious Incident Panel.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
Action
Monitor service transition and mobilisation through dedicated meetings and maintain an agreed contingency plan with HMPPS for significant welfare concerns.
Stated byNHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 16 August 2019.
Action
Monitor provider performance, serious incidents, complaints and funding proposals through quarterly contract-management meetings, escalating unresolved risks through partnership and regional boards.
Stated byNHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 16 August 2019.
Action
Appoint a clinical reviewer to attend HMP Lewes weekly and facilitate resolution of healthcare-delivery issues.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
Action
Work with prison governors to provide officer support for healthcare access, medication supervision, appointment movement and required out-of-hours access.
Stated byNHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 16 August 2019.
Action
Provide contract, partnership and local delivery quality-board oversight when the new healthcare contract starts.
Stated byNHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 16 August 2019.
Action
Review provider serious incidents through the Serious Incident Panel and capture and share associated learning.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
Action
Procure and award an integrated single-provider healthcare contract for HMP Lewes, using one provider and database to support integrated delivery.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
Action
Educate prisoners about the risks of illicit alcohol and promote health and wellbeing.
Stated byHM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 16 August 2019.
Action
Review and update HMP Lewes’s local Substance Misuse Strategy to address illicitly brewed alcohol, consequences and support for dependent users.
Stated byHM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
Action
Increase security procedures by checking known brewing locations and carefully selecting and searching kitchen workers with access to alcohol-production ingredients.
Stated byHM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
Action
Display control-room reminders and regularly issue staff notices requiring correct use of emergency codes and immediate ambulance calls.
Stated byHM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
Action
Publish the Prisons Drug Strategy to reduce the availability and use of drugs and alcohol in prisons.
Stated byHM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
Action
Review and improve commissioning and links across health, justice, local authority, probation and community services to align provision before, during and after custody.
Stated byDepartment of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 16 August 2019.
Action
Improve health and care data collection and information-sharing before, during and after incarceration to support continuity of care.
Stated byDepartment of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 16 August 2019.
Action
Publish the National Partnership Agreement for Prison Healthcare in England 2018–21 as a framework for collaborative delivery of safe and effective prison healthcare.
Stated byDepartment of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
Action
Continue working collaboratively across government to deliver high-quality prison health services and the National Partnership Agreement’s aims.
Stated byDepartment of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 16 August 2019.
Action
Input into health and justice policy development so prisoners’ health and social care needs and shared objectives are considered.
Stated byDepartment of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 16 August 2019.
Action
Revise the prison healthcare partnership agreement to add Department of Health and Social Care and Ministry of Justice oversight and accountability.
Stated byDepartment of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.8
Position
Responsibility for addressing prisoners’ ability to brew or distil alcohol lies with the Ministry of Justice, which will respond directly.
Stated byNHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The existing two-code medical emergency response system and staff reminders address responses to unresponsive bodies.
Stated byHM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Prison staff cannot access clinical records on SystmOne because such access is not appropriate.
Stated byHM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Healthcare-related concerns fall within healthcare partners’ responsibilities and will receive a separate response.
Stated byHM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHSE/I is responsible for commissioning healthcare in English prisons, not HMPPS.
Stated byHM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS England is responsible for commissioning healthcare services for prisoners.
Stated byDepartment of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Healthcare providers are responsible for the quality and safety of care, including investigating care and considering improvements.
Stated byDepartment of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The National Prison Healthcare Board is responsible for overseeing and managing the partnership agreement and delivering its shared objectives.
Stated byDepartment of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Information checked against the published report and official responses