PFD report

Martin Leslie Haines · Prevention of Future Deaths report

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Issued 16 Aug 2019•East Sussex

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.

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Concerns
7

Raised in this report

Recipients
4

Named on the report

Responses found
3

Of 4 recipients

Stated actions
24

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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

Concerns raised7

  1. Failure to carry out diagnostic testing and monitoring for diabetes
    Part of recurring concern: Unreliable diabetes care and management
  2. Fragmentation of responsibility for prison healthcare across multiple organisations
    Part of recurring concern: Unsafe coordination of shared care
  3. Standard of care falling below community level
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.11

  1. Action

    Review providers’ use of SystmOne tasks in response to concerns about communication and messages going astray.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 16 August 2019.
  2. Action

    Agree and monitor a Service Development Improvement Plan addressing provider performance and embedding required care improvements.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 16 August 2019.
  3. Action

    Procure and award an integrated single-provider healthcare contract for HMP Lewes, using one provider and database to support integrated delivery.

    Stated by NHS EnglandStated 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.7

  1. Position

    Responsibility for addressing prisoners’ ability to brew or distil alcohol lies with the Ministry of Justice, which will respond directly.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 carry out diagnostic testing and monitoring for diabetes

Wider context from the report

“(2) The failure to carry out diagnostic testing and monitoring for his diabetes and to confirm his considerable cardiovascular disease. ”

Is this part of a recurring concern?

Yes — Unreliable diabetes care and management.

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

Fragmentation of responsibility for prison healthcare across multiple organisations

Wider context from the report

“(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. ”

Is this part of a recurring concern?

Yes — Unsafe coordination of shared care.

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

Standard of care falling below community level

Wider context from the report

“(3) The standard of care appears to have fallen well below that which he could have received in the community. ”

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 confirm cardiovascular disease

Wider context from the report

“(2) The failure to carry out diagnostic testing and monitoring for his diabetes and to confirm his considerable cardiovascular disease. ”

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

Availability of means to brew or distil alcohol

Wider context from the report

“(1) The fact that the deceased was able to brew or distil his own alcohol. ”

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 protocols or agreements for responding to an unresponsive body

Wider context from the report

“(4) There were no protocols or agreements between healthcare staff and the prison service as to how best to respond to an unresponsive body. ”

Is this part of a recurring concern?

Yes — Unreliable emergency response to patient collapse.

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

Insufficient communication and information sharing between prison healthcare organisations

Wider context from the report

“(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. ”

Is this part of a recurring concern?

Yes — Unreliable inter-agency information sharing for coordinated care; Unreliable multi-agency communication procedures.

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 providers’ use of SystmOne tasks in response to concerns about communication and messages going astray.

Verbatim wording from the response

“the Prime Provider model, giving them greater control over use of more innovative IT and software solutions. All users of SystmOne can create tasks for other team members and which are linked to patient records where applicable, thus reduces the risk of messages going astray. NHS E Commissioners will review the use of tasks by providers by end of October 2019, as a result of concerns raised in this Regulation 28 notice.”

Source location

Response from NHS England
Page 4 · 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

Agree and monitor a Service Development Improvement Plan addressing provider performance and embedding required care improvements.

Verbatim wording from the response

“A Quality Improvement Plan was implemented following Mr Haines death, actions were agreed and achieved in 2018 but further reviews found they had not all been embedded into practice. As a result, SPFT was served with a Contract Notice in November 2018 relating to poor performance and a further Service Development Improvement Plan (dated 8 June 2019) was agreed with commissioners. Actions from this are in various stages of completion with some having been achieved, and others noted as in progress whilst embedding into practice.”

Source location

Response from NHS England
Page 2 · 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

Procure and award an integrated single-provider healthcare contract for HMP Lewes, using one provider and database to support integrated delivery.

Verbatim wording from the response

“NHS E have undertaken a procurement process for provision of these services after those dates. The services procured is an integrated model of delivery which means that the contract has been awarded to one provider for the delivery of all services to HMP Lewes residents. This is a tried and tested form of service delivery and puts the responsibility for delivery of all elements of the contract with one provider only. This will negate any communication issues and the provider will use one database system only.”

Source location

Response from 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

Review and update HMP Lewes’s local Substance Misuse Strategy to address illicitly brewed alcohol, consequences and support for dependent users.

Verbatim wording from the response

“Each prison has responsibility for reviewing their own local substance misuse strategy, which sets out how they identify residents with drug and alcohol issues and provide them with a range of services to help them to overcome their substance misuse problems and lead healthier, crime-free lives both in prison and in the community.”

Source location

Response from HM Prison and Probation Service
Page 1 · 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

Increase security procedures by checking known brewing locations and carefully selecting and searching kitchen workers with access to alcohol-production ingredients.

Verbatim wording from the response

“At HMP Lewes the local Substance Misuse Strategy was reviewed and updated in June 2019 to include a section on illicitly brewed alcohol. The strategy focuses on restricting availability, ensuring that there are appropriate consequences for those found in possession of alcohol, and offering appropriate support for dependent users. There has been an increase in security procedures to include thorough checks of known brewing locations, as”

Source location

Response from HM Prison and Probation Service
Page 1 · 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

Display control-room reminders and regularly issue staff notices requiring correct use of emergency codes and immediate ambulance calls.

Verbatim wording from the response

“Your fourth concern relates to the lack of a protocol between prison and healthcare staff as to how best to respond to an unresponsive body. In accordance with Prison Service Instruction 03/2013, all prisons are required to have in place a two-code medical emergency response system and, when used correctly, these codes should trigger the control room to call an ambulance and for healthcare staff to attend the scene with the appropriate emergency equipment. You may recall from evidence heard at the inquest that a notice is now displayed in the control room to serve as a visual reminder to staff of the need to call an ambulance immediately upon receiving an emergency code. The prison also issues notices to all staff regularly to remind them of the importance of using the emergency codes correctly.”

Source location

Response from HM Prison and Probation Service
Page 2 · 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

Publish the Prisons Drug Strategy to reduce the availability and use of drugs and alcohol in prisons.

Verbatim wording from the response

“Your first concern is that Mr Haines was able to brew his own alcohol. I share your concern, and would like to assure you that there has been a lot of work at national and local levels to tackle the availability and use of illegal substances in prison. In April 2019 the Prisons Drug Strategy was published. This guidance was developed in partnership between the Ministry of Justice and HMPPS with input from partner agencies in health, law enforcement and social care. The core aim of this strategy and our surrounding activity is to reduce the impact of drugs and alcohol in prisons by restricting supply, reducing demand and building recovery.”

Source location

Response from HM Prison and Probation Service
Page 1 · 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

Review and improve commissioning and links across health, justice, local authority, probation and community services to align provision before, during and after custody.

Verbatim wording from the response

“The Agreement sets out a joined-up, strategic approach to meet the complex nature of offender health care needs and provides the partnership members with an overarching framework for collaborative working at all levels. The Agreement has three shared core objectives to be delivered through ten high level priorities. These priorities are underpinned by the Agreement’s 2018 Workplan, which includes a commitment to deliver on three key issues that relate to the responsibilities of all organisations involved in prison care. These commitments are:”

Source location

2019-0486-Response-by-Department-of-Health-and-Social-Care
Page 2 · 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

Improve health and care data collection and information-sharing before, during and after incarceration to support continuity of care.

Verbatim wording from the response

“The Agreement sets out a joined-up, strategic approach to meet the complex nature of offender health care needs and provides the partnership members with an overarching framework for collaborative working at all levels. The Agreement has three shared core objectives to be delivered through ten high level priorities. These priorities are underpinned by the Agreement’s 2018 Workplan, which includes a commitment to deliver on three key issues that relate to the responsibilities of all organisations involved in prison care. These commitments are:”

Source location

2019-0486-Response-by-Department-of-Health-and-Social-Care
Page 2 · 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

Continue working collaboratively across government to deliver high-quality prison health services and the National Partnership Agreement’s aims.

Verbatim wording from the response

“You may be aware that the Health and Social Care Select Committee conducted an inquiry into prison health that reported in November 2018³. The Government’s response, published in January 2019⁴, outlined a range of actions, including those in the National Partnership Agreement, that will be taken to support the delivery of high-quality health services in prisons. We remain committed to working collaboratively across Government to achieve those aims. For example, in response to one of the recommendations, the National Prison Partnership Board published a Principle of Equivalence in October 2019. This states that the co-chairs of the National Prison Healthcare Board affirm that:”

Source location

2019-0486-Response-by-Department-of-Health-and-Social-Care
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

Revise the prison healthcare partnership agreement to add Department of Health and Social Care and Ministry of Justice oversight and accountability.

Verbatim wording from the response

“At a national level, the National Audit Office report into Mental Health in Prisons¹, published in June 2017, made a recommendation in relation to the way that NHS England, Her Majesty’s Prison and Probation Service and Public Health England manage their joint working on prison healthcare.”

Source location

2019-0486-Response-by-Department-of-Health-and-Social-Care
Page 2 · 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

Responsibility for addressing prisoners’ ability to brew or distil alcohol lies with the Ministry of Justice, which will respond directly.

Verbatim wording from the response

“1) The fact that Mr Haines was able to brew or distil his own alcohol.”

Source location

Response from NHS England
Page 2 · 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

The existing two-code medical emergency response system and staff reminders address responses to unresponsive bodies.

Verbatim wording from the response

“Your fourth concern relates to the lack of a protocol between prison and healthcare staff as to how best to respond to an unresponsive body. In accordance with Prison Service Instruction 03/2013, all prisons are required to have in place a two-code medical emergency response system and, when used correctly, these codes should trigger the control room to call an ambulance and for healthcare staff to attend the scene with the appropriate emergency equipment. You may recall from evidence heard at the inquest that a notice is now displayed in the control room to serve as a visual reminder to staff of the need to call an ambulance immediately upon receiving an emergency code. The prison also issues notices to all staff regularly to remind them of the importance of using the emergency codes correctly.”

Source location

Response from HM Prison and Probation Service
Page 2 · 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

Prison staff cannot access clinical records on SystmOne because such access is not appropriate.

Verbatim wording from the response

“Your final concern is that responsibility for healthcare is split between different contractors, and that there was insufficient communication between these bodies and their separate IT databases. As you know, the commissioning of healthcare in English prisons is the responsibility of NHS England and NHS Improvement (NHSE/I). HMPPS is responsible for ensuring access to healthcare services within establishments and, where required, at external healthcare facilities. With regard to the sharing of information between the various organisations, you will appreciate that it is not appropriate for prison staff to have access to clinical records on SystmOne. At HMP Lewes, there is a daily meeting between prison and healthcare staff at which important information is shared. Each staff team then ensures that their respective databases are updated.”

Source location

Response from HM Prison and Probation Service
Page 2 · 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

NHSE/I is responsible for commissioning healthcare in English prisons, not HMPPS.

Verbatim wording from the response

“Your final concern is that responsibility for healthcare is split between different contractors, and that there was insufficient communication between these bodies and their separate IT databases. As you know, the commissioning of healthcare in English prisons is the responsibility of NHS England and NHS Improvement (NHSE/I). HMPPS is responsible for ensuring access to healthcare services within establishments and, where required, at external healthcare facilities. With regard to the sharing of information between the various organisations, you will appreciate that it is not appropriate for prison staff to have access to clinical records on SystmOne. At HMP Lewes, there is a daily meeting between prison and healthcare staff at which important information is shared. Each staff team then ensures that their respective databases are updated.”

Source location

Response from HM Prison and Probation Service
Page 2 · 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

NHS England is responsible for commissioning healthcare services for prisoners.

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 Haines 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

2019-0486-Response-by-Department-of-Health-and-Social-Care
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, including investigating care and considering improvements.

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 Haines 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

2019-0486-Response-by-Department-of-Health-and-Social-Care
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

The National Prison Healthcare Board is responsible for overseeing and managing the partnership agreement and delivering its shared objectives.

Verbatim wording from the response

“The National Prison Healthcare Board has responsibility for the oversight and on-going management of the Agreement and delivery of the shared objectives.”

Source location

2019-0486-Response-by-Department-of-Health-and-Social-Care
Page 3 · response
Published 16 August 2019

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.13

  1. 1

    Mobilise the integrated Care UK healthcare contract through monthly boards involving incumbent providers, the prison, social care and the new provider.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 16 August 2019.
  2. 2

    Appoint a dedicated Quality Assurance Team comprising senior quality and quality-and-safety managers for Kent, Surrey and Sussex.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
  3. 3

    Implement a more rigorous approach to healthcare contract management, procurement and service mobilisation.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
  4. 4

    Establish a revised governance and reporting structure, including a Quality Board and Serious Incident Panel.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
  5. 5

    Monitor service transition and mobilisation through dedicated meetings and maintain an agreed contingency plan with HMPPS for significant welfare concerns.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 16 August 2019.
  6. 6

    Monitor provider performance, serious incidents, complaints and funding proposals through quarterly contract-management meetings, escalating unresolved risks through partnership and regional boards.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 16 August 2019.
  7. 7

    Appoint a clinical reviewer to attend HMP Lewes weekly and facilitate resolution of healthcare-delivery issues.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
  8. 8

    Work with prison governors to provide officer support for healthcare access, medication supervision, appointment movement and required out-of-hours access.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 16 August 2019.
  9. 9

    Provide contract, partnership and local delivery quality-board oversight when the new healthcare contract starts.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 16 August 2019.
  10. 10

    Review provider serious incidents through the Serious Incident Panel and capture and share associated learning.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
  11. 11

    Educate prisoners about the risks of illicit alcohol and promote health and wellbeing.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 16 August 2019.
  12. 12

    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 by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
  13. 13

    Input into health and justice policy development so prisoners’ health and social care needs and shared objectives are considered.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 16 August 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Healthcare-related concerns fall within healthcare partners’ responsibilities and will receive a separate response.

    Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Mobilise the integrated Care UK healthcare contract through monthly boards involving incumbent providers, the prison, social care and the new provider.

Verbatim wording from the response

“NHS E awarded the contract to Care UK in October 2019 and the services are currently being mobilised for a delivery start date of April 2020. Monthly Mobilisation Boards have been established and include all incumbent providers, the prison, social care and the new provider. These Boards are overseen by NHS E & I Commissioners.”

Source location

Response from 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

Appoint a dedicated Quality Assurance Team comprising senior quality and quality-and-safety managers for Kent, Surrey and Sussex.

Verbatim wording from the response

“• A dedicated Quality Assurance Team comprising a band 8c Senior Quality Lead and an 8b Quality and Safety Manager for Kent, Surrey and Sussex, have been appointed to bring additional oversight and support to the quality of healthcare delivery. A Serious Incident Panel has been established which looks at all serious incidents reported by providers and follows a process by which learning is captured and shared.”

Source location

Response from NHS England
Page 4 · 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

Implement a more rigorous approach to healthcare contract management, procurement and service mobilisation.

Verbatim wording from the response

“Commissioners have implemented a more rigorous approach to contract management, procurement and mobilisation of services, taking learning from HMP Lewes (and other prisons) into account. This is detailed more in response to Concern (5) below.”

Source location

Response from NHS England
Page 2 · 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

Establish a revised governance and reporting structure, including a Quality Board and Serious Incident Panel.

Verbatim wording from the response

“Since Mr Haines’ death, NHS E Health and Justice have made reviewed it’s commissioning contract performance and quality assurance systems. Improvements include:”

Source location

Response from NHS England
Page 4 · 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

Monitor service transition and mobilisation through dedicated meetings and maintain an agreed contingency plan with HMPPS for significant welfare concerns.

Verbatim wording from the response

“The SPFT Board has taken the decision to withdraw from prison healthcare delivery at the end of the current contract in March 2020 following prosecution of the Trust by the CQC. A detailed transition plan has been developed, to ensure the continued delivery of healthcare services during the mobilisation of new contract which will be closely monitored by commissioners via the Transition and Mobilisation Meetings. Performance will continue to be monitored at the Contract Meetings which form part of the usual governance process and have agreed a Contingency Plan with HMPPS should there be any significant issues or concerns for the welfare of men at Lewes.”

Source location

Response from 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

Monitor provider performance, serious incidents, complaints and funding proposals through quarterly contract-management meetings, escalating unresolved risks through partnership and regional boards.

Verbatim wording from the response

“Commissioners monitor performance in a variety of ways including Quarterly Contract Management meetings which are chaired by NHS England Commissioners. Agenda items include provider performance against a set of metrics, serious incident reviews, complaints and business cases for funding for initiatives. All providers attend these meetings any unresolved issues which require partnership working are escalated to the local Partnership Board, which is attended by healthcare providers, NHS England, Prison Governors, HMPPS, Public Health England, Local Authority and CCGs for resolution. Any risks and issues not resolved at local level are escalated to Health Wellbeing and Social Care Regional Care Board.”

Source location

Response from NHS England
Page 4 · 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

Appoint a clinical reviewer to attend HMP Lewes weekly and facilitate resolution of healthcare-delivery issues.

Verbatim wording from the response

“Despite previous clinical reviews, including the one conducted following the death of Mr Gallagher, SPFT have failed to embed the agreed improvements and there continues to be failings in care. An on-going action plan remains in place and will continue to be monitored closely for the remainder of the trust’s contract which ends on 31 March 2020. To support this, and ensure a reduction in any risk to patients, commissioners have appointed a clinical reviewer (previously Director of Nursing in an acute trust) to attend HMP Lewes weekly and act as a facilitator to resolve any issues which affect delivery of services.”

Source location

Response from NHS England
Page 2 · 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

Work with prison governors to provide officer support for healthcare access, medication supervision, appointment movement and required out-of-hours access.

Verbatim wording from the response

“Commissioners have worked more closely with Governors to ensure that they are able to provide officer support (enablement) to increase healthcare access to prisoners including supervision of medications, movement of prisoners to and from appointments and out of hours access where required.”

Source location

Response from 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 contract, partnership and local delivery quality-board oversight when the new healthcare contract starts.

Verbatim wording from the response

“Once the contract starts NHS E governance process will have oversight via Contract Review Meetings, Partnership Boards and Local Delivery Quality Boards.”

Source location

Response from 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

Review provider serious incidents through the Serious Incident Panel and capture and share associated learning.

Verbatim wording from the response

“• A dedicated Quality Assurance Team comprising a band 8c Senior Quality Lead and an 8b Quality and Safety Manager for Kent, Surrey and Sussex, have been appointed to bring additional oversight and support to the quality of healthcare delivery. A Serious Incident Panel has been established which looks at all serious incidents reported by providers and follows a process by which learning is captured and shared.”

Source location

Response from NHS England
Page 4 · 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

Educate prisoners about the risks of illicit alcohol and promote health and wellbeing.

Verbatim wording from the response

“Intelligence and information sharing is crucial to restricting availability, and the Governor of HMP Lewes can draw on the regional Dedicated Search Team when there is intelligence to suggest that prisoners are brewing their own alcohol. The consequences for those found in possession of fermenting liquid should be a deterrent, and can include additional days being added to sentences. Any prisoner suspected of alcohol use is referred to the Forward Trust for substance misuse support. The prison is also focusing on educating prisoners of the risks associated with the use of illicit alcohol, and continue to encourage and promote health and wellbeing.”

Source location

Response from HM Prison and Probation Service
Page 2 · 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

Publish the National Partnership Agreement for Prison Healthcare in England 2018–21 as a framework for collaborative delivery of safe and effective prison healthcare.

Verbatim wording from the response

“The National Partnership Agreement for Prison Healthcare in England 2018-21², published in April 2018, acknowledges the need for health and justice partners to work together to ensure “safe, legal, decent and effective care that improves health outcomes for prisoners, reduces health inequalities (particularly for those with protected characteristics), protects the public and reduces reoffending”.”

Source location

2019-0486-Response-by-Department-of-Health-and-Social-Care
Page 2 · 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

Input into health and justice policy development so prisoners’ health and social care needs and shared objectives are considered.

Verbatim wording from the response

“The Agreement sets out a joined-up, strategic approach to meet the complex nature of offender health care needs and provides the partnership members with an overarching framework for collaborative working at all levels. The Agreement has three shared core objectives to be delivered through ten high level priorities. These priorities are underpinned by the Agreement’s 2018 Workplan, which includes a commitment to deliver on three key issues that relate to the responsibilities of all organisations involved in prison care. These commitments are:”

Source location

2019-0486-Response-by-Department-of-Health-and-Social-Care
Page 2 · 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-related concerns fall within healthcare partners’ responsibilities and will receive a separate response.

Verbatim wording from the response

“You have expressed several concerns, some of which relate to the responsibilities of healthcare partners, from whom you will receive a separate response. I will respond to matters (1), (4) and (5) which relate to the responsibilities of HMPPS.”

Source location

Response from HM Prison and Probation Service
Page 1 · response
Published 16 August 2019

Open published response
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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