Michalla Jane SWEETING · Prevention of Future Deaths report

On 13/07/2016 I commenced an investigation into the death of Michalla Jane SWEETING. The investigation concluded at the end of the inquest.

The medical cause of death was:

1a) Aspiration of gastric content in association with methadone toxicity

The conclusion of the jury inquest was a narrative which read as follows:

“Michalla’s death was contributed to by inadequate carrying out and response to prison officer ACCT checks, unsatisfactory handover quality between shifts, inappropriate process of assessment at the medicine dispense hatch and inadequate communication between healthcare and prison staff.
These were neglect due to a combination of the following gross failures:
• Nurse to act on handover by HCA as noted on system on 1st June 2016 at 14.50 by physically assessing Michalla and making a plan and by still administering Methadone at 17.56
• Nurse failed to check and update Michalla’s records and contact a doctor and formulate a care plan after witnessing Michalla being sick at 22.14 1st June 2016
• Nurse performed woefully inadequate clinical observations from 1st June 2016 at 22.14 onwards, including 2nd June 2016 at 03.21”

Deceased was a remand prisoner. She was undergoing a detoxification programme and was on an ACCT. There were concerns raised by a number of people including a healthcare assistant that she was over sedated and this was reported to 2 nurses, Michalla was not physically assessed and she was still given her Methadone after this concern was raised.

It appears unlikely that Michalla’s over sedated appearance was handed over from the day to the night clinical staff.

Later that day she was seen by Nurse Mark Smith who saw Michalla unwell in her cell, he did not check her records which included a reference to her being over sedated that day; he did not put his entry in the records until after Michalla’s death; he did not carry out observations or make a plan and the one observation he did carry out at 03.21hrs on 2nd June 2016 was described as woefully inadequate by the expert.

Sadly Michalla was found unresponsive in her cell at 07.00hrs on 2nd June 2016.

Her cause of death is described above

For Bristol Community Health:

1. Handover:

a. That the handover includes all prisoners/patients undergoing detoxification.
b. That the handover is the responsibility of the registered nurse
c. That it includes a review of the records for the shift by that registered nurse – this was raised by ████████ and was reflected in the jury conclusion. I therefore report this to you for your consideration in preventing future deaths

2. Observations to prisoners/patients undergoing detoxification: they are taken at a time which is close to the time of dispensing medications so that the staff administering the medication have that information. Again this was raised by ████████ as being the best time to review the observations and was indeed reflected in the jury conclusion.