PFD report

Mr Jonathan Michael McCarthy · Prevention of Future Deaths report

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Issued 12 Oct 2023•Northamptonshire

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
4

Raised in this report

Recipients
4

Named on the report

Responses found
1

Of 4 recipients

Stated actions
9

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 raised4

  1. Failure to determine the clinical importance and urgency of pre-existing community hospital appointments in light of security issues
    Part of recurring concern: Unreliable management of prisoners’ outstanding hospital appointments
  2. Failure to verify prisoners’ pre-existing community hospital appointments
    Part of recurring concern: Unreliable management of prisoners’ outstanding hospital appointments
  3. Failure to determine medical hold
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.4

  1. Action

    Clinically triage patients arriving with external appointments and assign urgency categories to determine whether appointments are kept, delivered remotely, cancelled, or re-referred.

    Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 1 November 2023.
  2. Action

    Place patients receiving local-hospital treatment or urgent or specialised appointments on medical hold until treatment or appointments are completed.

    Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 1 November 2023.
  3. Action

    Review medical holds regularly and communicate them directly to the prison.

    Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 1 November 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Responsibility for arranging escorts to external appointments lies with the prison, not healthcare.

    Stated by Practice Plus GroupRedirects 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 determine the clinical importance and urgency of pre-existing community hospital appointments in light of security issues

Wider context from the report

“Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment. Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018. It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern. There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside. 1. verifying a prisoner’s pre-existing community hospital appointments. 2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment. 3. assessing fitness to transfer and determining medical hold. ”

Is this part of a recurring concern?

Yes — Unreliable management of prisoners’ outstanding hospital appointments.

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 verify prisoners’ pre-existing community hospital appointments

Wider context from the report

“Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment. Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018. It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern. There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside. 1. verifying a prisoner’s pre-existing community hospital appointments. 2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment. 3. assessing fitness to transfer and determining medical hold. ”

Is this part of a recurring concern?

Yes — Unreliable management of prisoners’ outstanding hospital appointments.

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 determine medical hold

Wider context from the report

“Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment. Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018. It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern. There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside. 1. verifying a prisoner’s pre-existing community hospital appointments. 2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment. 3. assessing fitness to transfer and determining medical hold. ”

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 assess fitness to transfer

Wider context from the report

“Upon Mr McCarthy’s arrival at HMP Altcourse on 5 June 2017, it is recorded that he had an outstanding hospital appointment. There was no evidence that HMP Altcourse took any steps to verify this appointment. Mr McCarthy was transferred to HMP Thameside on 7 May 2018. It is recorded that he had an appointment to see the cardiologist at Whittington Hospital on 13 June 2018. There was no evidence that HMP Thameside took any steps to verify this appointment. He was transferred from the prison on the next day, 14th June 2018. It was suggested in evidence that HMP Thameside automatically re-arrange all community medical appointments for security reasons. It was clarified that the prison would only try to get a new appointment if there was a specific security concern. There was also no evidence that Mr McCarthy had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside. 1. verifying a prisoner’s pre-existing community hospital appointments. 2. determining the clinical importance/urgency of pre-existing community hospital appointments and the impact of security issues upon this assessment. 3. assessing fitness to transfer and determining medical hold. ”

Is this part of a recurring concern?

Yes — Failure to ensure safe prisoner transfers.

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

Clinically triage patients arriving with external appointments and assign urgency categories to determine whether appointments are kept, delivered remotely, cancelled, or re-referred.

Verbatim wording from the response

“As part of the LOP noted above, HMP Thameside have put in place a process in which all patients who arrive with external appointments are highlighted to the GP/ANP or senior nurse to clinically triage. When considering the urgency of the appointment, multiple factors are taken into consideration. This includes what the appointment is for, whether it can be delivered on site, and if it needs transferring to a local hospital. Once a priority category has been has been allocated, admin are informed whether the appointment needs to be kept, can be moved to remote or can be cancelled and re-referred. The priority categories are urgent, routine and non-urgent or follow up.”

Source location

Response from Practice Plus Group
Page 3 · response
Published 1 November 2023

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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

Place patients receiving local-hospital treatment or urgent or specialised appointments on medical hold until treatment or appointments are completed.

Verbatim wording from the response

“Those undergoing treatment at a local hospital would be placed on “Medical Hold” in order for the treatment to be completed. If a patient has to be transferred, a Transfer of Care letter is sent with them to their new establishment which includes all appointments and reasons for them. This process is documented in the Transfer of Care LOP, which all staff have been made aware of. Our transfer process is detailed further below.”

Source location

Response from Practice Plus Group
Page 3 · response
Published 1 November 2023

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 medical holds regularly and communicate them directly to the prison.

Verbatim wording from the response

“Medical Holds are communicated directly with the prison and reviewed on a regular basis by healthcare.”

Source location

Response from Practice Plus Group
Page 4 · response
Published 1 November 2023

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

Undertake and record a fitness-to-transfer assessment for every patient before transfer to an establishment or court.

Verbatim wording from the response

“All patients will have a fitness to transfer assessment undertaken prior to transfer to any establishment or court, this is recorded on SystmOne and forms part of the transfer process. Healthcare are generally notified 24 hours prior to release or transfer of a patient. This can vary depending on external factors such as Court listings and timings.”

Source location

Response from Practice Plus Group
Page 3 · response
Published 1 November 2023

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 arranging escorts to external appointments lies with the prison, not healthcare.

Verbatim wording from the response

“If the patient has transferred in from another prison establishment then they would not be aware of the date of any external appointments. As noted at the Inquest, this is for security reasons. In such circumstances it is much easier for the appointment to be kept and it would not be cancelled unless for a security reason. Contact would still be made with the external provider to ensure that the appointment is still scheduled and then the prison would be informed accordingly so that escorts can be arranged. Escorts to external appointments fall to the prison and is not the responsibility of healthcare.”

Source location

Response from Practice Plus Group
Page 2 · response
Published 1 November 2023

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

    Use a new transfer process that sends receiving prisons a transfer document containing future external appointments and relevant patient information.

    Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 1 November 2023.
  2. 2

    Share lessons learned from the inquest across all Practice Plus Group services.

    Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 1 November 2023.
  3. 3

    Share lessons from the inquest with Heads of Healthcare at HMP Altcourse and HMP Onley.

    Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 1 November 2023.
  4. 4

    Log and track re-booked referrals through the NHS Electronic Referral System.

    Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 1 November 2023.
  5. 5

    Operate a Transfer of Care LOP covering incoming and outgoing patient transfers and external appointments.

    Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 1 November 2023.

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

Use a new transfer process that sends receiving prisons a transfer document containing future external appointments and relevant patient information.

Verbatim wording from the response

“All patients transferred from HMP Thameside will have a transfer document sent with them to the receiving prison, which will include future external appointments. This has been launched as part of the new transfer process implemented by PPG in November 2023. This new process has been implemented to ensure that the transfer of patients is safe and that all relevant information is easily accessible to the new establishment. The transfer assessment is undertaken face to face and the document is partially completed prior to the consultation using the information from SystmOne. As noted above and during the inquest, “Medical Hold” will be utilised to ensure that those patients booked for urgent or specialised treatments/appointments are not transferred until such time as the treatment or appointment has taken place.”

Source location

Response from Practice Plus Group
Page 3 · response
Published 1 November 2023

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

Share lessons learned from the inquest across all Practice Plus Group services.

Verbatim wording from the response

“Practice Plus Group is committed to ensuring the high quality provision of healthcare services to all prisoners at HMP Thameside. We will also ensure that the lessons learnt as a result of this inquest are shared across all of Practice Plus Group’s services. We can confirm that this has specifically been shared with the Heads of Healthcare at both HMP Altcourse and HMP Onley to ensure that similar processes and lessons can be learned.”

Source location

Response from Practice Plus Group
Page 4 · response
Published 1 November 2023

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

Share lessons from the inquest with Heads of Healthcare at HMP Altcourse and HMP Onley.

Verbatim wording from the response

“Practice Plus Group is committed to ensuring the high quality provision of healthcare services to all prisoners at HMP Thameside. We will also ensure that the lessons learnt as a result of this inquest are shared across all of Practice Plus Group’s services. We can confirm that this has specifically been shared with the Heads of Healthcare at both HMP Altcourse and HMP Onley to ensure that similar processes and lessons can be learned.”

Source location

Response from Practice Plus Group
Page 4 · response
Published 1 November 2023

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

Log and track re-booked referrals through the NHS Electronic Referral System.

Verbatim wording from the response

“If an appointment has to be re-booked, this is followed up by the admin team any concerns are escalated to the clinician who referred. In January 2024 HMP Thameside will be using the NHS’ Electronic Referral System that will ensure all referrals are logged. The admin team will then be able to track these more easily.”

Source location

Response from Practice Plus Group
Page 3 · response
Published 1 November 2023

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

Operate a Transfer of Care LOP covering incoming and outgoing patient transfers and external appointments.

Verbatim wording from the response

“HMP Thameside have developed a Transfer of Care LOP regarding the transfer in and out of patients. Included in this is details regarding external appointments.”

Source location

Response from Practice Plus Group
Page 3 · response
Published 1 November 2023

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