Mr Khairul Rahman · Prevention of Future Deaths report

Mr Khairul Rahman, an inmate at HMP Pentonville, died on 22 January 2021 at University College Hospital from COVID-19. I concluded, at an inquest into his death on 21 May 2021, that he died from natural causes. In box 3, I set out as follows:

Mr Rahman died from COVID-19 after treatment in hospital. There were intervals to reviewing his clinical condition, whilst he was detained in prison. However, it is not possible to state that this caused or contributed to his death.

In January of 2021 there was an outbreak of COVID-19 in the prison. Mr Rahman had been previously coded as a ‘moderate risk’ in May 2020, owing to his asthma diagnosis.

I heard evidence that he became unwell on the 4th of January 2021. However, he did not report this to prison staff, who first recognised that he was unwell at 10am on the 7th of January. Attendance of nursing staff was requested at approximately 10.30am. It is unclear when the nurse subsequently attended to Mr Rahman, owing to non-contemporaneous recording of the consultation, documented at approximately 5pm. The entry states:

Pulse rate 129 bpm
O/E – tympanic temperature 38.8 C
Pulse oximetry 97%
148 94 mmHg

Examination: Had a covid19 swab taken

I heard evidence that once-daily observations were planned to be undertaken. In oral evidence, Dr ████████, Regional Medical Lead of Practice Plus Group in London, stated that a NEWS2 early warning score system was used by prison healthcare staff, in order to establish what next steps should be taken, based on clinical observations (along with clinical judgement). It was established that the above observations would score ‘3’ on the NEWS2 system which, according to score calculators would prompt consideration of repeat observations to be taken every 4-6 hours.

When asked to account for the disparity between the planned daily observations and the NEWS3 prompted 4-6 hourly observations, Dr ████████ stated in oral evidence:

I think that the honest answer is that, at the time, that we were struggling across all prisons to be able to monitor people…on a regular basis, i.e. specifically between 4-6 hours but we were relying on the prisoners working with us to self-report any changes in their symptoms. I can’t explain why we didn’t do a further observation before that point actually.

In a statement provided after the conclusion of the inquest, provided in order to address concerns I had raised regarding this point, Dr ████████ set out:

When Mr Rahman was initially seen on 7/1/21 he had observations taken which were abnormal and were somewhat suggestive of Covid-19, and a swab was taken. The positive result was entered into Mr Rahman’s records on 11/1/21. It is expected that when the result was known to be positive the protocol would be activated, which means covid age would be worked out which would then guide us on our future observations. It is these subsequent observations which would include the NEWS2 and not necessarily the original observations taken on 7/1/21… Covid age is what Practice Plus Group were using to guide us on the frequency of observations and had to be calculated after a positive result… Mr Rahman was due to undergo once daily observation, which was appropriate given the known risk at that time…

Despite NEWS2 being a hospital based scoring system and it not being ideal for the prison estate it was the best we had at the time… Throughout the pandemic healthcare staff have been reminded regularly at daily handover meetings to use NEWS2 when carrying out observations and this is a message that has continued.

No further treatment or care was provided to Mr Rahman prior to concerns being raised to prison staff at approximately 1pm on 8 January, regarding a deterioration in his condition. Emergency services were called, with the details of the request given as ‘sats 46’. The ambulance service attended and, despite 15 litres per minute of oxygen being administered, were not able to get Mr Rahman’s oxygen saturations above 78%. He was transported to University College London Hospital where, despite intensive care treatment, he died on 22 January from the consequences of COVID-19.

1. There does not seem to be a robust system in place in the prison healthcare setting for contemporaneous or accurate retrospective documentation of the timing of clinical interactions. I heard evidence and received a further statement, following the conclusion of the inquest, which set out the difficulties that the prison environment causes, in terms of being able to document accurately. However, I remain concerned that the lack of accurate documentation means that subsequent review of the appropriateness of clinical care, in particular, response times is hampered;

2. The interval to further observations being undertaken were not inline with the NEWS2 scoring system and, in oral evidence, it was set out that prisoners were expected to self-report deterioration. This differs from latter information, provided after the conclusion of the inquest. However, it remains a concern.

The use of the NEWS2 scoring system remains unclear; the post-inquest information seemingly sets out both that this system was only to used after a positive COVID-19 result but also at daily handover.

Whilst recognising that the prison environment differs from a hospital setting, I remain concerned that the care provided was not as guided by the NEWS2 scoring system and that no alternative system appears to be in place that can be used effectively in the prison healthcare setting.