Anthony Benjamin Patrick Fraser · Prevention of Future Deaths report

On 30 September 2015 I commenced an investigation into the death of Anthony Benjamin Patrick Fraser, 62. The investigation concluded at the end of the inquest on 8 June 2016. The conclusion of the inquest was Natural causes. The cause of death was 1a. Relapsed Multiple Myeloma 2. Paraplegia, Diabetes, Epilepsy.

Mr Fraser was diagnosed as suffering from multiple myeloma in 2012 whilst an inmate at HMP Lindholme. He received treatment in hospitals in South Yorkshire for this terminal cancer and was kept under regular review of the haematologist from then until the time of his death on the 24th September 2015. In August 2015 his mobility became significantly compromised leading to referral to the hospital where investigations revealed that the disease process had significantly progressed and after investigations and MDD discussions a decision was made that he was for palliative care only and he passed away in the Doncaster Royal Infirmary on the 24th September.

I heard evidence that the medical records on the electronic Spine One contain a summary overview of a person’s medical status which should be sent to A&E Departments where patients have been referred. This information is readily accessible but in Mr Fraser’s case when he was referred to A&E on 15th August 2015, this information was not conveyed by them to the receiving hospital. I also heard in evidence that there is no system for ensuring that such information is sent and therefore is “hit and miss” as to whether or not it is sent. Whilst I concluded that in Mr Fraser’s case this did not affect the ultimate outcome due to him re-attending four days later and given the very aggressive nature of the cancer from which he was suffering, it is clear that for other inmates with different conditions, failure to provide such information may well delay diagnosis or make it extremely difficult to reach diagnosis. Accordingly consideration needs to be given to implementing a system where such information is conveyed for every such inmate in a timely fashion.

Summary of concerns:-

1. Absence of a robust system for conveying summary medical information to receiving A&E departments when inmates are transferred with an acute illness. .