Dear Sir

The Inquest touching upon the death of Mr Jonathan McCarthy

We write further to your Report to Prevent Future Deaths issued pursuant to Regulation 28 Coroners (Investigations) Regulations 2013 dated 12 October 2023 and following the inquest touching upon the death of Mr McCarthy, who sadly passed away on 12 August 2018 whilst residing at HMP Onley.

I would like to take the opportunity on behalf of Practice Plus Group to offer my sincere condolences to Mr McCarthy’s family and friends for their loss.

This letter addresses the matters of concern insofar as they relate to Practice Plus Group (PPG). As you are aware, PPG were not the healthcare provider at the time of Mr McCarthy’s death at either HMP Thameside or HMP Onley, however PPG have since started providing healthcare at both these sites.

Matter of Concern

We note that you have the following concerns: 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. In light of these matters, you consider that a Regulation 28 report is required in relation to the policies and procedures for: -
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.

Response

Pre-Existing Appointments

When a patient arrives into the prison a healthcare practitioner undertakes a first night screen, this consists of a face to face assessment of the patient establishing all pre-existing medical conditions and current risk. SystmOne is used to help inform this assessment. This assessment is known as the initial reception screening and forms part of the process for all new admissions.

As part of this reception process, any pre-existing external appointments are identified on arrival into the prison. This is identified through either checking the patients’ medical records, information from the sending prison or confirmation from the patient himself. Once an appointment is identified the healthcare practitioner will alert the administration team that there are outstanding hospital appointments. The administration team will then make contact with the hospital, or other external agency, to ascertain details of the appointment if this is not already available.

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 for any 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.

If the patient has transferred from another prison but the hospital is too far to travel for then these appointments are cancelled by the admin team and a task sent to the GP to inform them that the patient needs referring to the local hospital. Where new appointments are scheduled, the patient is not informed until the day of the appointment. This is standard practice due to security.

Where a patient is admitted into prison from the community they will often already be aware of any outstanding appointments. In this case, the external provider will be contacted to see whether the appointment can be carried out over the phone or via video link. This ensures that the appointment goes ahead as scheduled without the security risks of being escorted in person. If this is not possible for any reason then the appointment will be rescheduled. However, patients with external appointments are highlighted to the GP/ANP or senior nurse to clinically triage to ensure that nothing is missed and that their needs are met. If the appointment can be serviced within the prison then this will be carried out. Any urgent appointments will be discussed with the hospital and an urgent re-referral completed.

All appointments are recorded on SystmOne by the admin team when they are made so that all staff can see the appointments. The prison are informed in advance of external escorts that are

needed where, when and type of transport required. Prison staff are given as much notice as possible.

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.

Determining Clinical Importance

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.

If an urgent appointment has to be cancelled, this would be recorded on SystmOne and an urgent task sent through SystmOne to the senior clinician to follow this up. The hospital would be contacted to discuss and an urgent re-referral completed. The prison are advised of all escorts that cannot be cancelled. All escorts are discussed as part of the daily briefing which is a joint meeting which all staff attend. The cancellation of appointments is not undertaken without clinical consultation, and as previously noted, all patients affected will be seen by a GP/ANP or senior nurse to ensure their needs are met.

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.

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.

Assessment Fitness to Transfer

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.

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. For example, those having cancer care at specialised hospitals would be placed on Medical Hold.

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

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.

I do hope that this letter provided the necessary reassurance sought and if I can be of any further assistance you should not hesitate to contact me directly.