Although not found to have been either possibly or probably causative in the particular circumstances of Mr Black’s death, nonetheless (1) Extensive evidence was heard concerning the poor state of cleanliness of the Health Care Centre at the Prison. Evidence confirmed that the ground floor of the Health Care Centre was not part of the clinical areas for which the Northamptonshire NHS Foundation Trust, the providers of health care at the Prison, were responsible: this area remained the responsibility of the Ministry of Justice. Whilst Health Care patients would regularly be located there, designated ‘vulnerable prisoners’ were also routinely resident in this location and, in respect of this cohort, there would be both a high turnover and sometimes challenging hygiene issues accompanying them. The evidence confirmed that the levels of hygiene in the common ways, kitchens, sinks, showers and the cells was poor and that this was of concern to prisoner patients and medical staff alike. Evidence also confirmed that no ‘deep cleans’ took place in these areas save where blood, vomit or a ‘dirty protest’ was specifically involved. I am concerned that such poor levels of hygiene give rise to the risk of prisoners returning from surgery, with perhaps compromised immune systems, facing a significant risk of infection, itself giving rise to a risk of future death.

(2) Evidence disclosed, and was conceded by the Trust, that there had been a missed opportunity for consideration of whether or not anti-coagulation therapy should have been provided to Mr Black following the decision that he remain in Addenbrookes Hospital over-night on the 13th November following his surgery. Although she had been prompted by a pharmacist to review the VTE risk once the decision had been made that it was “unsafe” to discharge Mr Black on the afternoon of the 13th, the Senior House Officer involved failed to conduct the review as required by both NICE and Trust policy. Although this was on the face of it an individual failure by the SHO, I am concerned that (a) the system in place at the time did not pick up on this error; (b) that the SHO’s evidence indicated that the course she took was, in her experience, standard practice; and (c) in different clinical circumstances, the failure to ensure that the appropriate review took place gives rise to the risk of future (preventable) death.