the MATTERS OF CONCERN as follows
1. During the course of the inquest a GP who was responsible for medical care at HMP Warren Hill gave evidence in relation to the computer system, SytmnOne which was used to review and prescribed medicines to the prisoners at the time of Mark's death: The court was told that the SystmOne online prescription 'module' was not clear to read or easy to understand and appeared incompatible with the prison'$ own IT system The GP described that this left them in the situation of not being sure what a patient had been previously prescribed, not being sure what repeat prescriptions were in place and that had no way of readily understanding what had been taken by a particular patient or when were supposed to have taken it: It was also explained that there was no direct Iink on the system between medications prescribed and previous diagnoses. Due to the time it took to navigate the records it was reported that some GP's used their experience to identify a previous diagnosis from the repeat prescriptions recorded in the prescription module The GP further described that removing a prisoner's prescription from the system when it was no longer necessary was difficult: they they very

One of the contributing factors the jury found to Mark's death was directly related with poor adherence to his blood pressure medication regime on repeat prescription. Considering the difficulties GPs are facing when using the prescription module, and the testimony given by the GP in this case, it would appear there is no easy system for a doctor to verify exactly what their patient has already been prescribed and whether or not that prescription is still current: Further, in relation to potential misuse of drugs incorrectly or over-prescribed the GP explained that some medications, such as opioids or anti depression medication (including amitriptyline and sertraline) had 'currency within the prison and it was known would be traded by some prisoners: Therefore, not being able to readily identify what a prisoner should be, or already is being prescribed at the time of any specific consultation is clearly a cause for concern: In an interview the GP had with investigators from the Prisons and Probation Ombudsman's Office on the 30th December 2015 (just one after Mark's death) the GP described the prescription module as "an absolute nightmare and we are banging our heads against a brick wall. We're trying hard to get some changes done because we are concerned about safety" When specifically questioned at the inquest on the 3rd September 2019 the GP stated that the situation as it stood at the end of December 2015 had still not been resolved