Dear Sir , Regulation 28: Prevention of Future Deaths report; Alan George STEAD Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Care UK following the inquest into the death of Alan George Stead Deceased. Care UK would like to express its condolences to Mr Stead's family and friends_ Care UK is the provider of healthcare services at HMP Dovegate and has been since October
2014. Care UK provide a 24 hour healthcare service at HMP Dovegate_ Our response to your matter of concern, and action taken, is set out below Matter of Concern: The medical review has identified delays with the taking and testing of blood samples of prisoners at HMP Dovegate This was not something included in recommendation in the PPO report but was expressed as concern by the family at the inquest. This could have serious consequences in some cases: wonder if you have looked at this and have done or can do anything to improve the situation with this at HMP Dovegate and indeed at any other prisons where you provide healthcare if this is an issue. Response: On Tuesday 8 December 2015 Mr Stead was seen by an advanced nurse practitioner reported that he had occasionally been experiencing palpitations in his chest and a dull; left- sided when breathing: The nurse examined Mr Stead thoroughly, took his observations and checked his chest: As everything was clear, she decided to carry out an ECG, as well as Mr Stead's blood pressure, rate and rhythm and respiration rate to see if this would establish the cause of the palpitations_ A prison GP reviewed the results of the ECG but found nothing significant: The nurse also referred Mr Stead for blood tests to check his thyroid function, vitamin B12 levels and his ferritin level to rule out anaemia: Healthcare staff were unable to obtain suitable blood sample due to Mr Stead having poor veins, and so they booked an appointment for Mr Stead to see healthcare member of staff trained in Phlebotomy on Friday 11 December. Mr Stead was told to contact healthcare staff if he experienced any further symptoms in the meantime. Care UK Limited. Registered in England No 1668247 Registered Connaught House 850 The Crescent Colchester Business Park, Colcnester; Essex C04 90B having pain pulse Office"

The appointment on Friday 11 December did not take place. Healthcare records show that this was a No Access" visit which means that the prison were unable to move Mr Stead to the healthcare centre. However, the appointment was rescheduled for the next available blood testing appointment which was on Wednesday 13 January 2016. At the time there were not as many staff in the Healthcare Team at HMP Dovegate trained to undertake blood samples Although this was a gap of over a month; the blood test was considered routine. Had the test been considered urgent, another Healthcare professional, usually a Doctor, would have taken the blood sample Mr Stead attended the appointment and the results of his blood test were received by healthcare on 14 January 2016. The Doctor reviewed the results that day and his view was that they did not warrant treatment or referral to a specialist: However; Mr Stead was advised to speak to healthcare staff if there was a recurrence of his symptoms_ As noted by the independent clinical reviewer, this blood test would not have had an impact on Mr Stead's death on 21 January and an earlier test would not have resulted in Mr Stead receiving any different treatment: Care UK Action: On 14 December 2015 a programme was introduced at HMP Dovegate for all nurses and HCAs to be trained in phlebotomy. This programme was completed and all of the staff were deemed competent and signed off in March 2016. Now, blood tests are conducted as soon as required and on the same day whenever possible or if flagged urgent: If they are not performed on the day, patients are added onto a waiting list of a few days. Blood samples are sent to the hospital laboratory daily each afternoon: More widely, the Governance team have shared the events and learning from Mr Stead's death as part of the National Quality and Improvement Meeting for all Regional Managers Healthcare Commissioning at HMP Dovegate During the inquest; when giving evidence , Assistant Director of Serco was asked if Serco commissioned the healthcare service that Care UK provide within HMP Dovegate_ responded "yes" and am informed that this was reflected in your summing up. would respectfully like to take this opportunity to clarify the position as this is incorrect: NHS England commission health services within Health and Justice and Care UK has a contract with NHS England to provide healthcare services within HMP Dovegate. NHS England is thus the Commissioner and Care UK the health service provider. Serco do not feature anywhere in this contract, Care UK is committed to providing a high quality healthcare service at HMP Dovegate and across all of our services and trust that above response provides the information that you require. However, please do not hesitate to contact me if can be of any further assistance_