(1) It is clear that on 16'h October 2014 the deceased was seen by a general practitioner and a podiatrist at more or less the same time. The GP did not fully examine the deceased because he knew he was to see a podiatrist: The podiatrist discovered serious problems with the deceased's foot and planned an urgent referral to the GP and did so by means of an electronic note which was seen by the GP who had seen the deceased immediately prior to the podiatrist, the after, who then referred the matter to another GP to make a letter of referral and then because of administrative failures not referral to secondary care was made before the deceased died on 2"d November 2014. This shows a total lack of communication between the GP and the podiatrist who should have considered it appropriate to speak to one another whilst the deceased was still present in order t0 move matters forward elfectively. (2)The GP who had most contact with the deceased in a 2 year period considered making a referral to secondary care on 17ih Oclober 2014 and instead of making the referral himself, passed the responsibility t0 make a referral to another GP (who worked one per week) and who had previously sent a one page letter of referral to secondary care more than 2 years earlier: The GP gave evidence that he thought it appropriate for the original GP t0 make the referral as that GP had done the first one and was acquainted with the matter second GP gave evidence to say that she did not agree with this action because although, in principle, if there had been a recent referral it might have been appropriate for the original referring GP t0 make a second referral however after 2 years it was "stretching it a bit" . There was a lack of ownership and responsibility for the deceased's care and making a referral t0 secondary care_ There needs to be consideration given t0 the formulation of clear guidance as to which GP and in what circumstances has a responsibility for referrals to secondary care.

(3) The GP who agreed to make a referral to secondary care gave evidence that she hand wrote out a letter of referral and handed it to a member of the administrative team for typing and gave verbal instructions that this needed to be dealt with quickly and that if there were any problems she was t0 be contacted. For an unknown reason the letter of referral was not dispatched: Some consideration has been given to this issue following publication of the PPO report but in the light of the evidence given in court the thoroughness and robustness of that letter of direction , particularly bearing in mind there have been a number of changes to the providers of healthcare in the prison, should be considered