UK Inquiry Tracker

Derrick Stanmore

PFD Report All Responded Ref: 2015-0172

Date of Report 1 May 2015

Coroner Lydia Brown

Coroner Area Leicester (City & South)

Response Deadline ✓ from report 26 June 2015

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 26 Jun 2015

Coroner's Concerns (AI summary)

A registered nurse failed to recognise abnormal patient observations requiring escalation, and lacked access to essential healthcare records to contextualise findings. A system like EWS is needed for recognition and escalation.

View full coroner's concerns

In the circumstances it is my statutory duty t0 report t0 you Observations were taken on Ihe morning of Mr; Stanmore $ death by a registered nurse. The observations were abnormal and required further action t0 be taken but this was not recognised A system similar to the hospital "Early Warning Score" (EWS) may assist the healthcare staff in recognising this and escalating care accordingly. The nurse attending Mr. Stanmore did not access his healthcare records that were avallable and did not appear t0 have any information regarding the need for a healthcare assessment He was therefore taking observations without the benefit of relevant clinical information in order t0 consider_these_in context

Consideration should be given t0 ensuring all staff have appropriate access whenever possible t0 information before conducting examinations Or observations of prisoners

Responses

Leicestershire Partnership NHS Trust NHS / Health Body

1 May 2015

Action Planned
An adapted version of the Track and Trigger system will be introduced, with staff trained in its use across the three Prison Healthcare Teams by October 2015. Staff will be reminded to access clinical information before seeing Prisoners. (AI summary)

View full response

Dear Mrs Brown; Re_Derick James STANMORE Further to your report dated 01 May 2015,in accordance with paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, offer the following response. We have investigated the matters that you have raised relating t0 concerns about members of Leicestershire Partnership NHS Trust staff at HMYOI Glen Parva alleging issues ~surrounding observations and access t0 health records Leicestershire Partnership NHS Trust takes these matters very seriously and | hope that you and Mr Stanmore's family will be satisfied that we have taken the appropriate measures t0 prevent such an occurrence happening again; Service Manager for Prison Healthcare in response to the Regulation 28 has Fagreed t0 complete the following actions as this covers the scope of your matter of concern: Observations were taken on the morning of Mr. Stanmore' $ death by registered nurse: The observations were abnormal and required further action to be taken, but this was not recognised: A system similar to the hospital "Early Warning Score' (EWS) may assist the healthcare staff in recognising this and escalating care accordingly: The Healthcare Management Clinical Leadership Team will be introducing an adapted version of the Track and Trigger system as attached , Staff will need to be trained in the use of this tool across our three Prison Healthcare Teams and we anticipate that this will be in place by the October 2015 This will assist in ensuring that all healthcare staff are aware of the parameters of physical observations and be able to act swiftly in escalating any physical observations that present with potential concerns. This system iS used successfully within the Community Hospitals that are managed under the care of Leicestershire Partnership NHS Trust. Chair: Prolesor David Chiddick €BE Chiel Executive: Dr Peter Miller City willl Nout, ( 1 21548169

nurse attending Mr: Stanmore did not access his healthcare records that were available; and did not appear to have any information regarding the need for a healthcare assessment: He was therefore taking observations without the benefit of relevant clinical information in order to consider these in context Consideration should be given to ensuring all staff have appropriate access whenever possible to information before conducting examinations or observations of prisoners_ After review; can confirm that all staff are able t0 access clinical information prior t0 seeing Prisoners. Staff will be reminded that it is an expectation that when Prisoners are seen routinely, clinical notes should be accessed in order [0 make well informed clinical decision

Sent To

Leicester Partnership Trust

Response Status

Linked responses 1 of 1

56-Day Deadline 26 Jun 2015

All responses received

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On 14 July 2014 | commenced an investigation into the death of Derick James Stanmore: The inquest concluded on 30 April 2015. The conclusion of the inquest was Natural causes Cause 0f death Acute myocardial infarction 1b Coronary artery atheroma

Circumstances of the Death

Mr_ Stanmore was serving Iife sentence for murder and was at the time of his death in HMP Gartree He had number of recognised medical conditions, including cardiac disease and diabetes mellitus type Il. He complained of chest pains on 7in July 2014, and there were 3 encounters with healthcare over the next 3 days; none of which made potential diagnosis of cardiac problems and none of which resulted in a referral for review: On 10"" July 2014 Mr. Stanmore collapsed in his cell and despite prompt and effective CPR and paramedic assistance he was pronounced deceased shortly after his arrival at Kettering General Hospital.

Action Should Be Taken

In my opinion action should be taken t0 prevent future deaths and believe you have the power t0 take such action;