UK Inquiry Tracker

Garry Gilbey

PFD Report All Responded Ref: 2014-0533

Date of Report 10 December 2014

Coroner Karen Harrold

Coroner Area Portsmouth & South East Hampshire

Response Deadline est. 4 February 2015

State Custody related deaths

Judiciary.uk Report PDF

All 2 responses received · Deadline: 4 Feb 2015

Coroner's Concerns (AI summary)

The prison lacked a clear policy for calling ambulances or defining medical emergencies, leading to inadequate staff training for night-time assessments and inconsistent recording of critical healthcare information.

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_ Prison did not have a set policy about when an ambulance should be called. This was left to the judgment of the prison officer(s) making an assessment of the prisoner from outside the cell and whether what they observed amounted to a medical emergency. In addition, it was not clear what amounted to a medical emergency and that the threshold was high: This raises genuine concern in relation to those prisons who do not have 24/7 medically trained staff available to make emergency assessments of prisoners during the night X-ray bony X-ray and X-ray X-ray X-ray get days They they day day live The In turn this raises concern about the adequacy of training and clarity of what amounts to a medical emergency for those night time prison staff involved in having to make dynamic risk assessment especially for those prisoners who are at higher risk of a chronic condition developing into an acute episode e.g: during the referral period to a hospital especially when a very serious underlying condition is suspected such as lung cancer that has the capacity to affect breathing suddenly even though prisoner may initially appear to be able to speak_ There was no clear or consistent system to healthcare events during the and there seemed to be a variable practicelpolicy in place that not all healthcare staff seemed to be familiar with or followed so that less relevant information was recorded such as an additional pillow being supplied yet important information such as nebuliser treatment or having a low threshold for medical review if symptoms reoccur Or worsen was not consistently recorded in a way that would enable daytime medical staff to prisoner healthcare concerns to night-time prison staff. There were also worrying aspects to prison health care systems including checking that all necessary specialist investigations are fully recorded and carried out as well as results properly checked when they return.

Responses

Department of Health Central Government

7 Feb 2015

Noted
The Department of Health provides context regarding healthcare contracts for prisons being performance managed by NHS England's Area Teams, and refers to DH and NOMS guidance issued in 2011 regarding emergency access for ambulance services. They note that the Ministry of Justice will address prison-related issues such as training for non-medical prison staff. (AI summary)

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From Norman Lamb MP Minister of State for Care and Support Department of Health Richmond House 79 Whitehall London SWIA 2NS Karen Harrold Tel: 020 7210 4850 HM Assistant Coroner Coroner' s Office RECEIVED The Guildhall Guildhall Square 2 7 FEB 2015 Portsmouth BY HM CORONER POI 2AB 2 5 FEB 2015 Vc ksen Hacola , Thank you for your letter about the death of Garry Gilbey: Please extend my condolences to Mr Gilbey' $ family. Your report details events prior to Mr Gilbey's death, focussing on the conduct of the prison staff and the care provided. You also noted a number of concerns about operational practice in the prison at that time. You were concerned that prisons do not always have 24 hour a medically trained staff available to make emergency assessments of 'prisoners and that the prison in question did not have a set policy about when an ambulance should be called, instead leaving it to the judgment ofthe prison staff: You were also concerned about the adequacy of training for night time prison staff and the handover of medical information between daylnight staff: I am aware that you have also sent a copy of your report to the Ministry of Justice, which oversees the National Offender Management Service (NOMS), which will be able to address prison-related issues such as training for non-medical prison staff: Healthcare contracts for prisons are performance managed by NHS England's Area Teams at a local level; who have not alerted DH Offender Health or the NHS England Health and Justice central team to any particular problems. Guidance was issued by DH and NOMS in 2011 ("Emergency access to establishments for ambulance services to all prisons in England, NHS commissioners and NHS ambulance trusts. This sets out when an ambulance should be called to take a prisoner to hospital in life-threatening circumstances The guidance covers and night emergencies and makes the following main points: day, - day

The most important aspect of emergency care is that an ambulance is called in all cases where there are grave concerns about the immediate health of a prisoner: Examples of where an ambulance would always need to be called to a include suicide attempts or cardiac arrest: Prisons to minimise the delays that can be encountered in getting an emergency response to prisoners. There are set standards for the time it should take for an ambulance to respond to emergency calls. It is the responsibility of the Governing Governor/Director to ensure that a protocol exists at each prison (regardless of security status) to facilitate immediate access for the ambulance service to both the and the individual prisoner when required. As not all prisons in England have 24 hour provision as part of their healthcare contract, the absence of medical cover (e.g. a duty nurse on-call outside normal healthcare centre hours) does not necessarily indicate a service provision problem: the 2011 guidance above applies in emergencies outside normal health centre opening hours. The bodies regulating medical professionals have published comprehensive guidance for clinicians within the prison service, including communicating with non-clinical staff. The Nursing and Midwifery Council (NMC) has published "The code: Standards of conduct, performance and ethics for nurses and midwives This includes a requirement that nurses must keep clear and accurate records. Records should be made aS soon aS possible after an event has occurred for example recording the results of an observation as soon as it has occurred, rather than at the end of a shift: The GMC code of practice; "Good Medical Practice" contains a section covering the continuity and coordination of patient care which makes clear that all relevant information should be shared with colleagues involved in a patient '$ care. [ hope that this information is helpful and I thank you for bringing the circumstances of Mr Gilbey's death to our attention. NORMAN LAMB prison need prison prison (Q

HM Prison and Probation Service Central Government

9 Feb 2015

Action Taken
Since the death, Prison Service Instruction 2013/03 Emergency Response Codes has been issued, reminding staff who can call a medical emergency and providing guidance on the use of medical emergency codes. Also, the new specifications for prison healthcare services have a contractual requirement for the management of appointments and referrals, including automatic referrals to secondary care services for those who Did Not Attend (DNA). (AI summary)

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Dear Coroner;, RE: the death of Garry Gilbey on 3 July 2012 whilst in HMP Kingston: Thank you for your letter to Andrew Selous, Minister for Prisons dated 10 December; concerning the inquest into the death of Gilbey, who died at HMP Kingston on 3 July 2012. am replying as Equality, Rights and Decency Group (ERD) part of National Offender Management Service (NOMS) has ownership of suicide prevention and self-harm management policy in prisons and for sharing learning from deaths in custody. As you know HMP Kingston is now closed, This response includes the contribution provided from NHS England. have dealt with the points in the order that you raise them: Calling ambulances Since Mr Gilbey's death Prison Service Instruction 2013/03 Emergency Response Codes has been issued. The PSI reminds staff who can call a medical emergency, and provides guidance on the use of the correct medical emergency codes, and what information should be communicated to the control room from the scene of the incident, It also states that all Governors must have Medical Emergency Response Code protocol in place that is based on the PSI and that all prison staff must be made aware of and understand instruction and their responsibilities during medical emergencies _ have attached copy of the PSI for your information. Training and clarity on medical emergencies for night time prison staff PSI 24/2011 National Security Framework Nights Function Management and Security of Night State requires that all prisoners must be locked up during the night state and that Local Security Strategies (LSS) must state clearly the procedures staff should follow if faced with potentially life-threatening situation; Staff must have access to the LSs and be aware of the implications of this for their role in maintaining security during the night state. There are many incidents that may occur at night and it is difficult to be prescriptive about what actions to take in each particular case_ Under normal circumstances, authority to unlock a cell at night must be given by the Night Orderly Officer (NOO): No cell will be opened unless a minimum of twolthree (subject to local risk assessment procedures) members of staff are present one of whom should be the NOO. All staff have duty of care to prisoners, to themselves and to other staff and the preservation of life must take precedence over other directions. Where there is, or appears to an immediate danger to life, then cells may be unlocked without the authority of the NOO and an individual member of staff may enter the cell on their own. However; night staff should not take action that they feel would put themselves or others in unnecessary danger: 4th Garry the be,

Before entering a cell: a) Every effort should be made to gain a verbal response from the prisoner. b) This, together with what the member of staff can observe through the panel and any knowledge of the occupant(s) , should inform rapid dynamic risk assessment of the situation and decision on whether to enter immediately or wait for assistance_ C) The Communications Room/Control Room must be informed before entering the cell stating the location of the cell and describing the circumstances that require intervention_ Cells should only be entered the sealed pouches. There must also be clear instructions about the unhindered admission of the emergency services during the night state. Flagging healthcare events to night staff and healthcare systems for checking that all necessary specialist investigations are fully recorded and carried out as well as results properly checked when they return Under the Health and Social Care Act; NHS England has responsibility for commissioning and quality assuring an equivalent health service for prisoners to those who are in the community and as such NHS England believe have commissioned an equivalent service. Service specifications are reviewed on regular basis and changed in line with new national guidance from NICE or as a result of lessons learnt from previous deaths in custody or serious untoward events_ All establishments have access to the same level of service that would receive in the community which is an in-house healthcare service and access to Out of Hours urgent care to an equivalence of the community_ As such 24/7 healthcare would not always be provided in- house as this would not be an efficient use of limited resources. Some establishments where there is an in-patient unit will have 24/7 in house healthcare although for the majority of establishments this is not a requirement: Within the new specifications for prison healthcare services there is a contractual requirement for the management of appointments and referrals including those that Did Not Attend (DNA) having an automatic referral to secondary care services There is a requirement that systems must be in place to ensure that patients can attend medical appointments outside the establishment. Appropriateness of referrals must be subject to regular peer review: must keep and maintain a detailed database which includes the planning of appointments and follow up requirements_ NHS England are happy to work with NOMS to review pathways and protocols both at a national and local level to see if there are further lessons that we can learn as a result of this tragic incident hope that you find this response helpful and reassuring

Sent To

Department of Health and Social Care
Ministry of Justice

Response Status

Linked responses 2 of 2

56-Day Deadline 4 Feb 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 11"h July 2012 an investigation into the death of GARRY GILBEY was commenced. investigation concluded at the end of the inquest on 4th August 2014. The conclusion of the inquest was recorded as a narrative conclusion as follows: Mr Victor Gilbey was admitted to hospital from HMP Kingston on 25th June 2012 with a productive cough, weight loss and breathlessness On admission a chest X-ray showed signs of collapse of the upper lobe of the left lung and later tests diagnosed he was suffering from lung cancer: Despite treatment he died at 08.30 on 3rd July 2012. There were a number of missed opportunities in Mr Gilbey"s care and treatment in the preceding months but it cannot be said on the balance of probabilities that Mr Gilbey would have survived or life would have been prolonged if any or all of the opportunities had been taken.

Circumstances of the Death

In 2002, Mr Gilbey was imprisoned for serious offences and was first taken to HMP Manchester. At this time, he told healthcare staff that he had a long standing injury to a nerve in his left arm for which he took pain relief medication. He continued to receive prescribed medication in prison and was also referred for physiotherapy_ Mr Gilbey transferred to HMP Kingston in July 2010. Healthcare staff noted his existing health problems and also that he smoked between 20-40 cigarettes a but he tried to give up smoking in February 2011 In December 2011, Mr Gilbey complained of pain in his upper left arm and was initially prescribed additional pain relief medication_ He continued to experience arm pain over the following weeks and saw another doctor: He was prescribed a variety of medication in an attempt to manage the pain. By February 2012, Mr Gilbey told a prison doctor that he had a cough and pain in his left shoulder and back. The doctor who examined him was not sure what was causing the symptoms but indicated he would do some research to see if the symptoms were connected and told Mr Gilbey he would be reviewed again once this was complete. By March 2012, the same doctor spoke to a hospital neurologist and he concluded the most likely cause of the arm pain was carpal tunnel syndrome. However; to rule out the posSibility of a rare form of lung cancer he decided Mr Gilbey should have a chest X-ray: However this was never arranged andno one_in the_prison health care department To The Garry his Garry day identified that the required chest had not been performed. On 20 March; Mr Gilbey's shoulder was X-rayed, after a referral by the Modern Matron who as a nurse practitioner wanted a further test to explore whether a injury could be causing the ongoing back and shoulder pains. This referral was unrelated to the doctor's intention that Mr Gilbey should have a chest therefore purely coincidental: The hospital consultant radiologist who reviewed the shoulder concluded that it was normal. However; he missed the fact that the plain did in fact show some changes in the left lung apex which were indicative of upper lobe collapse: In early June; Mr Gilbey reported chest pains and breathlessness, which he said he had been experiencing for several months. His heart was checked and was normal. Mr Gilbey was diagnosed with acid reflux and prescribed medication by the Modern Matron. On 18 June, a prison doctor who examined him considered that his symptoms were highly suggestive of lung cancer Mr Gilbey was referred to the hospital for further tests and an appointment was booked for 25 June. Until then_ Mr Gilbey was seen most days by health care staff because of his cough and breathlessness. On 22 June he was seen by a nurse consultant during the day short of breath and struggling to out of bed: Nebuliser treatment was prescribed which eased the symptoms and staff were told to have a low threshold for a medical review if the symptoms should reoccur or worsen: He was seen on 23 June during the day by a nurse due to shortness of breath and an out of hours doctor was called who diagnosed a chest infection and prescribed antibiotics_ He attended the clinic on 24 June and requested nebuliser treatment but this was refused: Later the same morning a different nurse attended Mr Gilbey's cell due to coughing and breathlessness and he was nebulised. Details of the nebulising treatment given over the immediately before admission to hospital were not recorded in the wing log book to alert prison officers to prisoner medical issues Overnight 24/25'h June, two officers attended Mr Gilbey's cell as he was requesting an ambulance because of breathing difficulties. One officer was first aid trained. did not enter his cell and because he could talk decided it was not a medical emergency. Finally on the morning of admission to hospital on 25 June Mr Gilbey was given more nebuliser treatment by prison staff. Mr Gilbey had a chest X-ray at hospital later the same and was admitted as an inpatient that due to suspected lung cancer: On 27 June, he was told that he had inoperable lung cancer and that he might for up to 12 months if he received chemotherapy and radiotherapy and two months if he did not. However; Mr Gilbey's health deteriorated much more quickly than anticipated and he died the following week at 8.30am on 3 July:

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you as Ministers responsible for prisons and healthcare provision in prison have the power to take such action_ Although, HMP Kingston closed on 28 March 2013, heard evidence to suggest that there are other prisons across the country where healthcare staff are not present on prison premises on a 24/7 basis resulting in prison officers having to carry out dynamic risk assessments at night and similar issues could well arise as in this case.

Copies Sent To

7. have also sent it to Ursula Ward, Chief Executive of Portsmouth Hospitals NHS Trust

Inquest Conclusion

Mr Victor Gilbey was admitted to hospital from HMP Kingston on 25th June 2012 with a productive cough, weight loss and breathlessness On admission a chest X-ray showed signs of collapse of the upper lobe of the left lung and later tests diagnosed he was suffering from lung cancer: Despite treatment he died at 08.30 on 3rd July 2012. There were a number of missed opportunities in Mr Gilbey"s care and treatment in the preceding months but it cannot be said on the balance of probabilities that Mr Gilbey would have survived or life would have been prolonged if any or all of the opportunities had been taken.