Aaron Nunes

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Independent investigation into
the death of Mr Aaron Nunes,
a prisoner at HMP Parc,
on 21 February 2016
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to
any cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Aaron Nunes died in hospital of septic shock and diabetic ketoacidosis on 21 February
2016 while a prisoner at HMP Parc. This was caused by necrotising fasciitis (a rare but
serious bacterial infection) and insulin-dependent diabetes mellitus. Mr Nunes was 27
years old. We offer our condolences to Mr Nunes’ family and friends.
Mr Nunes had had Type 1 diabetes since childhood. We investigated his death with the
help of a clinical review commissioned by Health Inspectorate Wales (HIW) and in our
report, issued in November 2017, the then Ombudsman found that the management of Mr
Nunes’ diabetes had deteriorated because he failed to regularly monitor his own blood
glucose levels or follow advice from health professionals. The report concluded, on the
basis of the clinical review, that the diabetes and dental care Mr Nunes had received at
Parc was equivalent to that he could have expected to receive in the community. An
inquest held in December 2017 concluded that the direct cause of Mr Nunes’ death was
his failure to manage his own health adequately.
However, following representations from solicitors acting on behalf of Mr Nunes’ mother,
we agreed to reinvestigate his death and HIW commissioned two new clinical reviews.
This report is the outcome of our reinvestigation. It identifies a large number of significant
failings in the diabetic and dental care Mr Nunes’ received at Parc and concludes that his
death would have been preventable if he had received dental and diabetic healthcare of an
acceptable standard.
I am extremely troubled by the many clinical failures described in this report. HM Prisons
and Probation Service, NHS Wales and G4S, who run Parc, will need to ensure, as a
matter of urgency, that they cannot recur. There were also some non-clinical concerns
which the Director will need to address.
I apologise for the shortcomings of our original investigation and the delay in issuing this
final report. I recognise that this will have caused Mr Nunes’ mother additional distress
and I am writing to her to apologise in person.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman May 2024
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Contents
Summary ......................................................................................................................... 3
The Investigation Process .............................................................................................. 11
Background Information ................................................................................................. 12
Key Events ..................................................................................................................... 17
Findings ......................................................................................................................... 22
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Summary
Events
1. On 14 January 2015, Mr Aaron Nunes was recalled to custody. He was moved to
HMP Parc on 1 June.
2. Mr Nunes had been diagnosed with Type 1 diabetes as a child and was dependent
on insulin injections to manage his condition. He did not comply with his insulin
medication regime at Parc and was frequently aggressive to healthcare staff when
they told him how important it was that he should test his blood sugar and ketone
levels to manage his diabetes and prevent diabetic ketoacidosis. (DKA, a
potentially life-threatening condition).
3. Between June 2015 and February 2016, Mr Nunes was admitted to hospital with
suspected DKA on 14 occasions and discharged himself on several occasions
against medical advice. When he returned to Parc after being hospitalised, Mr
Nunes was frequently not assessed by a GP and his blood sugar and ketone levels
were not reviewed by healthcare staff.
4. In November and again in December, staff managed Mr Nunes under suicide and
self-harm monitoring and support procedures (known as ACCT) as they considered
that his failure to take responsibility for his health was a form of self-harm.
5. In November and December, Mr Nunes complained of toothache and was given
painkillers. Healthcare staff suspected he may have a dental abscess. They made
him an appointment with a prison dentist on 18 January 2016, which Mr Nunes
failed to attend.
6. On 5 February, Mr Nunes complained of toothache again. A prison dentist saw him
on 8 February but could not examine him properly as Mr Nunes was unable to open
his mouth wide enough because of pain and swelling. The dentist prescribed
antibiotics and planned to review him on 15 February.
7. On 10 February, Mr Nunes received his antibiotics, two days after they had been
prescribed. He did not attend his dental appointment on 15 February, and no
follow-up dental appointment was made.
8. On 17 and 18 February, Mr Nunes complained to nurses about pain from his
abscess. On 18 February, a nurse left instructions that he should be given
antibiotics overnight, but this did not happen as there was no one qualified to
prescribe antibiotics. On 19 February, a dental therapist assessed him but was
unable to examine him as he could not open his mouth. She booked an
appointment for him to see the dentist on 22 February.
9. On 20 February, Mr Nunes felt unwell. Healthcare staff noted that he was at a
considerable risk of DKA, and he was taken to hospital. This was Mr Nunes’
fifteenth admission to hospital. Mr Nunes insisted on discharging himself although
a hospital doctor told him he risked dying if he did so. When he returned to Parc,
no one from the healthcare team assessed him.
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10. Later that day, Mr Nunes did not collect his medication and did not attend a GP
appointment. He was not seen by anyone from healthcare.
11. On 21 February, roll checks were carried out at about 5.30am and 7.00am and no
concerns were raised about Mr Nunes. At 8.40am, an officer unlocked Mr Nunes’
cell door, but did not look into the cell to complete a welfare check.
12. At 9.04am, an officer found Mr Nunes unresponsive in his cell. He raised the alarm,
and an ambulance was called at 9.14am. At 9.34am, paramedics arrived at Mr
Nunes’ cell. They took him to hospital at 9.44am.
13. Mr Nunes’ condition deteriorated in hospital, and he died at 10.45pm with his family
present.
Findings
14. Parc could not offer the clinical care and observation required to meet Mr Nunes’
complex healthcare needs safely. His death would have been preventable if he had
received dental and diabetic healthcare of an acceptable standard.
15. Lack of expertise meant that healthcare staff failed to identify the seriousness of Mr
Nunes’ condition and mistakenly considered that he was to blame for his frequent
hospital admissions. Prison staff took their lead from healthcare staff.
Dental care
16. Mr Nunes’ dental care was unsafe and subject to a catalogue of failings. His dental
infection remained untreated for 43 days. Subsequent dental care fell well below
acceptable professional standards and resulted in a serious failure to meet the duty
of care to him.
17. Mr Nunes’ death from necrotising fasciitis (NF) arising from his mismanaged dental
infection would have been preventable if he had been treated appropriately and in a
timely manner.
18. Dental record keeping at Parc did not meet the standards set by the General Dental
Council (GDC) and was not fit for purpose for the provision of safe dental care.
19. The system for booking dental appointments at Parc was inefficient. Although Mr
Nunes had an acute dental infection and was an immune-compromised Type 1
diabetic patient, there were long delays before he received dental appointments.
20. Inadequate communication between dental and healthcare staff resulted in a series
of missed opportunities to refer Mr Nunes for urgent dental treatment or to highlight
that he had an acute dental infection requiring emergency treatment.
21. When Mr Nunes missed his dental appointments, no one from the dental or
healthcare team checked why he had failed to attend or arranged an alternative
appointment, and his acute dental infection was left unmonitored for unacceptably
long periods.
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22. There was no provision for emergency dental care out-of-hours on weekdays,
weekends or Bank Holidays.
23. The unacceptably long delay in dispensing Mr Nunes’ antibiotics contributed to his
dental infection developing into NF, which was one of the causes of his death.
24. The absence of a working x-ray machine resulted in a lost opportunity to identify the
cause of Mr Nunes’ dental infection at an earlier stage.
25. Time for Teeth, the dental provider, had not provided its dental staff at Parc with
specialised training in prison dental care and this contributed to the failure to
provide Mr Nunes with safe and effective dental care.
26. When Mr Nunes was eventually seen in the dental clinic, he was seen only once by
a dentist and once by a dental therapist.
27. The quality of dental care and treatment that the dentist provided Mr Nunes on 8
February fell significantly below the standards expected of a qualified dental
surgeon.
28. The dental therapist did not provide Mr Nunes with appropriate dental treatment on
19 February and as a result his dental care immediately before his death was
severely compromised. Her scope of practice and level of competence meant that
she should never have been expected to see or treat dental emergencies without
supervision.
Diabetic care
29. Clinical staff at Parc lacked experience and knowledge of acute diabetes
complications and, as a result, the diabetic care Mr Nunes received was
inappropriate and not equivalent to that he could have expected to receive in the
community.
30. In a number of respects the actions of healthcare staff at Parc fell below the
standards expected by the General Medical Council (GMC) and Nursing and
Midwifery Council (NMC). This had a detrimental effect on Mr Nunes’ health.
31. There were numerous occasions when healthcare staff omitted to administer Mr
Nunes’ insulin. Their failure to respond with the necessary urgency when this
happened was the result of inexperience and lack of knowledge about acute
diabetes complications.
32. It was important that Mr Nunes’ insulin was administered immediately before or
after eating a meal, but he was unable to do this because of the discrepancy
between the times the medication hatch was open and the times that prison meals
were served. This restricted Mr Nunes’ ability to use his insulin correctly.
33. Mr Nunes often had difficulty accessing blood sugar and ketone level testing strips
and accessing a working blood sugar testing meter.
34. Staff mistakenly believed that a blood sugar test was required before every insulin
injection.
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35. When Mr Nunes returned to prison from hospital after his many admissions,
healthcare staff took no clinical observations and did not record his blood sugar and
ketone levels.
36. The accumulation of these errors led to a critical and acute deterioration in Mr
Nunes’ health.
37. Healthcare staff failed to recognise and investigate Mr Nunes’ diabetic
gastroparesis and did not request that diabetes specialists visit him in prison, ask
for advice on treatment or transfer him to a prison with facilities better able to
manage this complex condition. This was a significant contributor to Mr Nunes’
repeated admissions to hospital and impacted adversely on his health.
38. When Mr Nunes was unwell, healthcare staff failed to assess, observe and examine
him adequately, using tools such as NEWS and sepsis screening, and frequently
failed to monitor his blood sugar and ketone levels. Clinical note-taking was too
brief and fell below the expected standards from the GMC and NMC.
39. Healthcare staff failed to recognise Mr Nunes’ poor understanding of his condition
and put an inappropriate onus on him to care for himself. It was unrealistic and
irresponsible to expect him to manage his complex diabetic condition without
adequate clinical support. Mr Nunes’ erroneous self-care was a major, inadvertent
cause of his repeated episodes of DKA. Staff should have identified this, and Mr
Nunes should have been offered the support of diabetes specialists and a
structured education programme.
40. Healthcare staff also failed to recognise that Mr Nunes’ poor compliance with his
diabetes regime was due to diabetes burn out and his poor understanding of his
condition, rather than being intentional self-neglect. As a result, Mr Nunes’ mental
health problems remained unresolved and inadequately managed, and this
contributed significantly to his poor diabetes control and recurrent hospital
admissions. If these problems had been addressed earlier, it may have prevented
his death.
41. Many of the nurses dealing with Mr Nunes were mental health or learning disability
nurses and were therefore working outside of their clinical competence as far as Mr
Nunes’ diabetes was concerned. This did not meet NMC standards and resulted in
Parc providing an unsafe environment for Mr Nunes.
42. In the absence of any formal healthcare multidisciplinary team meetings or a senior
clinician taking responsibility for Mr Nunes’ care, no one formulated a
comprehensive care plan for Mr Nunes.
43. ACCT procedures were not designed to address Mr Nunes’ specific diabetes-
related difficulties. ACCT monitoring was no substitute for adequate clinical care
planning and clinical leadership, including effective Supported Living Plans (SLPs)
and Clinically Vulnerable and Older Persons meetings (CVOPs).
44. Although a SLP was opened, it was of a poor standard and had little or no impact
on the care delivered to Mr Nunes by healthcare or operational staff. The CVOP
meetings were informal and unstructured and did not provide an opportunity for
effective care planning.
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45. There was an unacceptable delay in Mr Nunes accessing his antibiotics on 18
February as nurses did not have the authority to dispense them and did not contact
the out-of-hours GP.
46. Mr Nunes’ mother could have significantly contributed to his care if healthcare staff
had involved her more. Failure to do so was detrimental to his overall diabetes
care.
47. There is no evidence that Mr Nunes was obtaining illicit drugs when he went to
hospital. However, there was evidence that he may have been using psychoactive
substances (PS) in prison. Healthcare staff should have been more proactive in
raising the dangers of drug use with Mr Nunes and attempts should have been
made to identify or exclude drug misuse as a possible contributor to his poor
compliance and disengagement with his complex diabetes management.
Events of 20 and 21 February
48. When Mr Nunes returned from hospital on 20 February after discharging himself
against medical advice, he was not given antibiotics or insulin and healthcare staff
did not see him for 28 hours until he was found unresponsive in his cell the next
day. This was a gross breach in the duty of care.
49. If Mr Nunes had been given antibiotics and insulin, this might have managed his
infection and prevented the development of severe DKA. Healthcare staff should
also have supervised him closely, including carrying out hourly observations and
recording his vital signs.
50. The officer who unlocked Mr Nunes on 21 February did not look into the cell or
complete a welfare check on Mr Nunes as he should have done in line with national
policy. Another officer found Mr Nunes unresponsive in his cell 25 minutes later.
Although it is unlikely that the delay of 25 minutes made any difference to the
outcome for Mr Nunes, such a delay may be critical in other medical emergencies.
51. After the code blue medical emergency was called, there was a delay of around 10
minutes before the control room called an ambulance. Although this is unlikely to
have affected the outcome for Mr Nunes, in other emergencies, any delay could be
critical.
52. When Mr Nunes was taken to hospital on 21 February after being found
unresponsive in his cell, his mother was not informed by the prison until about three
hours later.
Recommendations
53. Health Inspectorate Wales (HIW) have made a number of detailed
recommendations about dental care and healthcare in their reviews, which the
Director and Head of Healthcare at Parc will need to address.
54. We have made five high level recommendations below, as well as some
‘housekeeping’ and non-clinical recommendations.
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➢ The Chief Executives of HMPPS, NHS England and NHS Wales should
write to the Ombudsman setting out what they have done to satisfy
themselves that the dental services provided by Time for Teeth (TfT) in
prisons in England and Wales are safe and fit for purpose, including that:
• a dedicated dental software system, which meets the professional standards
set out by the General Dental Council, operates alongside SystmOne in
prison dental surgeries;
• there is an efficient appointments system to book dental appointments
promptly;
• dental emergencies are prioritised for urgent care;
• failed dental appointments are followed up and rescheduled promptly so that
emergency patients are not lost in the system;
• patients at a higher risk of complications are flagged;
• regular updates on patients causing concern are recorded and acted on;
• prisoners have access to out-of-hours emergency dental cover equivalent to
the level of safety and accessibility available in the community;
• prescriptions, particularly those for antibiotics for acute infections, are
dispensed within hours;
• all surgery equipment, especially diagnostic equipment, is regularly serviced
and is fit for use, as required by statutory regulations;
• effective processes are in place to communicate critical patient information
between the dental and healthcare teams and within the dental team;
• prison dental staff receive specialist training to ensure competence in prison
dental care; and
• clinical sessions set out in the contract / SLA include the presence of a
dental surgeon in the dental clinic at specified times to deal with
emergencies as they arise.
➢ The Chief Executive of NHS Wales should ensure that prison dental
surgeries in Wales are subjected to the same level of scrutiny and
inspection as community dental surgeries.
➢ The HMPPS Executive Director for Wales and the Chief Executive of NHS
Wales should write to the Ombudsman setting out what they have done to
satisfy themselves that the nurse-led healthcare service provided at Parc
by G4S Medical Services is safe and fit for purpose, including that:
• there is an appropriate staff mix so that registered general nurses lead the
care and those with specialist expertise, such as mental health nurses,
support them within their competence;
• staff make accurate and timely records in line with GMC and NMC
standards;
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• prisoners with complex care needs are promptly considered for transfer to a
prison with a 24-hour inpatient facility;
• a senior clinician is responsible for leading and coordinating the care for
prisoners with complex conditions;
• effective care plans are created and implemented; and
• therapeutic psychological services are available.
➢ The Chief Executive of NHS Wales should investigate whether Parc
followed the PGD regulations and whether the use of verbal instructions
by GPs for nurses to dispense prescription-only medicines from the out-
of-hours medication cupboard complies with regulations.
➢ Health Inspectorate Wales should consider whether the dentist and the
dental therapist should be referred to their professional bodies with a view
to considering their fitness to practice.
Housekeeping recommendations
• The Director and the Head of Healthcare at Parc should:
• liaise with the local Health Board to ensure that newly arrived insulin-
dependent diabetic prisoners are assessed on their understanding of
diabetes management and self-care so that appropriate care is provided in
line with prisoners’ needs; and
• commission an outreach service from the community diabetes team to
ensure that nursing staff are adequately trained and know when to seek
advice from secondary services.
• The Director and the Head of Healthcare at Parc should ensure that all prisoners
are assessed by the healthcare team on their return from hospital.
• The Director and the Head of Healthcare at Parc should ensure that hospital
discharge summaries for prisoners are received in a timely manner and, if this does
not happen, that requests are followed up promptly.
• The Head of Healthcare at Parc should ensure that CVOP meetings are clinically
multidisciplinary, that effective care plans are created and implemented, and that
the meetings are accurately minuted.
• The Director and the Head of Healthcare at Parc should ensure that SLPs are
properly completed and shared with operational staff and are taken into account
when providing care to prisoners.
• The Head of Healthcare at Parc should ensure that the prison pharmacist:
• regularly reviews the medication needs of prisoners who use insulin and that
insulin prescriptions are ordered promptly; and
• ensures there are adequate supplies of lancets and blood testing strips for all
prisoners who use insulin.
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Non-clinical issues
• The Director at Parc should ensure that prisoners with substance misuse issues are
supported and that efforts to tackle the availability of illicit substances are
prioritised.
• The Director at Parc should ensure that staff manage prisoners at risk of suicide
and self-harm in line with national policy, in particular staff should:
• assess risk based on all relevant information, including that held in medical
records;
• mark caremap actions as completed only once they have been actioned fully;
and
• ensure that caremap actions are created and reviewed in line with national
guidance and are specific, meaningful and time-bound, aimed at reducing
prisoners’ risks; and
• obtain appropriate clinical input where appropriate before deciding to stop
ACCT procedures.
• The Director at Parc should ensure that staff:
• involve the prisoner’s next of kin in their care where appropriate, in line with
PSI 64/2011; and
• ensure that the next of kin are promptly informed when a seriously ill prisoner
is taken to hospital.
• The Director at Parc should ensure that Parc’s instructions to staff about roll checks
are consistent.
• The Director at Parc should ensure that when a cell door is unlocked, staff satisfy
themselves of the wellbeing of the prisoner and that there are no immediate issues
that need attention.
• The Director at Parc should ensure that control room staff call an ambulance
immediately they receive a medical emergency code.
Learning lessons
• The Head of Healthcare at Parc should share this report with Nurses A, B and C
and discuss the ombudsman’s findings with them.
• The Director should share this report with CM A and Officers A, B and C and
arrange for a senior manager to discuss the Ombudsman’s findings with them.
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The Investigation Process
55. We investigated Mr Nunes’ death, with the help of a clinical reviewer appointed by
Healthcare Inspectorate Wales (HIW) and issued a draft report to stakeholders in
December 2016. The solicitors representing Mr Nunes’ mother raised a number of
concerns about our investigation and conclusions. In November 2017, we issued a
final report into Mr Nunes’ death, and addressed the issues raised by the solicitors
in separate correspondence.
56. HM Coroner for South Wales Central Area held an inquest in November/December
2017. The jury concluded:
“Mr Nunes sadly passed away due to the failure to manage his own health
adequately … We the jury came to the final conclusion that despite
insufficient provision of care under G4S during the period of the 20th to 21st
of February 2016, Mr Nunes’ management of his own health is the direct
cause of death.”
57. Mr Nunes’ mother’s solicitors continued to raise concerns about our investigation
and in February 2018 we made some additions to our final report. However, in
response to further concerns, the Acting Prisons and Probation Ombudsman asked
a senior investigator and an Assistant Ombudsman to review our original
investigation and subsequent report. The Acting Ombudsman then asked them to
reinvestigate the circumstances of Mr Nunes’ death.
58. We also asked HIW to carry out a further review of Mr Nunes’ clinical care at Parc.
HIW appointed two new clinical reviewers to review the general clinical and dental
care provided.
59. The investigator reviewed documentation obtained during the original investigation
and obtained other relevant documents. He re-interviewed four members of staff
and interviewed a further five members of staff, including three from the prison’s
dental team. He carried out some of the interviews jointly with the clinical
reviewers.
60. We told HM Coroner that we were re-investigating Mr Nunes’ death and the
investigator reviewed some of the evidence given during the inquest into his death.
We have sent the Coroner a copy of this new report.
61. In November 2018, the investigator met Mr Nunes’ mother and he has updated her
through her solicitors throughout the course of the re-investigation. Mr Nunes’
mother and her solicitors have raised numerous concerns, which we have
addressed in the Findings section of this report and in the two clinical reviews.
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Background Information
HMP Parc
62. HMP Parc is a medium security prison near Bridgend in South Wales. The prison is
run by G4S Care and Justice Services and holds around 1,600 men and young
adults convicted or on remand. It also has a unit for around 60 young people under
18.
63. At the time of Mr Nunes’ death, G4S Medical Services provided primary physical
and mental health care services at Parc and the Abertawe Bro Morgannwg
University Health Board provided secondary mental health services. There were
24-hour general healthcare and palliative care facilities, but no inpatient facilities. A
local General Practitioner practice provided GP services, including a daily clinic and
out-of-hours cover. There were three healthcare staff available in the prison at
night.
64. Time for Teeth (TfT) provided all dental services at Parc under a service level
agreement (SLA) which started in 2012 and expired on 31 December 2015,
although it continued to remain in place until it was renewed in 2017.
65. The original SLA stipulated that six dental sessions a week took place at the prison,
with the renewed SLA providing eight dental sessions a week. The SLA made no
provision for out of hours emergency dental cover during the weekdays, weekends
or Bank Holidays. Healthcare staff and the GP service provided out-of-hours
emergency dental cover at Parc. Specialist referrals for secondary dental care
were available at the Princess of Wales (POW) Hospital in Bridgend.
HM Inspectorate of Prisons (HMIP)
HMIP inspection: January 2016
66. A HMIP inspection of Parc took place in January 2016. Inspectors reported that
experienced clinical managers and lead nurses provided effective clinical
leadership, but that significant recruitment and retention problems affected
secondary health screening. Inspectors reported that support for prisoners with
complex health needs, including life-long conditions, was generally good and that
the lead GP had developed comprehensive case management that had contributed
to improved outcomes for prisoners with complex epilepsy, which was being
expanded to prisoners with diabetes. However, inspectors reported that prisoners
remained overwhelmingly negative about prescribing, access to services, mental
health support and the quality of care.
67. Inspectors reported that prisoners with mild to moderate mental health needs were
not always assessed promptly, and that primary mental health provision was
inadequate as prisoners had no access to clinical psychology or psychiatry and did
not receive the ongoing support they needed.
68. Inspectors said medicines were given at clinically appropriate times but that many
administration records were incomplete, and it was unclear if prisoners had
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received their medication. Inspectors reported that medicines held for
administration under patient group directives (PGDs) were not audited regularly.
69. Inspectors reported that TfT provided equivalent dental services but waiting times
were too long at around eight weeks. Inspectors said prisoners requiring routine
appointments were triaged by a dental nurse within one to three weeks and saw a
dentist around six weeks later. Inspectors reported that emergency dental provision
was adequate, that the dental facility was excellent and clinical governance was
good.
70. Inspectors reported that prisoners monitored under suicide and self-harm
procedures felt supported and cared for and that prisoners in crisis, who required
higher levels of support, were held in the safer custody unit. Inspectors reported
that ACCT documentation was very good.
71. Inspectors reported that the ready availability of psychoactive substances (PS) was
having a severely negative influence in the prison and that over half of prisoners
told them that it was easy to obtain drugs. Inspectors reported that the prison had
failed to meet its mandatory drug testing target but was actively addressing supply
reduction and that the process for identifying managing and reducing violence were
good with interventions to support victims of violence.
HMIP inspection: November 2019
72. HMIP carried out a further inspection of Parc in November 2019. Inspectors
reported that, overall, the prison was fulfilling its core purposes well but there was
room for improvement. Inspectors reported that the quality of ACCT documents
was mixed and caremaps lacked detail.
73. Inspectors described access to health services and treatments as problematic but
found an appropriate range of primary care services, including from GPs, and that
care for patients with long-term conditions had improved because of enhanced
staffing. However, inspectors reported that there was insufficient capacity in the
secondary mental health team to deliver appropriate care and treatment for
prisoners with complex needs, that there were no occupational therapists and there
was minimal psychology input.
74. Inspectors reported that the prisoner ‘in possession’ medication policy needed to be
reviewed as risk assessments focused on the individual and were not reviewed for
each new medicine (such as antibiotics). Inspectors reported that this affected the
provision of effective treatment. HMIP reported that prisoners reported a delay in
receiving directly-ordered prescriptions, but they considered that the delays were
not unreasonable. Inspectors also reported that the supervised administration of
medicines took place at set times which meant that dosage schedules could not be
adhered to. However, they found that some provision was available for
administration at lunchtime and at night.
75. HMIP reported that TfT had an experienced team who provided an appropriate
range of treatments, including a dental nurse who assessed prisoners to ensure
that clinical priorities were identified, and routine appointments and ongoing
treatments were arranged on time. HMIP reported that access to dental provision
was good, and that equipment was appropriately maintained.
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Independent Monitoring Board
76. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In their report for the year to July 2016, the IMB reported that they
considered that Parc was well managed. The IMB reported an ongoing problem
with high numbers of prisoners not attending healthcare appointments because of a
lack of staff to escort them.
77. In their most recent report for the year to February 2019, the IMB reported that the
prison remained well managed and that positive changes had been introduced to
reduce the level of non-attendance at healthcare appointments.
Previous deaths at HMP Parc
78. In the 12 months before Mr Nunes’ death, six prisoners died at Parc: five of the
deaths were from natural causes and one was self-inflicted.
79. In three of our previous investigations, we made similar but not identical
recommendations to those that we make in this report. These included addressing
the lack and quality of formal care plans for those with chronic disease, delays in
administering medication, the failure of staff to liaise with secondary care services
and the need for those known to use illicit substances to be referred to the prison’s
substance misuse team for support. In one investigation, we also made
recommendations about weaknesses in the management of ACCT procedures,
about the need for staff to satisfy themselves about a prisoner’s wellbeing during
unlock, and about the need to address both the supply and demand for illicit drugs
at Parc.
80. There have been 27 deaths at Parc since Mr Nunes’ death: 17 were from natural
causes, five were self-inflicted and five were drug-related. In most of these cases
we have found that the healthcare the prisoner received was equivalent to that he
could have expected to receive in the community. However, in the case of five
deaths (in October 2016, November 2017, October 2018 and January and August
2019) we found that the standard of healthcare was below that in the community –
in some cases, well below – and in our report on a death in July 2018, we
recommended that that healthcare introduce a protocol for managing prisoners who
frequently refuse treatment and/or discharge themselves from hospital.
Type 1 diabetes
81. Type 1 diabetes, or insulin-dependent diabetes, is an autoimmune disease that
causes the destruction of the insulin-producing cells in the pancreas, meaning that
the body is not able to produce enough insulin to regulate blood glucose (blood
sugar) levels. The condition can develop at any age. Because Type 1 diabetes
causes the loss of insulin production, it requires regular insulin administration,
usually by injection.
82. Type 1 diabetes is a serious condition which can result in significant risks and
complications. These can occur if blood sugar levels go too low or too high and if
insulin injections are missed. Complications can include hypoglycaemia (low blood
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sugar levels) which can result in symptoms including sweating, fatigue, dizziness,
hunger, confusion, convulsions and loss of consciousness, and hyperglycaemia
(high blood sugar levels) which can cause the life-threatening condition of diabetic
ketoacidosis (DKA)).
83. DKA happens when the body starts to run out of insulin. This causes harmful
substances called ketones to build up in the body and can be life-threatening if not
promptly identified and treated. Symptoms of DKA include needing to urinate more
frequently, dehydration, stomach pain, breath that smells of pear drops, deep
breathing, tiredness, confusion and passing out.
84. Ketones are measured at four levels: 1 (normal), 2 (medium), 3 (high) and 4
(possible DKA). People with level 2 or higher should contact healthcare specialists
and for those with a level of 4, emergency medical attention is essential.
85. Symptoms of Type 1 diabetes are significantly reduced if individuals maintain good
control of their blood sugar levels by regular testing and administering insulin when
appropriate. Flexible insulin therapy usually involves self-injecting multiple daily
doses of insulin, with the doses adjusted based on taken or planned exercise,
intended food intake and other factors, including current blood glucose, which the
insulin user needs to test on a regular basis. This self-management needs the
insulin user to have the skills and confidence to manage the regime. One of the
most important roles of healthcare professionals providing diabetes care to adults
with Type 1 diabetes is to ensure that systems are in place to provide informed,
expert support, education and training for insulin users. Regular attendance at
diabetic clinics is also essential.
86. Diabetes is hard to manage, and it is common for people with Type 1 diabetes in
particular to suffer from ‘diabetes distress’. The symptoms of this include:
• feeling angry about diabetes and frustrated about the demands of managing it
• worrying about not taking enough care of your diabetes but not feeling motivated
to change
• avoiding going to appointments or checking your blood sugars
• regularly making unhealthy food choices
• feeling alone and isolated.
87. Having diabetes distress for a long period can lead to ‘diabetes burnout’ when the
patient stops taking care of themselves, including skipping insulin doses.
Assessment, Care in Custody and Teamwork
88. Assessment Care in Custody and Teamwork (ACCT) is the Prison Service’s care-
planning system used to support prisoners at risk of suicide or self-harm. The
purpose of ACCT is to try to determine the level of risk, how to reduce the risk and
how best to monitor and supervise the prisoner.
89. After an initial assessment of the prisoner’s main concerns, levels of supervision
and interactions are set according to the perceived risk of harm. There should be
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regular multidisciplinary review meetings involving the prisoner. As part of the
process, a caremap (plan of care, support and intervention) is put in place. The
ACCT should not be closed until all the actions on the caremap have been
completed. A post-closure review should take place after the closure of the ACCT
to identify whether any issues or concerns have been identified since the closure of
the ACCT and, if so, to consider whether to re-open the ACCT. Guidance on ACCT
procedures is set out in Prison Service Instruction (PSI) 64/2011
Psychoactive Substances (PS)
90. PS (formerly known as ‘new psychoactive substances (NPS)’ or ‘legal highs’) are a
serious problem across the prison estate. They can affect people in a number of
ways including increasing heart rate, raising blood pressure, reducing blood supply
to the heart and causing vomiting. Prisoners under the influence of PS can present
with marked levels of disinhibition, heightened energy levels, a high tolerance of
pain and a potential for violence. Besides emerging evidence of such dangers to
physical health, there is potential for PS to precipitate or exacerbate the
deterioration of mental health, and they are linked to suicide and self-harm.
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Key Events
91. A more detailed account of the key events is attached at Annex 1.
92. Mr Nunes had served several sentences in young offender institutions and prison,
most recently for drug offences and affray. On 14 January 2015, he was recalled to
custody and in May, he received a further 12-month sentence. He was moved to
HMP Parc on 1 June.
Diabetes
93. Mr Nunes had been diagnosed with Type 1 diabetes as a child. His mother
supported him in managing his diabetes in the community by monitoring his blood
sugar levels and administering his insulin, even into adulthood.
94. Mr Nunes did not comply with his insulin medication regime at Parc. He was
frequently aggressive to healthcare staff when they told him how important it was
that he should test his blood sugar and ketone levels to manage his diabetes and
prevent diabetic ketoacidosis. (DKA, a potentially life-threatening condition.) Mr
Nunes also raised issues with healthcare staff about not having access to
equipment to test his blood sugar and ketone levels.
95. Between June 2015 and February 2016, Mr Nunes was admitted to hospital with
suspected DKA on 14 occasions and discharged himself on several occasions
against medical advice. Staff suspected he might be deliberately making himself ill
so he could collect illicit drugs in hospital and bring them back into prison. When he
returned to Parc after being hospitalised, Mr Nunes was frequently not assessed by
a GP and his blood sugar and ketone levels were not reviewed by healthcare staff.
96. In September 2015, healthcare staff started to ask Mr Nunes to sign medical
disclaimers if he refused to take his insulin. During September alone, Mr Nunes
signed 14 medical disclaimers. In September and October, Mr Nunes failed to
attend three GP appointments, a hospital appointment and four nurse-led clinic
appointments.
97. In November and December, staff held two multidisciplinary case conferences to
discuss Mr Nunes’ poor diabetes management and his refusal to attend hospital for
further assessment. His mother attended the second case conference.
98. In November and again in December, staff started suicide and self-harm monitoring
and support procedures (known as ACCT) as they considered that Mr Nunes’
failure to take responsibility for his health was a form of self-harm. The second
period of ACCT management ended on 29 December. In December, he was
assessed by a mental health nurse.
99. On 14 December, Mr Nunes was seen by a GP for the last time. He failed to attend
three GP appointments in December and in January 2016. No follow-up
appointments were arranged.
100. Between 8 January and 12 February 2016, healthcare staff saw Mr Nunes regularly
for diabetes reviews. They noted that he had been reminded of the importance of
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managing his diabetes but that he continued to refuse to check his blood sugar and
ketone levels and was often abusive towards staff when they reminded him.
Healthcare staff made no changes to how they managed his healthcare.
Toothache
101. In November and December 2015, Mr Nunes complained of toothache. An
appointment was made for him to see a prison dentist on 18 January 2016 for a
suspected abscess, but he failed to attend. On 5 February, Mr Nunes complained
again. A prison dentist saw him on 8 February but could not examine him properly
as Mr Nunes was unable to open his mouth wide enough because of pain and
swelling. The dentist prescribed antibiotics and planned to review him on 15
February.
102. On 10 February, Mr Nunes received his antibiotics, two days after they had been
prescribed. He did not attend his dental appointment on 15 February, and no
follow-up dental appointment was made.
103. On 17 and 18 February, Mr Nunes complained to nurses about pain from his
abscess. On 18 February, a nurse instructed that he should be given antibiotics
overnight, but this did not happen as there was no one on duty who was qualified to
prescribe them.
104. On 19 February, a dental therapist assessed him but was unable to examine him as
he could not open his mouth. She noted that Mr Nunes had not been given
antibiotics and that she needed to discuss this with the prison GP. She booked an
appointment for him to see the dentist on 22 February.
105. On 20 February, Mr Nunes felt unwell in the early hours. Healthcare staff noted that
he was at a considerable risk of DKA, and he was taken to hospital by taxi. This
was Mr Nunes’ 15th and penultimate admission to hospital. Mr Nunes insisted on
discharging himself from hospital although a hospital doctor told him he risked dying
if he did so. When he returned to Parc, no one from the healthcare team assessed
him.
106. Later that morning, Mr Nunes did not collect his medication and did not attend a GP
appointment. Nurses noted that they had been told by prison officers that he could
not be bothered to get out of bed. He was not seen by anyone from healthcare.
Events of 21 February 2016
107. On 21 February, roll checks were carried out at about 5.30 and 7.00am and no
concerns were raised about Mr Nunes. At 8.40am, an officer unlocked Mr Nunes’
cell door but did not look into the cell to complete a welfare check.
108. At 9.04am, an officer found Mr Nunes unresponsive in his cell. The officer raised
the alarm, and an ambulance was called at 9.14am. At 9.34am, paramedics arrived
at Mr Nunes’ cell. Mr Nunes was stabilised, and he was taken to hospital at
9.44am.
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109. Mr Nunes’ condition deteriorated in hospital, and he died at 10.45pm, with his family
present.
Contact with Mr Nunes’ family
110. Mr Nunes was taken to hospital at 9.44am on 21 February 2016. At 12.15pm on 21
February, the prison appointed a chaplain as the family liaison officer. She
immediately telephoned Mr Nunes’ mother to tell her that Mr Nunes had been taken
to hospital.
111. Around three hours later, the chaplain went to the hospital to meet Mr Nunes’
mother and to offer her support. She asked Mr Nunes’ mother how she would like
to be told of any change in Mr Nunes’ condition. She said the chaplain should
contact her by telephone. The chaplain left the hospital at approximately 6.00pm
but returned at 10.20pm after she was told that Mr Nunes had deteriorated. She
conducted a prayer service and was with his family when Mr Nunes died at
10.45pm.
112. The following day, the chaplain and a prison manager visited Mr Nunes’ mother at
her home to offer their condolences and support.
113. The prison offered a contribution to the costs of Mr Nunes’ funeral in line with
national instructions, though his family declined the offer.
Support for prisoners and staff
114. On 29 February, a senior prison manager held a hot debrief for the staff involved in
the emergency response and the bed watch to ensure they had the opportunity to
discuss any issues arising, and to offer support. The staff care team also offered
support. A week later, the manager debriefed the staff involved in the bed watch
and she again offered them support.
115. The prison posted notices informing other prisoners of Mr Nunes’ death and offering
support. Staff reviewed all prisoners assessed as at risk of suicide or self-harm in
case they had been adversely affected by Mr Nunes’ death.
Post-mortem report
116. The post-mortem examination concluded that Mr Nunes’ death had been caused by
septic shock and DKA, caused by necrotising fasciitis of the left temple and insulin-
dependent diabetes mellitus.
117. Septic shock occurs when the blood pressure drops to a dangerously low level as
the result of an infection and causes organ failure. People with diabetes have an
increased risk of developing septic shock. Necrotising fasciitis is a rare but serious
bacterial infection in which toxins are released that damage nearby tissue.
118. The toxicology report found PS in Mr Nunes’ blood but noted that it was not
possible to ascertain when they were last used or what role they may have played
in his death.
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Mr Nunes’ mother’s statement to the Coroner
119. In a statement to the Coroner, Mr Nunes’ mother said that there had been no real
problems with Mr Nunes’ diabetes treatment when he had been in previous prisons,
and that it was only after he arrived at Parc that he began to complain about access
to his insulin. She said this worried her and she tried to contact the healthcare team
many times to discuss her son’s care.
120. Mr Nunes’ mother said that when she met the complex case manager and a prison
manager in November 2015, she was told that her son might be being bullied to
pick up drugs from hospital. Mr Nunes mother said she did not think this made any
sense as if this was the case, she would have been expected to have been
searched by his escorts in hospital, which had never happened.
121. Mr Nunes’ mother told the inquest that she had persuaded him to stay in hospital
many times in the past when he had wanted to discharge himself. She said he
required support with managing his diabetic regime and that she would have to tell
him when it was time to take his insulin. She said she did not think her son fully
understood the details of his diabetic regime and found it hard to adjust to his new
insulin regime.
122. Mr Nunes’ mother said that she was certain that her son was becoming more ill.
She said that she was told in December that she would be contacted if he was
admitted to hospital, but this never happened, apart from on the day that he died.
She said that if she had been contacted, she might have been able to stop him
discharging himself.
123. She said that on the day Mr Nunes died, she was not told that he had been
admitted to hospital until around 12.30pm, three hours after he had been found
unresponsive in his cell. She said she understood the hospital had asked the
prison to contact her.
124. Mr Nunes’ mother said her son liked everything in order and was very clean. She
said that when she saw her son’s cell after his death, it was awful, and she did not
believe her son had lived like that.
Accounts of other prisoners
125. After Mr Nunes’ death over fifteen prisoners provided statements.
126. A prisoner who shared a cell with Mr Nunes, said that towards the end of January,
Mr Nunes had a swollen face from toothache and cried a lot as he was not able to
eat properly. He said Mr Nunes told staff but that nothing was done about it. He
said that Mr Nunes would beg staff to help him and would cry himself to sleep. He
said that on one occasion when responding to a cell bell, a member of staff said to
him, “You again. You are always crying like a baby.” The prisoner said he asked
for a cell transfer on 19 February, as he felt no longer able to share a cell with Mr
Nunes because he was so unwell.
127. A friend of Mr Nunes said he had never seen Mr Nunes so ill as in the time leading
to his death. He said he told staff about his concerns, but no one took any notice.
He said officers ignored Mr Nunes and would just lock him behind his cell door
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when he became frustrated about his health and did not appear to care about his
welfare. He said officers would laugh and make jokes about Mr Nunes.
128. A prisoner said officers treated Mr Nunes as if there was nothing wrong with him
and would call him a baby. Another prisoner said that healthcare staff and officers
at the prison neglected Mr Nunes. He said that Mr Nunes could not eat properly
because of the swelling caused by the abscess. A third prisoner said he
complained to staff about the treatment Mr Nunes was getting. He said staff would
say Mr Nunes was crying like a baby and would tell him to “man up”.
129. A prisoner said in his statement that towards the end of his life, Mr Nunes would
break down and cry in the middle of the wing and that this was out of character for
someone who was strong. He said Mr Nunes could not eat for around about 10
days before his death because of toothache and the abscess in his mouth and that
no one took him seriously.
130. Statements from other prisoners gave accounts of witnessing Mr Nunes in pain,
with his face swollen and often crying in pain. Many expressed concerns in their
statements that they did not think Mr Nunes received appropriate treatment during
his time at Parc.
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Findings
131. HIW commissioned two clinical reviews as part of our re-investigation, one to
address Mr Nunes’ dental care and the other his general clinical care. We have
summarised the main issues identified in these reviews in our findings below. More
detail on these and other issues is contained in Annexes 2 and 3.
132. HIW have made a large number of recommendations. Although we do not repeat
them all here, they will all need to be addressed by the relevant parties.
Provision of dental care at HMP Parc
Overall conclusion
133. The post-mortem report concluded that one of the causes of Mr Nunes’ death was
necrotising fasciitis (NF) of the temple.
134. HIW said that the most common cause of NF affecting the head or neck is a dental
infection in patients with weakened immune systems, such as those with diabetes,
and linked Mr Nunes’ dental abscess to his NF. HIW said that early recognition is
critical for successful treatment as the infection can spread very rapidly and lead to
organ failure and death.
135. As it appears that the NF had a dental origin, we have considered whether the
dental care Mr Nunes received was appropriate, timely and equivalent to that he
could have expected to receive in the community.
136. HIW concluded that Mr Nunes’ dental care was unsafe and subject to a catalogue
of failings with systems not fit for purpose. They noted that Mr Nunes’ dental
infection remained untreated for 43 days and that subsequent dental care fell well
below acceptable professional standards and resulted in a serious failure to meet
the duty of care to him.
137. HIW concluded that the whole dental team mismanaged Mr Nunes’ dental infection
and said NF would not have developed if the dental infection been appropriately
managed. They found that Mr Nunes’ death from NF arising from his mismanaged
dental infection would have been preventable if he had been treated appropriately
and in a timely manner.
138. We have examined the various concerns in more detail below.
Record keeping
139. HIW noted that SystmOne (the electronic medical record system used by prison
healthcare staff) were the only records of Mr Nunes’ dental care at the prison. No
separate or additional dental notes or radiographs were identified during the
investigation by either Parc or Time for Teeth (TfT), the prison’s dental provider,
and a dedicated dental software system, as used in community dental surgeries,
was not being used.
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140. The dental therapist told the investigator that all dental records at Parc were kept on
SystmOne but that brown cards, stored manually, were used for charting teeth. The
dentist told the inquest that he did not keep handwritten records. Tft agreed that
SystmOne was not a robust system for recording dental records and said they had
raised their concerns about this with G4S.
141. HIW found that it was not possible for SystmOne to record the dental information
required for charting, a process used to note the description and condition of a
patient’s teeth, treatment plans and treatment provided. HIW concluded that dental
record keeping at Parc did not meet the standards set by the General Dental
Council (GDC), the dental professional regulatory body, and was not fit for purpose
for the provision of safe dental care.
Timely dental appointments
142. The HIW found that there were long delays before Mr Nunes received dental
appointments:
• On 27 December, healthcare staff identified that Mr Nunes may have a dental
abscess. A dental referral was made through a Task on SystmOne, and a dental
appointment was subsequently made for 18 January, 22 days later. HIW said
that this was an unacceptable delay, given Mr Nunes’ poorly-controlled diabetes
and suspected dental infection. They noted that this would not have happened in
the community. HIW also noted that there was no record on SystmOne to
explain why healthcare staff used the lengthy Task appointment system rather
than making an immediate emergency referral to the dental clinic, where a dentist
would be present on 29 December.
• On Friday, 5 February 2016, Mr Nunes was not offered an emergency referral to
the dental clinic, even though three calls had been made to ask for pain relief and
there was a dentist present in the prison that day. Mr Nunes was not seen by a
dentist until Monday, 8 February 2016.
143. HIW concluded that the system for booking dental appointments at Parc was
inefficiently organised and that poor communication between healthcare and dental
staff resulted in delayed appointments for acute dental care.
Failed appointments
144. TfT said there was a high failure rate of prisoners attending dental appointments in
prisons in England and Wales. HIW noted that there were no systems in place at
Parc to deal with failed prisoner appointments.
145. Mr Nunes failed to attend two of his dental appointments, the first on 18 January for
his suspected dental abscess, and a follow-up appointment on 15 February to
monitor the progress of his infection. HIW noted that Mr Nunes had an acute dental
infection at the time of both missed appointments. On both occasions, no one from
the dental or healthcare team checked why he had failed to attend, or his state of
health and wellbeing. HIW also found that no one arranged an alternative
appointment as there was no co-ordinated management of the appointment system,
and that this resulted in Mr Nunes being lost in the system for unacceptably long
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periods of time, during which his infection was not monitored. HIW concluded this
was a failure in the duty of care.
Out of-hours provision for emergency dental care
146. HIW noted that there was no provision for emergency dental care at Parc out-of-
hours on weekdays, weekends or Bank Holidays. They concluded that this fell well
below the standard of care expected in the community and put Mr Nunes’ safety at
serious risk.
Delay in dispensing medication
147. HIW found that on at least four occasions, Mr Nunes’ dental medication, including
antibiotics, was dispensed late or not at all:
• There were delays in providing pain relief to Mr Nunes when he complained of
toothache.
• Although the dental referral of 27 December indicated that Mr Nunes was on an
antibiotic regime, there is no record that antibiotics were dispensed.
• When Mr Nunes was prescribed antibiotics on 8 February 2016, they were not
dispensed until 10 February, two days later. HIW concluded that this delay was
inappropriate and unacceptable given the seriousness of Mr Nunes’ dental
infection.
• Although a further antibiotic was prescribed at around 8.00pm on 18 February, it
was not dispensed until the following day at around 11.30am, over 15 hours later,
because of system failures and poor communication. This unacceptable delay
occurred because nurses did not have the authority to dispense the antibiotics
from the Patient Group Directive cupboard, and HIW noted that nurses did not
contact the on-call GP to enable them to dispense the antibiotics.
148. HIW said that the efficacy of antibiotics is dependent on them being dispensed as
soon as possible after prescription and that the unacceptably long delay in
dispensing Mr Nunes’ antibiotics was a contributory factor to Mr Nunes’ dental
infection exacerbating and developing into NF which was one of the causes of his
death.
Maintenance of dental equipment
149. HIW noted that an extra-oral (OPG) x-ray machine is a valuable diagnostic tool,
especially when a patient cannot open his mouth because of infection or trauma, as
was the case for Mr Nunes. Although there was an extra-oral OPG machine in the
dental clinic on 8 February 2016, it had not been maintained and was not in working
order. HIW concluded that the absence of a working extra-oral x-ray machine
resulted in a lost opportunity to identify the cause of Mr Nunes’ dental infection at an
earlier stage.
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Communication
150. HIW noted that Mr Nunes’ dental care was unequally shared between healthcare
and dental staff. SystmOne recorded that Mr Nunes required dental attention 28
times at Parc, but he was only treated by dental staff twice. Although the dental
clinic at Parc was in the same building as the healthcare department, there was
only one occasion (19 February) when there was direct communication between
healthcare and dental staff and only three occasions when there was indirect
communication using Tasks.
151. HIW found there was no effective communication between healthcare staff and
dental staff about patients needing extra care, no effective “flagging” between
dental staff of patients in need of extra vigilance, and no policies or protocols in
place about the handover of care from dental to healthcare staff.
152. HIW concluded that there was a failure to provide safe and timely dental care for Mr
Nunes because of inadequate communication between dental and healthcare staff,
which resulted in a series of missed opportunities to refer him for urgent dental
treatment or to highlight that he had an acute dental infection requiring emergency
treatment.
Training
153. Public Health England’s survey of dental services in adult prisons in England and
Wales carried out in 2014, found that the prison population has poorer physical,
mental and social health, as well as higher levels of substance misuse. The survey
also identified poor levels of oral health in prison, four times higher than the general
population. As a result, Public Health England recommended specialised training
programmes for dental clinicians working in prisons.
154. HIW found no evidence that TfT provided its dental staff at Parc with a specialised
training programme in prison dental care and concluded that this contributed to the
failure to provide Mr Nunes with safe and effective dental care.
Failings in the dental treatment provided
155. HIW noted that the prison’s healthcare team, who were not dentally trained,
provided analgesia for Mr Nunes dental pain, treating the symptoms rather than the
cause of his pain. The review also noted that when Mr Nunes was eventually seen
in the dental clinic, he was seen only once by a dentist and once by a dental
therapist.
The dentist
156. HIW identified several failings in the standard of care provided the prison dentist
when he saw Mr Nunes on 8 February, including that:
• He failed to search SystmOne for any previous dental notes. Earlier notes were
available which would have provided a basis for the probable cause of Mr Nunes’
dental infection and would also have shown that he had missed an appointment
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on 18 January and had not been seen for 43 days since his original referral to the
dentist on 27 December.
• His notes fell below the standard of record keeping expected of a dental surgeon.
They were not accurate, clear, concise or complete and failed to record the
significance of Mr Nunes’ symptoms.
• He charted the suspected infected tooth as being on the right side, rather than
the left where there was facial swelling.
• He failed to identify and highlight Mr Nunes’ trismus (inability to open the mouth
completely) and failed to note the significance of this and the facial swelling in an
immune-compromised Type 1 diabetic patient.
• He failed to carry out an extra-oral examination to note the nature and extent of
swelling of Mr Nunes’ lymph glands in response to an infection.
• He failed to refer Mr Nunes to secondary care for an extra-oral radiograph (OPG)
to help identify the cause of the dental infection as the prison x-ray machine was
not working.
• He only prescribed amoxicillin but should have prescribed it in combination with
metronidazole, in line with the standard antibiotic protocol. He did not record why
he deviated from normal antibiotic protocol.
• He failed to ensure that Mr Nunes’ facial swelling and trismus were reviewed
within the week. There was a dentist in the prison on 12 February who could
have referred Mr Nunes for specialist care if his symptoms had got worse.
• He failed to note why he did not refer Mr Nunes for secondary care for specialist
treatment.
157. HIW concluded that the quality of dental care and treatment that the dentist
provided Mr Nunes on 8 February fell significantly below the standards expected of
a qualified dental surgeon.
The dental therapist
158. A dental care professional was employed as a dental therapist and provided dental
treatment to patients at Parc under the supervision of a qualified dental surgeon.
She did not have the authority to prescribe antibiotics as she was not included on
the Patient Group Directive (PGD). She told the investigator that although she was
qualified to take x-rays, she felt it was outside her scope and had never
independently taken one for a prisoner at Parc.
159. The dental therapist saw Mr Nunes once on 19 February. HIW identified several
significant failings in the standard of care provided by her, including that:
• If she checked previous records, she would have noted that Mr Nunes had
presented as an emergency on 8 February with a swollen face and unable to
open his mouth. Mr Nunes’ dental symptoms had not improved for 11 days. HIW
said that this should have alerted the dental therapist to the fact that Mr Nunes’
dental infection had been neglected for a dangerously long period. However, she
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treated Mr Nunes as a new dental emergency. HIW said that this was a
significant failure in the standard of care expected of a qualified dental
professional.
• She failed to carry out a thorough extra-oral examination to record the nature and
extent of the swelling, the degree of trismus and any significant swelling of the
lymph glands.
• There is no record that she considered an emergency referral to secondary care,
and she failed to note her reasons for not referring him.
• Her dental notes fell far below the standard of record keeping expected of a
qualified dental therapist.
160. HIW concluded that the dental therapist’s scope of practice and level of
competence meant that she should never have been expected to see or treat dental
emergencies without supervision. However, on 19 February, she treated Mr Nunes
alone and unsupervised. HIW concluded that she was incapable of providing Mr
Nunes with appropriate emergency dental care and that the failure to refer him
immediately to secondary care for specialist investigation and treatment was a
major breach in her duty of care to Mr Nunes.
161. HIW also said that, given there was no emergency dental provision at weekends at
Parc, and TfT failed to fully assess the risk of not having a qualified dentist present,
particularly on a Monday and Friday, able to make professional decisions, diagnose
and carry out the full range of dental treatment required. HIW concluded that a
dental therapist who needed to work under the supervision of a dentist was
therefore not an appropriately qualified staff member for the clinic.
162. HIW concluded that the dental therapist did not provide Mr Nunes with appropriate
dental treatment and that his dental care immediately before his death was severely
compromised. This was the result of placing inappropriately qualified dental staff on
the rota before a weekend when no dental services were available for emergency
care.
163. We recommend:
Health Inspectorate Wales should consider whether the dentist and the dental
therapist should be referred to their professional bodies with a view to
considering their fitness to practice.
164. We note that TfT provide dental services in a number of other prisons in England
and Wales. We make the following recommendation:
The Chief Executives of HMPPS, NHS England and NHS Wales should write to
the Ombudsman setting out what they have done to satisfy themselves that
the dental services provided by Time for Teeth in prisons in England and
Wales are safe and fit for purpose, including that:
• a dedicated dental software system, which meets the professional
standards set out by the General Dental Council, operates alongside
SystmOne in prison dental surgeries;
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• there is an efficient appointments system to book dental appointments
promptly;
• dental emergencies are prioritised for urgent care;
• failed dental appointments are followed up and rescheduled promptly so
that emergency patients are not lost in the system;
• patients at a higher risk of complications are flagged;
• regular updates on patients causing concern are recorded and acted on;
• prisoners have access to out-of-hours emergency dental cover equivalent
to the level of safety and accessibility available in the community;
• prescriptions, particularly those for antibiotics for acute infections, are
dispensed within hours;
• all surgery equipment, especially diagnostic equipment, is regularly
serviced and is fit for use, as required by statutory regulations;
• effective processes are in place to communicate critical patient
information between the dental and healthcare teams and within the dental
team;
• prison dental staff receive specialist training to ensure competence in
prison dental care; and
• clinical sessions set out in the contract / SLA include the presence of a
dental surgeon in the dental clinic at specified times to deal with
emergencies as they arise.
Prison dental surgery inspections
165. HIW have the statutory authority to inspect all NHS and private dental surgeries in
the community in Wales but have no authority to inspect prison dental surgeries,
which are left to regulate themselves. HIW concluded that the dental services at
Parc fell far below the standards in the community. We make the following national
recommendation:
The Chief Executive of NHS Wales should ensure that prison dental surgeries
in Wales are subjected to the same level of scrutiny and inspection as
community dental surgeries.
Provision of general clinical care
Diabetic care
Overall conclusion
166. HIW found that clinical staff at Parc lacked experience and knowledge of acute
diabetes complications and that as a result the diabetic care Mr Nunes received
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was inappropriate and not equivalent to that he could have expected to receive in
the community. HIW concluded that this had a detrimental effect on Mr Nunes’
health and that the actions of healthcare staff at Parc fell below the standards
expected by the General Medical Council (GMC) and Nursing and Midwifery
Council (NMC).
167. We have examined the specific concerns in more detail below.
Insulin regimes
168. HIW noted that when Mr Nunes was in hospital at the end of August 2015, his
insulin regime was changed, and hospital staff told healthcare staff at Parc that he
should be supervised when he administered his new insulin regime. Parc
misinterpreted this and removed Mr Nunes’ insulin from his possession so that he
had to attend the medication hatch to receive it. He then administered his insulin
himself in an adjacent corridor.
169. HIW said that this would have made it impossible for healthcare staff to observe Mr
Nunes’ injecting technique or the quantity of insulin he was injecting, and this
defeated the purpose of removing the insulin from his possession. HIW noted that
Mr Nunes had areas of lipohypertrophy (fatty lumps under the skin caused by
repeatedly injecting insulin into the same site) which healthcare staff had not
recognised. This condition is a common cause of poor blood sugar control because
insulin injected into these lumps does not work properly. If healthcare staff had
observed Mr Nunes more closely when he administered his insulin, they could have
prevented him from injecting in these areas and monitored the levels of insulin he
used.
170. HIW noted that Mr Nunes signed over fifteen medical disclaimer forms when he
refused to have his blood sugars tested before his insulin injections. HIW said that
a blood sugar test should not be required before every insulin injection and
concluded that Parc’s policy of requiring Mr Nunes to sign medical disclaimers
appeared to be more about healthcare staff’s concerns about their legal risk than
about providing him with appropriate care.
171. HIW also noted that between 20 August 2015 and 6 January 2016, when Mr Nunes
did not keep and administer his insulin, there were numerous occasions when
healthcare staff omitted to administer his insulin, something that should only happen
in exceptional circumstances. HIW noted that during this period, Mr Nunes was
admitted to hospital on seven occasions and for the first three weeks of November,
he missed nearly a quarter of his doses of insulin.
172. HIW identified several occasions when healthcare staff did not respond
appropriately when Mr Nunes missed an insulin dose. For example:
• On 2 September 2015, Mr Nunes told a nurse that he was annoyed that he had
not been given his evening dose of insulin. The nurse did not record why Mr
Nunes’ insulin had been omitted and did not check his ketone levels, even
though his blood sugar levels were high, although she did seek advice from the
offsite on-call prison GP. HIW said that the use of rapid-acting insulin may have
been clinically appropriate at this point. However, the GP advised no action and
HIW said that this was a clinically inappropriate decision which would have
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caused Mr Nunes’ blood sugar levels to rise further, causing him to become
dehydrated and unwell. HIW concluded that this decision, which demonstrated
a lack of knowledge about the management of diabetes, might have been a
precursor to the development of DKA.
• On 17 November Mr Nunes was not given his insulin as his prescription chart
had run out. HIW said that that the impact of missing a dose of insulin would
have led to hyperglycaemia, which might have led to Mr Nunes’ admission to
hospital four days later. HIW said that this could have been avoided if his insulin
had been administered correctly.
• On 22 November, the diabetic lead nurse noted that Mr Nunes was vomiting, his
blood sugar and ketone levels were very high and that he was very tearful and
blamed the nurse for his condition as she had not given him his insulin earlier
that day. HIW found that the omission of Mr Nunes’ insulin was clinically
negligent, and that the subsequent failure to monitor his blood sugar
demonstrated a further lack of care.
• In the early hours of 27 November 2015, Mr Nunes was distressed and told a
nurse that his ketones were raised, and he felt nauseous. The nurse told Mr
Nunes she would try to get him reviewed later that day. HIW concluded that this
was clinically negligent and that the nurse should have contacted the duty on-
call GP immediately to discuss an action plan and possible hospital admission.
HIW concluded that the nurse’s lack of action had a detrimental impact on Mr
Nunes’ health and caused a delay in him receiving the correct treatment.
• At 8.30am on 2 December, healthcare staff became aware that Mr Nunes was
feeling unwell. At 11.00am the prison GP told a nurse to give Mr Nunes a dose
of anti-sickness medication, to check if he was positive for ketones and that if he
was ketoic he might need hospitalisation. HIW noted that Mr Nunes’ ketone
levels were not checked until 7.30pm, over eight hours later, and said that this
was an inordinate delay in assessing vital aspects of Mr Nunes’ physical
condition. HIW said that Mr Nunes’ clinical signs indicated that he required
hourly monitoring and that the delay in assessment allowed his condition to
deteriorate further, once again needing hospital admission.
173. HIW also said that it was important that Mr Nunes’ insulin was administered
immediately before or after eating a meal, but that he was unable to do this
because of the discrepancy between the times the medication hatch was open and
the times that prison meals were served. HIW found that this restricted Mr Nunes’
ability to use his insulin correctly.
174. HIW concluded that the accumulation of these actions led to a critical and acute
deterioration in Mr Nunes’ health. HIW also concluded that the lack of urgency by
clinical staff in arranging the necessary monitoring and provision of insulin was the
result of inexperience and lack of knowledge about acute diabetes complications.
175. HIW made a number of recommendations which the Director and Head of
Healthcare will need to address, including the following issues:
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Blood strip testing
176. HIW noted that on numerous occasions during his time at Parc, Mr Nunes had
difficulty accessing blood sugar and ketone level testing strips and access to a
working blood sugar testing meter.
177. HIW concluded that healthcare staff should have regularly checked that Mr Nunes’
blood sugar testing meter was working properly, and that he could access the blood
sugar level testing strips that he needed. Healthcare staff appeared unaware that
Mr Nunes had not ordered supplies of test strips, and this showed a lack of
supervision and poor support, especially when he had extreme sugar levels. HIW
concluded that this was a failing in Parc’s duty of care to Mr Nunes.
178. We recommend:
The Head of Healthcare at Parc should ensure that the prison pharmacist:
• regularly reviews the medication needs of prisoners who use insulin
and that insulin prescriptions are ordered promptly; and
• ensures there are adequate supplies of lancets and blood testing strips
for all prisoners who use insulin.
Gastroparesis
179. Mr Nunes first presented to staff with gastrointestinal symptoms in June 2015 and
there were subsequently numerous entries in his clinical record about chronic
episodes of vomiting, abdominal pain and other symptoms of diabetic
gastroparesis. Prisoners who knew Mr Nunes also gave evidence of these
symptoms in statements submitted after his death.
180. HIW noted that healthcare staff tried to manage Mr Nunes’ symptoms with
intermittent use of anti-sickness injections and oral medication. HIW said that when
Mr Nunes had gastrointestinal symptoms, he was unable to eat and consequently
his insulin requirements would have changed and his glycaemic control would have
deteriorated, which would have contributed to his episodes of DKA.
181. HIW considered that healthcare staff at Parc failed to recognise and investigate Mr
Nunes’ gastrointestinal-related symptoms and did not request that diabetes
specialists visited him in prison, ask for advice on treatment or transfer him to a
prison with facilities better able to manage this complex condition.
182. HIW said that diabetic gastroparesis (a condition in which the stomach cannot
empty itself of food, causing nausea, vomiting and weight loss) is usually identified,
diagnosed and managed within secondary care settings and that it would not be
expected that it could be diagnosed in a primary care setting. Secondary care
experts would have been able to recommend appropriate therapies and strategies
that would have minimalised the unpleasant symptoms.
183. HIW said that healthcare staff should have been able to recognise that their
attempts to resolve Mr Nunes’ symptoms of gastroparesis were not successful, but
instead they continued to manage his gastric problems ineffectively without
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specialist guidance. The NICE guidelines for the management of diabetic
gastroparesis were not followed: there was no systematic approach to managing
his symptoms, clinical reviews were not held in a timely manner and interventions
were not reviewed. HIW considered that Parc’s inadequate management of Mr
Nunes’ gastroparesis was not equivalent to the treatment which he could have
expected to receive in the community. The clinical review said this was a significant
contributor to Mr Nunes’ repeated admissions to hospital and impacted adversely
on his health.
184. The Head of Healthcare at Parc will need to address this issue.
Clinical assessments and record keeping
185. HIW found that from Mr Nunes’ first contact with healthcare services at Parc and on
numerous subsequent occasions, healthcare staff failed to assess, observe and
examine him adequately, using tools such as NEWS and sepsis screening, and
frequently failed to monitor his blood sugar and ketone levels during periods of
illness.
186. HIW also found that healthcare staff’s clinical note-taking was too brief and fell
below the expected standards form the GMC and NMC.
Mr Nunes’ poor diabetic health literacy
187. HIW found that Mr Nunes’ had poor diabetic health self-management skills and
concluded that healthcare staff put an inappropriate onus on him to care for himself.
188. HIW noted that when Mr Nunes was admitted to hospital at the end of August 2015,
his diabetes treatment changed to a more complex basal-bolus regime. HIW said
that the few days Mr Nunes spent in hospital would not have been sufficient to
complete an in-depth education programme about the new insulin regime and that
in the community, this change would have been followed by a structured education
programme. This was not offered to Mr Nunes.
189. On 17 November, Mr Nunes experienced the first of two hypoglycaemic events
during his time at Parc, which confirmed his poor awareness of hypoglycaemia, as
set out in his hospital records. HIW concluded that prison healthcare staff treated
this first episode of hypoglycaemia inadequately, and also failed to recognise Mr
Nunes’ ignorance about the condition or to put a plan in place to address this
problem.
190. HIW also noted that in early December, when healthcare staff asked if he had taken
his insulin, Mr Nunes said he had not because he had not eaten anything. HIW
found that this was another example of Mr Nunes’ poor health literacy as he
believed inaccurately that if he had not eaten, he should not take his insulin. HIW
found that Mr Nunes’ inappropriate action was not deliberate but was the result of
his poor understanding of self-care management strategies. HIW concluded that Mr
Nunes’ erroneous self-care was a major, inadvertent cause of his repeated
episodes of DKA. The healthcare team should have identified and addressed this.
HIW concluded that while Mr Nunes was at Parc healthcare staff should have
referred him for specialist diabetic reviews.
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191. HIW also noted that in January 2016, Mr Nunes signed an agreement that he would
be responsible for controlling his diabetes by self-administering his insulin based on
his blood sugar levels. HIW concluded that it was irresponsible of healthcare staff
to expect Mr Nunes, who had diabetic gastroparesis, diabetes distress and burn
out, lipohypertrophy, hypoglycaemic unawareness, recurrent episodes of DKA and
poor health literacy to manage his complex diabetic condition without adequate
clinical support.
192. Healthcare staff made numerous entries in Mr Nunes’ medical notes saying that he
did not respond to advice on managing his condition. HIW said that it is standard
practice for a patient with compliance problems to be referred to secondary care for
specialist opinion and management, and that it was a failing and lack of care by
healthcare staff at Parc not to make repeated efforts to engage with secondary
care. HIW considered that Mr Nunes’ should have had face-to-face reviews with
diabetes specialists which would have allowed him to develop a therapeutic
relationship with healthcare professionals who were able to relate to his complex
needs and advocate for him.
193. We are concerned that because healthcare staff did not have a good understanding
of Mr Nunes’ complex diabetic condition, they failed to recognise how ill Mr Nunes
was and mistakenly blamed him for his repeated hospital admissions. Prison staff,
not surprisingly, took their lead from healthcare staff.
194. We recommend:
The Director and the Head of Healthcare at Parc should:
• liaise with the local Health Board to ensure that newly arrived insulin-
dependent diabetic prisoners are assessed on their understanding of
diabetes management and self-care so that appropriate care is
provided in line with prisoners’ needs; and
• commission an outreach service from the community diabetes team to
ensure that nursing staff are adequately trained and know when to seek
advice from secondary services.
Mental health
195. Mr Nunes had been prescribed antidepressants during previous periods of custody
and it was first noted that he may have mental health issues at Parc in June 2015.
Over the following months, numerous entries about Mr Nunes’ behaviour and
attitude towards his diabetes management were made in his medical records. HIW
considered that these behaviours and attitudes were clinical examples of diabetes
distress and burnout, and that healthcare staff misinterpreted them as poor
compliance and self-neglect.
196. HIW also noted that hypoglycaemia is known to cause unusual behaviour in some
people, including tearfulness and unprovoked hostility and aggression.
197. HIW concluded that although diabetes burnout and hypoglycaemia may have been
beyond the expertise of the primary and mental healthcare teams at Parc, they
should have recognised that he had significant psychological problems.
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198. HIW noted that although Mr Nunes was referred to the mental health team on 10
August, there is no evidence that this was actioned and there was no review
scheduled to ensure that he was assessed until a brief mental health assessment
on 29 December.
199. HIW noted that on 1 December, the prison GP diagnosed Mr Nunes with disabling
anxiety and prescribed an antidepressant at twice the normal starting dose.
Although the GP planned to see Mr Nunes weekly in the GP clinic, there is no
evidence that this was ever arranged and therefore a medication review never took
place to assess its impact. Mr Nunes stopped taking the medication for
unexplained reasons. HIW concluded that starting Mr Nunes on too high a dose
may have contributed to his discontinuation of the antidepressant.
200. HIW noted that the GP’s entry of 1 December described a patient with complex
health and psychological needs who required specialist treatment, but this was not
arranged.
201. HIW concluded that Mr Nunes’ mental health problems remained unresolved and
inadequately managed. The reviewer considered that this contributed significantly
to his poor diabetes control and recurrent hospital admissions, and that if these
problems had been addressed earlier, it may have prevented his death.
202. HIW also noted that Mr Nunes failed to keep appointments with the prison GP.
Healthcare staff did not identify this as a concern and did not take action to follow
up why he did not attend. HIW considered that Mr Nunes’ failure to attend GP
appointments was another sign of his diabetes distress which went unnoticed.
203. HIW noted that HMIP’s 2016 report noted that primary mental health services,
which supported prisoners with mild to moderate mental health needs, were too
limited and there was no clear care pathway. HMIP noted that nurses mainly
completed primary care activities and had insufficient time to complete
assessments promptly and manage their caseloads effectively. HMIP were also
concerned that despite a high demand for mental health support, primary mental
health provision was inadequate.
204. HIW concluded that healthcare staff failed to assess Mr Nunes’ clinical condition
effectively and to identify his diabetes distress and other psychological problems
correctly. This prevented him from accessing the specialist support services he
needed. HIW considered that the care Mr Nunes received was sub-standard, failed
to deliver many of the standards set out in the Standards for Prison Mental Health
Services – Quality Network for Prisons Mental Health Services, published in June
2015, and was not equivalent to treatment he could have expected to receive in the
community.
Transfer to a prison with 24-hour inpatient facility
205. During his time at Parc, Mr Nunes was admitted to hospital on 16 occasions for
DKA or symptomatic hyperglycaemia with ketosis or dehydration. Of the 266 days
that Mr Nunes was detained at Parc, he was in hospital for 46 of them and on eight
occasions, he was re-admitted to hospital within a week of being discharged. Nine
of Mr Nunes’ admissions to hospital ended in him discharging himself against
medical advice.
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206. HIW said that this number and type of admissions in less than nine months was
extraordinary and would be highly unusual even in specialist care settings. HIW
considered that after Mr Nunes’ second admission to hospital, a multidisciplinary
healthcare team should have reviewed and created plans to address his healthcare
needs. If, after the introduction of measures to prevent his further hospital
admission, Mr Nunes was re-admitted to hospital, the multidisciplinary team should
have concluded that it was unsafe for him to remain at Parc.
207. HIW considered that Mr Nunes should have been transferred to a prison with a 24-
hour inpatient facility as Parc could not offer the clinical care and observation
required to meet his complex healthcare needs. (HIW noted that the prison GP said
he did not know that it was possible to transfer Mr Nunes.) HIW concluded that the
failure to address Mr Nunes’ repeated admissions to hospital meant that Parc was
an unsafe environment for him, and that healthcare staff grossly breached their duty
of care to Mr Nunes.
Nurse competency
208. Healthcare provision at Parc is a nurse-led service with nurses acting autonomously
and with the GP service being advisory. Nurses refer and book prisoners for GP
appointments.
209. HIW noted that over 50% of nurses at Parc were either registered mental health
nurses or learning disability nurses. This meant that many nurses dealing with Mr
Nunes’ diabetes were undertaking the role of a registered general nurse and were
working outside of their clinical competence as their training would not have
equipped them with the knowledge and skills to deal with Mr Nunes’ complex
physical needs.
210. A nurse who failed to recognise the importance of Mr Nunes’ clinical symptoms on
20 February was a learning disability nurse. HIW considered that this exemplified
the poor general care that Mr Nunes received and the way in which inexperienced
staff who lacked expertise in diabetes management made inappropriate clinical
decisions.
211. Overall, HIW concluded that healthcare staff did not meet the standards of the
professional regulators in Mr Nunes’ routine and emergency clinical care. HIW
considered that this was due to several factors: staff were working outside of their
competence, the nursing skill-mix was inappropriate, there was a lack of knowledge
about basic diabetes care, documentation was sub-standard, communication
between professionals was poor, and there was a failure to administer antibiotics
and insulin in a timely manner. Contributory factors included staff shortages and
the absence of specialist services.
Assessments on return to prison from hospital
212. HIW noted that the failure to ensure that Mr Nunes was seen by a nurse in
reception when he returned from hospital on 20 February was not a solitary
episode. There were two previous occasions when this had happened. In addition,
HIW found that whenever Mr Nunes returned to prison from hospital, healthcare
staff took no clinical observations and did not record his blood sugar and ketone
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levels. HIW also noted that on the nine occasions that Mr Nunes discharged
himself from hospital, there was only one occasion when the reception nurse
discussed him with a prison GP.
213. HIW said this did not meet NMC standards and concluded that these failings
resulted in Parc providing an unsafe environment for Mr Nunes were a breach in
duty of care. HIW said it appeared that healthcare staff viewed prisoners arriving
back at the prison as an inconvenience which distracted from their other duties and
that it was a task to complete as quickly as possible.
214. HIW also noted that on the many occasions Mr Nunes was discharged or
discharged himself, there was only one occasion when healthcare staff received a
hospital discharge summary for Mr Nunes when he returned. When a discharge
summary was obtained, there was no evidence that a clinician saw it, took any
clinical action or reviewed Mr Nunes.
215. At inquest, the Head of Healthcare said that not receiving discharge letters had
been an historic issue with the POW Hospital which had improved. Despite this, we
make the following recommendation:
216. We were told that it is now Parc’s policy for every prisoner to see a member of
healthcare staff when they return from hospital, and they have introduced a system
to record how long it takes for a prisoner to see a nurse. Nevertheless, we
recommend:
The Director and the Head of Healthcare at Parc should ensure that all
prisoners are assessed by the healthcare team on their return from hospital.
The Director and the Head of Healthcare at Parc should ensure that hospital
discharge summaries for prisoners are received in a timely manner and, if
this does not happen, that requests are followed up promptly.
CVOP meetings
217. HIW said that, in the absence of any formal prison healthcare multidisciplinary team
meetings or a senior clinician taking responsibility for Mr Nunes’ care, the CVOP
meetings would have been the only opportunity for clinical staff to formulate a
comprehensive care plan for Mr Nunes. However, the CVOP meetings were simply
an informal gathering of clinicians to share information and discuss difficult clinical
cases on an ad hoc basis. HIW found there was no structure to the meetings, that
care plans were not discussed, evaluated or monitored, that no formal, significant
event analysis took place and that full and accurate minutes were not taken. The
lead diabetes nurse did not attend many of these CVOP meetings and so was
unable to provide continuity of care and expertise. As a result, Mr Nunes’ care
needs were never identified.
218. HIW noted, for example, that Mr Nunes’ refusal to have his blood sugars tested was
discussed at the CVOP on 21 September and it was agreed that a joint appointment
should be made for Mr Nunes to see the GP and lead diabetes nurse. However, an
appointment was not arranged for a further five weeks. HIW said that this was
alarming and showed a lack of care when it was obvious that Mr Nunes was
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experiencing extreme difficulties and had had seven hospital admissions. HIW
considered that this would have adversely affected Mr Nunes’ care.
219. HIW concluded that the CVOP meetings were inadequate and unable to fulfil a role
as a co-ordinating and planning meeting, that they failed to provide support for
prisoners at heightened risk and were irrelevant to Mr Nunes’ care.
220. We make the following recommendation:
The Head of Healthcare at Parc should ensure that CVOP meetings are
clinically multidisciplinary, that effective care plans are created and
implemented, and that the meetings are accurately minuted.
Support Living Plans
221. The SLP is a process which allows the sharing of medical information with prison
officers and is not a strategic care planning document.
222. An SLP was opened for Mr Nunes on 9 December, without his consent. Healthcare
staff had considered opening an SLP on two previous occasions, but Mr Nunes had
refused to agree. We consider that a SLP could usefully have been opened earlier
without his consent.
223. However, when the SLP opened it was of a poor standard. The immediate action
plan was poorly completed, issues appeared to have been confused with actions
and actions noted were not subsequently recorded as having taken place. Few
entries were made in the events summary, which was intended to update officers
on Mr Nunes’ wing and no entries were made at all between 11 and 22 December.
The process was not multidisciplinary and did not involve officers on the wing. The
review scheduled for 16 December did not take place, and there was no review
between 22 December and 2 February and then the next view was planned for
April. The SLP was not updated when Mr Nunes returned from hospital
admissions, including on his return from hospital on 20 February.
224. We consider that the SLP did little to add to the delivery of Mr Nunes’ care and was
probably a distraction, being seen as another process to be followed. It developed
into a tick box exercise which had little or no impact on the care delivered to Mr
Nunes by healthcare or operational staff. We recognise that Mr Nunes was also
being monitored under ACCT procedures for much of this time and that staff may
have thought ACCT took precedence or offered more support. However, if staff
considered that this was the case, they should have formally closed the SLP and
recorded the reasons for doing so.
225. Mr Nunes was monitored under ACCT, CVOP, SLP and complex case meetings.
We note that the SLP and complex case reviews appear to have fallen by the
wayside despite Mr Nunes’ ongoing issues, including non-compliance with testing
regimes and taking his medication. The level of monitoring under different schemes
is likely to have taken the focus of any one pla