Unlike most natural causes deaths that occur in the community, the law states that a Coroner must hold an inquest where the deceased has died whilst in custody or state detention (Coroners and Justice Act 2009, Section 1(2)(c)). However, unlike other deaths that occur in custody or state detention, where the death appears to be of natural causes, a jury is not mandated (Tyrrell v HM Senior Coroner County Durham and Darlington [2016] EWHC 1982 (Admin)).
Nonetheless, natural causes deaths in state detention often give healthcare providers an opportunity to reflect on the care provided to the deceased whilst in state detention and showcase the learning, actions and recommendations identified during both the service providers internal investigation and the Prison and Probation Ombudsman’s independent investigation into the deceased’s death.
Themes and Trends
We regularly represent healthcare providers at inquests arising following the death of a patient in state detention and the below provides an overview of the common recurring themes and trends arising at physical health related deaths in state detention.
- The use of NEWS2 (National Early Warning Score)NEWS2 is a scoring system which, based on a patient’ physiological measurements and parameters (including oxygen saturations, respiratory rate and pulse rate) calculates a score to indicate how acutely unwell a patient is. NEWS2 should be used by healthcare staff in prison to monitor acute illness and any deterioration in a patient’s condition. Good NEWS2 practice is often demonstrated by healthcare providers at inquests where it can be evidenced that mandatory NEWS2 training and compliance is up to date for all clinical staff and where NEWS2 scoring templates are accessible to staff via the electronic patient records system. Other notable practice includes issuing NEWS2 pocket guides or scoring cards to staff to carry on their persons when conducting clinical observations and regularly auditing the use of NEWS2 to monitor compliance.
- Handover between Healthcare staff and Prison staff Coroners are often interested in exploring the handover, safety netting and escalation advice either given by healthcare staff to prison staff or between healthcare staff between shifts. Advice regarding deterioration and worsening of a patient’s symptoms should be documented within the patients’ electronic medical records. Notable practice should include healthcare providing prison staff with a clear overview of the patient’s health condition causing concern, the required frequency of observations (visual only), signs of deterioration or worsening to look out for, and advice on when to seek advice from 111 or 999. Evidence of further good practice often includes details of the formal handover provision in place at the prison, often between a member of the senior healthcare team (i.e a Senior Nurse) going off duty and the Prison Orderly Officer in charge of the evening or night shift.
- Maintaining contemporaneous medical recordsTo evidence good practice, healthcare providers should ensure that all clinical staff maintain contemporaneous patient records in accordance with professional Codes of Conduct. Mandatory record keeping training modules and monthly record keeping audits are a good way to demonstrate to the Coroner that contemporaneous record keeping is a priority for healthcare providers.
COVID-19 Deaths
Monitoring Deterioration and Escalation to Hospital
We have recently seen numerous COVID-19 related deaths in state detention being heard at inquest. One of the key focuses at the inquest is the quality of monitoring of a COVID-19 positive patient’s oxygen saturation levels and the timeous escalation of acutely unwell patients to hospital.
Coroners are paying particular attention to the appropriateness of the monitoring and observations of COVID-19 positive patients in accordance with their COVID-19 age (as calculated by a scoring system of a patients existing comorbidities and age). Evidence is often required to prove that a patient’s observations were conducted at appropriate intervals in accordance with their COVID-19 age and that a deterioration in a patient oxygen’s saturation levels were timeously escalated and where required, an ambulance called. Contemporaneous medical record entries recording interval observations and clinical findings helps assist witnesses when giving evidence on the monitoring and escalating of a deteriorating patient to hospital.
Our team can assist your organisation with representation at or preparation for an Inquest following a death in state detention. Please do not hesitate to get in touch, should you wish to discuss this further.
For further information, please contact:
Sofia Bradford, Hill Dickinson
sofia.bradford@hilldickinson.com
