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Death in Prison Custody - Clinical Review Series

Part 2: What happens to the clinical review once complete?

Part 2: What happens to the clinical review once complete?

This article is part 2 in a series of pieces on clinical reviews in death in prison custody inquests. Part 1 is here.

Once the investigation is complete, the clinical review report is then submitted by the Clinical Reviewer to NHSE or HIW and it goes through a quality assurance process by the healthcare provider within the prison establishment and by NHSE/HIW. The aim of the quality assurance process is to check for factual inaccuracies and from an NHSE/HIW perspective to ensure the report is of a high consistent standard.

Once the clinical review report is finalised, it is submitted to the PPO and it is used to help inform the overall findings in the PPO report and where recommendations are made for the prison (often the Governor) and to the healthcare provider. The recommendations specifically made within the clinical review form part of an action plan that is agreed between NHSE/HIW and the healthcare provider within that prison estate. This action plan is then monitored by NHSE/HIW.

The clinical review report is annexed to the PPO report and is shared with all interested parties including the persons family, the Coroner, NHSE/HIW, the prison and the healthcare provider. The PPO report is then anonymised and published on the PPO’s website. The clinical review however remains confidential and is not published, but the key findings from the review are included in the PPO report.  

Hill Dickinson is one of the leading lawyers providing legal advice and support to national and international healthcare organisations. We have a wealth of knowledge and experience in handling complex cases involving NHS and Public Health authorities and the health and justice system. 

Our legal expertise spans across multiple NHS and public health sectors from mental health and social care, mental capacity, clinical negligence to inquiries and investigations. 

This article was co-authored by Lorna Warriner, RMN, Clinical Reviewer, on behalf of NHSE and HIW.

This article is part 2 in a series of pieces on clinical reviews in death in prison custody inquests. Part 3 is here. 

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