Death in Prison Custody - Clinical Review Series

This article is part 4 in a series of pieces on clinical reviews in death in prison custody inquests. Part 3 is here. 

In order for the clinical review to be an accurate representation of the facts it is important that all healthcare professionals who are invited to engage in the clinical review process are enabled to do so. The documentary evidence can only go so far in developing a picture of the clinical care the person received. In order to understand the realistic and practical elements of delivering care in a prison setting, it is often essential to interview and seek more information from the professionals who met the person and delivered their care.

It is important for Heads of Healthcare to engage in the clinical review process because ultimately the learning and recommendations made in the report will be the responsibility of the Heads of Healthcare to action and monitor. A Clinical Reviewer will seek to engage with the Head of Healthcare or equivalent managers (for example a Mental Health Matron) so the recommendations made can be mutually agreed as realistic and achievable.

It is also important that all healthcare staff who are invited to an interview are prepared for the interview, and this is done by refreshing themselves on the healthcare they delivered and to read and bring with them any statements or facts they may wish to share. Often the Head of Healthcare is invited to an interview with a request to share internal learning following the persons death, so the facts identified during the clinical review process can be discussed. It is therefore essential that the Head of Healthcare is prepared for this and brings with them any internal learning reports and findings.

All healthcare staff need to be aware that all interviews are recorded, and a transcript of that recording is annexed to the PPO report that goes to all interested parties, including the Coroner. It is therefore, essential that staff are supported properly to engage in the interview process and come to the interview prepared.

It is also helpful for the healthcare provider to engage at an early stage with the clinical review process because at a later stage the Coroner may wish to invite a healthcare professional involved in that persons care to the inquest, and the clinical review report allows for an early opportunity for professionals to contribute to the facts of the case.

It is important to remember that the Coroner will receive a copy of the PPO report, clinical review and any interview transcripts obtained and may wish to use these as part of the evidence for the inquest. It is therefore important, as far as possible, for those interviewed by the PPO and Clinical Reviewer are adequately prepared and ideally have a copy of any entries they have made in the records with them at the time of the interview. This will help ensure any information they provide at interview is accurate. It is also important for any interviewees to have sight of their interview transcript after the interview and have the opportunity to make any amendments to this. The reason for this, is many Coroners will use the interview transcripts as the witness’s documentary evidence at the inquest. If this is inaccurate or incorrect, this could cause the individual difficulties when providing evidence at the inquest.   

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 4 in a series of pieces on clinical reviews in death in prison custody inquests. Part 5 is here.