Death in Prison Custody - Clinical Review Series

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

The recommendations made in the clinical review will be pertinent to the learning identified during the clinical review process and need to be achievable, practical, and realistic. Recommendations will not be made for recommendations sake, and they should be directly addressing the clinical issues identified with an objective to improve the clinical care going forward.

There has been a positive shift recently directed by the new PPO Ombudsman to create impactful recommendations that are focused on higher level system issues. This approach is welcomed as it seeks to address the issue of making repeated recommendations by examining the higher level thematic systemic issues, and is parallel with the Patient Safety Incident Response Framework (PSIRF) agenda. 

It is important that all parties involved in implementing the recommendations made by the PPO and Clinical Reviewer are actioned to result in a positive change. Repeated recommendations are frustrating for all involved in the clinical review process, but this is why it is essential to ensure that the recommendations made in the clinical review are achievable. 

At inquest, a Coroner will explore any recommendations that have been made by the PPO and Clinical Reviewer as this is relevant to the Coroners’ duty to prevent future deaths. Coroners will often call the prison Governor and Head of Healthcare to provide evidence at inquest to demonstrate how they have addressed the recommendations made in the PPO report and clinical review. If a Coroner is not satisfied by the evidence they have heard and believe there remains a risk of future deaths, then the Coroner has a duty to issue a Prevention of Future Deaths Report (or PFD) to any person or organisation who the Coroner believes has the power to take action to address the risk. This is an important function of the Coroner, however, it can be seen as ‘a slap on the wrist’ for anyone receiving a PFD as it demonstrates that they have failed to take sufficient action to learn lessons and prevent future deaths. The provision of a PFD also creates additional work for the recipient, who must respond to the PFD within 56 days. Coroners will often publish PFDs and the responses they receive on the judiciary website, where there is a risk, they may be picked up by the media, resulting in unfavourable press attention. Many Coroners will also copy in regulators into any PFDs they send, including the CQC who may consider any PFDs they receive when determining their inspections.

It is therefore vitally important that the recommendations made by the PPO and Clinical Reviewer are addressed as soon as possible and robust lesson learning is put in place.

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 5 in a series of pieces on clinical reviews in death in prison custody inquests. Part 6 is here.