PFD reports in health in justice

This article explores themes arising from recent Prevention of Future Deaths reports relating to deaths in prison custody. These trends highlight issues that we see regularly in inquests where we represent prison healthcare providers. 

Staffing concerns 

Jack Zarrop: Prevention of future deaths report - Courts and Tribunals Judiciary

Thomas Huntley: Prevention of future deaths report - Courts and Tribunals Judiciary

Prevention of Future Deaths reports (PFD reports) issued in recent years raise concerns about inadequate staffing levels within prisons. Two matters of particular concern that have been raised relate to Custodial Nurse Practitioners (CNPs) and agency staff. 

Inadequate staff training poses a range of challenges. The training of agency staff in the Assessment, Care in Custody and Teamwork (ACCT) review process and recognising the appropriate threshold to open an ACCT are recurrent themes in PFD reports. ACCT is the care planning process for prisoners identified as being at risk of suicide or self-harm. It can be difficult to ensure that agency staff are provided with such training, given the high level of usage of agency healthcare staff in prison and given the nature of night and weekend shifts. 

To address this issue, prison healthcare providers should ensure that robust staff training processes are in place, particularly that there is consistency in the level of training offered to agency staff and healthcare staff employed directly by a prison healthcare provider. 

Temporary Registration at GP practices 

Samuel Jordan: Prevention of future deaths report - Courts and Tribunals Judiciary

The NHS Spine is the digital gateway that the NHS uses to store electronic patient records. Issues often arise when transferring patient records from community GP practices to prison healthcare teams. 

It is important to note that the NHS Spine only reflects records from a GP practice where a patient is permanently resident and not a practice where a patient has been consulted on a temporary basis. A recent case revealed that even using GP2GP, records from a temporary GP practice may not be readily available to prison healthcare staff, without active efforts being made to obtain these.

Prison healthcare providers should be proactive in making enquiries regarding temporary registration at the reception screening stage to ensure that they are in receipt of all medical records and so that assessments can be informed by patient’s medical history. 

Prison Deaths linked to Synthetic Cannabinoids

Kristopher Tilbury: Prevention of future deaths report - Courts and Tribunals Judiciary

Jason Williams: Prevention of future deaths report - Courts and Tribunals Judiciary

Synthetic cannabinoids are involved in nearly half of male prisoner deaths analysed in England and Wales: (Worrying increase in spice jail deaths highlights ‘crisis in prison system’ | Middlesex University London).

A team at Middlesex University’s Drug and Alcohol Research Centre analysed official investigation reports on the non-natural deaths of 129 prisoners in England and Wales between 2015 and 2020. Synthetic cannabinoids, some of which are known as spice and black mamba, were linked to 62 prison deaths, all but 8 of which were in men. The study found that understaffing, cuts to services, and inadequate support for the most vulnerable all contributed to fatalities.

Synthetic cannabinoids are chemical compounds that mimic the effects of Tetrahydrocannabinol, often referred to as THC, the active ingredient in cannabis. Spice and black mamba are often extremely potent, making them a serious threat to users. The chemicals are often sprayed on to paper, which is smuggled into prison, rolled up and smoked.

Prison healthcare providers should note that those who fatally overdosed often had a history of mental health issues and addiction. It is therefore crucial to look out for potential risk factors of illicit drug use in prison. Reports identified slow emergency responses, high levels of violence and bullying, and not engaging in purposeful activities as contributory factors. Finally, it is important to highlight that a proportion of these synthetic cannabinoid related deaths were found to be caused by the drug triggering a pre-existing medical condition. This is another important reminder of the need for prison healthcare providers to ensure that they have a patient’s comprehensive medical history on file at the initial reception screen.