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Investigating Serious Incidents in the prison healthcare service


There were two issues for the Trust; a preference for an independent investigation because of the sensitivities of the case and a need to get extra capacity to complete incident reviews.

The Issue

X Trust had recently had a cluster of serious incidents which occurred within the prison healthcare service. The Trust had carried out some internal RCA investigations but needed extra capacity so approached Niche to complete four investigations. Theses were:

  • patient underwent a hip replacement and was transferred back into prison. 21 days post-op he developed a wound infection and the wound dehisced;
  • patient on a drug rehabilitation programme tested positive for dihydrocodeine. Patient stated was given this by a nurse as codeine phosphate was unavailable;
  • patient presented with chest pain and received a clinical examination from the staff nurse on duty. 48 hours later re-attended healthcare service as the chest pain had not subsided. Clinically assessed and then sent out to Accident and Emergency department by an emergency (999 call) ambulance; and
  • patient had a history of myocardial infarction and strokes, prescribed warfarin. Review discovered that warfarin prescribing and dosage had not been carried out properly for last two months.

Our Approach

Niche allocated a team of two people to investigate four of the incidents.

We developed an investigation schedule that set out what the team wanted to look at and when. The investigation team were based on site at the Trust for a few days whilst documents were reviewed and people were interviewed. The team also observed carried out a series of telephone interviews. The people involved in the process were informed that their comments would be protected as confidential, unless there was a whistle-blowing or public interest issue. The purpose of this review was to obtain learning and ensure that changes could be made to prevent or minimise the chance of re-occurrence.

The outcome of the project/ review

The final product was four reports that set out findings, facts and contributory factors. Although the incidents were very different in presentation, there were themes common to all of them.

In summary, the review found that each of the incidents could have been prevented. The staffing levels in place were inadequate, the clinical and operational procedures in place did not ensure that patients got healthcare appointments on time, did not follow up patients who did not attend and did not ensure that clinical reviews were carried out on time. The infrastructure ensuring that clinical skills of staff were up to date and staff were following procedures was also not fit for purpose. The investigators reviewed some of the governance and assurance systems for the prison and found that managers in place at the time were aware of the potential problems in the team and had taken steps to rectify the problems but that these steps were ineffective. Our report provided clear recommendations for action and a way of checking that the actions made a difference.

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