Report details failings in prison healthcare
| Published date | 22 May 2021 |
But after suffering with chest pains Mr Forrester was taken to hospital for tests on August 2, 2020, as a nurse noticed he was unwell. He died after having a seizure two days later on August 4.
A post-mortem concluded Mr Forrester died from blood in the sac of the heart caused by an infection. An independent investigation by the Prison and Probation Ombudsman has been published, highlighting errors in the care the prisoner received before his death.
Key findings included: ¦When Mr Forrester had his first and second health screen, neither nurse looked at his health records and did not find out that he had ongoing hospital
Head of should ensure for daily with hospitals prisoner for appointments. ¦When a nurse was asked why she did not look at Mr Forrester's previous medical history, she said that she would not have had access to look at these records and it was not a requirement.
¦When the clinical reviewer spoke to the head of healthcare, she said that his health records should have been checked as part of the transfer reception screening process and that his outstanding hospital appointments should have been noted and actioned. ¦On July 22 the hospital reported that Mr Forrester had missed two appointments to be seen by the maxillofacial surgeon and a new referral would have to be made. When the clinical reviewer asked the head of healthcare how this had happened, she said Holme House had not received any appointments for Mr Forrester.
The clinical reviewer found that the standard of care Mr Forrester received at Holme House was "partly equivalent to that which he could have expected to receive in the community".
Concerns were also raised over Mr Forrester's reception health screenings, which "were not carried out in line with guidelines"
and those completing screenings "were not trained to do so".
The report notes how the inmate had a history of substance misuse and was on a methadone programme. It was also recorded that Mr Forrester had Hepatitis C, Endocarditis (a rare heart condition) and had previously had a deep vein thrombosis.
Over the next six months, a prison GP reviewed the inmate regularly because he said he had jaw and ankle pain.
The GP prescribed Mr Forrester with painkillers and referred him to the hospital for further investigations. On August 2 Mr Forrester said he had chest pains. The prison nurse...
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