Edward Hand: Prevention of future deaths report

The family requested that I refer to the deceased Edward James Hands as Eddie and therefore
I will reflect that in this report.  
The medical cause of death was:  
1a Aspiration Pneumonitis 
2 Methadone Use 

The conclusion of the jury inquest was a Narrative Conclusion – After consuming methadone,  the major contributing factor in Eddie’s death was a lack of follow up care by both healthcare and prison staff. Overall, Eddie’s death was contributed to by neglect. On the balance of  probabilities, Eddie’s death could have been prevented as there was a window of opportunity  to intervene. The following factors contributed to the death in a more than minimal way:  Insufficient training around the Under the Influence (UTI) protocol; A lack of awareness by  prison and healthcare staff in identifying and managing the signs of a UTI case; The  availability of staff on the day; High staff turnover, as well as inadequate onboarding of new  staff; A lack of cooperation between healthcare and prison management; An omission of  discussing the ongoing UTI case during afternoon briefings and/or handovers; An overall lack of accountability in taking ownership of handling the UTI case. 

2) Access to mental health support services did not contribute to the death. Access to  substance misuse support, although broadly beneficial, would not have directly impacted the  outcome. 
3)There was an Under the Influence Protocol (Bedford Staff Community Notice 265/2023) in  place at the time of the death. This protocol was not being used at the time, as evidenced by  the number of noted UTI (Under the Influence) incidents (34 in January and 15 in February)  and the lack of awareness and recording in the protocol by both prison officers and healthcare staff. Methadone administration at the prison was conducted by two members of staff  (healthcare and/or prison staff). However, this was applied inconsistently.  

4) Eddie was not prescribed methadone, and it is uncertain how he came to ingest it. 
On 16th February 2024, Eddie’s presenting condition was initially managed in line with the  protocol with prison staff raising a Hotel 2 call. Healthcare staff responded to this call. The  observations conducted by healthcare staff assessed that he was under the influence. At this  point, the UTI protocol should have been started by prison staff and/or healthcare staff, and  this did not happen. The lack of follow up visits or checks were a failure in his ongoing care.  Thereafter, there was a failure by healthcare staff to carry out a follow up medical assessment or by prison staff as per the protocol. In responding to the ‘Code Blue’, there was not a full  response by healthcare, in that only one of the designated staff members attended. Whilst the evidence does not establish that the following matters probably caused or contributed to  Eddie’s death, it was admitted that there was a failure of healthcare to use suction equipment  to clear the airway at the time he was found unresponsive in his cell and in cardiac arrest with stomach contents in his mouth and throat.  

The MATTERS OF CONCERN are as follows:  (brief summary of matters of concern) 
The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of  awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence.  

In this instance this confusion resulted in Eddie not being observed; had these checks and  monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not  recognised and escalated.    

It is understood that the NHFT policy is designed to cover the entire Trust and may well,  therefore, have relevance beyond Bedford prison. However, it is essential that the policy is  clear on what happens when the individual institutions have their own local protocols. 

Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison  residents at Bedford Prison. 

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