The inquest into the death of Mark Jarvis concluded on 4th September 2019.
At the time of his death, Mr Jarvis was detained at HMP Warren Hill which is a medium secure prison that holds nearly 250 adult men.
The conclusion of the inquest was that the death was the result of a cardiac event precipitated by the ingestion of a New Psychoactive Substance.
The medical cause of death was confirmed as 1a Ischaemic Heart Disease.
Mr Jarvis was found deceased in his cell on Oak Wing at 11.07 hours on Wednesday 30th December 2015.
During the course of the police investigation following his death, the prison was responding to intelligence concerning New Psychoactive Substances (a synthetic cannabinoid commonly known as “spice”) being available on the wing.
It was established that Mr Jarvis had several medical issues and was using prescribed medicines for these.
Following a post mortem examination it was found that in addition to a heart condition that could account for his death, a New Psychoactive Substance was also found in his system together with two types of non-prescribed medication.
Matters raising concern
During the course of Mr Jarvis’s inquest, the evidence revealed matters given rise to concern. This was sufficient to lead the Coroner to believe there is a risk that future deaths could occur unless action is taken.
Therefore, in accordance with the Coroner’s statutory duty to report these matters of concern a Regulation 28 report to Prevent Future Deaths has been directed to System One TPP Ltd and NHS England.
This arises from evidence during the course of the inquest of a GP who is responsible for medical care at HMP Warren Hill. She gave evidence in relation to the computer system, SystmOne, which was used to review and prescribe medicines to the prisoners at the time of Mr Jarvis’ death.
The Court was told that the SystmOne online prescription “module” was not clear to read or easy to understand and appeared incompatible with the prison’s own IT system.
This left GP’s in the situation of;
not being shown what a patient had been previously prescribed;
not being shown what repeat prescriptions were in place; and
that they had no way of readily understanding what had been taken by a particular patient or when they were supposed to have taken it.
The GP also told the Court that there was no direct link on the system between medications prescribed from previous diagnosis. Due to the time it took to navigate the records it was reported that some GPs use experience to identify a previous diagnosis from the repeat prescriptions recorded in the prescription module.
The GP went further described that removing a prisoner’s prescription from the system when it was no longer necessary was very difficult.
In Mr Jarvis’ inquest, the Jury found that one of the contributing factors to his death was directly related with poor compliance to his blood pressure medication regime on repeat prescription.
The Coroner is of the view that in light of the difficulties GP’s are facing when using the prescription module and the evidence given by the GP in this case, it would appear there is no easy system for a doctor to verify exactly what their patient has already been prescribed and whether or not that prescription is still current.
The Coroner has detailed in the report to prevent future deaths that in relation to the potential misuse of drugs incorrectly or over prescribed, the GP explained that some medications, such as opioids or antidepressant medication has what she described as “currency within the prison” and it is known that they would be traded by some prisoners. This is clearly a concern when GPs are not able to readily identify what a prisoner should be, or is already being prescribed at the time of any specific consultation.
Nearly 4 years on from Mr Jarvis’ death, the GP gave evidence at the inquest that the situation, as it stood at the end of December 2015, had still not been resolved.
In the circumstances, the report was issued.
Both SystmOne TPP Ltd and NHS England are under a duty to respond to this report and must set out details of action taken or proposed to be taken, and set out a timetable for action. In the event they do not intend to take any action they must explain why no action is proposed.
This report is welcomed as SystmOne is a centrally hosted clinical computer system used by healthcare professionals in the UK and is used to connect all prisons in England to a single clinical IT system for healthcare across prisons, young offender institutions and immigration centres.
For advice and representation during the inquest process, please contact Farleys Solicitors on 0845 287 0939 or submit your enquiry online.
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