Inquest into the Death of Leslie SHORTTE

Contributing factors

• Failure to complete annual health assessments between 2016 and 2019
• Inadequate follow-up of high-risk squamous cell carcinoma after initial removal
• Unacceptable delay in arranging ultrasound of neck mass
• Flawed 'paper slip' appointment booking system relying on prisoner self-management
• Lack of backup system for missed clinical appointments
• Failure to update active problem list in EcHO with SCC diagnosis
• Inadequate addressing of heavy smoking
• Prisoner's pattern of refusing diagnostic tests and medical treatment
• Lack of follow-up for non-attendance at critical appointments
• Failure to consider early release under Royal Prerogative of Mercy when prisoner classified as Stage 3/4 terminally ill

Coroner's recommendations

1. Reinforce requirements of COPP 6.2 to ensure briefing notes for early release of Stage 3/4 terminally ill prisoners under Royal Prerogative of Mercy are prepared in a timely manner
2. Implement compliance reporting on annual health assessments for each prison with rankings by age and colour flags for high-risk conditions
3. Ensure PMO education on proper use of EcHO 'interventions' functionality for follow-up appointments
4. Emphasise importance of updating prisoners' active problem lists in EcHO to ensure visibility of critical diagnoses
5. Implement backup systems to ensure follow-up of missed clinical appointments
6. Abandon reliance on 'paper slip' appointment booking systems in favour of electronic systems with alerts
7. Conduct full skin checks for all prisoners with history of skin malignancy
8. Provide PMO training on EcHO functionality and screening guidelines
9. Prioritise screening of prisoners with high-risk medical conditions