Inquest into the Death of Robert William ROMAN

Contributing factors

• Spontaneous (non-traumatic) subdural haematoma in dialysis patient
• Anticoagulation therapy (aspirin and heparin) for ischaemic heart disease
• Pre-existing diabetes mellitus
• Pre-existing ischaemic heart disease
• Chronic obstructive pulmonary disease
• Failure to place on Terminally Ill List despite complex health needs on admission to prison
• Delayed notification to family of clinical deterioration
• Only one next-of-kin recorded instead of required minimum of two

Coroner's recommendations

1. Education for all clinical staff about the Terminally Ill Module and patient suitability criteria, with nursing staff encouraged to proactively identify suitable patients upon admission
2. Implementation of Annual Health Review Policy (from 17 September 2020) to ensure screening component is completed for all prisoners on care plans, regardless of other comprehensive care arrangements
3. Updated Commissioner's Operating Policy and Procedure for Prisoner Access to Health Care to include guidance on next of kin notifications for serious illness and health deterioration
4. Implementation of procedures requiring recording of multiple next of kin contact details (minimum of two) for each prisoner, with at least two contacts to be recorded as standard practice
5. Establishment of protocols requiring extra onus on staff to record timing of contact attempts with next of kin and details of successful notifications
6. Early notification to families of prisoners when removed to hospital for serious illness or when health deterioration occurs, subject to security considerations