Learning Lessons Bulletin Issue 19

This learning lessons bulletin summarises the learning from Prisons and Probation Ombudsman (PPO) investigations into the deaths of those who died within 14 days of release from prison.

Prison leavers often have multiple and chronic co-morbidities or risk factors, including substance misuse and mental health issues.

The release of the new National Action Plan for Antimicrobial Resistance highlights surveillance and health inequalities as important areas for focus. NHSE have looked at data for antibiotic prescribing in the secure estate and compared this to primary care key indicators and between different secure setting types.

New courses starting

The Health Innovation Network Polypharmacy Programme is inviting clinicians to take part in NHS England funded Action Learning Sets to help build GP and prescribing health care professionals’ confidence in, and understanding of, the complex issues surrounding stopping inappropriate medicines safely.

Three cohorts available for booking:

• 19 June, 3 July, 17 July 2024
• 11 September, 25 September, 9 October 2024

Sessions will run 9:30-12:15 and are held online.

This online interactive course consists of three half-days over one month.

Clinical guidance update

Following a Medicine Supply Notification issued on 3 April 2024 about a national shortage and proposed discontinuation of parenteral (injectable) forms of Pabrinex, DHSC and NHSE have now developed additional clinical guidance for the treatment of alcohol dependence. Clinicians should consider prescribing the equivalent dose of unlicensed injectable thiamine where Pabrinex® is unavailable (which contains 250mg thiamine), where deemed clinically appropriate.

For secure settings

Information resources for measles and MMR in the Immigration Removal Centres (IRCs) for detainees, staff and visitors now published alongside other secure settings.

Covering adult prisons, young offender institutions and immigration detention

Inside every prison, young offender institution, immigration removal centre (IRC) and short-term holding facility (STHF), there is an Independent Monitoring Board (IMB), appointed by ministers to monitor and report on the treatment and conditions for those detained.

For the first time, this national annual report brings together IMBs’ key findings and themes across these settings throughout the year.

IADPC’s Spring 2024 newsletter

The Independent Advisory Panel on Deaths in Custody’s (IAPDC) Spring newsletter (link) provides an overview of the key activities over the past few months.

OHID substance misuse leads issue information

Following a Medicine Supply Notification issued by DHSC on 3 April 2024 about a national shortage and proposed discontinuation of parenteral (injectable) forms of Pabrinex, there has been concern among clinicians treating alcohol dependence and withdrawal in secure environments. OHID substance misuse leads have now issued the following information:

“…Clinical guidance for use in alcohol dependence is still being worked up but the consensus advice of leading clinicians is that, as and when you run short of Pabrinex, you simply replace it with an equivalent dose of injectable thiamine, ie 200-300mg thiamine for 1 ampoule/pair Pabrinex (which contains 250mg thiamine). This will mean you sourcing appropriate supplies of thiamine when they are needed.

The Medicines Supply Team in DHSC is working to ensure that thiamine stock is available in this country but, where stock is from imports of formulations not licensed in the UK, (it will need to be individually prescribed because) PGDs cannot be used for unlicensed products.“

The Independent Advisory Panel on Deaths in Custody (IAPDC) have published the latest statistical analysis of recorded deaths in custody between 2017 and 2021.

Some key findings from the report include:

• People in custody are at a significantly elevated risk of death compared with the general population.
• While numbers of deaths in police custody remain low, its rate of death is comparable to prisons and detention under the Mental Health Act, if the approximate length of time spent in detention is factored in
• Prisons have the highest number of deaths, with an average of 322 per year over the five-year period.
• When rates are considered, people detained under the Mental Health Act have the highest mortality rate across custody, including three times higher than prisons.
• People in custody under the age of 40 have the highest rate of suicide and other unnatural deaths.
• Men continue to have a significantly higher rate of overall deaths across all custody settings, particularly in prisons and police custody.

An important webinar on Health and Justice Continuity of Care (CoC) of medicines will be held on Thursday 18th April 2024 from 2:00pm – 3:30pm.

This online event will provide an opportunity to discuss the briefing findings, best practices, HMPPS systems and processes, SEAT templates used for recording medicines and prescriptions supplied for release and transfers and a pilot scheme for improving the security of medicines and prescriptions during transport. 

The webinar is for colleagues (NHS, healthcare providers, HMPPs, etc.) who are keen to learn more about:

• CoC briefing and key actions identified.
• HMPPS – End of Custody Supervised Licence (ECSL) and Fixed term recall (FTR) schemes; using BaSM and dPER systems.
• Sharing best practice in medicines supply for continuing care: Achieving practice Improvement and operational tools. 
• Using SEAT templates for release and transfer.
• HMP Bullingdon evidence bag pilot. 

Speakers include: Tim Allen (Prison Group Director – Capacity Gold) and Roy Stevenson (Deputy Head Prisoner Escort and Custody) from HMPPS; NHS England HJ CoC; and colleagues showcasing good practice from HMP Winchester, Spectrum CiC and HMP Bullingdon.

The webinar will conclude with time for questions from the audience.