RES_2023FAI022 (1)
Submitted: 05 July 2023
Form 6.2
HM17008894
SHERIFF COURT OF SOUTH STRATHCLYDE, DUMFIRES AND GALLOWAY AT HAMILTON
RESPONSE
to the
DETERMINATION OF SHERIFF DUNIPACE
UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS
ETC. (SCOTLAND) ACT 2016
IN THE
INQUIRY INTO THE DEATH OF XI BIAO HUANG, born 9 July 1964
Med-Co responds to the recommendations of the Sheriff as follows:
(i) All medical assessments and particularly clinical examinations should be carried out with the use of a professional interpreter where the detainee does not speak fluent English. Whilst the nature of the establishment may mean that it would not be possible or practicable to use professional interpretation services for every interaction with a detainee, the use of fellow detainees and/or members of staff to provide interpreting services should not be permitted for medical consultations and assessment when detainees present with complaints. Professional interpreting services should always be utilised in a medical context except in emergency situations.
(ii) The terms of the Home Office Detention Service Operating Manual and Detention Centre Rules 2001 [DSOMD[5]) should be amended to address the existing lack of guidance in relation to situations in which it is acceptable for the Centre to use other detainees, visitors or staff to interpret. Proper guidance should be provided to assist staff in relation to the situation in which it is acceptable for the Centre to use other detainees, visitors and staff to interpret. Proper guidance should be provided to assist staff in relation to the situations in which it would be appropriate for them to exercise their discretion in this regard.
In relation to recommendations (i) and (ii) set out above, as is set out in the submission on behalf of Med-Co and the joint minute, it is a matter of agreement between the parties that the Home Office Detention Service Operating Manual sets out the requirements in relation to interpreters. In medical matters it affords discretion to the healthcare staff as to whether to use an interpreter. It also permits healthcare staff to allow other detainees to interpret if the detainee is content with that arrangement.
The measures implemented by Med-Co for translation comply with the terms of the Manual. Med-Co is of course, not in a position to deal with amendments to the content of the Manual which, is a matter for the Home Office.
The position at present is Big Word Interpreting service is in place to aid translations. It is accessible via telephones in each clinic room. Staff also have access to Morfo tabs (electronic tablet-style devices) designed to assist with translation in the event a Big Word translator is either not available or has a lengthy wait. Residents may, at times, bring family or friends along to assist with translation. This may be accepted as a means of communication in relation to health issues where the Healthcare Professional deems it suitable at the time and has gained the consent from the resident who has a concern they wish to discuss.
There is a Med-Co Accessibility and Translation Policy is in place which covers written documentation and translation services. All staff have read and signed said policy to declare understanding and agreeing to adhere to this policy. We are confident that staff are aware of their responsibilities in relation to our translation policy.
(iii) In the event that it is necessary and appropriate to utilise the services of a fellow detainee rather than a professional interpreter, then the reason for this decision should be properly recorded and documented. There should be a system in place regulating the retention and availability of these records.
All nurses are registered with the Nursing and Midwifery Council and all doctors are registered with the General Medical Council. All practitioners are governed by these bodies and documentation therefore should be in line with these codes of best practice. All staff are aware of this.
The nursing team have also completed additional record keeping training (Documentation and Record Keeping - Level 2 - Online Course - CPDUK Accredited - Reed courses) and will also undertake an annual mandatory course on records management which will be required as part of their ongoing training and development. This is logged on our training matrix.
Med-Co now has access to an electronic patient management system at Dungavel called Vision. All patients' medical records are now electronic, which makes record keeping more efficient.
(iv) All medical assessments of and interactions with patients should be fully recorded and maintained in a manner that ensures that they are available to future healthcare staff when they are interacting with or examining patients. Training on the requirements of the Nursing and Midwifery Council Code would be considered to remind nurses of their professional obligations notwithstanding any employer based rules. Appropriate documentation should be provided to the medical staff enabling them to comply with the requirement of the aforementioned code.
As set out above, all interactions with patient detainees are now recorded on our NHS Vision system, an electronic system which has replaced our previous paper system.
Staff have completed additional training in relation to documentation in the form of the course, ‘Documentation and Record Keeping - Level 2 - Online Course - CPDUK Accredited - Reed courses’
Staff are also required to undertake annual refresher training in relation to record management. That is undertaken via e-learning portal. This course is part of the training matrix for staff ensuring it is undertaken annually.
As was heard during the Inquiry, records are audited at least bi-monthly to ensure compliance.
(v) The “Homely Remedy” policy should be amended to ensure it is cross referenced to other health records to safeguard that any such remedies dispensed cannot continue for a protracted period without a further clinical examination. The KardEx system, if it is to be maintained, should be amended to ensure that it enables the dispensing practitioner to complete details of; the patient’s reported complaints and symptoms; relevant medical history; observations; diagnosis; and treatment plan. In each case a separate record should be maintained on an appropriate Physical Care record outlining the symptoms, diagnosis and the results of any physical examinations which should be maintained with the patients clinical record.
Homely Remedies are over the counter medications such as paracetamol which those in the community can purchase from a pharmacy without the need for medical assessment, supervision or, a prescription.
The dispensation of Homely Remedies is governed by the Minor Ailments Policy. The Policy will not apply in respect of certain patients, for example, where the patient is under 18 or where the patient has blood pressure issues. In such cases, the patient is referred straight to a GP. Where the Policy applies, each Homely Remedy medication has its own policy in terms of which patients can be treated with a homely remedy for a maximum of 3 days. If a person presents with continuing symptoms for more than 3 days they are referred to a GP for assessment. Upon each administration of Minor Ailment medication, the reason for giving medication is recorded on the prescription KardEx. On the first administration of the Homely Remedy the medical notes are completed with a full assessment of signs and symptoms.
If there is a clinical change in presentation of the patient during the three days Homely Remedy administration as per policy then this would be annotated in the medical notes as a new concern or presentation. Further assessment, perhaps by the GP depending on the circumstances, will be sought.
At the time of Mr Xi’s death Homely Remedies which had been dispensed to patients were annotated on the Kardex but not on the patient’s notes. As was heard during the Inquiry, that system has changed and the dispensation of Homely Remedies is now annotated on the patient’s medical records also. Further, as set out above, staff now have access to an electronic record system called Vision.
Medical records are annotated on the first administration of the Homely Remedy medication, and subsequent doses are annotated on the Kardex. The Minor Ailments policy provides that full details of the triage must be recorded as a consultation in the patient’s clinical record. The consultation record must contain the patient’s reported signs and symptoms; relevant medical history; observations; diagnosis and treatment plan. Details of any medication administered must be documented on the medication chart at the time of provision. The resident will be encouraged to attend and any non-attendance with require the nurse to contact the individual to confirm the reason for the non-attendance. This will be documented in their medical notes including the reasons and the advice given.
(vii) The policy of using retired GPs on an ad hoc basis should be reviewed to ensure that there is always sufficient cover to meet existing demand. Where an appointment is made to see a GP this appointment should take place as arranged and in the event it cannot proceed an explanation should be provided and a further appointment arranged as soon as possible. Alternative appointments immediately be offered as soon as possible thereafter.
For the avoidance of doubt, Med-Co has never operated a policy of using retired GPs. The GP, Dr Ramsay, who gave evidence at the Inquiry was not retired at the time of Mr Huang’s death. Over the past few years, we have recruited a further 4 GPs join our team. We now have 6 GPs covering the rota (which is 1 GP per day) to meet the current demands of the site and ensuring consistency and flexibility. An appointment is made with the GP on the next available appointment which will be within 24 hours.
(viii) There should be a clear demarcation between areas set aside for dispensing and supervising medication and also areas earmarked for the presentation of patients for assessment and treatment.
(ix) All clinical assessments should take place within an appropriate consultation room to ensure confidentiality and privacy of the patient. They should not continue to take place in open corridors in view of other detainees.
In relation to (viii) and (ix) above, as we heard in evidence during the Inquiry and as was set out in the submissions for Med-Co, the layout of the pharmacy at Dungavel has changed. There is now a medication hatch from which medication is dispensed. Nurses are not allowed to see patients who present with issues at the medication hatch. Any patients who present with an issue are taken into a consultation room and have the full attention of the nurse.
(x) Any person carrying out assessments should ensure that in doing so they have full access and recourse to the existing medical records of the patients in all but emergency situations. It would be appropriate for each consultation room to have computer access so that medical records of detainees are always available to the medical staff at the time of assessments.
As above, Nurses have a consultation room available to them, and any patients who present with an issue at healthcare will be taken here to be seen. This allows the full attention of the nurse. There is computer access and access to translation services in each consultation room.
(xi) Access to the IS.91 and other Home Office forms should routinely be made available to all medical staff and in particular to the admissions nurse.
We have been informed by the custody managers that going forward the IS.91 will be provided to the admission nurse.
(xii) The issuing of language flashcards should be mandatory to ensure that all detainees are able to quickly point to their language to assist in the identification and sourcing of appropriate interpreting services.
Med-co believe that this is, to some extent, a matter for the operator of the service. The service at Dungavel IRC is no longer operated by Geo-group who were a party to the FAI. The new contract holder is Mitie C&C. They have operated the service since on or around September 2021 They hold the contract for the Bigword interpreter. The IS.91 form identifies the relevant language that the individual speaks meaning that it has been identified prior to admission. This information is provided to the nurse on admission and therefore appropriate interpreting services can be utilised either via Bigword Interpretation (telephone interpreters) or the Morfa Tablet which utilises online speech and written recognition and translation.
(xiii) There should be a system of automatic triggers for GP assessment following repeat presentations within a short time frame. Such a frequency of attendances should ensure that the patient is automatically registered for a GP appointment within a reasonable time frame.
(xiv) where doctors are asked to continue prescriptions under the Homely Remedy policy it should be that default position that this should trigger an appointment for assessment by the GP unless there are compelling reasons to believe this is not necessary.
In relation to (xiii) and (xiv) the Minor Ailment Policy has been updated to include - ‘treatment of minor self-limiting conditions without accompanying symptoms that could indicate a more complex etiology, and without the need for referral for a more in depth investigation. Treatment under this Policy must not continue for longer than 3 days for oral medicines. If the condition has not improved, or is worsening, the patient must be referred to the GP clinic for assessment’.
Where nurses have used the Minor Ailments policy, they are required to book a GP assessment if medication is required for more than 3 days. They are not able to prescribe further until assessed by a GP. The appointment with the GP will take place face-to-face and within 24 hours unless the patient requires to be seen more urgently.