Concerns raised over computer system after death of Suffolk prisoner
PUBLISHED: 06:05 09 November 2019
Serious concerns have been raised about a computer system which was said to be a contributing factor to the death of a prisoner in a Suffolk jail.
An inquest into the death of HMP Warren Hill prisoner Mark Jarvis, discovered in his Oak Wing cell in 2015, found the heart problems that killed him were brought on by the injestion a New Psychoactive Substance, thought to be spice.
Following the hearing in September this year, senior coroner Nigel Parsley asked for a regulation 28 Prevention of Future Deaths report (PFD) due to a number of concerns over a computer system used to prescribe drugs to prisoners.
He said there was a risk of future deaths unless actions were taken to address his concerns.
In the report, which was addressed to NHS England and computer company SystemOne TTP, Mr Parsley said there was a risk of future deaths unless actions were taken to address his concerns.
The computer program, called SystemOne was said to have a range of problems.
GPs reported that the program was "not clear to read or easy to understand" and that it was not compatible with the prison's IT system.
They also reported that the program made it difficult to see which drugs a patient had previously been prescribed, what repeat prescriptions were in place, which drugs had been taken by patients or when they were supposed to have taken them.
The report said that doctors were forced to guess which illnesses patients had from which drugs they had previously been given because the program had no clear link between prescriptions and diagnosis.
Also, such were the issues with drugs being incorrectly subscribed to prisoners that some medication such as opioids and depressions medication had become 'currency' within the prison.
The report listed how in an interview with investigators from the Prisons and Probation Ombudsman's Office after the death on Mr Jarvis, a GP described the system as an "absolute nightmare" saying "it is like banging our heads against a brick wall".
"We are trying hard to get some changes done because we are concerned about safety," the GP said.
When questioned at the inquest the GP told the court that as of September 3, 2019, nearly four years after the death of Mr Jarvis, there had still not been a resolution to the problems.
In the PFD report, Mr Parsley also raised concerns over poor adherence to Mr Jarvis' blood pressure medication regime, which was identified by the jury at the inquest as a contributing factor to his death.
Following the death of Mr Jarvis it was established that he was taking prescribed medication for a number of health issues.
A post mortem examination found that in addition to a heart condition which could have accounted for the death of Mr Jarvis, Spice or another psychoactive substance was found in his system - as well as two medical drugs which had not been prescribed to him.
Both NHS England and SystemOne TTP have been contacted for comment but said they will respond officially before the legal November 15 deadline.