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Provision of health care to prison inmate (14HDC01769)
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(14HDC01769, 15 June
Prison ~ Wound care ~ Treatment ~ Medication management ~
Pain ~ Circulation issues ~ Right 4(1)
An older man was transferred from one prison to a second prison
for short periods on two occasions in order to appear in Court. The
man's hospital discharge summary and other healthcare information
was provided to the health centre at the second prison. This
included instructions to dress blisters on the man's toes daily and
at other times as needed. At this time, the man was prescribed
medications for pain relief. Some of the man's medications and his
drug chart and signing sheets were left on the bus when he was
transferred to the second prison. They were returned to the second
prison several days later.
There is no record that the man's feet were checked or treated
while he was at the second prison. The clinical record states that
the man was to be seen in a nurse clinic to review the blisters on
his feet, but there is no record that this occurred. A doctor saw
the man and recorded in the notes that staff were to watch
carefully for any signs of infection. However, there is no record
that this occurred or that his feet were checked or treated after
The man shared a cell with another prisoner, who said he cleaned
the man's toes with toilet paper every morning.
The medication administration signing sheets show that the man
was not always administered paracetamol, OxyContin and OxyNorm in
accordance with the prescriptions, and there is no documentation
reporting the reason for non-administration.
When the man returned to the first prison, nursing staff
recorded comments in the clinical record about his poor physical
state, and noted that toilet paper was soaked off his toes with
The man returned to the second prison for a few days. The
healthcare plan sent to the second prison required health staff to
"check and dress feet daily to prevent further damage"; however,
there is no record that this occurred.
On his return to the first prison, the man handed a bag of
medications to an officer and said he had been given it when he
left the second prison, without instructions on what to take or how
often. The man was not an approved self-medication prisoner, and
there is no record of this medication having been handed to him at
the second prison.
The lack of treatment of the man's feet and the failures in
relation to medication management cumulatively amount to a
significant departure from accepted standards. There was a pattern
of failures by multiple providers responsible for the man's care,
and ultimately the second prison is responsible for those failures.
The operator of the second prison failed to ensure that the man was
provided services with reasonable care and skill and breached Right
Adverse comment is made about the failure of the operator of the
first prison's systems to ensure that the man's documentation and
medications arrived at the second prison.