Four Opportunities To Diagnose Prisoner With Brain Tumour Missed - Report

A prisoner with an inoperable brain tumour could have extended his life expectancy after it was found four opportunities to diagnose his tumour were missed, according to a report by the Prisoner Ombudsman.

The prisoner, known as Mr H, had been released from Maghaberry Prison at the end of July 2014 but died in September of the same year.

The investigation found that several prison officers and nurses showed compassion for Mr H while he was in prison. He was not always compliant with the care that was offered and it is possible that his attempts to manipulate the medication which was prescribed did not assist his diagnosis. Treatment was also delayed when he did not attend a hospital Accident & Emergency Department.
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The clinical reviewer recognised that some of Mr H's care was very good, in particular his mental health assessments. However four opportunities to diagnose his tumour were missed and care plans were not initiated when he became dehydrated and malnourished. Although earlier diagnosis would not have changed the final outcome, opportunities for an extended life expectancy and a reduction in his distress through earlier palliative care could have been provided.

The report makes fifteen recommendations for improvement, all of which have been accepted by the South Eastern Health and Social Care Trust (SEHSCT) and the Northern Ireland Prison Service (NIPS). Some of these are procedural, but a gap in clinical leadership was noted at Maghaberry Prison. One recommendation was previously made to, and accepted by the SEHSCT, in February 2012.

The SEHSCT accepted all of the recommendations of the report, and said they are committed to implementing improvements as a result of the lessons learned from all investigations. The NIPS said it is determined to use the report to strengthen systems already in operation throughout Northern Ireland's prisons.


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