Each day around 120 prisoners with ongoing medication needs are moved between prisons.

This investigation identifies opportunities and remedies that could be applied across the system to reduce the risk of prisoners with long term, chronic conditions being moved without crucial medication.

Reference event

The reference event in this investigation is the case of Martin, a 43-year old inmate, who suffered multiple seizures after his epilepsy medication wasn’t transferred with him to a new prison.

Investigation summary

We reviewed the entire reference event, from the start of Martin’s internment through to the moment where his medication was acquired by the Category C prison he was moved to.

The investigation followed the pathway of care and the processes that were involved, including the healthcare aspects and the operational side of the prison, to understand the decisions made.

The human factors that may influence decision making at all levels throughout the transfer process were considered, along with the complexity of the environment and the system in which staff work.

This investigation focused on the routine transfer of prisoners around the prison system.

Download and read the full report.

Safety recommendations

We made safety recommendations to the Care Quality Commission (CQC), the National Prison Healthcare Board for England and NHS England/Improvement as a result of this investigation.

All organisations responded to their safety recommendations within 90 days of publication of the investigation report.

Care Quality Commission

Safety recommendation

It is recommended that the Care Quality Commission amends its inspection criteria to ensure that interprison transfer processes are fully encapsulated within the inspection schedule to assure the provision of care throughout.


We have taken some short to medium term actions:

  • We have worked closely with Her Majesty's Inspectorate of Prisons (HMIP) on this throughout the investigation process and have flagged up the recommendation and asked them for suggestions for how we could improve the inspection of transfer medication.
  • We have discussed the recommendation with the Nursing and Quality lead for Health and Justice at NHS England, who is also considering how commissioners can impact on practice. We meet quarterly so this will remain on the agenda so that we can learn from each other.
  • The Health and Justice team are fully briefed to give this area more focus during inspections.

Longer term, fundamentally, the key lines of enquiry (KLOEs) and thus the framework need to be reviewed and strengthened. A review of the handbook was planned for this year but we are nearly out of time. Overall, it will be dependent on how we plan to inspect in the future.

This response was received on 8 November 2019.

National Prison Healthcare Board for England

Safety recommendation

It is recommended that the National Prison Healthcare Board for England oversees work to implement interoperability between SystmOne and the Prison-National Offender Management Information System, enabling sharing of essential information across the prison service which does not impinge on the confidentiality requirements of either system.


The National Prison Healthcare Board for England recognises the value of enabling interoperability between the prison health database (SystmOne) and the custodial services system (p-NOMIS).

NHS Digital has been working with the Ministry of Justice and the prison health database provider (TPP) to explore technical solutions to enable information sharing, with due regard for patient confidentiality. Currently, we expect to be able to test new approaches in information sharing across the two systems from Autumn 2020. If initial tests are successful, this could enable the joined-up approach to be used across the whole prison estate in England from April 2021.

In the meantime, further work will take place across organisations between clinical teams and prison staff to support effective information sharing.

This response was received on 7 February 2020.

NHS England/Improvement

Safety recommendation

It is recommended that NHS England/Improvement (NHS E/I) health and justice national commissioning team review how they monitor and assure the provision of healthcare in prisons to reduce variability in standards, particularly in the areas of incident reporting and investigations.


NHS E/I expect all providers to comply with the requirements set out in the NHS Standard Contract 2019/20 SC33: Incidents Requiring Reporting, which includes compliance with the NHS Serious Incident Framework (2015). The responsibility and assurance of contract compliance is delegated to the regional health and justice (H&J) commissioners.

In July 2019 NHS E/I H&J corporate team published Quality First: Quality Assurance and Improvement Framework for Health and Justice and SARCs. Section 4.1 of this framework covers Serious Incident reporting and management and states:

"Commissioners are accountable for quality assuring the robustness of their providers’ serious incident investigations and the development and implementation of effective actions by the provider, to prevent recurrence of similar incidents. Regional teams should ensure there are clear processes in place to support this."

This framework also includes information on the quality schedules developed annually which provide a national set of quality reporting requirements for health and justice services.

Under the NHS E/I Joint Working Programme we are in transition to the new operating model and a seven regional team structure. As part of this transformation, regional teams are developing their governance arrangements for all directly commissioned services, including health and justice. The Specialised Commissioning and H&J Strategy Group, chaired by the National Director for Transformation and Delivery, oversees the development and implementation of the governance arrangements which includes regional monitoring and assurance of prison healthcare provision.

The NHS Patient Safety Strategy, published in July 2019, sets out the focus for patient safety in the NHS as we deliver the NHS Long-Term Plan through the emerging local healthcare systems. The regional teams will support this delivery. The strategy highlights the impact better reporting and response can have on reducing harms and saving lives. The strategy will be supported by the Patient Safety Incident Reporting Framework, due to be published in early 2020. This framework is being piloted in a number of services, including prison healthcare.

This response was received on 7 January 2020.


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