Four opportunities were missed to diagnose a prisoner with an inoperable brain tumour, who died less than two months after he was released from jail, the prisoner ombudsman has found.
An investigation was carried out into the death of released prisoner Mr H in September 2014.
He had been released from Maghaberry Prison at the end of July due to an inoperable brain tumour.
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.
The report said that 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".
Other finds which were "not in accordance with best medical practice" are listed below:
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 its possible that his "attempts to manipulate the medication which was prescribed did not assist his diagnosis".
The report makes fifteen recommendations for improvement, all of which have been accepted by the SEHSCT and the NIPS. Some of these are procedural, but a gap in clinical leadership is again 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 Prisoner Ombudsman's report, stating they are committed to implementing improvements as a result of the lessons learned from all investigations. The NIPS said it is determined to use this report to strengthen systems already in operation throughout Northern Ireland’s prisons.
Prisoner Ombudsman Tom McGonigle, expressing sympathy to the next of kin, said: “This report again highlights the need for someone to actively take charge and manage the first line clinical care of patients in prison, where families are less able to assist or advocate on their behalf.
"The fact that we also published a report last week which raised virtually identical issues, reaffirms the need for the prison healthcare reform project to provide improved diagnoses and better palliative care for the terminally ill.”