Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0202, written 16 Sep 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Sep 2013 |
|---|---|
| Reference | 2013-0202 |
| Deceased | Reggie John |
| Coroner | Geraint Williams |
| Coroner area | Worcestershire |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 4. Governor, HMP Hewell 2. Chief Executive, Worcestershire Health and Care NHS Trust 3. Governor, HMP Bristol 1 | CORONER lam Geraint Urias Williams, Senior Coroner, for the coroner area of Worcestershire 2 | CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (investigations) Regulations 2013. 3 | INVESTIGATION and INQUEST On 27" October 2010 | commenced an investigation into the death of Reggie Johns then aged 58. The investigation concluded at the end of the inquest in the presence of a jury on 4" September 2013. The Jury returned a narrative verdict in the following terms:- "Mr Johns committed suicide. The contributing factors that provided Mr Johns the opportunity to commit suicide were the lack of communication between departments when reviewing Mr Johns ACCT document and deciding to remove him from constant watch without the appropriate input from the relevant qualified persons involved". 4 | CIRCUMSTANCES OF THE DEATH Mr Johns had been a former life sentence prisoner who was recalled to prison in March 2010 after 18 years in the community. He spent time at HMP Hewell, HMP Long Lartin and HMP Bristol having been moved between establishments because of his behaviour in the prisons concerned. On the 17" October 2010 whilst at HMP Bristol Mr Johns was placed on an ACCT form and was the subject of constant watch because of two separate attempts to hang himself. Previously during his time at Hewell he had been placed on protective measures on not less than 3 occasions and similarly at Bristol on two occasions. Mr Johns was due to appear at Redditch Magistrates Court on 19" October and, because of operational problems, HMP Bristol refused to agree that he should be returned there. There was limited communication between HMP Bristol and HMP Hewell but ultimately HMP Hewell agreed to accept Mr Johns from Redditch Magistrates court. Mr Johns appeared at Redditch Magistrates Court and was remanded to HMP Hewell where he arrived in the mid afternoon on the 49" October 2010. At that stage his constant watch status became apparent to the staff at Hewell. At Hewell his ACCT status was reviewed by two prison officers who decided not to continue his constant watch status. He was placed in a cell, where some 6 hours later he was found hanging from a ligature fashioned from a bed sheet. He was taken to hospital where he died the next day. Upon arrival at Hewell he underwent a health screen from a female nurse from the Healthcare Department. That nurse gave evidence saying that she was told that Mr Johns was to be placed in the segregation unit on constant watch. This lead her to conclude that there were no matters which were of concern to her because, as she said very plainly in evidence, everything that could be done for Mr Johns was (insofar as she had been told) going to be done. That nurse said that although she was aware that an ACCT review was to take place she was not consulted about it, took no part in it and made no contribution towards it. She said in terms that the two individual prison officers who in fact conducted the review did not at any time speak to her or seek to elicit her view on the matter. Her view on the matter was that Mr Johns should remain on constant watch to enable him to settle into the prison. Two prison officers conducted the review. One of those officers left half way through the review leaving Mr Johns in the company of his colleague. No member of the Healthcare Department or any other member of staff was present at the review. One of the officers gave evidence to the effect that when he was notified of Mr Johns arrival at the prison he spoke to a member of Healthcare staff who confirmed that there were "no issues” with Mr Johns. He was however unable to identify even the gender of the person to whom he said he had spoken. The other prison officer (the one who left the review early) gave evidence to the effect that, having left the review, he spoke to a male member of Healthcare who confirmed that there were “no issues". The evidence reasonably clearly demonstrated that there was no male member of Healthcare involved with Mr Johns at any stage. The officer who remained with Mr Johns in the review gave evidence that he knew Mr Johns from his previous time in Hewell, that he believed that they had a good relationship and that he could, therefore, be satisfied that when Mr Johns said he had no intend to harm himself that he could be believed. Mr Johns was therefore (with the concurrence of both of the prison officers) placed on normal location rather than in segregation or the Healthcare Department, removed from constant observation because in the opinion of the prison officers there were " no issues" and that the issues which precipitated HMP Bristol placing Mr Johns on constant watch had been dealt with. It appeared from the evidence and was clearly the basis of the jury's conclusion that there was an inadequate review conducted in this case. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell where aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status. (2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate. It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare. This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol causes significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review. Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed. (3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view. Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel. Whilst the Safer Custody process has, | am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you _have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11 November 2013 |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: EEE | have also sent it tol (Head of Healthcare HMP Hewell) and The Treasury Solicitors who may find it useful or of interest. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Signed Williams 16th day of September 2013 GU H M Senior Coroner
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
ae Equality, Rights and Decency National Offender Group (ERD) 4 . National Offender Management Service Management Service . 4.12 Clive House, 70 Petty France, London, SW1H 9EX:-.: G U Williams LLB HM Senior Coroner for the County of Worcestershire The Court. House Bewdley Road Stourport on Severn Worcestershire DY 13 8XE Your ref: GUW/TW/R1968.10 7 November 2013 Dear Mr Williams, Death of Mr Reggie Johns on 20 October 2010 Thank you. for your Regulation 28 Report of 16. September addressed to the Governors of HMP. Hewell and HMP Bristol. NOMS Equality, Rights and Decency Group (ERD) is responding to this report as we have ownership of suicide prevention and self-harm management policy in his letter is also being sent on behalf of the Governors of HMP. Hewell a - ified a number of concer ly and | have provided details 3s these issues since Mr Joh _ These have been taken. very it the action that has been taken to ecording- Information YX uwere concerned about the charing and vecording of information by staff at the __two prisons when Mr Johns transferred from HMP Bristol to HMP Hewell via Redditch Magistrates Court. Since Mr Johns’ death, HMP Bristol has introduced a system whereby their safer custody team contacts the receiving establishment via email and telephone whenever a prisoner on an open ACCT transfers out of the prison to make the receiving establishment aware of the prisoner's perceived risk of harm. In addition, the escort contractors are also now informed of those prisoners on open ACCTs prior to being transferred out to court or other establishments. These conversations are recorded on Prison-NOMIS and the enclosed Governor's Order has been issued to remind staff of their responsibilities in this area. At HMP Hewell the enclosed Staff Information Notice entitled ‘C-NOMIS Case Notes’ has been issued since Mr Johns’ death to remind staff of the need to make quality records on C-NOMIS of all conversations with prisoners and/or their families which are relevant to ensuring the safe management of that prisoner. A new local safer custody guidance document has been also issued at HMP Hewell since Mr Johns’ death to accompany PSI 64/2011. Within this guidance there is a section about information recording which states: All staff at HMP Hewell have a responsibility to inform the relevant people if they have received information from any source that indicates a change in the potential for a prisoner to harm themselves. If you have received such information, you must immediately pass this on to the Residential, Daily or Night Operational Manager. You can also open an ACCT Plan and make a recording in an appropriate source, e.9g., observation book, NOMIS or an SIR. Always report this information — you could save someone's life. You highlighted that the ACCT review at HMP Hewell upon Mr Johns’ arrival was not multi-disciplinary and no member of the healthcare team was in attendance or spoken to prior to the meeting taking place. Since Mr Johns’ death, the enclosed Operational Orders have been issued entitled ‘Chairing ACCT Reviews’ and ‘ACCT Reviews’ which provide guidance for selecting appropriate ACCT case managers, and confirm that it is the case manager's Fesponsibility to ensure that each revie ulti-disciplinary with views from all : iate de Fr ing ta tion. You identified that when Mr Johns arrived at HMP Hewell the nurse who carried out a medical assessment did not have access to his ACCT document. | am aware that you are now in receipt of Worcestershire Health and Care NHS Trust’s response to your report, which confirms that ACCT documents are now made available to nursing staff in reception in all cases when a prisoner arrives at HMP Hewell on an open ACCT. In addition to that response, | have enclosed a copy of a joint document which has been produced by HMP Hewell and Worcestershire Primary Care Trust which provides guidance to discipline and healthcare staff about the importance of working together and sharing information appropriately about the prisoners in their care. . | hope that you find this response helpful and reassuring. Yours sincerely, . = Equality, Rights and Decency Group
Worcestershire Health and Care NHS| NHS Trust Chief Executives Office Worcestershire Health and Care NHS Trust Isaac Maddox House Shrub Hill Road Worcester WR4 SRW. Your Ref: GUW/TW/R1968.10 Tel: 01905 733674 Our Ref: SD/RH/LM e-mail: rm www.hacw.nhs.u 15 October 2013 Mr G U Williams LLB RECEIV ED HM Senior Coroner for the County of Worcestershire ; The Court House 1? OCT 2a Bewdley Road r STOURPORT ON SEVERN HLM. ¢ C IRON ER Worcestershire “ DY13 8XE Dear Mr Williams Re: Reggie Johns (deceased) Regulation 28 Coroners and Justice Act 2009 Thank you for your letter dated 16 September 2013 and the enclosed Regulation 28 report. | have read your report with great care and in particular the concerns you have raised as a result of your investigation into Mr Johns’ death. | have also discussed this report with the lead for Offender Health [MY and the Head of Healthcare, HMP Hewell | do not intend to comment on your report in terms of the circumstances of Mr Johns’ death. | have read this section of your report and have discussed it with HE wh. confirms that it is an entirely fair reflection of the evidence given during the course of the inquest. With regard to your Matters of Concern | propose to consider each of these in turn. 1. Communication Whilst this concern largely focuses on the issue of communication between HMP Bristol and HMP Hewell | think it is appropriate to seek to reassure you about communication between the healthcare team at HMP Hewell and other HM Prisons. There is continuous dialogue within HMP Hewell between the healthcare and the discipline teams. Some of this is formalised through various meetings and forums and some is informal and reflects a relatively constant ebb and flow of communication on patient specific issues, task related discussion, operational issues and joint working. If prisoners are transferring to other prisons the prisoner's healthcare record is transferred to the receiving prison. In some cases the Nurse in Reception at HMP Hewell will contact the receiving prison to raise specific issues or concerns. Messrs and i! ensure that appropriate information is communicated to receiving prisons Chairman: Chris Burdon Chief Executive: Sarah Dugan when prisoners are transferred from the prisons in which the Trust provides healthcare services, namely HMPs Hewell, Long Lartin and Oakwood. 2. Prison Service Order 2700 Healthcare provides representation into Assessment, Care in Custody and Teamwork (ACCT) reviews as follows: * prisoners in the Inpatient Unit (Lower Medical) * prisoners in the segregation unit * prisoners actively managed by the mental health team / part of Multi-Disciplinary Team discussion * any other prisoner if requested by the prison (this may be telephone advice or attendance at the review). 3. ACCT Document At the time of Mr Johns’ inquest when this issue was discussed rote to all staff within the healthcare team at HMP Hewell to set out his expectations in respect of prisoners arriving in Reception at HMP Hewell on an ACCT. These are as follows: « The ACCT document is made available to the Nurse in Reception. This has been discussed with the Reception Governor to ensure that Prison Officers undertake to do this * The ACCT document must be reviewed while the prisoner is in Reception « A note must be entered into the ACCT document regardless of the level of risk presented by the prisoner * A note must be made in the reception screen or subsequent healthcare record that the ACCT has been seen and reviewed and any actions/plans are recorded. Subsequently these requirements have been re-iterated to all staff. | can also confirm that following the inquest into Mr Johns’ death EEE and Fe Prison Governor, HMP Hewell have reviewed Prison Service Instruction 64/2011 (updated) — in order to identify any areas of non-compliance and to address these. | trust that the foregoing has adequately addressed the Regulation 28 report issued subsequent to the inquest into Mr Johns’ death. Yours sincerely Sarah Du Chief Executive
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