Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0122, written 12 Mar 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Mar 2014 |
|---|---|
| Reference | 2014-0122 |
| Deceased | Andrew Hall |
| Coroner | Anthony Eastwood |
| Coroner area | Teesside |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. = REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. HM Prison Service ( NOMS) 2. North Tees and Hartlepool NHS Trust 3. Tees, Esk & Wear Valley NHS Foundation Trust 1 CORONER [ Tam Anthony Gerard Eastwood, Assistant Coroner, for the coroner area of Teesside. 2 | CORONER’S LEGAL POWERS I 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 31 March 2009 I commenced an investigation into the death of Andrew Ronald Hall aged 41 years (date of birth 6 June 1967). The investigation concluded at the end of the inquest on 13 June 2013. The conclusion of the inquest was that Andrew Ronald Hall killed himself while the balance of his mind was disturbed and the cause of death was contributed to by negligent, jury also recorded their findings in a narrative form : 4 | CIRCUMSTANCES OF THE DEATH Between 19.20 hours and 19.35 hours on 27 March 2009 in cell 5 of Health Care Unit at HM Holme House Prison the deceased caused incised wounds to his neck causing hypovolaemic shock which caused his death. On the said date the deceased was an inmate detained lawfully at Her Majesty’s Prison Holme House. 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concem. 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 set out below. I have for ease of reference highlighted in bold type where a particular body or organisation is specifically referred to, and in brackets at the end of the entry, where the jury were silent but where I consider the body or organisation being referred to has responsibility to deal with it — 1. In the assessment of risk and risk management the jury found (inter alia) information provided by mental healthcare nursing staff to Prison Officers was not correctly documented. 2. There was inadequate communication between members of the Mental Health team as to the deceased’s condition and the level of risk of self-harm. S:\AGE PERSONAL\AGE. Inquests\Hall.Inquest.Reg28.docx 3. There was inadequate communication between members of the Mental Health Team and the Healthcare Unit staff as to the deceased’s perceived condition and level of risk of self-harm. 4. There was inadequate communication between the Mental Health In Reach Team and the mental care unit staff as to the type and level of observation required when the deceased was re-admitted to the Healthcare Unit on 23 March 2009. 5. Insufficient attention was paid by healthcare professionals to the system | entries. 6. That both mental health staff and general nursing staff inadequately took into account the entry made by 7. That a post-closure interview in accordance with the (then) ACCT policy should have been conducted. ( Prison staff, healthcare staff and Mental Health team ) 8. Medication was not administered to the deceased on 23 March 2009 and 24 March 2009 as prescribed. ( Medical healthcare staff) 9. The deceased was not adequately observed between 6.30pm and 7.30pm on 27 March 2009. (Healthcare staff/Prison discipline officers) 10. The quality of CCTV images within the healthcare unit was inadequate. ( prison service) 11. Arrangements for staff members to use the CCTV screens were absent. (Prison service & Healthcare staff) 12. There was infrequent observation of the CCTV Screens on 27 March 2009. (Prison service & Healthcare staff) 13. Generally the training and induction to visiting Psychiatrists in respect of the ACCT Process was relevant to the circumstances in which the deceased died. 14. The practice of healthcare professionals regarding the reading of previous system ] entries was also relevant to the circumstances in which the deceased died. 15. The awareness of prison policies in relation to the use of camera cells was also relevant to the circumstances in which the deceased died. (Prison service & Healthcare staff) 16. The training and instructions given to prison officers and nursing staff regarding use of and manipulation of the CCTV image was also “relevant” to the circumstances in which the deceased died. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and /or your organisation have the power to take such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by [9 May 2014]. I, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons SAAGE PERSONAL\AGE Inquests\Hall. Inquest. Reg28.docx The Family of the deceased, Andrew Ronald HALL [and see panel 1 above]. Iam 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. 12 th March 2014
1 response 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.
ge M j nist ry of Equality, Rights & Decency Group National Offender Management Service T = 4.12 Clive House 70 Petty France London SW1H 9HD National Offender Telephone: Management Service Mr A G Eastwood Assistant Coroner for Teesside 21 March 2014 Dear Mr Eastwood INQUEST INTO THE DEATH OF MR ANDREW HALL AT HMP HOLME HOUSE ON 27 MARCH 2009 Thank you for your Regulation 28 report dated 12 March 2014, which has been passed to Equality, Rights and Decency Group in the National Offender Management Service (NOMS), as we have policy responsibility for suicide prevention and self- harm management, and for sharing learning from deaths in custody. | am responding on behalf of NOMS and HMP Holme House, and will address each of the points that you have made that refer to prison staff or the prison service. You are concerned that information about risk provided by mental healthcare nursing staff to prison staff was not correctly documented (point 1). ACCT reviews are chaired by supervising officers who record any information about risk that is received from the mental health team. Where a prisoner has mental health issues, a member of the mental health team is invited to attend all ACCT reviews. The mental health team has received ACCT training, and further training sessions are arranged when new members join the team. Mental health staff play an active role in the management of ACCT plans, and a significant number of ACCTs are opened by the team. The prison’s regular management checks confirm that members of the mental health team attend reviews and that their contributions are recorded. You are concerned that a post-closure review of the ACCT was not conducted (point 7). Asystem is now in place within the safer custody department to ensure that all post-closure reviews take place within the seven day period mandated in Prison Service Instruction (PSI) 64/2011 Safer Custody. A local policy that an additional post-closure review is conducted after one month has been introduced. You raise a number of concerns about the effectiveness of the arrangements to observe prisoners in cells in the healthcare centre using CCTV (points 9-12, 15 and 16). Cameras have been removed from all cells and any prisoner assessed as requiring high levels of observation is located in a constant observation cell and subject to constant supervision in accordance with the arrangements set out in chapter 6 of PSI 64/2011. You are concerned about the adequacy of the induction and training on the ACCT process provided to visiting psychiatrists (point 13). All new staff who work with prisoners are provided with an induction that includes guidance on the ACCT process. Training on ACCT has been provided to all visiting psychiatrists, and further courses will be arranged as required. | hope this provides you with assurance that the points that you have raised for prison staff and/or the prison service have been fully addressed. Yours sincerely
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