Satheeskumar Mahatheaven

Regulation 28:  Prevention of Future Deaths report 

Satheeskumar MAHATHEVAN (died 19.04.13) 

THIS REPORT IS BEING SENT TO: 

1. 

Governor 
HMP Pentonville 
Caledonian Road 
London  N7 8TT 

1 

CORONER 

I am:   Coroner ME Hassell 
           Senior Coroner  
           Inner North London 
           St Pancras Coroner’s Court 
           Camley Street 
           London  N1C 4PP 

2 

CORONER’S LEGAL POWERS 

I make this report under the Coroners and Justice Act 2009,  
paragraph 7, Schedule 5, and  
The Coroners (Investigations) Regulations 2013, 
regulations 28 and 29. 

3 

INVESTIGATION and INQUEST 

On  23  April  2013,  my  predecessor,  Shirley  Anne  Radcliffe,  commenced 
an  investigation  into  the  death  of  Satheeskumar  Mahathevan,  aged  31 
years. The investigation concluded at the end of the inquest on Friday, 19 
September  2014.  The  jury  made  a  determination  that  Mr  Mahathevan’s 
death was the result of an accident. 

4 

CIRCUMSTANCES OF THE DEATH 

Satheeskumar  Mahathevan  hanged  himself  in  his  cell  at  HM  Prison 
Pentonville on 14 April 2013. 

5 

CORONER’S CONCERNS 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 During  the  course  of  the  inquest,  the  evidence  revealed  matters  giving 
rise to concern. In the jury’s 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  contained 
determination made by the jury as follows. 

in 

the  narrative 

“Failures  in  relation  to  information  sharing,  multi  agency  communication 
procedures  and  inadequate  training  for  staff  at  the  prison  services  have 
contributed to this accident.” 

6 

ACTION SHOULD BE TAKEN 

Action  should  therefore  be  taken  to  prevent  future  deaths  and  I  believe 
that you 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 28 November 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 following. 

  HHJ Peter Thornton QC, the Chief Coroner of England & Wales 
 
  HM Inspectorate of Prisons 
  National Offender Management Service 

r, brother of Mr Mahathevan  

I  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 
interest.  You  may  make 
representations to me, the Senior Coroner, at the time of your response, 
about  the  release  or  the  publication  of  your  response  by  the  Chief 
Coroner. 

it  useful  or  of 

find 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 9 

DATE                                                   SIGNED BY SENIOR CORONER 

19.09.14 

3

ae Equality, Rights and Decency Group
< National Offender Management Service
National Offender 4th Floor, Clive House,

Management Service 70 Petty France,
London, SW1H 9HD

Email: shila.jassal@ noms.gsi.gov.uk

Ms M E Hassell
Senior Coroner

Inner North London
27 November 2014

Dear Ms Hassell,

Thank you for your Regulation 28 Reports of 19 September 2014 addressed to the Governor of
HMP Pentonville and the Director of HMP Thameside, following the recent inquest into the
death of Satheeskumar Mahathevan at HMP Pentonville on 20 April 2013. Your reports have
been passed to Equality, Rights and Decency Group in the National Offender Management
Service (NOMS), as we have the policy responsibility for suicide prevention and self-harm
management, and for sharing learning from deaths in custody.

| am responding on behalf of the Governor of HMP Pentonville and the Director of HMP
Thameside. | have liaised with staff in the establishments, including the healthcare providers,
and the healthcare commissioners, NHS England, in the preparation of this response.

The concerns raised in your report relate to the narrative determination made by the jury, which
refers to failures in relation to information sharing and multi-agency communication procedures,
and inadequate training for staff. The specific issues in each of these areas are not identified,
so | have considered each element relevant to the case.

Information sharing and multi-agency communication procedures

There appear to be three issues that arise in this area: the use of risk information sent from the
court to the prison, the communication of risk information between prisons, and requesting the
community health records for use by the prison healthcare provider.

Local policies are now in place at HMP Pentonville and HMP Thameside to ensure that
information is shared appropriately and that there is effective communication between prison
staff and the healthcare provider. At both prisons, staff involved in the reception and first night
processes have been reminded of the need to gather all relevant information, including
information received from court, and of the factors that they should consider when assessing
risk and sharing information between agencies.

At HMP Pentonville healthcare staff in reception now have access to all the relevant documents
that arrive with the prisoner from court. This will include the prisoner escort record, core record,
self harm warning form, custody record from police, and/or F2050 which contains the prisoner's
warrant. The procedure is that on the arrival of a new prisoner the supervising officer on the
reception desk checks the accompanying documentation. If any information regarding the
prisoner's physical or mental health is identified this will be handed to the healthcare staff. The
prisoner's file is then passed to staff on the induction wing who conduct a further check of the
documentation, providing a second opportunity for relevant information to be found should it
have been missed initially. This process is supplemented with a verbal handover from escort
staff to reception staff in cases in which they are aware of relevant risk information.

At HMP Thameside prison and healthcare staff work tagether at the same counter. A new form
has been designed specifically to ensure that all releyant information, including that received
from the court, is communicated between the two pane of staff.

On arrival at each prison, prisoners are requested to
provides consent for necessary information to be shar:
care between establishments.

co an "information sharing" form, which
d as required, so ensuring continuity of

Both prisons currently use electronic medical records SystmOne) and on receipt of a prisoner
on transfer the healthcare staff in reception read all) relevant information on this system to
ensure that they are fully aware of their health needs. Where there are concerns with a
prisoner’s well-being, the sending prison contacts the teceiving prison to ensure that there is a
verbal handover in addition to immediate access to the clinical records.

Community GP records are now routinely requested| in all cases in which there are health
concerns. All attempts to contact GPs and other relevant agencies are clearly documented on
the SystmOne electronic record.

| am informed by colleagues in NHS England that in response to this recommendation they
have added checks on the induction and communicatian policies and procedures to their annual
audit process for healthcare providers. The findings fon the next audit will be considered by
healthcare commissioners in January 2015 and action will be taken to identify any issues
identified.

Training for staff

Prison Service Instruction 64/2011 requires all staff
trained in the ‘Introduction to Safer Custody’ course, ai
in specific roles such as ACCT assessor and case ma
review and provide refresher training as required.

who have contact with prisoners to be
d there is more detailed training for staff
ager. Prisons keep training needs under

All new healthcare staff are shown how to use the SystmOne electronic record system correctly,
and must be confident in using the system before being allowed access without supervision.

All healthcare staff at HMP Pentonville are also being

trained in the use of PNOMIS to record

prisoner information and made aware of how to obtain community records.

In December 2014 HMP Pentonville will be issuing revised guidance to all staff to ensure that

appropriate codes are used in the event of a medical
will also receive revised instructions to ensure that an
relevant code being used.

emergency. Communications room staff

ambulance is called immediately on the

| hope this provides assurance that the matters of concern that you have raised have been

addressed and that NOMS continues to make stren
processes in these important areas. |

NOMS Equality, Rights and Decency Group

lous efforts to improve its systems and