Cherylin Norrell-Goldsmith

“ Equality, Rights and Decency

National Offender Group
3 National Offender Management Service
Management Service 4th Floor, Clive House,

70 Petty France,
London, SW1H 9HD

Email:

Coroner Mr Richard Travers
HM Coroner for Surrey
18 December 2014

Dear Mr Travers,

Re: the death of Cherylin Angela Maria Norrell- Goldsmith on 22 July 2013 whilst in HMP
Downview

Thank you for your Regulation 28 Report of 27 October 2014 to the Secretary of State, the Governor
of HMP Downview and others, concerning the recent inquest into the death of Cherylin Angela Maria
Norrell-Goldsmith. Your letter has been passed to Equality, Rights and Decency (ERD) Group, in the
National Offender Management Service (NOMS), as we have the policy responsibility for suicide
prevention, self-harm management and for sharing learning from deaths in custody.

You will be aware that since Ms Norrell-Goldsmith’s death HMP Downview no longer has a population
of female prisoners and is currently being re-roled to provide accommodation for Category C male
prisoners. The prison will reopen in Spring 2015.

| am responding to the concerns you have raised in your report as follows:

(1) Open pipe work within the cell- removal of easily accessible ligature points may serve to reduce the
tisk of self harm and suicide to vulnerable prisoners

The Ministry of Justice Estate Directorate (MoJ ED) are responsible for the delivery of prison and
construction projects. MoJ ED now routinely provide ‘safer cells’ in all new prison construction projects.
“Safer cells” are specifically designed to remove known ligature points thereby reducing the opportunities
for a prisoner to self-harm by means of ligature. MoJ ED also routinely provide “safer cells” when
refurbishing existing accommodation wherever it is physically possible to do so. The programme of new
construction and planned refurbishments means that the numbers of safer cells are increasing across the
prison estate.

If a particular establishment identifies that a cell presents opportunities for self harm, the Governor of that
establishment may commission the establishment's local works team to refurbish it to reduce the risk.
However, it must be noted that no cell can be described as “safe” and while one ligature point may be
removed, there will be others which remain. A “safer cell” provides staff with a location to relocate a
prisoner in immediate crisis. MoJ ED, as attached, publishes a guide to safer cell design which sets out
the specific requirements for a cell to be a designated “safer cell’. Most establishments maintain some
designated safer cells which can be used to accommodate prisoners identified at risk of self harm.

(2) Multi-disciplinary attendance and input_at Assessment Care in Custody and Teamwork (ACCT)
Reviews

PSI 64/2011 on Safer Custody aims to support effective multi-disciplinary case management and sharing
of information to reduce incidents of harm. In line with PSI 64/2011 Safer Custody, HMP Downview when
it re-opens in 2015, will issue a notice to staff explaining the importance of and procedures for conducting
multi-disciplinary ACCT case reviews. Particular emphasis will be given to the fact that multi-disciplinary
case reviews are to be held at the appropriate times, and where possible, a consistent case manager and

relevant personnel must attend the reviews. Where a relevant member of staff cannot attend an ACCT
review, then in exceptional circumstances, and per the instructions of PSI64/2011, a written report will be
submitted. When HMP Downview was a female prison, a system was in place to ensure that all staff who
arrived for duty were provided with a list of prisoners subject to an ACCT and the date of the next ACCT
case review in order that they could arrange to attend the review if they were involved in that prisoner's
care. This system will be reintroduced in Spring 2015. In addition, case managers will record in the ACCT
document any significant personnel who are involved with the offender, including, health care, offender
management and interventions or learning and development. The case manager will also email relevant
persons prior to the case review requesting their input to add to the details of the review and report.

Prior to the re-opening of HMP, Downview, all prison staff, including personnel employed by partnership
agencies within the prison will receive initial training or refresher training in the application of the ACCT
procedures as part of their induction programme. The 2.5 hour training package will then be delivered by
trained facilitators to each member of staff every 2 years, and the programme of training will be monitored
by the HR hub at the prison.

(3) Retention of primary source data within the Phoenix Programme - Consideration should be given to
ensuring that all primary source data should be either kept in hard copy format_or by way of faithfully
recording all the detail contained on the Prisoner's Systm One record

The local policies and procedures at HMP Downview have been reviewed and strengthened where
necessary. The NHS England Area Team has produced data sharing Agreements which set out the
required standard for sharing data between clinicians and also for a non-clinical (secondary) purpose.

NHS England is responsible for managing the audit and reporting for access to records in the clinical
system (TPP SystmOne and its successor) and for the appropriate use of patient information.

Providers are required to undertake spot checks of their own adherence to these Agreements either
directly or through monitoring of the standards referred to above. Any resulting report on the findings of
the audits concerning these Agreements can be reasonably requested by any Party to the agreement.

(4) Recording significant medical events on a prisoner's non-medical records

All staff, including health care staff, will be reminded of the ACCT procedures and the requirement to
record significant information about an individual’s self-harm or suicide risks, on Cnomis (Custodial
National Offender Management Information System) in addition to recording the information on
SystmOne- (the electronic medical records system). The induction pack available for health care staff has
also been updated to include governance information about ACCT procedures and what information can
be shared with non healthcare professionals.

| hope this provides assurance that the specific issues identified in this case, both at the inquest and by
the Prisons and Probation Ombudsman, are being addressed.

Yours sincerely,

NOMS Equality, Rights and Decency Group