Prevention of Future Deaths reports · 2014

Geraldine Kilborn

Regulation 28 report to prevent future deaths, reference 2014-0532, written 10 Dec 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report10 Dec 2014
Reference2014-0532
DeceasedGeraldine Kilborn
CoronerAndrew Tweddle
Coroner areaCounty Durham & Darlington
CategoryState Custody related deaths
Sourcejudiciary.uk record · original PDF
Responses published3

The report

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

THIS REPORT IS BEING SENT TO:

NOMS, Equality Rights and Decency Group, National Offender

Management Service, Fourth Floor, 70 Petty France, London SW1H 9EX

2. Tees, Esk, Wear Valley NHS Foundation Trust, Trust Headquarters, West
Park Hospital, Edward Pease Way, Darlington DL2 2TS

3. Care UK, Hawker House, 5 — 6 Napier Court, Napier Road, Reading, RG1

8BW

CORONER

| am Andrew Tweddle Senior Coroner, for the Coroner area of County Durham and
Darlington

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.
(see attached sheet)

INVESTIGATION and INQUEST

On 3" December 2013 | commenced an investigation into the death of Geraldine Liege
Kilborn aged 37 years. The investigation concluded at the end of the inquest on 5
December 2014.

The Jury could not determine the Deceased's intention when she hung herself. The Jury
concluded that following an ACCT review, the deceased was not appropriately located at
the time of her death and that she would not have ended her life when she did,
irrespective of her location.
CIRCUMSTANCES OF THE DEATH

Immediately upon entry into HMP Low Newton, the reception screen nurse deemed the
deceased to be of high risk of self-harm and advocated a constant watch. Over the next
22 days prior to her death the deceased self-harmed repeatedly with many of the
attempts being deemed by staff as being genuine attempts to take her own life. There
were a series of ACCT reviews. For a time she was on constant observations, on normal
location, in healthcare safer cell and healthcare normal cell. One ACCT review had no
mental health staff input when such staff had asked to be present and somewhat
incredulously, in evidence the ACCT case manager stated that he did not know that
mental health care staff were available to attend on the day in question. At the time of
her death mental health care staff did not work weekends and at two critical ACCT
reviews, there was no mental health input into the reviews. Several mental health
witnesses described tensions between mental health and wing staff, one such witness
calling wing staff “dinosaurs”. Senior key members of the last two ACCT reviews were
unaware of the detailed entry made in system one notes by a Consultant Psychiatrist
and did not take her views into account. On one of these two key reviews, which was
attended by a senior general nurse, she did not share with the other review team
members the knowledge that she had of the said system one Consultant Psychiatrist
entry. The Jury was critical of the Prison’s care of the deceased.

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) There was a clear breakdown in sharing of information known to the mental health

_

|

8 | COPIES and PUBLICATION

| Dated....... VS AME Oe

team with other members of some ACCT reviews. Evidence was given that there has
been a change in service provision contracts since the death of the deceased and that
mental health staff will now work weekends. Nevertheless, it is vital that in appropriate
cases where a prisoner is on an ACCT and has had substantial mental health input that
they both attend relevant ACCT reviews and their opinions are given sufficient weight. It
is noted that mental health nurses never chair such ACCT reviews as case manager and
this case has revealed that even in attendance, their views might not be given sufficient
weight.

(2) Witnesses confirmed that they often did not read much of the ACCT document prior
to the ACCT review and relied more upon input of other attendees who might know the
prisoner and upon their face to face assessment of the prisoner at the time. In this case,
some ACCT review members had limited day to day experience of the deceased, whose
temperament and presentation could change “like a light switch” and therefore face to
face presentation could well be misleading. Thus in cases where the ACCT review was
dealing with a particularly complex and challenging prisoner and where an enhanced
review was called for, it would seem appropriate for further consideration to be given to
the question of review panel membership generally as well as, as above, mental health
input in particular.

—

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe your
organisation 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 4" February 2015. |, 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.

| have sent a copy of my report to the Chief Coroner and to
Pe
Care Quality Commission
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.
——ees>

A Tweddle LLB, H M Senior Coroner
County Durham and Darlington j

Responses

3 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.

Response from Care UK (PDF)
Care £8 INHS|

Our Reference
Your Reference

Direct line
Main number
Fax

E-mail

HM Senior Coroner Andrew Tweddle
HM Coroners Office

PO Box 282

Bishop Auckland

County Durham

DL14 4FY

26" January 2015

Dear Sir,

RE: The inquest touching the death of Geraldine Liege Kilborn Deceased
Response to Requlation 28 Report to Prevent Future Deaths

| am writing in reply to you email dated 10"" December 2014 containing the Regulation 28
Report to Prevent Future Deaths (“PFD Report”) following the conclusion of the inquest
touching the death of Geraldine Liege Kilborn Deceased which was heard before you,
sitting with a jury, at the Coroner's Court, Crook commencing on 3% December and
concluding on 5" December 2014.

In hearing evidence at Ms Kilborn’s inquest you have identified matters of concern as
follows:

1. There was a clear breakdown in sharing of information known to the mental health
team with other members of some ACCT reviews. Evidence was given that there
has been a change in service provision contracts since the death of the deceased
and that mental health staff will now work weekends. Nevertheless, it is vital that in
appropriate cases where a prisoner is on an ACCT and has had substantial mental
health input that they both attend relevant ACCT reviews and their opinions are
given sufficient weight. It is noted that the mental health nurses never chair such
ACCT reviews as case manager and this case has revealed that even in
attendance, their views might not be given sufficient weight.

2. Witnesses confirmed that they often did not read much of the ACCT document
prior to the ACCT review and they relied upon input of other attendees who might
know the prisoner and upon their face to face assessment of the prisoner at the

Care UK Connaught House, 850 The Crescent, Colchester Business Park, Cotchester, Essex CO4 908
T 01206 752552 F 08703363914 www.careuk.com

time. In this case, some ACCT review members had limited day to day experience
of the deceased, whose temperament and presentation could change ‘like a light
switch” and therefore face to face presentation could well be misleading. Thus in
cases where ACCT review was called for, it would seem appropriate for further
consideration to be given to the question of review panel membership generally as
well as, as above, mental health input in particular.

Response:

At the time of Ms Kilborn’s death, the provision for mental health services delivered by
Tees Esk and Wear valley NHS Trust covered Monday to Friday 9.00am to 5.00pm with
on-call provision over the weekend. You heard evidence that the on-call facility was
accessed by staff, including the first weekend Ms Kilborn was at HMP Low Newton.

From April 2015 the health service delivery model will change from a Prime Provider
model to a 7 Lot commissioning model .The National Health Service Commissioning
Board has procured seven services - GP Services including Pharmacy, Dental,
Optometry, Community Care, Non-Clinical Substance Misuse, Mental Health and Support
Services. The new providers are to work collaboratively in defining a community focused
approach to which health care and substance misuse services will interface .The new
providers will continue to work very closely with key stake holders and prison governors
to map out pathways of care . Governance structures will promote an improved patient
safety culture.

Better communication is a requirement between all stakeholders. Daily reviews willbe
undertaken by a member of the mental health team, as on any patient allocated into
Healthcare with mental health issues. In addition all complex ACCT cases will be
discussed at morning handover to increase staff awareness. A registered nurse with
previous knowledge of the patient will be in attendance at an ACCT review.

In addition Mental Health staff are given access to the case review diary to give them an
opportunity to schedule or prepare for any upcoming reviews. If a mutual convenient time
cannot be accommodated a written or verbal input will be supplied by the Mental Health
team which will be appropriately documented on the case review notes.

As head of healthcare, | attend the Governors meeting each moming and pertinent
information is handed to the mental health team relating to individual patients.

With regard to the sharing of information from SystmOne, medical confidentiality is
ensured and information is shared with the consent of the patient. All staff are reminded
of the importance of reviewing previous entries in the ACCT document.

If you require any further information, please do not hesitate to contact me.

Yours sincerely

= . a.

HMP Low newton
Response from Noms (PDF)
Ministry of Equality, Rights and Decency Group

J U ST | Cc E National Offender Management Service
4th Floor, 70 Petty France,

National Offender London SW1H SEX

Management Service

Mr Andrew Tweddle

HM Coroner for Durham and Darlington
HM Coroner's Office

PO BOX 282

Bishop Auckland

County Durham

DL14 4FY

Dear Mr Tweddle

Thank you for your Regulation 28 report dated 10 December 2014, concerning the recent
inquest into the death of Geraldine Liege Kilborn on 2 December 2013 at HMP&YOI Low
Newton. This response has been formulated in consultation with the Governor of HMP&YOI
Low Newton. | am aware that your report was also sent to Tees, Esk, Wear Valley NHS
Foundation Trust and Care UK who will be replying separately.

Your letter raises two concerns, and | will address these in turn.

Prison Service Instruction (PSI) 64/2011 Safer Custody describes the importance of
information sharing and is very clear that healthcare staff have a duty to pass on information
that involves issues of patient safety, vulnerability or immediate risk to self or others to
relevant staff. This duty applies in any situation In which the prisoner's safety is
compromised, even if they are unable or unwilling to give consent.

This Is primarily a matter for the healthcare provider, but | can inform you that an amended
arrangement has been put in place to facilitate the presence of a member of the mental
health team at ACCT reviews that take place at the weekend. Effective mental health input
is now ensured in all cases in which a prisoner has mental health issues: for prisoners who
are located in the healthcare centre, a band 5 nurse is allocated as case manager; and for
prisoners located elsewhere a member of the mental health team attends all case reviews.
Briefing sessions have been introduced to facilitate the sharing of information between
prison staff and the mental health team, ensuring that all staff are able to make a
meaningful contribution to the decision about the level of risk.

Case reviews

PSI 64/2011 recognises that the ACCT process will operate more effectively if there is
continuity in the attendance of staff from relevant departments/services at case reviews.
Whilst not stated explicitly in the policy, it is clear from the list of mandatory actions for the

review team that those present must make themselves famillar with the information contained
In the ACCT document.

At HMP&YOI Low Newton the same staff attend ACCT reviews wherever possible. All
relevant information, including developments since the last review, is discussed at the case
review. This includes any information from the SystmOne record that it is appropriate for
healthcare staff to share. In complex cases the enhanced case review team involves all
relevant disciplines and is chaired by @ higher level operational manager than a typical ACCT
case review, usually the head of safer custody. In response to your report, all case managers
and case review chairs have been reminded of the need to familiarise themselves with all
relevant information, including the records of previous reviews and recent entries in the
ACCT document, before conducting a case review.

| hope this provides you with assurance that the matters of concern that you have identified
have been fully addressed.

Yours sincerely
Response from Tess Esk Wear Valleys NHS Trust (PDF)
Tees, Esk and Wear Valleys

NHS Foundation Trust
West Park Hospital
Edward Pease Way
Dartington
DL2 2TS
Direct Line:
Our Ref: iii "Fax:
Your Ref. iy Email;
30 January 2015
Andrew Tweddle LL.B.,

HM Senior Coroner for County Durham and Darlington,
H.M. Coroners Office,

PO Box 282,

Bishop Auckland,

Co. Durham,

DL14 4FY.

Dear Mr. Tweddle,
Geraldine Liege Kliborn deceased - HMP Low Newton, Durham

| thank you for your letter dated 8 December 2014, enclosing a Regulation 28 report
following the inquest into the death of Ms Liege Kilborn in HMP, Low Newton.

The Trust is always keen to leam lessons and take all possible steps to prevent such
deaths in the future. The Trust does reflect on practices and procedures and has
explored the systems in place at the time of the death of Ms Liege Kilbom -those
systems have and will continue to be improved. The coronial feedback assists in that
improvement process.

1. There was a breakdown In sharing of Information known to the Mental Health
Team, with other members of the ACCT review. it Is vital that In an appropriate
case where a prisoner Is on an ACCT and has had substantial mental health
Input that members of the Mental Health Team attend the relevant ACCT reviews
and their opinions are given sufficient weight.

The issue you have highlighted is appreciated. It is vital that all parties involved in the
care of a prisoner communicate well and have the opportunity to contribute to care
planning. This is particularly relevant with prisoners who are suffering from mental health
problems.

Regarding availability of staff, TEWV have already made changes to the availability of the
Mental Health Team staff over the weekend. Staff are on duty between 9.30 am —
12.30pm Saturday and Sunday, with a priority role to ensure that the relevant ACCT
reviews are attended and that those women in crisis are offered support. The ACCT
Case Manager would also have access to an on-call Mental Health Manager. This

INVESTORS
IN PEOPLE

ensures that they would be able to provide a meaningful contribution to any ACCT review
taking place, even on a weekend.

We have also completed the following action to ensure proper and timely communication
between prison wing staff and Mental Health Team members: the Mental Health Team
Manager attends both the daily healthcare and Governor's moming meeting to ensure
pertinent issues are discussed. A deputy will also attend the healthcare meeting if the
MHT manager is not available e.g. on leave.

Since the death of Ms Kilborn the use of multi-disciplinary meetings has increased for
those prisoners with complex care and risk needs. This is a proactive approach as,
through the multi-disciplinary discussion, all issues can be addressed and understood,
problems can be appropriately debated and consensus decisions reached. This therefore
enables the Mental Health Team to contribute appropriately to the ACCT process.

2. Witnesses confirmed that they often did not read much of the ACCT document
prior to the ACCT review and relied more upon the Input of the other attendees
who might know the prisoner and upon the face to face assessment of the
prisoner at the time.

This is a very helpful observation. We agree that both the interview and the past
information are important in making any decisions about a prisoner's care plan.

This relevant point was discussed at our clinical governance meeting and staff meetings
within the Mental Health Team. It is also part of the ACCT training delivered to all the
staff working in the Mental Health Team. Staff were reminded to read all the relevant
information in the ACCT document and on System One notes.

In complex cases, we endeavour to provide consistent attendance to the ACCT reviews
from the Mental Health Team in the form of an identified named nurse, who is well
informed about the prisoner. If that is not possible, we will ensure that the Mental Health
Team member attending the ACCT review would have detailed knowledge about the
prisoner's presentation and mental health difficulties. In cases where we are unable to
attend we would make sure that the relevant information is shared with the ACCT team
members making the necessary decisions. The Mental Health Team have access to the
Safer Custody electronic diary and on a daily basis planned ACCT reviews are diarised
accordingly on System One.

TEWV has been awarded a new contract for the provision of mental health services into
the local prisons and this will be in full service from 1 April 2015. The current
arrangements for the interface with prison staff is therefore under review and we shall
fully incorporate all the findings from the inquest into any new arrangements.

Yours sincerely,

Martin Barkley
Chief Executive

INVESTORS
IN PEOPLE

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