Alex Kelly

Central and North West London INHS|

NHS Foundation Trust

Executive Office
Tel
Fa

26 January 2015

Ms Patricia Harding

Senior Coroner

Mid Kent and Medway Coroners’ Court
The Archbishop’s Place

Mill Street

Maidstone

Kent, ME15-6YE

Sent by Post and e-mail

Dear Ms Harding,

Re: Regulation 28 — Report to Prevent Future Deaths
(Inquest into the death of Alex Kelly, HMYOI Cookham Wood)

| am writing with reference to the above-mentioned report which you issued on 28"
December 2014 under paragraph 7, Schedule 5, of the Coroners and Justice Act
2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

| read your report with great sadness. The death of Alex Kelly, aged 15, on 25"
January 2012 is utterly tragic.

Central and North West London NHS Foundation Trust (CNWL) commenced delivery
of child and adolescent mental health services in HMYOI Cookham Wood in April
2014, yet the recommendations you have made are clearly relevant to our work and
the work of our close partners — HM Prison Service, NHS England and Oxleas NHS
Foundation Trust. Whilst your Regulation 28 report was not addressed to CNWL, as
the incumbent provider of mental health services we feel duty-bound to provide you
with a formal response to your health-related recommendations.

1. Sharing of Information
a) Officers concerned with the management of the young person were
not informed in terms of his non-compliance with medication and the
potential effect of the failure to take the medication

CNWL’s Health and Wellbeing (mental health) Team in HMYOI Cookham Wood
includes a variety of mental health professionals, including a forensic child and
adolescent psychiatrist, clinical psychologist, art therapist and nurses. The team

Trust Headquarters, Stephenson House, 75 Hampstead Road, London NW1 2PL
Telephone: 020 3214 5700 Fax: 020 3214 5701
www.cnwl.nhs.uk

Qe Ss wis Wellbeing for life

copowesweon PARTNERSHIP London Milton Keynes Kent Surrey Hampshire

assesses for, and treats a wide range of mental health conditions and personality
and behavioural issues that young people present with, including ADHD, conduct
disorder, emerging personality difficulties as well as those who have been
perpetrators and / or victims of sexual abuse.

This range of service provision was not commissioned or available at the time of
Alex's death. The new service is well embedded in local custody management
programmes and governance systems, and the increased availability of staff has
improved partnership working and information exchange amongst the many
professionals working in HMYO! Cookham Wood.

Our healthcare staff are acutely aware that non-compliance with certain prescribed
medications may indicate that a young person’s mental state has deteriorated, or that
it may deteriorate in future. This can result in planned or impulsive self-harm or
suicidal acts. Healthcare staff are therefore required to share this knowledge with
other partners for patients receiving psychotropic and other potentially harmful
medications.

All of our staff have completed information governance training and have robust
policies to refer to, and assist them to make the appropriate decision about when and
how to share important healthcare information with other parties, both inside, and
outside HMYOI Cookham Wood. All clinical information is documented on the IT
program Systm1, which is shared with other healthcare providers working within the
establishment — namely, Oxleas NHS Foundation Trust. Information that is shared
with other parties on a ‘need to know’ basis is conveyed in person and recorded on
P-NOMIS (the IT program used by HM Prison Service staff), Wing / Unit Officer’s
observation books and in ACCT folders.

When our staff are involved in the care of a young person about whom there are
specific concerns they will use existing methods of communication within the prison
to ensure they are up to date and engaged in two-way sharing of information. Of
particular relevance is the Safer Regime meeting at HMYO! Cookham Wood where
complex cases are discussed by all involved agencies. A senior member of our team
attends this meeting.

In relation to the specific concern of medication non-compliance, our team have a
joint handover with Oxlea’s primary care team four days per week where such issues
are raised. They are also alerted via an electronic “task” on Systm. Any tasks are
discussed in daily handover meetings which would flag the need for review by our
psychiatrists. If there are concerns on review, these would be shared with officer staff
through the handover book or ACCT and Team Around the Child (TAC) processes if
appropriate.

2. Medication Management
a) Medication was found stockpiled in the young person’s cell; staff
dispensing medication had not ensured it had been taken when it was
probably recorded as having been taken.
b) Any failure to take medication was not sufficiently flagged for
healthcare / prison staff to deal with the issue.

Oxleas NHS Foundation Trust have responded in detail on this point, as it is their
staff who administer prescribed medications in HMYO! Cookham Wood. However, it
is our responsibility to provide urgent medical and psychological review of young
people who we are informed are non-compliant with prescribed medication, as they
could be; a) ‘stockpiling’ medication with which to overdose, b) ‘trading’ it as an
abusable commodity, c) they may feel that the medication is simply not helping them.

3. Recording of Information
a) Not all occasions when the young person was seen by the in-reach
team were recorded on System One.

As described above, all clinical contact by the Health and Wellbeing (mental health)
Team is recorded on Systm1. Office space and access to IT has improved. In August
2014, the new team relocated to a recently refurbished room which has four new
computers. All staff members have a direct line manager with supervisory
responsibility. Line managers are responsible for checking staff entries made on
Systm1 so that accurate and timely entries are made, which demonstrate appropriate
care planning, risk management and information sharing. All new team members
have received training to use Systm1, and an annual record keeping audit will serve
to monitor documentation standards.

| sincerely hope that our response wholly and adequately addresses the
recommendations that are relevant to our service.

Yours sincerely,

Claire Murdoch
Chief Executive

Po Director - CNWL Offender Care Service
joint Clinical Directors - CNWL

Service
ae: Director
Divisional Medical Director
- HMYOI Cookham Wood
Commissioner ee NHS England, Health in Justice Team (Kent,
Surrey & Sussex Area)
MS CEO — Oxleas NHS Foundation Trust

a Director of Forensic and Prison Service — Oxleas NHS
oundation Trust

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A RESTORATIVE APPROACH TO
COMMUNITY JUSTICE

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29 FEB 2015

Your ref:

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Date:
20t" February 2015

Medway Youth Offending Team

, Strood Youth Centre

oa P ean Montfort Road
enior Coroner Strood, Rochester

The Coroner's Office Kent ME2 3ET

Archbishops Palace co
Switchboard:

Mill Street _ Sl
Maidstone Email:keith
ME15 6YE

Tuesday 24" February 2015
Dear Ms Harding

Regulation 28 Report, Response by Medway Council (Youth Offending Team) in respect of

the death of Alex Kelly.

Please find enclosed the response from the Medway Youth Offending Team to your concerns as
outlined in your Report to Prevent Future Deaths, dated 28" December 2014. Please note item
3, concerning the Caseworker based at Cookham Wood has been drafted in consultation with
the Governor at Cookham Wood, as the staff there who are seconded by Medway Youth
Offending Team are operationally managed by the Prison Service, but remain the responsibility
of the Medway Youth Offending Team.

If | can be of any further assistance, or if you require any clarification in respect of this response,
please do get in contact.

Yours sincerely

Youth Offending Team Manager
Medway Youth Offending Team

This information is available in other formats and languages from (Medway YOT
01634 336225)

Draft response by Medway Youth offending Team to the Coroners concerns and
recommendations for preventing future deaths, arising from the Inquest into the
death of Alex Kelly.

The Coroner outlined the following concerns within her report published on 30"
December 2014. These relate to both the main Youth Offending Team (YOT) and the
Detached Team employed within the Case work Team (CT) at HMYOI Cookham
Wood.

1. Involvement with other agencies
a) Shortcomings in other agencies which affected the ability of the YOT
to manage the young person were not brought to the attention of
management.

2. Placement within the Secure Estate

a) There were inconsistencies in recommendations as to placement in an
STC or YOI, which were not reconciled.

b) Youth Offending Team Workers did not all appreciate that their
responsibilities included a role on the young persons welfare whilst in
custody.

c) Members of the Youth Offending Team did not all appear to appreciate
that the YOT could initiate a transfer within the Secure Estate.

3. Case worker based at Cookham Wood YOI

a) Outside agencies sharing responsibility of the welfare of a young
person in custody and foster carers were not kept informed of
significant events, asked to participate in ACCT reviews or asked for
input into the management of the young person.

b) Although involved in the ACCT reviews the case worker was unaware
of the range of options available to safely manage the young person
including requests to transfer to a different type of secure
accommodation and the use of enhanced reviews.

c) Paperwork was not submitted for early release on the basis of non-
compliance with the regime and concerns about absence of a
placement without consultation with any person responsible for
making decisions in relation to early release.

Response

The Medway YOT fully accepts the comments of the Coroner and the findings in her
report of 28 December 2014. The Medway YOT have or intend to implement the
following measures in an effort to address the concerns identified and to reduce the
potential risk of future deaths in custody occurring.

Following the death of Alex Kelly, Medway have produced an Agency action plan in
response to the Individual Management Review (IMR) and the Serious Case Review
(SCR). A copy of the latest version of the Agency action plan is attached to this
response at Annex 1. Actions have been agreed with and compliance monitored by
the Medway Safeguarding Children’s Board.

Point 1,a; this issue was identified within the IMR and SCR. As a result of these
publications a YOT escalation policy was formulated and has operated successfully
since March 2013. A copy of the escalation policy is attached at Annex 2. The policy
will be reviewed and its implementation monitored by YOT management on an
annual basis.

Point 2,a; There is now a procedural requirement for all placement alerts to the Youth
Justice Board to be monitored by a YOT Senior Manager, to approve the placement
recommendation prior to submission. In practice, the Duty Manager undertakes this
for that day. The Court Officer will contact the Duty Manager from court to inform
him/her that there is a possibility of remand or custody. The draft placement alert is
then viewed electronically for approval or amendment. Where there is a possibility of
remand or custody identified in a Pre Sentence Report, then this is brought to the
attention of the Duty Manager via the pre court planning meeting held weekly.

To support this change, training was provided to YOT employees in respect of
gatekeeping procedures. This training was delivered during regular monthly team
meetings by the YOT Operational Manager.

The YOT Operational Manager is required to undertake reviews of all
remand/custody applications and outcomes as part of the YOT quality assurance
arrangements. These procedures have been in place since March 2013. The Duty
Manager as outlined above receives all alerts of possible custody or remand. The
Operations Manager on a quarterly basis carries out reviews of custody or remands.
To date there have been no inappropriate cases identified.

The dramatic reduction in both Youth Remands and Custodial Sentences resulting
from the provisions of the “Legal Aid, Sentencing & Punishment of Offenders Act
(2012)”, has aided the practical implementation of our gatekeeping procedures.

Point 2,b; Training is being arranged by one of the YOT Senior Practitioners to
update case holders and/or other members of the YOT who may have contact with a
young person in custody or remand, of their ongoing responsibility towards their
clients when they pass into remand or custody. This will highlight the range of
welfare responsibilities in addition to those outlined in the National Standards for
Youth Justice. This training will be completed by April 2015.

Point 2,c; In conjunction with 2,b, training will be delivered to all case holding
practitioners and all other members of YOT staff who may have contact with a young
person in custody to ensure they fully understand the arrangements in place to request
a move from one custodial establishment to another. A flow chart and guidance notes
will be produced and cascaded to all practitioners. This training and documentation
will be completed by April 2015. Documentation will be available to the Coroner, if
so required upon completion.

Point 3,a; The arrangements now in place, require Case Workers at Cookham Wood,
to encourage the external YOT and Social Workers (where a Looked After Child
(LAC)) to visit young persons in custody at least monthly, to meet with the young

2

person and the Case worker to be updated on the case information and engage with
the YP to develop relationships.

The YJB National Standards 9: Planning and delivering intervention in custody and
resettlement into the community (9.27) states that YOT staff should maintain a level
of contact in no cases must the frequency of contact be less than every two months.
YOT / Social Workers from the community are able to book official visits to meet
with the boys on a one to one in the visits hall. The case worker will invite community
agencies to attend monthly progress meetings, in which the boys objectives and
targets in their training planning documents is updated.

In cases where YOT are reluctant to visit, the situation is escalated to the Head of
Case Work who in turn contacts the YOT manager in the community to advise of the
situation. If this does not resolve the situation, it is further escalated to the YOTs
Head of Service / Consortium Co-ordinator. In respect of the responsibilities of
Children Services Social Workers visiting, any discrepancies in timescales, support
offered is escalated to the YJB LAC / Safeguarding Social Worker with Cookham
Wood who will escalate appropriately with the Local Authority for resolution.

The Case Workers update the external YOT workers after every significant incident,
either by email or by telephone. A record of this conversation is noted on the eASSET
Case Management System.

The Duty Case Worker will update Parents; Social Workers and YOT workers, after
any significant incident, these being identified as being:

* On first reception;

* At the conclusion of the initial sentence planning process;

¢ After each important review;

* On transfer to another establishment;

* Prior to release, within the purpose of encouraging their contribution;

+ Where force has been used on the young person;

* Where a child protection referral is made, and;

* Other significant matters such as suffering illness, victimisation, or self-harm.

It is expected that the allocated Case Worker, once having further information
regarding the incident will be able to offer more insight into the event and update as
appropriate parents, Social Workers and YOT workers accordingly. Depending on the
situation, these parties will be invited to multi agency meetings regarding the
appropriateness of the placement; or Assessment of Care in Custody Teamwork
(ACCT) meetings in order that they may update their own Risk documentation and
follow their own processes for such information.

The Case Worker now routinely invites community agencies and parents or persons
with Parent Responsibility to the ACCT reviews. This requires Cookham Woods’
Custodial Managers or Supervising Officers who chair these meetings to arrange the
dates and times in advance of the next review so that the Case Workers can notify the
relevant parties. This action is supported by The Head of Safeguarding.

In cases where parents; or Social Workers or YOT workers are unable to or reluctant
to visit, the situation is escalated to the Head of Case Work who in turn contacts the

3

YOT manager in the community to advise of the situation. If this does not resolve the
situation, it is further escalated to the YOTs Head of Service / Consortium Co-
ordinator and to the YJB LAC / Safeguarding Social Worker with Cookham Wood.
ACCT reviews can be arranged to coincide with visits from parents; YOT workers
and or Social Worker if the case worker is made aware of the visit and given notice of
the ACCT review. Updates from these reviews will be scanned and forwarded to YOT
workers and Social Workers.

Point 3,b; Training is to be developed and presented to all case holding staff by the
YOT Manager at Cookham Wood. This will establish the welfare responsibilities of
Case Work Team staff and others in the establishment in respect of the welfare
options and responsibilities towards young people in custody.

New guidance for National Standards for Youth Justice Services 2013 has been
produced by the YJB in relation to Planning and Delivery of Interventions and
resettlement. All case workers have received a copy and work to this new guidance.

Annual safeguarding training is available from the Prison Service, Medway
Safeguarding Board training is available for all case workers and forms part of the
individuals annual SPDR/PDR.

ACCT training has been arranged, facilitated by Cookham Woods ACCT trainers for
the Resettlement Team as a whole.

Ongoing specific training will be identified for each case worker to develop and
update their skills and knowledge.

The Case Workers have now received guidance from the YJB in relation to the types
of accommodation available and new referral process to transfer a young person if
needed. At all Remand and Sentence planning meetings/reviews attendees discuss
whether Cookham Wood and/or the equivalent establishment is the appropriate
placement for the young person as requested by the Placement Review and Transfer
Protocol, YJB Placement Service (June 2013). This new policy lays down the process
by which a transfer request may be made. However, the final decision sits with the
YJB placements Team.

YJB National Standards (NS) state that “the Initial Planning meeting should be
arranged within 10 days of the young persons custodial sentence being imposed”

YJB NS (9.16). As already stated earlier National Standards (9.27) states that the
YOT should maintain a level of contact consistent with supporting them through
custody which should be every two months or more.

Immediately prior to release YJB NS (9.47) states that a final release meeting should
be arranged to finalise release plans.

All Case Workers are now obliged to attend annual training in relation to the ACCT
process and the use of enhanced reviews. A record of this training is maintained and
monitored by the YOT Manager at Cookham Wood.

ACCT training has been arranged, facilitated by Cookham Woods ACCT trainers for
the Resettlement Team as a whole. The facilitator is currently a Band 4 Officer, who
has a great deal of relevant prison related knowledge.

An enhanced review is one in which a Governor will oversee the ACCT process when
the young person is on a constant watch.

Point 3,c; Early Release paperwork (if the sentence is appropriate) is submitted to the
Governor for consideration regardless of whether the young person has engaged with
the sentence plan. The progress of the young person, measured against agreed targets
will be discussed at each of the sentence planning reviews.

YJB National Standards (NS) state that “the Initial Planning meeting should be
arranged within 10 days of the young persons custodial sentence being imposed”

YJB NS (9.16). As already stated earlier National Standards (9.27) states that the
YOT should maintain a level of contact consistent with supporting them through
custody which should be every two months or more.

Early Release documents should be with the Governor for approval at least 1 month
before the first early release date, in order that a decision in principle can be made and
final arrangements approved at least two weeks prior to release.

Immediately prior to release YJB NS (9.47) states that a final release meeting should
be arranged to finalise release plans, by which time accommodation and Education
Training or employment should have been secured.

When Early Release is an option, progress against this target is measured and
discussed with the young person, so that they are aware of each stage of the Early
Release process. The young person will be fully informed and assisted where
appropriate to conaply and succeed with the targets set with the consent by the YOT
and Case Worké'

Youth Offending Team Manager
Medway Youth Offending Team
February 2015.

: a
M i nistry of Head of Safer Custody Casework

Equality, Rights & Decency Group
National Offender Management Service
4.15 Clive House

70 Petty France

National Offender London SW1H 9HD
Management Service

Patricia Harding
HM Senior Coroner for the Area of Mid Kent and
Midway
13 March 2015

Dear Ms Harding

Thank you for your Regulation 28 Report to Prevent Future Deaths addressed,
amongst others, to the Secretary of State for Justice and the Governor of HMYO!
Cookham Wood, concerning the inquest into the death of Alex Kelly on 25 January
2012. Your report has been passed to Equality Rights and Decency (ERD) Group in
the National Offender Management Service (NOMS), as we have responsibility for
policy on suicide prevention and self-harm management, and for sharing learning
from deaths in custody. | am responding on behalf of the Secretary of State for
Justice, NOMS and HM Young Offender’s Institution (YO!) Cookham Wood. | am
grateful to you for allowing us an extension to enable us to provide a comprehensive
response to the concerns raised in your report.

You will be aware that the death of Alex Kelly was one of three tragic deaths of
young people that occurred in 2011-2012, and that in response to these deaths a
range of actions were taken to improve the care and management of young people.
This letter will focus on the actions that are relevant to your concerns, but before
doing so it may be helpful to provide you with some information about a broader
programme of reform currently being undertaken in the NOMS Young People’s
Estate (YPE). This touches on a wide range of operational policies and practices,
and will see fundamental changes made to the way in which the core day is
structured in the YPE in order to support delivery of an enhanced regime that will
provide young people with increased access to education and twice as much time in
the open air each day.

The reforms include the introduction of a standardised casework model in all
establishments within the YPE, addressing the inconsistencies in the current
provision of this key service. This multi-disciplinary model will ensure that young
people are better supported during their time in custody and that plans for their
resettlement into the community or transition into adult custodial services are
developed and implemented more effectively.

Our caseworkers will be at the heart of the model, co-ordinating the contributions of
all internal and external stakeholders to the plans for a young person’s time in
custody and the preparation for their transition or resettlement. Agreements will be
put in place to emphasise the obligation on all involved to work proactively together in
order to secure the specialist input required for each individual young person.
Casework managers will have a particularly important role to play in overseeing this
function of the model, making frequent management checks of the information
recorded by casework teams and addressing any issues that arise.

| will now proceed to address the concerns in your report that were directed to the
Secretary of State and the Governor of HMYOI! Cookham Wood.

The first of your concerns addressed to the Secretary of State is that children in
custody may not have had a forensic psychiatric assessment.

| am aware that in response to your report Oxleas NHS Foundation Trust (which, as
you are aware, was not the provider of healthcare services at the time of Mr Kelly’s
death) explained that the Comprehensive Health Assessment Tool (CHAT) is in use
for all new admissions at HMYOI Cookham Wood.

The CHAT is a validated screening and assessment tool for use with children aged
10-18 held in secure settings on youth justice or welfare grounds. The CHAT has
been rolled out across the YPE and has five parts:

1. Reception screen

2. Physical Health

3. Substance Misuse

4. Mental health

5. Neuro-disability
Part 1 is delivered by healthcare within 2 hours of reception. This ensures that areas
of concern are identified immediately and measures required to ensure safety are
taken promptly. This may include one or more of the further assessments, which will
all be undertaken within 10 days in any event.

All healthcare staff at HMYO! Cookham Wood are trained in the use of the CHAT,
and a set of standards is in place to monitor the effectiveness of its use. All young
people admitted to the establishment are offered these assessments, and, as the
response from Oxleas NHS Trust indicated, the take up is currently over 98%. For
the small number of young people who decline, arrangements are in place for staff to
discuss with them their reasons for doing so and to encourage them to undertake the
assessment at a later date. Following the completion of the assessment each young
person will be assigned a named nurse. The nurses are supported by Support, Time
and Recovery workers and Healthcare Assistants. Issues identified during the
assessment process are addressed through a referral to a nurse or GP, or to a
relevant specialist intervention within or beyond the prison.

You may be aware of the wider context of the 2011 commitment by the Secretaries of
State for Justice and Health to develop Liaison and Diversion services across the
country. The national Liaison and Diversion Programme is being taken forward in
partnership by the Department of Health, Ministry of Justice, the Home Office, NHS
England, Public Health England, and the various relevant criminal justice agencies.

Liaison and Diversion services will include services in the following settings: police
engagement with adults, children and young people in the community; police custody
suites and voluntary attendances at police stations; magistrates’ and youth courts
and the Crown Court; the National Probation Service; and youth offending teams.

Liaison and Diversion services aim to identify, assess and refer people with mental
health, learning disability, substance misuse and social vulnerabilities into treatment
or support services, when they first corne into contact with the police and criminal
justice system (CJS). When a person is assessed as having single or multiple
vulnerabilities, they will be referred to the appropriate treatment or support service
and an appropriate package of care and/or support will be instigated. Accurate,
timely information on the person will be shared with police and the courts to ensure
that any charging, sentencing or disposal decisions are based upon an authoritative

assessment of their mental health, any learning disability and whether they have a
substance misuse issue. Liaison and Diversion services support the most
appropriate outcome for those individuals. For many this contact with criminal justice
agencies will be the first time they will have been assessed and diagnosed.

£25 million has been invested during 2014-15 in police stations and courts in ten
areas of the country to fund Liaison and Diversion professionals in police stations
and courts. During this trial period, schemes have been developing a range of
Liaison and Diversion activities such as improving youth provision towards an all age
service, providing identification, assessment and referral services at all times to
reflect need and developing partnerships between judiciary, police and mental health
agencies.

From 1 April 2015, these services will be extended to a further 12 areas of the
country, bringing coverage to over 50% of the population of England. Almost 12,000
adults and over 1,500 children and young people have engaged with Liaison and
Diversion trial services in the 9 months to 31° December 2014. The expanded trial
sites will continue to run for 12 months and, if successful following a business case to
be submitted to the Treasury later this year, the model will be extended to all areas,
aiming to cover the population of England by 2017.

Addressing vulnerabilities is expected to lead to greater efficiency in the CJS, and
improved criminal justice outcomes for vulnerable individuals. The CJS itself will
benefit from the provision of information at an earlier stage, which could reduce the
duration of detention where appropriate disposals are an option; inform charging and
disposal decisions by the police and CPS: assist YOTs with assessments of health
needs to divert young people away from the CJS: and ensure earlier provision of
reports to the courts system. These reports to court will contain relevant and
informed health related information and offer proposals which take account of the
particular needs of the individual concerned (for example, a recommendation for a
community sentence involving a Mental Health Treatment Requirement). Where
Liaison and Diversion interventions are successful and the particular needs of an
individual are identified and addressed it is anticipated that their treatment will
improve their health which could contribute to a reduction in te-offending.

Vulnerable individuals should benefit from better-informed charging, sentencing and
appropriate disposal decisions by the police, Youth Offending Teams (YOTs), the
Crown Prosecution Service (CPS), magistrates’ and youth courts and the Crown
Court. Vulnerable individuals would also be enabled to better engage in
proceedings, through the provision of reasonable adjustments.

The core set of operational components are:

e Early Intervention - by ensuring that an individuals’ (adult and youths) health
and social care needs are identified and assessed as early as possible
following contact with police under suspicion of committing an offence.

¢ Information Sharing - making information on an individuals’ health and social
care needs available at all subsequent stages of the CJS, including police
custody, the CPS, courts, YOTs and probation. This will ensure that key
decision makers in the can make informed decisions about justice disposals;
and improve timeliness and efficiency of the justice process.

e Appropriate Referrals - ensuring that where health and social care needs are
identified, an individual is referred to appropriate treatment services

e Referrals Followed Up - ensuring that where referrals are made, they are
followed up both assertively, and flexibly, to ensure engagement with services.

The second concern that you have addressed to the Secretary of State is the
apparent conflict between the Assessment, Care in Custody and Teamwork (ACCT)
process and disciplinary procedures, and this is addressed in the section on ACCT
below.

The first concern that you have addressed to the Governor of HMYOI Cookham
Wood is about communication with outside agencies.

The planned improvements to the management of casework described above are of
relevance here, and NOMS believes that they will ensure more effective information
sharing and better integrated care and management of young people.

Prison Service Instruction (PSI) 08/2012 Care and Management of Young People
sets out a requirement for each under 18 YOI to have an information sharing policy to
ensure that relevant information is shared with professionals, parents or carers, and
others, at appropriate intervals. HMYOI Cookham Wood has such a policy, and the
Governor is currently conducting the annual review that is undertaken to ensure that
it always reflects current legislation and best practice. It mandates that information is
shared with families and other appropriate bodies or persons (for example, the YOT),
on each of the following occasions:

* On first reception;

¢ At the conclusion of the initial sentence planning process;

¢ After each important review;

¢ On transfer to another establishment;

¢ Prior to release, within the purpose of encouraging their contribution;

« Where force has been used on the young person;

e Where a child protection referral is made; and

¢ Following other significant events such as illness, victimisation or self harm.

The policy also states that information about a young person is not shared where to
do so would put that young person or others at increased risk of significant harm, or
an adult at risk of serious harm, or if it would undermine the security of the
establishment or the prevention or detection of a serious crime.

PSI 08/2012 also makes it clear that any concerns about prisoners raised by visitors
or others must be passed to relevant staff.

All NOMS staff are required to complete annual information assurance training which
covers the principles of data protection and information sharing, including the
importance of sharing risk-relevant information. Additionally, all staff in YOls have
been provided the Department of Health’s best practice guidance on when to share
information with other agencies in the youth justice system, and receive local
safeguarding training which highlights the need to share information pertinent to risk.

PSI 64/2011 provides detailed guidance on information sharing with respect to safer
custody concerns. It sets out the procedures that staff should follow to ensure that
reliable and accurate information is shared between relevant agencies to inform
appropriate decision making.

The second concern that you have addressed to the Governor of HMYO! Cookham
Wood relates to the local implementation of the ACCT process.

All staff at HMYOI Cookham Wood who are in direct contact with young people
receive the Introduction to Safer Custody training as part of prison officer entry level
training or during their induction. This is an introductory course that gives a general
introduction to safer custody, including suicide prevention, self-harm management
and violence, and the different roles and processes related to it.

ACCT refresher training continues to be delivered to both directly and non-directly
employed staff as part of the wider ongoing training programme. Most recently,
ACCT case manager training has been delivered to all Supervising Officers because
it is their responsibility to undertake this role. These training courses cover all
aspects of the ACCT process, including the requirements to record all relevant and
significant information.

As you may be aware, in 2013, following a recommendation from the Prisons and
Probation Ombudsman, NOMS established a working group to review the
effectiveness of the ACCT process for young people. This included representatives
from the Ministry of Justice, Youth Justice Board, Home Office and NHS England.
The review found that there is nothing in principle that makes the ACCT process unfit
for use within the under 18 estate. However, it found some deficiencies in the
implementation of the ACCT process and these were addressed in guidance that
was sent to Governors of under 18 YOls in 2013. In January 2015 a further letter to
the Governors of under 18 YOls set out a number of actions, including a requirement
to ensure that a quality assurance process is in place to identify and rectify any
deficiencies in the ACCT process. As a result a more rigorous quality assurance
process has been introduced at HMYO! Cookham Wood, and this includes individual
feedback to case managers. These quality assurance checks include ensuring that
all appropriate information has been recorded and that due consideration has been
given to the involvement of relevant outside agencies in the care of the young person
at risk.

In your report you also expressed your concern about information not being shared
with the safer prisons meeting. New terms of reference have been developed for this
meeting and a broader range of professionals now attend the safer regimes meeting,
including practitioners from physical and mental healthcare providers, the psychology
department, the substance misuse service, the education provider and the
chaplaincy, as well as representatives from the residential, safeguarding and security
functions within the establishment. The meetings are chaired by the Head of
Residence who is responsible for ensuring that all members have all the information
that they require, as well as agreeing the minutes of the meetings before they are
published.

The third concern that you have addressed to the Governor of HMYOI Cookham
Wood relates to what you describe as a conflict between regimes, in the sense that
the ACCT process and behaviour improvement plan were not sufficiently joined up
with the adjudications process.

A staff notice was published at Cookham Wood in November 2014 to remind staff of
the requirement to take ACCT plans to adjudications to ensure that adjudicators are
aware that a young person placed on report is being supported by the ACCT
process. This allows adjudicators to take into account any issues raised in the care
map or triggers for self-harm in order to ensure that adjudication awards do not
increase the risk of further self-harm.

The behaviour improvement plans in use at HMYO!] Cookham Wood have been
revised and are reviewed at the safer regimes meeting described above to ensure
that there is no conflict between the plan developed to support a young person and
the use of the adjudications process.

The planned improvements to the management of casework described above will
ensure that all assessments and individual department plans are co-ordinated.
There will be a single sentence plan that is reviewed in line with the requirements set
out in the YJB’s National Standards as a minimum, and more often where necessary,
and this will ensure that the various different processes, such as ACCT and
adjudications, complement each other.

The fourth concern that you have addressed to the Governor of HMYO! Cookham
Wood relate to early release.

All cases in which early release is a possibility are subject to a formal review. This is
conducted by a Board consisting of the young person’s establishment-based
caseworker, the YOT casework manager and the custodial manager, and is informed
by a contribution from the young person’s home/external YOT worker. The Board
considers the young person's custodial behaviour, progress against their training
plan, their resettlement plan and the recommendation of their external YOT, as well
as any security information. The Board makes a recommendation which is
considered by a senior manager within the establishment who makes the decision on
whether or not early release is approved.

The fifth concern that you have addressed to the Governor of HMYOI Cookham
Wood concerns cell entry.

Night operating procedures state that under normal circumstances the authority to
unlock a cell will be given by the duty Night Orderly Officer and requires the presence
of three operational members of staff. However, where there is, or appears to be, an
immediate threat to life, cells may be opened by a single member of staff. For this
reason, night patrol staff carry a sealed pouch containing a cell key to allow them to
unlock cells in an emergency. All staff performing night patrol duties at HMP
Cookham Wood are issued with a pack explaining this and other relevant
procedures, and are briefed to this effect at the start of their shift. :

The responses from Oxleas NHS Trust and the Central and North West London
(CNWL) NHS Foundation Trust have responded in detail to the concerns that you
addressed to healthcare at HMYO! Cookham Wood, but | would like to add one point

with regard to the sharing of information.

In addition to the requirement for healthcare staff to complete mandatory information
governance training that covers the information sharing guidelines, | can confirm that
as an additional safeguard an information sharing protocol between all relevant
agencies providing services at HMYO! Cookham Wood is being formulated and we
anticipate that this will be signed in the near future.

| hope that this letter has been helpful in explaining the action that is being taken to
address your concerns and provides reassurance that they are being taken very
seriously by staff and management at HMYO! Cookham Wood and across NOMS.

in I

ns Barneti-Fage

EMPLOYER

Oxleas INHS|

Improving lives NHS Foundation Trust

Oxleas NHS Foundation Trust

2 February 2015

Ms P Harding Pinewood House
Senior Coroner Pinewood Place
Mid Kent & Medway Coroner’s Court Dartford
The Archbishop’s Palace Kent
Mill Street DA2 7WG

Maidstone
KENT Tel:
ME15 6YE Fax:

Website: www.oxleas.nhs.uk

Dear Ms Harding
Re: Inquest Alex Kelly - Regulation 28, Report to prevent further deaths

Thank you for your letter and enclosed report dated the 30 December 2014, relating to your
findings of the review into the death of Alex Kelly on the 25 January 2012.

As you have identified within your report, Oxleas NHS Foundation Trust was not the provider of
healthcare at the time of this young man’s death. We began to provide primary care services in
HMPYOI Cookham Wood in April 2014. On the same date Central and North West London
(CNWL) NHS Foundation Trust were awarded the contract to provide the Child and Adolescent
Mental Health Service to Cookham Wood. | am therefore copying your report and this response
to the chief executive of CNWL.

| would like to begin by confirming that every child who arrives at Cookham Wood is assessed by
our staff using a Comprehensive Health Assessment Tool commonly known as the CHAT Tool. This
is an evidence based assessment tool addressing physical health, substance misuse, and mental
health issues. If indicated by this assessment, a key worker is allocated to the child with
responsibility for care planning and ensuring the young person’s needs are met.

All staff have been trained in the use of CHAT and we have implemented a series of standards to
ensure that we monitor its use and implementation. All new admissions to the prison are offered
these assessments and the take up rate is over 98%. Those who initially refuse are approached to
be assessed at a later date.

| will now address the specific issues relating to healthcare listed in your report.

Sharing of information.
Officers concerned with the management of the young person were not informed in terms of his
non-compliance with medication and the potential effect of the failure to take the medication.

Re &
MINDFUL Pa ele Se
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MINDFUL 5 e7e
EMPLOYER S

Healthcare staff are aware of the need to inform all those involved in the management of a young
person about their compliance with medication and to record such issues within the medical
record and other prison documentation — ACCT, NOMIS and wing observation book. All healthcare
staff complete mandatory trust and HMPS Information Governance training, which also includes
information sharing guidelines. The process is embedded in established clinical and safer custody
forums.

Medication Management
Medication was found stockpiled in the young person’s cell; staff dispensing medication had not
ensured it had been taken when it was probably recorded as having been taken.

The majority of medications are now dispensed under supervised conditions and, where risk
assessment deems it appropriate, in liquid form. Young people are asked to demonstrate the
medication has been taken by opening their mouths. Staff will only then record that the
medication has been administered using the electronic clinical record (SystmOne). If there are
concerns about the possible diversion or failure to ingest medication, this is recorded and the
relevant persons notified. This includes completing a security report and informing wing staff and
other clinicians, such as CAMHS.

Any failure to take medication was not sufficiently flagged for healthcare / prison staff to deal
with the issue.

Information is shared and recorded as detailed above. A young person’s failure to take medication
due to refusal or non-attendance generates a referral to the specialty which initiated the
treatment. They, in turn, review and update the individual’s care plan as well as providing further
advice.

| hope this response adequately covers the points of concern you identified.

M jncerel

Stephen Fifn
Chief Executive

Stephen.firn@oxleas.nhs.uk

ce Director Forensic & Prison Services
CE, CNWL

INQUEST INTO THE DEATH OF ALEX KELLY

RESPONSE from TOWER HAMLETS COUNCIL to the letter from the
Coroner dated 28 December 2014

Introduction

1. This is the response from Tower Hamlets Council (hereinafter “The
Council’) to the Coroner’s Regulation 28 report dated 28 December 2014
following the inquest into the death of Alex Kelly.

2. As stated in the report Alex Kelly (AK) was a looked after child under the
care of The Council from the age of 6. The Council undertook a detailed
Serious Case Review following AK’s death and as a result a number of
actions have been taken to ensure that lessons are learned for the future.

3. The Council provided formal evi inguest via a statement and
live evidence from myself, Interim Service Head,
Children’s Social Care, in relation to lessons learned by the Council.

4. This response sets out below the extracts from the Coroner's report and a
response from the Council. This response only addresses the points that
specifically relate to the Council.

Case Allocation

a) Alex Kelly was without a named social worker for a period of two months at a
time when he was in danger of being sent to custody and after he was sent to
custody. Difficulties in allocation were not escalated to senior management.

5. The Council agrees that it is not acceptable for a looked after child to be
left without an allocated social worker for a period of two months. The
circumstances at that time in 2011 (organisational change and the
absence, due to ill health, of the previous allocated social worker)
provided the context in which this occurred but that does not excuse the
lack of active social work involvement.

6. Children’s Social Care Services in Tower Hamlets has a clear expectation
that all children and young people looked after by the council will have an
allocated social worker. The number of social workers in the teams
providing this service have been maintained despite a reduction in the
number of looked after children and this has been reflected in smaller
case loads. Managers within the service are clear that ensuring that all
looked after children have an allocated social worker is one of their
primary responsibilities.

t.

The Children’s Social Care Management Team receives a monthly report
providing information about all children and young people receiving a
service. This includes confirmation of the allocation of looked after
children (and children subject to a protection plan); if the performance
report shows that any of these vulnerable children appears to be without
an allocated worker, then the responsible senior manager is required to
investigate this as a matter of urgency. There have not been any
unallocated looked after children over the course of the last 3 years, other
than the brief period in which they are being transferred between social
work staff / social work teams.

Since the completion of the organisational restructure in January 2012,
Service and Team Managers have been reminded of the need to ensure
that case transfer is undertaken in an efficient and timely manner and that
there is always an identified key worker for each case.

. The Head of Service has written to all of the Independent Reviewing

Officers to remind them of their responsibility to raise any concerns about
case allocation and planning to Team and Service Managers and
ultimately to the Head of Service via an escalation policy. This escalation
policy is based upon the use of alerts to draw to the attention of first line,
middle and senior managers the failure to implement any part of the plan
for a looked after child, including allocation to a social worker. The
escalation policy was reviewed and updated in 2013 and has been used
to highlight concerns about the lack of progress in the implementation of
plans for some looked after children.

Information Technology
a) Social Workers did not transfer documentation, including emails, onto

Framework | in a timely manner or at all

10.Children’s Social Care recording systems have become increasingly

11

complex with the need to ensure that a wide range of guidance and
regulation is adhered to, data captured and records maintained. There is
a balance to be achieved between social work time spent in front of a
computer recording this information and direct contact with the children,
young people and families for whom a social worker is responsible, as
was pointed out by Professor Eileen Munro in her review of child
protection service published in 2010.

.The case recording system used in Tower Hamlets, Framework |, is

acknowledged to be one of the more user friendly software systems
available. There is not an alternative available that would offer significant
benefits to staff in terms of ease of use or the automation of routine tasks.
Managers and staff have developed and implemented changes to the
processes within Framework | to improve its ease of use.

12.The Council accepts that, in this instance, significant information was not

recorded within Framework |. Social Work staff are trained at induction

and reminded at regular intervals of the need to ensure that they properly
maintain the records of the children and young people with whom they are
working.

13.The Council has reviewed the guidance issued to staff on recording and
provided briefing sessions for staff to reinforce the Council’s expectations
that relevant information is recorded / uploaded into Framework | in a
timely manner. First line managers are required to review case records on
a regular basis, through monthly case audits of the records and through
exercising management over sight of the work being undertaken. A report
demonstrating the extent to which managers are reviewing case files is
provided to the Children’s Social Care Management Team every month
which shows the percentage of cases that have been reviewed by the
relevant manager during the previous month.

b) There was no system in place for ensuring that urgent electronic
communications were flagged / diverted when the recipient was absent from
work.

14.The Council accepts that there is a need to ensure that there is a
mechanism to alert external agencies when a member of staff is absent
and to provide an alternative contact within the council during such a
period of time.

15.Managers and Social Work Staff have been reminded of the need to
ensure that if they are going to be absent from work, they must ensure
that a message is placed on their email account to indicate when they will
return to work and who to contact in the event of an emergency.
Reminders will be repeated every three months.

16.Unfortunately, it is more complicated to make similar arrangements for
members of staff who are away from work unexpectedly, e.g. because of
ill health. Some staff have access to their email accounts from home or
via a mobile device and can add an “out of office” message from home in
the event of unexpected absence from work. However, not all staff have
this facility and because access to the council’s email system requires
triple authentication together with a requirement to treat all passwords
confidentially, they cannot arrange for somebody else to do this on their
behalf. Managers have therefore been instructed that, in the event of the
unexpected absence of a member of staff, they should request that an out
of office message is added to the email account of the absent member of
staff by the Council’s information technology provider. This does not
happen immediately and it can take up to a week for the system to be
amended. However, we have undertaken random audits of the email
accounts of staff who are absent from work and will continue to do so in
the future. There has been an improvement in awareness of the need to
ensure that the messages are in place and in managers requesting that
systems are amended.

17.Colleagues in other agencies are aware that, in the event that urgent
email correspondence does not receive a timely response, then they
should contact the manager of the member of staff concerned to ascertain
why they have not received a response. Managers in turn should be
reviewing the work of a social worker who is absent from work and
making contingency plans in the event that absence continues beyond a
day or two.

Custody
Social Workers did not all appear to appreciate that their responsibilities as
Corporate Parents included a role in a looked after child’s welfare whilst in

custody.

18.The Council accepts that, on this occasion, Social Work staff did not
always appreciate that their statutory responsibilities as Corporate
Parents continued despite the fact that a young person was in custody. In
comparison to the overall numbers of looked after children relatively few
receive a custodial sentence and not all staff were familiar with this
situation.

19. The Children’s Social Care Service and the local Youth Offending Service
have devised a protocol setting out clearly the responsibilities of each
service in the event that a young person receives a custodial sentence
which has been updated to take account of changes in the legislative
framework. The launch of the revised protocol provided an opportunity to
remind Social Work staff that a custodial sentence does not remove their
statutory responsibilities towards a looked after child although they may
not be able to fully exercise those responsibilities.

20.In addition, the implementation of the Lega/ Aid, Sentencing and
Punishment of Offenders Act 2012 has meant that a larger group of young
people become looked after as a consequence of custodial remands. This
has meant that Social Work staff now have a greater awareness and
familiarity, through their day to day practice, of the parallel responsibilities
that the Council has towards young people who are both looked after and
in custody.

Conclusion
21.1 hope that the above addresses the concerns raised in the Coroner’s
report. The Council remains committed to learning lessons from untoward
incidents and continually improving the care provided to the young people
for whom we are responsible.

Yours sincerely,

Interim Service Head, Children’s Social Care
February 2015