Greg Revell

Leicestershire Partnership

NHS Trust
A University Teaching Trust
Lakeside House
4 Smith Way
Grove Park
8 June 2015 ree —_ Enderby
] Leicester
LE19 1SS

wi
tie be a | | Tel: 0116 295 0030
M Coroner | a7ways | Fax: 0116 295 0842
Leicester City & South Leicester | 6 JUN ZO1S | www.leicspt.nhs.uk
The Town Hall | |

Town Hall Square
Leicester LE1 9BG

Dear Mrs Brown,
Re. Mr Greg Revell

Further to your report dated 28 April 2015, in accordance with paragraph 7, Schedule 5 of
the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners
(Investigations) Regulations 2013, | offer the following response.

We have investigated the matters of concern that have arisen during the course of the
inquest of Mr Greg Revell. Leicestershire Partnership NHS Trust takes these matters very
seriously and | hope that you and Mr Revell’s family will be satisfied that we have taken the
appropriate measures to prevent such an occurrence happening again.

Carole Robson, Service Manager for Prison Healthcare, will be leading on our response.

The system for capturing all available healthcare information was insufficiently
robust. There was no clear monitoring of obtaining a GP summary promptly to ensure
medications and previous medical history could be checked as soon as possible.

We now have a robust system in regard how clinical information is sought and there is a flow
chart (Attachment 1) identifying team member's responsibilities to ensure consistency and
follow up if required. This flowchart details the responsibility of each discipline within the
team to ensure that there is a robust mechanism in place to ensure that Prisoners Clinical
Notes are requested and followed up

The flow chart details that staff have a responsibility to escalate their concerns initially to a
Clinical Nurse Manager who will then in turn liaise with the Healthcare Manager at the
specific Prison. Should the matter go unresolved that the Healthcare Manager will escalate
his / her concerns to the next level to the Prison Healthcare Service Manager. In addition the
situation will have been reported on our risk reporting system which also ensures that this
information is scrutinised at a senior level within the organisation.

Ao,

4

Chair: Professor David Chiddick CBE Chief Executive: Dr Peter Miller

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say

An opportunity for restarting anti-depressant medication in this case was missed.

P| the Clinical Director for Prisoners has reviewed the patient’s case notes and has
also reflected on the investigation findings. Anti-depressant medication was considered but
having reviewed the clinical notes it would appear that the prescribing of anti-depressant
medication was not clinically indicated. It is felt therefore that on this occasion an opportunity
for restarting anti-depressant medication in this case was not missed.

Yours sincerely

Dr Peter Miller
Chief Executive

Attachment 1 — Reception Information Gathering Process

Chair: Professor David Chiddick CBE Chief Executive: Dr Peter Miller

~ a

Equality, Rights and Decency

National Offender Group
* National Offender Management Service
Management Service 4th Floor, Clive House,
70 Petty France,

London, SW1H 9HD |

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

Ms Lydia Brown |

Assistant Coroner

Leicester City and Leicestershire South

19 June 2015

Dear Ms Brown
|
Inquest into the death of Mr Greg Revell on 11 June 2014 whilst in HMYOI Glen Parva

Thank you for your regulation 28 report of 28 April 2015 addressed to the Governor of HMYO!
Glen Parva and the Chief Executive of Leicestershire Partnership Trust concerning the recent
inquest into the death of Mr Revell. Your letter has been passed to Equality, Rights and
Decency (ERD) Group, in the National Offender Management Service (NOMS), as are
responsible for policy on suicide prevention and self-harm management and for sharing learning
from deaths in custody.

This response is provided on behalf of the Governor of HMYOI Glen Parva. As you have
requested, | will respond to your first six concerns in turn. | understand that the Chief Executive
of Leicestershire Partnership Trust will be responding separately to your seventh concern. |

(1) Greg had been in Glen Parva YO! earlier the same year. and on that occasion prese! nted

with a florid and undistinquishable ligature mark on his neck from an attempt at self-harm shorth ly
before his imprisonment. Notwithstanding this, he was not placed on an ACCT. |

It is accepted that Mr Revell should have been placed on an Assessment Care in Custody and
Teamwork (ACCT) when he first came into HMYO! Glen Parva. Local policies and procedures
have since been reinforced to ensure that an ACCT is opened on reception whenever there is
evidence of a recent self-harm attempt.

|
Anew Safer Prisons strategy was launched in October 2014. This includes anew procedure for
recording decisions made in response to the risk information on the self-harm warning form.
The new procedure has been disseminated through training and briefings with reception and
health care staff, who have been informed that they must refer to all relevant information about
newly arrived prisoners, including the Person Escort Record, and make an entry on C-| Nomis to
record what they have observed and decided. Healthcare staff have also be reminded to record
this information on SystmOne (the electronic medical records system). |

2) There was confusion amongst prison officers who gave evidence regarding when it was
appropriate to open an ACCT. |
In accordance with PSI64/2011 Safer Custody, the local Safer Prisons strategy gives clear
guidance to staff on when it is appropriate to open an ACCT. All existing staff have been

briefed on the strategy, and new staff will receive ‘Introduction to Safer Custody’ training to
ensure that they are confident about this process. A new Safer Custody team is now in place to

provide ongoing help, advice and support to staff on these matters and to monitor adherence to
the strategy.

All prisoners presenting with a risk of suicide or self-harm are placed on an ACCT, regardless of
the number of ACCTs that are already open in the establishment. At times when there are
particularly high numbers of ACCTs the Governor will ensure that resources are reallocated to
ensure that they are managed appropriately. |

All staff have been reminded of the local policy which states that an ACCT must be opened
whenever information is received to indicate that a prisoner is at risk, even if the prisoner _
himself does not present as being at risk. Case managers have also been reminded to take
account of all the relevant information and to have regard to the dynamic and static risk factors
for the individual when carrying out case reviews, and not simply to rely on their assessment of
the prisoner's presentation. This ensures that the level of risk is assessed on the basis of,
comprehensive information. |

All staff have been reminded that safer custody is everyone's responsibility, and that whenever

they identify a prisoner as being at risk of suicide or self-harm they must open an ACCT. —
|

| hope this provides assurance that the concerns that you have identified have been addressed.
Yours sincerely SS. |

NOMS Equality, Rights and Decency Group