Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0298, written 24 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Jul 2015 |
|---|---|
| Reference | 2015-0298 |
| Deceased | Carl Smith |
| Coroner | Elizabeth Earland |
| Coroner area | Exeter and Greater Devon |
| Category | Alcohol, drug and medication related deaths · State Custody related deaths |
| Organisation named | Dorset Healthcare University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT iS BEING SENT TO: 1. Dorset HealthCare University NHS Foundation Trust 2. HMP Exeter 3. 4 CORONER ! am Dr Elizabeth Earland, Senior Coroner for the coroner area of Exeter and Greater Devon. 2 | 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. 3 | INVESTIGATION and INQUEST On 29" November 2012 | commenced an investigation into the death of Carl David Roy SMITH, aged 35. The investigation concluded at the end of the jury inquest on 21st — 22" July 2015. The conclusion of the inquest was Drug Related Death. Mr Smith suffered with drug dependency and died of Methadone Toxicity whilst on a Methadone Stabilisation Programme within HMP Exeter. He was found collapsed and not breathing at 7.15am on 22nd November in Cell C1-01. He died sometime during the night of 21st - 22nd November 2012. Resuscitation stopped at 8.05hrs on the 22nd November 2012. Mr Smith had taken illicitly obtained Methadone prior to his death. The quality of custodial and welfare checks were insufficient for a prisoner on an ACCT and Methadone Stabilisation Programme. 4 | CIRCUMSTANCES OF THE DEATH PMH from GP - Asthma, heroin dependency first noted in 2004, O/D in 2010 (unsure of what). He was last seen by a GP on 10/10/12 with anxiety and depression, denied currently taking drugs and was not on any prescribed meds. He was keen to be given some diazepam but this was declined. His Mother states that he had a long history of drug abuse including heroin, speed, Valium and cannabis. His Mother believes that he had not taken any illegal drugs in the 2 weeks prior to going to HMP Exeter. She states that he has suffered from fits in the past which she thinks is due to detoxing from drugs. Mother's last contact with her son was a letter which she received on approx 19/11/12 in which he stated that he was planning to propose to his Girlfriend. The deceased was at HMP Exeter on remand having arrived there approx 1 week ago. He was due for a court appearance on 22/11. He was at risk of self-harm so was on 30- 60 mins obs an in a cell fitted with a camera. On the evening of 21/11/12 he was given medication for seizures and detox. On 22/11/12 at 0715 hrs Prison Officer called to him through the cell hatch but got no response so she entered the cell with another prison officer to find him unconscious with no signs of life. CPR was commenced whilst paramedics were called who found that his airway was blocked by vomit, resus attempted but unsuccessful and his death was confirmed at 0805 hrs. Forensic PM with toxicology authd . Post mortem examination carried out during which histological and toxicological samples were retained. An inquest was opened with evidence of identification and adjourned on 27/11/12. 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 MATTER OF CONCERN is as follows. — The quality of custodial and welfare checks were insufficient for a prisoner on an ACCT and Methadone Stabilisation Programme and information sharing in relation to the checks made, appeared to be deficient. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take the action the following - To Dorset HealthCare and HMP Exeter 1. To review the systems for information sharing re: those on drug treatment stabilisation programmes for substance misuse IDTS with Prison Officers so that all Prison Officers are aware of prisoners concerned. 2. To review training of Prison Officers as to when they ought to involve HealthCare when prisoners behaviour could be construed as erratic/odd, need assessment by HealthCare BEFORE deleterious consequences occur. To HMP Exeter 3. To review training and audit the operation of the ACCT document system so that it is made as robust as possible. 4. To ensure that there is a clear directive on the operation and retention of all CCTV footage which is not just a “live camera” — the Coroner received information that the footage outside the cell had been seen but was not available to the Police when called to investigate. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18" September 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons — MS | Deceased’s mother Treasury Solicitors Department Prisons and Probation Ombudsman Hugh James Solicitors . Devon Partnership Trust 6. a, Root Cause Analysis Lead Facilitator for Devon partnership Trust AAWNS | 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. 24™ July 2015
1 response 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.
1.1. 1.4. 1.5. 1.6. 2.1. 2.2. 2.3. 3.1. Dorset HealthCare NHS University NHS Foundation Trust Regulation 28 Report Regarding the death of Mr Carl David Roy Smith on 22 November 2012 Introduction The Trust commenced the provision of services within the Devon Prisons on 1 April 2013. It was recognised that prior to this there were significant issues with the quality of the service being provided and the Trust has been working hard to improve service provision since taking over the service. Since the contract award, the Trust has implemented new policies and procedures which ensure a quality service is being delivered and these are closely monitored. This report has been produced in response to the Regulation 28 report to prevent future deaths received by Ron Shields, Chief Executive on behalf of Dorset HealthCare on 29 July 2015. As at the 25 July 2013, Coroners Rule 43 reporting, which gave coroners the power to report at their discretion, has been replaced. Under Regulation 28 of The Coroners (Investigations) Regulation 2013, coroners now have a statutory duty to issue a report where, in their opinion, action should be taken to prevent future deaths. The term Rule 43 has been replaced by ‘Report on Action To Prevent Future Deaths (PFDs). The Regulation was issued by HM Senior Coroner for the County of Devon and Exeter and Greater Devon District Dr Elizabeth A Earland. The Trust is required to respond within 56 days of the date of the report (29 July 2015) no later than 18 September 2015. Devon Partnership Trust were the Commissioned Healthcare Provider at the time of the patient death. In response to the Regulation 28, a review of the case has been undertaken and this report outlines the process, findings and action arising out of this review. Investigation team and terms of reference The review was carried out by the Executive Quality and Clinical Risk Group, Chaired by the Medical Director a and Director of Nursing and Quality Fiona Haughey who have not had previous involvement in this case. The terms of reference for the review were to consider the recommendations relating to Mr Carl Smith and review the actions taken by the team, and ensure that the Trust is assured that a robust change in practice has occurred. This report constitutes the formal Regulation 28 report to HM Senior Coroner for the County of Devon and Exeter and Greater Devon District Dr Elizabeth A Earland. Coroner’s Concerns The regulation 28 letter related to concerns that arose out of the inquest held into the death of Mr Carl Smith, concluding on the 21 July 2015. These concerns were: 1 4.1. 4.2. Dorset HealthCare INHS| University NHS Foundation Trust It is noted that Mr Smith was at HMP Exeter on remand having arrived there approximately 1 week before his death. He was due his court appearance on 22 November 2012. He was at risk of self-harm so was on 30-60 minutes observations and in a cell fitted with a camera. On the evening of 21 November 2012, he was given medication for seizures and detox. On 22 November at 07.15 hours a Prison Officer called to him through the cell hatch but got no response so she entered the cell with another Prison Officer to find him unconscious with no signs of life. CPR was commenced whilst paramedics were called who found that his airway was blocked by vomit, resus attempted but unsuccessful and his death confirmed at 0805 hrs. The Matter of Concern is as follows: The quality of custodial and welfare check were insufficient for a prisoner on an ACCT and methadone stabilisation programme and information sharing in relation to checks made, appear to be deficient. Prison and Probation Ombudsman (PPO) Report Including Clinical Review The Trust received the Draft PPO report relating to Mr Norton in August 2013 (see appendix 1) which provides a chronology of events following which an action plan was drafted to address the recommendations. The PPO noted: While the investigation has not concluded that Mr Smith’s death was foreseeable, it has nonetheless identified a number of significant concerns about his short time at Exeter. The clinical reviewer makes a number of criticisms, including of dispensing arrangements and of substance misuse staff. It is of particular concern that the substance misuse team lacked clinical leadership. The investigation also identifies weaknesses in suicide and self-harm procedures, searching arrangements and the conduct of observations by night-time staff on someone on a methadone maintenance programme, PPO Nigel Newcome CBE The following recommendations were made by the PPO: The Head of Healthcare should ensure that all healthcare staff take and record prisoners’ basic observations after a reported seizure. The Head of Healthcare should ensure that opiate dependent prisoners are treated and monitored safely, within clinical guidelines and to the standards set out in PS! 45/2010. The Head of Healthcare should ensure that a clinical lead doctor in substance misuse is appointed urgently. The Head of Healthcare should ensure that appropriately trained nurses are used to dispense controlled drugs. 5.1. 5.2. 5.3. 5.4. 5.5. 5.5.1. Dorset HealthCare NHS University NHS Foundation Trust The Head of Healthcare should ensure that healthcare staff take appropriate lifesaving equipment to incidents when responding to an emergency code indicating a life- threatening situation. The Governor should ensure that appropriate searches are conducted to help support prisoners’ safety when they move cells. The Governor should ensure that ACCTs are managed in accordance with Prison Service Instruction 64/2011 and that observations and documentation are completed appropriately. The Governor should ensure that ACCT checks are recorded accurately and that staff responsible for conducting observations do so thoroughly and are alert to any concerns. The Governor should ensure that staff are trained to recognise the common symptoms of drug-induced unconsciousness and methadone toxicity and know how to respond. The Governor and the Head of Healthcare should ensure that there are adequate security measures including when dispensing methadone to prevent its illicit use in the prison. Trust response to the Regulation 28 Ruling The Trust recognises that there were failings in relation to Mr Smith’s care, and agrees with both the PPO and HM Coroners view that these issues are of concern. In order to ensure that these issues do not reoccur within the Trust services, an action plan was put into place at the time of receipt of the PPO report into Mr Smith’s death, as the Trust was not the provider at the time of Mr Smith’s death. This action plan assured the Trust that actions taken by the provider at the time of Mr Smith’s death addressed the issues outlined. The action plan is provided at Appendix 2, however it should be noted that this Trust did not take over the ownership of the draft report findings, final publication and the action plan until April 2013. The Trust did however comment and update its findings within 6 months of taking over the contract. The Trust is committed to ensuring provision of high quality responsive services. The following is a summary of the action taken to address the findings of this review. Concern 1 - To review the systems for Information Sharing reference those on drug treatments stabilisation programmes for Substance Misuse IDTS with Prison Officers so that all Prison Officers are aware of Prisoners concerned. All patients at HMP Exeter on drug treatment programmes are reviewed jointly by DHC substance misuse staff and prison service staff to ensure their location and observation levels are jointly agreed with clear decision regarding who/when monitoring will take place. Details of all patients on the caseload are held in a shared drive to which both Prison and DHC staff have access. Decisions to increase or decrease observation levels are taken by clinical staff and clearly communicated to the prison service staff. 5.6. 5.7. 5.7.1. 5.8 5.8.1 6.1. 6.2. Dorset HealthCare University NHS Foundation Trust Concern 2 - To review training of Prison Officers as to when they ought to involve healthcare when Prisoner’s behaviour could be construed as erratic/ odd, needs assessment by healthcare BEFORE deleterious consequences occur. . There is now an education package in place for all staff (prison and DHC) regarding substance misuse awareness. It contains information around the structure of the team, the different types of substances that are used, the complex nature of withdrawal, and signs and symptoms (including potential fatal consequences) of withdrawal. Training packages can be adapted and reshaped according to any new legislation or guidance that is produced in the future. This is provided at Appendix 3. The substance misuse service provides further update packages as appropriate for example following identified use of ‘spice’ or other New Psychoactive Substances (NPS). Concern 3- To review training and audit the operation of the ACCT document system so that it is made as robust as possible. This is the responsibility of NOMs at HMP Exeter- Appendix 4 details the response. Concern 4 —To ensure that there is a clear directive on the operation and retention of all CCTV footage which is not just a “live Camera”- the coroner received information that the footage outside the cell had been seen but was not available to the Police when called to investigate. This is the responsibility of NOMs at HMP Exeter- Appendix 4 details the response. Summary In addition to the Coroners Ruling noted in this report the Trust has introduced a robust system for the monitoring of patients arriving at HMP Exeter and requiring Night Welfare Checks (see appendix 5). This guidance was developed jointly with Public Health England (NTA), HMP Exeter National Offender Management Service and will be approved by NHS England at the Devon Prison Partnership Board in October 2015. Trust is assured through robust review at the Executive Quality and Clinical Risk Group that the recommendations made by the PPO and HM Coroner have been addressed and will continue to be monitored through compliance audit and review.
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