Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0446, written 29 Dec 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Dec 2015 |
|---|---|
| Reference | 2015-0446 |
| Deceased | Imran Douglas |
| Coroner | Melanie Williamson |
| Coroner area | West Yorkshire (East) |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
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.
H M Coroner, London inner South REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Rt. Hon Michael Gove MP, Lord Chancellor and Secretary of State for Justice, Ministry of Justice, 102 Petty France, London, SW1H 9AJ 2. Mr Will Tuckley, Chief Executive, London Borough of Tower Hamlets, Mulberry Place, 5 Clove Crescent, London, E14 2BG 3. EE Director of Fitness to Practice Directorate, General Medical Council, 350 Euston Road, London NW1 3JN CORONER | am Andrew Harris, Senior Coroner, London Inner South 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. INQUEST An inquest hearing at Southwark Coroner's Court touching the death of: Imran DOUGLAS, who died on 13° November 2013, in HM Prison, Belmarsh, Case Ref: 002952-2013 was concluded before a jury on 3rd November 2015. The jury’s conclusion as to the death was suicide. CIRCUMSTANCES OF THE DEATH The circumstances that the jury recorded are complex and lengthy, despite the direction to be brief, reflecting muitiple contributing factors to the death. They are laid out in an attached Record of Inquest, to enable the Ministry of Justice to understand the systemic failings throughout his detention, especially in the light of the Harris Review. Four particular significant contributory factors are relevant to this report: i) A lack of Transition Planning li) Systemic lack of communication between and within almost all agencies ili) The problem of overlapping data bases, not all accessible to every agency iv) Problems in handiing the deceased at HMP Belmarsh In summary of the circumstances, Mr Douglas suffered from brain injury, after a car accident aged 16. He suffered impulsivity, mood swings, and suicidal ideation afterwards. He was arrested and charged with murder aged 17, and entered custody in a special training centre, where his Youth Offending Team (YOT) worker recorded risk of suicide and a previous attempt. He was closely monitored and means of self harm removed and this was documented in a Suicide and Self Harm Form (SASH). The YOT recorded in a Placement Form on 29/05/13 that Mr Douglas would kill himself, using his clothes for suspension, if he is given a long sentence, and this was included in subsequent Placement Forms available on the E Asset System. He was admitted under 848/49 MHA for psychiatric assessment, but the psychiatrist had no recollection of seeing the SASH form, recorded no significant deliberate self harm and concluded he was of low suicide risk and not mentally ill, but vulnerable and impulsive on discharge. He was to be transferred to Feltham A YO! on 17" September. It appeared that neither Feltham staff, nor the YOT attended the CPA meeting, nor was his mother invited, so that the records did not represent the YOT worker's concerns about his risks nor his past suicidal behaviour. Feltham records never included the SASH, nor the YOT worker's 1 | F Hi concerns, and there was a dispute as to what discussions did take place between the YOT worker and a lead prison officer. Risk assessments and placement forms including suicidal behaviour and his medium risk of self harm were available to Feltham staff on the E Asset system. The prison officer agreed that had she seen them, an ACCT would have been opened (This is a prison suicide risk warning form, leading staff alerts and to close supervision). Despite a recommendation that he should have mental health supervision, and not knowing the past history, a nurse at Feltham discharged him from the mentai health team. There was a failure of Transition Planning, with social workers not being invited to a Transition meeting and the Head of Young People failing to contact the Youth Justice Board (YJB), Population Management Unit (PMU), nor Feltham B, despite his approaching his 18° birthday on 11" October. He attended court on 7" October, where he changed his plea to guilty and was observed to have a change of mood. On 7 YJB sent three Service Placement Confirmations to YOT, Feltham and escort staff, which indicated then that he was a suicide risk and he returned to Feltham A. His offender supervisor did not see him between plea and sentence and there was no apparent consideration of the impact of his change of plea to guilty. The YOT worker thought a Transition Plan had been made, in line with his, wishes, for him to transfer to Feltham B, when he appeared in court for sentencing on 8" November 2043 and that the YJB would organize this. A YJB spokesperson explained that she had no power to do this, as it was outside the young offenders estate and Mr Douglas was no longer a young offender. The Feltham Governor thought the plan was for him to return to A and later transfer to B, but this was not written down anywhere. in the event, the deceased was sent fo court on 8th, with all his belongings, with no indication of suicide risk nor “endorsement” on his prison escort record that he was to return, which the jury concluded meant he was not to return to Feltham A. He received an 18 year sentence, which was much longer than he anticipated and the YOT and escort staff were concerned about the effect of the sentence on him. His behaviour change led to an escort officer opening a suicide and deliberate self harm warning form. A YJB spokesperson advised that Feltham A had no authority to accept an adult, although on the phone to escort staff, they had agreed to have him back, they declined when the PMU rang. The court heard that Feltham A had 40 vacancies, but Feltham B was full, and the PMU allocated him to go to Belmarsh. The deputy director of Public Sector Prisons expressed surprise at this decision; the YOT worker agreed it was not a suitable placement. The jury recorded that there was no hot line between YJB and PMU for urgent borderline cases, nor a protocol to specifically speak to the YO! governor. In Beimarsh two officers and a nurse saw him in rapid succession, registering no concerns about his state of mind or age, with a nurse disregarding the court staff suicide warning form (it is noted that this nurse is no longer in the UK nor on the UK GNC register). No discipline staff, nor health care staff considered he needed an ACTT opening, although the duty governor considered it should have been, on the basis of his sentence and age alone. Had the warning form been seen by the First Night Centre, it was widely agreed that an ACCT would have been opened, but it never was. He received a medical assessment by a doctor who did see the court suicide warning form, but thought there was no risk of self harm, no need for observation nor referral, with no documentary evidence of history or examination and whose only records entry was “feels ok”. Another nurse relied heavily on the prisoner's denial of suicidal intent. The jury noted that staff in Belmarsh did not have access to the E Asset system in YOls. On the next day he was seen by a nurse whose secondary assessment was perfunctory and conducted without consultation with his electronic medical records (This nurse is not currently registered with the GNC). He was classed as a Vulnerable Prisoner due to high media interest, but officers were not initially aware of this and he was confined to his cell for 23 hours a day before his suicide on the fifth day in HMP Belmarsh. CORONER’S CONCERNS Many of the weaknesses and failures that were found have been addressed by stakeholders, by the time of the inquest. Nevertheless, the evidence revealed matters that still give 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. The system of placements at transition The YOT worker said that it was a problem having a sudden change of duties aged 18 and it would better if legal duties were kept in parallel with their work until the Transition Plan was completed. The Head of Placements and Safeguarding at YJB was taken to an extract of the YOT worker's reflections on the operation of the transition system, in which she said that historically there was an approach that when you are 18, our role just stops, (that did not occur here). The famous civil | said that “officials are the servants of the public and the official must not try to foster the illusion it is the other way round”. She was asked whether Imran Douglas had to fit into the system rather than the system serve him. She agreed that a more flexible policy was needed. She agreed that the Transition Process was bureaucratic, and to work, it depended on good will. She agreed that there was an inherent risk from the statutory change of duties at 18, especially when staff were under pressure, but was concerned if legislative change adds to bureaucracy. The Deputy Director of NOMS agreed that it made no sense that there was an legal hand over of roles at 18 years: it would be better if handover of responsibility took place when the Transition Plan was completed. | consider that there is an outstanding risk that, when a rising 18 enters the criminal justice system with insufficient time for the normal Transition Plan, and especially when staff are under pressure, that even with the changes in placements from courts that have been made, and the Joint National Protocol, the knowledge and expertise of the YOT and YJB may not be properly considered in a placement if the legal duty for placement has passed to the PMU before the Plan is complete. The Secretary of State is asked to consider whether a person based rather than rule based system would be safer, by legislating to allow flexibility for YJB and YOTs to decide when the duty for placement is passed to the PMU, in line with the completion of the person’s Transition Plan, rather than rigidly on the 18" birthday. 2. The adequacy of knowledge and interagency working between social care in London Borough of Tower Hamlets and the secure estate. Evidence pointed to a disconnection between Looked After Child pathway planning and Transition Planning. A social worker said that the LAC plan was “potentially informative’ but did not matter if it was not completed, but that now it is regarded as key and should be shared. One social worker said she did not know what a Transition Plan was. The current Head of Children’s Social Care at LB Tower Hamlets said that staff pressures at the time had eased somewhat, but that under her leadership the interface with the secure estate was through the YJB and so social workers do not directly talk to the secure estate staff. This was despite the requirement for the two to work together in the Youth to Adult Transitions Framework. Given the lack of documented communications of risks and concerns between YOT and Feltham in 2013, this evidence throws doubt on the reported improvements in training and changes in interagency communication have been put into operation since. 3. The adequacy of electronic communication systems between agencies The jury criticised the lack of access of HMP Belmarsh to the E Asset system and the fact that key documents from the Secure Training Centre were never accessed by the secure estate. The lack of a universal system of records throughout the offender's pathway results in information on risk not being known to others and may contribute to future deaths. | | 4. The competence of a medical practitioner, who no longer is employed in health care in HMP Belmarsh, but is on the GMC register and may practice elsewhere and as a genera! practitioner. The GP did not record history or examination or propose any interventions despite being aware of the young age, long sentence and suicide warning from court. The clinical review conducted as part of the Prison and Probation Ombudsman’s Report concluded that health care provision in HMP Belmarsh was below the standard expected. The GMC Fitness to Practice Directorate is asked to consider whether an assessment of his clinical practice is indicated. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe that these organizations have the power to take such action. The attention of the Ministry of Justice is drawn to concerns 1, 2 and 3 The attention of the London Borough of Tower Hamlets is drawn to concern 2. The attention of the General Medical Council is drawn to Concern 4. (Details of the identity of the doctor are disclosed under separate cover). YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday 23" of February 2016. 1, 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. If you require any further information or assistance about the case, please contact the case officer, COPIES and PUBLICATION | have sent a copy of my report to the following Interested Persons: The legal representatives of all interested i ——e of Hickman and Rose for (Father), f Bindmans LLP for (Mother), EN of Government Legal for HMP Belmarsh and HMP Feltham gigjguigppiietiof BLIM Law for HMP Belmarsh Healthcare and HMP Feltham Healthcare Care UK ii lof Government Legal for Youth Justice Board, for Serco (Transport), for Metropolitan Police, NN for Prison Officers Association, for London Borough of Tower Hamlets. | am also sending this to and HEB Prison Probation Ombudsman clinical reviewer and the General Practitioner in attendance at HMP Belmarsh. lam 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. [DATE] [SIGNED BY CORONER] Written: 18.12.15 ( Sent: 29" December 2015
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. 2. Mr Jim O'Sullivan, Chief Executive, Highways England, Bridge House, 1 Wallnut Tree Close, Guildford, GU1 4LZ 3.__ Chief Coroner 1 | CORONER | am Melanie Jane Williamson, Assistant Coroner, for the coroner area of West Yorkshire (Eastern) 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 11'" December 2014 | commenced an investigation into the death of Neil Layne Garry, aged 30 years. The investigation concluded at the end of the Inquest on 22 September 2015. The conclusion of the Inquest was Accidental Death with the medical cause of death being:- 1(a) Traumatic brain injury. 4 | CIRCUMSTANCES OF THE DEATH At approximately 6.30pm on Wednesday the 10" December 201 4, Neil Layne Garry was crossing the A6120 Ring Road in Seacroft in Leeds, in the proximity of Ramshead Approach. As he did so he was struck by a motor vehicle, as a result of which he sustained fatal head injuries. Neil was transported to The General Infirmary at Leeds where his death was certified at 0020 hours on the 11" December 2014. 5 | 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 is no pedestrian crossing at, or in the vicinity of, Ramshead Approach in Leeds. The Ring Road (A6120) is a busy road in that particular area and is frequently navigated by pedestrians, especially by children, in the manner adopted by Neil Garry on the 10" December 2014. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND/OR 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 21 December 2015. I, the C oroner, 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 seat a copy of my report to the Chief Coroner and to the following Interested Persons PIE <co2scu's mother). | 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. 26" October 2015 MELANIE J WILLIAMSON Assistant Coroner West Yorkshire (eastern)
4 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.
IN THE MATTER OF THE INQUEST TOUCHING THE DEATH OF IMRAN DOUGLAS Response from the London Borough of Tower Hamlets to the Coroner's Regulations 28 Report Introduction 1. i] wo > This Is the response from the London Borough of Tower Hamlets (‘the Council’) to the Coroner’s Regulation 28 Report dated 29 December 2015 following the Inquest into the death of Imran Douglas (‘ID’), . ID was a 17 year old Looked After Child at the time of his arrest for murder, having asked to be taken into the care of the Council 2 weeks previously. He turned 18 shortly after pleading guilty to the offence, but continued to be entitled to Leaving Care services from the Council through its Children’s Social Care team. The Youth Offending Service was also working with ID. He died in HM Prison Belmarsh on 13 November 2013 and the jury at the inquest concluded that his death was suicide. . T1e Council provided formal evidence at the inquest via statements and live evidence from [EEE Operational Court Team Manager from the Youth Offending Service (‘YOS’), I] Team Manager of the Cnildren with Disabilities Team and I Head of Children's S orvices. . Tis response addresses the concerns from the Coroner's report which relate to the adequacy of knowledge and interagency working between social care in London Borough of Tower Hamiets and the secure estate. The Council accepts the Coroner's concems and has taken the following actions to remedy these issues. | i | | a) Improvements to Policy and Guidance . On 30 November 2015 the Youth Justice Board circulated the Joint National Transitions Protocol, which they developed and agreed in partnership with the National Probation Service and National Offender Management Service. This is designed to support the planned and safe transition of appropriate young people and their sentence management from youth offending teams to probation service providers on or around their 18" birthday, to comply with Strategic Standard 11: ‘Establish and implement clear local policies and protocols in relation to the transition of young people between youth justice services and from the youth to adult criminal justice system (drawing on the Youth to Adult Transitions Framework for community transfers and relevant NOMS custody transitions guidance’ . The National Protocol will be presented to the Youth Offending Team Ma gement_ Board on "25 February 2016 for sign off. This is a statutory board, comprising senior managers from both Tower Hamlets and the City of London Youth Offending Services, and the Directors of both tocal authorities’ Children’s Social Care Services (‘CSC’). In addition to the National Protocol, a presentation has been itemised to discuss the concerns raised in the Coroners Report, together with a training session on the learning points arising from the inquest and the Thematic Review by Alex Chard (see below). b) Interagency and inier-departmental cooperation and communication . The Council recognises that the YOT and the rest of the CSC social work teams have historically worked in parallel rather than in an integrated way. In response to the recommendations of a Thematic Review which included ID's case (detailed below), the council has refocused the Risk Management Panel that existed within the YOT to a High Risk Management Panel, chaired jointly by an operational YOT manager and a senior manager in Children's Social Care. The purpose of this Panel is to share information and develop joint risk assessments and plans for older high risk children, including those engaged in the Youth Justice System. Other relevant agencies that can contribute to young people's safety and welfare attend the panel and it provides a muitiagency forum to consider how to reduce the risk posed to and from young people who are most challenging for their families and the agencies that support them. . The High Risk Management Panel meets fortnightly and it contributes to the care planning and case management of a range of young people, with direct access to the service manager level for conflict resolution. . The Council has also initiated a multi-agency Task and Finish Group, in order to undertake the following review of procedures and policy relevant to the findings of the inquest. 10.The group has already reviewed the internal Risk Management 1 = Procedures, and has planned an agenda of work through to June 2016. This includes the consideration of the full range of procedures that impact on young people in secure placements, on remand and thus in the care of the Local Authority. It is also is tasked with reviewing the transition process from the youth estate to the adult estate, in line with the Joint National Transitions Protoco! for managing the cases of young people moving from Youth Offending Teams to Probation Services. Training will then be provided to managers and front line staff to support implementation. .Finally, within Children’s Sociat Care, a Looked After Child Track Panel has been introduced to track every young person on remand on a quarterly basis and ensure officers are fully compliant with ail requirements in respect of care and transition planning and that proper services are in place to meet their welfare needs and support their return to the community. This is chaired by the Head of Children's Services, and attended by Service Head for the Youth Offending Service, Service Head for Looked After Children, Group Manager for the Independent Reviewing 3 Service and Designated LAC Medical Officer, as well as front line managers and social workers for the individual young people. 12.Additionally, Tower Hamlets is currently engaged in a project through the London Independent Reviewing Officer Managers Forum to improve communication and partnership working with the secure estate. | | Group Manager for the Independent Reviewing Officer (JRO) Service has visited Feltham Young Offenders Institute three times, and met with the Governor to discuss proposals to promote the welfare needs of young people in custody. Due to the success of this programme, similar meetings have now been scheduled with Cookham Wood YOI. 13.Matters addressed during these meetings include discussions around educational needs, personal allowances, reducing bullying and managing gangs. Of particular relevance to ID's case, on 21 December 2015, the group discussed Looked After Child reviews/Pathway Planning meetings and the difficulties for social workers and IROs in arranging to meet with young people in th their care. Feltham are trying to address this and have agreed to offer two slots for Looked After Reviews which will enable IROs to see the young person before the meeting. Feltham is undertaking work to see how they ensure young people are present for reviews and are in the process of securing another more private meeting space which should be operational from April 2016. Visits are reviews can also be booked on line. ¢) Training and information for social workers and Youth Offending Team officers 14. The concerns raised by the Coroner in respect of the understanding of the social workers giving evidence of the purpose of a Transition Plan is accepted. It is important to note that because HE the officer giving evidence on behalf of CSC works in the Children with Disabilities Team, Transition Planning has a different meaning, which led to confusion in the witness box. Her understanding of Transition Planning relates to children 4 with profound physical or learning disabilities transitioning to Adult Social Care provision. As ID's care needs did not reach the threshold for Adult Social Care services because of the progress he had made since his car accident, he would not have been in receipt of a Transition Plan in this context. Further, because of the needs of the young people who ordinarily receive a service from the Children with Disabilities as such that they are extremely unlikely to be remanded or sentenced to custody, this team has never previously had a case where they have been involved with the secure estate. However, it is accepted that in these circumstances, greater care should have been taken by senior managers to ensure that the allocated team was supported to understand that additional requirements of meeting the needs of a young person on remand. 15.Following the update to the Care Planning Guidance in April 2074 in respect of Looked After Children in contact with youth justice services, practice guidance was circulated to all social workers with a_work flow setting out ‘what to do if @ young person is remanded’, including statutory timescales for visits and reviews. This provided a copy of ad detention placement plan and an explanation of the additional matters to be addressed within the plan. 16. This is now being updated in light of the issues raised during the course of the inquest and will be recirculated by 31 March 2016 to all YOS and CSC teams, to specifically address the following issues: e The interaction between LAC pathway planning and Transition Planning in terms of moving to the adult secure estate « The requirement for social workers and YOS workers to attend Transition Planning meetings, and to invite relevant officers from the secure estate to Looked After Child reviews/Pathway Planning meetings ¢ The requirement to provide a copy of the young persons’ detention placement plan/pathway plan and the minutes of the LAC review! Pathway Planning meeting with the Governor of the Youth Detention Accommodation. e The importance of effective communication between professionals, including direct communication between social workers and officers within the secure estate, as well as YOS officers, in respect of young people for whom they are mutually responsible e The importance of confirming any verbal communication between professionals in writing, in particular where this relates to the immediate welfare needs or safety of the young person e Updating the precedent detention placement plan to the format provided by the Youth Justice Board 17.A training session was provided on 8 February 2016 for line managers, social workers and YOS offic icers, which. was well ‘attended. ‘In addition to giving an overview of ‘the “Legal Aid, Sentencing and Punishment of Offender Act 2012, the following topics were addressed: When a young person is remanded to Youth Detention Accommadation the importance of an assessment being completed to consider present needs but also post sentencing needs and post release needs. The need for all work to be jointly undertaken with YOS and CSC, t draw from the expertise of each service « Transition between YOS and Probation Services post-18. Staff were advised of the support available from the YOS probation officer e YOS will keep some young people post-18 if they have particular vulnerabilities, and this will be determined on case by case basis e High Risk Management Panel highlighted e Names of heads of each service for Feltham YOI were provided to enable social workers to make direct contact about a particular young person Held in custody; health, education, safeguarding and contact. Staff were advised that Feltham YO! staff have all signed up to be contacted directly by the IRO Group Manager or social workers. | | | e Discussion on the move from YOI to adult secure and requirements of the Joint National Protocol for Transitions were explained e Emphasised the importance of close communication between YOS, CSC and the secure estate to meet the welfare needs of children 18.In respect of concerns raised that conversations which took place between professionals where important information, such as ID's risk of self-harm, were not properly recorded, the Council has implemented a new Recording Policy and Procedu which was launched to s staff at the Social Work Conference on 41 “Nove ber 2013. Further training was delivered during February and March 2014 Including targeted workshops for key staff, and regular ‘refresher’ sessions take place at staff forums. All new staff receive an induction and in addition to being available on the Intranet, hard copies are available for staff. This policy will now be recirculated annually, to remind staff of the importance of clearly documenting communications. d) Thematic Review 19.In addition to the Critical Learning Review which was undertaken on |D's case specifi cally and provided to the Inquest, a thematic review that was instigated by the Tower Hamlets Safeguarding Children Board to study the common themes and professional interventions in the lives of six children. This followed a range of incidents which took place in 2013 and 2014 when several older children committed grave offences, which included ID. It was agreed that the key purpose of the review was to help to understand how we can reduce the likelihood of older children either coming to serious harm or harming others. The fi findings of tt this report were presented to the Local Safeguarding Children Board on 12 February 2016, to ensure that all of the Council's safeguarding partners could share in the learning points identified. The executive summary from the report is available on the Tower Hamlets’ Local Safeguarding Children Board website: http://www. childrenandfamiliestrust.co.uk/Awvp- content/uploads/2015/12/Troubled-Lives-Summary-Report-Final1 pdf 20.The learning from the ID inquest and the Thematic Review will be the focus of a development session for the Youth Offending Management Board on 25 February 2016 to ensure that partners with responsibility for the management of the Tower Hamlets and the City of London Youth Offending Service are fully appraised of the lessons learned and their responsibility towards the children and young people who are involved with the YOT. Conclusion 21.! hope that the above address 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 young people for whom we are responsible. Signed. Dated. 4S a. \ is Pe Head of Children's Social Care ondon Borough of Tower Hamlets
Mi nistry of Senior Caseworker: Safer Custody Casework 4.15 Clive House National Offender 70 Petty France Management Service London SW1H 9EX Andrew Harris Senior Coroner London Inner South BY EMAIL ONLY 23 February 2016 Dear Mr Harris Thank you for your regulation 28 report of 29 December 2015 addressed to the Lord Chancellor and Secretary of State for Justice concerning the recent inquest into the death of Imran Douglas on 13 November 2014. Your letter has been passed to the Equality, Rights and Decency Group in NOMS as we have responsibility for policy on suicide prevention and self-harm management and for sharing learning from deaths in custody. | have involved relevant officials across the Ministry of Justice in formulating this response. You have drawn the attention of the Ministry of Justice to the first three of the matters of concern that you have raised, which relate to the system of placements at transition; interagency working between local authorities and the secure estate; and electronic communications systems between agencies. | will address each of these in turn, but before doing so | should like to point out that | am doing so in the-context of the ongoing departmental review of the youth justice system, led by EE which began in September 2015, The review is examining evidence on what works to prevent youth crime and rehabilitate young offenders, and how this is applied in practice; how the youth justice system can most effectively interact with wider services for children and young people; and whether the current delivery models and governance arrangements remain fit for purpose and achieve value for money. An interim report was published on 9 February and the final report will be published in July 2016. | will ensure that your concerns are brought to the attention of the review. — In the meantime, you will be aware that with regard to the system of placements at transition, the NOMS’ Transitions Protocol, published in September 2012, sets out the process for transitioning young people from youth to adult custodial services. The protocol covers issues such as planning, information sharing and appropriate timescales, and describes how the involvement of the young person, their family and professionals from both youth and adult services must form a key part of the decision making process. The implementation of the protocol was supported through operational support visits to all under 18 establishments by NOMS young people’s group and in 2014 a Transitions service assurance module was completed Jointly by the Youth Justice Board (YJB) and NOMS young people's group to provide a formal assessment of delivery against the requirements. Additionally NOMS young people's group has been reviewing areas of the transitions process that have proved problematic in the past, and has worked with the YUB, the Prison Escort Custody Service and escort providers to agree protocols to follow when Equality, Rights & Decency Group : National Offender Management Service transitioning unconvicted and unsentenced young people. Historically, young people on remand or progressing through a trial could transition between youth and adult custodial services following an appearance at court - they would go to the court from a youth establishment and moved to an adult establishment after their hearing. It was always the intention that transition facilitated in this way would be to a pre-determined establishment, but in reality this did not always happen, and where the plan was disrupted, for instance by redirection to an alternative adult establishment, the transition plan was undermined and it was more difficult to ensure that the appropriate safeguards were in place. We have consequently reviewed this process and are now in the final stages of putting an agreement in place with the YJB to.ensure that wi the young person will return from court to the un é ently move from there to the identified adult establish ‘ oted that this transition. plan will, as now, be agreed between the two establishments and that NOMS Population Management Unit does not play the role in decisions over the placement of individuals that you suggest in your report. As a result of this work Governors of under 18 establishments will shortly be. issued with , instructions to ci nto th order to allow — for effective t Additionally, the YJB. has developed a National Protocol for Transitions between Youth Offending Teams .and Probation Services (this includes. supervision for those in custody), to take account of the recent changes to probation services and the creation of Community Rehabilitation Companies. This document was published in November 2015 and is supported by a process map that outlines actions required and where responsibility for those falis. They have also updated the case management guidance for youth justice practitioners. working with young people transitioning to adult justice services to reinforce it as business as usual for practitioners and managers. Turning to inter-agency working, there is an agreed casework model through which each under 18 establishment deliver a young person's. sentence plans. This model is underpinned by multidisciplinary integration and effective communications to meet the needs of each young person in custody. The casework teams act as the medium for co-ordinating the various specialist departments involved in the young person's care within the establishment and the wide range of external stakeholders, Including the local authority with responsibility for the individual's care. This provides a single, cohesive approach for managing the young person throughout the period in custody and effectively preparing them for transition to ensure that the process runs smoothly and is as positive as it can be. Finally, it is accepted that a universal system of records conveyed by electronic communication between agencies would be desirable. However, there are practical and resource constraints that mean that it is not possible to implement such a system, and this is not the only way to make the improvements to information sharing that are necessary to mitigate risk and address your concern. As you will be aware from the inquest, the YJB has worked with NOMS to develop the ‘Y2A Portal’, which is a web- based system which aims to improve information sharing between Youth Offending Teams YOTs to probation services and adult YOls. The Y2A portal has been successfully piloted with community services and is now being rolled-out across England and Wales. NOMS is currently reviewing the transitions protocol with a view to.developing it into a Prison Service Ins i) which will define the national and local procedures which governors must implement to meet the specific needs of young people who will transition to adult custody, with a particular focus on supporting effective assessments and information sharing as well as promoting collaborative working between the estates. The PS! will set out mandatory requirements for staff and in particular focus on safeguarding and safer custody procedures, highlighting the factors that affect young people during the transitions period. it will aim to provide clear guidance to all Staff with specific responsibilities in these regards and build on the current approach to provide improved support for young people who transition from youth to adult custodial services. | trust that this provides reassurance that the matters of concern that you have brought to the attention of the Ministry of Justice are being appropriately addressed. Yours sincerely Amy Harbin
OFFICIAL - SENSITIVE Bwrdd Cyfiawnder leuenctid Dr Andrew Harris H M Coroner London Inner South Letter sent - email: 26 February 2016 Dear Dr Harris, Regulation 28 Report to Prevent Future Deaths following the inquest of Imran Douglas who died in the care of HM Prison Belmarsh on 13 November 2013 | am writing in response to your investigation into the circumstances surrounding the tragic death of Imran Douglas. Whilst | recognise that the key matters of concern outlined in your Report to Prevent Future Deaths have not been directed at the Youth Justice Board (YJB), the YJB takes its responsibility to act on serious incidents that offer learning to the youth justice system very seriously. ; | therefore offer you this response to highlight where the YJB has and will continue to use its role to support and influence some of the changes you seek in your recommendations. Matter of concern one: The system of placements at transition Ultimately whether the YJB’s remit should be extended, as your report suggests, is a question for Government. The current review of the Youth Justice System, due to report in the summer, will explore how the youth justice system can more effectively interact with wider services and whether the current arrangements remain suitable for the future. The YJB are clear that young adults, such as Imran, who transition from or have previously been in the youth secure estate are often particularly vulnerable. In recognising this, and further to the evidence provided to your inquest, we have provided you below with an update about the work the YJB has undertaken with a number of partners and stakeholders to seek to improve the transition process between youth and adult justice services, both in the community and in custody. Most recently, this has included work alongside the National Offender Management Service (NOMS) on strengthening and revising transitions guidance, and in publishing the joint national transitions protocol' which was provided to you as a draft document in our evidence. The protocol between youth offending teams and probation services intends to ensure that there is a ' Published November 2015: https://www.gov.uk/government/publications/joint-national-protocol-for-transitions-in- england Youth Justice Board for England and Wales 102 _ France, London, SW1H 9AJ OFFICIAL - SENSITIVE clear understanding of the responsibilities of each organisation and the transition process is carried out as smoothly as possible. Since publication in November last year approximately 60% of Youth Offending Teams (YOTs) have now signed up to this protocol and committed to developing their local arrangements. We are working with the remaining YOTs to ensure commitment to the protocol. In January 2016 we also updated the YJB’s Case Management Guidance, which provides practitioners and managers with a comprehensive overview of how to deliver youth justice services. The guidance supports the joint national protocol and promotes best practice in planning for young people who turn 18 whilst under community supervision or in custody. |n line with your finding that transitions plans should be person-based, and not rule-based, the guidance focuses on making decisions on a case-by-case basis to best support individual safety and well-being, and continued protection of the public You will also be aware of the agreement in place between the YJB and NOMS to ensure that transition should not occur from court to the adult estate (unless it is part of a Transition Plan). Where transition is necessary, the individual would return to the young people's estate to ensure the move is made in a planned way and supported by a considered approach to their placement in adult custody. Matter of concern two: The adequacy of knowledge and interagency working between social care in London Borough of Tower Hamlets and the secure estate We know that looked after children are disproportionately represented amongst children in the youth justice system. Whilst the YJB recognise that there is still more that can be done to better support the interface between children’s social care and the secure estate, we are clear that the evidence provided by the Head of Children’s Services for Tower Hamlets on the way in which communication between their staff and the secure estate is facilitated was inaccurate and in contradiction to the evidence of YOT staff and National Standards for Youth Justice. We have written to the Director of Children’s Services at Tower Hamlets to remind them of expectations and assure ourselves of their practice in the future. For the avoidance of doubt, it is clear in both legisiation, policy and guidance that from a social care perspective local authorities retain their responsibilities to looked after children when they are in custody. Similarly, YOTs have case management responsibility for young people subject to community or custodial sentences until such time as their sentences end or their cases are transferred to adult services. Matter of concern three: The adequacy of communication systems between agencies We are clear that the safety and wellbeing of children and young people placed in custody is secured when there is timely and effective information sharing that allows for informed assessments of needs and the identification of risks to support appropriate interventions. As you have identified the use of different IT and case management systems by different organisations makes it difficult for these systems to speak to each other, impeding the fiow of information. The Y2A Portal, about which we gave evidence to the inquest, has been successfully implemented across England and Wales. Additional work is underway to consider how the portal can be to be used by YOTs to provide information to young adult establishments if a young adult was previously known to them. OFFICIAL - SENSITIVE Page 2 of 3 OFFICIAL - SENSITIVE | hope that the information | have provided offers some assurances that the findings of your investigations and the areas you have highlighted for the prevention of future deaths have prompted action as part of the YJB continuing commitment to support the safety and wellbeing of children throughout the youth justice system. Yours sincerely, Lin Hinnigan Chief Executive Youth Justice Board for Engiand and Wales E a OFFICIAL - SENSITIVE Page 3 of 3
Her Majesty’s Coroner Coroner’s Office Symons House Belgrave Street Leeds LS2 8DD Dear Mrs. Williamson Highways & Transportation Selectapost 6 Ring Road Middleton Leeds LS10 4AX 21st December 2015 Inquest touching on the death of Neil Layne Garry (deceased) - Regulation 28. I refer to your letter dated 26th October regarding the death of Mr Neil Layne Garry following a road traffic collision at the junction of Ramshead Approach/ A6120 Ring Road, Seacroft, Leeds. We have been working to design a scheme which provides safe pedestrian assisted facilities across the Ring Road at this location and the neighbouring Coal Road junction. Due to the close proximity of these heavily used junctions we have been considering options which will ensure that these two junctions can operate efficiently and effectively at all times, including meeting the needs of pedestrians. These design considerations have been concluded and a final layout has been confirmed, which will be compatible with proposed future improvements planned at the Coal Road/ Ring Road junction and also longer term aspirations along this strategic corridor. A Highways Board report is to be presented to the Chief Officer (Highways and Transportation) early in the New Year to seek formal funding approval to progress the junction improvement measures at the Ramshead Approach/ Ring Road junction. It is currently programmed that the scheme will then be issued to our contractors in this financial year, with an expected completion date onsite between May/June 2016. Yours sincerely, Chief Officer, Highways and Transportation www.leeds.gov.uk INVESTOR IN PEOPLE
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