Prevention of Future Deaths reports · 2015

Imran Douglas

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 report29 Dec 2015
Reference2015-0446
DeceasedImran Douglas
CoronerMelanie Williamson
Coroner areaWest Yorkshire (East)
CategoryState Custody related deaths
Sourcejudiciary.uk record · original PDF
Responses published4

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

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

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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.

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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
Also filed under 2015-0446: Garry-2015-0446.pdf
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)

Responses

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.

Response from London Borough Tower Hamlets (PDF)
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.

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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.

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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

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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

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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

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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.

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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
Response from Noms (PDF)
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
Response from Youth Justice Board (PDF)
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
Response from Leeds City Council (PDF)
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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