Kevin Forster

Andrew Tweddle

HM Coroner for County Durham & Darlington
HM Coroner's Office

PO Box 282

Bishop Auckland

Co Durham

DL14 4FY

Dear Sir

Inquest touching the death of Kevin Anthony Forster
Date of death: 14 September 2014 - HMP Durham

I write in response to your report dated 28 November 2015 made under paragraph 7, Schedule 5 of the
Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

In response to your concerns relating to the existence and applicability of a substance misuse policy at HMP
Durham, I confirm the faltowing:

G4S Forensic & Medical Services (UK) Ltd took over responsibility for provision of healthcare services at HMP
Durham on 1 April 2015. The contract does not include provision of GP and Pharmacy Services and as from 1
April 2015, Spectrum Community Health CIC was appointed to provide GPs, specialist substance misuse GPs
and Pharmacy Services at HMP Durham.

Between 2011 and 31 March 2015, Care UK were the healthcare providers at the prison. Prior to 2011,
healthcare services were provided by NHS England.

1 understand NHS England operated a “Drugs Overdose” policy at the prison and it is my understanding this
policy document was considered at the inquest touching the death of Mr Forster. This policy was written prior
to 2011 by a specialist substance misuse nurse employed by the NHS.

Following their appointment, Care UK produced new policy documents in relation to a number of practices
and procedures at the prison. The “Drugs Overdose" policy document was not updated or re-written by Care
UK. My recollection is that Care UK did not make a “Drugs Overdose” policy document available on the
intranet or in the Healthcare folder containing hard copies of written policy documents.

It is my belief that the absence of an updated policy document is the reason why there appeared to be
confusion on the part of the healthcare witnesses at the inquest regarding the existence and applicability of a
"Drugs Overdose” policy. In particular, whilst those nurses employed at the prison by the NHS prior to 2011
would have known about the existence and content of the policy, they were confused as to its application
once Care UK took over the contract, and the policy document was not readily available on the intranet or in
the Healthcare folder.

After G4S took over the contract in April 2015, it became clear to me that the situation relating to the “Drugs
Overdose" policy required clarification. The previous policy was too rigid and did not allow specialist
practitioners to exercise their expertise and manage individuals as safely and appropriately as possible. 1
therefore updated the Substance Misuse policy. The draft policy document was submitted to and approved
by the G4S Clinical Governance Lead, prior to formal introduction and implementation at the prison. Once
approved, the Substance Misuse Policy was introduced to all healthcare staff. A copy of the policy was sent by
email to every member of healthcare staff.

Some months after the introduction of the new Substance Misuse Policy, however, towards the beginning of
September 2015, I was made aware there had been changes in clinical practice which meant the Policy was
outdated in some respects. It was felt at this stage that clinical guidelines, would be a preferable, more flexible
“policy”, preferable to a formal Policy document, because clinical guidelines envisage all different situations
and respond accordingly.

Spectrum Community Health and G4S, in liaison with NHS England, therefore began a joint project, working
together to update the procedures in operation at the prison.

A GP employed by Spectrum Community Health, Dr Bray, and the Substance Misuse Clinical Lead, Deb Miller,
have been tasked to work together to produce clinical guidelines relating to all substance misuse issues,
including the treatment and care to be delivered to any patient presenting as under the influence of illicit
drugs. The work is being undertaken in conjunction with NHS England.

A draft report and overarching pathway for Drugs and Alcohol Recovery Teams was produced at the end of
November 2015. Following consultation between all contributors, including NHS England, the pathway is not
designed to be a weighty document, but one that all practitioners and prison staff can use to understand the
Drugs and Alcohol Recovery Team pathway, guidance, protocols and interventions. It is proposed the
pathway features space to embed documents and to hyperlink to guidance.

A final briefing session is scheduled for 22 December 2015 to discuss the pathway and next steps, to ensure
key leaders are fully briefed on the content of the pathway and the next steps, prior to wider circulation.

The belief in the clinical team is that clinical guidelines are preferable to an inflexible written policy, as given
the varying circumstances of how individual incidents can present, clinical guidelines will not restrict the ability
of doctors and nurses to utilise clinical discretion and decision making, taking into account all the aspects of
the patient's presentation, clinical observations and other external factors. Clinical guidelines will enable the
healthcare professionals to respond with absolute clarity to ensure individual patients receive the most
appropriate treatment and care for their precise circumstances and symptoms.

The clinical guidelines are intended for implementation at all prisons within the North East Cluster and
therefore it is essential that the guidelines are suitable and safe for implementation at each of the different
establishments within the North East Cluster, before they are implemented. This will ensure consistency and
suitability of approach, regardless of the establishment at which the patient is resident. It is also an important
reason why clinical guidelines are preferable to an inflexible policy document, to allow more flexibility in terms
of treatment and care, to suit an individual's needs, within the structure of the clinical guidelines.

G4S has appointed, on a consultancy basis, a substance misuse specialist doctor, Dr Martin Von Fragstein, to
oversee the content, form and appropriateness of the clinical guidelines and to act as G4S' advisor on any

substance misuse issue.

The following further steps have been taken to address your concerns surrounding other issues arising at the
inquest:-

2 Client Confidential

A request has been made to prison officers’ Line Management to inform officers at staff meetings that
they are advised to report any suspicions of substance misuse (whether alcohol or drugs) to
healthcare staff. {f there is any suspicion whatsoever then a report should be made to healthcare.

We have intraduced, under the leadership of Dr Bray. a monthly training event specific to ail aspects
of substance misuse issues which is held monthly on a Friday afternoon in the Prison Tra ning Centre
The training event is open to all staff at the prison from all disciplines of the various organisations
within the prison and wider region, both healthcare staff and discipline staff. Each session usua ty lasts
for a couple of hours. The training is a mixture of white board training, discussion, group wark, multi-
disciplinary discussions, sharing information and experiences and clinical reviews This training
reinforces the seriousness of substance misuse and overdose issues and emphasises the
inappropriateness and unacceptability of attitudes of complacency and acceptance towards the issues.

Clinical and non-clinical staff attend the training which improves knowledge, liaison and
understanding on all aspects of substance misuse within the custodial environment, as well as learning
and intelligence from the wider community, regionally and nationally

Substance misuse training is also being provided by the organ:sation. Lifeline, which employs the non
chnical Drugs and Alcohol Recovery Team at HMP Durham, which focuses on psycho-social issues,
undertaking a similar role to one undertaken by counsellors, and which provides Psychosocial support
m relation to addictions within the prison.

The clinical guidelines being developed for substance misuse issues will include a treatment plan
template to be included on SystmOne for use in substance misuse cases. The treatment plan will
include ail relevant care options, including the requirement far a care plan and regular observations

Healthcare staff have been reminded of the requirement and importance of making full and
contemporaneous notes in each patient's medical records

it ts my understanding that if any individual is found in medical distress, the first person to find the
individual has responsibility for calling the correct emergency code. As soon as “code blue” ts called, it
automatically triggers the calling of an ambulance by the prison’s contrai room staff, On 4 November
2015, at a full staff meeting of the prison, Mr Tim Allen emphasised the need for the correct cades to
be called in an emergency It is also Planned that posters will be sited for use in discipline staff areas
and training repeated to prison officers in the correct allocation of codes in a healthcare emergency

Recent incidents related to a significant increase in the illicit use of new psychoactive substances at
the prison, have demonstrated a high degree of cooperation and joint working between both
discipline and healthcare staff, with Patients being closely monitored in a wing environment or if
deemed necessary for the individual patient's circumstances, transferred to the healthcare in patent
department or external hospital, until clinically stable

| trust my response addresses the concerns outlined in your recent report.

Yours sincerely

Eric Stephens
Head of Healthcare at HMP Durham

\.

3 Chent Confidential

Ministry of

JUSTICE

National Offender BURA
Management Service

National Offender Management Service
North East Area

HMP Durham
Old Elvet
Ourham

DH1 3HU

Telephone 0191 332 3600
Fax 0191 332 3401

14" January 2016

Statement for HM Coroner in relation to the Emergency Code Protocol

Sir

Following the death of Mr Kevin Anthony Forster on 14" September 2015, while in custody at HMP Durham,
the following actions have already been taken by the prison to ensure all staff have a full understanding of the
Emergency Code Protocol which covers the use of Codes Blue and Red. These steps were taken prior to the
Inquest occurring and were in response to the comments made by the Prison Probation Ombudsmen Report
and also from the prison’s own learning exercise that was undertaken following this death.

All current staff either directly employed, those employed by HM Prison Service or non-directly employed,
those employed by partner agencies for example G4S and Manchester College have signed to say they have
full understanding of the protocol and how to implement it. Line managers have satisfied themselves prior to
staff signing that the staff members are fully aware as to how the protocol works by gauging there verbal
responses to the protocol.

All staff have been issued with pocket sized cards explaining the protocol.

All residential areas which are the wings on which prisoners live have displayed the protocol in bold colours in
prominent places which are A4 size. These posters can be located in the wing main offices which everyone
attending a wing must report to.

A Governors Notice to Staff has been issued to ensure that all new staff either directly or non-directly
employed attend the Safer Custody department and receive a full explanation of the Emergency Code Protocol

as part of the joining process. When safer custody staff are satisfied they have full understanding they sign to
this effect and are issued with a pocket size card from the Safer Custody department.

The Emergency Protocol has been an agenda item on monthly team meetings with staff and the protocol fully
explained. It is also discussed at the Safer Prisons meeting as part of a wider discussion on deaths in custody.
The Deputy Governor has addressed the emergency protocol issue with all functional heads at meetings and
this has been cascaded to staff by line managers

The Governor has issued a notice to staff which has been sent out by email and is on the intranet.

The Governor also used a full staff meeting to raise this issue with staff.

Yours Sincerely
A Turpin

Mrs Alison Turpin
Head of Safer Prisons and Equalities HMP Durham