Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0456, written 2 Nov 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Nov 2015 |
|---|---|
| Reference | 2015-0456 |
| Deceased | Richard Green |
| Coroner | David Roberts |
| Coroner area | Cumbria |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
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 RE: RICHARD SCOTT GREEN Deceased THIS REPORT IS BEING SENT TO: 1. Secretary of State for Justice 2. Chief Executive of National Offender Management Service CORONER |'am David Llewelyn Roberts, Senior Coroner for the coroner area of Cumbria. 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. INVESTIGATION and INQUEST On 14" May 2014 an investigation was commenced into the death of Richard Scott Green, aged 23 years. The investigation concluded at the end of the inquest on 23rd October 2015. The conclusion of the inquest was 1 (a) Death by Hanging Open Conclusion CIRCUMSTANCES OF THE DEATH The deceased was found hanged in his cell at Haverigg Prison on 9"" May 2014. He had made a ligature from a torn bed sheet and had used the narrow gap at the top of the door leading to his en-suite shower room as a ligature point. The Jury found that bullying and debt had contributed to his death. Whilst satisfied he had placed the noose about his neck, the Jury were not satisfied so as to be sure that he intended to kill himself. Evidence also showed he had, apparently unjustly, been refused a family day visit on 27" May. He had a well documented history of self-harm and apparent suicide attempts. 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. — | was clear that serious incidents of self-harm/suicide attempts from 2007 and 2013 were recorded on his SystmOne records. These do not appear to have been recognised or acted upon by various medical professionals in the prison system. This meant that a nurse at screening had not read the records, neither had a GP or a mental health nurse who later carried out an assessment. The result was that throughout his prison term at Haverigg no one was aware of the history and the risk he presented. As a result, there were missed opportunities which might have made a difference. Evidence showed that a) there appeared to be no reliable tool to help assess depression in a prisoner (community tools being unsatisfactory). b) Although entries were there to be seen on System One, none of the clinicians saw them. Pressure of work and the time needed to check were reasons cited, together with lack of resources. It seems SystmOne was not easy to use, some staff being unaware they could “search” and an absence of a way to clearly flag important historical information to ensure it was at the clinicians’ finger tips. ACTION SHOULD BE TAKEN Minister of Justice and Head of Prison Service. Action to be taken to consider the development of: 1) A tool or process to help clinical staff better assess and predict those prison inmates who are at greatest risk of deliberate self-harm or suicide. 2) Improvements to the SystmOne clinical records to make them more fit for purpose so that important entries relating to deliberate self-harm or suicide are easily accessible and staff have requisite training so they can use the system efficiently and to best advantage. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 28" December 2015. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: = igg Denby & Co Solicitors The Government Legal Department Cumbria Partnership NHS Foundation Trust Greater Manchester NHS Trust | have also sent it to Prison and Probation Ombudsman | 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. 9 | 2" November 2015 [SIGNED BY CORONER]
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
OFFICIAL-SENSITIVE PERSONAL r4't:kj England NHS England Birch House Ransom Wood Business Park Southwell Road West Mansfield Nottinghamshire NG210HD 29th December 2015 Mr David Roberts Senior HM Coroner Fairfield Station Road Cockermouth Cumbria CA13 0QT Dear Mr Roberts, Re: Death of Mr Richard Scott Green at HMP Haverigg on 9 May 2014 Thank you for your letter dated 2nd November 2015 regarding this sad case which was passed onto me by the Ministry of Justice. Nationally, it is recognised that identification of mental health problems, particularly depression and anxiety disorders, is poor within prisons1 due to the high incidence of co-morbities and dual mental health problems. It is also recognised that current evidence based tools, such as the PHQ9, are not reliable tools for assessing anxiety or depression within the prison population. NICE are currently developing guidelines on the identification and assessment of mental health of adults in contact with criminal justice system which includes prison. These guidelines will include identifying people at risk of developing and those with a mental health problem (including formal identification tools). A key concern for this guidance will be adapting existing NICE recommendations to the criminal justice system. The draft guidelines will be consulted on in June 2016 with an anticipated date for publication of November 2016. The current NHS England service specification, which healthcare providers are commissioned to deliver, states that all prisoners must undergo an initial health screen on receipt into establishment to identify any immediate health needs or risk, particularly in relation to suicide or self-harm. The Mental Health service specification requires all patients assessed by mental health services should use a suitable screening tool which adheres to national standards, such as National Service Framework for Mental Health (1999). 1 NICE DRAFT Guidelines on Mental Health of adults in contact with the criminal justice system. https //www.nrce.org . uk/guidance/indevelopment/gid-cgwave0726 Health and high quality care for all, now and for future generations OFFICIAL-SENSITIVE PERSONAL HMP Haverigg mental health provider, Greater Manchester West Mental Health Foundation Trust have commissioned an in-trust review of all of the available assessment tools to ascertain if there is anything better placed for use in the prison setting. The review is expected to be completed by the end of January 2016. In relation the second recommendation NHS England are re-procuring the healthcare electronic healthcare system, SystmOne. This system will include improvements on the current system such as the sharing of risk indicators (e.g. 'increased risk of suicide') between healthcare & NOMS and there is a joint commitment between NHS England and NOMS to implement the interface to show that proactive steps are being taken to address this issue in the longer term. The implementation of the new system will include a full training programme along with regular training updates undertaken. Cumbria Partnership Trust within HMP Haverigg are looking at the use of protocols to be used on SystmOne to pick up some key words within patient records, such as intoxication, intoxicated, illicit, spice, NPS, psychosis, self-harm, suicide that will be highlighted on the system and flag that there is a risk. The work is being carried out in consultation with other providers in the prison and in collaboration with NECs with the intention of putting protocols in place as soon as practicable. Yours sincerely National Clinical Quality Lead Health and high quality care for all, now and for future generations
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