Derek Thomas

“3. EOFS ¥

15 January 2016 Gare UK
Connaught House
850 The Crescent

en . Colchester Business Park

HM Assistant Coroner Crispin Oliver Colchester

HM Coroners Office Oe eC

PO Box 282 T 01206 752552

Bishop Auckland 20 FY

County Durham JAN 2016

DL14 4FY

22 December 2015

Dear Sir,

RE: The inquest touching the death of Derek Thomas Deceased
Response to Regulation 28 Report to Prevent Future Deaths

lam writing in reply to your letter dated 16th December 2015 containing the Regulation 28 Report to
Prevent Future Deaths (“PFD Report”) following the conclusion of the inquest touching the death of
Derek Thomas Deceased which concluded on 14th December 2015.

We are grateful to you for notifying us of the outcome of the inquest.

As you are aware Care UK Clinical Services Limited (“Care UK”) ceased to be the providers of primary
healthcare services at HMP Durham and for the North East cluster of prisons on 31st March 2015 and
as of 1st Apri! 2015 one of the providers appointed was G4S Medical Services who | note are also
copied into your letter.

In so far as healthcare are concerned it is understood that during the course of Mr Thomas’ reception
and first night induction at HMP Durham the SASH was overlooked and a member of healthcare failed
to read the history and events section of the PER. You also go on to discuss the inter-operability of
agencies and a failure in communication between them and potential weaknesses where they are
supposed to inter-connect.

As above | am unable to assist with regard to individual staff and local issues at HMP Durham as Care
UK are no longer the healthcare providers. However with regard to some of the agencies Including
GEO Amey and the prison service, where Care UK interact with them at other custodial facilities, | will
be forwarding your concerns to the heads of healthcare at those other facilities to highlight the
concerns you have raised and to ascertain whether they are issues they have encountered, and if so
what steps they can take.

Care UK Clinical Servicas Limited - Registered in England No 034
Registered Office: Connaught House, 850 The Crescent, Cokehaster Business Park, Coichester, Essex CO4 903

If you require any further information, please do not hesitate to contact me.

Yours faithfully,

For Care UK Limited

Page 2 of 2

Ge@oamey

Mr Crispin Oliver GEOAmey
Senior Assistant Coroner HSQE
4 Floor Civic Centre Units A & B
Crook 69 The Whittle Estate
County Durham Cambridge Road
DL15 9ES Whetstone
Leicester
LE8 6LH

Date: 9 February 2016

Dear Sir
Derek Thomas Deceased

We have reviewed your Regulation 28 Report and note your particular concerns at Sections 5(2) and
5(5) which directly relate to us.

In respect of Sections 4A and B of Concerns raised over Circumstances of Mr Thomas’ Death we
have filed a statement from [EE (Head of Compliance) dated 10 December 2015 which sets out
the procedures, training in place regarding the completion of a Prisoner Escort Record (“PER”) and
a Self Harm and Suicide Warning Form (“SASH Form”) and the new PER being piloted. We attach a
further copy of this statement.

We refer you to paragraph 15 of craic statement. GEOAmey escort and court officers are
undergoing refresher training regarding the completion of a PER. At 31 January 2016 1,911 officers
out of 2,102 officers (90.91%) had received this training including the officer who completed Mr
Thomas’ PER on 21 July 2014.

The Coroner’s Concerns (Section 5)
Procedure (Section 5(2))

We are a private contractor carrying out prisoner escort and custody services across the UK
pursuant to a contract with the Ministry of Justice (“the MOJ”). We refer you to paragraphs 3, 4
and 7 of Mr Airey’s statement which set out the relationship between the various bodies involved in
prisoner detention and escort, and the Prison Service Orders (“PSOs”), Prison Service Instructions
(“PSIs”) and Standard Operating Procedures (“SOPs”) we adhere to.

The escort of prisoners from Court to designated locations (e.g. prison) is set out in the contract
with the MOJ. On delivering a prisoner to a prison our escort officer has to hand over the
prisoner’s Warrant or Court Order (or faxed Warrant if agreed), property, official records including
PER (which must be fully completed with that day’s proceedings) and other documentation, and
any medication in their possession for the prisoner’s use. The escort officer has to ensure that the
receiving officer endorses each prisoner’s PER and their property, cash, official records and any
other accompanying documentation. The contract does not stipulate a particular prison’s
procedures; it states the paperwork to be handed over on the delivery of a prisoner.

Page 1 of 4

Geoamey

The escort officer who escorted Mr Thomas to HMP Durham on 21 July 2014 handed over to the
reception officer Mr Thomas’ Warrant, PER and SASH Form, F2050 and his property bag and
paperwork. The reception officer endorsed Mr Thomas’ PER. Whilst it is accepted that the escort
officer made omissions on the PER, it is apparent on reading it that comments had been received
from Mr Thomas’ barrister on 21 July 2014 regarding a potential self-harm risk and a SASH form had
been commenced on Mr Thomas. The reception officer who signed the PER accepting Mr Thomas
into HMP Durham custody stated whilst giving evidence at the Inquest that they had not read the
content of the PER as the front sheet had not indicated that there was SASH Form enclosed. This is
contrary to the PSOs and PSls in place.

PSO 1025 sets out the mandatory instructions and guidance for PER completion. The PER ensures
that escort staff and receiving agencies have information (particularly a prisoner's risks) regarding
a prisoner prior to and during escort and it ensures consistency across multi-agency use on a
national level. Section 4.13 states that after checking all details on the PER the receiving officer
completes the “record of handover” and signs the form and the escort officer retains the bottom
copy of the PER. Further, PS! 74/2011 states that a completed PER must be examined in prison
reception “to identify any immediate needs and risks already recorded” and the prisoner must be
interviewed to discover and record any further immediate needs and risks and any other
information about the prisoner that may be relevant (paragraph 2.15). The PER and any other
available documentation including the SASH Form must be examined and prisoner interviewed in
prison reception to assess the risk of self-harm or harm to others as part of the Cell Sharing Risk
Assessment (paragraph 2.18). The information is recorded and shared with other departments and
agencies (e.g. Healthcare) internally and externally and actions taken are to be documented
(paragraphs 2.19 and 2.20). We have no remit over HMP Durham staff (who are MOJ employees)
and their compliance with the PSls.

The prison reception officers gave evidence at the Inquest that the SASH Form had not been
handed to them on us delivering Mr Thomas to HMP Durham and had been handed in at a later
time. The Jury, however, accepted the escort officer’s evidence that the SASH Form had been
handed over to the reception officer on delivering Mr Thomas to HMP Durham on 21 January 2014.
This evidence was supported by us having in our archives a pink carbon copy of the SASH Form and
the top copy of the SASH Form being found on Mr Thomas’ prison file at HMP Durham following his
death.

Each prisoner’s paperwork is handed over to the prison reception staff separately. The escort
officer’s evidence was that on the right hand side of the reception desk at HMP Durham they
handed over the prisoner’s Warrant and F2050 to a reception officer and on the left hand side of
the desk they handed over the PER, SASH Form (if one existed) and property record to another
reception officer and said what documents they were handing over. If a SASH form was handed
over they would say to the reception officer that they needed to read it. The escort officer is not
permitted to leave reception until the reception officer has reviewed and signed all the necessary
paperwork, passed back the PER and SASH Form carbon copies (stapled together) and informed the
escort officer that they can leave. We would place the carbon copies the documents with the VOR
for the day and place them in our archives. The prison would retain the original documents and
place them on the prisoner’s prison file. The reception officers’ evidence, however, was that the
Warrant and the SASH Form would be handed to the reception officer on the right-hand side of the
desk and the PER and the property would be handed to the reception officer on the left hand side
of the desk which was located through an archway.

The HMP Durham reception process, as stated by the reception officers giving evidence, is peculiar
as it is a requirement on the PER to indicate that a SASH Form is “enclosed” (i.e. contained
within). As far as we (and our officers) are concerned, at the time of Mr Thomas’ escort to HMP
Durham on 21 July 2014 and until the reception officers gave evidence at the Inquest, there was no
lack of appreciation by GEOAmey officers of HMP Durham’s reception process. We were not aware
of a different process. In fact the reception process followed today on delivering prisoners to HMP
Durham is the same as stated by the escort officer. If HMP Durham has devised its own reception

Page 2 of 4

Geoamey

process, HMP Durham staff should inform our escort officers on arrival of its process and instruct
them as to whom the documents should be passed to on reception.

There are 207 prisons from/to which we collect/escort 1,000s of prisoners per week. We also
collect/escort prisoners from/to 100s of Courts, Police Stations and Detention Centres across the
UK. It is not feasible for us to request from each establishment, nor for it to draw up, a
specification sheet for individual operating processes. It would create an significant volume of
paperwork for our officers.

Inter-operability of Agencies (Section 5(5))
The Home Office/MOJ

We appreciate other agencies’ procedures and have devised and revised our SOPs to comply with
the HM Prison Services’ requirements set out in the PSOs and PSIs. We engage in dialogue with
other agencies (where possible) to develop best practice, procedures and documentation to be
shared between the agencies.

We, where required, can contact the Prisoner Management Unit (“PMU”), to obtain information
and assistance on the location of suitable prisoner accommodation. We have a system in place to
ascertain the number of prisoners collected from Police premises and prisons on a given day and
identify the likely number of custody beds required. We inform PMU of the requirements by 08:00
hours on that day and provides them with hourly updates from 12:00 hours to 17:00 hours.

As noted at paragraph 17 of Mr Airey’s statement, we are audited externally by Prisoner Escort and
Court Services (“PECS”) to ensure it is complying with the MOJ contract. These audits are not pre-
determined; PECS will arrive to carry out an audit unannounced.

The PER was introduced in May 2009 having been agreed by all agencies involved in prisoner
movements. We were not involved in the discussions as our contract with the MOJ not commence
until August 2011.

As has been referred to at paragraphs 19 to 28 of Mr Airey’s statement, the Home Office has
devised a new PER which is being piloted. We are undertaking a formal evaluation process and
shall provide feedback to the Home Office about the pilot programme.

The final say on policy, procedures and documentation is with the MOJ to whom we are contracted.
Healthcare

We do not have any contract, dialogue or contact with the Healthcare provider at HMP Durham nor
with any Healthcare provider at any prison across the UK. The contract for the provision of
Healthcare facilities and the policies and procedures in place is between the MOJ and the
Healthcare provider. We have no input into this.

We are aware that on a prisoner's arrival at prison he should be assessed by Healthcare as part of
the First Night Procedure during which the PER should be read. Mr Thomas was seen by Healthcare
on his arrival to HMP Durham. It was acknowledged by those giving evidence on behalf of
Healthcare at HMP Durham that the PER (containing Mr Thomas’ risk indicators) was with the
documentation sent down to Healthcare from reception but the PER was not read by them as the
front cover had not been ticked to state that a SASH Form was enclosed. On assessment by the
nurse self-harm and suicide factors were noted. Mr Thomas was also assessed by Healthcare on a
daily basis up to 24 July 2014 to monitor his alcohol withdrawal.

Page 3 of 4

Ge@oamey

It is unclear what further inter-operabitity could be put in place other than the correct completion
of the PER by our officers (and/or others) and the reading of PER and SASH Forms by the prison and
the Healthcare provider. Accordingly, we are of the view that the system is not “dysfunctional”.

We have taken your concerns on-board. We refer you to Mr Airey’s statement. There has been no
change to our procedures regarding the SASH Form or the PER. Following this Inquest there has
been no request by the MOJ or PECS for our procedures to be revised. We remain of the view that
we have the correct procedures and systems in place for the safe custody and escort of prisoners
and the Jury’s conclusion and your concerns regarding the company can be properly addressed by
the additional focused training in place which has been completed by over 90% of our officers with
the remaining officers to complete it as soon as possible.

Yours faithfully

Head of Compliance
GEOAmey PECS Ltd

Page 4 of 4

MrC A Oliver

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

PO Box 282

Bishop Auckland

Co Durham 9 February 2016
DL14 4FY

Dear Sir

Inquest touching the death of Derek Thomas
Date of death: 28 August 2014 - HMP Durham

I write in response to your report dated 15 December 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.

G4S Forensic & Medical Services (UK) Ltd took over responsibility for provision of healthcare services at HMP
Durham on 1 April 2015.

G4S Forensic & Medical Services (UK) Ltd is responsible for primary care and substance misuse care at HMP
Durham and employs a team totalling in excess of 40 individuals made up of qualified registered general
nurses, mental health nurses, substance misuse issues nurses and healthcare support workers, together with
separate administration staff, for this work.

An organisation called Spectrum Community Health CIC is contracted separately to provide GP, specialist
substance misuse GP and Pharmacy Services at HMP Durham.

Mental health services at HMP Durham are provided by Tees, Esk and Wear Valley NHS Trust. As part of its
responsibilities, the mental health team is responsible for conducting mental health assessments.

The reception process at HMP Durham involves prisoners being brought to the reception building by escorts.
Each prisoner is received by prison officers and undergoes initial reception assessments and procedures.

Healthcare staff undertaking initial assessments of individuals arriving at the prison from court are not located
in the reception building.

The arriving prisoner undergoes the full reception process with prison officers before the initial healthcare
assessment is undertaken.

Following completion of reception procedures, each prisoner is ready to be taken for initial healthcare
assessment. At this point the prisoner is escorted by prison officers from the reception building to a separate
building which houses the First Night Centre/Induction Wing.

Any documentation received with the prisoner on arrival at the prison is taken by prison officers with the
prisoner and all of the documentation received with the prisoner is handed to the nurse undertaking the initial
healthcare assessment. The reception procedure means nurses undertaking initial healthcare assessments rely
on prison officers to provide them with the correct paperwork for each prisoner they are to assess.

Healthcare procedures involve any Suicide/Self-Harm Warning Form (SSHWF) received for a prisoner being
scanned onto SystmOne so that it forms part of the prisoner's medical record.

If the relevant section on the PER form is completed to indicate the presence of a SSHWF and this form does
not arrive with the prisoner, then the nurse makes enquiries to locate the document.

The initial health screen involves the nurse completing an assessment covering all aspects of the prisoner's
health using an approved NHS assessment tool on SystmOne. The assessment is based on observations of the
prisoner's condition, behaviour and presentation, documentation and conversation with the prisoner. Any
documentation is one element making up the overall assessment to ensure the prisoner is safe, not at
immediate risk and is correctly referred for any additional support required.

Mr Thomas’ initial healthcare assessment notes information contained within the PER, including the correct
nature of the offence, 4 previous incidences of self-harm and prior treatment for depression.

Mr Thomas was referred by the nurse to a GP in relation to substance misuse issues. The nurse undertaking
the initial healthcare assessment is able to refer prisoners to a number of support services following initial
assessment, including the mental health team, a GP, the substance misuse team and counselling.

On 22 July 2014, Mr Thomas was assessed by a cop and, as a result, Mr Thomas was monitored by
healthcare staff for 4B hours for signs of substance withdrawal. The records suggest had no
concerns regarding suicide or self-harm risks.

All nurses working at HMP Durham are ACCT trained. if any nurse perceived a risk of harm to self for any
prisoner then ACCT procedures would be commenced.

The nurse who carried out Mr Thomas’ initial healthcare assessment is a qualified mental health nurse and
substance misuse worker. It is the policy at HMP Durham to aim to have all initial healthcare assessments
undertaken by qualified mental health nurses, unless there are circumstances preventing this. By arranging for
initial assessments to be undertaken by qualified mental health professionals, this ensures full consideration of
mental health issues during the assessments.

The deceased's medical records indicate pertinent information contained on the PER, including risks relating to
self-harm/suicide and mental health issues, was considered and noted by the reception nurse. The deceased
was not considered at risk of self-harm at that time, based on the documentation, his presentation,
conversation and the nurse’s observations. This view was reinforced by the assessment by EN on 22
July 2014.

On 24 July 2014, Mr Thomas again attended court. It is my understanding court/escort officers did not at this
time perceive any risk of suicide or self-harm and no SSHWF was completed.

Further, Mr Thomas presented with no mental health or suicide/self-harm issues over a period of the next 4
weeks prior to his tragic death on 28 August 2014. Mr Thomas was seen by healthcare staff on 8 occasions
prior to his death.

There was no indication or notification to healthcare from any member of staff, visitor or professional visitor at
any time whilst at HMP Durham that there were any suicide or self-harm concerns relating to Mr Thomas.

2 Client Confidential

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

¢ nursing staff have been instructed to read/review all documents given to them pertaining to all
patients when completing reception screening.

¢ at staff meetings/briefings, staff have been reminded of the importance of ensuring all paperwork and
documentation relating to an individual accompanies that person following their arrival at the prison.

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

Yours sincerely

Head of Healthcare at HMP Durham

Ministry of

Equality, Rights and Decency Group

JUSTICE National Offender Management Service
4th Floor, 70 Petty France,

National Offender London SW1H SEX
Management Service t: 0300 049 7051

Mr Crispin Oliver

Senior Assistant Coroner

H.M. Coroners Office

P.O. Box 282

Bishop Auckland

Co. Durham

OL14 4FY

24 February 2015
Dear Mr Oliver

Thank you for your report dated 15 December 2015 addressed, amongst others, to Michael
Spurr, Chief Executive Officer of the National Offender Management Service (NOMS) and

the Governing Governor of HMP Durham, concerning the recent Inquest into the

death of Derek Thomas at HMP Durham on 28 August 2014. 1 am responding on behalf of
NOMS as Equality, Rights and Decency Group has responsibility for the policy on suicide
prevention and self-harm management and for sharing learning from deaths in custody. !
have consulted with the Governor at HMP Durham in formulating this response, which | am
copying to the other recipients of your report .

Your report highlights a number of departures from correct procedure, and goes on to raise
concerns that:

~~ These circumstances [of 21 July 2014] were clearly very demanding but they were
not unforeseeable and may be repeated in future. When the procedures were
‘stress-tested’ in the way they were on 21 July 2014, they failed so that a SASH form
went unnoticed.

— there ts a lack of appreciation by GEOAmey escort staff of the prisons reception
procedures. There Is a lack of awareness by prison staff of GEOAmey staff's
ignorance of them. Alternatively the prison reception staff develop the procedures
without keeping GEOAmey staff Informed...

.« There Is an overreliance on the fidelity of the system, even when it has failed. No
questions were asked at any stage .. as to how a SASH form had arrived In the
prison without being previously noticed

That the above concerns are not addressed by, and go beyond, the Governors
Notice to Staff of 8 December 2015

That the above concerns go to the inter-operability of GEOAmey and prison and
healthcare procedures, which is not yet addressed by any of the agencies ... 1! am
concerned that this case provides a paradigm example of not just failure in
communication between agencies but a deeper failure in properly appreciating each
other procedures and potential weaknesses where they are supposed to inter-
connect...

A number of steps have been taken to strengthen procedures, training, and relationships
between the agencies to address these issues.

Reception — The Head of Operations at HMP Durham has instructed all staff working in
reception that, prior to the escort contractor leaving the reception area, all documentation
must be physically checked and read. The PER and all documentation must be cross
referenced. It will be signed for by both staff. A daily detail is published which clearly
identifies the members of staff who are working in reception on any given day and these are
retained. The escort contractor has been informed of the process and is aware that the
warrant and the SASH need to be handed to the supervising officer and the PER and
property to the officer. All staff working in reception are expected to be competent In all
areas of the process. Both are situated side by side. A custodial manager and the Head of
Operations will routinely observe this process.

As weil as the above procedures, reception staff must verbally hand over any self-harm
warnings to the officer from the First Night Centre. Should a prisoner be returning from a
court appearance the reception staff must verbally hand over this information directly to the
health care staff. The verbal hand over is in addition to the Health Care staff receiving all of
the documentation received on each prisoner.

Training - All staff working in reception must complete a level of training prior to working at
the point in reception where prisoners are Initially received. The level of training available to
reception staff is an on-line course and a classroom based course. The Head of Operations at
HMP Durham has deemed that as a minimum the on-line course must be completed. This
will be managed by the individual member of staff's line manager. It will be added to their
individual learning path and monitored through the staff appraisal system

Communications between agencies - The Head of Operations at HMP Durham meets with
the escort contractor on a monthly basis. Any changes in procedures are communicated at
this meeting. The entire contract is managed by a NOMS monitor. Escort contractor
managers make on-site visits to observe the process. There are seven individual providers
that make up the healthcare function. A monthly prison operational and clinical governance
meeting ts held and any issues between the prison and healthcare can be discussed at this
meeting.

{note that your concerns are wider than the issues covered In the Governors Notice to Staff
of 8 December 2015, however you may be interested to know that the NTS has been re-
issued to primarily target reception staff. It outlines the importance of checking all
documentation and advises that a failure to do so may result in disciplinary action. The
Notice to Staff is published on the loca! prison Intranet for a period of time. It’ fs also
available on the shared drive. The Head of Operations will also be positioning this on the
front desk of reception for all staff working there to be constantly aware of. This will be
followed up during staffs Individual performance reviews.

Yours Sincerely