Terence Adams

care 

Head  of Healthcare Services 
HMP Pentonville 
Caledonian  Road 
London 
N7  BTT 

Coroner MS  Hassell 
Senior Coroner 
Inner North London 
St Pancras Coroner's Court 
Carnley Street 
London 
N1C 4PP 

24 August 2016 

Dear Madam, 

Regulation 28:  Prevention  of Future Deaths report 
The inquest touching  the death of Terrence Darren  Adams  Deceased 
HMP Pentonville 
Date of death:  9th  November 2015 
Inquest:  18 - 20 July 2016 
Venue:  St Pancras Coroners Court 

Thank you for your Regulation  28  Prevention  of Future Deaths Report issued to Care UK following 
the  inquest into the death  of Mr Terence Adams Deceased. 

Care UK would  like to express its  condolences to  Mr Adams' family  and friends. 

Care  UK  is  the  main  provider  of  healthcare  services  at  HMP  Pentonville.  There  is  a  sub-
contracting  arrangement  in  place  with  Barnet,  Enfield  and  Haringey  Mental  Health  Trust  (BEH-
MHT) in  respect of the provision of mental health services. 

This  response addresses the matters of concern in  so far as they relate to Care UK. 

The  matters  of  concern  to  you  are  highlighted  in  bold  with  the  response  set  out  below  each 
concern 

1. 

heard  at 

inquest  that  the  prison  escort  record  (PER)  that accompanies 
each  prisoner  to  HMP  Pentonville  (and  which  in  the future  will  be  forwarded  to 
healthcare  staff),  is  not  checked  on  arrival  and  thereafter  to  ensure  that,  as  it 
progresses  through  the prison,  it  includes  the  attachments  described within  the 
document, for  example  the  risk  assessment  conducted  by  the  police.  This 
seems  an  unhelpful omission. 

Response:  In  so far as  this concern relates to  healthcare,  in  order to  allow healthcare 
professionals to  make the best possible  assessment of a person's risk of serious self-harm 
and/or suicide,  staff will  be  reminded to  check they have had sight of the core record and 

 
 
 
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any accompanying  information including the  PER,  relating to history,  index offence, 
sentence status,  clinical  history and  possible warnings. 

We  have allocated an  extra member of healthcare staff (healthcare assistant) to the 
reception  process who will  be  working  alongside the  reception front desk officer triaging 
prisoners and  reviewing  available information from the  PER,  warrant and  any other 
documentation  accompanying the  prisoner.  This way,  all  relevant information will  be 
available for nurses and  GPs when they conduct their assessment. 

If the  HCA encounters a prisoner with  a medical issue (physical or mental health), the HCA 
will  'fast track' them for screening  by the  reception  nurse and/or a doctor. 

2.  The  general  practitioner  (GP)  who  saw  Mr  Adams  when  he  first arrived  at  HMP 

Pentonville  did  not  have  the  key  for  the  first  night reception  template when  she 
considered  the  information  contained therein.  Mr Adams  scored  8.  The GP did not 
know that the advice on  the template for scores  of 6 and  over was  to  admit the 
prisoner to inpatient healthcare. 

Response:  This  information was available  in  SystmOne for the General  Practitioner. As a 
result  of it  having  been  overlooked,  we  will  be  rolling out a program  of refresher training to 
all  staff 

3.  Neither  the  nurse  nor  the  GP  conducting  the  first  night  reception  interviews  was 

clear  about  the  status  of  the  first  night  reception template.  The nurse, 
particularly, talked  about it being a document referring  to  historical  matters, 
whereas  the  reality 
issues. 
instructions are advisory rather than  mandatory. 

The document  did  not  give  any  indication  on  the  face  of  it  that  its 

it encompasses  both  past  and  relevant  current 

that 

is 

Response:  There is  an  expectation that nurses undertaking  reception  duties within the 
prison  complete an  assessment of a person's current risk  of self-harm  and suicidality when 
they are  initially received  into custody.  This is  particularly relevant  as  it  is  known  that,  for 
some prisoners,  the early days of custody  prove particularly stressful and so  increase their 
risk.  You  heard the evidence of the  Deputy Head  of Healthcare who explained that 
following  another recent death in  custody,  we were already undertaking  a review of the 
current  risk  assessment that is  in  use in  reception  in  an  attempt to improve its efficacy. 

The current  risk  assessment in  use within  the  reception  area is  largely actuarial in  nature 
which  means that it does not sufficiently employ the  use of clinical judgement but merely 
translates  certain  material to calculate a risk score which  then  directs which  action the 
assessing nurse or doctor takes.  Modern day thinking  around  risk  assessment is that we 
should  reflect theoretical,  clinical  and  empirical  knowledge  about the issue that we  are 
assessing by combining clinical  and  actuarial approaches (Douglas  &  Kroop,  2002). 

The risk assessment is  another tool  available to clinical  staff for them to  use alongside 
their own  assessment and  clinical decision of the presenting situation.  Staff should be 
using the  assessment as  a guiding tool  in  conjunction with their face to face consultation 
______  with the  patients  as well  as  any other inforrriati_c)_r:,~yai~El~-!~-t~el"!l__c3t_ the time_o_f___ 

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assessment (such  as  prison information,  warrant etc) in  order for them to finalise the  care 
pathway for the  patient. 

In  order to  allow healthcare professionals to  make the  best possible assessment of a 
person's risk  of serious  self-harm  or suicidality we  need to  ensure that we  focus  on  a 
number of key issues: 

•  That we  have had  sight of the core record and  any  accompanying  information,  relating  to 

history,  index offence,  sentence status,  clinical  history and possible warnings.  As 
highlighted  in  response to  concern  1,  we  have allocated  an  extra member of staff to  review 
this information  prior to  nurses and  doctors assessing  new receptions. 

•  That we  ask in  detail  about a person's previous history of self-harm  and suicide attempts -

paying particular attention  to the triggers. 

•  That we  ask about previous mental health  history including diagnosis. 
•  That we  consider their current presentation  in  terms of distress, hopelessness, suicidal 

ideation and  possible  plans. 

•  That we document a basic risk formulation  stating the factors  we  have considered,  and 

actions taken  and rationale. 

The National Offender Management Service (NOMS)  are currently undertaking  a review of 
the  current policy and  processes that we  nationally employ,  including the ACCT process. 
The focus of the  review relates  to three pillars:  Prevention,  Intervention  &  Education built 
on  a foundation  of analysis.  In  line with  NOMS  project we  are  currently working with the 
mental  health  leads (BEH  Mental Health  NHS Trust)  on  reviewing  our existing First Night 
Mental  Health Assessment at HMP Pentonville. 

We have currently presented the  initial  draft at the Clinical Governance Meeting and the 
next steps include final  approval  of the  new procedure and the  introduction of training  and 
implementation  of the  new risk assessment to  staff and  on  SystmOne.  We are  planning for 
a 'Go  Live' date by end August 2016.  In  addition the  risk  state  score will  be  accompanied 
by  the text that the guidunce is  advisory and to  be  used in  conjunction with  staff's clinical 
judgment. 

4.  Mr  Adams  told  the  GP  that  he  had  been  suicidal  on  and  off  for twenty  years, 

but she did  not explore with  him the  potential triggers for this.  In  fact,  one such 
trigger was incarceration. 

Response:  As  discussed  above in  Point 3,  a key issue is  asking in  detail  about a person's 
previous history of self-harm and  suicide attempts paying  particular attention to the 
triggers. 

5.  On  the  morning  he  died,  Mr  Adams  should  have  attended  his second 

reception screen, also known  as the well man clinic.  When he  did  not  arrive,  the 
healthcare  nurse  did  not  attempt  to  find  out why or to secure his attendance. 

Response:  New prisoners should receive their healthcare screenings within  72  hours. 
Healthcare book new prisoners into the well  man  clinic and  provide the prison  officer with  a 

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list of who  is to  be  seen that morning. The clinic time is given  but,  in  the same way that a 
hospital theatre  list operates for example,  the  prisoners will  all  be  listed for the  same 
appointment time.  For prisoners located  in  the first  night centre,  the prison officer will 
unlock everyone on  the  list and take them  to  the healthcare waiting  area.  The  nurse will 
work through the  list  and  return each  prisoner to the waiting  area.  At the end  of the clinic, 
the prison  office  will  collect the  prisoners from  the waiting  area  and return  them to the first 
night centre. 

Where a prisoner is  located elsewhere in  the  prison  (as  Mr Adams was),  they will  be  able 
to move from  one  area  of the prison to  another area during  set times known  as free-flow 
(at 8.15  am,  11.30 am,2 pm  and 4.15 pm)  . If the prisoner misses that window for moving 
for whatever reason,  the prisoner will  not be  allowed to  move to healthcare (unless it is an 
emergency). 

It is  not unusual for prisoners, especially those located outside of the first night centre,  to 
miss appointments.  This can  be for a number of reasons  including the prisoner refusing to 
attend,  an  emergency in  the  prison,  prison  officer shortages,  the prisoner attending a 
different appoint. 

When  a patient is  booked for a clinic  but does  not attend  {DNA),  nurses will  investigate and 
chase  up that  person  once the clinic is  over.  It would not be  possible,  nor an  efficient use 
of clinical  time,  for nurses to  chase up prisoners during the course of a clinic.  With  15-20 
new receptions everyday (Pentonville being  a remand  prison  and thus  having a high 
population turnover),  if nurses chased  up DNA prisoners during the course of the clinic, 
they would spend their time doing  nothing  else. 

After the clinic,  nurses  will  re-book prisoner into the  next clinic if they fail  to  attend.  In 
addition,  whenever a prisoner is  booked into an  appointment,  an  outcome must be 
recorded  on  SystmOne.  This can  be  confirmation that the  prisoner was  seen,  treatment 
was  given  or that the  DNA.  By default,  SystmOne will  also DNA everyone scheduled for an 
appointment {in  the overnight system  running)  if an  appointment outcome has not been 
manually entered  by the  nurse. 

In  this  case,  it is  likely that the code blue for Mr Adams'  death was recorded  on  SytmOne 
before a nurse could  enter a DNA. 

6.  The  root  cause  analysis  (RCA)  conducted  by  Care  UK  after  Mr Adams'  death  in 

November 2015,  and  finalised  in  February  2016, was  not  shared  with  HM 
Coroner  until  part  v.·ay  through  the  inquest,  and  then  only  following  the 
accidental  discovery  of  its existence by two of the inquest advocates.  It had  not 
been  shared with  HMP Pentonville's head  of safer custody governor;  nor even with 
the  deputy  head  of healthcare of Care  UK itself.  Its  existence had  not been 
disclosed to  HM  Coroner. 

Respons_E1_ At the  inque~;t  the learned Coroner commented that she had  seen  completed 
Root Cause Analysis  ("hCA") before from  ourselves and that they were robust documents. 

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This  is  always  a document that is  disclosable and  it was  not on  this  occasion.  Advice was 
sought from  our external  legal advisors  prior to the  inquest and  on  this  occasion the  Root 
Cause Analysis  was  not forwarded to  you  by  them.  Your concern  has been  discussed with 
the relationship  partner :1t  the  external firm. 

The agreed  position wiU1  NHS  England as  to  when  an  RCA is  conducted  is  as follows: 

•  Self-inflicted death - this  always requires  an  RCA. 
•  Expected death  (e.g.  palliative care) - this would  not normally require an  RCA unless 

there  are  significant cor 1cerns. 

•  Unexpected death but not a surprise (e.g.  heart attack in  a high risk  patient) - a 

judgement will  be  made  as  whether an  RCA is  undertaken. 

RCAs  are  shared  with  NHS  England  as  Commissioner (but staff names are  redacted).  We 
recognise that RCAs  sh-:)uld  be  share in  an  open  and transparent manner and the prison 
Governor will  automatically receive  (redacted)  copies going forward.  The findings  of all 
RCA's  should  be  shared,  reviewed  and  discussed during  individual site  Quality Assurance 
Meetings.  This  is the foum where Action  plans should be agreed on  and progressed 
forward.  The importance  of this  will  be  presented by the  in-house legal team  at  our next 
divisional Quality Assuru1ce  meeting. 

We  trust  that  the  above  respcnse  provides  the  information  that  you  require  but  please  do  not 
hesitate to  contact us if Care  U,( can  be  of any further assistance. 

e Services 

Pentonville 

On  behalf of Care  UK