Steven May

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Nottinghamshire Healthcare [/n53
ocitiwe ottinghamshire Healthcare

about integrated healthcare.

Chief Executive Office
The Resource [Trust HQ]
Duncan Macmillan House

E-mail: Po Porchester Road

Nottingham
NG3 6AA
Our ref:RH/JH/AP
Your ref: tC

13 April 2016

Mr McNamara

HM Coroner Nottinghamshire office
The Council House

Old Market Square

Nottingham

NG1 2DT

Dear Mr McNamara
Report to prevent future deaths following inquest into the death of Steven James May

| write in response to your Prevention of Future Deaths report dated of 16 March 2016 in
order to provide you with the information you have requested. This report was issued
subsequent to the inquest into the death of Steven May, who died whilst a prisoner at HMP
Ranby, where this Trust provides healthcare services.

The Trust welcomes any chance to improve the quality of its service and we have considered
the concerns you raise in your report with care. As you will be aware, the Trust commissions
internal investigations whenever Serious Incidents (Sls) occur. The purpose of these Sl
reports is to look at the whole circumstances of the incident, set against best practice, and to
identify opportunities for learning and improvement. In the context of any death in a prison
setting, the circumstances are always investigated by the Prisons and Probation
Ombudsman. If there has been any healthcare involvement with a prison, the Ombudsman is
assisted by a clinician, appointed by NHS England, who carries out an independent clinical
review. This ensures that whenever there is a fatality involving a patient of the Trust who is
held in a prison setting, there is both an internal and an external investigation.

Where considered appropriate by the investigators, each of those investigations can make
formal recommendations for changes in, or reviews of, clinical practice and management.

Both an internal and an external investigation were conducted regarding Mr May’s death. A
copy of the Trust's internal SI report was shared with your office. The Trust took action in
response to recommendations made in both its own SI report, and the PPO report, prior to the
inquest taking place. The actions taken by the Trust in response to these recommendations
were set out in Head of Healthcare, Aa written and oral evidence at the inquest.

Continued

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The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA IN PEOPLE Silver

Chair: Dean Fathers, Chief Executive: Ruth Hawkins PAG

Coroner’s Concerns
Of the 10 concerns listed in the PFD report, (1), (2) and (10) relate to healthcare. | will
address each of these in turn.

(1) The failure of reception nursing staff, by reason of lack of training and/or
instruction or lack of staff and/or time, to consult the deceased’s historical medical
notes prior to or during the reception interview.

As | have noted above the Trust's Serious Incident report made a number of
recommendations. One of the recommendations was as follows:

“In order to ensure there is a good knowledge of the patient before they are located into the
prison it is essential that previous records are reviewed to determine any immediate risk
issues. Whilst patient self-report is essential and vital it should not be relied on in isolation of
clinical records.”

Prior to Mr May’s death, staff were aware of the requirement to review a patient’s SystmOne
notes to check for any relevant history during the first reception screen. Although this should
have been done when Mr May was being reviewed during his first reception screen, it did not.

In response to this recommendation all staff were reminded via primary care team meetings
(minutes of the meetings have been emailed to all staff members) and during one to one
sessions with their line manager of the importance of reviewing patient notes for key
information during the reception health screen.

In evidence at the inquest, confirmed that she was, at that time, both aware of
the need to check for relevant medical history (in particular, any history of self harm/ suicide
attempts) and routinely did so.

As set out in F statement and oral evidence, in recognition of the fact that there is
a limited time a nurse on reception can spend with each individual prisoner, the Trust
introduced a key word search facility (i.e. nurses can search key words, such as ‘mental
health’ or ‘self-harm’). This enables nurses to identify key entries in a patient's SystmOne
medical history (which can be extensive if an individual is serving a long sentence) very
quickly.

In addition to this, | understand that gave evidence at the inquest that in
November 2015 the Trust submitted a business case to NHS England (the Trust’s
commissioner) seeking recurrent funding for further healthcare staff. This document was
provided to you by the Trust’s solicitors after the conclusion of the inquest. The funding
requested was secured, with the exception of that for a paramedic post, which the Trust may
bid for again in future. As a result, the Trust is now able to provide a designated reception
nurse, so that nurses on reception do not experience the time constraints — |
would have experienced in May 2015 due to her other duties.

Page 2 of 4
HM Coroner's Office

(2) The lack of experience and/or training of reception nursing staff in the field of
mental health.

Individuals arriving into HMP Ranby can have a history of physical illness, mental illness,
substance misuse or a combination of these. All healthcare needs must be considered, not
purely mental health in isolation. Reception nurses are generally primary health nurses.

When an individual arrives into reception, the nurse reviews any relevant documentation and
medication that is brought in with the patient and then completes general physical healthcare
observations. After this, the nurse will complete a very detailed template of questions with the
patient relating to their physical health, mental health and any history of substance misuse.
Further, as set out above, reception nurses are trained to look back through a patient’s
medical history and to search for key areas of concern such as a history of self harm/suicide.
If an individual has a history of mental illness then the reception nurse will refer the individual
to the Primary Mental Health Team. The Primary Mental Health Team will aim to have a triage
appointment with that patient withi nd must see the patient within 5 working
days). As confirmed in evidence ee ae Trust was compliant with this target in
2015.

If a reception nurse has significant concerns about a patient, they can seek immediate
assistance from a member of the Primary or Secondary Mental Health Teams.

(10) The accessibility of health and/or mental health care to inmates at weekends and
during Bank Holidays.

The Trust’s resources are of course limited in accordance with its contract with NHS England.
In May 2015, the Trust was not commissioned to provide mental health services at HMP
Ranby at a weekend. Despite this service not being commissioned, the Trust had identified a
need for weekend mental health cover and was providing limited cover by transferring
resources from elsewhere (which is why BB was available on Sunday 24 May
2015).

The Trust was in discussion with NHS England about securing extra resource for HMP Ranby
around one year ago. NHS England requested that evidence needed to be gathered to feed
into its assessment of healthcare needs in connection with those aspects of healthcare which
it commissions.

This led to the Trust instructing an independent company to complete a Healthcare Needs
Assessment (“HNA’”). The HNA identified that there was a particularly high level of healthcare
need at HMP Ranby and the demand for services was not fully met by the level of service
commissioned by NHS England. It was identified that part of the added demand was fuelled
by health problems caused by New Psychoactive Substances (“legal highs”).

The business case set out, among other things, the demand that the Primary Mental Health
Team was facing. In particular, it highlighted that the team had tried to deliver an out of hours
service at weekends, however this had caused the commissioned Monday- Friday service to
be stretched. The business case set out that if NHS England provided funding for a Band 6
Primary Mental Health Nurse, increased the existing Band 5 post to a Band 6 post and met

Page 3 of 4
HM Coroner's Office

additional costs associated with unsocial hours, it would enable the Trust to provide a safe an
effective service 7 days per week.

| understand that at the inquest, during her evidence, [EEE explained that following the
submission of the attached business case to NHS England in November 2015, NHS England
acceded to all of the requested funding (save for the paramedic post), which amounts to just
under £143,000.

As is clear from the business case, the Trust has already taken action to address this
concern. The Trust has been recruiting to fill the new posts at HMP Ranby for which funding
has been agreed. From the Trust’s perspective, and also we understand from that of NHS
England, this has been an effective example of partnership working that has also involved the
prison service, who were supportive of the Trust’s efforts to obtain the extra funding.

The Trust cannot respond to the other 7 concerns highlighted in the Prevent Future Death
report as they are matters for HM Prison Service and/or other parties.

Please do not hesitate to contact me should you require any further information.

Yours sincerely

Ruth Hawkins

Chief Executive
Nottinghamshire Healthcare NHS Foundation Trust

Page 4 of 4
HM Coroner’s Office

ME a

Equality, Rights and Decency

National Offender Group
. National Offender Management Service
Management Service. 4th Floor, Clive House,

70 Petty France,
London, SW1H 9HD

Erna

Andrew McNamara
Assistant Coroner for Nottinghamshire
11 May | 2016

Dear Mr McNamara,
Inquest into the death of Mr Steven James May on 25 May 2015 at HMP Ranby

Thank you for your Regulation 28 Report of 16 March 2016. Your report has been passed to
Equality, Rights and Decency (ERD) Group in the National Offender Management Service, as
we are responsible for sharing learning from deaths in prison custody. | am responding on
behalf of the Secretary of State for Justice, NOMS and the Governor of HMP Ranby.

You will be aware that healthcare at HMP Ranby is commissioned by NHS England and
provided by Nottinghamshire Healthcare NHS Foundation Trust, and | understand that the
matters of concern that you have raised at points 1, 2 and 10 have been addressed separately
by the Chief Executive of the Trust in a letter dated 13 April 2016, and by the Clinical Quality
Manager at NHS England in a letter dated 5 May 2016. This response therefore addresses the
matters of concern at points 3 to 9.

(3) The failure of prison staff when preparing the ACCT document to prepare as full a note as

possible. For example, to follow the subject_areas suggested _in the narrative accompanying
sections 1-8 of the Assessment interview.

As you know, Prison Service Instruction (PSI) 64/2011 Safer Custody sets out the policy
position, and the importance of fully recording and sharing information about risk is clear
throughout, and particularly in chapter 2 on information sharing. Chapter 5 describes the
Assessment, Care in Custody and Teamwork (ACCT) process, making reference to the need for
effective record-keeping and requiring that the assessor record the outcome of the assessment
interview on the ACCT plan.

Staff at HMP Ranby were reminded of the need to make comprehensive records of all such
interviews at a briefing on 23 March 2016. All ACCT documents at the prison are now being
monitored by the Head of Safer Custody and the quality assurance check that is conducted
addresses this point.

At national level a review of the ACCT process was conducted in 2015 and NOMS is taking
forward work on the recommendations, including issuing improved operational guidance for
staff, developing a shorter and clearer ACCT plan and improving the content and delivery of
safer custody training.

(4) Reliance by prison staff on verbal and/or oral handovers of information, rather than written
records, regarding the deceased.

PSI 64/2011 states that “it is vital that the on-going record contains sufficient information about
the progress and well-being of the prisoner. This information is critical to ensure that the risk is
being managed appropriately and the CAREMAP remains relevant”.

At HMP Ranby a notice was issued in February 2016 reminding staff that those responsible for
a prisoner on an open ACCT must record all relevant information in the ACCT document, the
wing observation book and on the P-NOMIS system. Both the prison and the healthcare
provider have recently reviewed their procedures to ensure that systems are in place for
information to be shared between prison and healthcare staff and recorded appropriately. In
order further to improve information sharing, meetings of the multi-disciplinary team for
prisoners identified as being vulnerable or at risk of harm are held every two weeks, and any
ongoing concerns are discussed and recorded.

(5) The involvement in the ACCT process of prison staff possessing neither relevant training nor
the appropriate rank.

PSI 64/2011 states that all staff in contact with prisoners must receive the foundation level
‘Introduction to Safer Custody’ training, and specific training is available for the roles of assessor
and case manager. It also requires governors to provide ACCT refresher training according to
local needs.

At HMP Ranby there are currently 30 trained assessors, 50 case managers and 464 staff of
various grades who have received the foundation level training, and the Governor keeps these
numbers under review.

One of the recommendations of the national review of the ACCT process referred to above was
for further work to clarify the band/grade requirements for staff in assessor and case manager
roles and work on this is being taken forward during 2016.

(6) The failure of prison staff to ensure the attendance of a medical professional at the First
Care Review.

It is a mandatory requirement of PS! 64/2011 that the first case review is attended by a member
of healthcare staff.

All case managers at HMP Ranby have been reminded that the initial case review must be
attended by a member of healthcare staff, and the healthcare provider has adjusted its delivery
model to make this possible.

(7) The selective training of prison staff in emergency First Aid (namely the first member of
prison staff on the scene of the death was not trained in the administration of CPR and was
ignorant of the location of and method of use of defibrillators).

PSI 29/2015 First Aid requires governors of public sector prisons to ensure that at all times such
numbers of suitably trained first aiders as is sufficient and appropriate for the circumstances are
available. These numbers must be determined by conducting a first aid risk assessment. First
aiders must be trained to levels which are appropriate for the circumstances — to either First Aid
at Work (FAW) level or Emergency First Aid at Work (EFAW) level.

The PSI becomes effective on 16 May 2016, and in preparation for its implementation, the
Governor of HMP Ranby is reviewing the band/grade and numbers of staff who need to be
trained in first aid. The prison currently has 61 staff trained in FAW and 73 in EFAW. 86 staff
have received training in the use of defibrillators, and all staff have been provided with
information on the location and use of defibrillators through a staff information notice issued on
16 July 2015.

(8) The hesitancy of the first member of prison staff on the scene to enter the deceased's cell in
apparent adherence to an instruction not to enter cells alone.

PSI 24/2011 Management and Security of Nights sets out the policy on how incidents should be
managed during the night state when prisoners are locked in their cells. Night operating
procedures must be agreed by the Governor and the Deputy Director of Custody and set out in
the prison’s Local Security Strategy (LSS), which must include the local procedures to be
followed in a potentially life threatening situation where there are no other staff in the immediate
vicinity. Where there appears to be an immediate danger to life, cells can be opened by an
individual member of staff:.in such circumstances, the staff member must make every effort to
obtain a response from the prisoner and then make a dynamic risk assessment of the situation
based on what they can see through the observation panel and on what they know of the
prisoner.

HMP Ranby has reinforced the relevant elements of its LSS, and issued a staff notice to this
effect on 9 September 2015. All staff have been given access to the LSS and their knowledge
of it will be tested annually.

(9) The inadequacy of First Aid training provided to prison staff in any event (namely, the
administration of CPR by prison staff whilst the deceased was lying on a bed).

PSI 29/2015 is clear that all training provided to NOMS staff must be delivered by competent
instructors, either by external providers from an approved list or trained and currently certificated
NOMS trainers.

HMP Ranby is currently taking steps to ensure compliance with this element of the instruction in
preparation for its implementation on 16 May 2016, alongside the review of the number of
trained staff described in the response to point 7 above.

Thank you for bringing these matters of concern to our attention. | hope that the contents of this
letter have been helpful in providing some national context and an assurance that the concerns
that you have raised have been, or are being, addressed locally at HMP Ranby.

Yours sincerely

Gre Deri

NOMS Equality, Rights and Decency Group