Matthew Sargent

Age (Y ) ctw
Care £3 NHS

P how Health In Justice Regional Office
Pra Oy HMP Oakwood Visitors’ Centre

. 3 Oaks Drive
; Featherstone WV10 70D
Tel: 01206 756594

18 May 2016

Mr G U Williams LLB

HM Senior Coroner
Worcestershire Coroner's Court
The Civic

Martins Way

Stourport on Severn
Worcestershire

DY13 8UN

Dear Sir
Mathew Colin Sargent (deceased) - Regulation 28: Report to prevent future deaths.

| am writing in response to your letter of 7 April 2016 addressed to Worcester Health and Care NHS
Trust, This has been passed to Care UK as the new provider of healthcare services at HMP Long
Lartin with effect from 1 April 2016.

i have noted the Matters of Concern which you identified in section 5 of your report and respond as
follows:

1) The Personal Officer of Mr Sargent appeared to have had little to do with him. It was
suggested that there should be regular meetings between Personal Officers and individual
prisoners so that more in depth knowledge of individual prisoners could be obtained and
shared.

The role and responsibilities of Personal Officers fall within the remit of the Prison Service and not
the Healthcare Provider. Care UK is therefore unable to comment on this but trusts that the
Government Legal Department will respond on behalf of the MoJ.

2) There was a concern thot historical information which was available to Officers and
Healthcare Staff was not reviewed when the prisoner first presented at the prison and it was
suggested that it would be beneficial if there was an instruction that any member of staff
dealing with a prisoner who hed access to historical information should make some enquiry
as to that historical information so as ta inform them of both the present and past risks.

Healthcare services are operated by Care UK (Clinical Services) Limited on behalf of the NHS.
Registered in England. Registration Number: 03462881, Registered office: Connaught House, 850 The Crescent,
Colchester Business Park, Colchester, Essex CO4 908.

As a provider of healthcare services within a custodial setting, Care UK is cognisant of the
framework provided by relevant Prison Service Instructions, PSI 74/2011 First Days in Custody {a
copy of which is attached for ease of reference) stipulates that key information on individual
prisoners should be identified at the point of entry to the Prison and for that information to be
recorded and shared with other departments and agencies, both internal and external. The PSI sets
out the requirement for the Person Escort Record (PER) form that accompanies each new prisoner,
and any other available documentation, to be examined in Reception by Prison staff to identify any
immediate needs and risks already recorded.

Communication is key in all areas and Care UK staff are expected to develop close partnership
working with the Prison to ensure that relevant information sharing occurs in the best interest of
the prisoner to ensure their safety.

We recognise that early identification of risk factors and effective management of prisoners in
relation to self-harm is imperative in addressing the rising incidence of suicide. The Care UK Suicide
Prevention Strategy (a copy of which is attached) draws on national external and internal evidence
relating to risk factors associated with suicide and provides a framework for local teams to address
this vital area in their prison. A number of the measures identified in the Suicide Prevention
Strategy have relevance to the concerns you have raised.

As stated above, Care UK was not the healthcare provider at HMP Long Lartin at the time of Mr
Sargent’s death. Going forward, the Care UK suicide prevention strategy will be shared and rolled
out across all sites. In addition, since taking over healthcare responsibility on 1 April 2016, Care UK
plans to review the reception screening process to introduce a standard template for first reception
screening across its prison healthcare settings. We are also looking at the process of information
gathering on reception and the culture around this. We will expect staff to ask ‘Where Is the
information for this patient?’ and the SystmOne template will reflect this, ensuring that staff
cannot proceed without seeking out the information and recording reasons why, in instances where
the information is not available. We will ensure our processes for obtaining information on
reception are clear and effective and build relationships with local community providers to improve
information flow. Furthermore, we will record lack of information at reception on our incident
system so that we understand the extent of the issues and can monitor trends and share good
practice. We recognise that we cannot rely solely on the first night reception and that on-going
assessment over several days is essential in order to ensure we are aware of any changing clinical
picture and to take account of any new information that arrives.

Since the death of Mr Sargent, discussions have been held with Prison colleagues to review
communication pathways between the Prison and Healthcare Services. These discussions are on-
going.

3) There was a concern that Healthcare stoff were not made aware of prisoners who arrive with
an ACCT history and it was suggested thot Healthcare should be informed in all cases where
a prisoner arrives at Reception with an ACCT history so that there is a continued sharing of
pertinent information.

Page 2 of 3

4) There was a concern that the Prisoner Escort Record (highlighting concerns and risks) was
not supplied to the Healthcare Department nurses at Reception. It was suggested that this
should be an imperative requirement for the further sharing of relevant information.

These two points raise similar issues and can be answered together. It Is the responsibility of prison
service staff to share information with other departments and agencies both internal and external.
PS! 74/2011 (First Days in Custody} sets out the requirement for the Person Escort Record (PER)
form to be examined in Reception by prison staff to identify any immediate needs and risks and for
this information to be forwarded to other staff and agencies as necessary, including healthcare. PSI
74/2011 sets out the mandatory requirements for prison staff and healthcare in respect of a
prisoner's ACCT status, ACCT alerts and risk assessments, Care UK thus expects PS! 74/2011 to be
followed and that prison personnel will record a prisoner’s ACCT status on their record and share
this and any concerns with Healthcare.

In order to ensure robust communication and partnership working going forward we will continue
to work closely with our prison partners on this and in particular, the Head of Healthcare is working
to address the concern with the Safer Custody Governor. In addition, all (prison and healthcare)
staff have been reminded that they must see the PER on every occasion and that non-access should
be escalated within the prison via a datix incident report. If the staff member does not have access,
an incident form should be completed as soon as it is apparent that a PER isn’t available.

| hope this letter answers your concerns, however, please do not hesitate to contact me if you
require any further information.

Yours faithfully

Lorraine McMullen
Regional Services Manager

Page 3 of 3

Ministry of — ,
QS justice = Sessa

4th Floor, 70 Petty France,

Management Service t 0300 049 7051
ee
G U Williams LLB
HM Senior Coroner
Worcestershire Coroner's Office
The Civic
Martins Way
Stourport on Severn

3 June 2016
Dear Mr Williams

Thank you for your Regulation 28 report dated 7 April 2016 addressed to the
Government Legal Department concerning the recent inquest into the death of
Matthew Sargent on 26 September 2014 at HMP Long Lartin. Your letter has been
passed to the Equality, Rights and Decency Group in NOMS as
responsibility for suicide prevention and self harm

learning from deaths in custody. | have consulted
Lartin in formulating this response.

with
As you will be aware, we work hard to learn lessons from each death in custody,
in particular look to recommendations from recent investigations by the Prisons
Probation Ombudsman and Coroner's inquests to help us identify areas
improvement. | wouid like to thank you for drawing our attention to the issues
raise in your report and assure you that these have been considered by the prison.
The actions that have been, or are soon to be, implemented are set out below.

prisoners on an informal or formal basis weekly to discuss any issues or concerns
and that a record of these discussions will be made in the case-notes on PNOMIS so
that all information is appropriately shared. For staff absences of over two weeks,
one of the supporting Personal Officers in the team will take on the role.

Following your concerns regarding the operation of the Personal Officer scheme at
HMP Long Lartin the prison will ensure that all staff are reminded of the policy. This
will be achieved through a range of communications with staff including the issuing of
a Safer Custody Bulletin and dissemination through Custodial Managers.

The effectiveness of the Personal Officer scheme is monitored on a monthly basis,
with Supervising Officers checking all case-note entries and ensuring that support
Officers are in place. Custodial Mangers also carry out quality checks on both
management checks and case-note checks. This is completed monthly and these
checks will be recorded on PNOMIS .

Your report raises the concern that staff did not access historical information when
ade. “yee er ephni net nae a. nS at
that staff should make enquiries regarding this information

| can confirm that In response to this concern, a process has been put in place to
ensure that staff gain access to historical information where this information is
available. Offender Management Unit staff are now responsible for ensuring that
historical risk indicators are disseminated to Healthcare, Reception and the Safer
Prisons team. This information is drawn from the pre-transfer report (a document
which includes all the prisoner's details including ACCT information and case notes),
which is sent to the receiving establishment before a prisoner is transferred.

Consideration has been given as to how to ensure Healthcare staff are made aware
of prisoners who arrive with an ACCT history, and action taken to resolve this. It is
now the case that when a new prisoner who has an ACCT history is received into
Long Lartin, reception staff notify healthcare by phone in the first instance.

Following this, Healthcare will also receive a copy of the first night induction
paperwork, which is completed with the prisoner and gives details of any ACCT
history. This documentation is sent with the prisoner as part of the Prisoner Escort
Record (PER) when they attend Healthcare, ensuring that any information regarding
relevant issues are available to staff.

On completion of Mr Sargent’s inquest @ new process was implemented in the
reception department whereby the PER form is now copied and taken to the
healthcare department with the prisoner.

Once staff have completed the first night induction paperwork with the prisoner,
reception staff will send a copy of this immediately to healthcare with the PER form.
This provides healthcare with all the known details of the prisoner's risks including
any history of self-harm.

| hope this provides you with assurance that the matters of concern you have
identified have been addressed.

Yours sincerely
Rute
pe