Kevin Dermott

19 DEC 2016

AB From Nicola Blackwood MP

Parliamentary Under Secretary of State for Public Health and Innovation
Department

Richmond FH
of Health 079 Whitehall
: London

SWIA 2NS
Mr N.L.Rheinberg

Senior Coroner for Cheshire 020 7210 4850
West Annexe

Town Hall

Sankey Street

Warrington

Cheshire

WA‘ 1UH

Dew My Rcinloays

Thank you for your letter to Secretary of State about the death of Mr Dermott. | am
responding as the Minister with responsibility for prison health services at the Department
of Health. Please accept my apologies for the delay in responding.

15 December 2016

| was saddened to read of the circumstances surrounding Mr Dermott’s death. Please
pass my condolences to Mr Dermott’s family and loved ones.

The safety and wellbeing of prisoners should be paramount which includes delivering high
quality physical and mental health services that meet the needs of prisoners. The
Department of Health is committed to working with the National Offender Management
Service (NOMS) and NHS England, as the commissioner of health and justices services,
to ensure that this happens. However, you have highlighted issues relating to Mr
Dermott’s care that demonstrate there is much more we need to do.

| would expect the prison service and NHS England to learn lessons where the care of Mr
Dermott fell short of expectations in meeting his clinical needs and ensuring his safety, to
prevent this happening again. | have ensured that colleagues at NOMS have received a

copy of your report and asked them to write to you directly.

The Government is committed to improving all prison health services, including mental
health treatments, which is why NHS England has allocated approximately £523m for
health and justice commissioning, including spending on mental health services in prisons
in England in 2016/17.

In February, the Government announced plans to trial six reform prisons, with full co-
commissioning between governors and NHS England. Subject to a review of outcomes
and performance, the Ministry of Justice will roll out this model across the prison estate in
England from 2017, supported by new legislation. The aim is to ensure that health
services provided in prisons are more closely matched to the often specific needs of a
particular establishment.

Work is underway to improve the way health services in prisons are delivered including
testing co-commissioning of health services between governors and NHS England, with
governors having a greater say in defining prison health services in their prison, and
budgets.

We also welcomed the Mental Health Taskforce's Five Year Vision for Mental Health in
February which recommends a non-custodial, integrated health and justice pathway to
support offender mental health needs in the community, including community sentences
with a mental health treatment requirement (MHTR) and Liaison and Diversion (L&D)
services. NHS England published an implementation plan in July to progress the NHS
recommendations of the Five Year Vision and we will publish a strategic implementation
plan later this year to progress the cross-Government recommendations.

Turning to the issues you raised in your report, you expressed concern that Mr Dermott's
relapse into depression was not recognised and the jury concluded that his death by
hanging was partly due to deficiencies in mental health care and failure to properly
observe ACCT procedures.

You suggested that, mental health provision failings are endemic within prisons and that
mental health facilities in prison are not adequate to address mental illnesses, justifying
the need for a fundamental review. NHS England has been responsible for commissioning
health and justice services since 2013. | am aware that Professor Sir Bruce Keogh,
National Medical Director, NHS England wrote to you on 4 August setting out the ways in
which NHS England is improving standards of care through improving service
specifications and developing performance indicators to raise the quality of services
across the board.

| also understand that Professor Sir Bruce Keogh’s response has addressed the following
other concerns:

i. inadequate consultant psychiatric support;
ii. lack of long- term care planning; and
iii. lack of continuity of care and lack of hospital facilities to deal with acute
psychiatric problems.

All prisoners should be entitled to an equivalent range and quality of treatment and
services from the NHS as people in the community can expect, according to clinical need.
NHS England conducts health and wellbeing needs assessments for each prison on a
regular basis to ensure that healthcare provision is commissioned to meet the needs of
that establishment. Within prisons, a prisoner has a health assessment on arrival,
particularly to establish the risk of self-harm and suicide and risk of harm from others. All
prisons have on-site primary health care teams who should provide mental health care,
refer to talking therapies or refer for a further psychiatric assessment for serious mental
illness.

The specific issues you raise about the failure to properly observe Assessment, Care in
Custody & Teamwork (ACCT) procedures are operational and should be addressed by
NOMS.

Department
of Health

With regard to the referral of Mr Dermott to mental health services, we expect that
prisoners that are clinically assessed as requiring mental health treatment in hospital
should be transferred without unnecessary delay. However, | acknowledge that delays
may occur and health and justice systems can work better together to make
improvements. NHS England is now revising national guidance for ensuring the timely
transfer of prisoners to hospital.

| hope that this information is useful. Thank you for bringing the circumstances of Mr
Dermott’s death to our attention.
Yours sincerely,

Nia Aue

NICOLA BLACKWOOD

Nicholas Rheinberg

a NHS|

‘= 9 AUG 2016 ngland

Professor Sir Bruce Keogh
National Medical Director
Skipton House

80 London Road

SE1 6LH

Senior Coroner

Cheshire Area

West Annexe, Town Hall,
Sankey Street
Warrington

Cheshire

WA1 1UH Ain August 2016

Dear Mr Rheinberg,

RE: Regulation 28: Report to prevent Future Deaths - Mr Kevin Dermott,
HMP Risley

Thank you for your Regulation 28 Report which was issued on Monday 13 June
2016 following the inquest into the sad death of Kevin Dermott, who died at HMP
Risley on 19 May 2014. | would like to express my deep sympathy to Mr
Dermott’s family.

Since 1 April 2013 NHS England is the organisation responsible for the
commissioning of healthcare in prisons following the implementation of the
Health and Social Care Act (2012). Mr Dermott spent his time from entering
prison on 26 September 2012 in four prisons until his death on Monday 19 May
2014 which covers the transition of healthcare commissioning from Primary Care
Trusts to NHS England commissioning hubs.

| wish to respond to your concern that the mental health facilities in prison were
not sufficient enough to address the mental illnesses such as the deceased
suffered. This includes concerns that there was seen to be inadequate consultant
psychiatric support, lack of long-term care planning, lack of continuity of care and
lack of hospital facilities to deal with acute psychiatric problems.

Since 1 April 2013 the commissioning of healthcare across the prison estate has
under gone some major reprocurements, led by the local NHS England health
and justice commissioning hubs. In some local areas commissioners have used
a ‘prime provider’ model which gives the prime contractor responsibility for the
management and delivery of the whole care pathway, with parts of the pathway
sub-contracted to other providers. In other local areas commissioners have
chosen to commission services on a “separate lots” model, whereby the
commissioner retains more direct oversight of the individual services. Whatever
the model local commissioners will always ensure that contractual compliance
with the care pathway is in place.

High quality care for all, now and for future generations

Better integration of health care services within prisons has also been supported
by the development of a national set of service specifications for primary care
services (including GP and nursing services), mental health services and
substance misuse services. The mental health service specification outlines the
requirement for mental health services to provide an integrated stepped care
model for mental health which enables patients to flow seamlessly between mild
to moderate and severe and enduring stages based on clinical need and include
the provision of a consultant psychiatrist. These service specifications were
developed in December 2013 and set the outcomes and standards required from
the services including long-term care planning and continuity of care. A planned
review of the specifications is underway to respond to the Health and Well-Being
Needs Assessments with substance misuse specification and mental health
services for immigration removal centres underway and expected to be
completed by the end of 2016. The review of the prison mental health
specification will also align to the Ministry of Justice review of mental health in
prisons as part of the prison reform agenda of which a date is to be set to
commence the work. This will provide NHS England with an Opportunity to
ensure lessons learnt from deaths in custody inform our commissioning
responsibilities.

NHS England is supporting the National Offender Management Services (NOMS)
with their review of the Person Escort Record (PER). This revised form ensures
that all current and relevant information, including health information, is held in
one document and transfers with the prisoner from police custody through to
reception into prison and during any subsequent prison transfer or release. The
roll out of the paper form pilot is still ongoing and work is being undertaken to
ensuring PER training will be available to all operational staff. This is expected to
be launched by March 2017. The digital PER form is being piloted in a couple of
prisons and NOMS are leading on this work.

During the financial year of 2014/15, a new data set in heatth & justice called
‘The Health & Justice Indicators of Performance’ (HJIPs) was introduced, The
data set collects information on the delivery and outcome requirements NHS
England are required to commission as part of their organisational
responsibilities and includes outcomes data on mental health service provision.
Formal reporting of this data commenced in 1 April 2016 with the first quarterly
data due to be submitted to NHS England in July 2016. This data forms part of
the quarterly contract meetings between the regional health and justice
commissioners and the prime providers.

NHS England recognises that there is a national issue regarding lack of secure
psychiatric beds which impacts on the timely transfer of acutely unwell prisoners,
The Health and Justice commissioning team are working with colleagues in the
NHS England Specialised Commissioning teams, who are responsible for secure
mental health provision, and other partners in Department of Health, National
Offender Management Services and Ministry of Justice and Home Office to look
at this issue and try to resolve it. .

NHS England Health and Justice and Specialised Commissioning teams have
developed updated guidelines for the transfer of prisoners to and remission from
High quality care for all, now and for future generations

secure mental health hospitals. This guidance is due for final consultation in
autumn 2016 prior to publication and unti! then the Department of Health 2011
guidelines remain extant. The HJIPs data set also contains transfer timelines to
mental health secure units.

| hope the information above addresses the concerns you have raised within your
report and provide assurances that NHS England recognises your concerns and
are working with a number of organisations to identify and hopefully address the
issues in an adequate manner.

| am grateful to you for bringing these matters to my attention.

Yours sincerely,

mi

Professor Sir Bruce Keogh KBE, MD, DSc, FRCS, FRCP
National Medical Director
NHS England

High quality care for all, now and for future generations

Ministry of Equality, Rights and Decency Group
U ST | C E National Offender Management Service
4th Floor, 70 Petty France,
# London SW1H 9E.
National Offender :
Management Service Ll

Mr Nicholas Rheinberg
Senior Coroner for Cheshire

19 August 2016
Dear Mr Rheinberg

Thank you for your Regulation 28 report addressed to the Governing Governor of HMP Risley,
concerning the recent inquest into the death of Kevin Dermott on 19 May 2014 at HMP Risley.
Your report has been passed to the Equality, Rights and Decency (ERD) Group at NOMS
headquarters, as we have responsibility for the policy on suicide] prevention and self-harm
management and for sharing learning from deaths in custody. | have consulted with the
Governor in formulating this response.

You have identified a number of matters of concern regarding the implementation of the
Assessment, Care in Custody and Teamwork (ACCT) process at the prison, and | will explain
the steps that are being taken to address them.

The level and depth of management checks on the ACCT process) have been increased. All
ACCT documents are checked daily by Offender Supervisors, and an additional weekly check
by a Custodial Manager is being introduced. The Head of Safer Custody will also be checking
a sample of ACCT documents each week, and will continue to do |so until he is satisfied that
the standards have improved and that the relevant processes are embedded.

A Governor’s Order will be issued setting out clearly which member of staff is responsible for
which ACCT documents at which time, encouraging personal] ownership and ensuring
accountability. Staff who have not completed an ACCT document|satisfactorily will be asked
to account for their actions, and, where necessary, action will be escalated through a verbal
warning, written warning or investigation for misconduct as appropriate. In support of this, all
Offender Supervisors and Custodial Managers are being briefed about the importance of the
ACCT process.

In order to ensure that any concerns that are raised about a prisoner are being acted upon,
staff have been informed that they must contact the Safer Custody department, who will
organise an immediate ACCT review for that day. If the named Offender Supervisor cannot
attend it will be escalated to the “Oscar” group (comprised of three Offender Supervisors), and
where they are not available it will be further escalated to the duty Custodial Manager (who is
available 24 hours).

| hope that this provides you with reassurance that your concerns are being acted upon. HMP
Risley will have these changes in place by the end of September 2016.

Yours sincerely