Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0320, written 6 Sep 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Sep 2016 |
|---|---|
| Reference | 2016-0320 |
| Deceased | Warren Sampson |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| Category | State Custody related deaths |
| Organisation named | North Essex Partnership University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: HMP Chelmsford Care UK Family Solicitors 1 CORONER I am Caroline Beasley-Murray, senior coroner, for the coroner area of Essex 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 7 September 2015 I commenced an investigation into the death of Warren Martin Sampson. The investigation concluded at the end of the inquest on 2 September 2016. The conclusion of the inquest was that Warren Sampson killed himself. The cause of death was 1a) Suspension 4 CIRCUMSTANCES OF THE DEATH Mr Sampson had been remanded to HM Prison Chelmsford on 3 August 2015. At the time of his death, he was subject to an ACCT – Assessment, care in custody and teamwork. He was found hanging in his cell. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) The “ad hoc” attendance at ACCT reviews of representatives from all disciplines especially Healthcare. The lack of written evidence within the ACCT documentation of contributory input from other agencies such as Healthcare. (2) The lack of a process for following up non- attendance at the Reception Healthcare first night screening (3) The lack of a system for ensuring that all officers are familiar with local directives and instructions 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your 1 organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 31st October 2016. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons – solicitors for the family] I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 6 September 2015 Caroline Beasley-Murray 2
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Mrs Caroline Beasley-Murray HM Senior Coroner Seax House Victoria Road South Chelmsford Essex. CM11QH 4 October 2016 care E3 HMPNOI Chelmsford 200 Springfield Road Chlemsford CM2 6LQ Care UK Clinical Services Limited www careuk.com Dear Madam, Regulation 28: Prevention of Future Deaths report The inquest touching the death of Warren Sampson Deceased HMP Chelmsford th Date of death: 4 September 2015 Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Care UK following the inquest into the death of Mr Warren Sampson. Care UK is the provider of primary healthcare services at HMP Chelmsford. North Essex Partnership Foundation NHS Trust provide 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) The "ad hoc" attendance at ACCT reviews of representatives from all disciplines especially Healthcare. The lack of written evidence within the ACCT documentation of contributory input from other agencies such as Healthcare. It is the process now that discipline staff each day will email healthcare with the ACCT reviews they are intending to hold that day and invite the appropriate healthcare professional to input into the process, whether it be primary healthcare, mental health or a member of the substance misuse team. Attendance will be in person where possible but where a healthcare professional is unable to attend, the input of healthcare, for example, by telephone, must be recorded on the ACCT document and in SystmOne. This has been reaffirmed to healthcare staff. (2) The lack of a process for following up non- attendance at the Reception Healthcare first night screening The process now is that a Second Health Screen is undertaken within 72 hours of an inmate arriving at HMP Chelmsford and at that second health screen there would be a Care UK Cltrncal SeMces llm,ted - Registered ,n England No 3462881 Registered Office Connaught House. 850 The Crescent Colchester Bus,ness Park, Cotcheste< Essex C04 908 check to ensure matters such as consent for obtaining GP records has been sought. On occasions where an inmate refuses to provide consent, that will be recorded in SystmOne. We trust that the above response provides the information that you require but please do not hesitate to contact us if Care UK can be of any further assistance. Yo1,1._rs faithfully Head of Healthcare, HMP Chelmsford Care UK Page 2 of 2
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