Haydn Burton

emery emma
Ministry of Senior Caseworker: Safer Custody

Casework

U T | = Safer Custody and Public Protection
Group

National Offender Management Service

National Offender 4.15 Clive House

* 70 Petty France
Management Service London SW1H 9EX

Mr GA Short
HM Senior Coroner for Central Hampshire

BY EMAIL ONLY
12 December 2016

Dear Mr Short

Thank you for your Regulation 28 Report to Prevent Future Deaths addressed to HM
Prison Service, and The Samaritans, concerning the inquest into the death of Haydn
Burton at HMP Winchester on 15 July 2015. Your report has been passed to the
casework team in the Safer Custody and Public Protection Group (SCPPG) in the
National Offender Management Service (NOMS), as we have responsibility for the
policy on suicide prevention and self-harm management and for sharing learning
from deaths in custody. The reply is provided after consultation with the Governor of
HMP Winchester.

| note your concern that evidence at the inquest suggested that staff at Winchester
are inconsistent in their implementation of the Assessment, Care in Custody and
Teamwork (ACCT) process, and that the practice of undertaking ACCT observations
is inadequate. | am grateful to you for raising this concern, and would like to reassure
you that the Governor of Winchester, | is committed to
ensuring that all operational staff are successfully trained in ACCT procedures to
enable them consistently to follow national ACCT policy contained within Prison
Service Instruction (PSI) 64/2011 Safer Custody. Local ACCT refresher training is
due to take place on 13 and 20 December 2016 for 48 members of staff and will be
delivered at least monthly thereafter. HMP Winchester is also holding a Safety
Awareness Day on 21 December 2016.

This local training will cover the whole ACCT process, including how to open an
ACCT, and will consider lessons learnt from previous deaths in custody, including the
requirement to ensure that the ACCT assessment is completed within 24 hours, the
need to make appropriate mental health referrals, and the fact that ACCT case
reviews must be multidisciplinary and attended by all those involved in the provision
of care for the individual concerned. A plan is being developed to deliver refresher
training for ACCT case managers and assessors already in post, and to increase the
number of staff trained in these roles.

In addition, more staff are being recruited, and 12 new Prison Officers are expected
to complete the Prison Officer Entry Level Training (POELT) course that includes
training on suicide and self-harm awareness and the ACCT process and start work at
Winchester by March 2017.

The Governor has recently introduced additional management assurance checks to
ensure that staff are completing ACCT documents correctly and to the required
standard, and that the appropriate level of care is given any person who requires to
additional support provided during the ACCT process. These assurance checks are
completed by Orderly Officers, Duty Governors and the Safer Custody Team. The
results are collated and will be discussed at the monthly Safer Custody meeting
where trends will be identified and appropriate actions taken. In addition quality
assurance checks will consider the role of ACCT Case Managers to confirm
compliance, and identify any development needs. ACCT Caremap actions are
checked by the Safer Custody Supervising Officer and Custodial Manager who
ensure that appropriate actions have been identified and taken forward.

In addition to the multidisciplinary ACCT case reviews, Winchester now holds a
weekly multi-disciplinary ACCT meeting, attended by the Head (or Deputy Head) Of
Safer Prisons, the Community Mental Health Team (CMHT) and the Offender
Management Unit, where every prisoner who is subject to an ACCT is discussed, to
ensure that important information and concerns are communicated to all relevant
departments.

In your report you also suggested that the local Prison Listener Scheme Protocol
include an additional exception to the confidentiality rules to allow Listeners
(prisoners who are trained by the Samaritans to offer confidential and emotional
support to other prisoners), to advise staff when a prisoner confirms that they have
active plans to self-harm or threatens self-harm in the future.

As the Samaritans have set out in their separate response to your report, the
principle of total confidentiality is central to their work, and applies equally to the work
of Listeners. This is reflected in the national partnership agreement between NOMS
and the Samaritans that governs the operation of the Listener scheme, and the
NOMS safer custody policy set out in PSI 64/2011. In the light of this it is not
appropriate for Winchester to adopt a different policy on this point. Without the
assurance of confidentiality, prisoners may not feel able to approach Listeners and
talk freely in an atmosphere of total trust. Any change to this approach may lead to a
reduction in the number of prisoners accepting this vital source of support and
sharing their concerns. Where a Listener believes that a prisoner is seriously at risk
of suicide, the Listener actively encourages the prisoner to seek further help, and if
they do not wish or are unable to do so on their own, the Listener is trained to
attempt to gain the prisoner’s permission to alert staff to the need for help.

You also raised your concern that NOMIS, the prison case management system, is
not used consistently to record details of ACCTs being opened and the reasons for
doing so, and you suggested that the ACCT post closure process be reviewed.

PSI 64/2011 requires staff to ensure that “The closure must be recorded within the
case notes section of NOMIS giving a brief summary of the relevant issues” (italics
indicate a mandatory requirement). The Governor at Winchester has introduced a
process whereby Wing Supervising Officers are informed each day of any ACCT post
closure reviews which are due to be held, and provided with copies of the relevant
ACCT plans. When the post closure interview has taken place, the ACCT is updated
and returned to the Safer Prisons team to be filed within in the prisoner's core record.
All Case Managers have been reminded of the importance of ensuring that the
NOMIS case notes are updated following an ACCT case review, and are using the
ACCT alerts on NOMIS to record the dates of an ACCT being opened and closed.
The post closure process is now embedded and Winchester has seen significant
improvements with regards to the completion of post closure ACCT reviews. The

management assurance checks described above include sample checks of NOMIS
following ACCT case reviews, and post closures reviews, and the prison is confident
that there have been improvements in this area.

| hope this letter reassures you that the Governor of Winchester is taking steps to
address your first and third concerns, and that, together with the separate response
from the Samaritans, it explains why we will not be taking action in response to your
second concern.

Yours sincerely

/ ae? |

ae
Lee