Richard Walsh

Date of report	25 Oct 2016
Reference	2016-0377
Deceased	Richard Walsh
Coroner	Andrew Harris
Coroner area	London Inner (South)
Category	State Custody related deaths · Suicide (from 2015)
Source	judiciary.uk record · original PDF
Responses published	4

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. Lord Chancellor and Secretary of State for Justice, The Rt. Hon Liz Truss,
Ministry of Justice, 102 Petty France, London, SW1H 9AJ

2. Home Secretary, The Rt. Hon Amber Rudd, House of Commons, London
SW1A 0AA

3. The Secretary of State for Health, Rt. Hon Jeremy Hunt, Richmond House,
79 Whitehall, London SW1A 2NS

4. Those who performed the Mental Health Act Pe |__|

DAC Beachcroft LLP, 100 Fetter Lane, London, EC4A 1BN
and Head of Legal Services, Hampshire County Council, Corporate Services,
R22, E11 South, The Castle, Winchester
“a Virgin Health Care Limited

CORONER

lam Dr Andrew Harris, Senior Coroner, London Inner South jurisdiction

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.

INQUEST

On 22nd July 2015, I commenced an investigation and on 24th July I opened an
inquest into the death of Richard Walsh, who died on 19th July 2015 in HMP
Belmarsh, Western Way, Thamesmead, London; Case Ref: 01936 -15 (JB).

It was concluded on 27th September 2016. The jury concluded in a narrative
conclusion that he came by his death by suicide. They returned a finding that
omissions in a Mental Health Act Assessment after his arrest and detention in a
police station, before transfer to prison, amounted to Neglect on four counts:
Failure of both psychiatrists and of the Approved Mental Health Act Practitioner
to seek clinical information, Failure to admit to hospital under MHA section, and
Failure to conduct an adequate Mental Health Act Assessment. The jury
concluded that he would not have died when he did if he had been “sectioned”.

CIRCUMSTANCES OF THE DEATH.

An expert psychiatrist gave evidence, having considered his behaviour of
unprovoked stabbing of 2 boys, his delusions, hiding under a blanket in the police
station, his obsession with a police woman, his outburst in prison, and study of a
previous admission under mental health care that he suffered from De
Clerambault syndrome (erotomania) and was suffering psychosis. After arrest and

charged with attempted murder, the deceased had delusions and refused to drink
or eat for 48 hours with a stated intention to police officers that he would thus die
on the 3rd day. He was remanded to HMP Highdown, where he was segregated;
transferred to HMP Belmarsh 3 days later, where he was isolated in a single cell,
ot his protection, for 23 4% hours a day, where he hung himself after 17 days.

CORONER’S CONCERNS

During the course of the inquest, the evidence revealed a matter giving rise to
concern that in my opinion means that there is still a risk that future deaths will
occur unless action is taken. In the circumstances it is my statutory duty to report
0 you.

The MATTERS OF CONCERN are as follows.

. The expert psychiatrist gave an opinion that there was a defect in the system of
communications between professionals and agencies involved in the care of Mr
Walsh. There appeared to be not only serious failures of communication, but
failures from inadequate processes of communication between custodial and
health professionals, between police, court, health care and prison services, that
progressively lost crucial information about the risks and needs of the deceased as
he passed through different hands. The expert described what staff knew at HMP
Belmarsh as diluted and grossly distorted. Evidence heard is listed:

a) Those conducting the MHA assessment did not discover that, on the very
evening of the assessment, the police had been in contact with the deceased
mother, who had key information about his mental health, nor did examine the
custody record or log, nor consult the Detained Persons Medical Forms, which
one described as usually containing little useful information. The Custody
officers and MHA assessors never spoke.

b) The AMHP said that the Mental Health Act (MHA) assessment was put on
RIO system for Hampshire NHS staff, and could be made available to general
practice or prison healthcare on request, but was not automatically transferred.
There was a need for a national process of information sharing.

c) The Custody Advisor informs the court that the national system was that the
Detained Person’s Medical Forms (DPMFs) were routinely scanned onto the
police RMS system, but the Mental Health Act Assessment is not. The logic was
not apparent, as both would appear to have the same quality of confidence.

d) Medical in confidence information from police stations was sometimes
transmitted in sealed envelopes marked Confidential, travelling with the prisoner,
but the independent psychiatric expert thought that this was the least effective
form of communication and recommended that the assessing team should
communicate with the next stage in the process, such as contacting the catchment
area forensic service by phone out of hours, advising that the prisoner is likely to
go to a particular court, and writing a letter with the assessment in office hours.
The Police Custody Advisor said that he would not expect the Mental Health Act

Assessment report to routinely go to the court or prisons with the Prisoner Escort
Record (PER), unless the prisoner was sectioned. The logic for this was also not
clear, as the non sectioned patient was more at risk of not having appropriate
mental health care from non communication, than the sectioned one.

e) No report or letter or appropriate communication about the MHA assessment
was completed in the police station to subsequent health care providers, nor was
there a system to require it.

f) There was no evidence that the police doctor (FME) and police nurses notes,
called Detained Person’s Medical Forms (DPMFs) were ever seen by anyone with
responsibility for Mr Walsh in Highdown or Belmarsh prisons, nor evidence of
any established process of transfer of the information. Prison staff said that
medical in confidence information can be scanned to prison health care, but
there was not an established system of securing medical records from police
stations.

g) The Pre-Release risk assessment was completed by a custody officer, indicating
that the deceased had no risks. The Custody Advisor indicated that the officer
did not appear to understand the system, as this particular questionnaire in the
custody record should not have been completed for transfer to court. But it
appeared that its negative entries may have misled others assessing risk at time of
transfer.

h) The completion of the PER in the police station did not reflect the contents of
the custody record or custody log, failing to record his attempt to commit suicide
by dehydration, his delusions, his obsession, or that he had been assessed as high
tisk of suicide, The Custody Advisor said that the system was meant to be that
the PER was signed off by the custody officer, who should have known that the
information was incorrect.

i) The police staff completing the PER indicated she routinely did this without
consultation with the custody log or custody record, which was not required,
although the Custody Advisor informed the court that this was not meant to be
the system.

j) The care plan at the police station which was recorded in detail in the custody
record (and is meant to record any risks and evidence of mental illness) was not
sent onwards with the PER, nor was the section on the PER marked Care Plan
completed, as the Custody Advisor informed it should be. Staff informed the
court it never is.

k) Staff at the first night centre assessment at HMP Highdown saw the basic
information about his offence and recent history and the police national
computer printout with no markers, although a subsequent one was found with
markers, indicating a previous attempt in custody to hang himself in custody and
a threat to stab anyone who takes his children. There was no explanation for a
false negative being sent.

1) It is not clear if the nurse doing the health screen at HMP Highdown was
shown or looked at the PER from the police station.

m) It is not clear whether the nurse assessing health fitness for segregation in
HMP Highdown by completing a proforma, did consult the System One Medical
Records, but the nurse agreed that he had no information on the prisoner’s
behaviour and health in the police station, nor over the preceding four weeks,
which he needed, and that he expected the reception nurse to bring information
to him and it was not for him to go to Reception to get it.

n) The PER completed at HMP Highdown did not even reflect the limited
information they had received from the police station three days earlier. It
recorded no current health risks although the previous PER from the police
station had indicated non compliance with MHA assessment and depression, a
GP letter received reported a previous overdose in February and the decision had
been made in reception that he needed mental health in reach service. The

”»

health care officer just recorded “fit for transfer”.

0) The prison officer conducting the first night centre assessment in HMP
Belmatsh did not see or consider the PER from police station to HMP
Highdown, three days previously. He did know he had a serious charge coming
up for sentence and had no family support and was going to be isolated for 23 2
hours a day in a single cell. He did not know he was depressed and on
antidepressants, and if he had he would have opened an ACTT. Yet this
information was known to health care staff. He reports that the nurse told him of
no concerns and he told her of none.

p) It was not apparent that the first night nurse assessment in HMP Belmarsh
knew of ot included consideration of his status on a “duty care regime”, which
isolated him for his protection from other inmates. The nurse did not feel there
was time nor was it his job to review the medical records. He completed his
proforma recording what the prisoner replied, even though he had information
that it may be untrue and did not regard it was his job to record or reconcile
differences.

q) The reception GP assessment in HMP Belmarsh did not consider his status
isolated on a “duty care regime”, although agreed it was risk factor, nor had any
knowledge of his behaviour in the police station or see any relevant information
from PNomis or discipline staff.

t) The GP doing the GP assessment in HMP Belmarsh informed the court that
there was insufficient time in his job to review the inmate medical records. He
agreed that the records showed that suicide six risk factors listed in Early Days in
Custody were present - recent change in circumstance, transfer another
establishment, violent offence, history self harm and suicide, potentially category

Aand history of mental illness and drug or alcohol problems. He had neither
been informed of these factors nor identified them from the records and so
neither opened an ACCT nor referred him to a psychiatrist.

s) He was referred to the MH in-reach team by the nurse. That team reviewed his
medical records, showing a history of alcohol abuse and depression on treatment
(which did not apparently include any from the police station, which the
psychiatrist said he does not routinely see) and were reassured by his not being
followed up by a psychiatrist in the community after a previous psychiatric
admission, and by his presentation not raising any concerns for almost all the
doctors and nurses, who had seen him in prisons. They did not see any PERs,
and was not informed he was being isolated in a “duty of care regime “ for 23 4
hours a day, nor that the victims were children. The decision not to conduct a
psychiatric assessment would have been different if he had seen the PERs or
DPMFs or MHA assessment, or his in patient psychiatric notes.

t) The independent psychiatrist gave an opinion that the loss of key information
was a particular concern as people move in and out of custody so that there was a
potential that information would be lost to the civilian GP.

Whilst some organizations had taken a number of steps to minimize the risks to
the lives of others, particular the development of a national PER, others had only
awoken to the risks in the closing days of the inquest. Virgin Health Care chose
not to attend, Southern Health and Oxleas NHS Trust submitted plans to prevent
future deaths before the inquest concluded. Hampshire Constabulary reported
changes in training and staff awareness. Hampshire County Council prepared a
short document of proposed actions, but it was not available as evidence as it was
received by the court after the conclusion of the evidence. The evidence taken as a
whole, suggested that there was a breakdown of communication at every
professional and organizational interface, 18 of which are illustrated above. There
was no agreed system for transfer of health care information from police station
court, or from either to prison. There was no functioning and consistent system of
passing risk information from one detained organization to another. There was
not agreement whether there just was a duty to pass the information or it if it was
not in possession, whether there was also one to ask for it and if so which
individual bore that responsibility. There appeared to be a focus by individuals on
completing the proforma or questionnaire required by the system, by rote with
either no time to consider the whole person, or no sense that it was their
responsibility to consider missing or discordant information or to be proactive in
communicating gaps in knowledge or concerns. From the evidence of a number of
witnesses, the pattern of communication was not exceptional in this instance but
reflected what usually happened.

2. That the standard of Mental Health Act assessments by these individuals needs
to be improved, and, given all three were in complete agreement, that also training
and provision for MHA assessments in police stations more widely may need to be

reviewed.

3. That the inadequacy of the nurse assessment of fitness for segregation in HMP
Highdown (see m) above) is a risk. a «.: not ACCT trained and it
appeared that he was unaware of PSI 1700. The inadequacy may reflect individual
or wider weaknesses in assessment or choice of assessors that mean that prisoners
go to segregation when they should be in the health care wing, or that they go
without observation, when they should be on an ACCT and receive extra support.

6

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths. I believe that the
following organizations or individuals have the power to take such action.

1. The Secretaries of State of Home Office, Health and Ministry of Justice are
notified of Matter no.1, the apparent defects in the system of communication.
They are asked to consider not only the adequacy of the instant organization’s
response, but whether there is a need to consider the risks are more appropriately
addressed nationally.

2. In view of the conclusion of the jury with regard to neglect, the following are
notified of Matter no. 2 about the adequacy and safety of MHA assessments.

y © | are asked to consider whether they should
refer themselves to their professional body, as has their colleague,

b) The Department of Health is also asked to draw to the attention of those
leading the Departmental Training programme for AMHPs the circumstances and
findings of this inquest and consider whether further guidance or training with
regard to the performance of Mental Health Act Assessments is required.

3. Virgin Health Care is notified of Matter no. 3, the weaknesses and lack of
training admitted by their nurse in conducting the fitness for segregation
assessment and asked to consider whether the process is fit for purpose or whether
redesign or further training is indicated.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this
report, namely by Tuesday December 20" 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.

If you require any further information or assistance about the case, please contact

the case officer, an

COPIES and PUBLICATION

Lhave sent a copy of my report to the following Interested Persons:

of Hickman and Rose Solicitors for the family, Government Legal for
HMP Belmarsh, Capsticks Solicitors for Oxleas, Thompsons Solicitors for Prison
Officers Association, Virgin Health Care, Hampshire Police, DAC
Beachcroft for and Stephen Fidler Solicitors for|
Medical Protection Society.

I have also sent it to The Royal College of Psychiatrists ~~ |

independent psychiatric expert, who may find it useful or of interest. The court is
happy to provide further documentation to the College or to Ministers, if it would
assist in their deliberations.

I am also under a duty to send a copy to the Chief Coroner as well as 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.

[DATE] [SIGNED BY CORON
7s ~- (0-l6 fi

+

Responses

4 responses 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.

Response from Department of Health (PDF)

From Nicola Blackwood MP
Parliamentary Under Secretary of State for Public Health and Innovation

Department
of Health sono Whitehall
SWiA DNS

Dr Andrew Harris

HM Senior Coroner — Inner London South
Southward Coroner’s Court

1 Tennis Street

London

SE1 1TD

Dy RY Maw 10 January 2017

Thank you for your letter to Secretary of State about the death of Richard Walsh. | am
responding as the Minister with responsibility for mental health policy at the Department of
Health (DH).

020 7210 4850

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

Mr Walsh committed suicide while an inmate at HMP Belmarsh. The Coroner has detailed
Mr Walsh's experiences while detained the police station and two prisons, finding a
number of failures. The inquest jury found that he would not have died had he been
‘sectioned’.

| note that your report has also been sent to Ministry of Justice, Home Office and local

healthcare providers for response. | am writing regarding the concern specificall
addressed to DH around Appropriate Mental Health Professional —

You wrote that ‘..the inadequacy of the nurse assessment of fitness for segregation in
HMP Highdown is a ‘i_— was not ACCT trained and it appeared that he

was unaware of PS! 1700. The inadequacy may reflect individual of wider weakness in
assessment or choice of assessors that mean that prisoners go to segregation when they
should be in the heaith care wing, or that they go without observation, when they should
be on an ACCT and receive extra support.’

You asked that the inquest findings be brought to the attention of those who lead the
‘Departmental training programme’ for Approved Mental Healthcare Practitioners (AMHPs)
and consideration be given as to whether further guidance or training regarding Mental
Health Act Assessments is required.

Responsibility for approving and monitoring AMHP programmes offered by Higher
Education Institutions in England (HEIs) is held by the Health and Care Professions
Council (HCPC).

The HCPC is an independent, UK-wide regulatory body which has responsibility for
approving and monitoring AMHP programmes offered by HEIs in England. They have

published criteria, that set out its expectations of educational providers and individuals
completing these programmes.

To explain, to be approved to act as an Approved Mental Health Professional by a local
social services authority, AMHPs must have undertaken an accredited training course
provided at a higher education institution , and on completion of that course, be able to
demonstrate competence to practise in the role. Schedule 2 of the Mental Health
(Approved Mental Health Professionals) (Approval) (England) Regulations 2008 sets out
the competences of an AMHP required by law.

There is a statutory requirement that the AMHP is approved each year. To achieve this,
the AMHP must complete at least 18 hours of training agreed with the approving Social
Services Authority as being relevant to their role as an AMHP as stated in the Regulations

[5(a)].

The criteria for approving AMHP programmes are designed to equip individuals with the
threshold skills necessary to engage in safe and effective practice. They set out the
processes and procedures that education providers delivering AMHP training must have in
place, and the knowledge, understanding and skills that an individual must have when they
complete their AMHP training, including the necessary knowledge and skills to undertake
formal Mental Health Act Assessments.

As requested, | have brought your report to the attention of the HCPC and asked them to
respond to you directly.

| hope that this information is useful. Thank you for bringing the circumstances of Mr

Walsh’s death to our attention.
4 Ans hardy

NICOLA BLACKWOOD

Response from Hampshire County Council (PDF)

Hampshire County Council & Portsmouth City Council

Response to the PFD (Prevent Future Deaths) Coroners report touching the death of
Richard Walsh

Date of Death: 19/07/2015
Case Number:-01936-2015

1.0

Introduction

1.1

This response is being provided on behalf of Hampshire County Council (HCC) as
the Approved
the responsible Local Authority which employed
Mental Health Professional (AMHP) involved in the Mental Health Act assessment of
Mr Richard Walsh conducted on the 27th June 2016.

This response is also being supported by Portsmouth City Council (PCC) as the
current employer of
in the local health and social care system in Hampshire.

in his role as AMHP and as a key agency involved

1.2

1.3

HCC and PCC share an equal commitment to address the serious concerns raised
by the Coroner and the findings of the Inquest Jury in relation to the tragic death of
Mr Richard Walsh. Having reviewed the PFD report, HCC and PCC have considered
the role of the local authority in the circumstances of their statutory responsibilities for
providing an AMHP to carry out an assessment under s13 Mental Health Act 1983
with specific reference to persons in Police Custody.

This response is structured in light of the review of the PFD report which references
specific concerns regarding AMHP practice, Information Management, the standard
of MHA assessments (in Police Custody), training and development of AMHPs,
professional registration of
and nationally, stemming from this incident.

and the wider systemic learning both locally

2.0

AMHP Professional Practice

2.1

Communication with Relatives & ‘Nearest Relatives’ as defined under s26 Mental
Health Act 1983

In light of evidence made available at the Inquest, a matter of concern has been
raised in the PFD report regarding communication between those conducting the
assessment and the patient’s relatives.

The Mental Health Act (s26) is prescriptive about the identification and statutory role
of the Nearest Relative of the patient as a means of providing a safeguard within the
Mental Health Act assessment process. The AMHP role in turn, is governed by a set
of duties under Statute to ensure that the Nearest Relative is properly consulted and
included in the process as required. Duties toward the role of ‘relatives’ is informed
by s13(1A) (b) requiring the AMHP have regard ‘to any wishes expressed by relatives

of the patient’. Best practice is also informed by principles of the Mental Health Act
Code of Practice for the AMHP role.

Due to the findings of the Inquest concerning the assessment conducted with Mr
Walsh, HCC/ PCC will be developing AMHP practice guidance to support decision
making for when a relative needs to be consulted about someone presenting in the
Police Custody environment. Such AMHP guidance will highlight the necessity for
such consultation on the grounds of the gravity of the presenting facts, the nature of
the offence, the history of the individual, the availability and suitability of the relative,
the views of the person subject to assessment and other relevant criteria.

2.2

Examination of the Custody Log and/or police station records

The Coroner has highlighted the fact that the MHA assessors did not directly
examine the custody record or log.

HCC/ PCC fully support the requirement that AMHPs need to directly scrutinise the
Police Custody record and not rely solely on verbal feedback from Police staff.

HCC/ PCC will be publishing guidance to AMHP staff referencing this requirement.

2.3

Consultation and consideration of the ‘patient’ medical forms

The Coroner has highlighted the fact that the MHA assessors did not directly
examine the ‘Detained Persons Medical Forms’.

HCC/ PCC fully support the requirement that AMHPs need to directly scrutinise the
‘Detained Persons Medical Forms’ and not rely solely on verbal feedback from Police
staff.

HCC/ PCC will be publishing guidance to AMHP staff referencing this practice
requirement.

2.4

Accessing information from Police Custody Officers

The Coroner has highlighted that the Custody Officers and the MHA assessors never
spoke.

HCC/ PCC concur that the AMHP needs to speak directly with the Police Custody
Officer as a priority when carrying out each assessment in a Police Custody Centre.

HCC/ PCC will publish guidance to AMHP staff referencing this requirement following
further liaison with Hampshire Constabulary.

3.0 Management of information related to the MHA assessment process

3.1

Sharing AMHP reports with Prison healthcare and/ or GP practice

The Coroner report has highlighted the need for a national process for information
sharing in view of the role, in this case, of general practice and/ or prison healthcare.

Local services across Hampshire record information about people using services on
a variety of different systems regulated by Information Governance policies. HCC/
PCC would concur that the sharing of such sensitive information will be necessary in
the specific ongoing provision of care and support of vulnerable persons involved in
the criminal justice system.

HCC/ PCC will provide a clear set of practice guidance to ensure that AMHPs are
able to provide relevant information ‘in confidence’ to GP practice/ prison healthcare
regarding people who have been subject to MHA assessment in Police Custody.

3.2

Sharing AMHP reports with Police

The Coroner report raised concern where there was no report or letter or appropriate
communication about the MHA assessment completed in the Police Station to
subsequent health care providers. The Coroner further stated concern in regard to
the availability of relevant information for the purposes of the Prisoner Escort Record
(PER).

HCC/ PCC will be working with local NHS Provider Trusts and Hampshire
Constabulary to review information sharing with the Police following joint assessment
in Police Custody.

In November 2016 HCC/ PCC have introduced a requirement for AMHPs to receive a
written medical report from the assessing Doctors in circumstances where their
assessment has not led to the provision of medical recommendations supporting
application for detention under Part 2 Mental Health Act 1983. The completion of this
report will evidence the rationale for clinical decision making and corresponding
AMHP decision making (see Appendix One).

4.0 Maintaining and improving standards of MHA assessments by practitioners in

Police Custody

The standard of mental health act assessments is brought into question by the
Coroner in light of the findings from this inquest. Certainly the conduct of each of the
practitioners involved in this case is referred to separately.

HCC/ PCC recognise that a robust governance framework is required to provide
greater assurance and transparency to the public whereby decisions are taken by
AMHPs when assessing persons under the Mental Health Act whilst in Police
Custody. Such a framework will include the monitoring of MHA outcomes for
persons arrested for an offence in need of a MHA assessment, information sharing –

both to inform decision making and outcomes for the benefit of other agencies,
communication with relatives/ carers, AMHP training records specific to assessments
for people arrested for an offence.

5.0

Training and Professional Development for AMHP staff when dealing with
assessments in Police Custody

The Coroner has raised concern about the availability and provision of AMHP training
on MHA assessments in police stations.

In light of the findings of this inquest, HCC/ PCC will be reviewing the current
professional development opportunities for AMHP staff in order to ensure the
standard of practice when assessing persons in Police Custody is consistent and in
line with best practice.

The findings of this report will also be shared with AMHP training providers, the
Health and Social Care Professionals Council (HCPC) and other relevant
professional training bodies to ensure that AMHP training and refresher training
includes the learning from this report.

6.0

Professional Regulatory review of

Following the tragic circumstances of this event,
Portsmouth City Council as his employer, can confirm that his professional practice
as a registered social worker was referred to the Health and Care Professionals
Council (HCPC) on the 03/10/2016.

and

HCPC requested information connected to the case and Portsmouth City Council has
provided them with the following documents:

1.
2.
3.
4.

The Jury's Narrative Verdict
The Coroner's Report
The Prisons and Probation Ombudsman's report into the death of RW
The independent social work report commissioned by Hampshire County
and dated the 16th of September.
Council written by
A report from a senior manager at Portsmouth City Council regarding

current practice.

HCPC have reviewed these documents and have decided that they will not be
holding a fitness to practice hearing. They will be taking no further action and the
case will be closed.

In addition to the above,
of the re-registration process to provide evidence of his continuous professional
development.
registration being confirmed.

has provided a portfolio of evidence and this resulted in his re-

was randomly selected by HCPC, as part

PCC have audited
standard. This practice is undertaken routinely within the Portsmouth AMHP service
and will continue for all AMHPs. The manager of the service has been satisfied that

assessments to ensure they are of a good

work is of a high standard.

7.0

Systemic learning

The PFD report highlights the range of organisations involved in the experience of Mr
Walsh and his family through the course of his dealings with the criminal justice
system.

HCC/ PCC will be seeking to work alongside the relevant agencies in respect to their
key responsibilities under the Mental Health Act 1983, specifically in relation to their
duties to make arrangements for providing an AMHP to consider a ‘patients’ case.

HCC/ PCC will be seeking to share the learning from this case with relevant agencies
to improve practice of the AMHP when assessing persons in police custody.

8.0

Summary

The inquest into the death of Mr Richard Walsh has highlighted the very sad
circumstances which led to his death by suicide on 19th July 2015. The Coroner has
raised a number of concerns about the role of the AMHP and both psychiatrists in
this case citing Neglect on four counts.

HCC and PCC are committed to learn from this tragic experience in light of the
findings of the Coroner.

Head of Mental Health and Substance Misuse

Signature:-

Response from Health Care Professions Council (PDF)

health & care |
C C professions
council |

Park House tel +44 (0)800 500 6184

184 Kennington Park Road fax +44 (0)20 7820 9684

London SE11 4BU www.hepc-uk.org

Dr Andrew Harris Chief Executive and Registrar: Marc Seale

Senior Coroner for Inner South District Greater London
Southwark Coroner's Court

1 Tennis Street

London, SE1 1YD

Dee Hew

PFD (Prevent Future Deaths) report touching the death of Richard Walsh
Date of death: 19/07/2015

13 February 2017

| am writing in connection with the above report. Nicola Blackwood MP wrote to me
in January 2017 in connection with your request that the findings of your report be
brought to the attention of those who lead the ‘Departmental training programme’ for
Approved Mental Health Practitioners (AMHPs). We understand that Ms Blackwood
advised you that she had brought this matter to our attention. /

We have given careful consideration to the findings of your report. We have a
statutory responsibility to set criteria for initial Approved Mental Health Professional
(AMHP) training and to approve training programmes. Having reviewed the criteria
that we first published in 2013, we are confident that they continue to set out
appropriate requirements for qualifying training, including requirements for those
completing training to have acquired necessary skills in carrying out mental health
assessments. However, as we only assumed responsibility for approving AMHP
training in 2012, we are cognisant that the nurse involved in this case may well have
undertaken training assessed against different requirements.

tam also mindful that our responsibility for AMHP training is due to become the
responsibility of a new regulator, Social Work England, in 2018. We will ensure that
the new regulator is aware of this report and our correspondence.

Successful completion of an approved programme only makes an individual eligible
to be approved to act as an AMHP. Under The Mental Health (Approved Mental
Health Professionals) (Approval) (England) (England) Regulations 2008 approval to
act as an AMHP rests with a Local Social Services Authority (LSSA) in

England. The LSSA also has responsibility under the regulations for ensuring that
the AMHPs they approve receive at least 18 hours of training per year relevant to
their role. This is likely to be the most effective means of addressing the specific

issues that you raise in your report. | have copied this letter to Nicole Blackwood MP
to suggest that bringing your report to the attention of LSSA’s in the context of their
ongoing training obligations might be an effective way of drawing attention to the
issues that you raise.

| hope this letter is helpful. Please do contact me if we can assist in any way in the
future.

RH 4

Marc Seale
Chief Executive and Registrar

cc. Nicola Blackwood MP

Response from Virgin Care Limited (PDF)

INHS'

Virgin Care Services Limited

Lynton House

7-12 Tavistock Square

London

Dr Andrew Harris, HM Senior Coroner WC1H 9LT

Southwark Coroner’s Office
Tennis Street

London
SE1 1YD wt www.virgincare.co.uk

19 December 2016

virgine

£: 0845 504 0694

Dear Sir
Inquest touching the death of Richard Walsh

We are providing this letter in response to the Coroner's Regulation 28 Report to Prevent Future
Deaths (“Regulation 28 Report”) issued pursuant to Regulation 28 and 29 of the Coroner's
(Investigations) Regulations 2013 dated 25 October 2016.

Within the Regulation 28 Report, we note the Coroner states that “Virgin Health Care chose not to
attend”. From the outset we would like to clarify that Virgin Care Services Limited (“Virgin Care”) did in
fact attend the Pre-Inquest hearing which took place on 16 August 2016 and it was recognised that
the deceased was remanded within HMP High Down for 3 days, where Virgin Care provide some but
not all of the healthcare services. Legal Counsel made submissions that, given Virgin Care's limited
involvement, witnesses could attend,the Inquest to provide evidence, but that there was no
requirement for Virgin Care to be listed'as an Interested Party in this matter, saving both healthcare
time and costs. The Coroner agreed with this approach. Subsequently, two witnesses attended the
Inquest on behalf of Virgin Care on the requisite days of the 3 week Inquest and gave evidence.

As a result of the Regulation 28 Report, the Coroner has requested that Virgin Care provide their
response to Matter 3 in respect of the Coroner’s Concerns:

“ I acy of the nurse assessment of fitness for segregation in HMP High Down is a risk.
mili not ACCT trained and it appeared that he was unaware of PSI 1700. The
inaaequacy may reflect individual or wider weaknesses in assessment or choice of accessors that
mean prisoners go to segregation when they should be in the health care wing, or that they go without

observation, when they should be on an ACCT and receive extra support’.

Virgin Care has been “asked to consider whether the process is fit for purpose or whether redesign or
further training is indicated”. We respond as follows:

Response

The Coroner has recognised that the Nurse involved in this Inquest was not ACCT trained and
unaware of PS] 1700. We accept the Coroner's recognition of events and can advise as follows. We
attach as Appendix A a copy of the “Induction Checklist” for HMP.High Down healthcare colleagues.
This protocol sets out the induction programme which all healthcare colleagues are required to
complete whilst they are supernumerary. This relates to a four week period where they work
supervised at all times and so are not considered within staffing numbers for off duty purposes. Pages

Virgin Care

Date: 19/12/2016 v1.0

NHS’

VIFTQIn:

one to three inclusive of the protocol set out a timetable for the expected timeframe for different areas .
of learning to be covered. The items on page three are expected to be completed within the first.

month of an individual commencing work at HMP High Down. Item 15 on page three of the induction
checklist is “ACCT Awareness”. This is current practice and was at the time of the death of Mr Walsh.
The induction process had been redrafted prior to the death but after EM had started and
therefore the Nurse accurately reflected in his evidence that he had not received this ACCT training
within his induction.

HMP High Down prison colleagues are responsible for the formal training of all colleagues (including
those in healthcare) in the ACCT Awareness process. During induction, an overview of the ACCT
process is provided and colleagues are made clear the expectations of healthcare staff as part of the
ACC process. Within this training session, the importance of the ACCT process is conveyed and the
attendance of Virgin Care colleagues attending the formal training — provided by the prison — is
emphasised.

Following the induction ACCT awareness training, colleagues are required to sign to say they are
satisfied that they have received satisfactory ACCT awareness training; their line manager is also
required to sign to say they are confident the new colleague.is capable of applying their training and
has understood.

In addition, on completion of their induction, arrangements are made for healthcare colleagues to sit
in as an observer with experienced members of staff at an ACCT review meeting. This will ensure

that new members of staff will not be required to take part in an A il they have seen
how the review meetings procéed.
adit hdc lnaabahaes Jade sete

Since the induction pack was introduced “Seg Algorithms” or alternatively “Fitness for Segregation”
forms are also part of the Virgin Care Induction pack for healthcare colleagues at HMP High Down.
During induction these are scrutinised between staff and their line manager. At the conclusion of the
training, the member of staff will sign, and thereby declare, that they have received relevant training
before their induction is completed and they are able to work independently. As part of the training
Virgin Care healthcare colleagues undergo scenario-based_training to allow them to practice
completing and signing “Fitness for Segregation” forms. An example of the form is attached at
Appendix B.

Again, this is confirmed by the line manager signing to say they are confident that the new colleague
has understood and has demonstrated their competence during the scenario-based training.

The Coroner considered at the Inquest that that the Fitness for Segregation form was not completed
accurately by Po in the case of Richard Walsh. However, having reviewed the
documentation as part of our response to the inquest, we consider that a had
completed this form correctly and the information he had at his disposal meant that this gentleman
was fit for segregation. The patient was further reviewed by another nurse who also deemed him fit
for segregation NM appears to have been led to doubt himself at the inquest.

Since the Inquest, Virgin Care has arranged additional ACCT awareness training with the WMP High
Rown’s Safer Custody department to ensure all current healthcare colleagues receive training in the
next few weeks and this will be completed by the end of January 2017. Once all colleagues have
received initial or refresher training, this will be monitored on the colleague training log and relevant
line managers will ensure all staff are given refresher training at least annually.

Virgin Care

Date: 19/12/2016 v1.0

INHS'

Until recently, the prison did not facilitate annual training but they have this year agreed to provide this
and all colleagues will, therefore, complete an annual refresher. We attach as Appendix C a copy of
the “Statutory and Mandatory refresher/update training — [month/year]” from which it will be seen that
‘ACCT — self harm and suicide prevention training’ will be carried out annually.

To further embed the requirement for ACCT awareness, any new member of staff who has joined the
Virgin Care healthcare team at HMP High Down will complete the induction process and thereafter
there is a requirement to complete annual ACCT training, which forms part of the appraisal review
process. At each appraisal, the training matrix is reviewed to ensure colleagues’ training is up to
date. It is the responsibility of the Head of Healthcare and the Deputy Head of Healthcare to ensure
that the matrix is updated as and when each member of staff completes the required training.

Virgin Care is therefore confident that we now have in place a robust process for ensuring that
colleagues have completed the appropriate ACCT awareness training and are aware of PSI 1700
when they commence work at HMP High Down, and that they complete annual refresher training in
these areas. Virgin Care is also confident that the training scheme in place gives colleagues
appropriate training regarding the ACCT process.

Although we are confident that in this case the Fitness for Segregation form was completed correctly,
we have also implemented an auditing process to further assure ourselves of this (see Appendix D).
Our Lead Nurses within the prison will now carry out four audits throughout each year ensuring that
these forms have been filled out adequately, that an appropriate entry is made on the clinical system
(SystmOne), an appropriate eniry is made on the prisoner's history sheet and, where appropriate, an
entry on the ACCT document is also made. Any material errors should therefore be picked up and,
where appropriate, will be addressed at management supervision sessions, with additional training to
ensure their competency.

In conclusion, Virgin Care welcomes the constructive comments made by the Coroner in his
Regulation 28 Report. The contents of the report have been considered carefully, and Virgin Care
has instituted changes to our procedures to ensure robust processes are in place to address the
concerns raised by the Coroner.

Should the Coroner have any queries once he has had an opportunity to consider this letter and the
attached documentation, he should not hesitate to contact us.

Yours faithfully

General Counsel and Company Secretary
For and on behalf of Virgin Care Services Limited

Virgin Care
w:

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