Matthew Russell

Central and North West London NHS

NHS Foundation Trust

Executive Office
Tel: 020 3214 5760
Fax: 020 3214 5761

26 January 2017

Mr Richard Travers

HM Senior Coroner for Surrey
HM Coroner's Court

Station Approach

Woking GU22 7AP

Dear Mr Travers,

Regulation 28 Report to Prevent Further Deaths following the Inquest of
Mr Matthew Russell dated 27 November 2016

We write in response to your letter dated 2 December 2016 enclosing the Regulation
28 Report issued following the inquest into the death of Mr Matthew Russell.

Central and North West London NHS Foundation Trust (CNWL) deeply regrets the
death of Mr Russell and the distress this has undoubtedly caused his family. While
Mr Russell did not die while in the care of CNWL, CNWL recognises the issues
raised by the death of Mr Russell and the increasing number of deaths nationally.
Our aim in responding to Regulation 28 and other deaths in custody nationally is to
proactively contribute to multi-agency initiatives that reduce the likelihood of further

deaths occurring.

The matters of concern raised in the Regulation 28 report are set out below in bold
followed by details of the action taken by CNWL and the actions we are proposing to

take within the next 12 weeks.

CNWL were awarded the contract to provide Mental Health In-Reach services in
HMP Highdown in May 2015, one month after the death of Mr Russell. Since this
time, we have continuously striven to improve the quality of services to patients, to
increase the range of services available to patients with mental health problems.
CNWL are consistently working with partners (who are separately contracted by
commissioners) to deliver integrated care for patients with mental health problems.

a. The proper and regular monitoring of anti-depressant medication that is
prescribed by way of a repeat prescription

Approach to managing anti-depressant medication

Many patients entering HMP Highdown will already be in receipt of anti-depressant
medication. Nearly all this medication will have been prescribed by their GP or from

Trust Headquarters, Stephenson House, 75 Hampstead Road, London NW1 2PL
Talanhone: 020 3214 5700 www.cnwl.nhs.uk

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© for life

London * Milton Keynes | Kent | Surrey | Hampshire

healthcare services in the transferring prison. The current primary care provider is
Virgin Care until 31 March 2017, at which point the primary care service will transfer
to CNWL. As part of the current mobilization, CNWL will make contact with the
community prescriber to both confirm the prescription and to clarify the treatment
plan. Very frequently patients will have been in receipt of this medication for many

years.

In September 2016 CNWL undertook a review of patients on anti-depressants in
HMP Highdown. The audit identified that on the 24 September 2016 there were 229
patients on prescriptions for anti-depressants. This represented nearly 23% of the
prison population. The current national rate for anti-depressants in primary care in
the community is circa 8%. Mirtazapine was the most commonly prescribed anti-
depressant. Mirtazapine has sedative properties and there was evidence from
medical records that prisoners commencing on this drug often requested it by name.
There was evidence from the audit that many patients reported feeling depressed
and anxious as a result of being in prison and reflecting on their current situation.
This would suggest that access to psychological therapies and support would
enhance outcome rather than longer term pharmacological interventions and first line
medications such as mirtazapine because of the sedative properties that can

reinforce dependence.

The audit clearly identified the need to consider interventions that addressed
insomnia, which appeared to be a key factor in prescribing sedating anti-
depressants. The review also questioned the efficacy of the PHQ9 (PHQ-9 is a
multipurpose instrument for screening, diagnosing, monitoring and measuring the
severity of depression) in the diagnosis of depression within the prison setting.
Whilst CNWL recognises the principle of equivalence with community services where
patients on anti-depressants are rarely referred to specialist mental health services,
we aim to go beyond equivalence, recognising the complex needs of our patient
group and the risks of imprisonment on mental health and wellbeing. CNWL is
contracted and works within a stepped model of care. We are currently auditing our
services against the new NICE guidelines for mental health services within prisons
and the NICE guidelines for Anxiety and Depression. This audit will be used to
identify gaps in provision and inform a review of the CNWL Mental Health pathway.
The CNWL Mental Health In-Reach Team provides a full range of services including:

Consultation and support for the prison and other agencies in understanding
and managing mental health problems.
e Integrated and interagency working in the trea

Diagnosis and multi-morbidity.
Case management of patients referred to the mental health team
Access to a range of therapies including CBT, psycho-education and groups

for managing anxiety and depression.

tment and management of Dual

Managing repeat prescribing

or ensuring that a treatment plan is in place for the
nti-depressant medication. In HMP Highdown we

rescribers with the clear understanding that the
f compliance and

The prescriber is responsible f
ongoing monitoring of repeat a
work in conjunction with other p
prescriber is responsible for ensuring the ongoing monitoring o

effectiveness of medication, including side effects (GPs and CNWL Psychiatrists/
NMP). This is supported through:

e In-line with community equivalence the GP would continue with repeat
prescribing but would ensure the treatment plan assures them that the patient
is in receipt of the appropriate level of supervision via primary care services.
However, should the GP have any concerns around ongoing monitoring or
psychological interventions, in-line with community equivalence, they are able
to refer the patient to CNWL Mental Health services through the Single Point
of Contact (SPOC) giving access to specialist assessment and access to a

range of psychological therapies.

e In-possession risk assessments to ensure patients can safely manage their
own medication and that side effects are not a significant risk (includes risk of
non-compliance and risk of diversion which is a significant risk in mood

altering medication).

e Medication Use Reviews by Pharmacy staff (provided by Virgin Healthcare).
e Review by a Mental Health nurse if the patient is on their caseload.

e Patients on the Mental Health caseload are reviewed through the weekly Case
Review Meeting. Minutes of the case review meeting are provided to GPs and
any risk or change in care and management plan recorded on SystmOne to
ensure a full a multi-disciplinary approach to care.

e Primary care nurses administer medication either daily or though in-
possession medication and are able to monitor self-reported side effecis by
patients, poor compliance or concerns over patients not attending, which is
recorded on SystmOne. CNWL will liaise with Virgin Healthcare and Achor
healthcare to ensure this is a standing agenda item on the Medicines

Management group.

e All CNWL Mental Health staff receive security training as part of their induction
from the prison and as part of key training. This includes reporting concerns

over diversion of medication.

e Increased access to psychological therapies is a key strategy in the
management and treatment of anxiety and depression. Ongoing use of anti-
depressants can be addressed in a patients care plan in Psycho-education
groups and CBT therapies may touch on the use of medication in the
treatment of anxiety and depression. However, these interventions enhance
the required monitoring and do not replace them. A Standard Operating
Procedure is in place to support GPs in the referral of patients to the service.
The Mental Health Team is currently finalising marketing material for staff and
patients on the range of services available and referral criteria.

Any prisoner who has had an antidepressant commenced by the CNWL psychiatrist
will have had a comprehensive mental health assessment recorded on SystmOne.
In-line with community equivalence, it would be usual practice for the patient's

mary care. However, if the patient presents with

rist/MH Non-Medical Prescriber will continue to
ger and

prescribing to be referred back to Pri
complexity and high risk, the Psychiat
prescribe. Any patient on the mental health caseload will have a case mana
will undergo further review by the Consultant Psychiatrist 4-2 weeks after prescribing
is commenced. Once stabilised, the case management transfers from the Consultant
Psychiatrist to the mental health nursing staff within the team who continue to
monitor the patient and will refer back to the Consultant Psychiatrist if there are any

issues, side effects or compliance concerns.

It is routine at all appointments/reviews that the nursing staff discuss both the current
mental state and the ongoing use of medication including side effects, reduction and
compliance with the patient. Where there are concerns identified, these are then
raised with the Consultant Psychiatrist and a further medical review arranged.

The multi-agency Medicines Management group (led by Virgin healthcare) meeis bi-
monthly. Prescribing trends and issues concerning medication are standing items.
The CNWL Psychiatrist and GPs are routinely invited to the Multi-disciplinary
meeting. Minutes of the meeting are circulated to all agencies. Any actions are
recorded on SystmOne and via the task function on SystmOne. Any immediate
concerns would be communicated directly to the GP by a member of the Mental

Health team.

CNWL have recently undertaken a full review of anti-depressant prescribing from
SystmOne records. This included a review of the number of patients entering the
prison on prescriptions. This review was undertaken by the lead Consultant
Psychiatrist responsible for HMP Highdown. As a result of the review, a paper was
provided to Commissioners and GPs, which will discussed via the commissioning
process and the next Partnership Board. The review identified capacity issues within
the Mental Health team due to the very high numbers of patients who are either
historically prescribed in the community, or for whom prescribing commenced in

either HMP Highdown or other prisons.

CNWL are currently reviewing our Standard Operating Procedure for working
effectively with Primary care in managing dual diagnosis and co-morbidity via the
Care Quality Management Meeting, and is due for review in February 2017 and

ratification by the Clinical Director in April 2017.
b. The preparation of structured care plans for each patient.

All care is delivered in line with the service specification and CNWL mental health
pathway and local process map and care pathway. In HMP Highdown, the Mental
Health team leads the Multi-disciplinary meeting chaired by the Consultant
Psychiatrist. GPs are invited to attend this meeting. As a secondary mental health
service, the focus is on patients with severe and enduring mental illness, and those
with dual diagnosis and complex co-morbidity. As above, the minutes are circulated
to GPs and outcome recorded on SystmOne, clearly identifying inter-agency

management issues and risk.

element of the new CNWL model in the Surrey prisons is based on Medicines

A key
y services focused on delivering individual

Optimisation for all patients, with pharmac’

medication reviews that in turn informs individualised care planning. Our new
Behavioural health model emphasizes building healthy behaviours that, where
appropriate, reduce reliance on medications of dependence by a range of
psychologically informed interventions that support pharmacological interventions.
The Offender Care Psychosocial Strategy will be launched in March 2017.

CNWL recognises that patients with depression who are traditionally managed in
primary care are not fully reviewed in this meeting, as the secondary mental heaith
care team does not have the capacity to do so. However, a full business plan is being
developed by Prison GPs in consultation with [MIC NWL Consultant
Psychiatrist, to be submitted to NHSE to enable the team to take on the ongoing
management of patients with anxiety and depression.

A Care Plan audit was undertaken in October 2016. The audit identified that 100% of
patients on the In-reach caseload had care plans in place. The team is monitored on
a monthly basis on:

© 100% of urgent mental health referrals seen within 24 hours
e 100% of patients receive CPA review every 6 months

HMP Highdown has been fully compliant with these CNWL key performance
indicators (KPI) for the past 12 months. This data is monitored at Directorate,
Divisional and Trust level. Local managers are required to provide exception reports
on any breaches and to provide corrective action plans.

However, as identified above, the majority of patients in receipt of anti-depressants
would be unlikely to meet these thresholds.

All staff in HMP Highdown underwent Best Practice Care Plan training in November
2016.

c. Aneffective procedure for following up patients who fail to attend pre-
booked appointments.

The CNWL In-Reach Team has a DNA (Did Not Attend) Standard Operating
Procedure in place which has been shared and discussed with all staff members.

CNWL is an experienced provider of healthcare in prisons and recognises there are a
number of factors that may lead to a patient not attending an appointment.

A member of the team will meet with patients who fail to attend any Mental Health
Inreach appointment that day to establish the reason for non-attendance. This now
forms part of the daily function of the team. Where there are any concerns or risks
identified, they will be seen by a member of the Inreach Team for a more detailed
review that day. Where there are no immediate risks or concerns, a further
appointment will be made and at that appointment the previous non-attendance will

be discussed.

DNA rates are monitored and reported via the Contract monitoring process and the
local team level.

DNA rates are also discussed in the Partnership Board, themes identified, multi-
agency responses identified and action planned.

The Mental Health Inreach service has a Standard Operating Procedure in place for
managing patients who DNA therapies appointments.

d. The effective use of Read codes on System One record, to flag up and
highlight significant risk factors in patient care.

SystmOne is a national system used across all prisons. Whilst it is a national system
with national templates, it is possible for all agencies within the local healthcare
system to customise and develop or alter specific areas of functionality. CNWL
recognises that as a result of customization by the lead provider, staff locally, appear
not to have been fully aware of how a partner agency was utilising the system on a

daily basis.

CNWL recognises the need for improved interagency co-operation and
communication in the local use of SystmOne. All CNWL staff using SystmOne upon
login are taken to the patienthomepage which includes an “exclamation mark icon’.
This icon identifies that a patient is of high risk of self-harm, open ACCTs, suicide risk
and any other significant risk areas that staff need to be aware of. All CNWL staff will
receive refresher training by the end of February 2017 to ensure they know how to
set this icon up on the client record should the need arise.

CNWL will raise this as an ongoing area of risk and opportunity in the multi-agency
Partnership Board in February 2017 and ensure this is a standing agenda item.

CNWL has a dedicated Performance Lead for the Surrey cluster and we will ensure a
full review of the use of SystmOne is undertaken in each site, and that this is a
standing agenda item in all local Clinical Quality Meetings. We have recently
appointed a performance and data analyst who is currently working with managers
and senior clinicians across all our prison sites to improve local recording and
support with local induction and ongoing support for teams.

CNWL is currently developing a training package for staff on the effective use of
SystmOne on the functionality of the system, and the use of READ codes. We
recognise that the homepage is a vital screen for agencies communicating risk and
essential information in relation to a patient’s care. All staff have been advised
through local meetings of the requirement to log in via the homepage and this will be
included in the CNWL Standard Operating Procedure going forward.

CNWL has been appointed as the Lead provider for Primary Care Services in HMP
Highdown and across the Surrey prisons cluster. As part of the mobilization and
transfer process, CNWL will undertake a full review of the system in conjunction with
partner agencies to optimise system usage and risk assessment and management
processes across prescribing and pharmacy services. This will include the
development of a multi-agency protocol on the use of SystmOne that includes
communication of risk and medicines optimisation.

CNWL is currently working closely with NHS England in preparation for the new
version of SystmOne, which is due for rollout later in 2017. We are advised that all
SystmOne templates have been reviewed to improve functionality across all prisons.
It is our understanding that this new system will curtail the opportunity for agencies to
make their own local changes. The implementation of the new system will involve
local training for staff. CNWL will implement a train the trainer programme to ensure

ongoing support for staff post rollout.

e. Ensuring all staff with responsibility for patients in prison have received
adequate foundation training and on-going training in the ACCT
procedure.

ACCT training is prison provided training. CNWL works closely with the
establishment to facilitate staff access training as far as possible within their

probationary period.

Following serious incidents in other establishments, CNWL established a Task and
Finish Group in summer 2016. As a result of the lessons learned, the organisation
has developed a number of initiatives that includes suicide prevention training:

An e-Learning module for the management of harm and suicide in prison
environments is a mandatory requirement for all staff joining CNWL on all prison
sites. This training forms part of our mandatory training list and is retaken annually by
all staff. At HMP Highdown, we are 100% compliant with this requirement. Statutory
and mandatory training compliance is monitored via internal CNWL quality systems.
Where non-compliance is identified, this would be addressed within a two week

period.

In addition to the CNWL Mandatory Suicide and Self Harm training, which includes
ACCT processes, all new starters at HMP Highdown attend the prison ACCT training
provided by the prison on local procedures and pathways — this includes
expectations of the team, the service and individual staff members’ responsibility.
Unfortunately, CNWL is dependent on the frequency of training within the prison.
This has been raised directly with the Safer Custody Governor.

We understand from recent discussions that safer custody are now looking to make
this an annual refresher training course which all CNWL staff will attend.

CNWL have developed a new e-learning package that details the ACCT process and
outlines the specific roles and responsibilities of healthcare within this process. This
will be rolled out within the next 3 months.

The training will be mandatory for all CNWL staff working within secure settings.
Compliance is monitored at a service and directorate level.

Mandatory training and Continuous Professional Development is monitored via
supervision.

Currently over 70% of CNWL mental health staff are ACCT compliant, the remaining
three staff are currently non-compliant and 100% of staff have undertaken CNWL’s

Suicide and Self harm awareness training. We are working with the prison
establishment to facilitate staff access to training as soon as possible. Delivery of
ACCT training is the responsibility of the prison and has been raised at the Quality
Partnership Board with the Safer Custody Lead Governor and we are awaiting dates
from the prison for the full ACCT training. It should however be noted that all CNWL
staff have completed CNWL's Suicide and Self Harm awareness training which
includes basic ACCT refresher information. All CNWL staff who are not ACCT
compliant do not take the lead in ACCT reviews and are supported by a CNWL staff

~ member who has completed this full prison ACCT training.

f. Ensuring caseworkers are aware of and attend ACCT case reviews for
patients under their care.

Directorate Actions

In summer 2016 CNWL, established a Task and Finish group that identified key

themes in relation to Deaths in Custody. The group identified key themes that

included the ACCT process and healthcare’s relationship, roles and responsibilities in ,
relation to the ACCT. As a result, CNWL has developed a draft mental health
pathway that includes both required standard operating procedure and also identifies

a gold standard that we would also seek to achieve.

CNWL mental health pathway recognises the need for the Mental Health team to
attend ACCT case reviews for all patients on the mental health caseload. Our
pathway recognises as good practice that the Mental Health team should attend all
ACCT reviews. However, while this is accepted as a gold standard for prison mental
health teams, CNWL is sometimes unable to meet this standard due to the capacity
of mental health services. Attendance is monitored via the monthly contract review
meeting attended by the prison, and capacity and local inter-agency operational

issues are discussed and recorded.

Following the recommendations of the Death in Custody Task and Finish Group,
CNWL has now established the Clinical Oversight Group. The clinically led group
reviews all serious incidents. It aims to reduce the likelihood of further incidents while
examining in detail, emerging themes from serious incidents and near misses. The
meeting is attended by the Trust's Lead for Serious Incidents ensuring lessons can
be shared across Directorates and any Divisional and Trust learning can be ;
effectively actioned. Directorate lessons learned are circulated via the Directorate
Care Quality Meeting (CQM) and cascaded to ail local CQMs for discussion and local

implementation.

Local Actions

Local prison led operational procedures and communication is integral to the Mental
Health team fulfilling this requirement. CNWL are working actively with HMP

Highdown to address these issues.
Safer custody at HMP Highdown now provide CNWL with a Daily Open ACCT Log,

which is sent to three managers within the team. This is then circulated to all staff on
duty that day and a daily copy posted on the Inreach Staff Office Notice Board.

During the daily morning briefing, which is attended by the CNWL mental health
team, this log is reviewed to ensure that ACCT reviews are attended.

Further, the duty RMN establishes, each morning, whether there have been any
additions to the ACCT register and arranges to assess the prisoner that day. This
has resulted in all prisoners who have an ACCT open being seen by a Mental Health
Nurse within 24 hours of the ACCT being opened. This is a new initiative that has
been in place since September 2016.

Attendance at ACCT reviews is monitored quarterly, and where staff non-attendance
is indicated, an exception report is included to outline the reasons for this absence.
Where there is an absence, for example, in case of late notification and availability or
staff sickness, an ACCT contribution form regarding the mental state of the prisoner
will be provided to the ACCT Review by a member of the healthcare team. In an
extreme situation where there is no staff availability, the mental health team will
actively seek out feedback from the ACCT review.

g. Ensuring that there is regular communication about a patients needs
with the GP and the primary healthcare practitioners at HMP Highdown.

CNWL recognises the complexity of need, co-morbidity, and the prevalence of dual
diagnosis in the patient population. We have implemented the following strategies:

e Appointment of a dedicated Regional Operations Manager to the Surrey
cluster to lead and oversee the new CNWL Directorate integrated governance
and quality assurance structures and processes including Lessons Learned
from Serious Incidents, ensuring Board to Floor communication.

e Weekly Mental Health team meeting that includes standing open invitation to
GPs. We do ensure that the agenda and minutes of the meeting are sent to
the lead GPs. Urgent matters that arise in this meeting are communicated in a
timely way to the GP’s if they are not present. Should the consultant
psychiatrist not be present in the meeting then the responsible manager in that
meeting contacts the Consultant Psychiatrist. Other or non-urgent maiters
are discussed at the Complex Case Review meeting (see point below).

e Psychological Therapies supervision group led by CNWL Lead Psychologist
providing feedback to referrers on areas of risk and concern via SystmOne.

* Introduction of the CNWL Consultant Psychiatrist Complex Case Review
Meetings at HMP Highdown to include GPs, Primary Care, Mental Health,
Substance Misuse, Social Care, Safer Custody and Pharmacy that will
commence in February 2017 to ensure that there is regular communication
with all healthcare providers.

e CNWL Mental Health team is represented at all multi-agency integrated
meetings including, but not limited to: Partnership Board, Quality Board
Meetings, Medicines Management, Safer Custody, Drug Strategy meetings.

In conclusion | would like to state that CNWL regrets the death of Mr Russell and
would like to extend our sympathies to Mr Russell's family.

As a significant provider of healthcare services within prisons, we recognise ihe
increasing risk to patient safety due to a number of complex and interrelated factors,

some of which are outside the control of CNWL.

ke to extend our assurances to yourself and the family, that we
have reviewed our governance structures and processes and our mental health
pathway to ensure we are continuously learning lessons that enable us to positively
contribute to reducing the likelihood that anyone under our care dies in custody. We
are actively working with NHSE and NOMs to address some of the national issues,
and locally we are working with NHSE commissioners to ensure that services are
commissioned and resourced appropriately to meet the significant mental health care
demand we are seeing in both HMP Highdown and prisons nationally.

However, we would li

Yours sincerely,

Claire Murdoch
Chief Executive