Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0056, written 17 Feb 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Feb 2017 |
|---|---|
| Reference | 2017-0056 |
| Deceased | Dean Saunders |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| Category | State Custody related deaths · Suicide (from 2015) · Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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: Her Majesty’s Prison Service Care UK Clinical Services South Essex Partnership Trust NHS England 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 5 January 2016 I commenced an investigation into the death of Dean Gary Saunders. The investigation concluded at the end of the inquest on 20 January 2017. The conclusion of the inquest was:- Dean Gary Saunders killed himself whilst the balance of his mind was disturbed and the cause of death was contributed to by neglect. The jury provided in addition the following Narrative conclusion:-. This has been an extremely challenging case; the jury would first like to express its sincere condolences to Dean’s family. We believe that a number of serious failings led to Dean’s death and we set out these as follows. There is no particular significance to the order in which we present them. The mental health assessment at Basildon police station was not adequate due to a failure to pass information pertinent to Dean’s then mental state and its consequent risks. The delay in carrying out the assessment contributed to this serious failing. While we do not believe that the result of the assessment itself was predetermined, the pathway to prison was. On the balance of limited evidence and lack of a proper audit trail we are unable to conclude whether sufficient enquiries were made into the availability of beds out of area or privately. The only certainty is that a bed at Brockfield House was 1 only available on 4th January 2016. It was clear Dean was in need of a place of safety, as such his route from Basildon police station to prison was the only available option. In our view the ACCT assessment on 21st December 2015 was not adequately conducted for the following reasons: No medical or mental health professional attended the assessment; The assessment did not have sufficient multi-disciplinary attendance; The head of healthcare had, to a very large extent, predetermined that the result of the assessment would be the removal of constant watch; The head of healthcare treated financial considerations as a significant reason to reduce the level of observations; The attendees at the assessment failed to review sufficient background information prior to the assessment, including full and detailed knowledge of key events such as the plastic bag incident, which had taken place moments before the ACCT review; The assessment was held prior to the completion of the psychiatrist’s assessment. HMP Chelmsford’s response to the family in general and on 23rd December 2015 in particular was inadequate. These include but are not limited to basic administrative errors, such as a failure to record and pass on telephone numbers, failure to record all information, failure to initiate usage of the phone PIN system, and no consideration of family attendance at ACCT assessments which we feel would have been appropriate in the circumstances. At HMP Chelmsford, there were multiple failings in recording and communicating pertinent information relating to Dean’s circumstances. These included but are not limited to: Discrepancies between various official records; Failure to provide full explanations in recorded entries; Failure to record key incidents; A complacent approach to Dean’s state of mind and circumstances. There was an absence of clinical leadership in the healthcare wing of HMP Chelmsford. There was confusion regarding the head of healthcare’s qualifications by members of staff. The administration and performance of ACCT reviews was wholly inconsistent 2 and record keeping incomplete. Such as confirming a case manager throughout the ACCT, confirming risk level on 24th December and other information that must be completed in every case. Finally there was a total lack of consistency and logic regarding the level of risk ascribed to Dean’s situation and consequent levels of observation. On 4th January 2016, the performance of the observations was perfunctory as the member of staff did not engage with Dean as required in the PSI and checks were not carried out on an irregular basis. There was a failure to transfer Dean to a medical facility as the section 48 process in operation at HMP Chelmsford is contrary to industry best practice. In addition the psychiatric assessment on 21st December failed to take into account the fact that Dean’s observation levels had been reduced at the ACCT meeting earlier that day. In summary, Dean SAUNDERS and his family were let down by serious failings in both mental health care and the prison system. 4 CIRCUMSTANCES OF THE DEATH Dean Saunders was 25 years old at the time of his death. On 16 December 2015 he was detained under s136 Mental Health Act and assessed at Rochford Hospital. He was discharged to his parents’ home where an incident took place involving him stabbing two family members and threatening to take his own life. He was arrested and taken to Basildon Police Station. On 17 December 2016 Mr Saunders was assessed and not made subject to a section of the Mental Health Act. He was charged with two counts of attempted murder and after an appearance in Basildon Magistrates’ Court, he was remanded in custody to HM Prison Chelmsford. An ACCT – Assessment, Care in Custody and Teamwork - document was opened. He was initially placed under constant supervision but this was later reduced to twice hourly observations. Seven ACCT reviews were held between 18 and 31 December. At 10.25am on 4 January 2016 Dean was found unresponsive lying on a mattress in his cell. His death was confirmed and the cause of death provided by the pathologist, CORONER’S CONCERNS was 1a) electrocution 5 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. FOR SEPT:- The admitted lacuna in the SEPT admissions protocol governing the transfer of mentally disordered people from police custody. The current admissions protocol does not allow for the transfer of any individual from police custody, irrespective of the criminal charges the individual is facing. Cont…… 3 2. FOR SEPT AND NHS ENGLAND:- The absence of a written record of in his the “best practice” forensic pathway referred to by evidence, and consideration of whether the transfer of individuals such as Dean to prison is indeed “best practice”, taking into account the consequent delay in transfer and the suitability of the prison environment for mentally disordered individuals. 3. FOR CARE UK, NOMS, SEPT:- The lack of clarity regarding the hospital transfer process. The evidence at the inquest demonstrated that this is currently shrouded in confusion and contradiction (if the PSI and the NHS England “good practice” is compared). Given that rationalisation of the process is still a “work in progress”, the family consider that it should be given urgent consideration. 4. FOR NOMS:- Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet the same mistakes are being repeated. Meaningful action in required in this regard. 5. FOR NHS ENGLAND:- The resilience of psychiatric cover at Chelmsford prison, which would need to be raised with NHS England who commission such services and decide on the budget. 6. FOR NOMS:- The meaningful involvement of families in the ACCT process, including by ensuring the formal recording, and communication of concerns raised by a prisoner’s family. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your 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 14 April 2017. 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. Cont…… 4 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons – Bindmans, 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 [DATE] 17 February 2017 Caroline Beasley-Murray 5
3 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.
Care UK Clinical Services Limited Hawker House 5-6 Napier Court Napier Road Reading Berkshire RG1 8BW T 0333 999 2570 F 0333 200 4063 www.careuk.com Mrs Caroline Beasley-Murray Senior Coroner HM Coroner’s Office County Hall Seax House Victoria Road South Chelmsford CM1 1QH 13 April 2017 Dear Madam Regulation 28: Prevention of Future Deaths report The inquest touching the death of Dean Gary Saunders HMP Chelmsford Date of death: 4th January 2016 Thank you for your Regulation 28 Prevention of Future Deaths Report dated 17 February 2017 issued to Care UK following the inquest into the death of Mr Dean Saunders. Care UK is the provider of primary healthcare and mental health services at HMP Chelmsford. Care UK would like to express its condolences to Mr Saunders’ family and friends. The matter of concern to you in so far as it relates to Care UK are highlighted in bold with the response set out below each concern. I am responding in my capacity as National Medical Director for Health in Justice 1. The lack of clarity regarding the hospital transfer process. The evidence at the inquest demonstrated that this is currently shrouded in confusion and contradiction (if the PSI and NHS England “good practice” is compared). Given the rationalisation of the process is still a “work in progress”, the family consider that it should be given urgent consideration. I can confirm what I explained in evidence at the inquest. The Department of Health’s 2011 Good Practice Procedure Guide on the transfer and remission of adult prisoners under Section 47 and Section 48 of the Mental Health Act sets out the procedure that is best practice to be followed in order to enable transfer of a patient under those sections from prison to a secure mental health facility. The Transfer Policy that had been drafted locally at HMP Chelmsford is at odds with that best practice. However, the policy at HMP Chelmsford had been developed locally through the mental health team’s experience of how best to speed up the transfer process. At the date of the inquest, this Transfer Policy was also a work in progress and not the perfected version. As I discussed in evidence, the Mental Health Pathway has been revamped and further work has been undertaken with the team to improve mental health services in HMP Chelmsford. . Care UK Clinical Services Limited - Registered in England No 03462881 Registered Office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex CO4 9QB This revamped Mental Health Pathway is a strategic national policy and local sites develop local operating policies to describe how they will meet the requirements of the pathway. This will include a local Transfer Policy to outline the local processes (see below). The Mental Health Pathway was initially developed by Care UK in Yorkshire with a group of clinical staff, NHSE commissioners and service users. The pathway has been subsequently reviewed by a group of Care UK experienced senior clinicians and further adapted to ensure it takes account of best practice. The work adapting the pathway from the Yorkshire model involved a multidisciplinary group including the national medical director, national lead nurse, regional manager, a head of healthcare and mental health team leader, all of whom have a wealth of experience with managing mental health in prisons. The pathway has been out to a wider group for consultation, including Care UK subcontractors (mental health trusts) and has been further amended to take account of their comments. The new pathway has been shared with the local team at HMP Chelmsford and work has been undertaken to embed changes to clinical practice. It has been further shared nationally with Care UK regional managers and senior clinical leaders. Under the transfer pathway section, the first referral to the secure mental health facility should encompass the first clinical recommendation under the Mental Health Act in order to trigger the transfer process. Exactly which secure mental health facility a patient is referred to will depend on a number of factors including where in the country the prison is located, where the prisoner lived before coming into prison and where a bed is available. Each prison will add its own local detail (such as contact details) to their Transfer Policy. The new Mental Health Pathway was formally signed off at the quality assurance meeting held on 28 March 2017 and is currently being rolled out across all Care UK sites via a series of mental health workshops which will examine processes and quality of care provided. These workshops are facilitated by senior clinicians to support local teams to continuously improve the quality of their mental health service provision. As you may be aware, there is due to be a change of healthcare provider within HMP Chelmsford and, therefore, the mental health pathway within the establishment may change. I trust that the above response provides the information that you require but please do not hesitate to contact me if Care UK can be of any further assistance or if you would like copies of the Mental Health Pathway and Transfer Policy for HMP Chelmsford. Yours sincerely National Medical Director Health in Justice Care UK Page 2 of 2
NHS Essex Partnership University NHS Foundation Trust SM/PR/BW/30 ror 4 10 April 2017 4q . : Trust Head Office "4 4: am The Lodge Mrs Caroline Beasley-Murragy Lodge Approach HM Senior Coroner en Essex S811 XX Seax House, Coroner's Court Victoria Road South Tel: 01268 739677 Chelmsford ue Fax. 01268 739675 Essex CM1 1QH a ae Email: S _ 13 APR 2017 A ae co et Acting chair: A Chief Executive: Sally Morris Dear Mrs Beasley-Murray | am writing to set out the Trust's formal response to the Regulation 28: Report to Prevent Future Deaths, dated 17 February 2017. | would like to begin by extending our condolences to the family of Mr Saunders. | hope this response provides them and you with assurance that the Trust regards this situation very seriously and is taking action to address the issues raised. In response to the three matters of concern addressed in the report to SEPT: Although the admissions protocol used by the Trust is an all-inclusive one and does not exclude any scenario (provided that the individual has been detained under the Mental Health Act 1983) the Trust has submitted the protocol for regional review by the Secure Services Catchment Group for East of England and will ensure you are informed of the outcome. The Trust has taken the issue of best practice in relation to the forensic pathway to the Secure Services Catchment Group for East of England for regional discussion. We will ensure you are informed of the outcome. Unfortunately, as the delay in transfer in Mr Saunders’ situation was not within the Trust’s contro!, we are unable to address this issue. The Trust has been in discussion with NHS England, as the commissioners of the service, on the hospital transfer issue and understands that the commissioners are taking this forward with Care UK as the providers of the healthcare service and with NOMS. Please be assured that learning from Mr Saunders’ death is being shared across the Trust in order to help prevent the same issues arising again. We have also been in touch with Mr Saunders’ family as part of this learning process. Finally, | would like to reiterate my condolences once again to Mr Saunders’ family. | hope that this response goes some way to providing assurance that the Trust regards their loss very seriously indeed and is taking steps to address the issues raised during the investigation and the inquest. Yours sincerely Yours sincerely Sory A A —. SALLY MORRIS Chief Executive
INHS|
England
Professor Sir Bruce Keogh
National Medical Director
Skipton House
80 London Road
SE1 6LH
Caroline Beasley-Murray
HM Senior Coroner
Essex
H.M. Coroner's Office
County Hall
Seax House
Victoria Road South
Chelmsford
CM1 1QH
Sent via email: coroner@essex.gov.uk '2thApril 2017
Dear Mrs Beasley-Murray,
Re: Regulation 28: Report to prevent Future Deaths — Mr Dean Saunders,
HMP Chelmsford
Thank you for your Regulation 28 Report which was issued on Friday 17
February 2017 2016 following the inquest into the sad death of Dean
Saunders, who died at HMP Chelmsford on 4 January 2016. | would like to
express my deep sympathy to Mr. Saunders’ family.
In your Regulation 28 Report you have raised two concerns for NHS England
which are addressed in the responses below.
Concern 2: For NHS England and SEPT - The absence of a written record of
the “best practice” forensic pathway referred to by{MMin his evidence,
and consideration of whether the transfer of individuals such as Dean to
prison is indeed “best practice”, taking into account the consequent delay
in transfer and the suitability of the prison environment for mentally
disordered individuals.
The following information describes the commissioning arrangements for
healthcare for someone being held in police custody.
Police custody healthcare at Basildon is commissioned by the Essex Police and
Crime Commissioner and is provided by G4S who are responsible for assessing
people as being fit to be detained, interviewed and charged, where requested to
by custody officer.
NHS England commission South Essex Partnership Trust to provide Liaison and
Diversion (L & D) services for Essex, which includes Basildon Police Station.
Where police custody staff have a concern around an individual's vulnerabilities,
a referral is made to the L & D service who will assess and identify any mental
High quality care for all, now and for future generations
health, learning disability, substance misuse and/or other treatment services to
provide options to divert from or work alongside other criminal justice
interventions.
The decision to remand someone to prison is made by the courts and, if
required, will be informed by an assessment of their current presenting health
and vulnerabilities. In this case, the decision to remand Mr Saunders to HMP
Chelmsford was made by Basildon Magistrates Court.
The NHS England Liaison and Diversion Standard Service Specification 2015
(attached at Appendix A for information) outlines that the service provider will
develop care pathways with identified local health and social care services in
partnership with key stakeholders, including community rehabilitation companies,
drug action teams and local mental health providers, and other service providers.
Concern 5: For NHS England - The resilience of psychiatric cover at
Chelmsford prison, which would need to be raised with NHS England who
commission such services and decide on budget.
NHS England commissions healthcare in prisons using an outcomes-based
service specification. NHS England (Midlands and East) is responsible for the
performance management of the healthcare contract. The provider, Care UK, is
required to submit quarterly data on a range of qualitative and activity/based key
performance indicators.
NHS England (Midlands and East region) has considered the resilience of the
psychiatric care service at HMP Chelmsford, a category B local prison. Care UK
are the current providers of mental health services at HMP Chelmsford and
deliver a total of 5 sessions of psychiatry per week for a population of 710
men. A health needs assessment was conducted in 2016 by an independent
author who concluded that the overall provision of psychiatry cover at HMP
Chelmsford meets the needs of the population. The Health Needs Assessment is
provided at Appendix B
At the time that Mr Saunders was in HMP Chelmsford the regular psychiatrist
was on annual leave. A cover psychiatrist saw Mr Saunders and provided the
first signature for the document which would have supported his transfer to a
secure mental health placement. Due to the regular prison psychiatrist's leave
there was a five day delay in obtaining the required second signature for the
Mental Health Assessment document.
This was followed up by NHS England commissioners with Care UK who
informed the commissioners that it had circulated a document to all staff which
provides details of the names and contact details of medical staff who can sign
Mental Health Assessment documents. This will ensure that there are no further
recurrences of delays in completing the required documentation and transfers.
In addition, from 27 May 2017, a new provider will be delivering healthcare at
HMP Chelmsford. The new provider is a local mental health provider and the
psychiatry service will be supported by a wider service than currently offered,
High quality care for all, now and for future generations
providing greater access to a pool of psychiatrists who could provide signatures if
required.
We acknowledge the concerns you have expressed and hope that this response
provides confirmation that those concerns are being addressed in national policy
or practice.
| am grateful to you for bringing these matters to my attention.
Yours sincerely,
ul
Professor Sir Bruce Keogh KBE, MD, DSc, FRCS, FRCP
Nationa! Medical Director
NHS England
High quality care for all, now and for future generations
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