Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0094, written 28 Mar 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Mar 2017 |
|---|---|
| Reference | 2017-0094 |
| Deceased | John Williams |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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: Prevention of Future Deaths report John WILLIAMS (died 26.06.16) THIS REPORT IS BEING SENT TO: 1. Mr Mike Parish Chief Executive Care UK 29 Great Guildford Street London SE1 0ES (see points 5.1, 5.2, 5.3 and 5.5) 2. Governor HMP Pentonville Caledonian Road London N7 8TT (see points 5.4 and 5.6) . Professor Sir Bruce Keogh National Medical Director NHS England PO Box 16738 Redditch B97 9PT (see points 5.3 and 5.5) . Mr Michael Spurr Chief Executive National Offender Management Service Clive House : 70 Petty France London SW1H 9EX (see points 5.3 and 5.7) CORONER lam: Coroner ME Hassell Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP CORONER’S LEGAL POWERS | make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. INVESTIGATION and INQUEST On 1 July 2016, one of my assistant coroners, Richard lan Brittain, commenced an investigation into the death of John Williams aged 54 years. The investigation concluded at the end of the inquest on 24 March 2017. The jury made a narrative determination, which | attach. CIRCUMSTANCES OF THE DEATH Mr Williams hanged himself whilst a prisoner at HM Prison Pentonville, however, he had told members of staff that he would do so if his perceived needs were not met, rather than with the aim of taking his life. CORONER’S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. The first reception nurse who saw Mr Williams when he entered HMP Pentonville gave evidence that he had no thoughts of self harm or suicide, but she recorded that he had. It appears she may benefit from additional training and/or supervision. . There was no second reception screen conducted. If Mr Williams was not brought to healthcare staff for his second reception screen then healthcare staff needed to follow this up. . The first reception nurse did not make the referral to the mental health team (though this took place in any event because the court diversion team had already made the referral). | heard that it is now done automatically when that box is ticked on the system, and | wonder whether other prison healthcare providers would benefit from such a system. . Mr Williams said to several members of staff that he would self harm or hang himself if he wanted something done and it was not happening quickly enough (rather than because he actually wanted to die.) This was recorded on his assessment, care in custody, teamwork (ACCT) document. Some prison officers did not seem familiar with the very important contents of the ACCT, not even the inside cover. The senior officer in charge on the weekend of Mr Williams’ death did not look at the inside cover or record any events within. Again, It appears there may be benefit in additional training and/or supervision. . Mr Williams also told the member of Phoenix Futures who saw him that he felt cannabis gave him what the mental health team did not. However, the staff member felt he did not have the training or experience to explore either of these issues in greater depth. It may be that Phoenix Futures staff would benefit from additional training, perhaps alongside prison healthcare staff. . The issue of the difference between a code blue and a code red is one about which | have written before. One senior prison officer said in evidence that if she did not know the difference between a code blue and a code red, then there would be some serious concerns. She did not. She had been given a small card describing code blue and code red (a card which another officer kept about her person and even produced from the witness box), and she still retained that card. However, she had never considered it worthwhile to read. She said in court that she still thought it appropriate that she had never read the card. . The prison officers did not have even the most basic first aid and cardiopulmonary resuscitation (CPR) training. | am aware from other inquests that this is not provided at a national level. | have written about this before. It seems a significant gap, even allowing for the fact that there are always two trained nurses on site. ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and | believe that you 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 29 May 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. COPIES and PUBLICATION | have sent a copy of my report to the following. e HHVJ Mark Lucraft QC, the Chief Coroner of England & Wales e HM Inspectorate of Prisons | 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 Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. SIGNED BY SENIOR CORONER WWE to
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
HMP Pentonville Healthcare Department Caledonian Road London N7 8TT Dear Madam, Regulation 28: Prevention of Future Deaths report The inquest touching the death of John Williams Deceased HMP Pentonville Date of death: 26 June 2016 th Thank you fo r your Regulation 28 Prevention of Future Deaths Report dated 28 March 2017 issued to Care UK following t he inquest into the death of M r John Williams Deceased. Care UK is the provider of primary healthcare services at HMP Pentonville. I have addressed the issues you have directed to Care UK only which you have highlighted as paragraphs 5.1, 5.2, 5.3 and 5.5 The matters of concern to you in so far as they relate to Care UK is highlighted in bold with the response set out below each concern. 5.1. The first reception nurse who saw Mr Williams when he entered HMP Pentonville gave evidence that he had no thoughts of self-harm or suicide but she recorded that he had. It appears she may benefit from additional training and/or supervision The nurse who completed the First Reception Health Screen on 30 May 2016 recorded in the free text section in Syst mone that Mr Wi lliams had made a statement of int ent to self-harm and that was a reason as to why Mr Williams was placed on an open ACCT. This was clearly recorded by the nurse at the time. The nurse has been reminded of t he process of giving evidence at an inquest and to listen carefully to th e question that is being and to take t ime in considering her answer. Enquiries have been made by the Interim Head of Healthca re who is satisfied that the nurse in giving evidence at the inquest was confused and made a mistake in response to your question. Further reassurance, support and guidance has already been given to the nurse involved. 5.2. There was no second reception screen conducted. If Mr Williams was not brought to healthcare staff for his second reception screen then healthcare staff need to follow this up. On this occasion no Second Reception/Wellman assessment was completed. An appointment was arranged for 1 June 2016 but was not completed as Mr Williams did not attend his appointment. This was marked as "DNA" in Mr Wil liam's Systm0ne record. As you heard in evidence, it is the case now that a register is kept of any Second Reception/Wellman assessments that are not completed . It is then th e responsibility of t he Lead Nu rse to arrange for the patient t o be contacted and an appointment for the assessment to be completed. In the event that the patient declines the Second Reception/Wellman assessment then t hey are asked to sign a disclaimer which is then scanned into Systm0ne. I have set out below a copy of the register for December 2016 and January 2017 as follows: Snapshot for December 2016 388 receptions for t he month (100%) 18 patients in prison less than 72 hours (5%) 100 patients refused (26%) disclaimer signed 12 patients transferred from a Care UK prison with a Valid Wellman Assessment (3 %) 88 missed assessments due to location other than Fi rst Night Centre (23%) 0 patients outstanding for assessment (0%) 170 completed assessments (44%) Snapshot for January 2017 476 receptions for the month (100%) 23 patients in prison less than 72 hours (5%) 58 refused (12%) disclaimer signed 7 patients transferred from a Care UK prison with a Va lid Wellman Assessment (2%) 128 missed assessments due to location other t han First Night Centre (27%) 23 patients outstand ing for assessment (5%) 231 completed assessments (49%) 5.3. This first reception nurse did not make the referral to t he mental health team (although this took place in any event because the court diversion team had already made the referral). I heard t hat it is now done automatically when that box is ticked on the system, and I wonder whether other prison healthcare providers would benefit from such a system As you heard in evidence, we have investigated t he process with reg ard to t he templates and referrals to mental health as part of the First Reception Health Screen and whether it would be possible to not being able to pass onto a second page until the task has been completed. The investigation has been completed and t he template has been changed at HMP Pentonville with immediate effecr. It is now a mandatory box to say if a Mental Health referral is required and that one has been made. The referral is then made electronically directly to the mental health in-reach team. As of Friday 24 March 2017, this revised tem plate is being followed at HMP Pentonville. Care UK are looking into implementation of this template at all the prisons where they undertake the First Reception Health Screen. In addition we will raise the revision with NHS England and ask them to inform other healthcare provi ders of the revision we have made. 5.5. Mr Williams also told the member of Phoenix Futures who saw him that he felt cannabis gave him what the mental health team did not. However, t he staff member felt he did not have the training or experience to explore either of these issues in greater depth. It may be that Phoenix Futures staff would benefit from additional training, perhaps alongside prison healt hcare staff. Page 2 of 3 Again as you heard in evidence, this service is commissioned by NHS England. As you were also advised th is service has also gone out to tender and we await details as to who has been awarded t he procurement. It is our understanding that NHS England are making t he service specification very much a j oint, integrated and collaborative working model. It was confirmed to you t hat at this stage there are daily handovers where we capture staff attendance and prisoners and the attendance of Phoenix Futures is requested at handover. However we are unable to comp el their attendance. We trust that the above response provides the information that you require but please do not hesitate to contact us if Care UK can be of any further assistance. Yours sincerely. Head of Healthcare HMP Pentonville Page 3 of 3
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