Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0185, written 7 Jun 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Jun 2017 |
|---|---|
| Reference | 2017-0185 |
| Deceased | Callum Smith |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Community health care and emergency services related deaths · Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) |
| Organisation named | Avon and Wiltshire Mental Health Partnership NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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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:
41. Bristol Community Health
South Plaza
Marlborough Street
Bristol
BS1 3NX
2. Avon & Wiltshire Mental Health NHS Trust
Jenner House .
Langley Park Estate
Chippenham
Wiltshire
SN15 1GG
CORONER
| am Maria Eileen Voisin, Senior Coroner, for the area of Avon
2 | CORONER’S LEGAL POWERS
{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 11" March 2016 | commenced an investigation into the death of Callum Oliver
SMITH, Aged 27. The investigation concluded at the end of the inquest on 26" May
2017. The conclusion of the jury inquest was: :
Cause of death
1a) Hanging
Conclusion - . :
Callum Smith’s death, caused by suicide whilst suffering extreme anxiety and distress
was contributed to by the following:
e Inadequate attention to the concerns of Callum’'s family, his own.requests for.
help and for communication with his family, the level of his anxiety and acts of
self-harm whilst in police and prison custody.
* Failure to record key events on the PER and to include health and mental health i
records on transfer to prison :
e Inadequate communication between those involved in Callum’s care.
e Inadequate mental health assessment and failure to carry out a timely full
_ mental health assessment and to ensure proper referrals took place with
handover.
« Repeated failures to open an ACCT due to lack of training, inadequate training
and staff understanding, failure to take responsibility for the opening of an ACCT
and failure to recognise that self-harm extends to intentionally banging head
against a wall or door.
e inadequate integration between and access to |.T systems which led to key
information being missed
« Failure to support Callum by not allowing a follow-up assessment to take place.
CIRCUMSTANCES OF THE DEATH
Callum was in the care of HMP Bristol at the time of his death. He was found hanging in
his cell by a prison officer. .
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. ~
4, At the conclusion of the inquest | expressed my concern in relation to assessing
risk of suicide and self-harm and how from the evidence heard it appeared that
there was a possible conflict between how healthcare/mental healthcare staff
assess risk in this area and the requirements of the ACCT policy for all staff
working with prisoners to follow the requirements of PSI 64/2011.
2. There was evidence that healthcare/mental healthcare staff needed to be
reminded of the lower threshold for opening an ACCT and that this is
fundamentally different to the way that they carry out an assessment and/or risk
assessment of a patients risk of suicide or self harm for medical/mental health
care and treatment as per PS! 64/2011.
3. {was concerned that staff who apparently had been trained did not appear to
consider that they had when giving evidence and therefore | would ask that this
is reviewed to ensure that healthcare/mental healthcare staff receive detailed
training on the ACCT process as it is clearly an important and recognized policy
in preventing a risk of self-harm or suicide.
4. | indicated that | would ensure that this report was copied to the prison as they
would need to be aware of this, as it is often they who provide the ACCT training
for healthcare/mental healthcare staff.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you have the
power to take such action. .
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 2"? August 2017. |, 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 Chief Coroner and to the following Interested
Persons — the family and HMP Bristol. | have also sent a copy to the PPO.
| 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 fo 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.
7.6.17 M. E. Voisin
-
a
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.
Inspire @etter Health Prevention of Future Deaths Following the above inquest, the Coroner has expressed concerns about the way Bristol Community Health manage risk of self harm and suicide and has made recommendations in regard to the prevention of future deaths. These concerns have highlighted learning for Bristol Community Health and the action plan has been completed to address this learning. 1. The inquest demonstrated that healthcare understanding of the Prison Service Instruction (PSI) 64/2011 did not fully meet the requirements of this policy. In particular this related to the low threshold in place for opening an ACCT document. Healthcare were considered to be possibly applying clinical judgement in response to a prisoners declaration of self harm/suicide and this does not reconcile with the required actions within the PSI. All healthcare staff will therefore revisit the PSI through Suicide and Self Harm (SASH) training and local training/meetings. This training will ensure that staff are fully aware of their obligations when adhering to PSI 64/2011. 2. Staff who gave witness statements within the inquest did not appear to recall their ACCT training or provide assurance they had completed this. A number of activities will be completed to reinforce the meaning and purpose of the PSI to support this recollection. This will also include the process of how and when to open an ACCT and healthcare responsibilities in regard to attending First Case Reviews. Evidence of training and local learning will made available for review to the Coroner. Head of Prison Health Services 13/07/2017 Agenda Page 1 of 1 TA uejd uonse ys wnye9 areouyeay “paulejulew pue pajejjoo ag 01 paaleoas Jo peay Suluses} JO psodaJ ayesngoe ue ajqeua |[IM YDIYM padojanap aq PF LU/8/TE 0} xXLuyeW JUaWdojeAap pue Bulules} els Yyeapayageoudsu| “ysanbaJ uo ajgejieae apew aq ||IM SoleUadS BsaU} JO BDUAaPIAZ “LO0V ue Suluado jo ssouajeldosdde uo UOlssnosip Wea} YUM sBuljaaw Weal je pajuasaid aq ||IM SoeUads ,pazis 311g, aseoyyeay Jo 3]OyM aU} ssou9e “sSuljaow saaseuel weap AjuUoIA Wea} AjyJUOW padlojulad Je aq 0} sjUdWaINbas BUIUIE HSS : *a0UR}d900e UIs |[IM SABqUIaLU J4e1s MON “Sulpue}sJapUN pue Bulpeas aunsua ||IM JJeyS JO aueoyyeaHy Jaquaw Mau yim ssaz0id UO!ONpU! Buijajduu0s sioyUaW 4421S Jo peay “ssaooid _ LT/8/TE UONONpPU! jyeJs MaU O}U! 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Healthcare All such incident forms will be shared with Head of Safer Prisons governor and discussed at the Local Quality & Delivery Board. Ongoing thereafter. Callum Smith action plan V1
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