Sarah Reed

Date of report	28 Jul 2017
Reference	2017-0238
Deceased	Sarah Reed
Coroner	Sir Peter Thornton QC
Coroner area	London City
Category	Suicide (from 2015) · State Custody related deaths · Mental Health related deaths · Hospital Death (Clinical Procedures and medical management) related deaths
Organisation named	West London NHS Trust · South London and Maudsley NHS Foundation Trust
Source	judiciary.uk record · original PDF
Responses published	2

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:

THE MINISTRY OF JUSTICE (MoJ)

HM PRISON AND PROBATION SERVICE (HMPPS)

HM COURTS & TRIBUNALS SERVICE (HMCTS)

CENTRAL AND NORTH WEST LONDON NHS FOUNDATION TRUST
(CNWL)

Pons

CORONER

|am HH SIR PETER THORNTON QC, Assistant Coroner for the coroner area of
the City of London.

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.

INVESTIGATION and INQUEST

On 11 January 2016 a coroner’s investigation was commenced into the death of
SARAH LYNNE REED who died in HMP Holloway on that date, aged 32 years.
The investigation concluded at the close of the inquest on 19 July 2017. The
inquest, which was held with a jury, ended with a narrative conclusion. The
medical cause of death was given as ligature compression of the neck.

The jury concluded that Sarah Reed took her own life at a time when the
balance of her mind was disturbed to which a failure in management of her
medication contributed. The jury was not sure that Sarah intended to take her
own life. The jury also concluded that the failure to finish the fitness to plead
assessment process in a sufficiently timely manner contributed to her death.

The jury also concluded, amongst other things, that there was -

(a) failure by the mental health staff at HMP Holloway to act in a timely manner
on the recommendation of a community health team psychiatrist that anti-
psychotic medication be considered, despite specifically requesting his input;
(b) failure in the management of her medication, including failing to provide an
anti-psychotic medication as a safer alternative to Quetiapine (which had to be
stopped for good medical reasons), particularly pending transfer to hospital, and
a lack of a contingency plan to manage her psychosis or the recurrence of it,
with the result that Sarah was not receiving adequate treatment for her
deteriorating mental health state, leaving her in a distressed state;

(c) inappropriate reduction of the frequency of observations at Assessment Care
in Custody and Teamwork (ACCT) Review No.4 on 5 January 2016, six days
before her death, with the decision being made by a review team that was not
multi-disciplinary;

(d) failure by some of those attending ACCT Reviews to read and review the
whole ACCT document before making a decision;

(e) unacceptable delay before holding a Care Programme Approach (CPA)
meeting for long-term planning and inappropriate quality of the meeting when
held; and

(f) an unacceptable number of cancelled visits including a solicitor’s visit, which
contributed significantly to Sarah’s isolation.

CIRCUMSTANCES OF THE DEATH

The deceased took her own life on 11 January 2016 in a single occupancy cell
in C1, the mental health assessment unit, of HMP Holloway, North London. She
strangled herself with a tight ligature made from bed linen.

She had been remanded in custody by the Inner London Crown Court on 14
October 2015 solely for the purpose of obtaining one or more reports on her
fitness to plead and stand trial on a charge of alleged serious assault upon a
nurse at a psychiatric hospital. She had previously been on bail, but while on
bail she had failed to attend two appointments in the community with
psychiatrists for the purpose of their assessment of her fitness to plead.
According to the Case Log, the Judge at the Crown Court expressed the view
on 14 October 2015 that ‘I can’t see any way these reports will be prepared
whilst the defendant remains on bail.’ At the hearing on 14 October 2015 the
Judge therefore ordered the Court to obtain these reports and remanded Sarah
in custody. She was taken to HMP Holloway.

By the time of Sarah’s death on 11 January 2016, three months later, one report
had been obtained. It was dated 11 January 2016. A second report was due on
15 January 2016. No date had been fixed by the Crown Court for a hearing to
determine the issue of her fitness to plead.

There was agreed evidence that Sarah’s mental condition deteriorated in HMP
Holloway for the last three weeks of her life, particularly from 5 January 2016
when she was moved to the mental health assessment unit (C1). She had been
on observation watch under an ACCT procedure (the second procedure since
reception), which had been opened on 28 December 2015 and was still open at
the time of her death.

On reception, it was noted that Sarah had been assessed as previously
suffering variously from Emotionally Unstable Personality Disorder (EUPD),
schizophrenia, psychosis, bipolar affective disorder, alcohol and substance
abuse, and bulimia nervosa. She had been admitted to HMP Holloway and other
prisons since 2005 and had been ‘sectioned’ on a number of occasions. The
deterioration of her mental health and appearances before criminal courts dated
in the main from the period after the death in September 2003 of her six month
old daughter from spinal muscular atrophy.

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 could occur unless
action is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

A. Fitness to Plead Reports

(1) The deceased had been remanded in custody for the sole purpose of the
Court obtaining two reports by psychiatrists on her fitness to plead and stand
trial. Yet by the time of her death, three months later, this objective had not been
achieved and no date for a hearing of the issue had been fixed. It is clear from
the evidence that Sarah was uncertain what was happening and when she
would be going to court.

(2) On 7 January 2016, four days before her death, doctors at HMP Holloway
had decided that Sarah should be referred to a secure hospital for assessment
and treatment. They concluded that she suffered from EUPD and psychosis and

was in effect unmanageable in prison, having refused medication and failed to
comply with requests for blood and ECG tests. Had the Court obtained the
psychiatric reports on fitness to plead earlier, the Court may well have imposed
a hospital order (with or without a restriction order) under section 5(2)(a) of the
Criminal Procedure (Insanity) Act 1964. The two necessary requirements would
have been easily satisfied: the reports were to find her unfit to plead and she
had admitted the act charged, namely striking a mental health nurse over the
head with a metal bar in June 2014.

(3) By the time of her death the deceased had been given no target date for the
hearing of the issue of her fitness to plead. Her diary entries suggest that the
hearing was important to her and in the forefront of her mind. An earlier date of
14 December 2015 had been vacated and not replaced. Her mental state and
behaviour in prison deteriorated markedly from late December 2015 to 11
January 2016.

(4) It was not clear on the evidence who took responsibility for obtaining the
reports. The Court had ordered them, but the formal request for the first report,
dated 27 October 2015, was (a) directed to HMP Holloway, but (b) sent by email
from the Court to an administrative officer employed not by the prison but by the
Central and North West London NHS Trust (CNWL) who worked from HMP
Holloway. One month later, on 27 November 2015, a psychiatrist employed by
CNWL in HMP Holloway wrote back to the Court, apologising for the delay and
indicating that the request be directed not to CNWL but to the South London and
Maudsley NHS Trust. As a result, by about six weeks after the Court’s order, no
psychiatrist had yet agreed to prepare a report.

(5) The jury found that the evidence that key members of Sarah’s mental health
team in HMP Holloway were unaware that the sole purpose of her remand in
custody was for the preparation of fitness to plead reports was
‘incomprehensible’.

(6) The jury concluded that the failure to conclude the fitness to plead
assessment process in a sufficiently timely manner contributed to Sarah’s death.

B. ACCT Reviews and Observations

(7) The jury concluded that the decision to reduce the frequency of observations
on Sarah Reed at ACCT Review No.4 on 5 January 2016, six days before
Sarah’s death, was inappropriate given the clear evidence of the deterioration of
her mental state.

(8) The jury also found that the above decision was not multi-disciplinary, which
it should have been (as the senior Governor conceded in evidence).

(9) The jury also found that not all members of the ACCT Review team fully
reviewed the ACCT document before making a decision.

(10) The jury also found the system of some members of the multi-disciplinary
team recording observations which were not accessible to all other members of
the team to be ‘detrimental’. For example, many helpful observations about
Sarah’s behaviour were recorded in the prison medical notes on SystemOne by
doctors and nurses, but they were not accessible to prison officers.

(11) In addition the Coroner observes that HMP Holloway maintained a practice
of recording observations on prisoners which deviated from the national
instruction. According to the national policy Management of prisoners at risk of
harm to self, to others and from others (Safer Custody) (PSI 64/2011)
observations should be recorded ‘immediately or as soon as practicable
thereafter’. According to the local policy at HMP Holloway, as implemented in
this case, any observations at any time need be recorded only at four hour
intervals in summary form.

C. CPA Meeting
(12) The jury concluded that the delay in holding a Care Programme Approach
(CPA) meeting was unacceptable. The evidence showed that a CPA Meeting for

assessing a prisoner's long-term care should have been held within four weeks
from reception. In this case it was held after nine weeks.

(13) The jury also found that the quality of the meeting was not appropriate. It
lasted five minutes and only the nurse care coordinator and community
psychiatrist were present with the prisoner.

D. Visits

(14) The jury concluded that the number of cancelled visits was unacceptable,
particularly for a prisoner such as Sarah with Emotionally Unstable Personality
Disorder where engagement is a principal means of treatment.

(15) The senior Governor at the time of Sarah’s death found records that in the
relevant period 19 visits were scheduled, of which eight were cancelled (one
visitor did not attend, three were cancelled because of Sarah’s behaviour and
four were cancelled with no reason given), three were completed and eight were
listed as ‘scheduled’ (which probably meant completed but was not clear). The
last cancelled visit was by a solicitor; she was simply told that Sarah was
‘unwell’.

(16) The Governor conceded that the records for cancellations were insufficient
and all cancellations should have been sanctioned at the level of Duty Governor
(which they were not) and not by staff of lesser seniority.

(17) The Coroner also observes that with a little thought and effort arrangements
could be made for a visit for Sarah even when her mental state had affected her
behaviour. For example, on one occasion on 2 January 2016 (and apparently on
one occasion only), Sarah's mother was allowed to see Sarah in the
adjudication room on the Segregation Unit (where Sarah was then housed). It is
clear from the evidence that this visit was helpful to Sarah and that more
completed visits would have assisted her. The jury so found.

(18) The Coroner also observes that the information provided to visitors
including close family was often short on detail and lacked helpful information.

E. Notification of Prisoner’s Release

(19) There was evidence from Sarah's care coordinator in the community, a
social worker with the START Team, that she was never informed by HMP
Holloway of the release of any prisoner whom she had previously supported in
the community, despite the care coordinator having close links with the prison,
for example visiting prisoners she had supported and sometimes taking part in
CPA meetings. The care coordinator said that this would be ‘incredibly helpful’.

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.

A. Fitness to Plead Reports
MoJ; HMCTS; HMPPS; CNWL

You may wish to consider whether the procedures for obtaining and providing
psychiatric reports on the issue of fitness to plead, when ordered by the court,
are sufficiently timely, sufficiently robust and sufficiently well-managed. In
particular HMCTS may wish to consider whether the courts have sufficient
control over the process under present procedures so as produce reports
sufficiently promptly and whether timetabling including the setting of court dates
could be more efficiently and effectively scheduled.

| am aware, from a helpful letter in reply to me as Coroner from the Senior
Presiding Judge (SPJ), dated 21 April 2017, that this specific issue is not
covered by either the Criminal Procedure Rules or the Criminal Practice

Directions issued by the Lord Chief Justice. The SPJ has also informed me, as
has HMCTS, that the office of the SPJ and HMCTS will be reissuing guidance
on the provision of psychiatric reports for sentencing purposes, although fitness
to plead is a separate issue from sentencing and is not included in the current
guidance.

B. ACCT Reviews and Observations
MoJ; HMPPS; CNWL

Despite much past consideration of the ACCT process and a number of reports
from coroners about it, the Ministry of Justice and HMPPS in particular may wish
to consider afresh whether action should be taken to improve the ACCT process
and the process of review.

In particular consideration could be given to the following:

(i) whether a single sheet of ongoing risk and assessment, noting especially
negative highlights, should be introduced for easy access and reading by those
attending a review;

(ii) whether all those attending a review should be required to read the ACCT
document in full; and

(iii) whether those attending a review should always be multi-disciplinary (as
required) and whether those attending should be more consistently the same
personnel.

Consideration should also be given to access to the recording of observations,
particularly of adverse behaviour of the prisoner, for all staff who have the care
of prisoners. In this case medical staff had made extensive records (not of a
medically confidential nature) to which prison officers did not have access, thus
rendering their information about the prisoner incomplete.

The Ministry of Justice may also wish to consider whether it is acceptable that a
prison should be permitted to develop a local policy, in this case on recording
observations, which is at variance with a national policy. This is not the first time
that a local policy may have been in conflict with a national policy. In the
decision of the High Court in R (Maxine Hamilton-Jackson) v HM Assistant
Coroner for Mid Kent and Medway [2016] EWHC 1796 (Admin), the local policy
on when to open an ACCT document differed from the national policy, partly
because it was based on an out-of-date national policy.

In this context the Coroner notes that the Government Legal Department have
indicated in a helpful letter to the Coroner dated 25 July 2017 that Safer Custody
Learning Bulletins, which highlight the need to record ACCT observations ‘as
soon as possible after they are made’, will be issued to all prisons on 27 July
2017. The Coroner welcomes this and notes that this approach accords with the
national policy and not the local policy which was in force at HMP Holloway at
the time of Sarah’s death (and which had previously been criticised by the
Prisons and Probation Ombudsman).

C. CPA Meeting
MoJ; HMPPS; CNWL

Consideration should be given to ensuring that the purpose of CPA Meetings is
properly satisfied both as to their nature and quality. According to the evidence
they are intended for long-term planning of the prisoner's care. In this case the
meeting was held after nine weeks, not within four (as required); it lasted five
minutes; and only two persons in addition to the prisoner were present. It is not
sufficient for the care coordinator to say, as in this case: ‘| was not able to get

the right people together on an earlier date.’

D. Visits
MoJ; HMPPS

A remand prisoner is entitled to a visit every day subject to the requirements of
good order and security. The evidence also emphasised the importance of visits
for a prisoner with Sarah’s mental disorders so as to encourage engagement
and to avoid isolation and feelings of isolation.

Consideration should therefore be given to the procedure for cancelling visits, -
(i) whether visits should be cancelled only at Duty Governor level and not by
less senior staff;

(ii) whether there should be better recording of visits including cancelled visits
and the reason for cancellation;

(iii) whether better and clearer explanation could be given to a visitor (family,
friends and lawyers) when a visit is cancelled and preferably in advance of the
meeting; and

(iv) whether special visiting arrangements could be made more often for
prisoners, particularly remand prisoners, who have exhibited problem behaviour.

E. Notification of Prisoner’s Release
MoJ; HMPPS; CNWL

Consideration should be given to informing external agencies, in this case such
as the START Team, of the impending or actual release of a prisoner. (On the
facts of this case Sarah was not released or due to be released. But there was
evidence that other prisoners had been released without the prison informing
relevant agencies who were known to the prison and would be expected to
provide care and support to the vulnerable in the community.)

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this
report, namely by 22 September 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 mother of Sarah Reed and SLAM. | have also sent it to
HM Inspector of Prisons, the Prisons and Probation Ombudsman and NHS
England Liaison and Diversion Services, who may find it useful or of interest.

| 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.

28 JULY 2017 HH SIR PETER THORNTON QC

Responses

2 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 Noms (PDF)

Michael Spurr 

                                                                                                             Chief Executive 

        HM Prison & Probation Service 

            8th Floor 102 Petty France 

            London 

            SW1H 9AJ 

Sir Peter Thornton QC 
HM Assistant  Coroner 
City of London Coroner’s Court 
Walbrook Wharf, 
78-83 Upper Thames Street 
London, EC4R 3TD 

E-mail: coroner@cityoflondon.gov.uk 

25 September 2017 

Dear Sir Peter 

Inquest into the death of Sarah Reed 

Thank you for your Regulation 28 Report of 27 June 2017 following the conclusion of 
the inquest into the death of Sarah Reed.  I am responding to the matters of concern 
that  you  have  raised for  the  Ministry  of  Justice, including  Her  Majesty’s  Prison  and 
Probation  Service  (HMPPS)  and  Her  Majesty’s  Courts  and  Tribunals  Service 
(HMCTS).    I  understand  that  the  Central  and  North  West  London  (CNWL)  NHS 
Foundation  Trust  are  responding  separately 
to  your  concerns  about  Care 
Programme Approach (CPA) meetings, notifying the care coordinator of a prisoner’s 
release, and the recording of ACCT observations on SystmOne by healthcare staff. 

I  know  that  you  will  be  sharing  a  copy  of  this  response  with  Sarah’s  mother, 

,  and  I  would  like  first  to  express  my  sincere  condolences  for  her 
loss.  Every death in custody is a tragedy and the safety of those in our care is my 
absolute priority. 

 
 
 
 
 
 
 
            
 
 
 
 
 
 
 
 
 
 
 
 
 I  am  grateful  to  you  for  bringing  these  matters  of  concern  to  my  attention.    I  will 
address the issues that you have raised in the order that they appear in your report. 

Fitness to Plead Reports 
Your  first  concern  is  about  the  procedures  for  obtaining  and  providing  fitness  to 
plead psychiatric reports. 

Work  to  review  the  procedures  for  obtaining  and  providing  psychiatric  reports  is 
already underway, recognising the particular gap in relation to provision of reports for 
the purposes of fitness to plead.  Following your letter to 
, Chief 
Executive HMCTS, I can confirm that in July 2017 HMCTS and the Judicial Office re-
issued  existing  guidance  from  2010  on  this  process,  with  the  caveat  that  it  is 
recognised that some information may be out of date.  The Senior Presiding Judge 
has asked the Criminal Procedure Rule Committee to look at this issue with a view 
to providing greater certainty and clarity for the judiciary and court staff when dealing 
with psychiatric reports.  A working group under the Committee, involving a number 
of  agencies,  including  representatives  from  HMPPS  and  operational  staff  from 
HMCTS, has been set up to consider the issues further and is scheduled to meet for 
the first time in October. 

The  working  group  will  consider  new  practice  directions,  and  in  view  of  your 
concerns, it may decide to suggest new rules to govern the procedure on obtaining 
assessments  of  fitness  to  plead,  and  psychiatric  reports  for  sentencing  purposes.   
Even  though  listing  is  a  judicial  function,  the  working  group  may  also  recommend 
that new practice directions, or rules, should prescribe default time limits for steps to 
be taken and progress reviewed, subject to judicial adjustment in individual cases. 

I  should  add  that  the  Criminal  Procedure  Rule  Committee  is  an  independent 
statutory  body  chaired  by  the  Lord  Chief  Justice,  and  that  the  issue  of  practice 
directions  is  a  matter  for  the  Lord  Chief  Justice  himself  (who,  with  the  Senior 
Presiding  Judge,  has  convened  the  working  group  to  assist  and  advise  them).  
Therefore,  nothing  I  say  should  be  interpreted  as  prejudging  what  the  Rule 
Committee or the Lord Chief Justice may decide; but I am confident that they will act 
with your report firmly in mind. 

ACCT Reviews and Observations 
Your  next  concerns  are  about  ACCT  reviews  and  observations.    You  have  first 
suggested that HMPPS may wish to look afresh at improving the ACCT process by 
introducing  a  single  sheet  listing  ongoing  risk  and  assessment;  by  considering 
whether all those attending a review should be required to read the ACCT document 
in full; and by considering whether ACCT reviews should always be multidisciplinary 
and more consistently attended by the same personnel. 

The ACCT document is currently being redesigned with a view to its nationwide re-
introduction in early 2018.  As part of this redesign, we will consider your suggestion 
that a summary sheet of ACCT observations and conversations be included. 

Whilst  national  policy  acknowledges  that  in  certain  circumstances  it  may  be 
preferable to hold a review and make any necessary decisions promptly, rather than 

 
 
 
 
 
 
 
 delaying simply to allow a specific person to attend or contribute, it makes clear that 
there  must  be  continuity  of  membership  of  the  ACCT  multidisciplinary  team.    The 
basis for this is that team members can make a meaningful contribution only if they 
are  fully  briefed  and  familiar  with  the  prisoner’s  situation.    In  order  to  reinforce  this 
message,  a  learning  bulletin  (ACCT  -  Case  Reviews,  CAREMAPs  and  Levels  of 
Conversations  and  Observations)  was  issued  to  all  prisons  in  July  this  year.    The 
bulletin  reminded  staff  that  ACCT  review  meetings  must  be  multidisciplinary  and 
must take place within the specified timescales.  It further stated that that where any 
individual  involved  in  the  prisoner’s  management  cannot  attend  the  review,  they 
must submit written contributions. 

You  have  also  raised  the  issue  of  access  to  the  non-confidential  information  in  the 
healthcare records on SystmOne, and I understand that the CWNL NHS Foundation 
Trust  response  to  your  report  explains  how  their  staff  are  expected  to  share  this 
information with prison staff. 

You ask whether it is acceptable that a prison should be permitted to develop a local 
policy which is at variance with national policy.  I can confirm that it is not.  As you 
rightly state, under national policy, observations should be recorded immediately, or 
as  soon  as  possible  thereafter.    I  can  confirm  that  this  was  reiterated  in  a  learning 
bulletin  (ACCT  -  Conversations  and  Observations)  published  in  July  this  year,  to 
which you refer in your report. 

Care Programme Approach (CPA) Meetings 
Your next concern is about the scheduling of CPA meetings and attendance at them.  
Whilst  you  have  directed  this  concern  to  HMPPS,  CPA  meetings  are  controlled  by 
healthcare  providers,  and  whilst  we  stand  ready  to  assist  where  appropriate,  we 
would not necessarily expect to be involved in these meetings. I am aware that the 
CNWL NHS Foundation Trust has responded to you separately on this point.   

Prison visits 
You  have  also  raised  some  concerns  about  visits.    Specifically,  you  have  asked 
whether  the  decision  to  cancel  visits  should  be  made  at  Duty  Governor  level; 
whether  there  should  be  better recording  of  cancelled  visits  and  the  reason for  the 
cancellation; whether better information should be given to prospective visitors when 
a visit is cancelled; and whether special visiting arrangements could be made more 
often for prisoners who have exhibited problem behaviour. 

The  national  policy  on  visits,  Prison  Service  Instruction  (PSI)  16/2011  Providing 
Visits  and  Services  to  Visitors,  and  its  annexes,  provides  guidance  on  the 
cancellation of visits, stating that visitors must be informed at the earliest opportunity 
if a visit cannot be facilitated. 

The  PSI  also  states  that  unconvicted  prisoners,  such  as  Sarah  Reed,  must  be 
allowed  more  frequent  visits,  and  that  establishments  with  a  large  number  of 
unconvicted  prisoners  will  require  a  more  flexible  system  to  enable  rebooking  of 
cancelled visits. 

 
 
 
 
 
 
 
 Our current policies on visits do not provide specific guidance on the issues that you 
have  raised.    They  are  being  reviewed  and  the  issues  raised  will  be  considered 
when the new policy framework, due to be launched in the summer of 2018, is being 
developed.  In accordance with our general approach the framework will include less 
detailed prescription than the current policy, but it will provide guidance on how best 
to  support  families  and  friends  with  prison  visits,  including  in  relation  to  the  points 
that you have raised. 

We  are  also  working  to  ensure  that  the  recommendations  arising  from  the  Farmer 
Report,  The  Importance  of  Strengthening  Prisoners’  Family  Ties  to  Prevent 
Reoffending  and  Reduce  Intergenerational  Crime,  published  in  August  2017,  are 
implemented.    Work  has  already  commenced  on  the  development  of  a  strategy, 
which  will  take  forward  the  recommendations,  and  arrangements  have  been  put  in 
place to discuss progress with Lord Farmer on a regular basis. 

Notification of Prisoner’s Release. 
Your  final  concern  is  that  external  agencies  with  responsibility  for  the  provision  of 
care  and  support  are  not  routinely  informed  of  a  prisoner’s  release.    I  understand 
that the CNWL NHS Foundation Trust has also responded to you on this point. 

Our service specification ‘Manage the Custodial and Post Release Periods’ is clear 
that  all  individuals  in  custody  must  have  a  resettlement  plan  and  that  the  offender 
manager must ensure that external agencies are notified of a prisoner’s release.  All 
prisons are expected to adhere to this specification, but I know that it is not fully in 
place across the estate, and we are currently implementing a new model of offender 
management  in  custody.    This  includes  making  available  additional  resources  to 
ensure that there are dedicated staff in each establishment who can provide support 
to prisoners, including by facilitating their engagement with services prior to release.  
This is scheduled to be in place in all prisons by March 2019. 

Thank  you  again for  bringing these matters  of  concern to my  attention.   I trust that 
this letter has provided you with assurance that they are being addressed. 

Yours sincerely 

Michael Spurr

Response from Cnwl NHS Trust (PDF)

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

5 September 2017 

Her Majesty’s Coroner 
City of London 
Walbrook Wharf 
78-83 Upper Thames Street 
London EC4R 3TD 

Dear Mr Thorogood, 

Re: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS FOLLOWING 
THE INQUEST OF MS SARAH REED 

I write in response to the Regulation 28 Report, issued by HH Sir Peter Thornton QC, 
following the inquest into the death of Ms Sarah Reed.  

Central and North West London NHS Foundation Trust deeply regret the death of Ms 
Reed and the distress that this has caused her family.  

We have noted the matters of concern raised in the Regulation 28 Report. We accept 
these and below outline our responses to them, current processes and intended 
actions we intend to take over the next 12 weeks. 

A.  Fitness to Plead Reports 

We have had a discussion with Her Majesty’s Prison and Probation Service 
(HMPPS) who have agreed to clarify the process and procedure for the provision of 
psychiatric reports to Courts.  

Producing psychiatric reports, including in relation to fitness to plead and sentencing, 
is not something we do routinely within Offender Care services. Notwithstanding this, 
we fully accept that there was a delay in the communication to the responsible 
clinician in this case the request for this to be provided to the Court.  

Under normal circumstances, the request should be communicated to the Consultant 
carrying clinical responsibility for the service, and then a decision is made as to how 
best to undertake this work. If the Consultant is unable to complete this work, the 
Court is informed so alternative experts can be instructed.  

It now forms part of our Standard Operating Procedures that any requests for reports 
are communicated to the Consultant as soon as they are received; this includes 
instructions from the Court, defence solicitors, Crown Prosecution Service and/or any 
other relevant external agencies including Probation Services.  

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 B. ACCT Reviews and Observations 

CNWL Offender Care have developed a “Roles and Responsibilities for Attendance 
at ACCT Reviews” Local Operating Procedure for all of our staff at our prison sites. 
This has been written in conjunction with NOMS Prison Service Instruction 64/2011 
and has been operationalised at all of our prison sites.  

The aim of this document is to give clear guidance to all healthcare staff about what 
is expected before, during and after planned and unscheduled ACCT reviews.  

It is part of our procedures that registered healthcare professionals represent 
healthcare at ACCT reviews.  This includes registered nurses, psychologists, social 
workers, doctors and/or occupational therapists. Where a healthcare professional is 
not registered, for example a Healthcare Assistant or Mental Health Associate 
Practitioner, and is familiar with the prisoner, then they can attend in addition to the 
registered professional.  

Our procedures are comprehensive and explain:  

  Our response in hours and out of hours;  
  Who and how to update records both on prison systems and our own 

electronic patient record;  

  How we assess risk and complexity; and 
  What actions we take following a review and our role when making a decision 

to close an ACCT.  

Prior to attending an ACCT review it is the responsibility of the Healthcare 
Professional to review SystmOne notes and fully update themselves of the current 
situation, relevant history and risk factors in addition to any recent ACCT reviews.  

During the ACCT review the attending Healthcare Professional is expected to 
contribute to the review updating the multi-disciplinary team on any outstanding care 
map actions.  

The Healthcare Professional should be vocal in any concerns they have and ensure 
that they are documented within the ACCT review. This includes decisions regarding 
observation levels, which are considered jointly by the ACCT Manager and the 
attending Healthcare Professionals.  
Following the ACCT review, the Healthcare Professional is responsible for making an 
entry onto the medical records using the appropriate template in addition to the 
ACCT book. 

It is expected that all Healthcare Professionals attending ACCT reviews should have 
attended ACCT training provided by the prison and attend refresher training every 
three years.  

In addition, CNWL Offender Care has developed its own bespoke training for the 
management of harm and suicide in prison environments. This training forms part of 
our mandatory training list and is retaken annually by all staff. Across Offender Care, 

 
 
 
 
 
 
 
 
 
 
 
 
 we are currently 94% compliant with this requirement. Statutory and mandatory 
training compliance is monitored via internal CNWL quality systems.  

C. CPA Meeting 

Care Programme Approach (CPA) is the national framework for the mental health 
services assessment, care planning, review, care co-ordination, and service user and 
carer involvement focussed on recovery.  

The framework includes CPA and Lead Professional Care (LPC) arrangements. CPA 
is for those who have more complex needs, are at most risk or have severe and 
enduring mental illness. Lead Professional Care (LPC) is for people who need 
secondary mental health services but have more straightforward needs, for example, 
contact with only one professional or one agency requiring a more simple care plan.  

There is a lack of guidance specific to CPA in prison and as such, there lacks a 
consistent approach within prison mental health services nationally, not only in the 
allocation of cases to CPA, but also in the timing of reviews.  

Decisions about whether to allocate a particular case to CPA or LPC must be based 
on current assessment information and discussion in the care team, including 
services users and any carers involved. Where a prisoner is referred to the Mental 
Health Services and is already subject to CPA (from the community or a different 
prison) then it is expected that their care will continue under CPA. Where a person is 
awaiting transfer to hospital under Sections 47/49 or 48/49 of the Mental Health Act 
1983 (as amended), it is expected that they are managed under CPA.  

CNWL Offender Care services align our approach to CPA with current national 
practice. That is to say, any prisoner subject to CPA would be expected to have had 
a CPA review within 6 months of reception into custody, and further, a physical 
health check on an annual basis. We monitor this internally.  

Further, our prison services assess new admissions within five days of arrival unless 
considered emergency, where they would be seen within four hours, or urgent, when 
they would be seen within 48 hours. 

We are aware of the Jury’s conclusions in regards to medication management in the 
case of Ms Reed. Clinicians who prescribe are autonomous practitioners, making 
decisions and rationale for medication management.  They also use multi-disciplinary 
team discussions between clinicians to consider alternative when treating individuals 
who are mentally unwell.  

We accept that in this case a CPA meeting should have been arranged sooner. Ms 
Reed’s mental health and social functioning had deteriorated to the degree that this 
should have been prioritised. Further, we recognise that a CPA meeting would have 
allowed more detailed discussion regarding medication management.  

As a result of this case CNWL Offender Care has produced prison specific guidance 
highlighting these requirements which has been disseminated to all prison sites 

 
 
 
 
 
 
 
 
 
 
 
 
 
 regarding expectations around CPA management, for comment. We expect this to be 
formally ratified as a new policy by 1 October 2017.  

D. Visits 

We have had a discussion with HMPPS who have agreed to provide a response 
regarding the procedure for cancelling visits.  

E. Notification of a Prisoner’s Release 

A new discharge policy – “Continuity of Care on Release/Discharge or Transfer from 
Prison” has been written by CNWL Offender Care. This has been written in line with 
the recently published NICE guidance (Physical Healthcare of People in Prison 
(NG57) 2 November 2016, and will be used across all CNWL Offender Care sites. 
Once ratified, by 1 October 2017, the below will become standard and expected 
practice. 

In regard to carrying out a pre-release health assessment for people with complex 
needs, this will be led by primary healthcare and involve multidisciplinary team 
members and the prisoner. It will take place at least 1 month before the person’s 
planned release date. For people who may be in prison for less than 1 month, pre-
release health assessments will be planned during their second health assessment.  

The following is included in the care summary and post-release action plan for all 
prisoners:  

  Any significant health events that affected the person while they were in 

prison, for example new diagnoses, hospital admissions and instances of self-
harm;  

  Any health or social care provided in prison;  
  Details of any on-going health and social care needs, including medicines they 

are taking, mental health and/or substance misuse; 

  Future health and social care appointments, including appointments with, 

secondary and tertiary care, mental health services, substance misuse and 
recovery services, and, social services.  

The prisoner will be given a copy of the care summary and plan post-release and 
help given to those who are being released from prison to find and register with a 
community GP, if they were not previously registered. Before any individual with 
diagnosed mental health problems is released, we will liaise with services that will be 
providing care and support to them after they leave prison, for example referral to 
community mental health services, if appropriate, on release.  

This will include (as needed):  

  Primary care;  
  Secondary and tertiary specialist services (for example, HIV, TB, oncology);  
  Mental health or learning disability services; 
  Substance misuse services;  

 
 
 
 
 
 
 
 
 
 
 
   National Probation Service;  
  Community Rehabilitation Company (CRC);  
  Social Services;  
  Family or carers;  
  External agencies such as home care.  

Finally, there are a number of other areas that CNWL Offender Care continues to 
work across our estate to ensure the safety, effectiveness and responsiveness of the 
services we provide across our entire Offender Care estate. These include: 

Staffing, recruitment and workforce planning  

We have employed a dedicated Recruitment and Retention Lead for the directorate. 
All advertisements and job descriptions, including bank staff, have been updated. We 
are investing in recruitment incentives, such as welcome bonuses and enhanced 
benefits for staff. We monitor recruitment activity weekly and have relationships with 
regular temporary staff to ensure our units are safely staffed and we provide 
continuity of care. We continue to develop and innovate workforce planning by 
implementing new roles such as engaging pharmacists to run pharmacy-led clinics 
that support medication optimisation. 

Benchmarking 

Offender Care has been reviewed in line with recommendations set out in the 
“Learning from PPO investigations – Prisoner Mental Health, January 2016” and we 
are currently auditing against the recently released NICE guidance for prison primary 
and mental health service delivery. We are also currently finalising our suicide 
reduction strategy which will be completed for distribution amongst our prison estates 
by 1st October 2017. 

Training 

We have a range of training including statutory and mandatory, suicide and self-harm 
awareness, and, ACCT and continue to monitor staff compliance with it. Currently our 
Offender Care Services are 94% compliant with our statutory and mandatory training 
requirements. 

Learning lessons 

We have developed a Clinical Oversight Group to review all serious incidents. This 
group aims to reduce prisoner’s risk to self, 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 and learning 
actioned.  

The Trust has also recently launched an Offender Care Transformation Board with 
an ambition to ensure that all patients in a custodial setting have timely access to 
quality physical and mental healthcare services that meet their needs. The Board will 
drive strategy to reduce self-harm and avoid unexpected deaths. It will also seek 

 
 
 
 
 
 
 
 
 
 
 
 
 
 assurance that learning from inspections and Coroner reports are fully embedded 
across our entire Offender Care portfolio. The Board meets fortnightly and formally 
report to the Divisional Board and Trust Executive Board.  

Further, we continue to work closely with NHSE Commissioners to ensure that our 
services are commissioned and resourced appropriately to meet the level of acuity 
we are currently witnessing, both nationally, and within our service delivery units.  

I hope this provides you with sufficient assurance that the Trust has taken 
appropriate action following the death of Ms Reed, and has accepted the 
recommendations and continues to work to improve the service we provide.  If you 
have any questions or comments on the above please contact me directly on the 
numbers above.  

I would like to conclude by saying that the Trust is passionate about good health care 
in prisons.  Any failing or omission is taken very seriously and for the sake of future 
people we care for and in memory of Sarah Reed’s tragic death, we will work 
tirelessly to make improvements in care. 

Yours sincerely, 

Claire Murdoch 
Chief Executive 

cc:  

, Divisional Director of Operations, CNWL 
, Chief Operating Officer, CNWL 

, Interim Service Director, Offender Care, CNWL 

, Clinical Director, Offender Care, CNWL

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