Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0258, written 13 Jul 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Jul 2017 |
|---|---|
| Reference | 2017-0258 |
| Deceased | Edwin O’Donnell |
| Coroner | Andre Rebello |
| Coroner area | Liverpool & Wirral |
| Category | State Custody related deaths |
| Organisation named | Lancashire Care NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
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:
Michael Spurr
Chief Executive and Chief Executive Officer
HM Prison and Probation Service
Clive House
70 Petty France
London
SW1H 9EX
1
CORONER
I am André Joseph Anthony Rebello, Senior Coroner, for the area of Liverpool & Wirral
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 1st November 2016 I commenced an investigation into the death of Edwin Lewis
O'DONNELL, Aged 26. The investigation concluded at the end of the inquest on 3rd
July 2017 and subsequent days to the 13th July 2017. The cause of death was found
as:
Ia Asphyxia
Ib Compression of the Neck
Ic Hanging by a Ligature
The Jury concluded: -
Edwin Lewis O'Donnell died from an Accidental Death contributed to
by neglect. Mr O'Donnell was in a dependent position because of
incarceration. Edwin Lewis O'Donnell's death was contributed by neglect
relating to the following issues.
A) The events of the early morning of the 23rd October 2016 when Ned
said he would kill himself, we the jury agree there should have been an
Assessment Care in Custody and Teamwork (ACCT) review. This was a
failure.
B) On the early morning of the 23rd October 2016 the nurse completed a
ledger for the day staff to bring his entry to the attention of the Mental
Health Team. There is no evidence that this was acted upon. We the jury
agree there should have been a Mental Health assessment. This was a
gross failure.
C) Following the evidence the senior officer on duty was told Ned said he
would be dead by 8.00 p.m. The supervising officer should have called an
ACCT review. This was gross failure.
1
4
CIRCUMSTANCES OF THE DEATH
Mr Edwin Lewis O'Donnell has died from an accidental death. We, the jury find that it is
more likely than not, that Mr O'Donnell put himself in the position in which he was found
but did not intend to end his life. He put himself in this position for a reason which
inadvertently proved fatal.
Ned was known to numerous authorities throughout his life. It was documented that Ned
had a history of self-harm and was on a waiting list to engage with counselling services
whilst in prison. He was transferred to another prison and there was a failure to provide
that prison with relevant information.
On arrival, there was an inadequate handover of previous medical history and
insufficient available information to nursing staff, resulting in a lack of continuity of care.
Ned was not always consistent with his engaging of healthcare and mental health
services within the institution.
The first Assessment Care in Custody and Teamwork (ACCT) document was opened
when Ned began a fire in his cell, (23 September 2016). It is documented as an act of
self-harm. Ned stated he began a fire to be moved to the segregation unit, with no
intention of self-harm. The ACCT was closed.
The condition of the cells Ned resided in whilst in segregation were recognised by prison
staff as being not fit for purpose.
Ned had a history of drug use and we the jury find it more likely than not that Mr
O'Donnell was using synthetic cannabinoids during the days leading to his death. We
the jury conclude this contributed to his behaviour and presentation but did not
contribute to the fatal event.
On the 21st October 2016, the second ACCT was opened after Ned deliberately cut his
ear with a razor. The evidence states this incident of self-harm was a way of drawing
attention to his concerns about his health issues.
On the 22nd October 2016, following a multidisciplinary team meeting (first case review)
the ACCT remained open. Hourly observations were agreed upon.
In the early hours of the 23rd October 2016, Ned told prison staff that he was going to
kill himself, before someone else does. The prison officer informally increased Ned's
observations but this was not documented and there was a failure to effectively
communicate with other staff that observations had been increased.
Ned was seen by healthcare. Healthcare referred him for an emergency mental health
review. This referral was not acted upon.
During the day Ned engaged in extremely disruptive behaviour and protests along with
several other prisoners. There were allegations of bullying which we the jury conclude
did not contribute to his death.
Ned told a cleaner that he would be dead by 20.00 pm. The cleaner told a senior officer
on duty at the time of this information.
The senior officer on duly failed to escalate this information despite informally increasing
observations on Ned. Nothing was communicated to the following prison staff.
During the 23rd October 2016, we the jury agree Mr O'Donnell's state of mind was not
appropriately documented or communicated between prison staff.
When utilising the ACCT document, there were several failings: -
The evidence highlighted that there was an inconsistency and lack of understanding
with regards to the threshold of opening and reviewing an ACCT.
There were a number of missed opportunities to increase interactions/observations, or
call for an ACCT review.
The documentation was inappropriately completed, with interactions being documented
at regular intervals (e.g. hourly) and the level of initial level of risk not being identified.
The legibility of handwriting and signatures was unsatisfactory.
During a prison officer's first interaction with Ned at 18.00 pm, whilst completing a
required ACCT interaction, Ned did not engage verbally.
At 18.45 pm, Ned was unresponsive and out of view to the prison officer. The prison
officer escalated this as he was concerned.
Oscar (the orderly officer) was called, senior officers and other prison staff entered
Ned's cell.
Ned was unresponsive and hanging by a ligature from his tap.
Cardio pulmonary resuscitation was attempted and unsuccessful
Ned was pronounced deceased at 19.15 pm.
2
5
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. –
During the course of the inquest into the death of Edwin Lewis (Ned) O’Donnell
it was apparent that a nurse carrying out the first health reception screening was
not given access to the PER (Prisoner Escort Report) which had accompanied
the prisoner from another prison establishment.
a) The PER form had content which was pertinent to mental wellbeing
which was inconsistent with the information provided by Ned.
b) Though the previous prison indicated that they had sent a print from the
digital IMR System One the nurse conducting the first health reception
screening had no recollection or notes to indicate whether this was
available at the time of the screening.
c) There is expected to be a second health screening of inmates some 24
to 48 hours later – which enables information from the community to be
received and fuller informed access to the digital IMR System One. In
this case the second screening was not until the 27th March 2016.
Whereas the first screening was on the 9th March 2016.
d) An offender supervisor (Probation) working in the prison has been ACCT
trained but did not know that there was a low threshold for opening an
ACCT
The Court considers that in other cases important information in assessing risk
could be missed if action is not taken to remedy these matters by making it a
requirement that prison discipline staff record on C-Nomis all documentation
received with a prisoner in particular
PER forms
SASH forms
Printed summaries from System One
Prescriptions
C-Nomis should also be noted that these have been handed to (or copies have
been handed to healthcare in reception.
It could also be a mandated requirement that the digital IMR System One be
updated (possibly when the digital IMR System Two is rolled out if that is
imminent) with forced fields to ensure that nurses carrying out the first health
reception screening record the documentation provided by the Prison staff which
accompanied the prisoner.
The Court has heard evidence of the new training developed for the ACCT
protocol and that this is being rolled out in a prioritised manner within HMP
Liverpool. The Court considers it important that the Probation service takes
responsibility to ensure that (offender managers and supervisors) probation staff
working within prisons all receive basic ACCT training. Probation staff often
have to break unwelcome news and this must require a risk assessment of the
effects of that news on inmates.
3
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 with if necessary cooperation from other
parts of government.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by Friday 8th September 2017 at 16.00. 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
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons Ned O’Donnell’s family, HMP Liverpool, Lancashire Care NHS Foundation
Trust.
I have also sent it to the Prison and Probation Ombudsman
PPOFIIAdmin@ppo.gsi.gov.uk , HM Prison Inspectorate
hmiprisons.enquiries@hmiprisons.gsi.gov.uk who may find it useful or of interest.
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.
8
9
André Rebello
Senior Coroner for the
City of Liverpool
Dated: 13 July 2017
4
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.
Par Received HM Prison & Probation Service H.M. Coroner Michael Spurr Chief Executive HM Prison & Probation Service 5" Floor 102 Petty France London SW1H 9AJ Enait: ‘André Rebello OBE Senior Coroner Liverpool and Wirral Area HM Coroner's Court Gerard Majella Courthouse Boundary Street Liverpool L5 2QD 18 September 2017 Dear Mr Rebello Thank you for your Regulation 28 Report of 14 July 2017 following the recent inquest into the death of Edwin Lewis (Ned) O’Donnell on 23 October 2016. The matters of concern that you have raised are primarily the responsibility of HMPPS, but the issue of information sharing and recording is one that we manage in partnership with colleagues from NHS England and they have contributed to this response. | know that you will share a copy of this response with Mr O’Donnell’s family and | would like first to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. | am grateful to you for bringing to my attention your concerns about: the sharing of information between prison and healthcare staff in reception and the recording of that information; the timing of the second heaith screening; and suicide and self-harm prevention training for probation staff. | will address each of these issues in turn. Information Sharing and Recording : Your first concern is that the member of healthcare staff carrying out the first health screening for Mr O’Donnell did not have access to the Person Escort Record (PER). Following the investigation into Mr O’Donnell’s death, the Governor tasked the Heads of Operations and Healthcare at the prison with devising a process to address this. The Senior Officer in reception now provides a copy of the Person Escort Record (PER) to the healthcare member of staff based there, ensuring that they have access to all the relevant information. All reception staff, and healthcare staff who may work in reception, have been made aware of this process, and the.Head of Operations carries out spot checks to ensure that it is being followed. In addition, you have suggested that receipt of the PER, Suicide and Self Harm forms, prints from SystmOne (the electronic patient record) and prescriptions should be recorded on NOMIS, and that a note should be made on NOMIS that copies of the documents have been handed to healthcare staff in reception. This would be time . consuming for reception staff, and could involve changes to the NOMIS system that would come with a cost. On the basis that the system for sharing information with healthcare staff described above has been implemented, and that a PER is received with every prisoner who arrives at the prison, we do not believe it to be necessary to make these notes on NOMIS. . As well as highlighting any self-harm or suicide risk, the PER includes a healthcare assessment, and a record of any prescribed medication. Any open ACCT document also travels with the prisoner. An entry is made on NOMIS whenever an ACCT is opened or closed and the current and previous ACCT history is therefore. available to view by the receiving prison when a prisoner is transferred. The SystmOne record is also available to the receiving establishment on a terminal in the reception area. We are therefore confident that the system that has been introduced at Liverpool ensures that the relevant information is routinely available, shared with healthcare staff and recorded. The operation of this system is assured by management checks by the Head of Operations, and an additional copy of the PER is sent to the Safer Custody department who cross-reference it with the information held on NOMIS to ensure that nothing has been missed. Your final suggestion is that SystmOne be updated with mandatory fields to ensure that nurses carrying out the first health reception screening record the documentation provided by the Prison staff which accompanied the prisoner. | understand that NHS England is piloting the use of a set of six national clinical templates for SystmOne, including one for the reception screening process, that support the recently published NICE Guidelines NG57 (Physical Health of People in Prison and NG66 (Mental Health of Adults in Contact with the Criminal Justice System). The development of the templates and the user guides that accompany them has been informed by learning from investigations into serious incidents, including deaths in custody, and will reinforce the need for nurses carrying out the first health reception screening to record the documentation that accompanied the prisoner. An evaluation and review of feedback from the pilot will take place this autumn prior to a full national rollout during 2078. Timing of the Second Health Screening Your second concern relates to the delay in Mr O’Donnell’s second health screening. | understand that the Head of Healthcare at Liverpool and a member of the prison’s senior management team are meeting shortly to re-evaluate current practices and implement revised procedures to ensure that second health screenings take place within 24-48 hours. Suicide and Self-Harm Prevention Training for Probation Staff Your final concern is that a Probation Officer at the prison had received ACCT training but was unaware of the threshold for opening an ACCT. The individual concerned has been reminded of the circumstances under which it is appropriate to open an ACCT. You have drawn attention to the importarice of training for probation officers, and noted that HMPPS is rolling out revised suicide and self-harm training for staff. | can reassure you that this training is being rolled out at pace to all staff with prisoner : contact, including probation officers. At Liverpool the training is being delivered at the ‘Academy Training Days’ which take place twice monthly. Thank you again for bringing these matters of concern to my attention. We will ensure that learning from this tragic incident is shared widely across the prison estate. Yours sincerely Michael Spurr
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