Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0375, written 18 Dec 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Dec 2017 |
|---|---|
| Reference | 2017-0375 |
| Deceased | Mark Doyle |
| Coroner | Heather Williams |
| Coroner area | Inner North London |
| Category | State Custody related deaths |
| 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
MARK ANTHONY DOYLE (died 28 March 2017)
THIS REPORT IS BEING SENT TO:
1.
,
Acting Governor
HMP Pentonville
Caledonian Road
London N7 8TT
(See points (1) and (4))
2. Mr Michael Spurr,
Chief Executive
HM Prisons and Probation Service
Clive House
70 Petty France
London SW1H 9EX
(See point (4))
3.
Managing Director
Care UK
29 Great Guildford Street
London SE1 0ES
(See points (2) and (3))
1
CORONER
I am Heather Williams QC,
Assistant Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
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 April 2017 an investigation was commenced into the death of Mark Anthony Doyle,
aged 45 years old. The investigation concluded at the end of the inquest on 12
December 2017. The jury found that Mr Doyle died on 28 March 2017 at University
College London Hospital, as a result of injuries earlier sustained when he suspended
himself from the bars of his cell window at HMP Pentonville with a ligature. The jury
made a narrative determination that his intention at the time was unclear; and that his
death may have been caused or contributed to by errors in the identification and
recording of the anniversary of his son’s death on his ACCT; his inappropriate transfer
1
from F Wing; and an undue delay in responding to his cell bell on the evening of 21
March 2017. The medical cause of death was found to be: 1a post cardiac arrest
hypoxic ischaemic brain injury; 1b ligature compression to the neck.
4
CIRCUMSTANCES OF THE DEATH
See section 3 above; Mr Doyle was found suspended by a ligature attached to the bars
of his cell window on the evening of 21 March 207. Following emergency resuscitation
he was taken to University College London Hospital, where he remained until his death
on 28 March 2017 from injuries sustained by his suspension with the ligature.
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 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. –
(1) Although recent developments regarding multi-disciplinary involvement in ACCT
case reviews and quality assurance ACCT checks are encouraging (as described to me
by
, Head of Safer Custody), I remain concerned that the following failings
were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20
March 2017, but are not addressed / adequately addressed by the recent initiatives
(including the new Weekly Quality Assurance Check):
Insufficient appreciation of the importance of identifying and recording trigger
factors for a particular prisoner on their ACCT inside front cover;
Officers undertaking case reviews without reading recent entries on the ACCT
daily record relevant to risk;
Officers determining the frequency of observation levels for an ACCT prisoner
without considering relevant material in the ACCT file;
The ACCT reviewer failing to appreciate the value of involving at least one
member of the prison staff who knows the prisoner; and
Circumstances in which a prisoner’s family could or should be contacted as part
of the ACCT review process were poorly understood.
(2) Although,
, Head of Healthcare, described how healthcare
staff have received recent encouragement to make entries on a prisoner’s ACCT in
relation to matters that could bear on risk, I am concerned that this does not go far
enough to change past practice and ensure that relevant information is shared, in light of
the prison staff’s lack of access to System One records and the infrequent occasions
that Care UK staff made entries on Mr Doyle’s ACCT daily record.
(3) Decisions that prisoners are fit to be transferred from F Wing are made and
conveyed to prison staff by the charge nurse on duty that morning annotating by hand a
list of the prisoners on the Wing. There appears to be no clear criteria for assessing
when a prisoner is fit for transfer; the information that should be considered in making
this determination is left to the discretion of the decision maker; and there is no process
for recording the decision, the reasons for it or the identity of the decision maker in the
prisoner’s records or otherwise.
(4) There is no mandatory first aid training for existing (as opposed to new) prison
officers. I was informed that Orderly Officers and OSGs have / are being provided with
first aid training, but I am concerned this remains a serious lacuna. I appreciate it is a
nationally made resourcing decision and that it has been raised previously, but I raise it
for further consideration; in light of the limited number of prison and nursing staff on duty
overnight, there is a real prospect of medical emergencies arising where no trained first
aider is available.
2
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and/or
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 13 February 2018. 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons
, the sister of Mark Anthony Doyle (via her solicitors,
Hickman and Rose);
Barnett, Enfield & Haringey Mental Health NHS Trust
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
18 December 2017
3
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 HM Assistant Coroner Heather Williams QC Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 19 January 2018 Dear Madam, Regulation 28: Prevention of Future Deaths report, Mark Anthony Doyle (died 28 March 2017) Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Care UK on 18 December 2017 following the inquest into the death of Mr Mark Anthony Doyle at HMP Pentonville. Care UK would like to express its condolences to Mr Doyle’s family and friends. Care UK is the main provider of healthcare services at HMP Pentonville. I have addressed the issues you have directed to Care UK only which you have highlighted as paragraphs 5.2 and 5.3. The matters of concerns are highlighted in bold with the response set out below each concern. , Head of Healthcare, described how Matter of Concern 1: Although, healthcare staff have received recent encouragement to make entries on a prisoner’s ACCT in relation to matters that could bear on risk, I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff’s lack of access to System One records and the infrequent occasions that Care UK staff made entries on Mr Doyle’s ACCT daily record. Response: Following the inquest I have reflected and reviewed healthcare processes and there have been discussions within the healthcare team. Going forward we will ensure that the Local Operating Procedures (LOPs) are embedded, with senior management undertaking audits, to ensure that where any relevant risks and triggers are identified, we will share information with the prison in the following ways:– Update on C nomis – entry to be made by allocated healthcare staff Update the ACCT document and highlight any trigger points Share with Safer Custody team their the via functional mailbox SafercustodyPentonville@hmps.gsi.gov.uk. By sharing triggers with the Safer Custody team, healthcare can ensure that the senior managers on the landings and units are updated on what information has come through to their team. Care UK Health & Rehabilitation Services Limited - Registered in England No 10498997 Registered Office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex CO4 9QB Matter of Concern 2: Decisions that prisoners are fit to be transferred from F Wing are made and conveyed to prison staff by the charge nurse on duty that morning annotating by hand a list of the prisoners on the Wing. There appears to be no clear criteria for assessing when a prisoner is fit for transfer; the information that should be considered in making this determination is left to the discretion of the decision maker; and there is no process for recording the decision, the reasons for it or the identity of the decision maker in the prisoner’s records or otherwise. Response: We agree that the system described above requires improvement. We have therefore, with immediate effect, implemented a Patient Wing Movement Assessment. This is similar system to what we have in the in-patients unit as follows. All prisoners who are deemed necessary to be admitted to the Substance Misuse Unit will remain on the unit for a period of stabilisation and until it is deemed safe for them to be moved off this unit and to be placed on normal location. By default, prisoners should not be discharged from the in- patients unit for two weeks as a minimum. If someone needs to be moved from the unit then the senior manager and clinical lead (either a GP or Care UK employed Nurse Medical Prescriber) must review the patient’s notes and make a decision on whether or not they are fit to move. This decision and the reasons for it will be recorded in the new Assessment template in the patient’s SystmOne medical notes. “Ward rounds” and “review meetings” will be undertaken three times a week. All patients should be discussed in the review meeting and agreement reached and whether they are suitable or not to be moved from the unit and transferred to either E wing (an overspill wing for stable Substance Misuse Service clients) or to ordinary location. This ward round should always be attended by senior clinicians including either a GP or unit clinical lead. The discussion and outcome of the meeting will be recorded in the patient’s SystmOne notes and the decision shared with the wing officer so that they are aware of who can and cannot be moved from the unit. We are committed to providing a high quality healthcare service at HMP Pentonville and are doing everything we can to ensure those detained there are as safe as possible and receive the best quality care. We are committed to ensuring that the lessons learnt following this inquest are not just implemented at HMP Pentonville but across Care UK’s services. We trust that the above responses provide the information that you require but please do not hesitate to contact us if Care UK can be of any further assistance. Yours Regional Service Manager London & IOW prisons On behalf of Care UK Care UK Health & Rehabilitation Services Limited - Registered in England No 10498997 Registered Office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex CO4 9QB
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