Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0379, written 20 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 | 20 Dec 2017 |
|---|---|
| Reference | 2017-0379 |
| Deceased | Craig Royce |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| Category | State Custody related deaths · Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Essex Partnership University 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.
ANNEX A 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: Her Majesty’s Prison Service Care UK Essex Partnership University NHS Foundation Trust Bindmans Solicitors Phoenix Futures 1 CORONER I am Caroline Beasley-Murray, senior coroner, for the coroner area of Essex 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 29 December 2016 I commenced an investigation into the death of Craig David Royce. The investigation concluded at the end of the inquest on 12 December 2017. The conclusion of the inquest was:- Craig David Royce died as a result of an accident whereby he committed a deliberate act which unexpectedly and unintentionally led to his death. We the jury believe Mr Royce’s risk of self-harm/suicide was not properly reviewed with appropriate precautions taken to manage the risk 4 CIRCUMSTANCES OF THE DEATH Craig Royce, who was 46 years old at the time of his death, had a long history of mental health problems and he also suffered from epilepsy. On 15 August 2016 he was remanded in custody to HM Prison Chelmsford. On 26 October 2016 he was sentenced to 20 months imprisonment. During his time in custody he was subject to three ACCT processes and on the evening of 24 December 2016 he we found hanging in his cell. The medical cause of death was 1a) Hypoxic brain injury b) Suspension. After an incident of self-harm on 16 October 2016 he was placed on the second of these ACCTs and a note within the documentation reads “refer to MH”. It would appear that no referral to the mental health service was made. 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. – There is no form/template to deal with the situation of a prisoner who needs to be referred to the mental health service. Reliance upon the transfer of this vital information to Healthcare by means of a telephone conversation could be unreliable. A robust, simple documentary system is required for the communication of such important information, namely that a prisoner needs to be referred to mental health services for an assessment to be carried out by mental health services. This would be distinct from the TAG system which caters for a brief assessment to be relayed across. 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 working days of the date of this report, namely by 12th March 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 – Bindmans, (solicitors for the family), Phoenix Futures 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 20 December 2017 HM Senior Caroline Beasley-Murray
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.
NHS} Essex Partnership University NHS Foundation Trust 20 February 2018 SM/BW/20 Trust Head Office The Lodge Lodge Approach CONFIDENTIAL inary Mrs Caroline Beasley-Murray Essex SS11 7XX HM Senior Coroner Seax House, Coroner’s Court et Tel: 01268 739677 Victoria Road South SC aaa a ye a Fax: 01268 739675 Chelmsford CM1 1QH : Ba Email: sally.morris@eput.nhs.uk 2 3 FEB 2018 fad Chair: Professor Sheila Salmon e ea tee Chief Executive: Sally Morris NAwweye gers 2 SEE Dear Mrs Beasley-Murray | am writing to set out the formal response to the Regulation 28: Report to Prevent Future Deaths, dated 20 December 2017, which was issued following the inquest into the death of Mr Craig Royce. When Mr Royce died in December 2016, the prison healthcare service was provided by Care UK. Essex Partnership University NHS Foundation Trust (EPUT) began providing the service from May 2017. | am the Chief Executive of EPUT, but have no connection with the previous service provider. | would like to begin by extending my deepest condolences to the family of Mr Royce. This has been an extremely difficult time for them. | hope this response provides them, and you, with assurance that the Trust regards the situation seriously and has taken action to address the issue raised in the report. In response to the matter of concern relating to the former provider of the prison healthcare service; | can confirm that since EPUT took over the service in 2017 a robust documentary system for referral of prisoners to mental health care has been put in place across the prison. A referral form had been used for some time by GPs and nurses in the prison healthcare team, but EPUT ensured the availability of this form was widened significantly. It is now used by the entire prison staff in every department and other staff associated with the care of prisoners. The form is used to make a full and direct referral for mental health assessment and care. In an emergency, referrals to mental health will be taken by telephone still, but MUST be followed up using the form to make a written referral. The mental health referral form is available via the prison’s IT system. Paper copies are provided on all wings of the prison too. Safer Custody, a department of the prison, is responsible for ensuring these are constantly available. It is distinct from the TAG system. | would like to finish by reiterating my condolences to Mr Royce’s family at this very sad time. | hope this response goes some way to providing assurance that the Trust regards their loss very seriously and has taken steps to address the issue of concern about the mental health care referral system in place under the previous provider. Yours sincerely Sates |} IS es SALLY MORRIS Chief Executive
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