Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0063, written 2 Mar 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Mar 2018 |
|---|---|
| Reference | 2018-0063 |
| Deceased | Emily Hartley |
| Coroner | David Hinchliff |
| Coroner area | West Yorkshire (East) |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
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: 1. Mr Michael Spurr, Chief Executive National Offender Management Service, 7 Floor, Clive House, 70 Petty France, London, SW1H 9EX 2. Rt Hon Jeremy Hunt, Secretary of State for Health, Department of Health, Richmond House, 79 Whitehall, London, SW1A 2NS CORONER | am David Hinchliff, Senior Coroner, for the Coroner area of West Yorkshire (East) 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 26" April 2016 | commenced an investigation into the death of Emily Jayne Hartley age 21. The investigation concluded at the end of the inquest held on 15" January 2018 until 1* February 2018 before a Jury. The conclusion of the inquest was in narrative form, a copy of which is attached. CIRCUMSTANCES OF THE DEATH Emily Jayne Hartley was a serving prisoner at Her Majesty’s Prison New Hall. On Saturday 23% April 2016 Emily was allowed out of the confines of the winged building for exercise. She was recorded as being on exercise at 15:00 hours that day, yet CCTV material shows that she left the wing at 14:24 hours with other prisoners. They left the wing through the main wing entrance door and were on exercise. The exercise area extends to the rear of the winged building which is itself a large detached two story block with a grassed area at the rear surrounded by a high perimeter fence. There was a part of this area declared to be “out of bounds” and Emily would have been aware of this. Nevertheless this area can be easily accessed. Once exercise is complete the prisoners should be counted back onto the wing. At 16:45 hours staff realised that Emily had not collected her meal and she could not be found. It was apparent that Emily had not returned to the wing. At 16:50 hours following a perimeter check Emily was located suspended from a torn piece of bed sheet fastened to a steel security gate in a recessed area in the out of bounds section. Emily was cut down, CPR was commenced by prison staff which was continued when Paramedics arrived. Her death was confirmed by Paramedics at 17:43 hours at that location. Emily was the subject of an ACCT plan (assessment, care in custody and team work) and should have been observed at twice per hour intervals. Emily had mental health issues and suffered from an emotionally unstable borderline personality disorder which made her impulsive and prone to self-harm and suicide. Concerns were expressed that the management of self-harm and suicide procedures, in particular the monitoring and recording were seriously deficient and that some of the noted failings were systemic. Information sharing was weak, there was a lack of integrated planning. The supervision of Emily when she died and whilst on Suicide prevention was so poor that she was not found for nearly two and a half hours. There were allegations of bullying when she was on a wing designated as being a therapeutic setting. 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. — (1) It became apparent from the evidence of many Prison Officers and Healthcare Workers that Prison was not the appropriate environment for someone with Emily's mental health problems. The emphasis should have been on treatment but within a secure environment which Prison, with the most well intentioned staff, cannot adequately provide. (2) Coincidentally ten years ago | heard an Inquest into the death of Petra Blanksby, also at New Hall Prison. At the conclusion of this Inquest | made a recommendation pursuant to what was then Rule 43 of the Coroner's Rules 1984. | attach a copy of my Rule 43 recommendations which | repeat in every detail in respect of the death of Emily Jayne Hartley. Furthermore | state that a Prison is not the appropriate place to accommodate Emily and that there should be facilities, particularly in the Prison’s female estate, to provide a therapeutic yet secure environment with the emphasis being on treatment. | repeat ten years later that the Prison’s department and the Department of Health should conduct a collaborative exercise io achieve ite provision of suitable, secure, therapeutic environments in order to treat those with mental health problems of the nature of those demonstrated by Petra Blanksby ten years ago and now Emily Jayne Hartley. | would refer you to a paper prepared by “Inquest” entitled Preventing the Deaths of Women in Prison and the Need for an Alternative Approach which was published in June 2013 and also a report a review of Women with Particular Vulnerabilities in the Criminal Justice System. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe that your organisation 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 27" April 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- of Harrison Bundey Solicitors Mills & Reeve Solicitors of A2 MOJ Private Law Litigation lam 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 | 2™ March 2018 A b, - 2
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.
ae HM Prison & Probation Service Michael Spurr Chief Executive HM Prison & Probation Service 5" Floor 102 Petty France London SW1H 9AJ E-mail: ceohmpps@noms.gsi.gov.uk David Hinchliff Senior Coroner for the County of West Yorkshire (Eastern District) HM Coroners Office 71 Northgate Wakefield WF1 3BS E-mail: hmcoroner@wakefield.gov.uk 18 May 2018 Dear Mr Hinchliff Inquest into the death of Emily Jayne Hartley Thank you for your Regulation 28 Report of 2 March following the conclusion of the inquest into the death of Emily Jayne Hartley. | am responding to the matters of concern that you have raised for Her Majesty's Prison and Probation Service (HMPPS). | have liaised with colleagues in the Department of Health and Social Care (DHSC) to provide a joint response that has been cleared by the Minister responsible for Regulation 28 Reports within the Department. | know that you will share a copy of this response with Emily's family. | would first like to express my sincere 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 your concerns to my attention. You have said that because of her mental health problems, a secure facility with an emphasis on treatment would have been a more appropriate environment than prison for Emily. You have also repeated the recommendation that you made ten years ago, at the conclusion of the inquest into the death of Petra Blanksby, about provision within the female prison estate of a suitable and secure therapeutic environment for the treatment of women with mental health problems. Since the publication in 2007 of Baroness Corston’s report, to which you refer, significant progress has been made in the management of female offenders in the criminal justice system. In recognition of their specific needs, the Government is developing a strategy to improve outcomes for women both in the community and in custody, building on the principles set out in Baroness Corston’s report, and will publish this in due course. This is a complex issue and one that the Government is committed to getting right. It might be helpful to explain first that Liaison and Diversion services, commissioned by NHS England, are now operating across most of England. Clinical staff at police Stations and courts identify those with mental health problems and other vulnerabilities, undertake assessments and make referrals to treatment and support and provide information to inform charging and sentencing decisions. When appropriate, this enables offenders to be diverted away from the criminal justice system altogether, or for a community sentence with a mental health treatment requirement to be imposed instead of a custodial sentence. In August last year the HMPPS Women's Team published a practice guidance document, Working with Women Offenders, to help practitioners deliver services to women in a way that captures and reflects best practice, including advising staff of the factors to be taken into account at every stage of contact with a female offender. The guidance emphasises the benefits of community sentence options for women, particularly where they have caring responsibilities, and work is ongoing to reduce the use of short custodial sentences through the provision of bespoke community sentences that are more suited to women's risks and needs. We are continuing work to improve the quality of pre-sentence reports for women, including providing better and more easily accessible information about sentencing options to probation staff responsible for writing the reports. We will also be issuing further guidance and examples of good practice based on the findings of a pre- sentence report audit undertaken earlier this year. When women are committed to custody, we want to provide the best rehabilitative regimes possible in order to break the reoffending cycle. In 2016, we changed the way that the female custodial estate was managed, from a geographical to a functional model, facilitating closer working between the prisons and more sharing of good practice. All women’s prisons are resettlement prisons so that women are situated as close to home as practicable taking into account the interventions needed to further their rehabilitation. We are also developing a bespoke model for offender management within the female custodial estate. This will capture information about the factors, including the risk of serious harm, relevant to each female offender, to inform decisions about the level and nature of the resources needed to manage and support them. As part of our continuing work to support those with the most complex needs, including mental health problems, a Centralised Case Supervision (CCS) system was established by HMPPS in September 2015. It is designed to provide centralised supervision for women who have difficulties engaging with mainstream offender management and prison processes. A multi-disciplinary forum ensures that they have access to the most appropriate interventions and regimes available. We plan to review the system later this year in order to identify areas of good practice which might be more widely utilised as well as possible improvements and learning points. A strategy for improving the care and management of female offenders with personality disorders, jointly planned and delivered by HMPPS and NHS England, was implemented in 2013. It increases the availability of, and access to, specialised personality disorder services including a therapeutic community at HMP Send, and supports staff to develop their knowledge, skills and confidence in working with female offenders with personality disorders. The programme also offers enhanced community-based services for female offenders, including the delivery of community- based treatment programmes, specialist case management and mentoring and advocacy services. HMPPS has committed to developing a trauma-informed approach to working with women, given that a high proportion of them will have experienced some degree of trauma during their lives. We have started a programme to ensure that staff in women’s prisons are able to understand and respond to behaviours arising from a history of trauma and we are looking at how the key learning from this approach can also be embedded in training for probation staff managing women offenders. We have a wide-ranging Prison Safety Programme that is co-ordinating our activity to address the issues of violence, self-harm and self-inflicted deaths. As part of this programme, we have begun rolling out revised and improved Introduction to Suicide and Self-harm Prevention training for new and existing staff. The training comprises six modules including mental health awareness training, which is of particular importance to increase the confidence and skills of staff in supporting prisoners in distress and in raising their awareness of mental health issues. Over 15,500 new and existing staff have been trained in at least one of the six modules, and over 7,000 have completed the training in full. In partnership with Samaritans we have launched a new suicide prevention learning tool that is designed to give staff more confidence in engaging with prisoners who may be at risk of suicide, and we recently refreshed our partnership with Samaritans, guaranteeing funding for their valuable Listeners Scheme until 2021. In terms of the specific needs of women, The National Institute for Health Research has recently granted funding unti! December 2021 to Manchester University to enable them to deliver a psychodynamic interpersonal therapy (PIT) programme to female offenders to determine whether it is effective for women who self-harm in prison. The therapy which has been shown to reduce depression and suicidal ideation and self-harm in the community will be delivered to 262 female offenders across 7 female prisons. Manchester University will evaluate the effectiveness of PIT. At Eastwood Park prison a Rapid Response Project is being piloted to work with women who are prolific self-harmers and who do not meet the criteria for other services. We are also working with Public Health England to assist each female establishment to develop its own suicide prevention plan. The intention is to improve access to and engagement with community based services, especially offenders vulnerable to suicide and mental health problems. Finally, NHS England has also developed a Ten Point Plan for Mental Health which will describe how the secure care pathway can be improved to ensure it works more effectively and efficiently. This includes new guidance (including standards) for transfers and remissions between prison and hospital (which will ensure that recommended transfer timescales for adult prisoners with severe mental health problems are based on clinically informed evidence and patient need), improved data and performance monitoring, and learning from existing good practice in secure services and prisons. The plan is due for publication imminently and will be implemented during 2018-19. A considerable amount of valuable work is being done in the area of improving provision of services for women in custody with mental health problems. Please be assured that | am aware of the importance of this issue and will keep it under review, alongside heaith colleagues, in order to identify any further steps that can be taken to improve work in this area. Thank you again for bringing this matter of concern to my attention. Please be assured that learning from the circumstances of Emily Hartley's tragic death will be shared widely with colleagues across the prison estate, NHS England and the Department of Health and Social Care. Yours sincerely M, Chot Spurs MICHAEL SPURR
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