Anthony Paine

Michael Spurr 

                                                                                                             Chief Executive 

        HM Prison & Probation Service 

            8th Floor 102 Petty France 

            London 

            SW1H 9AJ 

                      Email: ceohmpps@noms.gsi.gov.uk 

Andre Rebello 
Senior Coroner 
The Coroners Court and Offices 
Liverpool and Wirral Areas  
Gerard Majella Courthouse 
Boundary Street 
Liverpool L5 2QD 

5 June 2018   

Dear Mr Rebello, 

Thank you for your Regulation 28 Report of 23 March 2018 following the recent 
death of Anthony Paine at HMP Liverpool on 19 February 2018.  I am responding on 
behalf of the Secretary of State for Justice and Her Majesty’s Prison and Probation 
Service (HMPPS).     

I know that you will share a copy of this response with Mr Paine’s family and I 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.   

You have expressed concerns that the healthcare provision in HMP Liverpool is 
inadequate, insufficient and not equal to that provided in the community and also that 
mental health care provision is grossly deficit.  You question why, when the prison 
could not replicate his community mental health care plan, there was no mental 
health act assessment carried out in Mr Paine’s case with a view to transferring him 
to a secure mental health facility. I understand that NHS England have responded 
directly to these concerns. 

In response to your concern that HMPPS and the Ministry of Justice were aware of 
the matters referred to in point two of your Regulation 28 report. HMPPS is 

 
 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
 
 
 
                                                                                                           
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 committed to ensuring that healthcare provision in prisons is equal to that delivered in 
the community. The National Partnership Agreement in place with NHS England, 
considers the reduction of incidents of self-harm and self-inflicted deaths to be a 
priority and we continue to work collaboratively to make improvements in this area. 
From 1 April 2018 responsibility for the healthcare provision at HMP Liverpool 
passed from Lancashire Care NHS Foundation Trust to a new provider, Spectrum 
Community Health CiC (Spectrum), in partnership with Mersey Care NHS Foundation 
Trust, who are current providers of mental health community services in Liverpool. 
This will provide a consistent approach to the continuity of care for people within the 
criminal justice system. Spectrum currently provide healthcare across six prisons in 
the North of England. 

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

“17 7

Y

England 2A

a

Professor. Stephen Powis
National Medicai Director

Mr A. J. A. Rebello OBE Skipton House

Senior Coroner ’ 80 London Road

Liverpool and Wirral Coroner Area : SE1 6LH

Gerard Majella Courthouse Received

Boundary Street

Liverpool 2 9 MAY 2018

L5.2QD Lif” May 2018
H.M. Coroner

Dear Mr Rebello .

‘

Re: Report to Prevent Future Deaths (Regulation 28) concerning the death
of Mr Anthony Paine, who died at HMP Liverpool on ag” February 2018.

Thank you for your letter and Regulation 28 Report (“Report”) issued on Friday
23" March 2018 which was received on Tuesday 27" March 2018 following the
inquest into the death of Anthony Paine. | would like to express my deep
sympathy to Mr Paine’s’ family.

In your report you raised concerns regarding:

1. The mental healthcare provision of HMP Liverpool provided by Lancashire
Care NHS Foundation Trust, as being inadequate and insufficient and is
not in parity with the provision in the community.

.2. That Her Majesty's Prison and Probation Service (HMPPS), the Ministry of
Justice (“MoJ”) and NHS England are aware of this as evidenced by the
number of fatal incident investigations that have occurred over the last few
years.

3. When a prisoner experiences an enduring mental health illness for which
he has a community mental health care plan, you ask, why there was not
a Mental Health Act assessment and transfer to a secure mental health
facility to keep him safe.

The provider of healthcare services in HMP Liverpool at the time of the incident
was Lancashire Care NHS Foundation Trust (“LCFT”) who served notice on their
contract and are no longer providing services in HMP Liverpool with effect from
31° March 2018.

A procurement process has taken place and the contract has been awarded to
Spectrum Community Health CiC (“Spectrum”), who currently provide healthcare
across six prisons in the North of England. This contract.commenced on 1* April
2018. Spectrum have subcontracted the Mental Health provision in HMP
Liverpool to Mersey Care NHS Foundation Trust, who are also the current
providers of the local community services for mental health and also the Liaison
and Diversion service in Liverpool, ensuring a consistent approach to the
continuity of care for people entering and leaving the criminal justice system.

High quality care for all, now and for future generations

. pre \,

NHS England (North) has reviewed the fatal incidents that have occurred in HMP
Liverpool over the previous two yéars and are currently working with the new
provider Spectrum to ensure that learning for health is evident from these deaths.

’ The remedial action plans for previous deaths in custody are reviewed and
managed as part of the quarterly contract review meetings. In the previous two
years there have been twelve deaths in HMP Liverpool of which six have been
considered as self-inflicted. Each death is regrettable and NHS England
acknowledges are also potentially preventable.

In addition to the above, NHS England (North) has regular clinical quality visits
which supports health commissioners to obtain assurance that all the
recommendations from action plans have been adhered to and that, where
required, practice has changed or improved. This will be evidenced by reviewing
policies, procedures, reviewing practice and service delivery.

The NHS England Health and Justice Nursing and Quality Leads meet on.a
quarterly basis and review the learnings from deaths in custody reports. Once the
independent investigation has been concluded into this death the report will be
shared at the next meeting, following the report and action for national learning
will be agreed and implemented. There are also opportunities within NHS
England to share the learning from this report with other healthcare
commissioners. —

NHS England (North) currently have a multi-agency project board in place to
oversee the smooth transition of change of the healthcare provider. Patient
safety is a core feature of the project plan, which is monitored monthly by the
project board. In addition, patient safety is embedded in the quality framework,
which is reviewed and monitored quarterly as part of the quarterly contract review
process, supported by quality assurance visits of the healthcare provision. The
management of recommendations from previous death in custody reviews and
Regulation 28 Prevent Future Death Reports will continue to be managed within
the quality framework with the new provider, ensuring that they are accountable
for the safety of patients within their care, and that learning from previous deaths
is shared across the organisation.

NHS England (North) are awaiting the outcome of the independent investigation
to determine whether the care provided to meet Mr Paine’s mental healthcare
was in accordance with his assessed need.

Nationally NHS England and its partners Ministry of Justice (“MoJ”), HMPPS,
Public Health England (“PHE”) and the Department of health and Social Care
(“DHSC”) have signed up to a revised National Partnership Agreement! (NPA)
covering 2018 — 2021 for healthcare services in prisons. The partnership
agreement on prison healthcare has been in place since 2013 and supports the
commissioning and delivery of healthcare in English prisons. The revised NPA’
sets out our commitment to working together and sharing accountability for
delivery through linked governance structures and core objectives and priorities"
for 2018 — 2021. Priority one is to continue to work collaboratively to improve

1 https:/Awww.qov.uk/quidance/healthcare-for-offenders
High quality care for all, now and for future generations

practice and reduce incidents of self-harm and self-inflicted deaths in the adult
secure estate by strengthening multi-agency approaches to managing prisoners
at serious risk of harm and further embedding shared learning.

Collectively, the partnership objectives are to improve health and reduce health
inequalities; support rehabilitation and reduce reoffending, and enable continuity
of care across health and justice care pathways.

Nationally NHS England is completing a programme of work to refresh all health
and justice service specification, which the regional health commissioners
procure services against. The mental health service specification refresh has
been completed and published in March 2018. This refresh entailed redesigning
the structure of the specifications to allow them to be more easily adapted to the
defined needs of the individual prison population. The new provider, Spectrum
has reviewed the new specifications and are currently benchmarking against
them as part of the new model development work ongoing with partners at HMP
Liverpool. We anticipate that this work will be completed by the end of June
2018. - ;

In addition to the work NHE England is undertaking in partnership with HMPPS

- and PHE to improve and redesign services for people in prison with mental’
heaith needs we are revising the approaches to secure hospital transfers
ensuring when a person needs to be in a hospital setting for their mental health
needs this is done in a coherent, timely and appropriate manner. As part of this,
a comprehensive ten-point plan “Right Care, Right Place, Right Time” for the
transfer and remission of prisoners under the Mental Health Act is being
developed.

| hope the information above addresses the concerns you have raised within your
Report and provide you with assurances that NHS England is working with our
healthcare providers to make improvements to the provision of healthcare in
HMP Liverpool, and the wider prison estate.

Yours sincerely,

ane (de

Professor Stephen Powis
National Medical Director
NHS England

High quality care for all, now and for future generations