Andrew Craig

Core &

C/O Healthcare
HMP Guys Marsh
Rachael C Griffin Shaftesbury
HM Senior Coroner for Dorset Dorset
The Coroner’s Office for the County of Dorset SP70AH
Town Hall
Bournemouth
BH2 6DY

By email: coroner@bournemouth.gov.uk

7" August 2018

Dear Madam,

Regulation 28: Prevention of Future Deaths report, Andrew Craig
Your Ref: RCG/03237-2016/LJ

Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Care UK on 25"
June 2018 following the inquest into the death of Mr Andrew Craig at HMP Guys Marsh, who
sadly passed away on 16" September 2016. Care UK would like to express its sincere
condolences to Mr Craig's family and friends.

As of 1“ April 2017, Care UK has. been the..main provider of healthcare services at HMP Guys
Marsh. There is a sub-contracting arrangement in place with EDP Drug and Alcohol Services in
respect of the provision of the substance misuse service. This response addresses the matters of
concern in so far as they relate to Care UK. For ease, we have outlined some actions that the
prison service has agreed to undertake insofar as they impact on healthcare. Our response should
also be read in conjunction with the separate response from the prison service.

The actions below form part of the overall action plan across healthcare and the prison service.

The matters of concern which you raised are highlighted in bold with the response set out below
each concern.

Matter of Concern 1:

The use of drugs on the Units at HMP Guys Marsh is rife and these drugs can be
transferred between inmates at any time. One of the occasions when prescription
drugs can be concealed in order that they can distributed by Prisoners, is following
the dispensing of medication at the Healthcare Unit's medication hatch.

Care UK Health & Rehabilitation Services Limited - Registered in England No 10498997
Registered Office: Connaught House, 850 The Crescent, Caichester Business Park, Colchester, Essex CO4 90B

Care &

Response:

We are aware that medication is diverted from the Healthcare department and we have already
implemented a number of factors that will help to reduce this.

We have CCTV working in this area and we follow the adjudication process if diverting of
medication is observed. All healthcare staff understand that if they suspect a patient is concealing
medication then they can confront the patient and ask them to show the evidence that the
medication has been swallowed. However, we don’t think it is practical or appropriate to embed
this practice into every individual medication administration. The prison service is looking at
creating a specific job description for the officer working within the healthcare department which
will improve the management of behaviour in the medication queues and help prevent diversion.

Action: See below table which outlines the actions that have been implemented:

Objective Immediate action Training To be completed by
Review the role and New Job Description n/a Prison Service
responsibilities of the that identifies the

officer working within expectations and

healthcare. responsibilities.

Ensure staff have the All relevant staff invited | RCGP online Healthcare

relevant substance to partake in the RCGP | substance misuse

misuse training to Substance Misuse training. Completed 27" June
identify diversion training to enhance 2018

techniques and understanding.

understand behaviours.

ISMS agreed to provide | ISMS department
a training package to all | to arrange in
healthcare staff. house training. November 2018

Matter of Concern 2

Evidence was given by the Head of Healthcare, 2: there are 3 allocated
times during the day when Prisoners collect medication. During these times, there are
around 70 prisoners collecting their medication. The room can be quite chaotic and loud,
and prisoners can be in close contact clambering over each other. She described the hatch
as overloaded. This is an ideal scenario to pass medication to one another without
detection.

Response:

We have made some changes to our practice already to improve this situation. We have reviewed
our prescribing in line with the ‘in Possession Policy’ and as a consequence, the number of
prisoners in receipt of supervised medication in the morning and evening has been reduced to
approximately 55 patients per medication dispensing times.

Cara UK Heallh & Rehabilitation Services Limited - Registered in England No 10498997,
Registered Office: Connaught House, 850 The Crescent, Colchestei Business Park, Colchester, Essex CO4 SQB

Cafe &

We have marked the floor in front of the dispensary with a large green box that indicates to the
patients where they are able to stand, in order to respect confidentially and allow for patient

privacy.

The healthcare staff are aware that they must not start medication rounds until there is a prison

officer present.

The prison service coordinates and controls the level of attendance for medication by calling
individual units to send their patients. However, we acknowledge that we need to manage this
better and have requested that smaller numbers attend so that the healthcare waiting area doesn't

get overcrowded.

A medication list is sent to each unit every day and only the patients on this list should be allowed

to collect medication.

Action: We have implemented the actions outlined in the table below:

Objective immediate action To be completed by
Place written guidance on Make a poster that clearly Healthcare

individual dispensaries to educate | advertises the purpose of the

the purpose of the green box. green box. 23" July 2018
Ensure officers enforce patient Officers to encourage prisoners | Prison Service
confidentially and privacy to to respect other prisoner's

prevent potential bullying of personal space to prevent

vulnerable patients. bulling and knowledge of

personal information.

Continue to monitor Not lh Review NIP patients during
Possession (NIP) status of patients | medication management
and change to weekly or monthly meeting. Patients booked for
possession when safe to do so. review with pharmacy
technicians if appropriate
changes could be made.

Healthcare

Review the process of coordinating | Create a new job description for
and controlling the amount of the Prison Officer detailed to
patients in the healthcare waiting work within healthcare.

area at one time, as currently we

have three wings at a time arrive in | Review the volume of prisoners
healthcare which could be 20+ attending healthcare at each
prisoners. medication session.

Prison Service

Continue to encourage prison wing | Ail prison staff reminded of the
staff to use the lists provided for purpose of medication list and
approved patients for medication. how they must to adhere to it.

Prison Service

Care UK Health & Rehabilitation Sarvices Limited - Registered in England No 10498997
Registered Olfice: Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex CO4 908.

Cafe &

Improve the appearance and Replace broken chairs Prison Service
furnishing within the waiting area.
Increase seating capacity Completed 16" July
2018

Paint the waiting area and
remove graffiti.

Matter of Concern 3.

During the routine medication dispensing, there are no checks done to confirm that
Prisoners have actually swallowed the medication. This can allow them to retain the
medication for redistribution.

Response:

Whilst we understand the diversion of medication happens we do not think it is acceptable to ask
for visual evidence each time. We do not have the ability within the medication queues to ensure
prisoners show us they have swallowed their medication. We have a physical wall between
medical staff and the patient and would not be able to ensure this happens. Due to confidentiality
reasons we do not feel it would be appropriate for officers to check patient's mouths either.
However, healthcare staff do ask to check a patient's mouth if we have reason to believe that a
patient has diverted their medication.

Currently the officer working within healthcare could be any prison officer in the establishment
which doesn’t provide any consistency. Expressions of interest have been sent out on a notice to
staff to have a pool of officers that will be attached to healthcare. This will enable consistency and
enhance sharing of information between healthcare and prison staff.

Plans to move the ISMS dispensary to the healthcare department have been discussed. This will

enable us to dispense all controlled drugs under the same scrutiny and security as ISMS
medication. However this requires investment by the prison.

Action: The prison service has implemented the actions outlined in the table below:

Objective _ Immediate action | To be completed by
Expressions of interest sent out to Prison Service
staffing group for a dedicated group

of prison staff to work within

healthcare.

All cells to have suitable secure This task is being carried out | Prison Service
storage facilities to store weekly and | via the decanting and
monthly medication. refurbishing of each unit.

Care UK Health & Rehabilitation Sarvices Limited - Registered in England No 10498997
Registered Otfice: Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex CO4 908

Core &

Capital bid to move the ISMS Governor to write capital bid. | Prison Service
dispensary to the healthcare
department.

Matter of Concern 4.

At the last inspection by Her Majesty's Inspectorate of Prisons these issues were
raised and attempts have been made to improve the situation. There are now Prison
Officers at the Healthcare department during dispensing times, but usually only one
Officer stood in the room where the medication hatch is located and another outside
the room. Despite these changes, Mrs Jameson advised that the arrangements at
medication dispensing times continue to be an ongoing problem that facilitates the
illicit supply of prescription drugs in the Prison. She advised that the process could
be made safer and more secure. Similar concerns were also raised by one of the
Prison GPs

Response:

The role of the Healthcare Prison Officer needs to be addressed and organised by the prison
service.

Action: The prison service has implemented the actions outlined in the table below:

Objective Immediate action To be completed
by
Review the role and New Job Description that identifies the | Prison Service

responsibilities of the officer | expectations and responsibilities.
working within healthcare

All cells to have secure These have already been ordered and | Prison Service
safes to store in possession | will be incorporated as each wing is
medication. refurbished.

Matter of Concern 5.

| gave evidence that the Prison is overwhelmed with illicit drug use,
particularly psychoactive substances and that the Healthcare team receive 3
emergency calls a week at HMP Guys Marsh to assist in resuscitating Prisoners from
drug overdoses.

Response:

This is predominantly a matter for the prison service in terms of looking at how to reduce and
control the use of illicit drugs within the prison.

Care UK Health & Rehabllitation Services Limited - Registered in England No 10498997
Registered Offica: Connaught House, 850 The Crescent, Calchester Business Park, Colchester, Essex CO4 908.

Cafe &3

As you heard evidence on, the HMP Guys Marsh has large amounts of new psychoactive
substance ("NPS") use. These drugs cause a variety of problems in the prison estate, in addition
to drug overdoses such as debt, bullying, diverting medication, staff assaults, conditioning of staff,
on gong illegal activity and prisoner on prisoner assaults.

The table below details the amount of NPS incidents that are responded to by healthcare each

month from April 2017 — July 2018:-

NPS incidents requiring treatment

April 2017

May 2017 6

June 2017 22

July 2017 22

August 2017 27

September 2017 14

October 2017 21

November 2017
December 2017 39

January 2018 29

February 2018 33

March 2018 21

April 2018 44

May 2018 22
June 2018 18

We have worked closely with the prison service to provide first aid training by prison staff.

Objective Immediate action To be completed by
Healthcare staff to provide a bite | Lead Nurse and Paramedic to Healthcare
size training first aid session. provide this training.
Completed
2"4 July 2018
Prison CM's to have bespoke Training arranged via external Prison
emergency response training. provider. Training is named as Service
COIL (Custody Officer
Immediate Life Support)
On-going health promotion New posters sourced from NHS | Healthcare
advertised around the estate England
highlighting the risks of using Completed
NPS 19" July 2018

Care UK Heallh & Rehabilitation Services Limited - Registered in England No 10496997
Registered Otfice: Connaught House, 850 The Crescent, Calchesler Business Park, Colchester, Essex CO4 SOB

Care &

We are committed to providing a high quality healthcare service at HMP Guys Marsh and are
doing everything we can to ensure that prisoners are as safe as possible and receive the best
quality care. We will ensure that the lessons arising from this inquest are not just implemented at
HMP Guys Marsh 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 sincerely

Head of Healthcare
HMP Guys Marsh
On behalf of Care UK

Care UK Health & Rehabilitation Services Limited - Registered In England No 10498997
Registered Olfica: Connaught House, 650 The Crescent, Colchester Business Park, Colchester, Essex CO4 8QB

HM Prison &
Probation Service

Michael Spurr

Chief Executive

HM Prison & Probation Service
8" Floor 102 Petty France

London

SW1H 9AJ

Email: ceohmpps@noms.gsi.gov.uk

Rachael C Griffin

Senior Coroner for Dorset

The Coroner’s Office for the County of Dorset
Town Hall

Bournemouth

BH2 6DY

Our ref: RCG/03237-2016/LJ

Date: 23 October 2018

Dear Ms Griffin,

Thank you for your Regulation 28 reports of 25 June following the conclusion of the
inquest into the death of Andrew Craig at HMP Guys Marsh on 16 September 2016. |
am responding on behalf of Her Majesty’s Prison and Probation Service (HMPPS). |
would also like to apologise for the delay in responding to your concerns. This delay
was in order for us to be able to provide you with a full and detailed response.

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

You have expressed concern about the use of drugs at Guys Marsh. As well as
saying that there should be further consideration around restricting the supply of
drugs you have suggested that thought be given to replacing or adapting cell
windows at the prison. You have also asked that the policies and procedures relating

to the dispensing and monitoring of medication are reviewed. | am grateful to you for
bringing these matters to my attention.

In terms of your concern about the design of the cell windows at the prison, as you
know, in January 2017 the Governor submitted an estate investment proposal to
replace the cell windows throughout the prison. | am pleased to tell you that the plan
to upgrade the windows has now been approved and is provisionally on the Ministry
of Justice programme for delivery in 2019/20, subject to funding from the Strategic
Asset Management Board. The new windows will be compliant with ‘safer cell’
standards and will be vented which will restrict the opportunity to pass items between
cells.

With regard to wider drug strategies and procedures, the Governor and staff at Guys
Marsh are committed to helping men to address their substance misuse issues and
are determined to prevent the number of illicit substance misuse related deaths in
custody. The prison has made a number of changes following the tragic death of Mr
Craig and will continue to monitor actions in order to improve safety and reduce the
supply and misuse of drugs in the prison. Staff are committed to working to reduce
the use of illegal drugs and recognise that the trading and consumption of illegal
substances can have a serious impact on the welfare of those who are in custody.

A new local substance misuse policy has been developed in line with the
Government Drug Strategy. The policy emphasises the importance of information
sharing to tackle the problems associated with drugs in custody and prioritises
reducing the availability of drugs in the prison through the use of search dogs and
mandatory drug testing. The prison also tries to monitor any distribution of drugs
around the prison through patrols and the use of CCTV.

‘Spice, an all prison approach’ is an action plan designed to tackle the drug culture
at the prison. As part of the plan, briefing sessions aimed at improving knowledge
and understanding about substance misuse are available to all staff. To date, the
sessions have covered psychoactive substances (PS), prescription medication and
steroids and have been well attended by both operational and non-operational staff.

Staff from different areas in the prison including security, safer custody and
healthcare attend weekly meetings which are held to discuss and review the action
plan. The meetings provide an opportunity to discuss a wide range of relevant issues
such as security intelligence and the dissemination of information about spice use.

The prison has also devised the Persistent Psychoactive Substances Intervention
Plan (PPSIP) which works in a similar way to the ACCT document. This plan is used
as a monitoring and reviewing tool for prisoners who persistently abuse PS. Effective
information sharing is key and the care of men on a PPSIP document is through a
multi-disciplinary approach, using the skills of different staff as appropriate. The
initiative allows early intervention and preventative work to promote prisoners’
wellbeing. It also helps them to take responsibility for themselves and to make
informed, safer choices whilst in custody and out in the community.

At a national level, we have created the Prison Improvement Directorate within
HMPPS HQ, in which is a new Drugs Taskforce set up to tackle the use of drugs in

prison, including psychoactive substances (PS). The Taskforce includes secondees
from the Police and NHS England, and experienced senior operational managers
from prisons, so that expert advice and support can be provided to prisons. In
addition to directly supporting the operational line, in the coming months the
Taskforce will publish a strategy for tackling drug misuse in prisons, alongside
practical guidance and good practice for prisons to follow.

Speakers from the taskforce attended a symposium at Guy’s Marsh in August
alongside key partners from NHS England, Specialised Services AWP Mental Health
NHS Trust and the Exeter Drugs Project. The event was attended by staff and also
prisoners with PS issues, some of whom spoke of their experiences.

| know that Care UK is responding to your concerns about the dispensing and
monitoring of medication from a healthcare perspective, but it may be helpful if | set
out the steps which the prison has taken.

HMP Guys Marsh and Care UK are working together to make improvements to the
way that medication is dispensed and have introduced a number of measures to
reduce the opportunity for prisoners to access medication which has not been
prescribed to them.

In future, managing the conduct of those queuing for medication, ensuring that there
is no bullying and that no medication is concealed, will be the responsibility of one
person, rather than a different officer every day. This will both provide consistency
and improve security and information sharing between prison and healthcare.

The floor in front of the dispensary has been clearly marked so that prisoners know
where to stand both for security purposes and to ensure that their own and other
people’s privacy is respected. CCTV is in place in the dispensary area and wing staff
are provided with lists of those who should be attending healthcare for medication.

Having seen the response from Care UK | understand that healthcare staff will not be
checking each person’s mouth to ensure that they have swallowed their medication.
However, prison staff will be present to deal with any issues and will support
healthcare staff when they have reason to believe that a prisoner has not swallowed
medication or is being otherwise non-compliant.

Finally, HMP Guys Marsh has implemented a practice of medication management by
which certain drugs will not be in the possession of prisoners but will be dispensed by
healthcare. This is to prevent the drugs being diverted from one prisoner to another.
Individual secure medication boxes have been ordered and will be fitted in each cell
by the end of the year to allow each prisoner to safely store their in-possession
medication. It is hoped that this will help to reduce the opportunity to take and misuse
prescription drugs from others.

Thank you once again for bringing these concerns to my attention. Please be
assured that learning from the circumstances of Mr Craig's death will be shared more
widely with colleagues across the prison estate.

Yours sincerely

Uichoa! Spurr

Michael Spurr