Thomas McAuley

DIRECTORATE OF PROFESSIONALISM

Mr Andrew Harris Richard Martin
Senior Coroner Deputy Assistant Commissioner
Southwark Coroner's Court 6" Floor
Tennis Street New Scotland Yard
London SE1 1YD Victoria Embankment
London
Coroner’s Clerk: SW1A 2JL

Ema:

To!

Your ref: 2341-2017
Our ref: [X/1676/18

Date: 24th December 2018

Dear Mr. Harris

Re: Inquest Touching the Death of Thomas Patrick McAuley
Response to Prevention of Future Deaths Report

| am the Deputy Assistant Commissioner for Professionalism in the Metropolitan Police Service (MPS).
| write in response to your Regulation 28 Report to Prevent Future Deaths dated 31st October 2018.
Your report was initially sent to Commissioner Cressida Dick following the conclusion of the inquest
into the death of Mr Thomas Patrick McAuley.

| note that the medical cause of Mr Thomas Patrick McAuley's death was recorded as:

1a) Bronchopneumonia;

1b) Chronic Bronchitis. Alcoho! and Drug Dependence;

In your report, you raised the following six matters of concern:

1.

The reception nurse said that she would have had access to DPMFs (Detained Persons Medical
Form) but does not always have time to look at these. The DPMF was not available in the wings.

. A manager of the drug addiction services in the prison said that health care staff were not

always given the DPMF.

. An Oxleas manager said that the case history notes from the prison were uploaded onto

PNomis, but a prison doctor did not think that he had access te this.

. Arepresentative of Oxleas HC reported that a new process required a nurse to tick a box when

the DPMF was uploaded onto the medical records, but there was no evidence that the DPMF
is universally available to health care staff.

There was no evidence that police doctors communicated directly with health care staff in
prison, or arranged for transfer of medical information between doctors. (The police doctors
were not called).

6. In conclusion, there is no assurance that doctors attending in custody, the prison service and
those providing health care in prisons have established a fail-safe mechanism of ensuring that
medical assessments on vulnerable individuals and records from custody are seen and
considered by medical staff in prison.

In drafting our response, we have consulted with the relevant subject matter experts namely
es Medical Director, the College of Policing, HM Prison and Probation Service (HMPPS)

and National Offender Management Service (NOMS).

When considering this response, it should be remembered that the MPS was not afforded the benefit

of being involved in the inquest touching the death of Mr McAuley and was not invited to be an

interested person to the proceedings. We have therefore lacked the disclosure that other interested

persons will have had, as well as the benefit of hearing the oral evidence.

Response to Matters of Concern:

Matters 1-4 relate to actions of the prison service and are beyond the responsibility of the MPS to
influence. Matters 5-6 raise issues relating specifically to police handover of detainees and sharing of
medical information; we have responded to these below:

5. There was no evidence that police doctors communicated directly with health care staff
in prison, or arranged for transfer of medical information between doctors. (The police
doctors were not called).

‘erbal communication between heaith professionals within the
IPS and those we courts or prison service. The MPS Custody Policy provides”
instructions regard tained at police stations. This policy supports, and should be
read in conjunction with legislation and the College of Policing’s Authorised Professional
Practice (APP). It should be noted that the MPS Custody Policy will continue to reflect APP
however, for officers and staff, the Custody Policy is the primary source of instruction and
should be referred to in the first instance.

Prisoner Escort and Custody Services (PECS) are part of the National Offender Management
Service (NOMS) and are responsible for managing contracts for escorting detainees. The
contract for transferring detainees from MPS custody suites to court is provided by SERCO,
who accept responsibility for the detainee upon leaving custody.

Prior to departure, custody staff complete a Person Escort Record (PER) and give the form to
SERCO officers. If the detainee has been assessed by a Health Care Professional (HCP) in
custody, the HCP will complete a Detained Person’s Medical Form (DPMF). The purpose of the
DPMF is to highlight areas of medical concern to custody staff, and to provide, where
necessary, a chronological medical report relating to a detainee’s period of detention. The
information contained in the DPMF together with a risk assessment contribute to the safe and
effective detention of the detainee. The MPS Custody Policy states that the DPMF (where
applicable) is to be included in the documentation attached to the PER and should be referred
to in the ‘escort handover’ page. The MPS also provide a print of all risk assessments, property
sheets, PNC warning signals, ‘exceptional risk’ forms (where applicable) and Juvenile
Detention Certificates (where appropriate) with the PER.

The transfer of medical information to SERCO is further supported by a verbal briefing by MPS
custody Staff at the time of transfer. The handover procedure identifies any heightened risk or
increased vulnerability, both verbally and in writing. All relevant risks pertaining to the detainee
are to be further considered, upon arrival at court or prison, by their HCPs or doctors as part of
their medical and risk assessment procedure.

6. In conclusion, there is no assurance that doctors attending in custody, the prison
service and those providing health care in prisons have established a fail-safe
mechanism of ensuring that medical assessments on vulnerable individuals and records
from custody are seen and considered by medical staff in prison.

There is currently work in progress to change the PER to mitigate such risks when transferring _

a delaines between pariner agenclés. HMPPS are leading o on this project, which includes
attaching additional documentation and notes to highlight the increased risks to partner
agencies. The new PER will contain additional health and social care information, which will
mitigate the identified risks when vulnerable people are being transferred between the police

escort contractors and HMPPS custody. It is anticipated that this project will be completed and
delivered by April 2019.

record system (EMRS) for several years. The EMRS is ; expected to a to allow a better facilitation of
healthcare information on an électronic platform. Information will be shared across police,
prison and potentially court services and may include mental health, physical health and
medication information, where appropriate agreements are in place. The first stage of
implementing the communication network (N3) and the hardware into all MPS custody suites
has been completed. The N3 connection provides healthcare professionals in MPS S custody
suites, with access to NHS Summary Care Records and is required for an EMRS. The full
implementation’ has been inadvertently delayed due to factors beyond the control of the MPS,
however it is now likely that delivery could be achieved withi

record stem (EMR working in partnership with the NHS to introduce an electronic medical

There is also further work being undertaken by NHS England and HMPPS to develop an
electronic. version of the PER. (ePER) wi i
ePER is being used in five prisons and is bein | piloted b 6Y PoliGes The |

that, by the time the new PECS contract is operational iI (late 2020) the product will be fully digital.
In the interim period, whilst these innovations are taking place, the MPS will continue to ensure

that any relevant medical information available on NSPIS is also recorded in the PER.

Conclusion:

The MPS will continue to attach all relevant medical information to the PER when detainees leave our
custody suites to highlight any increased health risks. We are committed to continual training and
partnership working and in the short-term it is anticipated by April 2019 the new PER will be introduced,
‘ which will seek to address limitations on the current PER. The MPS has also supported the
dissemination of the learning opportunities presented by your report through engagement with NOMS,
NHS England and HMPPS leads in the preparation of this response and as a result, we have been
invited to evaluate and comment on the new ePER. The MPS will be introducing the EMRS platform,
hopefully within one year, which will enable the medical assessments and treatments of vulnerable
individuals to be considered by medical staff in prison.

Yours sincere, “a

Richard Martin
Deputy Assistant Commissioner
Professionalism