Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0369, written 1 Aug 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Aug 2018 |
|---|---|
| Reference | 2018-0369 |
| Deceased | Jerome Jones |
| Coroner | Joanne Lees |
| Coroner area | Shropshire, Telford & Wrekin |
| Category | State Custody related deaths |
| Organisation named | Shropshire Community Health NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Governor HMP Stoke Heath, Warrant Road, Market Drayton, Shropshire, TF9 2JL. 2. , Shropshire Community Health NHS Trust, William Farr House, Shrewsbury, Shropshire, SY3 8XL. 3. Head of Governance, Forward Trust, Head Office, The Foundary, 17 Oval Way, London, SE11 5RR 1 CORONER I am Mrs Joanne Lees, Assistant Coroner, for the coroner area of Shropshire, Telford & Wrekin. 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 the 30th October 2017 I commenced an investigation into the death of Jerome Jason Omri JONES, 26 years of age. The investigation concluded at the end of the inquest on the 18th to the 20th July 2018. The conclusion of the Jury in the Record of Inquest (ROI) was a narrative conclusion recorded in Box 4 as: The deceased passed away due to a combination of an underlying heart condition and the effects of a synthetic cannabinoid on his heart. Recorded in Box 3 of the ROI the jury found that ‘proactive steps were taken to safeguard Mr Jones prior to the incident but these were ultimately insufficient’. 4 CIRCUMSTANCES OF THE DEATH The deceased was a serving prisoner at the time of his death in HMP Stoke Heath. He had been transferred there in July 2017. He had a pre existing congenital heart defect and was a known user of New Psychoactive Substances (NPS). He died on 27/10/17 in the Princess Royal Hospital, Telford. Earlier that evening he had been found unresponsive in his cell having been suspected of using NPS. A post mortem revealed the cause of death as 1a) Sudden cardiac death 1b) congenital heart disease with fibrosis of the left ventricle and toxic effect on myocardium. Toxicology found a synthetic cannabinoid known as 5F‐ADB in his blood. Between his arrival at Stoke Heath and his subsequent death on 27/10/17, Mr Jones had at least 3 known instances of NPS use the most recent on which was only a week before his death where he received emergency treatment although he was not admitted to hospital. A week later, he was again found unresponsive in his cell and was determined by paramedics to be in cardiac arrest. Despite concerted efforts to save his life by prison staff and paramedics he remained in PEA and was later sadly pronounced dead at 21.10 pm at the Princess Royal Hospital. The inquest focused on the following central issues; ● The events leading up to the discovery of Mr Jones in his cell on 27/10/17; ● The measures taken by HMP Stoke Heath to manage both his heart condition and his known use of NPS with particular reference to the incident on 20/10/17; ● The measures taken by HMP Stoke Heath to Mr Jones mental health in so far as it related to his drug use; ● How Mr Jones was able to access NPS and what policies and procedures were in place at H M Prison, Stoke Heath to prevent this? ● If there was any delay in calling an ambulance to Mr Jones, the impact of any delay if it is possible to say. 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. – (1)During the inquest evidence was heard that apart from some hourly checks by prison officers during the evening of the incident on 20/10/17 (the third known instance of NPS use by the deceased) no other specific checks were made on the deceased leading up to the date of his death . This was a prisoner who had 3 known instances of NPS use within a relatively short space of time. I heard evidence that the requirement for further checks would have had to come from the Healthcare team rather than from prison officers. I was told here is no policy or guidance to cover additional checks for a prisoner in a situation such as this. (2)The inquest heard evidence from two Forward Trust Drug workers who although not medically qualified, considered that Mr Jones was at a ‘higher’ risk from NPS use due to using NPS with his existing congenital heart defect. I was told there was no method of communicating this to either Healthcare or prison officers to enable further periodic checks to be undertaken particularly in light of the recent incident on 20/10/17. (3)The two Forward Trust Drug workers were only aware of Mr Jones existing heart condition because he disclosed this to them himself. This enabled them specifically to tailor their advice to cover the impact of Mr Jones continued NPS use on his heart. Forward Trust do not appear to have access to prisoner medical records for reasons of patient confidentiality and there does not appear to be any alternative way of ensuring they have all the information about a prisoner in order to help them with their drug use. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you or your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 26th September 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: 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 Mrs Joanne Lees Assistant Coroner Shropshire, Telford & Wrekin 1st August 2018
2 responses 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.
Michael Spurr
Chief Executive
HM Prison & Probation Service
8th Floor 102 Petty France
London
SW1H 9AJ
E-mail: ceohmpps@noms.gsi.gov.uk
Mrs Joanne Lees
Assistant Coroner for Shropshire, Telford and
Wrekin ,
HM Coroner’s Services,
Shirehall, Abbey Foregate,
Shrewsbury
Shropshire,SY2 6ND
E-mail: coroner@shropshire.gov.uk
04 October 2018
Abbey Foregate
Shrewsbury
Shropshire
Dear Mrs Lees,
Postcode:
Inquest into the death of Jerome Jones
SY2 6ND
HM Coroners Office
Thank you for your Regulation 28 Report of 1 August addressed to the Governor of
MK45 2HX
HMP/YOI Stoke Heath, the Shropshire Community Health NHS Trust and the
Forward Trust following the conclusion of the inquest into the death of Jerome
Jones. As Chief Executive Officer I am responding on behalf of Her Majesty’s Prison
and Probation Service (HMPPS). Thank you for allowing me additional time in which
to do so.
I know that you will share a copy of this response with Jerome’s family and I 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.
I am grateful to you for bringing your concerns to my attention. I am aware that the
Shropshire Community NHS Trust wrote to you on 31 August. In addition to the
information in their response, an updated drug strategy has been launched at the
establishment. All staff were notified of this last month by way of a Notice to Staff
which also reminded them that healthcare staff are responsible for determining
when additional checks of prisoners at risk from repeated use of psychoactive
substances are necessary, and that this must be communicated by them to all
prison discipline staff.
In September, a staff notice was also issued by the Governor to all Forward Trust
Drug workers at the establishment to remind them of how to share information with
prison and healthcare staff. To further improve communication between Forward
Trust drug workers and healthcare staff, every member of Forward Trust will be
given access to SystmOne by April 2019, in order that they can both enter
information onto the system and access it.
Thank you again for bringing these matters of concern to my attention. Please be
assured that learning from the circumstances of Jerome Jones’ tragic death will be
shared more widely with colleagues across the prison estate.
Yours sincerely
Michael Spurr
Corporate Affairs William Farr House Shrewsbury Shropshire SY3 8XL Telephone: 01743 277 661 Fax: 01743 277 663 Website: www.shropscommunityhealth.nhs.uk Mrs Joanne Lees Assistant Coroner Shirehall Abby Foregate Shrewsbury Shropshire SY2 6ND 31st August 2018 Dear Mrs Lees RE JEROME JASON OMRI JONES Subject to your Regulation 28 Report below is the response for Shropshire Community Health NHS Trust in relation to your concerns 1) Observations following repeated use of NPS Current practice is that following a prisoner using any illegal substance nursing staff will instruct prisoner officers to conduct additional observations for a short period of time to ensure the prisoners has fully medically recovered from the effects of the substance. They are also instructed to contact healthcare staff if there any concerns. This is part of HMP/YOI Stoke Heath joint strategy document for the management of NPS. Repeated use will trigger referral to Forward Trust staff to engage with the prisoner to motivate them to modify their drug taking habits. Whilst there is no separate guidelines for long term increased observation of a prisoner engaging in drug risk related behaviour, there is an overall policy and safeguarding mechanism for prisoners at risk of harm to themselves (the ACCT process). Any member of staff within the prison can instigate the safeguarding process if they feel this is appropriate. This is likely to increase observation but will not prevent the prisoner from engaging in risk taking behaviour. 2) Communicating congenital heart defect. Healthcare staff were aware of his condition. The Forward Trust can be given access to medical records, they are in discussion with NHS England, the commissioner of the service, to action this. As with any other prisoner arriving at HMP/YOI Stoke Health, Mr Jones would have been asked at reception as part of disability information sharing if he had any conditions that he would like to share with the prison authorities. This form would have been sent to the disability liaison officer at the prison. As with any other Trust patient we would not share medical information without the patient or patient representative consent. Mike Ridley –Chairman Julia Bridgewater – Chief Executive 3) Access to medical records As stated in (2) the Forward Trust is addressing this with the service commissioners, NHS England. The receipt of this notice has emphasised the value of healthcare staff attending these and similar inquests, even though there may not be any identified issues to address. We will ensure attendance in the future. Yours sincerely Corporate Risk Manager Shropshire Community Health NHS Trust By email only Mike Ridley –Chairman Julia Bridgewater – Chief Executive
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