Thomas Nicol

24.23 (Jw)

det From Jackie Doyle-Price MP

Parliamentary Under Secretary of State for Mental Health,
Department Inequalities and Suicide Prevention

of Health &
j 39 Victoria S
Social Care ctoriaSreet
SW1H 0OEU
Your Ref: 2428 020 7210 4850

Our Ref: PFD-1158745

Mr Geoffrey Sullivan

HM Senior Coroner, Hertfordshire
The Old Courthouse

St. Albans Road East

Hatfield

AL10 OES

/5 March 2019

Thank you for your correspondence of 30 November to the Department of Health and
Social Care about the death of Mr Thomas Nicol. I am responding as Minister with
responsibility for mental health and prison health services and I am grateful for the
additional time in which to do so.

I have noted the concerns raised in your report about the time taken to assess
prisoners for a mental health inpatient bed and the availability of beds in secure adult
hospitals. I note that these matters are not found to have contributed to the death of
Mr Nicol but were raised as general concerns by those providing evidence at the
inquest into his death as an issue common to the prison estate.

Alongside the Department, you issued your report to the Ministry of Justice and NHS
England. I am advised that NHS England has responded in detail to your concerns.
As you will know, NHS England is responsible for the commissioning of prison
health care services and the commissioning of specialist mental health services,
including secure adult mental health beds.

I will not repeat the detail of NHS England’s response. However, I hope you will be
assured by the work outlined by NHS England around improving access to mental
health services, including secure inpatient care, for offenders with mental health
difficulties.

In line with the Five Year Forward View for Mental Health' and the Strategic
Direction for Health Services in the Justice System’, NHS England is working with
partners to ensure that offenders receive the right care, in the right place, at the right
time. It is carrying out service reviews across all adult high, medium and low secure
services. The review will include the service capacity required, taking into account a
number of criteria such as levels of security, gender, service types and geographical
location.

NHS England is also reviewing the current prison transfer and remission guidance,
published by the Department of Health and Social Care in 20113. In particular, the
review is looking at whether the timescales within the guidance take into account
clinical urgency and need. The revised guidance will be subject to full, public
consultation in due course.

In addition, a new service specification for an integrated mental health service for
prisons in England‘ is being implemented, its aim to provide clear, minimum service
requirements that will deliver improved standards and outcomes, including on
transfer times where appropriate.

I hope this information is helpful and outlines the steps that are being taken to
improve access to mental health services for offenders with mental health difficulties.
Thank you for bringing these concerns to my attention.

CKIE DOYLE-PRICE

' https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-F YF V-final.pdf

? https://www.england.nhs.uk/wp-content/uploads/2016/10/hlth-justice-directions-v11.pdf

3 https://www.gov.uk/government/publications/the-transfer-and-remission-of-adult-prisoners-under-s47-and-s48-of-the-
mental-health-act

4 https://www.england.nhs.uk/publication/service-specification-integrated-mental-health-service-for-prisons-in-england/

Mr G Sullivan  
Senior Coroner for Hertfordshire 
The Old Court House,  
St Albans Road East,  
Hatfield,  
Hertfordshire,  
AL10 0ES  

Professor Stephen Powis  
National Medical Director 
6th Floor, Skipton House 
80 London Road 
SE1 6LH 

14th February 2019 

Dear Mr Sullivan 

Report to Prevent Future Deaths (Regulation 28)  
Mr Thomas Nicol, HMP The Mount (date of death 25 September 2015)  

Thank you for your letter and Regulation 28 Report (“Report”) issued on Wednesday 
30 November 2018 which was received on Tuesday 4 December 2018 following the 
inquest into the death of Thomas Nicol. I would like to express my deep sympathy to 
Mr Nicol’s family. 

The Report raised a concern regarding the length of time taken to assess prisoners 
for a mental health in-patient bed and the availability of beds in adult secure hospitals. 
You acknowledged that this had not contributed to the death of Mr Nichol. However, it 
had been raised as a concern at the Inquest in relation to future deaths. 

The  statutory  context  within  which  to  consider  the  transfer  of  prisoners  to  a  mental 
health facility is provided by the Health and Social Care Act 2012 (HSCA 2012) and 
the Mental Health Act 1983 (MHA 1983). Under the HSCA 2012, NHS England has 
responsibility for the commissioning of healthcare in prisons and the commissioning 
of adult secure mental health beds, amongst other specialist mental health services. 
Clinical  Commissioning  Groups  (CCGs)  are  responsible  for  the  commissioning  of 
other mental health services, including psychiatric intensive care units (PICU). Both 
adult  secure  mental  health  beds  and  PICU  beds  can  be  accessed  for  transferred 
prisoners  who  require  detention  under  the  Mental  Health  Act  1983  (MHA  1983)  to 
mental health in-patient services. Such prisoners will be subject to the requirements 
and effects of sections 47 (and 48) of the MHA.  The provisions of the MHA do not 
stipulate a timescale within which prisoner transfers from prison to mental health in-
patient  services  must  take  place.  In  addition,  NHS  England  also  has  regard  to  the 
guidance issued by the Department of Health in relation to transfer times from prison 
to mental health in-patient services (that being the Good Practice Procedure Guide, 
2011,  hereafter  “the  Good  Practice  Guidance  2011”).    As  Mr  Nichol  had  not  been 
referred by prison mental health services or assessed for a mental health in-patient 
bed by  a  secure  or PICU  service,  it  is not  possible  to  comment  on  any  specifics in 
relation to this case. The information below provides details of work being undertaken 
by NHS England to improve and enhance the pathway to and from prisons to mental 

Health and high quality care for all, now and for future generations 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 health in-patient services. 

Since 2016, NHS England and respective stakeholders have been engaged in various 
multi-faceted programmes of work with the specific intention of improving the mental 
health pathway and is focused on ensuring timely referral, assessment and access to 
high quality care, and similarly ensuring that remission back to prison also takes place 
without delay to enable good throughput. This then allows appropriate capacity within 
the  overall  system  to  be  used  effectively  for  those  who  require  this  type  of  mental 
health care. The work undertaken by NHS England should be understood within the 
context  of  the  overall  process  of  mental  health  bed  commissioning  and  recognition 
that  the  prison  estate  is  but  one  source  of  local  admissions  at  any  given  time. 
Therefore,  considerable  work  has  been  undertaken  regarding  the  structuring  of 
services  and  improving  access  to  commissioned  beds.  These  programmes  of  work 
include the following key initiatives: 

Improved performance management and capability;  

1.  An annual audit benchmarking data in relation to transfers and remissions;  
2. 
3.  Demand  and  capacity  service  reviews  in  relation  to  adult  low  and  medium 
secure  services,  an  initiative  to  increase  local  ownership  of  the  pathway 
through  collaborative  commissioning  and  the  development  of  new  forensic 
community models of care;  

4.  Demand and capacity service reviews in relation to adult high secure services: 
5.  Revised  service  specifications  for  adult  medium  and  low  secure  services, 

ongoing work to revise the high secure service specification, and: 

6.  Revised  integrated  service  specification  for  the  delivery  of  mental  health 

services within the prison estate. 

Further details of the above initiatives are set out below.  

As part of these work programmes a national annual audit now takes place to establish 
benchmarking data on the transfer and remission of prisoners (this is in additional to 
local audits undertaken by local commissioners). The last audit was published on 16th 
November 2018. The next audit is due to commence on 28 February 2019. By way of 
clarification,  the  transfer  process  refers  to  referral,  assessment  and  transfer.  The 
transfer process  data  is  drawn from those  who have  been  engaged  in any  or all of 
these stages. In this regard, some patients can remain in prison to address their MH 
needs, following their assessment and therefore not all patients will require a transfer 
as  per  the  MHA  1983,  however,  the  timeliness  of  such  assessments  is  monitored. 
Remission  data  is  drawn  from  those  who  have  been  identified  by  an  adult  secure 
mental health hospital as requiring return to prison. 

These audits permit scrutiny on a national and local level and have helped to develop 
a better understanding of any obstacles leading to delays in the timely assessment 
and if appropriate, transfer and/or remission of prisoners to and from mental health in-
patient services. This knowledge is being used to build on best practice and identify 
areas  for  further  service  development.  For  example,  a  previous  audit  led  to  the 
examination of the escalation process to be applied regionally and nationally to those 
persons for whom an assessment and / or referral remained outstanding. The audit 
indicated  that  gaps  in  the  information  required  to  facilitate  the  escalation  of  care 
incurred a delay in its processing. As a result, a template was developed confirming 

Health and high quality care for all, now and for future generations 

 
 
 
 
 
 
 the information that was required as well as presenting it in a complete and meaningful 
manner  to  support  the  escalation  process.  In  so  doing,  the  template  allowed  the 
escalation to achieve its intended outcome in a timely manner.  

In addition, improved performance management and capability is being developed in 
this area. Good practice examples relating to the pathway in some parts of the country 
within prison and respective mental health in-patient services are being identified and 
processes to disseminate and share this information nationally is a specific focus. For 
example, a national transfer and remission best practice conference is scheduled to 
take place on 19 March 2019 which will allow NHS England to present its findings and 
service expectations to local commissioners and providers alike, particularly in relation 
to  escalation  processes.  In  addition,  responsibility  for  reviewing  the  Good  Practice 
Guidance 2011 has been passed to NHS England, which is revising this document in 
order to clarify and standardise the transfer process. The proposed guidance will be 
submitted for public consultation prior to implementation nationally.  

In  relation  to  adult  medium  and  low  secure  services  specifically,  NHS  England  is 
conducting  a  demand  and  capacity  review,  ensuring  that  in-patient  services  are 
situated in the correct geographical location, delivering the right type of service in a 
timely  way.  These  services  must  be  integrated  with  local  pathways  and  for  some, 
these  are  community  mental  health  services  and  for  others  this  will  be  prison.  The 
reconfiguration of beds sits alongside other new developments, including the piloting 
of  new  specialist  forensic  community  models  and  collaborative  commissioning 
approaches with much more emphasis on local ownership. The effect of this will be to 
ensure  existing  capacity  and  throughput  (including  remission)  is  optimised.  New 
specifications  for  these  services  were  published  in  March  2018  and  specialised 
commissioning teams are working with providers during 2018 / 2019 to implement the 
new specifications.    

In  relation  to  high  secure  services,  a  similar  demand  and  capacity  review  will  be 
undertaken as part of strategic commissioning  work and the current specification  is 
being  reviewed  via  the  established  NHS  England  processes  of  co-design  and  co-
production. This review  is  in  its  early  stages  and  NHS  England aims  to publish  the 
results of this review during 2019/20.  

The above initiatives are already leading to reductions in length of stay in adult secure 
services  and  better  throughput,  which  enables  the  whole  system  to  work  more 
effectively and makes better use of available capacity overall. This is, of course, in line 
with the relevant policy direction in terms of the Five Year Forward View (published 
October 2014), and Building the Right Support for the Learning Difficulties and Autistic 
Spectrum  Disorder  population  (published  October  2015)  as  well  as  the  recently 
published ‘Long Term Plan’ (published 7 January 2019).  

In March 2018 NHS England published a new integrated prison mental health service 
specification  which  significantly  revised  the  previous  specifications.  It  included 
provision for more flexible mental health services with seven days a week provision to 
ensure that those in mental health crisis are able to access the appropriate support 
even  at  the  weekends.  It  also,  for  the  first  time,  included  the  Royal  College  of 
Psychiatrists Quality Network for Prison Mental Health Services (QNPMHS) standard 
for  mental  health  care  in  prisons.  These  standards  were  written  with  mental  health 

Health and high quality care for all, now and for future generations 

 
 
 
 
 
  
 service  providers  within  prisons  to  drive  up  standards  overall  and  naturally 
complement and support the further work being undertaken to improve transfer times. 
This specification is currently being implemented nationally, with over sight from the 
NHS  England  Health  and  Justice  Oversight  Group.  All  prisons  are  expected  to  be 
compliant with the new specification from April 2019.  

The prison mental health service specification also requires the healthcare provider to 
have local transfer and remission navigator functions (that is, an identified person with 
specific responsibility in this regard) to ensure the timely and appropriate transfers of 
mental health care to mental health hospitals are undertaken in a co-ordinated way.  

As referred to above, NHS England now has responsibility for reviewing the current 
Good Practice Guidance 2011 (originally published by Department of Health), entitled 
‘The transfer and remission of adult prisoners under s47 and s48 of the Mental Health 
Act: A good practice procedure guide’ (April 2011). The aim of the review is to provide 
for more clinically informed timescales for the transfer and remission of prisoners to 
and  from  mental  health  hospital.  This  revised  document  has  been  developed  with 
stakeholders and is currently being prepared in readiness for public consultation which 
is anticipated to take place early in 2019. This will take into consideration the report 
into  the  Independent  Review  of  the  MHA,  published  in  December  2018.  The 
Independent Review of the MHA recommends two statutory timeframes for the first 
assessment  and  transfer  of  patients  under  the  MHA  1983.  Fourteen  days  are 
recommended  for  assessment  from  the  first  point  of  identification  of  the  need  to 
transfer  the  patient.  Fourteen  days  are  also  recommended  from  the  point  of 
assessment to the physical transfer of the patient to a mental health hospital. Until the 
new guidance is published, the Good Practice Guidance 2011 is extant pending the 
completion  of  the  revision  process and  publication.  Those  delivering  the  healthcare 
service specification within a prison (as well as those providing adult secure mental 
health  services)  will  be  expected  to  read  their  relevant  service  specification  in 
conjunction  with  the  prevailing  Good  Practice  Guidance  in  relation  to  transfer  and 
remission times.  

I  hope  the  information  above  addresses  the  concerns  you  have  raised  within  your 
Report and provide you with assurances that you requested. If you require any further 
information please do not hesitate to contact me.  

Yours sincerely 

Professor Stephen Powis 
National Medical Director   
NHS England  

Health and high quality care for all, now and for future generations