John Delahaye

Date of report	18 Dec 2018
Reference	2018-0388
Deceased	John Delahaye
Coroner	Emma Brown
Coroner area	Birmingham and Solihull
Category	Suicide (from 2015) · State Custody related deaths
Organisation named	Birmingham and Solihull Mental Health NHS Foundation Trust · Birmingham Community Healthcare NHS Foundation Trust
Source	judiciary.uk record · original PDF
Responses published	1

The report

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:

i.
ii.
iii.
iv.
v.
CORONER

NHS England
Birmingham and Solihull Mental Health Foundation Trust (‘BSMHT’)
Birmingham Community Healthcare NHS Trust (‘BCHT’)
G4S
The Ministry of Justice (‘MOJ’)

I am Emma Brown Area Coroner for Birmingham and Solihull

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.

INVESTIGATION and INQUEST

On 09/03/2018 I commenced an investigation into the death of John Anthony Delahaye. The
investigation concluded at the end of an inquest on 14th December 2018. The conclusion of the inquest
was that on a balance of probabilities Mr. John Delahaye deliberately took an overdose of insulin with
the intention of ending his life. At the time of his death Mr. Delahaye was a remand prisoner at HMP
Birmingham and it was further determined by the jury that:

ii.

iii.

It was not appropriate that Mr. Delahaye was discharged by the mental health team (after
taking an overdose of insulin on the 31st December 2017) on the 2nd January 2018 and not
reviewed again and this possibly caused or contributed to his death.
There should have been involvement of mental health and/or physical healthcare in the
ACCT process, the absence of which possibly caused or contributed to his death.
It was not appropriate for Mr. Delahaye to have insulin in his possession and this probably
caused or contributed to his death.

CIRCUMSTANCES OF THE DEATH

Mr. Delahaye was found dead in his cell, M301, at HMP Birmingham on the 5th March 2018. As a result
of post mortem examination and toxicology it was identified that his death was a result of an insulin
overdose. Mr. Delahaye was a type 1 diabetic and had been given an insulin pen to keep in his possession
in his cell. Mr. Delahaye had previously been admitted to City Hospital, Birmingham on the 31st
December 2017 as a result of an insulin overdose. He returned to HMP Birmingham on the 1st January
2018. On the 2nd January 2018 Mr. Delahaye was reviewed by a mental health nurse who found no
evidence of an acute mental illness and discharged Mr. Delahaye. At that time he stated he did not
remember what had happened at the time of the overdose. On the 2nd January 2018 a primary
healthcare nurse opened an Assesment, Care in Custody and Teamwork book (an ‘ACCT’), as a
consequence of the initial ACCT assessment and review on the 3rd January 2018 he was referred back to
the mental health team for an mental health assessment but no assessment was carried out. He
remained on the ACCT book until the 17th January 2018. At no time did the mental health team have
any involvement in the ACCT process, the team was invited to attend by the custodial first line manager
but declined. Following his return after the overdose Mr. Delahaye had initially not been allowed to have
his medication in his possession but on the 29th January 2018 a GP assessed Mr. Delahaye and
determined that he was suitable to have his self-administering insulin pen in his possession. He was last
issued a pen on the 3rd March and it was found empty in his cell on the 5th March 2018 indicating he
had taken an overdose of between 230 and 270 units.

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. There is confusion surrounding the meaning of the following question from NHS England’s

national clinical template for in possession Risk Assessments in the Secure Estate: “Have you had
problems in the last 6 months with not taking, or not remembering to take your medicines as
prescribed?” The Risk Assessment had not been used in the assessment for Mr. Delahaye’s in
possession modification on the 29th January 2018 when it ought to have been. However, during
the course of considering what the outcome would have been if the risk assessment had been
undertaken, more than one clinician interpreted the question as pertaining only to
consideration of incidents where medication had not been taken. It was the Coroner’s view that
the question is also asking about incidents where medication may have been taken but not “as
prescribed” thus encompassing an overdose (accidental or deliberate). The question is not clear
and this creates a risk that the score generated may be incorrect and in possession medication
may be authorised where it ought not to be, putting lives at risk.

2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the
2nd January 2018 and the GP who assessed him for in possession medication on the 29th January
2018, had not identified from his notes all relevant past medical conditions. It emerged that
whilst the System One records (a case management system used across the prison estate) has
the facility to provide a summary of significant past and current medical conditions, it is not
reliable at HMP Birmingham because conditions are not consistently given the correct ‘read
code’. Evidence from the NHS England clinical reviewer,
, was that this problem
is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a
change of culture and practice to bring the system for read coding into line with that in the
community. The absence of a reliable source for quickly identifying relevant past and current
medical conditions puts lives at risk from misinformed decision making.

3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was
identified during the inquest that a member of either the mental health team, primary care or
the drug/alcohol service ought to have been present at the first review at least. It was the
evidence of a first line manager who had involvement in the ACCT that a member of the
custodial team had contacted healthcare and asked them to attend but this was not
documented and the healthcare team maintained they were unaware of the date of the first
review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it
does not include making healthcare aware of the first review. As this is a national Ministry of
Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT
review could result in useful knowledge or expertise not being available to the ACCT team and
could put lives at risk.

4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately
07:50. It is likely that he was already dead at this time (and had been so for some hours) but he
was not found because the prison custody officer who unlocked his cell did not look into the cell
or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant
PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The
Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been
emphasised to senior managers and leads through a bilateral document covered at formal
briefings. However, it was not clear how this is then communicated down to the individual
custody officers and how they are being audited to make sure they are conducting a welfare
check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life
saving assistance at the time of unlock is not identified.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe:

i.
ii.
iii.
iv.

NHS England have the power to take such action with respect to matters 1 and 2 above;
BSMHT and BCHT have the power to take such action with respect to matter 2 above;
The MOJ have the power to take such action with respect to matter 3 above; and
G4S and the MOJ have the power to take such action with respect to matter 4 above.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 12
February 2019. I, the coroner, may extend the period. You are asked to respond to the matters relevant
to your organisation as identified in section 6 above but you are not prohibited from responding on other
matters if appropriate.

Your response must contain details of action taken or proposed to be taken (in respect of the matters
relevant to your organisation), setting out the timetable for action. Otherwise you must explain why no
action is proposed.

COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to Mr. Delahaye’s family. I have also sent a copy
of the report to the Prison and Probation Ombudsman who may find it useful or of interest.

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.

18/12/2018

Signature

Emma Brown Area Coroner Birmingham and Solihull

Responses

1 response 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.

Response from S (PDF)

| (CO) | Birmingham and Solihull

Mental Health
NHS Foundation Trust

Chair & Chief Executive's Office

Private and Confidential : : Unit.1, B41
Ms. Emma Brown . 50.Summer Hill Road
Area Coroner, Birmingham and Solihull Ladywood
50.Newton Street © Birmingham B1.3RB
Birmingham ‘
B4 6BNE : 2 : Tel:0121 301.1114
: Fax: 01213011301

4 February 2019

Dear Ms Brown

’ Response to PFDiregulation 28 in relation to the death of Mr Delahaye

Thank you for your Regulation 28 report relating to the death of Mr John Delahaye which
we received from your office on 31 December 2018. Please do be assured that we have.
taken your concerns and findings very seriously. We note that actions are required to. be

«delivered bya number of agencies. This response relates to the actions to be delivered by”
Birmingham and Solihull Mental Health NHS Trust and Birmingham Communty,
Healthcare NHS Trust.

The concerns that you raised pertinent to BSMHFT and BCHT were:-
“Matter.2. During the inquest it emerged that the mental health nurse who assessed Mr.
Delahaye on the 2nd January .2018 and the GP who assessed him for in possession
medication on the 29th January 2018, had not identified from his notes all relevant past
medical conditions, ‘It emerged that whilst the System One records (a case management
system used across the prison estate) has the facility to provide a summary of significant
past and-current medical conditions, it is not-reliable at HMP Birmingham because
conditions are not consistently given the correct 'read.code’.' Evidence from the NHS
England clinical reviewer was that this problem is not.unique to HMP
Birmingham and is found in other prison healthcare teams and requires a change.of
culture and practice to bring the system for read coding into line with that in the
community. The absence of a reliable source for quickly identifying relevant past and
current medical conditions puts lives at risk from misinformed.decision making, .

HMP Birmingham healthcare, both BCHC and BSMHFT identify past medical conditions
from System using both read codes and a ‘search’ facility on System1. Ifa clinician (in
any prison healthcare setting) has identified a medical condition and used 4 read code

when documenting this, it will then flag the patient. has a medical condition wlth the

Chair: Sue Davis, CBE Chief Executive: John Short
. 07 x *Sionewall

Customer Relations Mon-Fri, 8am—8pm Tel: 0800 953 0045 Text: 07985 .883 509 s xy DIVERSITY

Email: bsmhft.custonerrelations@nhs.net Website: www.bsimhft.nhs.uk DAS CRAMPION

summary and family history. However there are multiple read codes for conditions and
they are not used consistently across the prison -healthcare system nationally.

System1 is.a national system and is out of the local control of Birmingham and Solihull
Mental Heaith NHS Foundation Trust. It is therefore recommended that this issue is :
highlighted by. HM Coroner to NHS Engiand for national resolution indeed we can'see that
this has been raised with NHSE as part of the same regulation 28 report. BSMHFT does -
however recognise that it could put'some additional local controls in place to‘mitigate the
tisk associated with SystemOne and-Read Codes and we are therefore implementing the
following action as a provider of Healthcare in HMP. Birmingham. i

The Head of:Healthcare-at HMP Birmingham will remind all clinical staff (including those
working within BCHT) that when reviewing a patient's records for previous medical
conditions that the following most be followed: ; :
“4... The clinician. will check the ‘summary and family history’ section of System
2. The clinician will check the ‘quick glance’ section of System1
3, The clinician will use the ‘search function’ to.check for the medical conditions
‘relevant to the clinical Intervention they are undertaking

- This reminder will be sent out to all staff in writing on the 1% February 2019,
We will of course also work i in collaboration with NHSE in terms of any national resolution
to SystemOne.

We would like'to thank you for drawing this matter to our attention and sincerely hope that
the controls outlined above will help to. prevent future deaths of this nature.

’ Yours:sincerely
weet
a Pieces &

John Short
CEO, Birmingham and Solihull Mental
Health NHS Trust

Cc::-BCHC, Legalservices (BIRMINGHAM COMMUNITY HEALTHCARE NHS
FOUNDATION TRUST) :

Dawn Clift, Associate Director of Governance, Birmingham and Solihull Mental Health .
NHS Trust

| Solicitor, Birmingham and. Solihull Mental. Health NHS Trust

HM Prison &
Probation Service

Michael Spurr

Chief. Executive

HM Prison & Probation Service
8" Floor 102 Petty France

London ;

SW1H 9AJ

E-mail: ceohmpps@noms.gsi.gov.uk

Ms Emma Brown

Area Coroner
Birmingham and Solihull
The Coroner's Court,
Birmingham, B4 6NE

”. E-mail: coroner@birmingham.gov.uk

13 February 2019

Dear Ms Brown,
Inquest into the death of John Delahaye

Thank you for your Regulation 28 Report of 18 December 2018, issued following the
inquest into the death of John Delahaye and addressed to NHS England, Birmingham
and Solihull Mental Health Foundation Trust, Birmingham Community Healthcare NHS
Trust, G4S and the Ministry of Justice. As Chief Executive Officer of Her. Majesty's

- Prison and Probation. Service (HMPPS), |.am responding on behalf: of the MOuJ..1
understand that the NHS Trust, Healthcare Trusts and G4S will be responding to you
separately, : :

[-know that you will share a copy of this response with Mr Delahaye’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.

| am grateful to you for bringing to my attention your concerns. You have raised the
issue of healthcare attendance at all first ACCT case reviews, and said that the

checklist of actions within the ACCT booklet does not incude a requirement to make
staff aware of the first:review. °

PSI|'24/2011 Safer Custody chapter 5 states that healthcare must be informed when
an ACCT is opened, and should attend the first case review which must be held within
24 hours of opening an ACCT:

In July 2018, HMPPS issued:a Learning Bulletin (ACCT - Case Reviews, CAREMAPs
and Levels of Conversations and Observations) to. all prisons. The Bulletin reminded
staff that ACCT review meetings must be multi-disciplinary and must take place within
‘the specified timescales. It further stated that that where any individual involved in the
prisoner’s: management: cannot. attend. the review, they. must. submit: written
contributions

Following a review of ACCT, we are currently in the.process of piloting an updated
ACCT. document and revised guidance, which is clear that healthcare must attend the
first case review, and is expected also to attend every subsequent review (and where
this is not possible to provide a written contribution). in. cases in. which issues of
physical or mental health have been identified as relevant. The pilot. will run for. a4
month period from mid-February. It will be evaluated, and we hope to roll out the new
procedure nationally.in the autumn.

In June 2018 all. HMP. Birmingham ACCT case managers and members of healthcare
staff including those from the mental health team and integrated drug services, were
reminded by way.of.a written. staff briefing that they. must attend all first ACCT case
reviews, and any subsequent reviews where necessary. Since Mr Delahaye’s death,
staff are now alerted at the. Governing Governor's daily. staff. meetings of the first
ACCT: case. reviews which are scheduled for the day, and reminded of such by the
communications room. staff.In September 2018, the establishment set up. a new
quality assurance process by which members of the Safer Custody team check that
all ACCT documents are completed .in accordance. with instructions and _ that. all
necessary actions have been taken. ‘Since December 2018, a member of the senior
leadership team has carried out a.daily check ofall ACCT documents, including
verifying that healthcare staff did attend the first case review.

Your second concern is that.whilst you were told at the inquest that senior. staff had

been advised that unlocking prisoners should include a welfare check, it was not clear...

how this had been communicated to the staff who were actually unlocking prisoners,
or how compliance would be monitored.

“PSI 75/2011 Residential Services, states that.there must be clearly understood.

systems in place for staff to assure themselves of the well-being of prisoners during
or. shortly after. unlock. . Since October. 2018, HMP.: Birmingham has met. this
requirement by the introduction of anew compliance process known as Residential
Activities, Basics and Cleanliness (ABC). Since January this year, senior managers
carry out weekly checks to ensure that staff are following the correct procedures. All
staff were made aware of the process by way of a staff briefing.

Thank you again for bringing these matters of concern .to.my attention. Please be
assured that learning from.the circumstances of John’s tragic death willbe shared
more widely with colleagues across the prison estate.

Yours sincerely

Michael Spurr

G4S Gare & Justice Services

: o Southside
7 | ‘ 2-705 Victoria Street
London
. SWiE 6QT
oe : Telephone: +44 (0)20 7963 3112

www.g4s.com

Ms Emma Brown

Area Coroner.
Birmingham and Solihull
The Coroner's Court,
Birmingham, B4 6NE

By email: coroner@birmingham.gov.uk and first class post.

Tuesday 12" February 2019 :

Dear.Mrs Brown,

Inquest into the death of John Delahaye

Thank: you for your Regulation Root dated 18 December 2018 addressed to. NHS England,
Birmingham and Solihull Mental Health Foundation Trust, Birmingham Community Healthcare Trust,
G48 and the MO4J. Your report was written concerning the recent death of Mr.John Delahaye at HMP.
“Birmingham on 5! March 2018, This response is sent on behalf of G4S Care and Justice Services —
(UK) Ltd ("G48").

The report raises four concerns but it is noted that only.the fourth concern is highlighted by you as
being capable of being addressed by G4S and so we respond below to that concern only. You have ):
indicated that your fourth.concern is:- :

"On the. morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07: 50.
It is likely that he was already dead at this time (and had been so for some hours) but he was not found
because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of

acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the.Safer
Custody Manager.that.unlock ought to have involved.a:welfare:check. The Safer Custody: Manager's
evidence is that the need for a welfare check on unlock has been emphasised to senior managers and
leads. through a bilateral document covered at formal briefings. However, it was not clear how. this is _
then communicated down to the. individual custody officers and how they are being audited to make
sure they are. conducting a welfare check on unlock. The absence of a welfare check creates a risk that
a prisoner in need of life saving assistance at the time of unlock is not identified.” :

It is acknowledged that the Inquest heard that the PCO who unlocked Mr Delahaye on 5" March did
not.carry out a welfare check on him at that time and that further, that PCO. conceded that he knew he
ought to have done, a position reiterated by the Head of Safer Custody. When officers first enter the
employ of G4S at HMP. Birmingham, they do as part of their induction training receive instruction on the
process of unlocking prisoners. It is explained to them that as well as unlocking prisoners, they should
assure themselves that each prisoner is alive and well at that time. New recruits also undergo a period
. of shadowing experienced officers who will also demonstrate to them how ‘the unlocking process is
- carried out and how a welfare check should be conducted. :

You will recall that the Inquest heard that on 20 August 2018, HMPPS took over.the day to day
running and management of HMP Birmingham for a period of six months, subject to further extension
by the MOJ. Any instruction to staff does therefore come direct from HMPPS and not G4S at this point
in time. However, we can confirm that since October 2018, HMP Birmingham has met this requirement
by the introduction of a new compliance process .known as Residential Activities, Basics and
Cleanliness (ABC). Since January this year, senior managers have been carrying out weekly checks
to ensure that staff are following the correct procedures. All staff were made aware of the process by
way of a staff briefings during October 2018.

ots Gare and Justice Services (UK) Limited

Securing Your World _ iio ro

Registeted in England No. 390328

We.can further: confirm that when the.time comes for HMPPS. to."step ‘out! of HMP. Birmingham.:The :
system in place as. described in the. paragraph above will continue. with .G4S_ Senior Residential
Managers continuing to audit that welfare checks are being carried out, correctly by Conducting weekly :
checks of.staff.

Yours sincerely,

Managing Director
Custodial & Detention Services _
G4sS Care'& & Justice Services (UK) Limited

Securing Your World

England
By ; Professor Stephen Powis
Ms.Emma Brown : National:Medical Director
Area.Coroner, Birmingham: and : : 6" Floor, Skipton House
Solihull ; : 80 London Road
Coroner's Court ‘ SE1.6LH
50 Newton Street : " :
Birmingham oe . : ;
B4 6NE ; : 8!" February 2019

Dear:.Ms Brown

Re: Report to Prevent Future Deaths (Regulation 28) concerning the death of Mr
John Anthony. Delahaye ‘who. died whilst remanded into the care of HMP
Birmingham on 5 March 2018.

Thank you for your letter and.Regulation 28 Report (“Report”) issued on Tuesday 18
December 2018 following the inquest into the death of John Delahaye. | would like to
express my deep sympathy to Mr Delahaye’s family.

In your.report you raised two concerns for NHS England; :

4. There is confusion surrounding the meaning of the following question from

NHS England's national.clinical template for In-Possession Risk Assessments

“inthe Secure Estate: “Have. you had problems in the last 6 months with not

taking, or not remembering to take your:medicines as prescribed?”

2. The read coding in: SystmOne is not consistent across the prison estate to

“provide a reliable summary of significant past and current medical.conditions. -
to ensure consistency in care due to incorrect read codes being applied.

| will answer both your concerns below taking each one in turn.
1. In-Possession Risk Assessment Template

In 2018 NHS England developed and rolled out a national clinical template to support
the completion of in-possession (IP) risk assessments .in prisons. This supports the
implementation ‘of ‘the provider's local. in-possession medication policies. The
assessment template was developed by.a multidisciplinary group of stakeholders. who
were experienced in-using local in-possession risk assessments. The template aligns
with national guidance on in-possession medication in prisons!?.; The template was
piloted. successfully before it was implemented: and training for all providers -was
commissioned by NHS.England and delivered as part of the roll out process. It is the
_ responsibility of the provider to ensure that clinicians using the assessment template
understand how to use it effectively and that it is used ‘in line with their Jocal in-

+ National Prescribing Centre 2004 “In-possession medication” fink
2 RPS 2017 “Professional Standards for Medicines Optimisation in Secure Environments 2" Edition” link

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

possession medication policy.

‘The full assessment is designed to be used_on initial admission into’a prison. This
assessment outcome is then accessed by clinicians such as GPs who wish to review
and update the status of an individuals in-possession medicines during their time in
prison. Clinicians have. the option. of completing the full assessment again. thus
replacing the. previous assessment in full or viewing the ‘previous assessment
information as an IP. review. This means they can adjust the possession status during
a consultation, documenting the rationale for any change.

The.national incpossession risk assessment has 10 questions included with weighted
scoring foreach question. The. overall score informs the assessor about whether it is.
safe for.the person to have their medication in-possession: The score.is a guide and
the suggested outcome can be over-ridden by the assessor based on their clinical
judgement about the person and their ability to manage their medicines independently.

The. question detailed in your:Report:(question 5 in the assessment) is focussed on
unintentional non-adherence rather. than: intentional non-adherence/overdose with
prescribed medicines. There is an additional question 6 in IP. risk assessment (see the
attached- user guide) that asks about specifically medicines overdoses:

In the last 12:months have you:
a) Self-harmed or attempted suicide?
b) Overdosed with medicines?

The assessor is prompted to pause the assessment. to check clinical notes: for
information ‘about this and the reception screen outcome. which: may also have
information included about risks of self-harm.

It is not.clear from your Report whether: the GP.who reviewed the in-possession status
for Mr Delahaye used the previous assessment information to inform the changes to
his in-possession ‘or whether there was a clear record of Mr. Delahaye's previous
overdose of insulin that would alert clinicians to this specific risk. It is the healthcare
provider's. responsibility to ensure that the in-possession risk assessment us used
effectively and that their in-possession -policy aligns with the RPS standards? and
guidance about how in-possession policies should be developed’.

On this basis NHS England-does not feel that the assessment tool needs to be revised.
The provider:at HMP. Birmingham can take local action to reduce the ‘risk of future
harm by. using local audits. of in-possession risk. assessments and. ensuring that
clinicians using the template do so in line with:the User Guide, national guidance 2 and
the provider's .local-in-possession: medication policy.

In-relation.to this case NHS. England ‘Regional Health and Justice Commissioners
(North Midlands) will. monitor the in-possession. process. including use -of:.the -In-
Possession Risk Assessment ‘Template through the: Death in Custody. and ‘Her
Majesty’s Inspectorate of Prison action plans that have ‘been. produced at HMP
Birmingham. The monitoring and oversight of the action plans and learning will also
be included for review at the 2019 clinical quality visit, scheduled for the 6th June 2019,
undertaken as part of the quality assurance of healthcare at HMP Birmingham. Any

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

further concerns relating to the use and implementation of the In-Possession Risk
Assessment template will be escalated to the NHS England central team for support
and review. :

2. SystmOne Read Codes
By way of background this concern is not limited to prison healthcare and exists across

all primary care general practice settings. Historically.there have been. two clinical
coding systems in use in general practice, with not all general practice systems using

the same coding system causing inconsistency in coding. NHS Digital began rolling .

out a new. mandated coding system called SNOMED. CT coding from April .2018.to
~o replace all other.coding systems. The rollout schedule varies depending on the clinical
system provider but will.be complete by April 2020. SNOMED CT will provide.a single
Clinical terminology, enabling clinical data to be exchanged accurately and consistently
across.all care settings. This. will allow better patient care and improve how clinical
data can be analysed and reported on.

SNOMED. CT will be subject to an update and management processes whereby
coding can be added jf it is deemed necessary but only by.a central system; UK
Terminology Centre. There will be no ability to update or change. coding at.a local
level. :

SNOMED cT has been introduced as an alternative coding system into the prison
general practice electronic medical records, SystmOne since 14 January 2019. In May
»2019 SNOMED -CT.:will be the default coding system forall health and justice
SystmOne.

In terms: of transition to SNOMED CT, all historic data will have a Read and SNOMED
code applied via the mapping tables, the dual coding approach will: support users in

ensuring they can.revise their clinical searches as necessary..NHS England: are °
working with NHS Digital and regional commissioners to support HJIS users during

the transition phase.

| 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

The report

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