Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0396, written 19 Dec 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Dec 2018 |
|---|---|
| Reference | 2018-0396 |
| Deceased | Kirsty Walker |
| Coroner | Anna Crawford |
| Coroner area | Surrey |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: The Inquest Touching the Death of Miss Kirsty Walker A Regulation 28 Report — Action to Prevent Future Deaths THIS REPORT IS BEING SENT TO: • The Rt Hon Matt Hancock MP Secretary of State for Health and Social Care Department of Health and Social Care London SW1H OEU • Simon Stevens Chief Executive Officer NHS England P0 Box 1673$ Redditch B979PT 2 3 CORONER Miss Anna Crawford, HM Assistant Coroner for Surrey CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 1 4 INQUEST The inquest into the death of Miss Kirsty Walker was opened on 7 October 2015. returned their conclusion on 13 November 2018. It was resumed on 29 October 2018 with a jury. The jury They found the medical cause of death to have been: la. Hypoxic brain injury lb. Cardiorespiratory arrest lc. Ligature compression to the neck They concluded with a short-form conclusion of accidental death together with a narrative conclusion. 5 CIRCUMSTANCES OF THE DEATH Miss Walker died at St Peters Hospital in Surrey on 27 September 2015. At the time of her death she was 26 years old and serving a prison sentence at HMP Bronzefield. HMP Bronzefield is a private prison run by Sodexo Justice Services, which contracts out secondary mental health services to Central and North West London NHS Foundation Trust (CNWL). Miss Walker had been diagnosed with borderline personality disorder and had a history of self-harming, both in the community and during previous periods of imprisonment. She began her final period of imprisonment at HMP Bronzefield on 24 March 2015 and from 25 March 2015 onwards she was managed under the prison’s suicide and self-harm prevention procedures (ACCT procedures). During the period from 25 March until 25 September 2015 Miss Walker engaged in 235 acts of self-harm, with 215 of those acts involving the tying of ligatures around her neck. On 25 September 2015 she was found unresponsive in her cell with a ligature tied around her neck. She was taken by ambulance to St Peter’s Hospital but she did not recover and she died at the hospital on 27 September 2015. 2 6 CORONER’S CONCERNS The court heard evidence in relation to the process and timeframes for transferring prisoners under s.47 of the Mental Health Act 1983 to secure hospitals. In particular, the court heard from Consultant Forensic Psychiatrist and the Clinical Director of CNWL Offender Care as well as two other Consultant Forensic Psychiatrists acting as independent experts, and , a The court heard that where a prisoner is assessed as being detainable under the Mental Health Act 1983, they ought to be transferred to hospital within 14 days, pursuant to the recommendations in the 2009 Bradley Report. However, the court heard that the process for carrying out such transfers is in fact a long and convoluted process and that the 14-day timeframe envisaged in the Bradley Report is not complied with as a matter of practice. told the court that the average waiting time at HMP Bronzefield for transfer to a secure hospital bed is 2-3 months, and that this compares well as against the waiting times at other prisons. told the court that the average waiting time for transfer to a secure hospital bed in London was 10-12 months. told the court that in his opinion the lengthy waiting times were due primarily to a dearth of secure hospital beds across the country. The MATTER OF CONCERN is: I am concerned that the average time to transfer a prisoner to a secure hospital under s.47 of the Mental Health Act 1983 is well in excess of the 14 days envisaged by the 2009 Bradley Report and presents a risk of further deaths. 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action. 3 8 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 9 COPIES I have sent a copy of this report to the following: 1. Miss Walker’s family 2. Sodexo Justice Services 3. Central and North West London NHS Foundation Trust 4. Cimmaron (Healthcare) 5. Prisons and Probation Ombudsman 6. The Chief Coroner 10 Signed: DATED this cL D-c_,-j 2o1 4
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.
ae From Jackie Doyle-Price MP Parliamentary Under Secretary of State for Mental Health, Department Inequalities and Suicide Prevention of Health & Social Care 39 Victoria Steet SW1H OEU 020 7210 4850 Our Ref: PFD-1161207 Miss Anna Crawford HM Assistant Coroner, Surrey HM Coroner's Court Station Approach Woking GU22 7AP 3 March 2019 Deoy Mum WouLerdad Thank you for your correspondence of 20 December to Matt Hancock about the death of Miss Kirsty Walker. 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 length of time it takes to transfer a prisoner to a secure hospital under section 47 of the Mental Health Act 1983! and the risk this poses to future deaths. It is not clear from the detail in the report as to the extent that this was a contributing factor in the death of Miss Walker. However, I acknowledge the evidence given at inquest in relation to this and the cause for concern of future deaths. You issued your report to NHS England as well as the Department. 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. It is therefore for NHS England to respond to you in detail. However, I am aware of, and hope you will be assured by, the work currently being undertaken 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 20114. 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. ls / eeaae DOYLE-PRICE 3 https://www.england.nhs.uk/wp-content/uploads/2016/10/hith-justice-directions-v1 |_pdf ‘ https://www.gov.uk/government/publications/the-transfer-and-remission-of-adult-prisoners-under-s47-and-s48-of-the- mental-health-act 5 https://www.england.nhs.uk/publication/service-specification-integrated-mental-health-service-for-prisons-in-england/
Professor Stephen Powis
National Medical Director
6th Floor, Skipton House
80 London Road
SE1 6LH
13th March 2019
Ms Anna Crawford
Assistant Coroner for Surrey
HM Coroner’s Court
Station Approach
Woking
Surrey
GU22 7AP
Dear Ms Crawford
Re: Report to Prevent Future Deaths (Regulation 28) concerning the death of Ms
Kirsty Walker who died whilst under the care of HMP Bronzefield on 27
September 2015.
Thank you for your letter and Regulation 28 Report (“Report”) issued on Wednesday
19 December 2018 following the inquest into the death of Kirsty Walker. I would like
to express my deep sympathy to Ms Walker’s family.
The report raised a concern regarding the average time to transfer a prisoner to a
secure hospital under s. 47 of the Mental Health Act 1983 which is in excess of the 14
days envisaged by the 2009 Bradley Report.
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. More recently NHS England has
devolved responsibility to secondary MH providers in respect of managing budgets
and planning for their local populations. These New Care Models (NCMs) comprise of
a lead provider arrangement or a collaborative of providers who are responsible for
planning the pathway for their local populations in terms of adult medium and low
secure 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 MHA 1983 to mental health inpatient
services. Such prisoners will be subject to the requirements and effects of sections 47
(and 48) of the MHA 1983.
Health and high quality care for all, now and for future generations
The provisions of the MHA 1983 do not stipulate a timescale within which prisoner
transfers from prison to mental health inpatient services must take place.
Lord Bradley, in his report published in April 2009 following an independent review of
the experiences of people with mental health problems and people with learning
disabilities within the criminal justice system called on the Department of Health to
“develop a new minimum target for the NHS of 14 days to transfer a prisoner with
acute, severe mental illness to an appropriate healthcare setting”, and that “this new
target should be included as a mandated item in the Central Mental Health contract
and included in the next edition of the Operating Framework” (Bradley 2009, p.106).
The Government did not accept these recommendations, but placed them ‘under
review’ stating that:
“The Government agrees with the goal behind this recommendation and considers
that the time to transfer those with acute severe mental ill health from prison should
be reduced to a minimum. The Board will consider what further guidance should be
issued to the NHS and criminal justice agencies along with improved commissioning
of services to achieve this.”
In April 2011 the Department of Health published the Good Practice Procedure Guide:
The transfer and remission of adult prisoners under s47 and s48 of the Mental Health
Act1 (The Good Practice Guide). This Good Practice Guide sets out suggested time
limits for assessments and transfers under section 47 and section 48 of the MHA 1983
with transfer to secure mental health hospital within 14 days of the initial request for
assessment. Appendix 1 of the guide provides full details of suggested timeframes for
each part of the assessment and transfer process.
NHS England has regard to the above Good Practice Guide in relation to transfer times
from prison to mental health inpatient services and is now responsible for reviewing
the Good Practice Guide. 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.
Until a new Good Practice Guide 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 and PICU 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.
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 inpatient
services.
1 https://www.gov.uk/government/publications/the-transfer-and-remission-of-adult-prisoners-under-
s47-and-s48-of-the-mental-health-act
Health and high quality care for all, now and for future generations
NHS England is aware that there are instances where the transfer process takes
longer than the suggested 14 days and are working with all stakeholders to better
understand the issues. Part of this work is to determine how long is appropriate for the
process to take from initial identification of the need for a referral to a mental health
inpatient service to the point that someone is transferred. Within this timescale it is
important to specify key elements of the process, one of these being the time taken
from the decision that an inpatient bed is required to the transfer taking place. The
suggestion in the recent Independent Review Report of the MHA (1983)2 describes
two new, sequential, time limits of 14 days each (total 28 days):
i.
ii.
from the point of initial referral to the first psychiatric assessment;
from the first psychiatric assessment until the transfer takes place
It is also very important that, where it is evident that there is an urgent clinical need for
treatment, that the whole process can be delivered to shortened timelines. This would
be determined by the clinical presentation of an individual and the requirement for
urgent treatment that could not be provided in the prison.
NHS England is undertaking a number of pieces of work, liaising and engaging with
all stakeholders to better understand the issues that can cause delay and to explore
how this can be alleviated. These include:
1. An annual audit benchmarking data in relation to the transfer and remission
process;
2. Improved performance management
through
increased and
improved
collection and analysis of data;
3. A demand and capacity review in relation to adult high, medium and low-secure
services;
4. An initiative was proposed in December 2015 and then piloted from 2016,
where mental health care providers were encouraged to take on the
management of tertiary budgets for adult medium and low secure services and
were able to work in partnership with other providers to enable the local system
to be responsive and take ownership of the whole pathway including where that
related to prison transfers. In February 2018 it was agreed that this approach
would be rolled out nationally;
5. The development of pilot sites for intensive community forensic models of care
to enable earlier discharge with appropriate levels of support outside secure
hospitals;
6. Revised service specifications for adult medium and low secure services,
ongoing work to revise the high secure service specification.
All of the work described above will enable better throughput across the whole secure
pathway, thus enabling the appropriate capacity to be available when it is required.
Further details of some of these 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 process for prisoners. This is in
2 https://www.gov.uk/government/groups/independent-review-of-the-mental-health-act
Health and high quality care for all, now and for future generations
addition to local audits undertaken by NHS England regional commissioners. The last
audit was published on 16th November 2018 and can be
seen here:
https://s3.eu-west-2.amazonaws.com/nhsbn-
static/Other/2018/Data%20Transfers%20and%20Remissions%20Census%20Report
.pdf.
The next audit is currently underway, based on a census date of 28 February 2019. It
is anticipated that the report will be available by the end of May 2019.
In respect to the improved performance management and capability that is being
developed in this area, good practice examples relating to the pathway between
prisons and respective mental health inpatient services are being identified in some
parts of the country and processes to disseminate and share this information nationally
is a specific focus.
Another example of good practice is the development of a prison transfer service
within a secure inpatient service. This service focusses specifically on transfers from
prison, enabling timely transfers and remission where appropriate to ensure that
particular capacity is used exclusively for this patient group.
As above a review of the Good Practice Guidance 2011 has taken place, led by NHS
England. The revised guidance will be submitted for public consultation prior to
implementation nationally, and will consider the whole process of referral, assessment,
transfer and remission.
In relation to adult medium and low secure services specifically, NHS England is
conducting a demand and capacity review, ensuring that inpatient 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 whilst for others prison services. The
reconfiguration of beds sits alongside other ongoing work as described above. The
effect of this will be to ensure existing capacity and throughput is optimised.
In relation to high secure services, a similar demand and capacity review is being
undertaken as part of strategic commissioning work. This review is in its early stages
and NHS England aims to publish the results 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 by making better use of available capacity overall, and making the process
of transfers from prison more timely and efficient. This is 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 recent ‘Long Term Plan’
(published 7 January 2019).
As it stands the Good Practice Guidance (2011) is extant pending the completion of
the revision process and the publication of the new guidance. Those delivering the
Health and high quality care for all, now and for future generations
healthcare service within a prison (as well as those providing adult secure mental
health services) are expected to read the relevant service specification in conjunction
with the prevailing Good Practice Guidance in relation to transfer and remission times.
It has proven and is further anticipated that the above works and initiatives, alongside
the implementation of the new more clinically based guidance, will make the
transfer/remission process as a whole more efficient.
I hope the information above addresses the concerns you have raised within your
Report and provides you with the 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
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