Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0014, written 4 Jan 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Jan 2019 |
|---|---|
| Reference | 2019-0014 |
| Deceased | Nicky Reilly |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester North |
| Category | Mental Health related deaths · State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. HM Prison and Probation Service 2. Greater Manchester Mental Health & Social Care Trust CORONER | am Ms Joanne Kearsley, Senior Coroner for the Coroner area of Manchester North CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 INVESTIGATION and INQUEST On the 7" December 2018 | concluded the Inquest into the death of Mr Nicky Raymond Reilly (NR) also known as Mr Mohamed Saeed-Alim, who died on the 19" October 2016 in HMP Manchester. A jury reached the following findings and conclusion : “In October 2016 the deceased was an inmate at HMP Manchester having spent 6 years at Broadmoor High Security Hospital. He had a diagnosis of Emotionally Unstable Personality Disorder and Aspergers. On the 19" October 2016 he was found hanging by a ligature in his cell. He was pronounced deceased at 14.43. On the balance of probabilities the deceased died as a result of hanging whilst in HMP Manchester. It is more likely that not that he did not intend to end his life and he acted impulsively as a result of his Emotional Unstable Personality Disorder and Aspergers Syndrome.” CIRCUMSTANCES OF DEATH The circumstances leading up to NR’s death are as follows: In 2009 NR was convicted and sentenced to life imprisonment following an incident in May 2008 when he had attempted to detonate explosives in the Giraffe Café in Exeter. In the time prior to the incident NR had converted to Islam, changed his name and subsequently developed extremist views as a result of being tadicalised. Prior to the incident NR had been diagnosed with Asperger's Syndrome and had been under the care of Mental Health Services. He was subsequently also diagnosed with Emotionally Unstable Personality Disorder. Following his conviction the Court imposed a life sentence as opposed to a hospital order. During his remand he had been held in HMP Belmarsh on the healthcare unit, following his conviction a referral to the high security hospital was made and he was transferred to Broadmoor. He remained an inpatient in Broadmoor hospital for the next 6 years. In July 2015 NR and another inpatient assaulted members of staff, following which a clinical decision was made resulting in NR being transferred back to the prison estate. A meeting was held between HMP Belmarsh and Broadmoor prior to NRs return to the prison estate. Subsequently he was referred to the Managing Challenging Behaviour Scheme and his care was overseen by the Central Management Group (CMG). A decision was made to transfer NR to the Specialist Interventions Unit at HMP Manchester in order for work to be undertaken in relation to his extremist views. The longer term plan was that he would be moved to the Westgate Unit at HMP Frankland when a place became available. Whilst on the SIU the Court heard evidence with regards to the management of his care and the input of both the prison psychologists, part of (HMPPS) and the Mental Health In-Reach team, the prison mental health service provided by Greater Manchester Mental Health & Social Care Trust (GMMHT). The Court does not intend to repeat the evidence heard in relation to the contact with NR and sets out its concerns below. 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:- HM Prison Service e CPA Whilst NR had been an in-patient at Broadmoor he had been subject to the Care Program Approach (CPA). There was no explanation as to why this was not continued when he was transferred back into the Prison Service. The lack of continuation of the CPA and the missed opportunities this presented, particularly in respect of earlier input from Psychiatry, for someone with such complex needs is of concern to the Court. Care plans relating to NR, as discussed below, should have had the benefit of Psychiatric input. e Managing Challenging Behaviour Scheme and Challenge Support and Intervention Plan The Court acknowledges that as of the 1“ February 2019 the MCBS will be replaced by the new CSIP providing management of the prisoner to the individual establishment rather than with the CMG. Whilst recognising this significant development there were concerns heard during the course of NR’s Inquest which remain relevant. The Court also recognises the complexity of the challenging behaviour presented by NR in that he had a diagnoses of both emotionally unstable personality disorder, Asperger’s and in addition, remained someone who held extremist views. The Court heard evidence in respect of the quarterly meetings held by the CMG in respect of managing NRs care plan. The quality of documentary record keeping in respect of these meetings was limited. The absence of important multi-disciplinary attendees and lack of requirement of formal reports meant there was no-one who could provide full, accurate, informed information regarding NR, upon which decisions regarding his care could be made. e Psychology Input NR had been allocated a Psychologist i to undertake the specialist extremism work. However this meant he did not have an allocated psychologist who was based within the SIU. The evidence to the Court from several witnesses including the Psychologists and SIU staff showed there was confusion as to whom was NR’s allocated Psychologist. The reality was from May 2016, NR received no psychological input and did not have an allocated Psychologist in any meaningful form. The Court received a copy of the psychology records kept by which the Court heard were the only Psychology records available. It was evident to the Court that there was little to no recording of information within the Psychology department. NR’s psychology medical records were at best, woeful. Moreover, as they were not kept in the Psychology department they were not available access to any other Psychologists. The Extremism Risk assessment work had been concluded ~~ May 2016. Despite this, her report had not been completed at the time of NR’s death in October 2016 and she did not anticipate being in a position to complete the report until the New Year, some 8 months later. Whilst there is no evidence that in NR's case this held up his referral to the Westgate Unit, given that a significant reason for his placement on the SIU prior to placement at Westgate, was to undertake this piece of work, a significant time had elapsed. In the meantime whilst waiting transfer, the Court heard no further Psychological input would be started with NR. e Services available within Prison for Prisoners with Aspergers and/or Personality Disorder The Court heard evidence as to the increase of prisoners within the Prison Service who potentially have a personality disorder or a degree of Aspergers and the limited services and places available. Of significance was the lack of training or guidance to staff on how to interact or accommodate someone with high functioning Aspergers such as NR. Please note the Court recognises the care provided by the SIU staff and the attempts some staff went to interact with NR, however there was no specific training or assistance given to them. HMP Prison and Greater Manchester Mental Health & Social Care Trust ¢ Complete Separation of the Mental Health In-Reach Team and Psychology Team The Court heard how the Mental Health team providing mental health services within HMP Manchester have a completely separate record keeping system (system 1) to the Psychology Team. Whilst acknowledging the Psychologists are employed by HM Prison Service. However not all the psychologists were forensic psychologists as the Court hoor ae 3: a clinical psychologist. There will inevitably be prisoners who require clinical psychological input for a range of diagnosis. Within a community setting such psychological services would be provided by the Mental Health Trust. Hence Psychologists would have access to the patients mental health records within the same Trust, where the same existed. Where a prisoner is receiving both Mental Health input and Psychological input within a prison, there should be access to the appropriate medical records in order for each service to have a clear understanding of the patients clinical presentations and need. Having access to the totality of the information should then assist in appropriately assessing a patients risk to self and others. , Greater Manchester Mental Heaith & Social Care Trust e Medication Refusals The Court heard evidence as to the lack of action taken by staff following NR’s refusal of medication. The Court heard the process which should happen but this is not clearly documented in one policy which covers the situation for both weekdays and also weekends. There remains a risk particularly at a weekend that an appropriate escalation process would not be actioned by staff. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe each of you respectively have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 4"° March 2019. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- the legal representatives for Mr Reilly's family. | 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 from. 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. Date: 4" January 2019 Signed:
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.
Greater Manchester Mental Health | NHS Foundation Trust. Trust Management Offices "First Floor, The Curve Bury New Road: Prestwich Manchester. M25 3BL : Tel: 01613582014. - Web: www.gi IS.UK __ PRIVATE & CONFIDENTIAL M Senior Coroner Ms J: Kearsley -. Manchester North HM Coroner's Court Phoenix Centre Po L/Cpl Stephen Shaw MC Way “Heywood OL10-1LR "48 March 2019. Dear Ms Kearsley Re: Mohammed Saeed-Alim formerly known as Nicky Rellly (Deceased) Regulation 28 Report : GMMH Response - Further to your email highlighting your concerns following Mr Nicky Reilly’s Inquest please see below the . Trust's response to this concerns: 1. Complete Separation of the Mental Health In-Reach Team and Psychology Team ¢ When a prisoner is receiving both Mental Health input and Psychological input aS within a prison, there should be access to the patient’s mental health records in ~ order for each service to havea clear understanding of the patient’s clinical presentations and need. Having access to the totality of the information should then assist in appropriately assessing a patients risk to self and others. a Where a prisoner is receiving input from thé ‘prison Psychology team access to the NHS record can be requested by the psychologist responsible for delivering that input to the patient, Subjectto the normal consent being given. The prison Psychology team have been informed of how theycan.. gain access to the patient's clinical record. : ee Where such access is given, it is expected that the Psychologist will: document their involvement. © with the patient in the clinical record, to inform the multi-disciplinary healthcare team of the input that is being provided. Psychology access fo the system will allow them to see the current package — of care that is being delivered by medical and mental health services. : The trustic committed to safeguarding children, young People and vulnerable adulis'and = “requires ¢ r iteers to share this conimitmentt. oe ‘Greater Manchester Mental: Health’ NHS Foundation Tru: urve, Bury New Road, Prestwich, “improving Lives Menchester M25 SL (Tsl-O184 778.6124) NHS Greater Manchester An audit of psychology access to the system, patients viewed and documented entries made, will be conducted Mental Health by the Head of Healthcare. HS Foundation Tru Mental Health and psychology staff now attend the weekly comphtt Is Fo undation Trust. minuted, where those prisoners with complex needs are reviewed by the multi-disciplinary team. This allows a multi —disciplinary approach to care planning anda forum for the sharing of information. HMP Manchester has just received funding from NHS England from the 1*' April 2019: to increase mental health services within the prison. Part of this funding will be used to fund a Psychologist, employed by Greater Manchester Mental Health Trust, to provide psychologically informed, evidence based specialist support for all those assessed as requiring interventions to address mental health, personality disorder, and support for individuals with learning disabilities. As a GMMH employee this psychologist will be expected to document all patient interactions within the patient's systmone clinical records. 2. Medication Refusals -“@ The Court heard. evidence as to the lack of action taken by staff following NR’s refusal of medication. The Court heard the process which should happen but this is not clearly documented in one policy which covers the situation for both weekdays and. also weekends. There remains a risk particularly at a weekend that an appropriate escalation process would not be actioned is proposed. The guidance document for staff, for patients who are non-concordant with medication, has been rewritten This guidance document now makes refererice to the actions staff should take if a patient misses critical medication during the weekend as well as during the week. This document was circulated to all staff in December 2018 and has been added to the Trust Health and Justice Intranet for all staff to view. Ms Kearsley, | hope you and Mr Reilly's family are satisfied with the response we have provided. If you have any further questions in relation to the contents of this letter, please do let me know. Yours Sincerely Dr Chris Daly Medical Director The Trust is committed to'safeguarding childrén, young people and vulnerable adults ‘and requires all staff and yolunteors'to share this commitment ‘Greater Manchester Mental Healtty NHS Foundation Trust, ‘The Curve, Bury New Road, Presiwich, Manchester M26 3BL (Tel: 0161. 773 9121) improving Lives
Director General Prisons HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Email:DirectorGeneralPrisons@justice.gov.uk Dear Ms Kearsley, 17th June 2019 Inquest into the death of Nicky Reilly, also known as Mohamed Saeed-Alim Thank you for your Regulation 28 Report of 4 January 2019, following the conclusion of the inquest into the death of Nicky Reilly, also known as Mohamed Saeed-Alim. As Director General for Prisons, I am responding on behalf of Her Majesty’s Prison and Probation Service (HMPPS). I am grateful to you for bringing to my attention your concerns as directed at HMPPS, and for this opportunity to respond to them. I know that you will share a copy of this response with Nicky’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. Your first concern is that, when Nicky was returned to the prison estate from Broadmoor, the Care Programme Approach (CPA) was not continued. As the CPA is a clinically-led programme to support those with mental health needs, the healthcare provider, or mental health services at a prison, is responsible for determining whether a CPA is required for an individual. During his time managed by the Managing Challenging Behaviour Strategy (MCBS), Nicky was supported by a co-ordinated, multi-disciplinary case management approach, the Care and Management Plan. In Nicky’s case, this process resulted in him being located at the Specialist Intervention Unit (SIU) at Manchester, with the intention of re-integrating him into the custodial environment and stabilising his behaviour, at that time his most pressing identified needs. The Care and Management Plan aimed to support Nicky through to the Personality Disorder service on the Westgate Unit, seen as the best available option for clinical and operational support once he had adjusted and was ready to access treatment in a prison setting. His care at the SIU was overseen by the central management group, a multi-disciplinary team including mental health services and a dedicated mental health nurse. Whilst recognising the significance of the introduction of the new national case management model, Challenge Support Intervention Plan (CSIP), which replaced the MCBS policy on 1 February this year and is currently being implemented and embedded across the prison estate, you have expressed concern that some of the issues covered during the inquest may still be relevant. You have specifically referred to poor record keeping, the lack of multi- disciplinary attendees and the lack of requirement for formal reports. CSIP is a multi-disciplinary approach which focuses on those who pose a raised risk of being violent, and works to change their behaviour. It is centred on the needs of the individual, providing them with the right support to improve and manage behaviour. As part of the implementation process all establishments were provided with guidance and a range of materials, including terms of reference that set out the need for multi-disciplinary engagement and a template for the agenda and minutes for the multi-disciplinary risk management Safety Intervention Meeting (SIM). This will ensure that information sharing is embedded in the process, along with a requirement to maintain effective records of the information which informed decision making. HMP Manchester has been holding a weekly multi-disciplinary meeting to manage complex and challenging prisoners since April 2018, and CSIP was introduced in June 2018. The purpose of the weekly meeting is assist the Residential function by providing multi- disciplinary case management for prisoners who require additional resources over and above their CSIP or ACCT Intervention, Support or Care plans. Departments who do not attend are expected to provide written submissions to the meeting. The meetings are chaired by a Senior Manager from the Residential and Safety function, and minutes are kept to ensure an ongoing record of decision-making is maintained. Your next concern is that Nicky did not have an allocated psychologist in the SIU and that no interventions were carried out following his completion of the Extremism Risk Assessment. While I recognise both points, I should clarify that Nicky’s allocation to the SIU was based on a range of factors, not solely so that formal interventions could be delivered. It is not uncommon for some complex individuals to be encouraged to focus on their involvement in the regime rather than on specific interventions at certain times. Nicky’s difficultly in coping within the custodial environment and the potential for this to present a high risk both to himself and to others meant that the SIU, as a small unit with a high staffing level, was considered the best environment for him to readjust to the prison setting and be offered sufficient support and care from staff. You have referred to mental health and psychology services record-keeping operating separately, with clinical records being held on SystmOne to which psychologists do not have access. While I recognise that this separation does carry the risk that information is not effectively shared, I must respect the medical in-confidence issues that make this necessary, and I expect all staff working in prisons to use the many forums available to them to work in a multi-disciplinary, collaborative way to ensure that decisions about prisoners are made with all available information. You have also raised the issue of training for staff in how to support and manage prisoners with Asperger syndrome or personality disorders. Prior to starting work on the unit, all staff receive a training module which provides guidance on managing those prisoners with challenging behaviour including as a result of personality disorders or learning disability. This ‘Working with Challenging Behaviour’ training is available to staff across the Close Supervision Centre system and those working in segregation units. A number of establishments have delivered awareness events aimed at improving staff confidence in dealing with prisoners with these needs, and nationally a toolkit has been developed to help staff better meet the needs of those in our care with Learning Disabilities and Challenges (LDC). The toolkit is designed for prisons and for probation service operational leaders at prisons, helping them to look at how their support, services and surroundings can better meet those needs and provide a more equal and fair service for those with LDC needs. It includes resources and practical tips, such as how to display information and make environments more engaging and inclusive. We are also increasing our support for prisoners with autism with a new, dedicated unit due to open in 2019 at HMP Wakefield. This unit will cater for men on the autistic spectrum who struggle to cope in the mainstream prison regime. The unit has been developed in consultation with the National Autistic Society, and will operate to an agreed set of standards which will lead to it being assessed and accredited by the National Autistic Society. Our Head of Psychology at Wakefield was named as Outstanding Health or Social Care Professional at the 2019 Autism Professionals Awards, which recognise and reward services and professionals who are leading the way in innovative autism practice and making a real difference to the lives of autistic people in the UK. Thank you again for bringing these matters of concern to my attention. I hope that this response provides assurance that lessons have been learned from the circumstances of Nicky’s tragic death. Yours Sincerely, Director General - Prisons
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