Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0028, written 23 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 | 23 Jan 2019 |
|---|---|
| Reference | 2019-0028 |
| Deceased | Tyrone Givans |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | State Custody 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.
Regulation 28: Prevention of Future Deaths report
Tyrone GIVANS (died 26.02.18)
THIS REPORT IS BEING SENT TO:
1.
Acting Governor
HMP Pentonville
Caledonian Road
London N7 8TT
2. Mr Mike Parish
Chief Executive
Care UK
29 Great Guildford Street
London SE1 0ES
3. Mr Michael Spurr
Chief Executive
National Offender Management Service
Clive House
70 Petty France
London SW1H 9EX
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 8 March 2018 I commenced an investigation into the death of Tyrone
Givans, aged 32 years. The investigation concluded at the end of the
inquest yesterday.
1
The jury made a narrative determination, which I attach, concluding that
Mr Givans hanged himself in his cell at HM Prison Pentonville, his
intentions being unclear.
His medical cause of death recorded was:
1a suspension by ligature.
4
CIRCUMSTANCES OF THE DEATH
Mr Givans was a chronic alcoholic and drug user; he suffered with long
term anxiety and depression; he was homeless; and he was profoundly
deaf.
He handed himself in to Islington Police Station on 5 February, was
arrested for assault occasioning actual bodily harm, interviewed on 6
February and remanded by Highbury Magistrates into custody on 7
February 2018, at which point he was admitted to HMP Pentonville.
He said before his hearing on 7 February that he would kill himself if
returned to prison, though he later told prison staff that he had said this
to try to avoid being remanded in custody. During a previous custodial
sentence he had been noted as having an elevated risk of self harm.
5
CORONER’S CONCERNS
During the course of the inquest, the evidence revealed matters giving
rise to concern. In my opinion, there is a risk that future deaths will occur
unless action is taken. In the circumstances, it is my statutory duty to
report to you.
The MATTERS OF CONCERN are as follows.
1. Mr Givans’ former cell mate gave evidence that he had seen Mr
Givans smoking Spice in their cell on two or three occasions,
saying that its use is common within the prison. The jury heard
that Spice often makes the user scared and paranoid, and can
provoke immediate, extreme and uncharacteristic behaviour.
Drugs are of course a problem in all prisons and dealing with them
a great challenge, but Spice poses a particular danger in all sorts
of ways, both in Pentonville and across the prison estate.
2. A past spelling error meant that there were two sets of NOMIS
prison records for Mr Givans. This meant that there were then
two sets of SystmOne healthcare records.
2
This meant that staff did not have access to records of the
assessments conducted before 8 February 2018. However, later
consultations were not paused to make enquiries about this. The
nature of the IT error was discovered after Mr Givans’ death, but
at the time, staff did not seem to recognise the significance of
having no earlier records.
Evidence was given
is
unsatisfactory and does not lend itself to human intervention. The
jury found that the IT system was unfit for purpose.
that NOMIS
its present
form
in
3. Some members of discipline and healthcare staff did not
appreciate that Mr Givans was deaf, although others did. He was
not formally referred to the prison equalities officer and there was
a general lack of awareness of the role of equalities officer.
There was a delay in seeking Mr Givans’ hearing aids and it took
two weeks for one to be brought in by a family member. Whilst
systems in HMP Pentonville have changed since Mr Givans’
death, such a situation might exist in prisons elsewhere.
remains no equalities/disabilities questionnaire
for
There
completion on prisoners’ arrival to the prison. The first night form
could be adapted, but this would be an exercise to be undertaken
nationally.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 25 March 2019. I, the coroner, may extend the
period.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise you must explain
why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
3
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
HM Inspectorate of Prisons
, mother of Tyrone Givans
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 Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
9
DATE SIGNED BY SENIOR CORONER
23.01.19
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.
HM Senior Coroner Mary Hassell Inner North London St Pancras Coroner’s Court Camley Street London NC1 4PP 14 March 2019 Dear Madam, HMP Pentonville Healthcare Department Caledonian Road London N7 8TT Tyrone Givans (Deceased) Regulation 28: Prevention of Future Deaths report Thank you for your Regulation 28 Prevention of Future Deaths Report dated 23 January 2019, issued following the inquest into the death of Tyrone Givans. Care UK would like to express its condolences to Tyrone’s family and friends. Care UK is the provider of healthcare services at HMP Pentonville. Care UK makes the following comments in response to the issues identified within the report: Drugs – Spice Care UK acknowledges the problem presented by the supply and distribution of illicit drugs within HMP Pentonville and across the prison estate. Care UK is committed to working with partner agencies throughout the estate in supporting efforts to tackle illicit substance supply and trading, and to feed in to disciplinary, support and education processes requiring multidisciplinary team input and engagement. In addition, healthcare continue to treat and educate the prison population as to the dangers associated with the use of illicit drugs, including Spice. This management of people using psychoactive substances (PS) is supported by a Care UK’s PS strategy and Local Operating Procedures. Reception into prison The evidence given at inquest confirmed that an erroneous spelling of Tyrone’s surname during his time in police custody was replicated by HMCTS in the warrant authorising his detention and again by discipline staff on his entry into HMP Pentonville on 7 February 2018. This resulted in the uploading or creation of a new medical record set for Tyrone on 8 February 2018 when NOMIS interfaced with SystmOne. The new record did not include his historical medical information or that from his reception medical screening on 7 February 2018. Unfortunately, the creation of a new set of medical records for Tyrone was not identified, or if it was, it was not queried by clinicians who accessed those records on and after 8 February 2018. Care UK has shared the learning from the inquest, including the existence of the anomaly which can cause the creation of more than one set of medical records for the same patient (for example should they be allocated a new prison number and NOMIS record as a result of a different spelling of their name) with its clinical team at HMP Pentonville and across its prison healthcare estate. This has been by way of a discussion at Care UK’s national Quality Assurance meeting and a cascading of the minutes of that meeting to all sites via regional Quality Assurance meetings. In addition, NHSE are running a project to provide a new functionality in SystmOne whereby patient records are now matched to the NHS Spine, rather than the warrant. HMP Pentonville was one of the first pilot sites but this will be rolled out across the country. Clinicians have also been reminded to thoroughly review relevant records and to query apparently missing records or other anomalies. In addition, at HMP Pentonville, the structure of the clinics has been altered to minimise interruption and disruption by other patients, which transpired as a concern through GP evidence in the inquest. All healthcare reception staff at HMP Pentonville have attended a 3 day NHS England run reception screening course titled “Reducing Deaths in Custody”. Tyrone’s disability , and Deputy Head of Healthcare, Care UK acknowledges that the identification of Tyrone’s disability and the communication of his need for hearing aids, and possibly for other adjustments, could have been better handled. As the Head of Healthcare, , explained in evidence, changes have been made to systems of communication within healthcare and between healthcare and the prison. This includes involving the input of senior management in ensuring that action is taken and information is communicated by and to the most appropriate individual where unusual situations arise; increased awareness of, and referrals to, the prison’s equalities officer and a reminder to healthcare staff regarding making notes of wing conversations in the SystmOne medical records. A new Health and Wellbeing model has been implemented at HMP Pentonville with effect from 14 May 2018. In addition to its primary purpose, which is to deliver primary care mental health treatment whilst preventing silo working, reducing duplicate referrals and the time patients wait to be seen and preventing patients having the same conversation multiple times to various professionals, this acts as an additional safety net for patients coming into prison. We are confident that this would have identified Tyrone’s disability and enabled better management of his care. Care UK welcomes your suggestion that the first night form could be adapted to include an equalities/disabilities component. The SystmOne first night template is mandated by NHS England and whilst Care UK is more than willing to adapt the screening process, this will require discussions with NHS England. We will therefore forward your report and this response to them and work with them in the development of this additional safeguard. We are committed to providing a high quality healthcare service at HMP Pentonville and are doing everything we can to ensure those detained there are as safe as possible and receive the best quality care. We will ensure that the lessons learnt following Tyrone’s death are not just implemented at HMP Pentonville but across Care UK’s services. We trust that the above responses provide the information that you require but please do not hesitate to contact us if Care UK can be of any further assistance. Yours faithfully Head of Healthcare HMP Pentonville On behalf of Care UK
Director General Prisons HM Prison and Probation Service R ) i 8" Floor Ministry of Justice 102 Petty France London SW1H 9AJ HM Prison & Email: DirectorGeneralPrisons@justice.gov.uk Probation Service Ms ME Hassell, Senior Coroner DirectorGeneralPrisons@justice.gov.uk Inner North London Coroner's Office St Pancras Coroner’s Court Camley Street London N1C 4PP 31 May 2019 Dear Ms Hassell Thank you for your Regulation 28 Report of 23 January following the inquest into the death of Mr Tyrone Givans at HMP Pentonville. | am responding, as Director General of Prisons, to the matters of concern you have raised for Her Majesty's Prison and Probation Service (HMPPS). | am sorry for the delay in providing this response, which was due to the number of contributions required in order to provide you with a comprehensive reply. ! know that you will share a copy of this response with Mr Givans’ family and | would like first to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. In response to your concern about the dangers posed by the use of Spice, the joint Ministry of Justice (MOJ) and HMPPS Drugs Taskforce has brought together operational and policy colleagues and key partners to help tackle the problem of drugs, including psychoactive substances like Spice, in our prisons. As part of this, we have been working closely with those in law enforcement, health, and other government departments to develop a national Prison Drugs Strategy which was published in April this year. It provides strategic direction on how to reduce the use of drugs in prisons by restricting supply, reducing demand and building recovery. Alongside this, a Drugs Guidance Document provides examples of best practice for consideration by all those working within and in partnership with HMPPS to reduce the misuse of drugs in our prisons. At a local level, in recognition of the dangers posed by the use of psychoactive substances, HMP Pentonville is revising and republishing its drug strategy and a Drug Strategy Committee has been reinstated as part of the local Safety Programme. The prison’s strategy takes an approach whereby access to psychoactive substances and other illegal substances is, as far as possible, limited, while meaningful support, in the form of education and psycho-social interventions, is provided to those who have used drugs or may be tempted to use them. Sophisticated intelligence systems designed to stem the supply of illicit substances into the prison involve collaboration with a range of HMPPS and Police colleagues. Searching, the use of specialist drug-detection dogs, and the use of technology to identify secreted substances are also part of the prison’s efforts to limit the availability of drugs. You have raised the issue that when the name of a prisoner who has previously been in custody is spelt differently, a new record, which will not contain all the information about the prisoner, is created. At HMP Pentonville a monthly report is now run to identify any such cases and merge the records. Because NOMIS and SystmOne are separate IT platforms, designed and operated by separate government departments, the level of connectivity is limited. However, there are good local working practices now in place which encourage communication between prison and health teams. | understand that Care UK are also writing to you about this. The last matters you have raised are about Mr Givans’ deafness and the issue that there is no national questionnaire to record equality or disability information on first reception. In June this year, HMPPS will publish a Policy Framework document which will replace the existing Ensuring Equality Prison Service Instruction. It will include guidance on the implementation of reasonable adjustments, and will be complemented by the publication this summer of guidance for frontline staff on disability and reasonable adjustments. In terms of the recording of information about disability, we are working with colleagues in the MOJ to refresh the categorisation system for disabilities so that the recording of such information on NOMIS is carried out more efficiently and is more descriptive, moving away from the ‘Yes/No’ method of recording. This will provide staff with more valuable and usable information about the needs of prisoners in their care and across the estate. The categorisation of disabilities will be based upon the categorisation of impairment used by the Office for National Statistics and Government Statistical Service. In addition to the above, a resource tool is being developed that will digitally collect more personalised information from prisoners, allowing staff to better understand their needs and identify adjustments that could be implemented to improve their quality of life and reduce unequal outcomes. This is currently in early development but we are looking to finalise proposals this month and to begin implementation in June/July 2019. Thank you again for bringing these matters of concern to my attention. Yours Sincerely, PHIL COPPLE
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