Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0074, written 27 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Feb 2019 |
|---|---|
| Reference | 2019-0074 |
| Deceased | Kelvin Speakman |
| Coroner | Geraint Williams |
| Coroner area | Worcestershire |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. HM Prison service and HMP Hewell 3. 1 | CORONER | am Geraint Urias Williams, Senior Coroner, for the coroner area of Worcestershire 2 | CORONER’S LEGAL POWERS | 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. 3 | INVESTIGATION and INQUEST On 9th of May 2016 | commenced an investigation into the death of Kelvin Sean Speakman then aged 30 years. The investigation concluded at the end of the inquest on 7th of December 2018. The conclusion of the inquest was Set out in a questionnaire format (attached) the medical cause of death being Pneumonia caused by a hypoxic cerebral injury consequent upon ligature suspension . 4 | CIRCUMSTANCES OF THE DEATH Mr Speakman was a serving prisoner at HMP Hewell and who had a long history of mental ill-health and extensive self harming acts including multiple attempts to hang himself. He was for most of his time at HMP Hewell monitored under the ACCT process. Ultimately following an incident of self ligaturing he suffered a hypoxic brain injury and was admitted into the Alexandra Hospital in Redditch where he declined and, on 9 May 2016, he died 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) The evidence in the case disclosed that the ACCT process was not handled completely in accordance with national and local policies and in particular the standard of documentation was often inadequate. The input to ACCT reviews by the health care department was often absent or the content of such input was not clearly identified. Communication between various staff members was either not consistent or documented leading to a conclusion that staff members making decisions about Mr Speakman were not aware of the full picture of his presenting condition. Although the evidence suggested that more was being done for him than the documentation might suggest it was clear from the evidence that there were gaps in information and potentially in the actions being undertaken. This is not the 1st inquest into a death at HMP Hewell where these criticisms have been made (frequently commented upon in successive PPO reports). In this and earlier inquests the prison have accepted the recommendations made by the PPO to improve the operation of the ACCT process and have given assurances that "lessons have been learned". However this case has highlighted the fact that notwithstanding those assurances the same failings appear time and time again. Furthermore deaths at HMP Hewell subsequent to Mr Speakman's and which are due to be heard at inquest later this year demonstrate clearly that the same failings exist and are perpetuated. | consider that the entirety of the operation of the ACCT process within HMP Hewell is in need of urgent and radical overhaul for the protection of prisoners being looked after under its auspices. (2) (3) ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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 by 25" April 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 The next of kin of the deceased, Care UK, Midlands Partnership _ . | have also sent it to who may find it useful or of interest. | 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. Signed ———— GU Williams 27 day of February 2019 H M Senior Coroner
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.
Phil Copple Director General Prisons HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Email:DirectorGeneralPrisons@justice.gov.uk Mr G R Williams Senior Coroner The Coroner’s Court, County Hall, Spetchley Road, Worcester,WR5 2NP E-mail: coroner@worcestershire.gov.uk 24 April 2019 Dear Mr Williams, Inquest into the death of Kelvin Speakman Thank you for your Regulation 28 Report of 27 February issued to HMP Hewell and Her Majesty’s Prison and Probation Service (HMPPS) following the inquest into the death of Kelvin Speakman. I am responding as Director General of Prisons. I know that you will share a copy of this response with Kelvin’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. I am grateful to you for bringing to my attention your concerns about the management of the ACCT process at HMP Hewell. You have specifically highlighted a lack of compliance with national and local policy, inadequate documentation, and poor information sharing and communication. You have also identified that although the prison has accepted repeated recommendations made by the Prisons and Probation Ombudsman about the same failings, they continue to occur. As such you consider that the operation of the ACCT process at the prison is in need of an urgent and radical overhaul. In order to improve adherence to ACCT policy, from April 2019, the Group Safety Lead at the West Midlands Regional Office will deliver coaching sessions to ACCT case managers at the prison. These sessions will emphasise the importance of sharing information and of accurate and comprehensive recording, so that staff have everything they need to make appropriate decisions and prisoners subject to ACCT procedures are properly managed. She will also work with senior managers at the prison and will carry out bi-monthly assurance checks of all ACCT documentation. Any learnings from the coaching sessions and bi-monthly checks will be discussed with the Governor and at the monthly Safer Custody and Safety Intervention meetings at the prison. Since January 2019, HMP Hewell has been operating a new quality assurance process. A member of the senior leadership team now carries out a daily review of all ACCT documents, making sure that they have been completed in accordance with instructions. They also check that healthcare staff attended first case reviews and that all necessary actions have been taken. In terms of healthcare attendance at all first case reviews, in March 2019 all members of healthcare staff at the prison were reminded by way of a written staff briefing that they must attend all first ACCT case reviews, as well as any subsequent reviews when necessary, and must record their attendance clearly in the ACCT document and on their IT system. They must also record any information relevant to risk. In the event that healthcare staff are exceptionally unable to attend the first review, an ad hoc review will be held as soon as possible after the initial review in order that healthcare views can inform the management of the case. Staff have also been reminded about the HMPPS Learning Bulletin (ACCT - Case Reviews, CAREMAPs and Levels of Conversations and Observations), which was issued to all prisons in July 2018. This highlights the importance of healthcare attendance at case reviews. On a national level, following a review of ACCT, HMPPS is in the process of piloting an updated ACCT case management system, which will be evaluated in the summer of 2019. The evaluation will inform the final revised version that will be rolled out nationally in early 2020. As part of this exercise we have developed clearer guidance to all prisons about the ACCT process, including advice about recording how decisions were arrived at. The guidance also reiterates the importance of health care attendance at case reviews. The new guidance will be made available on our intranet, so it can be accessed by all staff. We have also produced a new case review document, requiring the names of everyone who contributes to a case review to be recorded, along with details of key conversations and events such as appointments. This will make information more readily available to all staff. A new quality assurance tool is also being rolled out alongside the updated ACCT document, which assesses whether the process is being followed correctly. Thank you again for bringing these matters of concern to my attention. Please be assured that learning from the circumstances of Kelvin’s tragic death will be shared more widely with colleagues across the prison estate. Yours Sincerely, PHIL COPPLE Director General - Prisons
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