Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0175, written 21 Mar 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Mar 2019 |
|---|---|
| Reference | 2019-0175 |
| Deceased | John Wright |
| Coroner | Darren Salter |
| Coroner area | Oxfordshire |
| Category | 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 THIS REPORT IS BEING SENT TO: 1. Mr Michael Spurr, HM Prison and Probation Service, 102 Petty France, London, SW1H 9AJ 2. Mr Jim Easton, Chief Executive Officer, Healthcare, Care UK, Hawker House, 5-6 Napier Court, Napier Road, Reading, Berks, RG1 8BW CORONER lam Mr D M Salter, HM Senior Coroner for Oxfordshire. 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. INVESTIGATION AND INQUEST At Oxford Coroner's Court on 26, 27 and 28 February 2019 | conducted the inquest into the death of John Wright at HMP Bullingdon. The Jury returned a Narrative Conclusion as follows: ‘ohn Wright was found at 23.45 on 14 December 2017 in cell 114 unresponsive with an electrical cord as a ligature around his neck. The cord was suspended over the head of the bed and brackets on the left-hand wail of the cell. John Wright’s life was pronounced extinct at 00.58 on 15 December by the South Central Ambulance Service. Cause of Death, declared by the Pathologist to be ‘Compression of the neck consistent with suspension’. Based on the evidence presented we, the Jury, believe that it was Mr Wright’s intention to end his life that evening by deliberately placing a ligature around his neck. We, the Jury, believe that the opportunity for Mr Wright to end his life was afforded by the decision to downgrade the level of observation from constant watch pre-arrival at HMP Bullingdon to twice hourly in the Healthcare wing for the first night. The decision to downgrade the level of observation taken by the Duty Governor, The Senior Prison Officer and the Healthcare representative was taken based on how Mr Wright presented during screening without due consideration to the information provided in the PER and accompanying SASH form. This decision taken was further compounded by inconsistencies and inadequacies in the systems and processes for sharing important and pertinent information at the appropriate time and to relevant parties. Being in possession of all the information available would have assisted the staff in their decision making around the level of observation required.’ HMP Bullingdon/Ministry of Justice were legally represented at inquest. In addition to family, other ‘Interested Persons’ included the main health care provider, Care UK, and also Midland Partnership NHS Trust to whom the secondary mental health provision is sub-contracted. Evidence was collated prior to inquest and a copy of the inquest file was provided to the Government Legal Service. For this reason, | am not providing you with a full copy of the inquest file, but | anticipate it would be helpful for you to have a copy of wi at were obtained from = (Prison Governor) te of Healthcare at HMP Bullingdon). The statements contain evidence concerning various recommendations made by the PPO/Clinical Review and Care Uk’s internal investigation. lam also sending this letter to Care UK because, largely speaking, the issues which | raise apply to both organisations. CIRCUMSTANCES OF THE DEATH ’ idnight on Thursday nadon Prison in cell 114 in the healthcare ni. He was found partially suspended with an electrical cable from a bed. He d with murder’ young woman. was due to return to court on Friday 15 December. re had expressed suicidal thoughis and had been on constant waich at the ion and at court and when being transported frorn the court to HMP Bullingdon. [t was his first time in orison. For juriher circumstances relating to Mr Wright’s deain | refer you to the Jury's ~ Narrative Conclusion above. CORONER’S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concerns. 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 make this report to you. It is reassuring however to see that significant measures have been put in place following this incident and an action plan has been formulated to comply with recommendations. For this reason, | am restricting my Regulation 28/Prevention of Future Death Report to relatively narrow issues which | do not believe are adequately addressed elsewhere. The MATTERS OF CONCERN are in relation to the following: 1. The first concern which | raise applies to both the prison and healthcare and relates to the receipt of information by the prison and/or healthcare about a heightened risk of self-harm/suicide for a prisoner who has yet to artive at prison. | heard evidence that it is not uncommon for outside agencies to pass on concerns, and, for example, copies of relevant mental health assessments, in anticipation of the prisoner arriving at the prison in a state of heightened risk requiring help and assessment. | also heard evidence that the software system operated by healthcare (System One) does not enable healthcare staff to make entries prior to the prisoner being received at reception and a prison officer opening a record on the computer and allocating a prisoner number. This being the case, | understand that the practice has been to email or print a hard copy of the document and take it to reception. In this case, a mental health nurse who was part of the secondary mental health team received a report about heightened risk and telephoned the nurse in reception to pass on details. The secondary mental health nurse said in evidence she would normally take a hard copy of the mental health assessment that she received and place it in a tray in reception. There was an alternative of emailing, but this was not considered the best way to bring it to the attention of the relevant healthcare staff in reception. Of course, information about an incoming prisoner, who is assessed at high tisk of suicide, is precisely the sort of important information which should not be allowed to fall through any gaps. Itis high priority. An outside person or agency has considered it necessary to bring the matter to the attention of the prison or health care. | understand that Care UK have set up a generic email address for healthcare staff in reception which may assist. Clearly, this still relies on healthcare staff checking to see if any such emails have been received. | appreciate that it is very busy in reception in the late afternoon/early evening. | will also be copying this report to Midland Partnership NHS Foundation Trust to request their response in relation to this matter. There is a related concern about the availability and sharing of such information or documentation amongst prison or health care staff in reception. From the evidence [ heard at inquest, it appeared to me that the system for ensuring the staff in reception have access to all available information is in need of improvement. The senior prison officer in this case did not have all relevant information and she said that, if she had, there may have potentially been a different decision (| understand her to mean that Mr Wright may have remained on constant cell watch). | understand the Governor has created a position of ‘Head of Early Days’ and a system is in place to improve the process of documentation so that it follows the prisoner. The second matter | wish to raise, also to the prison and healthcare, is in relation to the level of observations. | heard evidence that this is often a joint responsibility held by the prison and healthcare. In this case, Mr Wright had been on constant watch, but a decision was taken during the reception process to step down to twice hourly observations. Given that staff may not have access to all available information in those first few hours, and the fact that there will not have been an opportunity for a prisoner to be observed over a significant period of time, and the fact that a more detailed assessment will not have taken place yet, there should in my view be some guidance to staff when reducing observations from constant watch. | note that the Prison and Probation Ombudsman stated at the beginning of her report that ........ ‘Mr Wright had been under constant watch by police and court staff because he said he wanted to take his life at the earliest opportunity. Although prison staff started suicide and self-harm prevention procedures when Mr Wright arrived at Bullingdon, they reduced the level of observations from constant to twice an hour. In my view, this decision was misjudged and taken far too quickly, without a proper assessment of Mr Wright's risk.’ | appreciate there is a great deal of responsibility on prison and healthcare staff when making assessments. Much depends on how they assess the prisoner in front of them. It may be appropriate to reduce a newly arrived prisoner from constant cell watch to less frequent observations on occasions. The concern which | raise relates to such decisions being made in reception and | enquire if there should be some guidance available to assist staff in their decision-making process? For example, should such a decision be postponed until a further assessment has been carried out the following day? | realise that this issue is not straightforward and there are significant resource implications in keeping a prisoner under constant watch. 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. | may extend the period on request. 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 | confirm that a copy of this report and your response will be sent to Mr Wright’s family. 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 Date GA Met. to i4 ‘I. Salte HM Senior Coroner for Oxfordshire
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.
HMP Bullingdon Patrick Haugh Road Arncott Bicester Oxfordshire OX25 1PZ Tel: 01869 353348 Cuk.bullingdonhealthcare@nhs.net careuk.com HM Senior Coroner, Mr Darren Salter The Oxfordshire Coroner’s Office Second Floor 1 Tidmarsh lane Oxford OX1 1NS 16 May 2019 Dear Sir Regulation 28 – Prevention of Future Death Report: Mr John Wright- HMP Bullingdon I am writing in response to the Regulation 28 report which you issued following the inquest touching on the death of Mr John Wright, a prisoner at HMP Bullingdon. Care UK would like to express its sincere condolences to Mr Wright’s family and friends. In your report you raised 2 issues of concern, both of which are addressed to Care UK, in its capacity a healthcare provider and to Her Majesty’s Prisons and Probation Service who will respond separately to the concerns raised. Concern 1 The first concern which I raise applies to both the prison and healthcare and relates to the receipt of information by the prison and /or healthcare about a heightened risk of self-harm/suicide for a prisoner who has yet to arrive at prison. I heard evidence that it is not uncommon for outside agencies to pass on concerns and for example, copies of relevant mental health assessments, in anticipation of the prisoner arriving at the prison in a state of heightening risk requiring help and assessment. I also heard evidence that the software system operated by healthcare (SystmOne) does not enable healthcare staff to make entries prior to the prisoner being received at reception and a prison officer opening a record on the computer and allocating a prison number. This being the case, I understand that the practice has been to email or print hard copy of the document and take it to reception. Of course information about an incoming prisoner, who is assessed at high risk of suicide, is precisely the sort of information which should not be allowed to fall through any gaps. It is high priority. An outside person or agency has considered it necessary to bring the matter to the attention of the prison or healthcare. I understand Care UK have set up a generic email address for healthcare staff in reception which may assist. Clearly this still relies on healthcare staff checking to see if emails have been received. Response Care UK is the prime provider of health services at HMP Bullingdon. Part of this service includes the screening of all new receptions into the prison. Care UK uses SystmOne which is Care UK Ltd. Registered in England No 1668247 Registered Office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex CO4 9QB an electronical clinical record system which is recommended by NHS England. A copy of your letter and our response will be shared with NHS England. It is acknowledged that there is a flow of information between Liaison and Diversion Services and Mental Health Services and on this occasion it could have been improved. To this end further work has been undertaken to ensure that the communication pathways with external partners have been strengthened. A new process flow has been developed in partnership with the Liaison and Diversion team which specifies how to contact and share risk and special care needs information of patients from Police Custody (Via Court) to HMP Bullingdon Healthcare in Reception. The new process provides a direct telephone number to the Reception nurse from 08.00 to 20.45 Monday to Friday and 08.00-17.00 on Saturdays. The process flow now advises if there is no answer via telephone, the Reception nurse should be contacted via the prison communications room who will contact the nurse via their prison radio. Outside of these times detailed above, the prison communications team can contact the senior nurse on duty. This phone call alerts the Reception nurse that a report or information is being emailed to a new secure NHS email account which Healthcare at HMP Bullingdon have set up and circulated to all reception staff. The content of the email will be accessed after the telephone call alerting the Reception nurse to its existence. The Reception nurse will reply to the email to acknowledge receipt of the email. To further support this process, healthcare administration staff will routinely check the inbox during core daytime hours of 9am to 5pm and will alert Reception staff to all emails received. . All staff, including agency staff, who work in Reception have been provided with an nhs.net email account to securely access the risk information in the email. In agreement with the Liaison and Diversion service this new system went live on 25th April 2019. The requirement of a prompt made via telephone which is clearly outlined in the new process flowchart, will provide assurance to Liaison and Diversion services that their information has been effectively communicated and received by Reception staff. A copy of the process is attached. With a view to enhancing working relationships with external agencies, Care UK is working with NHS England and has identified the healthcare providers in police custody suites and the Liaison and Diversion services, that feed into HMP Bullingdon to propose setting up quarterly telephone conference calls to highlight good practice and identify emerging concerns or issues that may impact on partnership working. Additionally, Care UK has also offered Liaison and Diversion service staff an opportunity to visit the healthcare department and Reception at HMP Bullingdon to further develop an understanding of the respective work environments. Concern 2 The second matter I wish to raise also to the prison and healthcare is in relation to the level of observations. I heard evidence that this is often a joint responsibility held by the prison and healthcare. In this case Mr Wright had been on constant watch, but a decision was taken during the reception process to step down to twice hourly observations. Given that staff may not have access to all available information in those first few hours, and the fact there will not have been an opportunity for a prisoner to be observed over a significant period of time, and the fact that a more detailed assessment Page 2 of 3 will not have taken place yet, there should in my view be some guidance for staff when reducing observations from constant watch. Response Care UK recognises that early identification of risk factors and effective management of prisoners in relation to self-harm is imperative in addressing the rising incidence of suicide. Care UK are committed to training all staff in Suicide and Self Harm awareness training (SASH) and wherever possible, participating in multi-disciplinary assessments of the management of risk. Processes to request Healthcare staff to participate in all ACCT reviews at HMP Bullingdon are now imbedded throughout the establishment and have been reinforced at joint partnership meetings. These include Healthcare staff attending the prison morning meetings where they are informed of all scheduled ACCT reviews for that day. A register of Care UK staff and all sub-contracted staff who have completed the SASH training is maintained and compliance is monitored monthly. All staff are trained to adhere to the requirements of PSI 64/2011, Management of Prisoners at risk of harm to self, to others and from others. The PSI specifies that staff should be trained at least every three years. In addition, Care UK have substantially consolidated this training with it’s PROTECT initiative which upholds standards to protect patients and maintain safety, including thoroughly assessing all patients and proactive involvement with the ACCT process. A copy of the PROTECT initiative is attached. Staff meetings are held every two weeks to continue to improve and share knowledge and lessons learned regarding the management of prisoners in custody. Currently HMPPS are providing specialist HMPPS training for both healthcare and discipline staff; “Understanding Risk: Why is Risk Risky?” and “Defensible Decision Making”, both of which seek to reinforce rational and appropriate decisions when applying the ACCT process and understanding suicide risk. Care UK are providing ASIST - Applied Suicide Intervention Skills Training, which is an internationally accredited and licensed 2-day course to all patient-facing staff to increase their confidence in identifying suicide risk. This improved learning, supported by SASH training will better inform decision making in all cases, including those cases where removal from constant watch is being considered. I trust this provides assurance that Care UK are committed to improving processes to support the safety of men coming into HMP Bullingdon and developing strong communication pathways with partner organisations in the justice sector. Yours faithfully Head of Healthcare, HMP Bullingdon Page 3 of 3
Phil Copple
Director General Prisons
HM Prison & Probation Service
8th Floor 102 Petty France
London
SW1H 9AJ
DirectorGeneralPrisons@justice.gov.uk
Mr D M Salter, Senior Coroner
Oxfordshire Coroner’s Office
The Oxford Register Office
2nd Floor
1 Tidmarsh Lane
Oxford
OX1 1NS
14 May 2019
Dear Mr D M Salter
Thank you for your Regulation 28 Report dated 21 March 2019, following the inquest
into the death of Mr John Wright at HMP Bullingdon.
I know that you will share a copy of this response with Mr Wright’s family, and I 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.
You have raised two matters of concern: information-sharing and setting the level of
observation for prisoners identified as being at risk, and I will deal with each in turn.
Ensuring that all relevant information is available and used when making decisions
about risk is a key priority. As you acknowledge in your report, Care UK has taken
action following this case. NHS England Commissioners, Mountain Healthcare (the
healthcare providers for Thames Valley Police) and the liaison and diversion service
have been informed of the process for contacting the prison healthcare team with
concerns about anyone coming into HMP Bullingdon. This includes details of an
email address to which Care UK staff have immediate access, and telephone contact
details for the reception nurse on duty at HMP Bullingdon.
Separately, the courts that serve HMP Bullingdon and the escort contractors (GEO
Amey) have been reminded that safety concerns should be recorded on the Person
Escort Record and shared with reception staff at HMP Bullingdon. Clinical
information should be attached in a sealed envelope clearly marked “MEDICAL IN
CONFIDENCE” so that it can be read by a nurse in reception. They have also been
provided with contact numbers for the safer custody team and reception, and told
that urgent matters should be raised with the orderly officer.
All staff working in reception have been reminded of the importance of sharing risk
information and ensuring that it is recorded on the prisoner passport. The first night
custodial manager conducts regular audits of the prisoner passports to ensure that
relevant information is being recorded, and that the document is being seen and
used by staff working in reception.
With regard to you second concern, setting the appropriate level of observations for a
prisoner who has been identified as being at risk is a difficult decision, and we have
recently issued a learning bulletin to all prisons providing guidance about the issues
to consider when making it. At HMP Bullingdon, the Governor has reminded the
escort contractors of the importance of alerting reception staff in all cases in which
constant supervision has been in place prior to a prisoner’s arrival. In all such cases
the process is that the duty governor is informed and all documentation is studied to
establish definitively the level of observations to which the prisoner has been subject,
in order to avoid confusion over different organisational terminology. In all cases in
which constant supervision has been in place, an Assessment, Care in Custody and
Teamwork (ACCT) is opened and any decision to reduce the level of observations
will be taken at a multidisciplinary case review (including the Duty Governor, a nurse
and a member of prison staff, as well as the prisoner) and recorded in the ACCT
document. All duty governors have been briefed and will frequently be reminded that
decisions about the use of constant supervision should be based on the level of risk
and must not be affected by resource constraints.
All staff at HMP Bullingdon understand that the risk of suicide and self-harm is at its
greatest during early days in custody. The prison receives around 4,500 new
prisoners every year, with at least 70% of these presenting with at least some static
risk factors. The Governor is committed to redoubling efforts to prevent the loss of
life through a programme of learning. All reception and first night staff have received
an enhanced briefing from the head of safer custody, and all senior officers and first
night staff have received risks and triggers training from the safer custody lead for the
South Central prison group. At national level, an early days in custody and
transitions toolkit was launched in April 2019, which provided prisons with a range of
resources to support work in this area.
Thank you again for bringing these matters of concern to my attention.
Yours sincerely
PHIL COPPLE
Director General - Prisons
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