Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0209, written 23 Jun 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 Jun 2019 |
|---|---|
| Reference | 2019-0209 |
| Deceased | Marcus McGuire |
| Coroner | Emma Brown |
| Coroner area | Birmingham and Solihull |
| Category | State Custody related deaths · Mental Health 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 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: HMP Birmingham, the Ministry of Justice, G4S CORONER 1 I am Emma Brown, Area Coroner for Birmingham and Solihull 2 CORONER’S LEGAL POWERS I 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 01/05/2018 I commenced an investigation into the death of Marcus William George McGuire. The investigation concluded at the end of an inquest on 17th June 2019. The conclusion of the inquest was ascertained by the Jury completing a questionnaire that confirmed that the Deceased died as a result of suicide which was possibly contributed to by: 1) Failing to carry out a mental health assessment; 2) The fact that no action was taken in response to Marcus refusing or failing to take his prescribed anti-psychotic medication every day between 13 April 2018 and 23 April 2018. 3) The failure In relation to the ACCT that was opened on 19 March 2018 to involve the mental health team. 4) The assessment within the ACCT that Marcus was at ‘LOW’ risk (of self-harm and/or suicide) which was not based on all relevant and available evidence. 5) Failings within the management of the ACCT to complete the care map, to close the ACCT, to conduct a post closure assessment, to re-open the ACCT. 4 CIRCUMSTANCES OF THE DEATH (as taken from the Jury’s conclusions at Question 3 of the Record of Inquest) Mr McGuire died at HMP Birmingham on 24 April 2018 between the hours of 12.45am - 8.45am when he was found in cell D1, 15 with no signs of life, cold to touch, early signs of rigor mortis, with a ligature around his neck. ~~~ On 1st February 2018 Mr McGuire was transferred from HMP Oakwood to HMP Birmingham due to aggressive behaviour. A mental health referral had been made at HMP Oakwood but was unable to be carried out due to combative behaviour. An inadequate reception screening took place at HMP Birmingham on arrival with failure to refer Mr McGuire to mental health. A follow up email on 19 February by HMP Oakwood referred Mr McGuire for a mental health assessment. This was not actioned and he was discharged on 26th February 2018. On 19 March 2018, Mr McGuire was found in his cell D1, 15 with a severe cut to his left wrist which was potentially life threatening, a second cut was later found on his right wrist. He was sent to City Hospital. An ACCT book was immediately opened. The concern and keep safe form lacked detail, a failure to comply with ACCT guidance. Whilst in hospital on 21 March 2018, Mr McGuire gave a statement of intent to commit suicide. This was logged appropriately. He returned to hospital on 22nd March 2018 and was seen on 23 March 2018 for the ACCT assessment interview. Insufficient information was gathered, mental health was not consulted against ACCT Book guidance. The assessment form was lacking detail and a CPN referral was suggested. The first case review immediately followed. The first line manager for D Wing was not trained in case management and an appropriate manager was in attendance. Mr McGuire's risk was assessed as low without all pertinent available information. Mental health was not present and the case map was not filled out, all against ACCT book guidance. Subsequent case reviews up to the 5th April all failed to follow ACCT guidance including inconsistencies in case management, care maps not appropriately filled out, pertinent history not consulted and no mental health care present. This resulted in a consistent low risk assessment and the ACCT was placed into post closure on 5 April. All observations were stopped, not reduced, as guidance suggests. During this time, there were several incidents, prior to post closure involving Mr McGuire, including signs of paranoia and aggressive behaviour. The mental health assessments were booked but neither were completed. Having asked twice previously for his medication to be amended, Mr McGuire refused his medication on 12 April and a more serious refusal on 13 April, having an altercation with a nurse. Mental health subsequently visited Mr McGuire for triage but no full assessment was ever completed. The ACCT book was not found to document visit. On the same day, an inappropriate post closure review was recorded. No paperwork was completed and there was further failure to comply with ACCT guidance. Mr McGuire missed his third dose of medication on 15 April and there was failure to notify proper channels. He took no further medication until one dose on 23rd April. On 23rd April Mr McGuire was last spoken to at approximately 9pm and was then found deceased at approximately 8.45am following constriction by ligature around the neck on 24th April 2018. Prior to Mr McGuire's death there was a shortage of ACCT trained staff leading to case management inconsistencies, repeated failure to check pertinent information and failure to adhere to ACCT guidance including the closure of the book. Mental health care was not appropriately involved at any stage of Mr McGuire's stay at HMP Birmingham. Following a post mortem the medical cause of death was determined to be: 1a) CONSTRICTION BY LIGATURE AROUND THE NECK 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. Many of the deficiencies in Mr. McGuire’s ACCT plan, such as the absence of a properly completed care plan, the failure to involve the mental health team, failure to consider all relevant and available information and failure to carry out an effective post-closure review, were attributable to the absence of an identified case manager which resulted in different members of staff chairing his case reviews and no-one taking responsibility to follow up on action points. 2. At the time of Mr. McGuire’s death it was not uncommon for ACCTs not to have an identified case manager. 3. Evidence was given at inquest that there has been an increase in the number of trained case managers to enable all ACCTs to have a designated single case manager who will remain the case manager for the life of the ACCT so far as reasonably possible and where a change is required, there is a formal hand-over process. 4. Following completion of the evidence, the Report on an independent review of progress at HMP Birmingham by H. M. Chief Inspector of Prisons based on an inspection of the 7th to 9th May 2019 was brought to my attention. Paragraph 2.27 of the report provides: “The quality of ACCT casework was not yet good enough. In response to our concern at the last inspection, managers had sought to deliver single case management and provide prisoners in crisis with activities. This ambition has not yet been realised. None of the eight cases we checked had a single case manager…” I am also aware that in a letter dated the 11th June 2019, Contracts responded to the Report on the review of progress on behalf H. M. Prison & Probation Service. In the response it is recognised that “we need to do more to embed single case management”. I am concerned that I was given the impression that single case management is embedded at HMP Birmingham: if I had been aware that it was not, I would have sought additional evidence on why, what needed to be done to “embed” single case management and how it is intended to achieve it. I am concerned that the disparity between the evidence given to me and the findings upon , Head of Custodial 5. 6. 7. inspection 6 weeks earlier indicates that Managers at HMP Birmingham are either not aware of or not conveying the reality of the extent to which improvements in the ACCT process have been achieved. 8. The absence of an embedded system of single case management will put lives at risk as compliance with the ACCT process cannot be assured. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 21st August 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 Chief Coroner and to the following Interested Persons: the family of Mr. McGuire, Birmingham Community Healthcare NHS Trust and Birmingham and Solihull Mental Health NHS Foundation Trust. 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 coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 23/06/2019 Signature Emma Brown Area Coroner Birmingham and Solihull
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.
G4S Care & Justice Services Southside | 105 Victoria Street London SW1E 6QT Tel: +44 (0)207 963 3100 www.g4s.com/uk HM Area Coroner, Ms Emma Brown Birmingham and Solihull The Coroner’s Court Birmingham B4 6NE 21 August 2019 Dear Ms Brown, Inquest touching upon the death of Mr Marcus William George McGuire Thank you for the Regulation 28 Report dated 23 June 2019 (‘the Report’) addressed to HMP Birmingham, the Ministry of Justice and G4S. The Report was written concerning the unfortunate death of Mr Marcus William George McGuire who died at HMP Birmingham on 24 April 2018. This response is sent on behalf of G4S Care and Justice Services (UK) Ltd (‘G4S). HM Area Coroner will be aware that HMP Birmingham is now operated and managed by HMPPS, eing the current governing Governor. Any decisions in terms of actions to be taken at HMP Birmingham are not therefore within the remit of G4S. G4S take every death in custody very seriously indeed and have carefully considered HM Area Coroner’s concerns. G4S would like to reassure HM Area Coroner that they reflect on every death in custody, consider lessons learned and use these to inform best practice across their establishments. Yours sincerely, ri Jerry Petherick Managing Director Custodial & Detention Services G4S Care & Justice Services (UK) Limited G4S Care & Justice Services (UK) Ltd Registered Office: 105 Victoria Street London SW1E 6QT Securi ng Your World Registered in England No. 0390328,
Director General Prisons HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Email: DirectorGeneralPrisons@justice.gov.uk Ms Emma Brown Area Coroner Birmingham and Solihull The Coroner's Court Birmingham B4 6NE By email: Coroner@Birmingham.gov.uk 20 August 2019 Dear Ms Brown Thank you for your Regulation 28 Report of 23 June addressed to HMP Birmingham, the Ministry of Justice and G4S, which you issued following the conclusion of the inquest into the death of Marcus McGuire. As Director General for Prisons within Her Majesty’s Prison and Probation Service (HMPPS), I am responding on behalf of HMP Birmingham and the Ministry of Justice. I know that you will share a copy of this response with Mr McGuire’s family and I would first like to express my sincere condolences for their loss. The safety of those in our care is my absolute priority, and every death in custody is a tragedy. I am grateful to you for bringing to my attention your concerns. You have raised concerns about the quality of the Assessment, Care in Custody and Teamwork (ACCT) processes at HMP Birmingham, and specifically the issue of the extent to which single case management is embedded at the prison, which you believe may have not have been accurately described in the evidence that you heard at the inquest. In accordance with Prison Service Instruction (PSI) 64/2011, HMP Birmingham operates a single case manager model, and consistency of case management continues to improve. There are ongoing operational challenges in delivering this model in every case but, since the inspection to which you refer, the prison has trained additional case managers and this means that each individual has a lower caseload and is more frequently able to attend their prisoners' case reviews. Compliance with the single case manager model is being monitored daily, and is reviewed at the monthly Safer Custody meetings. All case managers have been given additional briefing about the importance of consistent delivery of it, and the safety team for the West Midlands Prison Group is providing support and additional assurance measures to ensure that the process is embedded. The operational reality is that there continue to be some occasions on which the case manager for an individual prisoner is not able to conduct a case review. This would include, for example, situations where an unanticipated review is required following an act of self- harm or other notable event, and the person concerned is not on duty. When this occurs , another case manager thoroughly reviews the ACCT documentation and, wherever possible, speaks to members of staff who know the prisoner to enable them to understand the relevant risks prior to chairing the review. Similarly, if the case manager is going to be absent for an extended period then the case is transferred to a different case manager. I am sorry to hear that you felt that the evidence that you heard did not reflect the ongoing challenges of embedding the single case manager model. Such challenges are a feature of the operational environment, but I trust that this letter will provide reassurance that consistency of case management is a priority at the prison, that wherever possible the single case manager model is being delivered, and that, where it is not, measures are in place to detect this and to mitigate the risk. The prison has also introduced further quality assurance of every ACCT document, with checks taking place 72 hours after opening, weekly while open, and on closure. If these checks reveal evidence of a failure to comply with the national guidance contained in PSI 64/2011, the members of staff involved are provided with relevant feedback and questioned about their actions. If the non-compliance is serious and/or repeated, disciplinary action may follow. You may also be interested to know that we are continuing to develop the ACCT process. We piloted a revised version of the form and associated guidance in nine prisons and one immigration removal centre from February to June 2019. The feedback from the sites has been positive, and a formal evaluation of the pilot is currently being undertaken. The findings will inform the development of a new version of ACCT that we intend to begin to roll out nationally in early 2020. Thank you again for bringing these matters of concern to my attention. I would like to reassure you that the lessons learned following the circumstances of Mr McGuire’s tragic death will be shared more widely with colleagues across the prison estate. Yours sincerely, PHIL COPPLE Director General for Prisons
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