Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0267, written 16 May 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 May 2019 |
|---|---|
| Reference | 2019-0267 |
| Deceased | Daniel Davey |
| Coroner | Darren Salter |
| Coroner area | Oxford |
| Category | State Custody related deaths |
| Organisation named | Midlands Partnership University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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 Phil Copple, Director General, H M Prison and Probation Service 102 Petit 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 3. Mr Neil Carr, Chief Executive, Midlands Partnership NHS Foundation Trust, St George’s Hospital, Corporation Street, Stafford ST16 3SR 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 Coroners Court between 29 April and 7 May 2019 | conducted the inquest into the death of Daniel Davey at HMP Builingdon. The Jury returned a Narrative Conclusion as follows: Mr Davey died on 12 January 2018 at 12:31am at the John Radcliffe Hospital after taking approximately 63 tablets of propranolol at around 8pm in cell E114 at HMP Bullingdon Prison. The Jury concludes that Mr Davey deliberately took an overdose of his propranolol with the intention to commit suicide. HMP Bullingdon failed to adequately train prison staff in ACCT management, assessment and review processes. It also failed to implement national policy regarding the inclusion of healthcare in the ACCT process and also failed to perform a search of Mr Davey’s cell upon opening ACCT 2. Healthcare providers failed to adequately and regularly risk assess ‘in possession’ Medication. Healthcare failed to adequately share risk relevant information given by Mr Davey on 29 December 2017. Mr Davey’s request to reduce his medication was based on misleading information relating to a move to Grendon and wasn’t challenged or adequately assessed by any healthcare professional. Following the reduction of medication on 4 January and the incident of self-harm on 7 January, there was no follow up or intervention from the secondary healthcare team and a system wide failure to recognise a pattern of behaviour and escalating “cries for help”. The Jury concludes that there was a failure to act on the sum of information that was reasonably available to both prison and healthcare personnel in order to keep Mr Davey safe. HMP Bullingdon/Prison and Probation Service were legally represented at inquest as was Care UK (CUK) and Midlands Partnership Trust (MPT). Mr Davey’s father, was also legally represented. A copy of the inquest file was available to Interested Persons prior to inquest. For this reason, | am not providing you with a full copy of the file, but | anticipate that it would be helpful for you to have a copy of the witness statement for (Prison Governor) and (Head of Healthcare, Care UK). The statements contain evidence concerning recommendations made by the PPO and Care Uk’s internal investigation. It will be seen that this Regulation 28 Report is being sent to HMPPS, CUK and MPT because the issues which | raise apply to all organisations albeit to varying degrees. CIRCUMSTANCES OF THE DEATH Daniel Davey was 21 Years old when he was pronounced deceased just after midnight on 12 January 2018 at the John Radcliffe Hospital, Oxford. The cause of death following a post mortem examination was ‘Aspiration of gastric contents and propranolol intoxication’. He initially became unwell at about 10pm in his cell prior to suffering seizures and a cardiac arrest at the prison and being taken to hospital by ambulance. Mr Davey said to prison staff at the prison that he had taken an overdose of his prescribed medication, propranolol. He had been in Bullingdon Prison since 1 December 2017 (just over a month) having been sentenced to 10 years for sexual offences. It was his first time in prison. He had a history of mental health probiems including suicidal thoughts. It will be seen that further circumstances relating to Mr Davey’s death are outlined in the Jury’s Narrative Conclusion including reference to failures in his care. 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. During the course of the inquest | heard evidence from members of prison and healthcare staff. It was apparent that improvements were introduced after the death of Mr Davey and the system operates differently now. | also heard evidence specifically about improvements from Governor Blakeman and Ms Lutton. This helpfully provided a level of reassurance. However, | remain concerned about a number of issues. The MATTERS OF CONCERN are in relation to the following: 1. Healthcare attendance at ACCT reviews — This concern relates to both the prison and healthcare. It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews. This is a significant concern and it is not in accordance with local and national policy. | understand that there were occasions when prison staff requested healthcare attendance, but no one was available. The system of providing advance notification to healthcare about the date of ACCT reviews was not comprehensive. It resulted in ACCT reviews, as in this case, taking place without key information being available to the assessor/reviewer. For example, information about — suicidal ideation/attempts and other information disclosed to healthcare and also information about ‘in possession medication’. Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance and/or input (perhaps over the telephone). It would be helpful if there could be a further level of reassurance provided about, firstly, communications between prison and healthcare staff in the conduct of ACCT reviews and, secondly, a process of auditing ACCT reviews in order to pick up cases where there is no healthcare input. Reviews of ‘in possession’ medication risk assessments — The second concern also relates to prison and healthcare. In particular, it relates to a prisoner placed on an ACCT. | heard evidence that, initially, a template is used at the reception healthcare screen to determine if medication should be held in possession or not. | was told that, now, this is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK’s new policy. In the case of Mr Davey, there was an initial risk assessment at reception and he was deemed suitable for in possession medication, but this was not reviewed when he was subsequently placed on the 2 ACCT documents in December and January or when he disclosed to a mental health nurse on 29 December that he had a plan to kill himself. | understand that new systems are in place (with healthcare) but it would be reassuring if there is a system of audit to ensure compliance, namely, that the in possession risk assessments are reviewed. | appreciate a review might not necessarily result in medication being taken away. | also appreciate this is a difficult area in view of patient confidentiality and, of course, the danger that a prisoners physical or mental health could be put at risk if medication is taken away. A related concern is the fact that prison officers did not appear to have in mind the risks associated with in possession medication. It appeared to be disregarded because it was information that was not available to them and it was therefore deemed a maiter for healthcare. | am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and healthcare involvement/reassessment. It appears there needs to be joint liaison between the ACCT case manager and healthcare and a plan to intervene and remove medicine if necessary. This leads to a final related concern. There is the question of cell searches for stockpiled medication and the collection of properly held in possession medication when there is a change of risk such as an ACCT document being opened. | did not hear much evidence about practice or policies relating to searching and potentially removing medication. This is clearly a task that rests with prison staff and it would be helpful to have further information about this. 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 Davey'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 . 16/05/2019 Pa rv r D.M. Salter HM Senior Coroner for Oxfordshire
3 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 OX25 1PZ HM Senior Coroner, Mr Darren Salter The Oxfordshire Coroner’s Office Second Floor 1 Tidmarsh lane Oxford OX1 1NS 3 July 2019 Dear Sir Regulation 28 – Prevention of Future Death Report: Mr Daniel Davey - HMP Bullingdon I am writing in response to the Regulation 28 report which you issued following the inquest touching on the death of Mr Daniel Davey, a prisoner at HMP Bullingdon. Care UK would like to express its sincere condolences to Mr Davey’s family and friends. In your report you raised two issues of concern, both of which are addressed to Care UK, in its capacity as the healthcare provider, our sub-contractor Midland Partnership NHS Foundation Trust, and also to Her Majesty’s Prisons and Probation Service who will respond separately to the concerns raised. Concern 1: Healthcare attendance at ACCT reviews. It would be helpful if there could be a further level of reassurance provided about, firstly, communications between prison and healthcare staff in the conduct of ACCT reviews and, secondly, a process of auditing ACCT reviews in order to pick up cases where there is no healthcare input. Response In your report you highlighted “Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance and/or input (perhaps over the telephone).” This status continues to be supported by Care UK’s Local operating procedure (“LOP”) for “Healthcare attendance at ACCT’s”. This LOP was reviewed and updated in February 2019 and ensures a member of healthcare staff is detailed daily to attend the day’s planned ACCT reviews. This member of staff can be contacted daily via radio from 08.00 until 17.00hrs. Any requests for healthcare attendance at new ACCTs opened throughout the day are communicated from the prison to the Healthcare Coordinator. All ACCT reviews are added to the SystmOne Ledger and appointments closed down on the system to demonstrate and record completion of the ACCT review. Care UK Health & Rehabilitation Services Limited - Registered in England No 10498997 Registered Office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex CO4 9QB Care UK continues to work closely with the HMP Bullingdon Safer Custody department to improve partnership working throughout the management of the ACCT process. In order to ensure continued healthcare attendance to ACCT reviews a new electronic quality assurance process has been introduced. This is supported by Safer Custody staff spot checking compliance and escalating where necessary. Concern 2: Reviews of ‘in possession’ medication risk assessments. a. It would be reassuring if there is a system of audit to ensure compliance, namely, that the in possession risk assessments are reviewed. b. I am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and healthcare involvement/reassessment. It appears there needs to be joint liaison between the ACCT case manager and healthcare and a plan to intervene and remove medicine if necessary. Response I can confirm that HMP Bullingdon is fully compliant with Care UK’s mandatory monthly audit in ensuring all prisoners have an ‘in possession status’ recorded on their medical notes from reception. HMP Bullingdon also adheres to the Care UK “In possession policy for Prisons” which reviews ‘in possession’ status: 1. After any relevant incidents 2. If the prisoner’s circumstances change or medication is no longer deemed appropriate 3. Following the opening of an ACCT document. The “CUK Health contribution to ACCT” template also supports and prompts healthcare staff to complete an ‘in possession’ risk assessment when documenting, an ACCT has been opened and to review when attending an ACCT review. 4. Or otherwise when a member of healthcare staff believes it to be necessary, e.g. concerns are raised that the prisoner is being bullied. I would like to provide assurance that random spot checks are undertaken to support concordance and reduce the risk of diversion or stockpiling for overdose. These spot checks are undertaken by a member of the healthcare team supported by prison disciplinary staff. Where there is a discrepancy between the numbers of tablets a patient should have and the number found, the patient is reviewed to see if the medication is still required or if it needs to be moved to not in possession. At any point in time, any member of healthcare staff having concerns regarding patient safety can ask for the In-possession status to be reviewed to ‘Not In-possession’ by contacting the prescriber. This would be clearly Page 2 of 3 documented on SystmOne. In-possession status can also be removed, whilst the review is pending. I have met with the Safer Custody Governor and discussed the need for prison staff to have a joint responsibility when considering ‘in possession’ medication is a potential risk. The Safer Custody Governor is recommending this awareness is included in case manager training and is taking this action forward. I trust this provides assurance that Care UK is committed to working in partnership and improving processes to support the safety of men whilst at HMP Bullingdon. If you would like to review copies any of the policies or procedures mentioned in this letter please let me know. Yours faithfully Head of Healthcare, HMP Bullingdon Page 3 of 3
Phil Copple Director General Prisons HM Prison and Probation Service 8'" Floor Ministry of Justice 102 Petty France London SW1H 9AJ HM P r ison & Email: DirectorGeneralPrisons@justice.gov.uk Probation Service Mr D M Salter, Senior Coroner Oxfordshire Coroner’s Office The Oxford Register Office 2nd Floor 1 Tidmarsh Lane Oxford OX1 1NS 05" August 2019 Dear Mr D M Salter Thank you for your Regulation 28 Report dated 16 May 2019, following the inquest into the death of Mr Daniel Davey at HMP Bullingdon. | am also grateful to you for granting a short extension to the usual deadline for reply. | know that you will share a copy of this response with Mr Davey’s 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. | was pleased to read that you were reassured by the evidence that you heard at the inquest that improvements had been made at the prison. You have raised two outstanding matters of concern: the attendance of healthcare staff at Assessment, Care in Custody and Teamwork (ACCT) reviews; and reviews of in possession medication risk assessments, with a related question about the policy for cell searches for stockpiled medication. | will deal with each concern in turn. In June 2019 a new way of operating the ACCT case management system was implemented at Bullingdon, with a specific case manager being allocated to each ACCT case. This system allows ACCT reviews to be booked by the case managers on a spreadsheet that is overseen by the safer custody department. Reviews can be organised earlier through this booking system, giving healthcare better capability to ensure attendance at all reviews, ‘and each day an identified member of healthcare staff is responsible for attending each review or allocating an attendee to go in their place. If there are any issues with healthcare attendance, case managers are asked to inform the safer custody department and remedial action is taken. Although this new process is still being embedded, early indications are that healthcare staff are now attending all reviews. The allocation of a dedicated case manager allows for a consistent review and key information is much more likely to be available. Additionally, once the key worker model, in which officers are responsible for managing a small number of offenders, is fully implemented, these staff will have a good knowledge of the individual and will be able to feed into the ACCT reviews. Where possible this will be by attending, but it could also include.a verbal or written submission to be included in the review. New electronic quality assurance checks are to be introduced and embedded by the end of August 2019, and these will include checking healthcare attendance at reviews. In the meantime, the safer custody department is performing spot checks to monitor progress. At national level we are working to improve the ACCT case management system and piloted a new version of the form and associated guidance in ten prisons during the spring of 2019. We realise the importance of the healthcare contribution to ACCT, and NHS England, and their Welsh equivalents, have been involved in this pilot project. The revised form and guidance are clearer about the expectations of healthcare staff. We are currently evaluating the pilot and plan to implement the new model nationally during 2020. We will ensure that the learning from this case is used to inform the development of the materials that are used to inform the national roll out of the new model. Your second concern relates to reviews of in possession medication risk assessments. | understand Care UK and Midlands Partnership NHS Foundation Trust will be replying to you separately on this point. At Bullingdon, if the ACCT case manager is concerned about the immediate welfare of an individual they are required to conduct a review immediately, and to ensure that there is healthcare input to that review. The prison has issued guidance to all case managers stating that in possession medication is one of the topics that should routinely be discussed in ACCT reviews, and that a risk assessment must be conducted, informed by the advice of healthcare staff. If this advice is not immediately available then ACCT case managers can at their discretion remove in possession medication until they can confirm that it is safe for the prisoner to continue to have it in their own possession. Lastly, you asked about the policy for cell searches for stockpiled medication. The safer ’ custody department has distributed a safety briefing on in possession medication to all staff to ensure that they are aware of the risks and know what action to take if they discover . unusual amounts of in possession medication when conducting fabric checks or cell searches. In future, the issue of stockpiled medication will also be covered in the local ACCT case manager training so that, when immediate actions plans are completed, consideration is given to the need to check for and remove in possession medication as a temporary measure before a full assessment and review has taken place. This is in line with existing national policy, and we will ensure that this continues to be the case, and that it is prominent in the guidance that is issued when the revised version of ACCT is rolled out, so that the learning from Mr Davey’s tragic death is shared as widely as _ possible. Thank you again for bringing these matters of concern to my attention. | hope this response has provided reassurance that they are being fully addressed at Bullingdon and at national level. Yours sincerely, Ko apple PHIL COPPLE Director General for Prisons
INHS Midlands Partnership NHS Foundation Trust A Keele University Teaching Trust Neil Carr Chief Executive Trust Headquarters St George’s Hospital Corporation Street Stafford ST16 3SR Tel: 0300 790 Mr DM Salter HM Senior Coroner for Oxfordshire Coroner’s Office Oxford Dear Mr Salter RE: Daniel Davey Thank you for your letter dated 16"" May 2019, reporting a matter to us, in accordance with Regulations 28 and 29 of the Coroner's (Investigations) Regulations 2013. May | take this opportunity to reassure you that following Mr Davey’s death, we undertook a thorough investigation into the care delivered by the Trust. Following discussions with all parties, | am now in a position to respond to your concerns. Matter of Concern 1: “Healthcare attendance at ACCT reviews: It was clear from evidence from prison and healthcare staff that it was not routine for healthcare to attend ACCT reviews. This is a significant concern and it is not in accordance with local and national policy. Encouragingly, the evidence from prison and healthcare staff was that ACCT reviews no longer take place without healthcare attendance and/or input (perhaps over the phone).” You would like “reassurance provided about firstly, communications between prison and healthcare staff in the conduct of ACCT reviews and, secondly a process of auditing ACCT reviews in order to pick up cases where there is no healthcare input”. Jogether we are making life better for our communities Response; We continue to work with colleagues in Care UK and the prison to ensure we support attendance at ACCT reviews and maintain the improved processes. We comply with the Care UK Local Operating Policy for Healthcare and Subcontracted teams input into the ACCT process. The Local Operating Procedure identifies there is an expectation that the staff attending the ACCT record this on SystmOne and future reviews are diarised for attendance. We will actively contribute to quality assurance checks of compliance with this Local Operating Policy including those done as part of the PROTECT audits and are committed to improving our service delivery in response to any actions identified within these checks. In addition we will work with Care UK and the prison in the development of procedures for escalation should healthcare, for any reason, be unable to attend an ACCT review. Matter of Concern 2: “Reviews of mental health “in possession medication risk assessments: relates to a prisoner placed on an ACCT. Initially a template is used at the prison healthcare screen to determine if medication should be held in possession or not. This is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK’s policy. In the case of Mr Davey, there was an initial risk assessment at reception and he was deemed suitable for in possession medication, but this was not reviewed when he was subsequently placed on the 2 ACCT documents in December and January or when he disclosed to a mental health nurse on 29"" December that he had a plan to kill himself. You would like reassurance that the in possession risk assessments are reviewed. A related concern was that information about in possession medication was not available to prison officers thus there could be a time delay between a person experiencing a mental health crisis and healthcare involvement/reassessment, potentially leaving the person with access to in possession medication at a time of crisis.” Response: As was stated at the inquest, our prescriber's always record on the prescription form whether the medication they are prescribing should be held in possession. We have reminded our staff to ensure when they are reviewing any medication that they, where necessary, include an update of the ‘Medication In possession risk assessment’ which goes onto SystmOne, which in turn will feed into the ACCT. This ensures that both dispensing staff and prison staff are aware of any changes and respond accordingly, this will include the removal of any medicines currently being held. As part of the ACCT LOP we are committed to working with colleagues in Care UK, Pharmacy and Safer Custody regarding medication reviews and “stop checks”. In addition, this case has been reviewed with the staff involved and the learning shared that whenever a patient indicates changes in presentation in relation to serious self-harm, such as changes in suicidal ideation or a plan, that in all circumstances this will trigger the opening of an ACCT. | hope this response helps to address your concerns. However if you require any further information please do not hesitate to contact me ~~ Neil Carr Chief Executive
See every Prevention of Future Deaths report matching Midlands Partnership University NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.