Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0445, written 20 Dec 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Dec 2019 |
|---|---|
| Reference | 2019-0445 |
| Deceased | Tomasz Nowasad |
| Coroner | Nigel Meadows |
| Coroner area | Manchester City |
| Category | State Custody related deaths · Suicide (from 2015) |
| Organisation named | Greater Manchester Mental Health NHS Foundation Trust |
| 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. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: e¢ Mr Phil Copple, Director General of HM Prison Service (HMPS) 102 Petty France, London SW1H 9EX © EE Medical Director of Greater Manchester Mental Health NHS Trust (GMMh) Trust HQ, Prestwich Hospital, Bury New Road, Manchester M25 3BL Copied for interest to e Chief Coroner e The Family of the deceased e The PPO e Inquest Org CORONER tam Mr Nigel Meadows — H M Senior Coroner for the Manchester City Area 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 INQUEST | concluded the inquest into the death of Tomasz Nowasad on the 12" December 2019 and the jury recorded that died from: 1a Hanging The Jury came to the Conclusion : Suicide Contributed to by Neglect CIRCUMSTANCES OF THE DEATH The deceased was born on 16 March 1989 and was found dead in his cell A34 on A wing at HMP Manchester on 2 February 2017 at about 7 20 pm as a result of him hanging by a ligature attached to the window about 27 hours after arriving on the wing at about 4 20 PM on 1 February having been transferred from the healthcare centre (HCC) This was an ordinary wing location and in a “non-safer” cell with a number of potential ligature points His death was reported to the police and to the Coroner and an investigation into his death immediately commenced The PPO also commenced an investigation and appointed an investigator and the NHS appointed a clinical reviewer It appears that the clinical review report was completed on 10 April 2017 and the initial PPO report was published on 14 July 2017 . The clinical reviewer was a registered nurse and health visitor and Is a registrant panellist with the NMC. The clinical reviewer says that “for the last eight years | have inspected health services which will care in places of detention including prisons, with a focus on primary care services, mental health services and substance misuse services | have previously completed 6 clinical reviews for NHS England and the PPO ” The clinical reviewer was not a registered mental health nurse, a GP or a Psychiatrist and does not appear to have any experience of working In healthcare services as a practitioner in a category A high security prison The Clinical Review Report The terms of Reference are identified at Paragraph 1 01 and 1 04 identifies what are described as Key questions and at 1.04 says “the review will; examine the provision of clinical care and treatment, including both risk assessment and risk management , identify any care or service delivery failings along with the factors that contributed to these problems , Identify any route cause(s) that inform the identification of learning opportunities ,make timely clear and sustainable recommendation prison healthcare provider and service , provide explanations and insight for the relatives of the deceased” The copy of the system 1 records provided to the court amounted to 81 pages and that was within the jury bundle during the inquest The jury also had a complete copy of the ACCT and other relevant documentary evidence The Review report is a total of 51 pages and has a chronology as appendix 2 of the review report It appears at face value to be a copy of the original System 1 records comprising paginated between 28and 51 However, the entry related to 16 January appears on pages 45 and 46 Is headed “scanned from Mersey care NHS notes of “Dr C” The 23rd January note !s similarly referred to and included on page 48 The last interview on 30 January Is once again similarly referred to and appears starting on page 49 These entries replicate word for word I (y02c notes of the interviews that were obtained during the inquest but had not been seen by the court before but there Is no indication whatsoever as to how these entries came to be added to the system one records or when and why the typed notes on Mersey Care NHS notepaper were not simply scanned in It would seem on the face of it that the contents have been removed from that those notes and scanned in separately It is apparent that the reviewer was unaware or even understood the correct position and when, if at all, the healthcare staff could have had access to the full notes and considered them The reviewer needed to be absolutely clear as to when they were actually uploaded onto the system and how they appear on the system 1 records which may be different from how they appear in appendix 2 of the reviewers report In addition exactly when they were there were uploaded, how and by whom? Why do they seem to appear in the format in appendix 2? The reviewer had to look at both a physical healthcare and mental health care It is also said that the deceased was “admitted” to hospital under section 2 of the MHA between 20/1/16 and 25/1/16 and again between the6/4/16 and the 6/6/16 The first of those dates is correct but the second Is incorrect The correct date for the next admission is between 5/4/16 and 2/5/16 He was then “detained” under section 3 of the MHA between 3/5/16 and 2/6/16 The statutory criteria for those admissions are different All of these are compulsory admissions and not voluntary GMMH were the responsible NHS Trust for the community admissions and they are also the responsible health provider for their physical and mental health when a prisoner Is In custody at HMP Manchester. The conclusions of the clinical review The reviewers’ conclusions are recorded in section 7 of the report In particular paragraphs are relevant 7 02 Having reviewed the physical and mental health clinical care extended to Mr Nowosad, |! consider that the majority of care received was of a reasonable standard and was largely equivalent to and perhaps in some instances, particularly in relation to some aspects of the mental health care, better than that which he would have received in the wider community 7 06 In relation to the timing of his transfer from the healthcare unit to the main prison, Mr Nowosad had indicated on several occasions while he was on the healthcare unit, that he felt safer there and that he was frightened about how he would feel if he was moved back to a prison wing. The final decision to move him appears to have been made at least partly on the basis of him asking for this move, yet none of the records describe this request There did not appear to be any particular pressure to free up spaces on the healthcare unit at that time 7 07 Steps were taken to make Mr Nowosad’s transition from the unit into the main prison as safe as possible including an ACCT review and a risk assessment before he was moved He remained on an ACCT with checks made at intervals during the day and the night and he was to have a 72 hour period of assessment on A wing However tn the light of his consistently expressed fears regarding how he might feel on a main wing, It appears more might have been done to better identify the source of his specific fears and whether his mental state was as stable as tt appeared In the light of his expressed fears, it might have been prudent to keep him on the unit until he indicated that the fears had receded However, | acknowledge, that even had his move to the main prison been postponed a little longer, sadly he may still have decided to end his own life, albeit at a later point A summary of the main or significant evidence admitted and heard at the inquest and the ury's conclusion The deceased had an established diagnosis of schizophrenia which required three compulsory detentions Mental Health Act ( MHA ) from January 2016 and then was alleged to have committed a serious assault shortly after his last discharge in June 2016 and in the context of him being abstinent of consumption of his prescribed medication. He was remanded In custody and arrived at Manchester prison on the 26th September 2016 GMMH was the detaining authority in the community and also provides physical and mental healthcare in the prison During an initial health screening process conducted by a Mental health Nurse he disclosed his diagnosis of schizophrenia and that he was being prescribed Olanzapine (an anti- psychotic drug) It was recognised straight away that English was not his first language and that he would require the use of the language Line (LL) interpretation service Whilst he may have been able to speak a little English the extent of his real understanding and comprehension was a different matter and was never established during the course of his time in prison Thereafter there was intermittent use of the language LL interpretation service In contacts with healthcare staff and at subsequent ACCT reviews A repeated feature was that although he was asked regularly about self-harm or suicidal thoughts there was a lack of | understanding between some of the health care staff that prisoners will frequently deny have such thoughts or ideating but nonetheless still have those experiences and that they may not deliberately disclose this or otherwise disguise It He saw a locum Consultant Psychiatrist on 28th September and then a mental health nurse on 29th September and then saw the same locum Consultant Psychiatrist on 13 October and although the deceased had stopped taking his prescribed medication as from 5 October but which had been initiated on 28 September The locum Psychiatrist told the court he was entirely satisfied that the deceased did suffer from schizophrenia and had exhibited genuine symptoms It is not possible to compel a patient prisoner take medication in a prison but this can be undertaken in a mental health hospital The Court had instructed an independent Consultant Forensic Psychiatrist (Dr M) to provide expert evidence and he told the court that a symptomatic schizophrenic who refuses to take medication that was previously considered to be therapeutically beneficial was bound to deteriorate and relapse Consideration should have been given for transfer out of prison to a hospital where he can be more easily and successfully treated This would have been appropriate in the period of some months when he was abstaining from taking his medication On the 10" November he reported a Paranoid episode but an appointment to see a Psychiatrist was not progressed due to staffing levels In Dr M’s opinion this was an indication of his deteriorating mental health and a sign of relapse Another locum Psychiatrist saw him on 30th December but this Dr had only been working at the prison for approximately three weeks and had no training on the use of the LL interpretation service and was not expecting to use it when she saw him. This was despite the deceased telling her that he needed an interpreter. She tried to explain to him that he would become unwell again if he did not take his medication 9th January 2017 he presented to a mental health nurse who did use the LL telephone interpretation service He was acutely unwell voicing paranoid thoughts and auditory hallucinations and was unable to communicate in English and the nurse considered this to be another indication that his mental state had deteriorated In particular she recorded that the deceased heard voices telling him to hang himself Furthermore, that he feared if he was sent back to the wing someone would kill him. In addition it was recorded that he had made no previous serious attempt on his life Quite appropriately an ACCT was opened to try and ensure his immediate safety He was transferred the HCC and placed In a safer cell The prison has 19 cells in the HCC , 9 of which are “Safer” cells and of those 5 have CCTV monitoring The rest of the prison has only 2 “Safer” cells and no CCTV monitored cells On the 10 January he saw the same psychiatrist who he saw on 30 December She accepted that he was psychotic the day before and he was prescribed with olanzapine which he agreed to take She did use the LL service on this occasion He voiced delusional thoughts but it was noted he disclosed to the RMN he saw the day before a presentation that would be consistent with “Thought Insertion” In addition his thoughts and voices he heard were worse in the evening He then saw a Consultant Forensic Psychiatrist (Dr C) on the 16th, 23rd and 30" of January At the first interview Dr C recorded in the System 1 records that the deceased still had some residual delusional beliefs His subsequently prepared typed note revealed that the deceased had revealed a previous attempt to hang himself but some time before Dr C usually works at Ashworth High Secure mental health Hospital and was employed by a different NHS Trust with whom GMMH had an arrangement for him to work at the prison usually one day a week He had done so since 2013 and his practice was to make some brief hand written notes during his interviews and then subsequently dictate a more detailed note which was passed to his secretary to be typed up and uploaded to the HMPS System 1 medical records The original typed notes were produced to the court and Dr C's first interview record was not uploaded until 1 February and his other two not until 8 February, two days after the deceased died Consequently, they were not available to be read and considered by other healthcare staff He accepted that it was his duty appropriate clinical records as soon as possible and they should have been put on the system sooner | required him to produce his original manuscript records but he could only find those for the 16" and 23" January but not the 30 Those notes did not accord with his typed notes and he told the court he used those and his recollections to formulate the typed note and the record was not made and recorded on System 1 at the time but only very brief notes During his interview with the deceased on 16th January he disclosed for the first time that he had previously tried to hang himself Dr C accepted that this was inconsistent with his denial that he had any thoughts or plans of deliberate self-harm now or ever When Dr C saw the deceased on 23rd January he could not explain why he thought a couple of weeks earlier that his brother wish to cut off his ears and take his eyes out whereas now he denied that was ever the case Dr C felt that the deceased was now responding well to his medication and that he could remain on the HCC days before being transferred back to normal location and follow-up by the MHIT. His dosage had also been increased to the maximum The deceased had been subject to ACCT reviews on the 9th (raised risk of self-harm or suicide) and 13th of January when the risk of suicide or self-harm was recorded as being low He was further reviewed on 15th January when LL service was used and Nurse R (the HCC Deputy manager) was present and once again his risk was assessed as being low It was recorded that he was scared to return to the wing as there are people talking about him and he does not know what they are saying This was followed by another review on 21st January when once again the risk was assessed as being low The third ACCT review took place on the 22"4 January and the level of risk was still assessed as being low although tt was reported by him that he had no current thoughts of self-harm or suicide but still has delusional thoughts about his family The fifth review took place on the morning of the 30th January and was attended by Nurse R, the deputy manager of the HCC This took place in the morning before Dr C saw in the afternoon Nurse R recorded that the deceased disclosed no current thoughts of self-harm or suicide but the consensus of the meeting was that if he returned to the wing he would develop suicidal thoughts Deceased reported that he stilt felt that people were trying to hurt him The level of risk was still assessed as being low but on no occasion was there any recorded explanation as to how and why this assessment of risk had been arrived at or what factors had been taken into account He was seen again by Dr C on the afternoon of the 30" January and Dr C considered it was appropriate for him to be discharged from the HCC to what he understood to be the own protection or vulnerable prisoners wing. However, the deceased had told him that whilst he disclosed no current thoughts of self-harm or suicide if he was moved back to a normal location he may hurt someone else or himself. In addition he felt safe on the HCC Dr C recorded tn his typed note uploaded to the System 1 records after the death that “now he was better and had taken his medication that we would be unable to keep him longer term on the HCC wing as this was for the most vulnerable patients with severe illnesses who cannot be managed in another place” Furthermore “Tomasz agreed to discuss with the officers making himself a vulnerable prisoner for his own protection” This was putting the onus and responsibility of this on a schizophrenic patient whose first language was not English Dr C accepted just because he did not report thoughts of self-harm and suicide does not mean that he was not having those thoughts or that he may still be suffering from paranoid delusions but no objectively or subjectively disclosing them. However, Dr C additionally told that the court that he understood there was a process for transfer but did not know that this involved a 72 hour period of assessment and that there was no guarantee that he would actually be transferred and that he was going to be placed in practical terms on an ordinary wing location He thought that he would be treated as a vulnerable prisoner in the meantime but still would have to be placed in an ordinary cell with a number of ligature points Dr C maintained that SO B/r was present at this interview but the officer denied this and was no record of who was present, if anyone whether they be nursing staff When the expert witness Dr M gave evidence he told the court that the VP or Own Protection unit was not an appropriate placement in any event for a schizophrenic patient that although was improving still was suffering some symptoms In addition he would have to understand exactly where he was going to and the nature of the regime and the other prisoners he may be associating with On the 31% January a Case review prior to discharge from the HCC was undertaken Nurse R attended once again. A member of healthcare staff who spoke Polish acted as an interpreter although he was not recognised officially as being one He told the court that he simply told the deceased that he was being transferred to A wing which he understood had been explained to him before Nurse R told the court that at this time the process and procedure for transferring prisoners was changing or had changed She also told the court that she had not seen the typed records of his interviews with Dr C but there was very significant and important clinical information contained within them Had she been present at any interview when clinically significant information was obtained particularly relating to risk she would have made a record on System 1 and there was none to reflect any attendance by her at interviews conducted by Dr C His risk of self-harm or suicide was still assessed as being low on 1 February but had she seen and been aware of the true position and the content of Dr C’s clinical records in full she would have stopped the discharge from the HCC and regarded the risk of self-harm or suicide as being high No one from the receiving wing attended this case review although It was understood that SO B from A wing had been invited It does not appear that this officer had been interviewed and asked whether or not this was correct and, if so, why he had not attended or sent another member of staff from the wing SO O’C was the supervising officer in charge of A wing on 1 February but had not been on duty the previous day He told the court that had he been involved the previous day he would have arrange to attend himself or send a member of staff PO C was the movements officer for the wing who received a phone call indicating that the deceased was being transferred She could not remember who made the call Upon his arrival at about 4 20 PM she noted that he was on for daily observations four at night but did not read the act or the ACCT file or the recent case reviews Neither did SO O’C The deceased was placed In a cell on his own because he had a high risk CSRA He had a handful of contacts with the wing staff that day and on 2 February he was last seen by PO C at about 5 pm and she had an interaction with him but made no record of this in the observation log At about 7 20 pm two prison officers went to his cell to get a spare mattress from it and discovered him hanging by a torn bed sheet attached or secured to the window. There were no safer cells on the wing He was cut down from the ligature and that was removed The alarm was raised and other prison officers and then healthcare staff arrived Extensive efforts were made to resuscitate the deceased which continued when paramedics arrived and continued thereafter Unfortunately this proved unsuccessful and he was pronounced officially dead about 8°15 pm. The Court appointed expert witness Dr M told the court that consideration for him to be transferred out of prison to a hospital should have been given when he was refusing medication and it was very likely that this would have been almost certainly accepted Dr C had made the decision to discharge the deceased from the HCC on a complete misunderstanding of the correct position with regards to the transfer process and the belief that the deceased was not going to an ordinary wing location when he had tndicated he felt safe on the HCC and was then located in an ordinary cell. Dr M described this as a perfect storm of misunderstanding Whilst it was not possible to predict with certainty that the deceased would have killed himself exactly when it was predictable that transferring him off the HCC in the circumstances and to what was an ordinary wing location would inevitably increase the risk of self-harm or suicide It was also not clear that the deceased understood the nature of the wing he was going to or regime and this was reinforced because of Dr C’s misunderstanding The jury returned a conclusion of Suicide contributed to by Neglect In the context of a prison death this is a high threshold reach Their determinations of how the deceased came by his death were critical of several aspects of his care management and were recorded in some detail CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern In my opinion there ts 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 The below specific issues of concern could have wider application throughout the whole prison estate rather than simply being regarded as local to Manchester prison 5 1 The context of this case has to be seen in the light of the fact that in 2019 two self- inflicted deaths happened at HMP Manchester There were four in 2018 and my records indicate that there have been 29 from the beginning of 2006 up to date In view of the evidential issues highlighted above It is suggested that there has been a repeated theme in the majority of these cases that there was an over rellance and emphasis on the assertions made by a prisoner that they “had no thoughts of self-harm or suicide” This is often simply recorded in ACCT reviews by ticking boxes on the review document. Whilst it is appropriate for this issue to be addressed whenever a prison is on an ACCT either by healthcare staff or at ACCT reviews because In many cases prisoners still go on to harm themselves or commit suicide It should not be regarded as definitive This was recognised and recorded in the latest PPO Investigation Report relating to a death that occurred on 5 April 2019 This was specifically referred to in paragraph 26 of the report which said “In previous investigation into self-inflicted deaths at Manchester, we identified weaknesses in the risk assessment of prisoners at risk of Suicide and self-harm We found in particular that staff placed too much emphasis on prisoner's presentation and did not give sufficient consideration to their risk factors” 5 2 PSI-64/2011 recognises that there are a number of potential triggers to self-harming behaviour or suicide All staff should be alert to the increased risk of self-harm or 53 54 55 56 57 58 59 suicide posed by prisoners with these risk factors and should act appropriately to address any concerns, including opening an ACCT if necessary However, It is suggested that the list of factors is not exhaustive and everything neds to be considered in light of the overall picture This will usually involve discipline staff and health care staff It is suggested that thereafter, particularly if the prisoner is moved to the HCC, considering all the risk factors and the changing position taking into account the previous recorded history of the prisoner from both a health care and general prison service records. This is especially so when ACCTs are being reviewed and a prisoner is being discharged from the ACCT or moved out of the limited number of safer cells available in the prison There has to be consideration of the overall or ‘big picture’ with regards to the risks that the prisoner poses It is suggested that whenever an assessment of risk of self-harm or suicide is undertaken there Is a written record made of the factors or issues involved in this or what weight or consideration was given to them and how the risk assessment was arrived at It is suggested that It would be appropriate for GMMH and HMPS to ensure that this Is introduced It appears that there was no consistent use of the language line interpretation service by HMPS or GMMH staff, and it is suggested that wherever an identified need for the use of this service Is recognised it should be used on all healthcare interviews as well as at ACCT reviews While some prisoners may speak some, little or virtually no English, it is essential that every effort is made to ensure that they can understand, so far as it possible, the issues being raised and discussed with them. It is suggested that there was an absence of timely, full and accurate clinical record keeping by members of GMMH healthcare staff (whether they be healthcare assistants, nurses or doctors) This Is a professional requirement under GMC Good Practice and the NMC code of conduct It is suggested that steps are taken to ensure this Is completed in all cases and appropriate audits undertaken to check on this. It is suggested that whenever there Is a healthcare interaction with a patient prisoner and more than one healthcare member of staff is present, their identities should be recorded and all clinically relevant information is included within the System One records and checked between those present as being full and complete It is suggested that whenever there is a healthcare interview and a member of prison discipline staff is present, records should be kept by GMMH and HMPS of who was there, but also HMPS staff should record separately within their records evidence and information relevant to the risk of self-harm or suicide It is suggested that whenever there Is a decision made to move a prisoner who Is subject to an ACCT from the HCC to another location in the prison, prison staff of the receiving wing should ensure that they attend any final case reviews prior to discharge so that they are familiar with the relevant history and risks that the patient prisoner presents, make appropriate documentary records and ensure that relevant information is handed over to colleagues It is suggested that receiving HMPS staff should ensure that they read and consider the ACCT file with particular emphasis on the assessment of risk of self-harm and suicide and how it has been managed to date and whether or not that needs to be reviewed on arrival Any concerns should be escalated 510 Itis suggested that GMMH and HMPS staff should ensure as Is far as is reasonably possible that the patient prisoner has a real understanding and comprehension of the | reasons for transfer and a regime to which they are going, particularly if they have been moved from the HCC when they occupied a safer cell but were going to an ordinary cell with a number of ligature points The staff themselves have to have a clear understanding of the reasons for transfer and what the new wing regime or locations means for the prisoner and whether or not it is appropriate Records should be kept of the reasoning and justification 511 Itts suggested that there should be an auditable process of ensuring that all appropriate information is handed over between different shifts of GMMH and HMPS staff so that there Is a continuity and consistency of available information 512 Itis suggested that GMMH staff should ensure that when they have any clinical interactions with patient prisoners they familiarise themselves with all the developing relevant medical history including recent events and record what they have reviewed or considered 5 13 It 1s suggested that since that the overwhelming majority of prisoners who kill themselves do so by ligatures particular care should be taken when prisoner who is on an ACCT is moved from a safer cell to an ordinary cell and their ACCT should be carefully reviewed and the number , type and frequency of observations Prisoner can quickly get used to the regularity of observations and undertake self-harming or surcidal behaviour when they think they will not be seen or have contact from HMPS or GMMH staff 5.14 It is suggested that HMPS should consider increasing the number of Safer cells throughout the whole of the prison and also having more CCTV monitored cells. 5 15 It is suggested that it is not appropriate for GMMH clinical or Nursing Staff to put the onus or responsibility on a prisoner to interact with HMPS staff to try and understand why they may be moving from one location to another without both being present and the language line service used to try and ensure no miscommunication and that appropriate written guidance should be given to all staff 5 16 It is suggested that it is not appropriate to indicate to a patient prisoner that they are not so ill or vulnerable as others in considering a move out of the HCC because that may influence their cooperation and disclosure of their symptoms and presentation It Is suggested that guidance Is issued to GMMH staff about this ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation 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 the 2 March 2020. |, 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 Interested Persons | have also sent it to organisations 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 DATE: NAME OF CORONER: Dated : 20°" December 2019 Mr Nigel Meadows HM Senior Coroner for Manchester City Area Signed: 10
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.
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 Nigel Meadows HM Senior Coroner for Manchester Manchester City Coroner's Court and Offices The Royal Exchange St Ann's Square Manchester M2 7EF Dear Mr Meadows 6 March 2020 Thank you for your Regulation 28 Report of 20 December 2019 following the inquest into the death of Tomasz Nowosad at HMP Manchester on 2 February 2017, and for allowing a small extension to the statutory deadline for my reply. I am grateful to you for bringing to my attention a number of matters of concern, many of which are relevant across the prison estate. I have consulted with the Governor of HMP Manchester and, where relevant, will mention action that has been taken locally at the prison as well as work that is taking place at national level. I understand that the healthcare provider is responding separately to your concerns about clinical issues. I know that you will share a copy of this response with Mr Nowosad’s family, and I would first like 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. Before turning to your concerns, I would like to clarify the position with regard to the number of self-inflicted deaths at HMP Manchester in recent years. At 5.1 you correctly point out that there were two such deaths in 2019, and four in 2018. However, it is not the case that there have been 29 such deaths since 2016. The correct figure for the period 2016-2019 is 11 self-inflicted deaths. A number of your concerns relate to the Assessment, Care in Custody and Teamwork (ACCT) case management process for those identified as being at risk of self-harm or suicide. We have been working hard to improve the way that this system operates. Following a comprehensive review, we have devised a new version of the form and associated guidance, and I am pleased to note that much of what you have suggested has been adopted as part of that. We believe the new version will make the system easier to operate and thereby improve the quality of care offered to prisoners. It was piloted in ten establishments in 2019 and the feedback has been positive. We are currently making some further changes before rolling it out across the prison estate later in 2020. I am confident that this will address the concerns that you have raised and bring further improvements to the work that staff do to keep prisoners safe. I would like to comment more specifically on four issues that are at the heart of the concerns that you have raised. First, risk assessment (5.1-5.3). You have described an over-reliance on a prisoner’s presentation and what they say, rather than a consideration of all risk factors, and drawn attention to the fact that this has also been identified by the Prisons and Probation Ombudsman in relation to other self-inflicted deaths at the prison. You have explained the need for a holistic approach to risk assessment, and for decisions to be made in a defensible way, and recorded appropriately. These are issues that have been at the centre of our thinking as we have redesigned the ACCT guidance, which will be much clearer about the risks, triggers and protective factors that staff should be seeking to identify, and the ACCT form itself, which will provide prompts to look for other factors that may be relevant as well as space for staff to record the reasons for decision. The associated training packages are currently being redeveloped and will be delivered to all new staff through POELT training and made available as refresher training for existing staff. A specific session on the risks and triggers for self-harm and suicide will form a major part of this training. Second, interpretation services (5.4). You express concern about inconsistent use of such services by staff. A national contract with The Big Word ensures the availability of interpretation services across the prison estate. The new ACCT guidance will emphasise the importance of their use throughout the process, and the new ACCT form will include prompts to consider the use of the service at every significant point, including assessments and case reviews. In advance of the roll out of the new version of ACCT, the Governor of HMP Manchester has taken action to improve the use of the service at the prison, for example by making conference style telephones available for use at case reviews. Third, the movement of a prisoner subject to ACCT to a new location, particularly where this involves discharge from a specialist location such as inpatient healthcare (5.7-5.11). Your concern here is that information should be passed between locations, and particularly that staff at the receiving location - and the prisoner themselves - should be clear about the reasons for the move. Again, the new ACCT form will assist with this, providing a specific template for use at case reviews that occur in specialist locations, including healthcare centres and segregation units. Where a decision to discharge is the result, it provides a prompt to share relevant information with the receiving location (from which a member of staff must attend the review). The new ACCT guidance is much clearer about the need to involve the prisoner in all decisions that are taken, including those concerning location. In advance of implementing the new system, it is now the practice at HMP Manchester for a case review to be held prior to any location move, including moves from healthcare to residential wings. These reviews are attended by a representative from the new location, providing an opportunity to discuss any concerns and issues relating to risk, including how a change to location and regime might affect risk. Notes of the review and any decisions made are recorded in both the ACCT document and in the NOMIS case notes. Where an enhanced assessment has been completed by the psychology department, this is also forwarded to the new location. Fourth, safer cells (5.13-5.14). You are concerned that more such cells should be available, and that the movement of prisoners who are subject to ACCT from a safer cell to another location should be carefully managed. I understand the importance of reducing access to the means of suicide wherever possible. Physical safety, including increasing the provision of accommodation free of ligature points, is one of the work streams in our national prison safety programme. You will appreciate that large amounts of capital investment are necessary to improve the environment in this way, and we are not able to move as swiftly as we would want to. However, wherever possible we are increasing the numbers of safer cells available to governors. At HMP Manchester there are currently fourteen safer cells. Ten are in the healthcare unit, five of which are equipped with CCTV. Four non-CCTV cells around the prison have electro-chromatic doors. Whilst there are currently no plans to increase the number of safer cells, we will keep this under review. Whilst safer cells are an important part of our strategy for managing acute risk of suicide, they are not a long-term solution in terms of care for individuals. The multi-disciplinary engagement and support that is provided through ACCT is designed to manage and mitigate risk by identifying and meeting individual needs. In most cases this can be done without the removal of ligature points or observation through CCTV. As explained above, the new ACCT form and guidance are clear that all changes of location, including moves out of safer cells, require careful management. Thank you again for bringing these matters of concern to my attention. I hope that this response has provided reassurance that those that are for HMPPS are being addressed, at national level through the roll out of improvements to ACCT and, wherever possible, locally at HMP Manchester in advance of this. Yours sincerely PHIL COPPLE Director General for Prisons
Professor Stephen Powis
National Medical Director
Skipton House
80 London Road
SE1 6LH
6th March 2020
Mr Nigel Meadows
HM Senior Coroner
HM Coroner’s Office
Manchester City Area
The Exchange Floor
The Royal Exchange Building
Cross Street
Manchester
M2 7EF
Dear Mr Meadows
Re: Letter of Concern written under Paragraph 37 of the Chief Coroners
Guidance number 5 on Prevention of Future Deaths – Mr Tomasz NOWOSAD,
Date of Death 2 February 2017.
Thank you for your letter dated 20 December 2019 (hereinafter the ‘letter’)
concerning the death of Tomasz Nowosad on 2 February 2017. At the very outset I
would like to express my deep condolences to Mr Nowosad’s family.
Following the conclusion of the inquest you raised concerns regarding the skills and
knowledge of the Clinical Reviewer whose report was used as part of the evidence
provided to the inquest.
Your letter mentions that you are aware of the NHS England Guideline for Health
and Justice Clinical Reviewers1, published on 21 September 2018. Alongside this
document, NHS England also published a suite of supporting documents and
templates for Clinical Reviewers and commissioners. These can be found at:
https://www.england.nhs.uk/publication/guidelines-for-health-and-justice-clinical-
reviewer/
In addition to the above guidelines NHS England also published, on 21 September
2018, Guidelines for the provision of Clinical Reviewers to support Health and
Justice deaths in custody investigations2. On 12 June 2017
Deputy Prison and Probation Ombudsman and
National Clinical
Quality Lead for Health and Justice at NHS England, met with you in order to
inform and shape the development of these guidelines. NHS England has sought to
implement and develop a robust framework based upon your comments and
feedback arising
the sad
circumstances of this case have prompted further concerns. I hope that the
is deeply regretted
that meeting.
from
that
It
1 https://www.england.nhs.uk/wp-content/uploads/2018/10/guidelines-for-health-and-justice-clinical-
reviewer.pdf
2 https://www.england.nhs.uk/wp-content/uploads/2018/10/guidelines-for-the-provision-of-clinical-
reviewers-to-support-health-justice-deaths-in-custody-investigations.pdf
NHS England and NHS Improvement
following information will help to assuage those further concerns in relation to
Clinical Reviewers and Clinical Reviews.
After considering feedback relating to the provision of clinical reviews across the
North region NHS England resolved to procure a more robust and secure
contractual arrangement in order to address concerns and act upon that feedback.
A revised procurement exercise for the Death in Custody Clinical Review service
across the North of England was undertaken during 2018/19 with a contract start
date of April 1st 2019. The procurement included the incorporation of the newly
approved guidance from NHSE (the links of which are provided on the previous
page and in ‘1’ and ‘2’) into the service specification, including sections regarding
compliance with governance and quality aspects of service delivery along with
confirmation of appropriate payments. Robust processes around quality assurance,
approval pathways and relevant performance monitoring were included in the
contract and compliance with the guidance was mandated. The compliance is
monitored through the quarterly contract performance meeting, against the clinical
service provider data in the quality schedule return (see template in Annex 1).
As part of the new arrangements NHSEI Health and Justice Quality Leads are
required to approve the identification and selection of appropriately skilled and
suitable individuals by the service provider. This involves ensuring the clinical
reviewer has the appropriate skill set through review of qualifications. There is a
recognition that there may be gaps in knowledge, in some instances, however
these are mitigated by the clinical reviewer accessing support from other
professional advisors and subject matter experts as required. All appointments
must be agreed by NHSEI and an up to date register is kept of all reviewer’s
professional registration, either as a nurse or doctor. In addition data regarding
qualifications and training and evidence of ongoing mentorship and supervision by
experienced professionals, within the service is also documented. Reviewers are
assessed for their suitability to carry out specific reviews through discussion
between the service provider and NHSEI. For example, only reviewers who have
experience within mental health services will be considered suitable for reviews
with a mental health component and likewise with physical health. The final draft
clinical review produced after each investigation must now be quality checked and
approved by NHSEI Health and Justice Quality Leads before being passed to the
Prison and Probation Ombudsman for their approval. It is explicit in the contract for
the service and in the guidance that clinical reviewers should not be expected to act
as an expert witness but are expected only to review the service provided to the
deceased and map against the service they could have expected to receive in the
community.
Contract meetings are held quarterly between the commissioner of the services,
the quality leads from the North West, Yorkshire and Humber, and Cumbria and the
North East regions, and provider representatives from the service. There is a
performance and quality data set for the service which is provided at the meeting
and for which the service is held accountable (See Annex 1). Current progress with
this contract demonstrates good practice in maintaining an accurate record of
professional registration and qualifications, clinical reviewer supervision and
appraisal. There are some process issues with some clinical reviews regarding a
range of reasons e.g. access to information and clinical records, some of which are
outside of the providers control. All processes throughout the period of an
NHS England and NHS Improvement
investigation are jointly agreed between NHSEI, the service provider and the PPO
and any issues or problems are dealt with in the contract meetings with action
plans for service improvement being formulated.
It is hoped that such additions to the procurement and oversight of Clinical Reviews
will ensure the robustness of future Clinical Reviews.
In relation to the review concerning Mr Nowosad, I recognise the concerns you
have outlined in your letter.
NHSE were informed of the tragic death of Mr Nowosad on 3rd February 2017 by
Health Care Provider Staff. NHSE were contacted on 23rd March 2017 to inform
them that there would be a delay to the publication of the first draft of the clinical
review due to delays in the reviewer interviewing staff. The PPO therefore granted
an extension. The first draft of the clinical review was sent to NHSE on 10th April
2017, which was quality checked by NHSE. The Quality lead made a range of
comments on the report and a revised version was produced on 5th May 2017. The
comments were largely asking for further clarification regarding observations made
by the clinical reviewer such as why a particular action wasn’t followed up and the
reason why certain actions had not been undertaken in Mr Nowosad’s care. There
were two references made to use of outdated guidance suggesting the reviewer re
look at the more recent guidance.
On 14th July 2017 the first draft of the PPO report was submitted for factual
accuracy checking by the prison and health services. On 19th July 2017 concerns
consultant forensic psychiatrist, regarding potential
were raised by
“misinterpretation” of comments which he had made and which he felt may not
have been fairly reflected in the report. Further suggested factual accuracy
changes were submitted to NHSE by the prison health provider, along with an
action plan to address recommendations made in the report. These suggested
changes were submitted by the NHSE quality lead on 24th July 2017 for comment
by the clinical reviewer and PPO. The clinical reviewer responded to these
suggestions on 25th July 2017 by stating that, over the course of several email
discussions with
they had reached an understanding of the position.
The reviewer acknowledged that the purpose of the report was to identify
opportunities to learn lessons. She felt, however, that good mental health care was
provided to Mr Nowosad. The final report was published by the PPO in October
2017 after additional suggested changes to the report were received from the
prison service.
Since the very sad death of Mr Nowosad in 2017, and in recognition of the scope
for improvement that had been identified, NHSE has published an amended
specification for the provision of mental health services in prison (see Annex 2) and
all providers must comply with the scope of the specification. HMP Manchester
audited its services against the requirements of the specification and, as a result,
additional resource was provided by NHSE to enhance the service accordingly.
This resulted in additional investment into HMP Manchester which provided for
additional mental health, nursing, psychology and well-being staff.
NHS England and NHS Improvement
Additionally, I am aware that HMPPS are currently rolling out revisions and
amendments to the ACCT process which will include enhancements to the multi-
disciplinary contribution of the clinical team within the prison.
I trust that the steps outlined above relating to the framework for clinical reviews
and reviewers will reassure you that NHS England has taken steps to ensure the
robustness of such reviews in the future.
I am deeply saddened by Mr Nowosad’s death and the fact that you have identified
concerns in the area of clinical reviews. I am however grateful for the opportunity to
highlight in this letter the work that has been carried out to ensure that such
concerns do not arise in the future.
Yours sincerely,
Professor Stephen Powis
National Medical Director
NHS England and NHS Improvement
NHS England and NHS Improvement
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