Martin Haines

bs From Nadine Dorries MP

Parliamentary Under Secretary of State for Mental Health,
Department Suicide Prevention and Patient Safety

of Health &

Social Care Mallets
SW1H OEU

Your Ref: ARC/LEH/Haines/0 1252-201 8/Gallagher/1 117-2016 a A a ht

Our Ref: PFD-1187269

Mr Alan Craze

HM Senior Coroner, East Sussex
East Sussex Coroner’s Office
Unit 56, Innovation Centre
Highfield Drive
St.-Leonards-On-Sea TN38 9UH

KA January 2020
Yay Whv Cx Nye /

Thank you for your correspondence of 16 August 2019 to Matt Hancock about the
death of Mr Martin Leslie Haines. I am replying as Minister with responsibility for
prison health services and I apologise on behalf of the Department for the delay in
reply. I am grateful to you for the additional time in which to issue this response.

Firstly, I would like to offer my sincere condolences to the family and loved ones of
Mr Haines. We know that more can be done to better meet the healthcare needs of
people within our prison system and I am grateful to you for bringing these matters to
my attention.

Providers of healthcare services are responsible for the quality and safety of the care
they provide. I expect the healthcare providers at HMP Lewes to look into the care
provided to Mr Haines and to consider where improvements can be made. This
includes how they work with the prison authorities and other relevant organisations,
including NHS England which is responsible for commissioning healthcare services
for prisoners. Given its role in monitoring, inspecting and regulating the providers of
health and social care in prisons, my officials have brought your reports to the
attention of the Care Quality Commission (CQC).

Ata national level, the National Audit Office report into Mental Health in Prisons’,
published in June 2017, made a recommendation in relation to the way that NHS
England, Her Majesty’s Prison and Probation Service and Public Health England
manage their joint working on prison healthcare.

As a result, the original tri-partite partnership agreement (developed and signed in
autumn 2013) was revised to include the Department of Health and Social Care and
the Ministry of Justice as partners to bring additional oversight and accountability to
the commissioning and delivery of healthcare services in prison.

The National Partnership Agreement for Prison Healthcare in England 2018-217,
published in April 2018, acknowledges the need for health and justice partners to
work together to ensure “safe, legal, decent and effective care that improves health
outcomes for prisoners, reduces health inequalities (particularly for those with
protected characteristics), protects the public and reduces reoffending”’.

The Agreement sets out a joined-up, strategic approach to meet the complex nature of
offender health care needs and provides the partnership members with an overarching
framework for collaborative working at all levels. The Agreement has three shared
core objectives to be delivered through ten high level priorities. These priorities are
underpinned by the Agreement’s 2018 Workplan, which includes a commitment to
deliver on three key issues that relate to the responsibilities of all organisations
involved in prison care. These commitments are to:

e Improve the quality of data and intelligence collection and enable better data-
sharing between partners. This includes improving the sharing of information
before, during and after incarceration to support continuity of care;

e Input into the development of policy amongst the health and justice partners,
and across Government, to ensure that the potential impact on prisoners’ health
and social care needs are properly considered and that shared objectives are
maintained; and,

e Review and improve commissioning between health and justice partners and
links with local authorities, probation services and health commissioning in the
community, so that health and social care services are aligned for better and
more consistent provision before, during and after custody.

Effective delivery of the ten objectives will be observed by existing scrutiny bodies,
including HM Inspector of Prisons, Independent Monitoring Boards, the CQC and
Healthwatch.

The National Prison Healthcare Board has responsibility for the oversight and on-
going management of the Agreement and delivery of the shared objectives.

You may be aware that the Health and Social Care Select Committee conducted an
inquiry into prison health that reported in November 20187. The Government’s
response, published in January 2019*, outlined a range of actions, including those in
the National Partnership Agreement, that will be taken to support the delivery of
high-quality health services in prisons. We remain committed to working
collaboratively across Government to achieve those aims. For example, in response
to one of the recommendations, the National Prison Partnership Board published a
Principle of Equivalence in October 2019. This states that the co-chairs of the
National Prison Healthcare Board affirm that:

‘Equivalence’ is the principle which informs the decisions of the National Prison
Healthcare Board so that member agencies’ statutory and strategic objectives and
responsibilities to arrange services are met, with the aim of ensuring that people
detained in prisons in England are afforded provision of and access to appropriate
services or treatment (based on assessed population need and in line with current
national or evidence-based guidelines) and that this is considered to be at least
consistent in range and quality (availability, accessibility and acceptability) with
that available to the wider community, in order to achieve equitable health
outcomes and to reduce health inequalities between people in prison and in the
wider community.

The Board is working with analysts and scrutiny bodies to understand the extent to
which available indicators could help evidence the achievement of equivalence of
care and what would be both useful and feasible.

Finally, I am aware that NHS England and NHS Improvement, as the commissioner
of healthcare services for people in prison, has responded to your report providing
detail on the actions taken to support healthcare services at HMP Lewes. You will
therefore know that this includes the procurement of a single provider of healthcare
services at HMP Lewes to deliver better integrated services. In addition, NHS

u https: ‘publications. parliament.uk/pa/cm201719/cmselect/emhealth/963/963.pdf

+ www.parliament.uk/documents/commons-committees/Health/Correspondence/2017-19/Government-Response-to-

twelfth-report-into-prison-health-cp4.pdf

England and NHS Improvement have taken steps to review and strengthen its quality
assurance and contract performance systems.

I hope this response is helpful.

bd ne

NADINE DORRIES

Director General Prisons 
HM Prison and Probation Service 
8th Floor Ministry of Justice 
102 Petty France 
London SW1H 9AJ 

Mr Alan R Craze 
HM Senior Coroner for East Sussex 
East Sussex Coroner’s Office 
Unit 56, Innovation Centre 
Highfield Drive 
St Leonards-On-Sea 
East Sussex TN38 9UH 

24 October 2019 

Dear Mr Craze 

Thank you for your Regulation 28 Report of 16 August 2019 following the inquest into the 
death of Martin Haines at HMP Lewes on 18 March 2018. I am responding on behalf of Her 
Majesty’s Prison and Probation Service (HMPPS). 

I would first like to express my condolences to the family and friends of Mr Haines for their 
loss. The safety of those in our care is my absolute priority, and every death in custody is a 
tragedy. 

You have expressed several concerns, some of which relate to the responsibilities of 
healthcare partners, from whom you will receive a separate response. I will respond to 
matters (1), (4) and (5) which relate to the responsibilities of HMPPS. 

Your first concern is that Mr Haines was able to brew his own alcohol. I share your concern, 
and would like to assure you that there has been a lot of work at national and local levels to 
tackle the availability and use of illegal substances in prison. In April 2019 the Prisons Drug 
Strategy was published. This guidance was developed in partnership between the Ministry 
of Justice and HMPPS with input from partner agencies in health, law enforcement and 
social care. The core aim of this strategy and our surrounding activity is to reduce the 
impact of drugs and alcohol in prisons by restricting supply, reducing demand and building 
recovery. Each prison has responsibility for reviewing their own local substance misuse 
strategy, which sets out how they identify residents with drug and alcohol issues and 
provide them with a range of services to help them to overcome their substance misuse 
problems and lead healthier, crime-free lives both in prison and in the community. 

At HMP Lewes the local Substance Misuse Strategy was reviewed and updated in June 
2019 to include a section on illicitly brewed alcohol. The strategy focuses on restricting 
availability, ensuring that there are appropriate consequences for those found in possession 
of alcohol, and offering appropriate support for dependent users. There has been an 
increase in security procedures to include thorough checks of known brewing locations, as 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 well as careful selection and searching of those working in kitchen areas who have access 
to ingredients commonly used in the production of alcohol. 

Intelligence and information sharing is crucial to restricting availability, and the Governor of 
HMP Lewes can draw on the regional Dedicated Search Team when there is intelligence to 
suggest that prisoners are brewing their own alcohol. The consequences for those found in 
possession of fermenting liquid should be a deterrent, and can include additional days 
being added to sentences. Any prisoner suspected of alcohol use is referred to the Forward 
Trust for substance misuse support. The prison is also focusing on educating prisoners of 
the risks associated with the use of illicit alcohol, and continue to encourage and promote 
health and wellbeing. 

Your fourth concern relates to the lack of a protocol between prison and healthcare staff as 
to how best to respond to an unresponsive body. In accordance with Prison Service 
Instruction 03/2013, all prisons are required to have in place a two-code medical emergency 
response system and, when used correctly, these codes should trigger the control room to 
call an ambulance and for healthcare staff to attend the scene with the appropriate 
emergency equipment. You may recall from evidence heard at the inquest that a notice is 
now displayed in the control room to serve as a visual reminder to staff of the need to call 
an ambulance immediately upon receiving an emergency code. The prison also issues 
notices to all staff regularly to remind them of the importance of using the emergency codes 
correctly. 

Your final concern is that responsibility for healthcare is split between different contractors, 
and that there was insufficient communication between these bodies and their separate IT 
databases. As you know, the commissioning of healthcare in English prisons is the 
responsibility of NHS England and NHS Improvement (NHSE/I). HMPPS is responsible for 
ensuring access to healthcare services within establishments and, where required, at 
external healthcare facilities. With regard to the sharing of information between the various 
organisations, you will appreciate that it is not appropriate for prison staff to have access to 
clinical records on SystmOne. At HMP Lewes, there is a daily meeting between prison and 
healthcare staff at which important information is shared. Each staff team then ensures that 
their respective databases are updated. 

I understand that a new database is being created by NHSE/I which will supersede the 
current clinical system. The plan is for this to have some inter-operability with the NOMIS 
database used by prison staff, and this will enable better sharing of information between 
prison and healthcare staff. 

Responsibility for the provision of healthcare at Lewes will be moving in April 2020 to a new 
provider which will have responsibility for all services, and I believe that this will lead to 
improved communication and continuity of care. 

Thank you again for bringing your concerns to my attention, and I hope that this response 
provides assurance that action is being taken. 

Yours sincerely, 

Director General for Prisons

Mr Alan  Romilly Craze,  Senior Coroner for the 
area of East Sussex 
Unit 56 
Innovation Centre 
Highfield  Drive 
St Leonards on  Sea 
East Sussex 
TN38 9UH 

National Medical Director 
Skipton House 
80 London Road 
SE1  6LH 

/cf!"?,  December 2019 

Dear Mr Craze, 

Re:  Regulation 28 Report to Prevent Future Deaths - Martin Leslie Haines, who died 
in  Lewes Prison 18th  March 2018 

Thank you for your Regulation  28  Report (hereinafter the 'report') dated  16 August 2019 
concerning the death of Martin Leslie Haines on  18 March  2018.  Firstly,  I would  like to 
express my deep condolences to  Mr Haines' family. 

I note that the recent inquest concluded that Mr Haines' death whilst detained  in  HMP 
Lewes was as a result of cardiac arrest in  the presence of Venlafaxine,  Amitriptyline and 
alcohol. 

Following the  inquest, you  now raise concerns iri your report to  NHS England  regarding: 

1.  The fact that Mr Haines was able to  brew or distil his own alcohol. 

2.  The failure to carry out diagnostic testing  and  monitoring of his diabetes and  to 

confirm  his considerable cardiovascular disease. 

3.  The standard of care appears to have fallen  well  below that which  he.could  have 

received  in the community. 

4.  There were no protocols or agreements between healthcare staff and the prison 

service as to how to  respond to an  unresponsive body. 

5.  Responsibility for healthcare. fell  between the  prison service,  Sussex Partnership 

Foundation Trust ( contracted to provide both  mental and  physical health within the 
prison),  Medco Ltd  who  provided the GPs,  and  Forward Trust who were contracted 
to supply the alcohol  and  substance misuse treatment service In the prison. There 
was  insufficient communication between these bodies and they had separate IT 
databases. 

This  response  seeks  to  set out the  actions  which  have  been  taken  following  the  death  of 
Mr  Haines  and  the  learning  that  has  been  taken  forward  by commissioners  from  this  very 
sad  incident.  I  am  also  mindful  when  responding  of the  earlier  death  of  Mr  Justin  Peter 

NHS  England and  NHS Improvement 

00 

 
 Gallagher who  died  whilst  detained  at  HMP  Lewes  in  June  2016,  the  action  plan  instilled 
following  his death,  the delays  in  embedding  necessary changes,  and  the  similar concerns 
you  raise in the related  Regulation 28 report. 

I now respond to  the concerns raised in turn: 

1) The fact that Mr Hainei:; was able to brew or distil  his own alcohol. 

I understand that The  Ministry of Justice will respond  directly to  the  Coroner on this. 

2)  The  failure to carry  out diagnostic testing  and  monitoring  for  his  diabetes  and  to 
confirm his considerable cardiovascular disease 

I  can  confirm  that  Sussex  Partnership  NHS  Foundation  Trust  (SPFT)  undertook  a  Root 
Cause  Analysis  Investigation following  Mr Haines  death  and  three  recommendations  were 
made: 

a.  healthcare  staff  should  be 

trained 

in  how 

to  detect  diabetes  and 

hypertension; 
long term  conditions  such as diabetes and  hypertension are  managed  in  line 
with  National  Institute for Care  Excellence (NICE) guidelines; and 
reviews  of repeat medication comply with  NICE guidelines. 

b. 

c. 

In  response  to  this  SPFT  created  a  training  session  for  all  staff which  was  completed  by 
the  end  of 2018  and  is  now incorporated  in  the  yearly training  programme,  covering  NICE 
guidelines  on 
the  management  of  diabetes,  hypertension  and  Chronic  bbstructive 
Pulmonary Disease. 

3)  The  standard  of care  appears to  have  fallen  well  below that which  he  could  have 
received in the community 

Despite  previous  clinical  reviews,  including  the  one  conducted  following  the  death  of  Mr 
Gallagher, SPFT have failed  to  embed the agreed improvements and  there  continues to  be 
failings in care.  An  on-going  action plan  remains  in  place and will  continue to be monitored 
closely for the  remainder of the  trust's contract which  ends  on  31  March 2020.  To support 
· this,  and  ensure  a  reduction  in  any  risk  to  patients,  commissioners  have  appointed  a 
clinical  reviewer  (previously  Director  of  Nursing  in  an  acute  trust)  to  attend  HMP  Lewes 
weekly and  act as  a facilitator to  resolve any issues which affect delivery of services. 

Commissioners  have  implemented  a  more  rigorous  approach  to  contract  management, 
procurement  and  mobilisation  of  services,  taking  learning  from  HMP  Lewes  (and  other 
prisons) into account.  This  is detailed  more in  response to Concern  (5) below. 

A  Quality  Improvement  Plan  was  implemented  following  Mr  Haines  death,  actions  were 
agreed  and  achieved  in  2018  but  further  reviews  found  they  had  not  all  been  embedded 
into  practice.  As  a  result,  SPFT  was  served  with  a  Contract  Notice  in  November  2018 
relating  to  poor performance and  a further Service  Development  Improvement Plan  ( dated 
8  June  2019)  was  agreed  with  commissioners.  Actions  from  this  are  in  various  stages  of 
completion  with  some  having  been  achieved,  and  others  noted  as  in  progress  whilst 
embedding into practice. 

4)  There  were  no  protocols  or agreements  between  healthcare  staff and  the  prison 
service as  to  how to respond to an  unresponsive body 

The  Prison  and  Healthcare  providers  have  reminded  staff  of the  protocols  in  relation  to 
responding  to  an  unresponsive body,  including  the  need for prison  staff to  elicit a verbal  or 
non-verbal  response  from  each  prisoner when  cells are  unlocked.  Further reminders  have 
been  issued  on  the  need  to  immediately call  an  ambulance  when  a  Code  RED  or  Code 
BLUE  is called,  including a new poster in  the control  room. 

NHS  England and  NHS Improvement 

Cri!J 

 5)  In  my opinion, the underlying  problems were due to the fact that responsibility for 
healthcare  in  prison  was  split  between  the  prison  service,  Sussex  Partnership 
Foundation  Trust (contracted  to provide  both  mental  and  physical  health within the 
prison),  Medco Ltd  who provided the  GPs,  and  Forward  Trust who were contracted 
to  supply the  alcohol  and  substance  misuse treatment service  in  the  prison.  There 
was  insufficient  communication  between  these  bodies  and  they  had  separate  IT 
databases. 

In  2017,  NHS  England  iNHS E)  reviewed  the  model  of commissioning  in  Kent,  Surrey and 
Sussex as  it was  becoming  increasingly apparent the model was not delivering the benefits 
anticipated  and  services were  not integrating  effectively.  In  line with  other prison  groups in 
England  , NHS  E made the decision to commission  services using  a Prime Provider model. 
This  model  ensures  a  single  contract  and  provider,  accountable  for  the  delivery  of 
integrated  healthcare  in  a  prison  (or  group  of  prisons).  This  model  has  been  found  to  be 
more  effective  in  management  of  services,  development  and  delivery  of  integrated 
pathways  between  the  different  healthcare  teams  in  the  prison.  Commissioners  have 
worked  more  closely with  Governors to  ensure that they are  able to  provide  officer support 
(enablement) 
including  supervision  of 
medications,  movement  of prisoners  to  and  from  appointments  and  out  of  hours  access 
where required. 

increase  healthcare  access 

to  prisoners 

to 

The  current  healthcare  contracts  with  existing  providers  end  in  March  2020  (SPFT  and 
Medco) and  October 2020 (Forward Trust) respectively. 

NHS  E have undertaken a procurement process for provision  of these  services  after those 
dates.  The  services  procured  is  an  Integrated  model  of  delivery  which  means  that  the 
contract  has  been  awarded  to  one  provider  for  the  delivery of all  services  to  HMP  Lewes 
residents.  This  is  a tried  and  tested  form  of service  delivery and  puts  the  responsibility for 
delivery  of  all  elements  of  the  contract  with  one  provider  only.  This  will  negate  any 
communication issues and  the provider will use one database system only.· 

NHS  E  awarded  the  contract  to  Care  UK  in  October 2019  and  the  services  are  currently 
being  mobilised  for  a  delivery  start  date  of April  2020.  Monthly  Mobilisation  Boards  have· 
been  established  and  include  all  incumbent  providers,  the  prison,  social  care  and  the  new 
provider.  These Boards are overseen by NHS E & I  Commissioners. 

Once  the  contract  starts  NHS  E  governance  process  will  have  oversight  via  Contract 
Review Meetings,  Partnership Boards and  Local  Delivery Quality Boards. 

Transition of Services 

The  SPFT Board  has taken the  decision to  withdraw from  prison healthcare delivery at the 
end  of the  current contract in  March  2020 following  prosecution  of the Trust by the CQC. A 
detailed transition  plan  has  been  developed, to  ensure the  continued  delivery of healthcare 
services  during  the  mobilisation  of  new  contract  which  will  be  closely  monitored  by 
commissioners  via  the  Transition  and  Mobilisation  Meetings.  Performance will  continue  to 
be  monitored  at  the  Contract  Meetings  which  form  part  of  the  usual  governance  process 
and  have  agreed  a Contingency  Plan  with  HMPPS  should  there  be  any  significant  issues 
or concerns for the welfare of men at Lewes. 

Electronic Patient Records 

All  healthcare  providers  are  given  access  to  electronic  healthcare  software,  SystmOne. 
Substance  misuse  services  have  their  own  database  which  records  performance  and  on 
which  payment is  based.  Clinical  information  is  recorded  on  SystmOne.  At present'NHS E 
holds  responsibility  (and  the  budget) 
for. the  provision  of  IT  into  prison  healthcare  in 
Ken/Surrey and  Sussex.  This  responsibility will  transfer to  providers  as  part of the  move to 

NHS  England and  NHS  Improvement 

0:0 

7 

 the  Prime  Provider  model,  giving  them  greater control  over use  of more  innovative  IT  and 
software  solutions.  All  users  of SystmOne  can  create  tasks  for other team  members  and 
which  are  linked  to  patient  records  where  applicable,  this  reduces  the  risk  of  messages 
going  astray.  NHS  E  Commissioners  will  review  the  use  of tasks  by  providers  by end  of 
October 2019,  as  a result of concerns raised  in  this  Regulation  28 notice. 

Since  Mr Haines' death,  NHS  E Health and Justice have made  reviewed  it's commissioning 
contract performance and  quality assurance systems.  Improvements include: 

•  Revised  governance  and  reporting  structure  including  establishment  of  a  Quality 

Board and  Serious  lnciderit Panel  (in  place) 

•  A  dedicated  Quality  Assurance  Team  comprising  a  band  Be  Senior  Quality  Lead 
and  an  8b  Quality  and  Safely  Manager for  Kent,  Surrey  and  Sussex.  have  been 
appointed  to  bring  additional  oversight  and  support  to  the  quality  of  healthcare 
delivery A  Serious  Incident  Panel  has  been  established  which  looks  at  all  serious 
incidents  reported  by providers and  follows  a process by which  learning is  captured 
and shared. 

Commissioners  monitor  performance  in  a  variety  of  ways  including  Quarterly  Contract 
Management meetings  which  are  chaired  by  NHS  England  Commissioners.  Agenda  items 
include provider perform.,nce against a set of metrics, serious incident reviews,  complaints 
and  business  cases  for  funding  for  initiatives.  All  providers  attend  these  meetings  any 
unresolved  issues which  require  partnership working  are  escalated  to  the  local  Partnership 
Board,  which  is  attended  by  healthcare  providers,  NHS  England,  Prison  Governors, 
HMPPS  ,  Public  Health  England,  Local  Authority  and  CCGsfor  resolution.  Any  risks  and 
issues  not  resolved  at  local  level  are  escalated  to  Health  Wellbeing  and  Social  Care 
Regional  Care Board. 

Thank you  for bringing  these  important patient safety issues to  my attention  and  please do 
not hesitate to contact me should you  need any further information. 

Yours sincerely, 

National  Medical Director 
NHS England and NHS Improvement 

NHS England and  NHS  Improvement 

CJJ