Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0010, written 14 Jan 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Jan 2020 |
|---|---|
| Reference | 2020-0010 |
| Deceased | Marlon Watson |
| Coroner | Andrew Haigh |
| Coroner area | Staffordshire (South) |
| Category | State Custody related deaths · Suicide (from 2015) |
| 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.
Her Majesty’s Coroner 2. | Staffordshire (South) Coroner’s Jurisdiction r Private and Confidential e| ‘Head of Healthcare Please note sad agli? oa HMP Dovegate be included on all corresponden Marchington Date: 14 January 2020 Uttoxeter Staffs one AAH/EAS 149963 Our ref: ST14 8XR ea ZS Your ref: d : eo AndrewAHaigh Re: Marlon Roy WATSON (deceased) Senior Coroner Margaret J Jones | make this report under paragraph 7 Schedule 5 of the Coroners and pono G aga Justice Act 2009 and regulations 28 and 29 of the Coroners oa aaaan (Investigations) Regulations 2013. lanS Smith pesca cee On 1st October 2018 | commenced an investigation into the death of peg cioticetem Place Marlon Roy WATSON aged 32. The investigation concluded at the end of Stafford the inquest on 8" January 2020. The conclusion of the inquest was Side 2ir Suicide by hanging. DX 712320 Stafford 5 Tel No: 01785 276127 The jury’s findings were: A. Basic circumstances: Marlon Roy Watson was ee , 2 Serving prisoner at HMP Dovegate when he died by hanging in his cell on wi a rordshivegovuk29th September 2018. B. Probable causative factors : Breakdown of relationship with partner, bullying, debt, poor mental health and use of illicit substances. Combined effect of this being too much pressure. . C. Possible causative factors: The mental health team's reliance on self- referral and prison mentors rather than a pro-active approach. Admin errors leading to missed opportunity for support and unanswered/unacknowledged phone calls from sister. Failure for different health care teams to have access to relevant patient information. During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future ap may occur unless action is taken. In the circumstances it is my statutory duty to report to you. ' : The MATTER OF CONCERN is as follows. — 1. At the inquest there was a concern that members of healthcare staff at HMP Dovegate do not have a full and proper a understanding of the ACCT process. | would appreciate reassurance that appropriate initial training and refresher training takes place and that (if possible) this is audited. In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. You are under a duty to respond to this report within 56 days of the date of this report, namely by 9.3.2020 . | may extend the period if required to do so. Your resporise must contain details of action taken or gh es to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | have sent a copy of my report to the Chief Coroner and to the following other persons e The Chief Coroner e Solicitors acting for Care UK, Serco and the family e Prisons and Probation Ombudsman e Independent Monitoring Board | am also under a duty to send the Chief Coroner and others interested 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 at the time of your response about the release or the publication of your response by the Chief Coroner. Yours sincerely hal Andrew A Haigh HM Senior Coroner Staffordshire (South)
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
HMP Dovegate Healthcare Department Marchington Uttoxeter Staffordshire ST16 8XR HM Senior Coroner Andrew Haigh Staffordshire (South) Coroner’s Office No 1 Staffordshire Place Stafford ST16 2LP 9 March 2020 Dear Sir, Regulation 28: Prevention of Future Deaths report, Marlon Roy Watson (died 29 September 2018) Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Care UK on 14 January 2020 following the inquest into the death of Mr Marlon Watson Deceased which concluded on 8 January 2020. Care UK would like to express its condolences to Mr Watson’s family and friends. Care UK is the main provider of healthcare services at HMP Dovegate. You have directed your report to me and I am responding on behalf of Care UK. The matters of concern are highlighted in bold with the response set out below to your concern. I have set out the action taken in response to your report and the timetable for the action plan. Care UK are committed to ensuring that the lessons learnt following this inquest are not just implemented at HMP Dovegate but more widely across Care UK’s prison healthcare sites. Matter of concern: At the inquest there was a concern that members of healthcare staff at HMP Dovegate do not have a full and proper understanding of the ACCT process. I would appreciate reassurance that appropriate initial training and refresher training takes place and that (if possible) this audited. Response: In order to deal with your concern, I have discussed the following matters: • The action taken • The timetable for action Your concern relates to a prison doctor who had commenced working at HMP Dovegate in July 2018. He is a GP with over 20 years’ experience in the community. Initial ACCT and Suicide and Self Harm Awareness (SASH) training takes place during initial induction, for every member of staff and refresher training is completed annually thereafter. Mandatory refresher is every 3 years, in line with HMPPS guidance. Assessment, Care in Custody and Teamwork (ACCT) is the care planning process for prisoners identified as being at risk of suicide or self-harm. The ACCT process requires that certain actions are taken to ensure that the risk of suicide and self-harm is reduced. This is a prison process and training is provided by the prison as part of a professional’s induction before they work within the prison. The GP received that training on 25th July, 2018 as part of his induction. Given your concern the GP and all staff have been offered additional training including refresher ACCT training. We have asked the prison to provide this training which will take place over the next 12 weeks. HMP Dovegate already have a system to monitor the uptake of ACCT and SASH training in line with the 3 yearly expectations and we are implementing a system to ensure that there is senior oversight on this across all Care UK sites. We trust that the above response provides the information that you require but please do not hesitate to contact us if Care UK can be of any further assistance. Yours sincerely Head of Healthcare HMP Dovegate On behalf of Care UK Care UKRegistered Office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex CO4 9QB Health & Rehabilitation Services Limited - Registered in England No 10498997
iUAAGS Care £3 | HMP Dovegate Healthcare Department | Marchington | Uttoxeter Staffordshire | ST16 8XR HM CORONER'S OFFICE STAFFORDSHIRE SOUTH 12, MAR 2020 T 01283 829513 HM Senior Coroner Andrew Haigh Staffordshire (South) Coroner's Office No 1 Staffordshire Place Stafford ST16 2LP 9 March 2020 Dear Sir, Regulation 28: Prevention of Future Deaths report, Marlon Roy Watson (died 29 September 2018) | Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Care UK on 14 January 2020 following the inquest into the death of Mr Marlon Watson Deceased which concluded on 8 January 2020. | Care UK would like to express its condolences to Mr Watson's family and friends. Care UK is the main provider of healthcare services at HMP Dovegate. You have directed your report to me and | am responding on behalf of Care UK. The matters of concern are highlighted in bold with the response set out below to your concern. | have set out the action taken in response to your report and the timetable for the action plan. Care UK are committed to ensuring that the lessons learnt following this inquest are not just implemented at HMP Dovegate but more widely across Care UK’s prison healthcare sites. — Matter of concern: At the inquest there was a concern that members of healthcare staff at HMP Dovegate do not have a full and proper understanding of the ACCT process. | would appreciate reassurance that appropriate initial training and refresher training takes place and that (if possible) this audited. | | Response: In order to deal with your concern, | have discussed the following matters: e The action taken | e The timetable for action Your concern relates to a prison doctor who had commenced working at HMP Dovegate in July 2018. He is a GP with over 20 years’ experience in the community. | Initial ACCT and Suicide and Self Harm Awareness (SASH) training take | place during initial induction, for every member of staff and refresher training is Greensloraae thereafter. Mandatory refresher is every 3 years, in line with HMPPS guidance. | ! Assessment, Care in Custody and Teamwork (ACCT) is the care planning pr for prisoners identified as being at risk of suicide or self-harm. The ACCT process requires that certain actions are taken to ensure that the risk of suicide and self-harm is reduced. This is a prison process and training is provided by the prison as part of a professional’s induction before they work within the prison. The GP received that training on 25" July, 2018 as part of his induction, Given your concern the GP and all staff have been offered additional training including refresher ACCT training. We have asked the prison to provide this training which will take place over the next 12 weeks. HMP Dovegate already have a system to monitor the uptake of ACCT and SASH training in line with the 3 yearly expectations and we are implementing a system to ensure that there is senior oversight on this across all Care UK sites. We trust that the above response provides the information that you require but please do not hesitate to contact us if Care UK can be of any further assistance. Yours sincerely Head of Healthcare HMP Dovegate On behalf of Care UK Care UK Registered Office: Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex CO4 9QB Health & Rehabilitation Services Limited - Registered in England No 10498997
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