Andrew Goldstraw

Executive Office 
Tel: 020 3214 5760 

17 April 2020 

Mr Simon N Burge 
Assistant Coroner for Central Hampshire 
Coroner’s Office 
Castle Hill, 
The Castle, 
Winchester, SO23 8UL 

Dear Mr Burge, 

Re: Regulation 28: Report to prevent future deaths in relation to Andrew 
Goldstraw 

I am responding to the Regulation 28 report issued on 21st February 2020 following 
the inquest into the death of Mr Goldstraw. 

Central and North West London NHS Foundation Trust (CNWL) deeply regrets the 
death of Mr Goldstraw and the distress this has caused his family. 

Following this very sad incident, we have made a number of changes to the Trust’s 
provision of healthcare services at HMP Winchester. We have responded to each 
concern raised in the Regulation 28 report below. 

SystmOne is the medical records system for all prisoners and this contract with TPP 
is managed by NHS England and not directly by CNWL. However, with internal 
training and audit we hope to be able to overcome a significant proportion of the 
limitations identified.    We will also be raising  the Coroner’s concerns and our work 
arounds with TPP so that they can consider them  in any future developments of the 
system 

A.  The computer system used by CNWL is known as SystmOne. Healthcare 
staff working on Reception when Mr Goldstraw first arrived at the prison had 
access to his previous medical notes and history (around 240 pages in all) 
stored on SystmOne. The records contained numerous references to suicidal 
ideation and previous attempts at deliberate self-harm. Mr Goldstraw had 
attempted to take his own life on several previous occasions, the most recent 
of which was only three months prior to his arrival at the prison. However, 
despite a proliferation of entries making reference to his mental health history 
the mental health nurse who had access to SystmOne was seemingly unaware 
of the relevant entries. Had he been, he said he would have opened an ACCT. 

Trust Headquarters, 350 Euston Road, London NW1 3AX 
Telephone: 020 3214 5700   
www.cnwl.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Trust has modified its staff training to ensure this type of issue does not re-occur 
in the future. All staff are required to complete this training as part of their induction 
and to sign that they have completed the training and are competent to undertake 
reception screening. For existing staff this training and compliance issues will be 
discussed through management supervisions. 

A reception guide has been developed for all CNWL nursing staff undertaking 
reception screening. This includes clear guidance on how a staff member is able to 
access previous medical records when registering a patient within the prison. A 
patient must be registered with the prison by the nurse in the reception and then the 
records saved prior to the nursing staff having access to all the medical records. This 
is clearly outlined in the reception guidance document.  

Staff are expected to perform a search of the previous medical records to identify 
any suicide or self-harm history (as outlined in response to point C below). 
Additionally staff should check the “alerts” section on the top right hand corner of the 
Systmone screen.  

B.  SystmOne makes it difficult for a doctor or mental health nurse to ascertain 
the key information needed to undertake a risk assessment and to decide 
whether or not to open an ACCT. Too much reliance is placed on the individual 
prisoner’s presentation and how he answers a series or pre-set questions.  

Whilst the risk assessment template on SystmOne does ask pre-set questions the 
clinician is not reliant solely on the information disclosed during the assessment. 
When completing the risk assessment there is a section on the right hand side of the 
template with previous values that have been entered in relation to these questions. 
This allows the clinician to have an understanding of previous answers to these 
questions and gives them some context when considering a response to a question. 
For instance if a patient’s response contradicts a previous statement they have made 
the staff will be able to ascertain this and ask appropriate follow up. When the cursor 
is put in the box relating to risk incidents and triggers previous entries about this 
come up on the right hand section of the template. In addition SystmOne prompts 
the clinician to review the physical presentation of the individual and not just their 
response to questions. The clinician will note how the patient is communicating, 
whether they are making eye contact, their tone when speaking and the clinician 
should be documenting these factors and using them to help inform their clinical 
assessments. 

C.  At best, SystmOne makes it difficult for a mental health nurse to ascertain 
the relevant information and at worst it actively misleads them. For example, a 
search can be made of the “Journal” section but this would rely on the exact 
words being searched (such as “suicide” or  “deliberate self-harm”) and it 
would then be necessary to go through the various entries (in Mr Goldstraw’s 
case spread across 111 pages) using the “Key Word Search” function. Further 
the functions that would (on the face of it) serve to assist in this situation 
(such as the “Summary” page or “Active Problems” section) were not 
populated with the information relevant to an accurate assessment. It was 
conceded by the legal representatives acting on behalf of CNWL that the 
“Summary” section is “very limited in its contents” and is not routinely used 

 
 
 
 
 
 
 
 by healthcare staff within the prison in order to gain an insight into a 
prisoner’s past medical history.  

The Trust has sent out guidance to all offender care sites in relation to the search 
function. Whilst this is a function owned by SystmOne CNWL has given staff 
directions on how to best utilise this function. For instance, when trying to get a 
history of suicide attempts rather than searching suicide the clinician should search 
“suic” which will bring up results for suicide, suicidal, suicidal thoughts. 

The population of the Summary section is an automatic function on SystmOne which 
covers current medication, allergies, recent physical observations and the patient’s 
last three consultations. It does not provide any details on Mental Health (other than 
that which can be ascertained by a patient’s medication and last three consultations) 
and as such is of limited usefulness to clinicians. Healthcare staff are aware the 
summary is useful for current physical health but is of limited use for mental health 
and they should not solely rely on information provided in a summary. 

The usefulness of the “Problem section” is reliant on the information added to it by 
whichever establishment the patient is in. However, CNWL offender care have sent 
out a memo to all staff to inform them how to review problems which are on the 
SystmOne record. In addition, since this inquest, CNWL Offender Care have sent out 
the SystmOne guidance section on how to input diagnosis data and link it to 
consultations in a standard way across the service.  This is referred to as “creating a 
problem”. To ensure this memo is acted upon, Offender Care will undertake a review 
of the use of problem section in conjunction with their annual medical records audit. 
This audit generates site specific action plans highlighting areas for improvement. 
Sites requiring improvement in their use of the “Problem section” will have these 
actions added to Health Development Action Plans which are reviewed monthly by 
the Heads of Healthcare and reviewed by the Service Director and Clinical Director 
at the Offender Care Clinical Oversight Group. If a problem has not been added to 
the problem section when an offender is in another establishment the guidance 
circulated to staff outlines how multiple consultations can be linked to a problem 
when it has been added. So if “self-harm” is identified as a problem in a CNWL 
establishment staff can add previous episodes of self-harm to this active problem. 

We will also remind staff that other organisations use SystmOne and that they may 
not enter data in an easy to view way. Staff have been advised to use search 
functionality to find data that may have not been entered properly by staff from other 
organisations.  

D.  The “Active Problems” section of SystmOne is subdivided into a number of 
distinct areas and it appears to be wholly inadequate in terms of identifying 
key areas of concern such as the risk of suicide or deliberate self-harm. The 
only information contained in the “Active Problems” section of SystmOne in 
Mr Goldstraw’s case was four years out of date. None of the relevant 
information was contained in “Active Problems” but a great deal of irrelevant 
information was there. 

The Problem list is populated by staff who use SystmOne. CNWL are not the only 
provider who use SystmOne and therefore an accurate Problem list is dependent on 

 
 
 
 
  
 
 
 
 all providers updating the record. The problems in the problem section are listed on 
the left hand side of the screen and when the problem is clicked on all consultations 
that are linked to this problem are show (see figure 1). 

This functionality has the potential to be very helpful if used appropriately as, for 
instance, every episode of self-harm could be linked to a problem “Self-harm” 
meaning all episodes are collated in one place. CNWL has sent out guidance to all 
staff on how to manage problems on SystmOne. Training will be provided on 
“problems” for every member of staff during their induction.  The use of problems on 
SystmOne will be audited through the Offender Care, Care Quality Meetings initially 
on a quarterly basis to review progress of this function. 

Figure 1 

E.  The “Communications” section of SystmOne contains a chronological 
record of correspondence with the hospital, GP surgery and psychiatric units. 
However, the “Key Word Search” facility does not function at all and short of 
going through all of the correspondence there is no way of identifying the key 
information needed to undertake an effective risk assessment. The 
“Communications” section in Mr Goldstraw’s case amounted to 83 pages. 
Although the relevant information concerning Mr Goldstraw’s mental health 
issues was contained within the “Communications” section of SystmOne there 
was no way of easily extracting it.  

Many complex patients or patients with extensive forensic history will come in with a 
large number of letters and other correspondence in their communication section. 
There is no functionality within SystmOne to view information from these 
correspondences without opening each independent letter.  

However, if a new letter is received when the patient is in custody there is a process 
for this to be reviewed. If for instance a prisoner returns from a hospital visit with a 
correspondence this will be seen and reviewed by the reception nurse who will read 
the letter and take appropriate action where required (book a GP appointment, order 
medication etc). All letters of this nature will also be reviewed by the GP and any 
additional actions identified before being scanned onto SystmOne. 

 
 
 
 
 
 
   
 
 
 
 F.  Accordingly a busy, under pressure mental health nurse or doctor is very 
likely to struggle to find the relevant entries using SystmOne, which may 
explain why (in Mr Goldstraw’s case) too much reliance was placed on how he 
presented during interview. A prisoner who chooses not to disclose his true 
state of mind or suicidal ideation is unlikely to come to the notice of the 
healthcare staff whose job it is to identify the risk that he may pose to himself 
because SystmOne does not facilitate this.  

As previously mentioned, previous entries relating to certain questions are displayed 
when the risk assessment template is completed. Whilst it is true that the 
presentation and answers to questioning are considered important, clinicians are 
expected to use all the information they have at their disposal. For instance if a 
patient comes in with multiple pages of medical records and correspondence they 
would be considered complex and so a more comprehensive review of the collateral 
would be required rather than relying on a lone assessment. As the management of 
problems is improved within the CNWL this will provide more information for staff to 
complete appropriate risk assessments. 

G.  There also appeared to be a lack of training in relation to the effective use 
of SystmOne. In particular, it was not clear whether any steps had been taken 
to ensure that the staff who were working at the prison at the time of Mr 
Goldstraw’s death had been retrained or had their competencies assessed in 
light of the failures identified. There is a real concern that some staff are still 
failing adequately to carry out assessments of a prisoners risk of suicide/ 
deliberate self-harm. 

The staff in question in this case have left the organisation and no longer work for 
CNWL in the prison settings. However, measures have been put in place to ensure 
all staff receive adequate training.  

All staff are trained in SystmOne during their induction. SystmOne training is now 
available on the Trust’s Learning and Development Zone (LDZ) and all staff 
identified as requiring additional training (through six weekly supervision) will 
complete the SystmOne training on LDZ. 

All staff are now required to complete annual Suicide and Self Harm training and 
annual ACCT training. In these training packages, identification of suicide and 
deliberate self- harm risk are covered and all staff have to successfully pass a test 
which covers these areas to be signed off as compliant.   

Additionally, Offender Care is carrying out quarterly review of risk assessments. 
Mental Health risk assessments have been developed across CNWL offender care 
services and have been uploaded onto SystmOne. These risk assessments include 
a patient’s risk of harm to themselves and to others. These risk assessments should 
be updated whenever there is a recognised change in a patients risk and should 
form the basis of a care plan. Both risk assessments and the care plans they help 
formulate are audited every three months and also form part of the annual medical 
records audit to provide assurances that risks are being appropriately identified. 

 
 
 
 
 
 
 
 
 
 H.  The Head of Healthcare at HM Prison, Winchester has indicated that she 
intends to provide (in conjunction with the Prison Governor) a joint learning 
bulletin to all staff, stressing the importance of sharing information, most 
notably in reception and during the early days in custody. However, this does 
not address the technical shortcomings of SystmOne which present a matter 
of considerable concern, even if healthcare staff undertake all reasonable 
steps to ascertain a prisoner’s previous mental health history as part of the 
prison induction. 

The Head of Healthcare has drafted the attached Learning bulletin which, once 
agreed by the prison, will be circulated to all staff.  

I hope this provides you with sufficient assurance that the Trust has taken action 
following the death of Mr Goldstraw and has accepted the points raised, and 
continues to work to improve the service we provide both in HMP Winchester and in 
our wider Offender Care Services. If you have any questions or comments on the 
above please contact me directly on the details above.  

Yours sincerely, 

Claire Murdoch 
Chief Executive 

 Early days bulletin. March 2020.docx