Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0064, written 12 Mar 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Mar 2020 |
|---|---|
| Reference | 2020-0064 |
| Deceased | Ian Weeks |
| Coroner | Geraint Williams |
| Coroner area | South Wales Central |
| Category | State Custody related deaths · Suicide (from 2015) · Wales prevention of future deaths reports (2019 onwards) |
| Organisation named | Cardiff and Vale NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Cardiff & Vale NHS Trust 1. CORONER I am Geraint Williams HM Assistant Coroner, for the coroner area of South Wales Central. 2. CORONER’S LEGAL POWERS I 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. 3. INVESTIGATION and INQUEST On 26th October 2017 I commenced an investigation into the death of IAN JAMES WEEKS. The investigation concluded at the end of the inquest on 11th March 2020. The medical cause of death provided was: 1(a) Pressure on the neck consistent with hanging; 2. Synthetic cannabinoid use. The Coroner’s conclusion at the end of the Inquest was: A case of suicide 4. CIRCUMSTANCES OF THE DEATH These were recorded as:- Ian Weeks was remanded into custody at HMP Cardiff on the 7th August 2017. He was assessed by prison and healthcare staff as not being at risk of self- harming or suicide. Sometime between 20.20 on the 20th of October and the 21st of October whilst alone in his cell , Cell 13, 2nd floor, F-wing believing that personal relationships had recently broken down he made a ligature from the bed sheet and hung himself from the shower rail in his cell. 5. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) Although it was recorded on System 1 that Mr Weeks had recently attempted suicide in another prison shortly before his admission to HMP Cardiff no member of Healthcare staff checked the medical records and further that although the GP records which were sent to the prison confirmed that Mr Weeks was prescribed anti-depressants in the community no member of Healthcare staff noticed this and as a consequence Mr Weeks was not given anti-depressants in HMP Cardiff. The Healthcare witnesses, including the Head of Healthcare, indicated that a red flag for suicide or self-harm would be of great value for staff who because of insufficient staff and a heavy workload did not have time to review the System 1 record in any or any sufficient detail. Further it was considered that all System 1 records should be reviewed when an individual is admitted into the prison and that there should be in place a process for doing so. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 8 May 2020. I, the Coroner, may extend the period upon request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8. COPIES and PUBLICATION I have sent a copy of my report to the family who may find it useful or of interest. I 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. 12th March 2020 SIGNED: Geraint Williams Assistant Coroner for South Wales Central
1 response 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.
Executive Headquarters / Pencadlys Gweithredol f Q. GIG | Bwrdd lechyd Prifysgol c re “> YmMeu | Caerdydd a’r Fro Woodland House ti¢——, s) . Maes-y-Coed Road Corogr IB Maes yoCed Cardiff and Vale ° A . Cardiff Caerdydd WALES | University Health Board = rig aun 1 Acaay4 Boro Eich cyf/Your ref: ece} Ein cyf/Our ref: LR-jb-05-7099 Re ved ann | Welsh Health Telephone Network: Direct Line/Llinell uniongychol: 02921 836010 . Len Richards Chief Executive 11 May 2020 Mr Geraint Williams Assistant Coroner for South Wales Cenitral Coroner's Office The Old Courthouse Pontypridd CF37 1JW Dear Mr Williams Regulation 28 Report — lan James Weeks (died 21 October 2017) Thank you for your letter dated 12 March 2020, following the inquest touching the death of lan James Weeks. | recognise that this has been an extremely difficult time for Mr Weeks family and | would wish to offer them my sincere condolences on behalf of the University Health Board. The Health Board has reviewed the concerns you have raised within the Regulation 28 report following the inquest. My response has been informed by senior clinical and managerial staff who are able to advise me on the arising concerns and pursue the improvements required as a result. With regards to the specific matters of concern that you raised within the Regulation 28 report, | have outlined them here for ease of reference: 1 Although it was recorded on System 1 that Mr Weeks had recently attempted suicide in another prison shortly before his admission to HMP Cardiff no member of Healthcare staff checked the medical records and further that although the GP records which were sent to the prison confirmed that Mr Weeks was prescribed anti-depressants in the community no member of Healthcare staff noticed this and as a consequence Mr Weeks was not given anti-depressants in HMP Cardiff. On re-review of Mr Weeks records, the team has advised me that he was in HMP Bristol in February 2017 and an entry was made during an Assessment, Care in Custody and Teamwork (ACCT) care planning review, that he had attempted suicide 2 days prior. He had regretted it and was adamant that he would not make further git Atay, s y sYY/S Bwrdd lechyd Prifysgol Caerdydd a‘r Fro yw enw gweithredal Bwyrdd Iechyd Lleol Prifysgai Caerdydd a’r Fro = Oa Cardiff and Vate University Health Soard is the operational name of Cardiff and Vale University Local Heath Board say Croasawk y Bwrdd ohebiasth yn Gymraeg neu Seeaneg. Skerhawn byddwn yn cyfathrebu & chi yn olch dewis lath. Mi fydd gohebu yn Gymraeg yn creu unrhyw oedi The Board welcomes correspondence in Welsh or Engish. We will ensure thal we wif communicale in your chosen language, Coresportence in Welsh will not lead 10 « delay: attempts on his life. He was not known for suicide attempts and there was nothing further recorded around this. Mr Weeks came into HMP Cardiff in August 2017. During his first and second health screening reviews he was noted to be calm and making good eye contact with staff. He knew how to access help if he required it and reported no thoughts of suicide or self-harm. He advised staff that he had not tried to harm himself in prison or outside. The team received a summary from his GP in August 2017. It highlighted that he had been seen last in May 2017 and was diagnosed with anxiety and depression. The information provided to prison staff indicated he was advised counselling and review in one month's time. There was no evidence of prescription of antidepressants although there was comment made that Mr Weeks was open to taking antidepressants. This is in keeping with recognised treatments of mild anxiety and depression when talking therapies are first line. 2 The Healthcare witnesses, including the Head of Healthcare, indicated that a red flag for suicide or self-harm would be of great value for staff who because of insufficient staff and a heavy workload did not have time to review the System 1 record in any or any sufficient detail. SystmOne is designed to be a secure, centralised software solution for a single shared Electronic Health Record (EHR), with modules available for multiple healthcare settings. It contains a significant amount of information and reviewing the entire record for each patient would present a significant challenge. The Summary Function would normally be used by staff due to the volume of information and amount of men being assessed due to the nature of HMP Cardiff being a busy remand prison with a high turnover. There are two screenings of new individuals to the prison setting to aid the process of assessing their needs. The healthcare staff work in conjunction with prison staff who also have a role in reviewing the SystmOne records to ensure important information is identified and shared appropriately. SystmOne has been used for many years in the prison setting and there is therefore a great deal of legacy information within it, the quality of which has been variable over the course of time but on an improving trajectory. The team recognises the importance of sound clinical documentation and will ensure they implement a process of clinical documentation audits in 2020. In order to pursue a red flag system, a partnership with TPP (SystmOne technology provider), NHS England, NHS Wales Informatics Service (NWIS) and other prisons will be required as this would be a change that would affect all prisons. The clinicai team from HMP Cardiff intend to raise this issue at their next All Wales Prison Healthcare Meeting which Public Health Wales and Welsh Government also attend. RS LY? PAYA) ‘Swrdd lechyd Prifysgol Caerdydd a’r Fro yw enw gwelthredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a'r Fro - * Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Heatth Board: aye Croesewir y Burdd ohebleeth yn Gymraeg neu Seemeg. Sicrhewn bycdwn yn cyfathrebu & chi yn eich dewis jeth. Ni fydd gohebu yn Gymraeg yn creu unrhyw ood! The Board welcomes correspondence in Welsh or English. We will encure thet we wif communicate in your chosen languege. Correspondence in Welsh wil not lead to @ delay” 3 Further it was considered that all System 1 records should be reviewed when an individual is admitted into the prison and that there should be in place a process for doing so. As indicated, a large volume of information is contained within SystmOne. Existing process is for healthcare staff in the prison to undertake two screening reviews of new individuals in order to assess and plan their care. This is done in conjunction with prison staff who also review the SystmOne records and share important information. The team receive a GP summary on individuals which is particularly helpful in allowing the team to review a current list of medication so they can assess whether a continued prescription in prison in appropriate. There is a key difference in NHS Wales to NHS England in that men entering prison in England can register with the prison which allows their whole GP record to become available to the prison healthcare team. This is not currently in place in NHS Wales. The team has recently gained funding for an IT / data specialist. Recruitment to this role will be pursued once a workforce review is complete. The post holder will have a key role in progressing work with NWIS to improve IT in the prison. This work has an important part to play in assisting clinical staff in their care of men in the prison. | hope that the information set out in this letter provides you with the assurance that the Health Board has fully considered the issues raised as a consequence of the inquest into Mr Weeks death and continues to implement appropriate action in response. Yours sincerely L hbk Len Richards Chief Executive Ap at Ato, > , Seyeys> Bwrdd Iechyd Prifysgol Caerdydd a'r Fro yw enw gwelthredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a'r Fro ~ ty Cardiff and Vale University Health Board Is the operational name of Cardiff and Vale University Local Health Board SOT od (Croesawi y Bwrdd oheblesth yn Gymraeg neu Seerneg. Sichawn byddwn yn cyfathrebu @ chi yn eich dewis lath. Ni fyad gahebu yn Gymraeg yn creu unrhyw ced! The Board welcomes correspondence in Welsh or Engish. We will ensure that we wil communicate in your chosen janguage. Correspondence in Walsh wil not lead fo # delay
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