Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0074, written 23 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 | 23 Mar 2020 |
|---|---|
| Reference | 2020-0074 |
| Deceased | Lewis Francis |
| Coroner | Nicholas Rheinberg |
| Coroner area | Exeter and Greater Devon |
| Category | Mental Health related deaths · Suicide (from 2015) · State Custody related deaths |
| Organisation named | Devon Partnership NHS Trust · Birmingham and Solihull Mental Health NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. 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: 1. Devon Partnership NHS Trust as lead for the South West Provider Collaborative (Devon Partnership NHS Trust, Cornwall Partnership NHS Foundation Trust, Livewell Southwest, Somerset Partnership NHS Foundation Trust, Elyslum Healthcare, Cygnet Healthcare, Avon & Wiltshire Mental Health Partnership' NHS Trust and Gloucestershire Health and Care NHS Foundation Trust) 2. Devon and Cornwall Police, Avon and Somerset Police, Wiltshire Police and Gloucestersh ire Police 3. Prison and Probation Service CORONER I am Nicholas Leslie Rheinberg, assistant coroner for the coroner area of Exeter and Greater Devon CORONER'S LEGAL POWERS I make this report under parag raph 7 , Schedule 5, of the Coroners and Justlce Act 2009 and regulations 28 and 29 of the Coroners (lnvestigations) Regutations 2013. 1 I 3 INVESTIGATION and INQUEST On 27th April 2017 an investigation into the death of Lewis Charles Francis aged 20 was opened. The investigation concluded at the end of the inquest on lBth March 2020.The conclusion of the inquest was that Lewis died by suicide as a result of suspension by a ligature. Contributory factors included insufficient collaboration, communication and ownership between and within organisations along with a lack of understanding of the deceased's complex individual needs together with insufficient knowledge of the process and implementation of the Mental Health Act. 4 CIRCUMSTANCES OF THE DEATH Lewis Francis whilst acutely psychotic stabbed his Mother on 15th February 2017. He was arrested on suspicion of attempted murder and taken to Bridgwater Custody Suite. His psychosis continued at such a level that he was deemed unfit to be interviewed. Although his condition mandated a transfer to a medium secure mental health hospitat for an assessment and / or treatment under section 2 and / or 3 of the Mental Health Act 1983 no ready facility existed for such a transfer and Lewis Francis was remanded in custody to HM Prison Exeter from where he was not transferred to a medium secure mental health hospital under the provisions of section 48 of the Mental Health Act 1983. He died at the prison as a result of self-inflicted suspension on 24th Apnl2017 . 5 CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. ln my opinion there is a risk that future deaths will occur unless action is taken. ln the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. - (1) At present there is no mechanism for the ready transfer of a person in police custody within the police areas of Devon and cornwall, Avon and somerset, wiltshire and Gloucestershire from police custody to a medium secure mental health facility for assessment / treatment under sections 2 and 3 of the Mental Health Act 1983 where such a person is suspected of or charged with a serious crime. Such an arrangement exists in the west Midlands where a Memorandum of Understanding has been developed and agreed between relevant agencies. (2) Evidence at the inquest suggested that there was an insufficient understanding of the special needs and vulnerabilities of those prisoners who are within the autistic spectrum 6 ACTION SHOULD BE TAKEN ln my optnion action should be taken to prevent future deaths and I believe your organisations have the power to take such action as follows: (1) Evidence at the inquest suggested that steps were already being taken by the members of the South West Provider Collective to develop a Memorandum of Understanding between relevant organisations and agencies so as to provide for the transfer of mentally ill prisoners direct from police custody. Confirmation of the action be taken in this regard together with a time frame for implementation is required. (2) Further evidence at the inquest suggested that an initiative was already underway through the good offices of Avon and Somerset Police to cooperate with the South West Provider Collaborative in the development of the Memorandum of Understanding detailed above. Confirmation on behalf of the named police forces is required that they are wilting to work towards the development of such a Memorandum of Understanding. (3) lt appeared desirable that training with regard to the special needs and susceptibilities of those prisoners within the autistic spectrum be provided for prison officers, support staff and newly appointed prison officers undergoing training both in the form of face to face training and the provision of information through prison intranet systems. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 2gtn May 2020 l, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for actron. Otherwise you must explain why no action is proposed B COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following lnterested Persons namely the legal representatives of the interested persons participating in the inquest. 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. --. or 2020 SIGNED Assistant Coroner 2
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.
HM Assistant Coroner for Exeter & Greater Devon Your Ref: PCS/NR/VTVL Your File no: 3935 12th June 2020 Re: Inquest into the death of Lewis Charles Francis, Regulation 28 Report Dear Mr Rheinberg, I am responding on behalf of the Chief Constable of Avon & Somerset Police further to the Report to Prevention Future Deaths under paragraph 7, Schedule 5 Coroners and Justice Act 2009 and Regulation 28 Coroners (Investigations) Regulations 2013, issued by you on 16th April 2020. Specifically in respect of the ‘Actions Should be Taken’, the Chief Constable can confirm: Action 1: Evidence at the inquest suggested that steps were already being taken by the members of the South West Provider Collective to develop a Memorandum of Understanding between relevant organisations and agencies so as to provide for the transfer of mentally ill prisoners direct from police custody. Confirmation of the action be taken in this regard together with a time frame for implementation is required. Response: The actions taken to date include: 1. Review and communication within the Provider Collaborative: • Communication has been undertaken setting out the process for out of hours admissions to all secure inpatient unit across the region. This has clarified that admissions can occur out of hours if an urgent admission is clinically indicated – 5 March 2020; • A review of the national specifications and contracts with our Providers across the region has been undertaken, with confirmation made to Providers that services are commissioned to admit out of hours if there is a clinical indication of urgency. 2. Development and implementation of South West Provider Collaborative 24/7 Support to the secure inpatient service providers, enabling these services to progress admissions which are considered to be clinically appropriate. Consultation was undertaken through March 2020 and implementation commenced on the week commencing 13 April 2020. 3. Work has been undertaken for the mapping of key organisations, individuals, and relevant organisations and agencies to ensure the right people are involved in the final production of the Memorandum of Understanding. This work was undertaken between 22 April 2020 and 15 May 2020. 4. There has been engagement with those directly involved in the drafting of the Memorandum of Understanding (those considered ‘relevant organisations and agencies’): • Key clinical leads within the Provider Collaborative co-opted as a clinical advisory group – 20 and 27 May 2020; • Police (Inspector 2020; Avon and Somerset Police) – 19 May and planned on 11 June • Her Majesty’s Court and Tribunal Service Legal Team Manager (Business) Devon, Cornwall & Dorset South West Region) – 19 May and planned on 11 June 2020; • Crown Prosecution Service Senior District Crown Prosecutor, CPS South West) – 19 May and planned on 11 June 2020. Agreement was reached that the above mentioned individuals will represent their organisation or agency across the South West footprint. 5. Further engagement has also occurred in relation to wider stakeholders as follows: • Head of Mental Health Section at the Ministry of Justice on 1 May 2020; • South West Division of the Care Quality Commission on 5 May 2020; • NHSE/I South West Specialised Commissioning Project Director on 6 May 2020; • • Clinical Director for Secure Services, Birmingham and Solihull Mental Health NHS Foundation Trust (Mental Health trust enacting the Memorandum of Understanding taken in expert evidence) on 28 April and 15 May 2020; on 27 May 2020 (expert evidence to the Coroner’s Court). Communication with both hand understanding as to to the development, clinical application, and service impact of the Memorandum of Understanding. has assisted considerably in enabling a first- and Progress We have met with our multi-agency partners, and agreed a high level set of principles (Appendix 1), which will guide our final Memorandum of Understanding As a result of this meeting, the partners have developed a suitable process, which is currently in final draft within the South West Provider Collaborative. Similarly, our multi-agency partners have also drafted a proposal. We are meeting again on 11 June 2020 to review how these dovetail, to ensure that we can implement the recommendations and introduce a region-wide Memorandum of Understanding. Next Steps 1. Agree, in the multi-agency forum, a final Memorandum of Understanding based on our agreed set of principles; 2. Final Memorandum of Understanding to be reviewed and approved by our respective organisations or agencies; 3. Agree an implementation plan to include communications within our organisations, agencies, and with key stakeholders. Implementation Plan and timescales 1. Trialling the draft clinical process within Devon Partnership NHS Trust on 2 cases as a test of change (May 2020); 2. Final agreement of Memorandum of Understanding by the end of August 2020; 3. Relevant organisation/agency approval – by the end of October 2020; 4. Communication to other key stakeholders – by the end of November 2020. It is acknowledged local areas will then develop operational procedures to support the practical implementation of the memorandum of understanding including provision of services run by local authorities and the adult MH services we work alongside in our organisations. On behalf of the South West Provider Collaborative we trust this provides you with the further assurance to the evidence provided to you during the inquest that you were seeking. Action 2: Further evidence at the inquest suggested that an initiative was underway through the good officers at Avon and Somerset Police to cooperate with the South West Provider Collaborative in the development of the Memorandum of Understanding detailed above. Confirmation on behalf of the named police forces is required that they are willing to work towards the development of such a Memorandum of Understanding. Response: I can confirm that Inspector has been liaising with partner organisations within the South West Provider Collaborative on behalf of Avon & Somerset Police, and will continue to engage with the important work that is needed on the issues raised in your report. Action 3: It appeared desirable that training with regards to the special needs and susceptibilities of those prisoners within the autistic spectrum be provided for prison officers, support staff and newly appointed prison officers undergoing training both in the form of face to face training and the provision of information through prison intranet systems. Response: We believe that this action is directed towards the Prison Service alone and therefore we understand that a response from the Chief Constable is not required on this particular issue. Yours sincerely, Lawyer Legal Services Directorate On behalf of the Chief Constable of Avon and Somerset Constabulary
WILTSHIRE POLICE RECEIVED O 4 JUN 2020 Mr N Rheinberg HM Assistant Coroner for Exeter and Greater Devon County Hall Topsham Road Exeter Devon EX2 40D Ref: CC/00696/AW Dear Mr Rheinberg Police Headquarters London Road DEVIZES Wiltshire SN10 2DN Telephone: 101 Ext: 774 33741 Direct Dial: 01380 861741 3 May 2020 Inquest into the death of Lewis Charles FRANCIS Regulation 28 Report - Ref PCS/NR/VTVL File ref: 3935 This letter is in response to Regulation 28 Report dated 16 April 2020. -It has been identified there is an issue with the pathways within Mental Health Services and not within in the Police Service. There are limited options using criminal justice powers and the Police are reliant on the NHS to divert from those. In line with Recommendation 6 (2) of the Coroner's Regulation 28 report, Wiltshire Police is working1with other force areas and the South West Provider Collaborative to develop the proposed Memorandum of Understanding. Yours sincerely Chief Constable of Wiltshire Police Proud to servo and protect our corn munities O O CCJ1w 1ltshirepol1ce
See every Prevention of Future Deaths report matching Devon Partnership NHS Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.