Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0104, written 24 Apr 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Apr 2020 |
|---|---|
| Reference | 2020-0104 |
| Deceased | Dean George |
| Coroner | Colin Phillips |
| Coroner area | Swansea and Neath Port Talbot |
| Category | Alcohol, drug and medication related deaths · State Custody related deaths · Suicide (from 2015) · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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.
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: 1. Vaughan Gething Minister for Health 1 CORONER lam Colin Phillips, acting senior coroner, for the coroner area of SWANSEA and NEATH PORT TALBOT 2 | CORONER’S LEGAL POWERS | 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 11 April 2016 | commenced an investigation into the death of DEAN GARY GEORGE aged 40. The investigation concluded at the end of the inquest before a Jury on 16" March 2020. The Medical Cause of Death was given as 1a) Hanging. The conclusion of the inquest was a narrative conclusion. The Jury found that Dean’s death was a suicide caused by hanging and Dean intended to take his own life, some indicators of this were: Expressing suicidal thoughts Withdrawing from social contact Being very down Degree of planning in use of razor blade Previous hanging attempt The Jury found there were contributing factors such as: Withdrawing from opiates against his will Inadequate risk assessment Insufficient info passed between medical and prison staff ACCT training was inadequate with some staff being untrained The opiate detox system was not equitable to what Dean would have access to in the community 4 | CIRCUMSTANCES OF THE DEATH The deceased was found hanging in his cell on the 16'* March 2016 in HMP Swansea 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — The evidence was that drug treatment in Wales is organised differently to that in England. Integrated Drug Treatment System had not been funded and implemented in Wales. The main difference between English and Welsh prisons is that those arriving from the community who are addicted to opiates but not engaged with community treatment are not automatically offered opiate substitution therapy on the day of arrival. There is a concern over this inequality in health care provision There have been Inquiries into this in the Welsh Assembly the most recent in 2019. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe that the Welsh Assembly has the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 19" June 2020. |, the coroner, may extend the period. 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons | have also sent it to Chief Executive of Swansea Bay University Health Board who may find it useful or of interest. | 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. 24.04.2020 hb, [SIGNED BY CORONER]
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.
Dirprwy Brif Swyddog Meddygol
Deputy Chief Medical Officer
Mr Colin Phillips
HM Acting Senior Coroner
Swansea and Neath Port Talbot
16 June 2020
Dear Mr Phillips
Regulation 28 Report to Prevent Future Deaths – Dean Gary George
Thank you for your letter enclosing the Regulation 28 report following your
investigation into the death of Dean Gary George in HMP Swansea in March 2016. I
am responding on behalf of Vaughan Gething, Minister for Health and Social Services.
The Regulation 28 report notes that the Integrated Drug Treatment Service (IDTS)
which is implemented in England, has not been funded and implemented in Wales. It
states that those arriving from the community who are addicted to opiates but not
engaged with community treatment are not offered opiate substitution therapy on the
day of arrival – giving rise to concerns over inequality of healthcare in prisons in Wales.
Prison healthcare (including substance misuse treatment and services) in public sector
prisons is delivered by the NHS and overseen by the local health boards. There is a
policy of equivalence in place, whereby treatment and services available in the
community should also be available in prisons. This principle is central to the
Partnership Agreement on Prison Health, which outlines agreed priorities between the
Welsh Government, Her Majesty’s Prison and Probation Service (HMPPS), Health
Boards and Public Health Wales.1
Although, in Wales, we do not have IDTS, we do offer comparative services, which
are set out in the Welsh Government’s Substance misuse: Treatment of offenders
(2009) guidance, and in the 2017 UK Guidelines on Clinical Management Drug Misuse
and Dependence (the Orange Book).
The Welsh Government’s Substance Misuse Treatment Framework (SMTF 2009)
confirms people in prison should have the same treatment options for opioid
detoxification as people in the community. There is also Guidance for Evidence Based
1 https://gov.wales/partnership-agreement-prison-health-wales
Parc Cathays, Caerdydd CF10 3NQ Cathays Park, Cardiff CF10 3NQ
Ebost/Email:PSChiefMedicalOfficer@wales.gsi.gov.uk
Ffon/Tel: 03000 257143
Community Prescribing in the Treatment of Substance Misuse which sets out that
community prescribing is a Tier 3 service that is implemented across a number of
settings, and which includes criminal justice programmes, prisons and other offending
services.
The SMTF does include for opioid substitution treatment to be provided in prisons by
Local Health Boards in accordance with NHS clinical governance arrangements and
the 2017 UK Guidelines on Clinical Management Drug Misuse and Dependence (the
Orange Book). All relevant NHS standards in Wales apply to health care services for
prisoners, with exceptions only where the constraints of the custodial environment are
over-riding. Prisoners in a Welsh prison may access opiate substitution if they have
an existing prescription or if clinically assessed and prescribed opiate substitution
following remand.
Opiate substitution therapy is now offered routinely in HMP Swansea, the day following
admission, where appropriate and safe. In addition, the healthcare team in the prison
is expanding to provide a more joined up service (with GPs employed by the Health
Board alongside nursing and pharmacy staff) and strengthening the availability of
mental health support for primary mental health issues and crisis response.
In 2018, an Early Days Opiate Treatment Pilot was launched in HMP Swansea which
provides a pathway for opiate substitution therapy on the day of arrival. The pilot has
been formally reviewed by Public Health Wales and will inform future planned
improvements to substance misuse services in the prisons in Wales. Through the
Partnership Agreement for Prison Health, Welsh Government is working with Public
Health Wales to develop a new Substance Misuse Treatment Framework for prisons.
The new Substance Misuse Treatment Framework will underpin the provision of
services in prisons in Wales, and the draft of the SMTF will be available by Autumn
2020.
Welsh Government has also identified prison health and wellbeing as a priority for
health boards, and has allocated an additional £1million per year to improve access
to health services in the public prison estate. This includes the provision of an
additional £329,026 for 2020/21 (reoccurring) for Swansea Bay University Health
Board. This funding is being used to provide a team of mental health practitioners to
broadly fulfil the tasks of the Primary Mental Health Service in the community, as well
as providing a service to those in mental health crisis. The Substance Misuse Nurse
Prescriber (SMNP) in the healthcare team in HMP Swansea works directly with the
new mental health team in planning care for those with a dual diagnosis and in
continuing to support the Early Days Opiate Treatment Pilot.
Yours sincerely,
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