Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0143, written 7 May 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 May 2021 |
|---|---|
| Reference | 2021-0143 |
| Deceased | Corin Bonaparte |
| Coroner | Nicholas Rheinberg |
| Coroner area | Exeter and Greater Devon |
| Category | State Custody related deaths · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
HMP Dartmoor Tavistock Road Princetown Yelverton PL20 6RR HM Assistant Coroner Nicholas Leslie Rheinberg Exeter and Greater Devon Coroner’s Office 2nd July 2021 Dear Sir, Re: Regulation 28: Prevention of Future Deaths report, Mr Corin Bonaparte Thank you for your Regulation 28 Prevention of Future Deaths Report issued to Practice Plus Group on 7th May 2021 following the inquest touching upon the death of Mr Corin Bonaparte at HMP Dartmoor. Practice Plus Group would like to express its sincere condolences to Mr Bonaparte’s family and friends. This response addresses the matters of concern in so far as they relate to Practice Plus Group, who have been the lead provider of healthcare services at HMP Dartmoor since 1st April 2017. Within the service delivery model, there is a sub-contracting arrangement in place with Devon Partnership Trust (DPT) in respect of the provision of mental health services. As the issues raised within the Prevention of Future Deaths Report touch upon the mental health team, in order to ensure a full and comprehensive response, Practice Plus Group have sought assurance that the matters of concern have also been addressed by DPT. Therefore, in the response set out below references to ‘all healthcare staff’ include those working in primary care, mental health and substance misuse services. Matter of Concern: Corin sought help from the mental health department at HMP Dartmoor. He revealed to a nurse in the mental health department the fact that he had recently deliberately harmed himself and made this fact known to other mental health workers. An ACCT was not opened despite the provisions in Chapter 2 of PSI 64 / 2011 which made the opening of an ACCT in these circumstances mandatory. In the light of the evidence from relevant Practice Plus Group Health and Rehabilitation Services Ltd. Registered in England No 10498997 Registered Office: Hawker House, 5-6 Napier Court, Napier Road, Reading, Berkshire RG1 8BW witnesses at the inquest hearing it could not be confidently assumed that their actions would be any different if similar circumstances were to arise in the future. This suggested a lack of adequate training. Response: To address the above matter of concern a number of actions have been taken. The Head of Healthcare and clinical team at HMP Dartmoor have reviewed and made additions to the Local Operating Procedure (LOP) for healthcare involvement in the ACCT (Assessment, Care, Custody & Teamwork) process. The additions that have been made specify that recently reported or observed self-harm must be documented and that, in accordance with the requirements of PSI 64/2011, an ACCT must be opened. The revised LOP was submitted to the Local Quality Assurance Meeting and approved on 22nd June 2021. A staff signatory sheet will be signed by all staff acknowledging they have read and understood this guidance by 12th July 2021. A copy of the revised LOP is attached for ease of reference and I would specifically refer you to the amendment at paragraph 1 of the local arrangements section of the LOP. The DPT LOP has also been updated and was approved via their respective governance process on 8th June 2021. A copy is attached and I again refer you to paragraph 1 of the local arrangements section which illustrates where the corresponding amendment has been made. With regard to promoting staff training and awareness, the prison last held ACCT / Suicide and Self-Harm (SASH) training on 8th December 2020 and this was attended by twelve health staff. Following this all healthcare staff in post had completed prison ACCT training. Training was then placed on hold due to the Covid- 19 outbreak, as a result of which, at the time of the inquest, we had four new members of staff requiring training. However, for two of these members of staff this would have constituted refresher training as they had transferred from other prison establishments and had received ACCT training before. Since the inquest we have had further health staff join and we currently have twelve staff who require training and sessions have been booked for 2nd July. HMPPS are currently also Page 2 of 5 developing a revised version of Suicide and Self-Harm (SASH) training. When the new training is available health staff will be prioritised alongside operational prison staff. A record of all training undertaken is held locally and attendance will be monitored on an ongoing basis by the Head of Healthcare. In addition to the above, from July 2021, nationally updated ACCT guidance (V6) is being rolled out across all prisons in England & Wales by Her Majesty’s Prison and Probation Service. This training provides further clarity on the roles and responsibilities of healthcare staff within the ACCT process. The training is multi-disciplinary and will be open to all colleagues (including healthcare). The ACCT V6 training will commence at HMP Dartmoor on 5th July 2021 and the Head of Healthcare has received assurance that healthcare staff will be included in the updated training programme. This will provide the opportunity for joint training sessions in which all healthcare staff and discipline colleagues will review and refresh their knowledge of the ACCT process, increase their awareness of vulnerability and risk factors, and enhance their understanding of when an ACCT should be opened. In addition to the above, the Practice Plus Group General Induction Booklet contains a section on the ACCT process and as part of our induction process for new staff, ACCT is discussed within the twelve week induction period. A confirmatory signature is required from the inducting supervisor to evidence completion. To ensure a robust and quality induction experience, additional sign off will now be undertaken by the Head of Healthcare on completion of the induction period. Devon Partnership Trust have a similar process in place for the mental healthcare team, with an induction booklet signed by both the individual staff member and the Mental Health Team Manager. We will monitor this and obtain further assurance that all new starters in the mental health team have sufficient knowledge of how and when to open an ACCT through our quarterly sub-contractor review meetings with DPT. In a further collaborative learning initiative, Practice Plus Group and Devon Partnership Trust have arranged to hold weekly meetings for all healthcare staff to discuss ‘hot topics’ (for example ACCT reviews, clinical record keeping, transfer and discharge processes, mental health awareness sessions and other clinical bitesize sharing best practice sessions). This will further support embedding of lessons learned in to daily practice. Page 3 of 5 Managing healthcare involvement within the ACCT process is also audited through our Practice Plus Group bespoke prisons patient safety audit, which is called ‘P.R.O.T.E.C.T’. This audit tool was developed from an evidence base of key themes from lessons learnt through deaths in custody, and is undertaken throughout the year on an annual audit schedule. The audit standards assess compliance in mental health referrals, timeliness of assessment, and of mental health team involvement in the ACCT process. Results of the audits are reviewed and discussed through Local Quality Assurance meetings within HMP Dartmoor. Where required themes are escalated to Regional Quality Assurance meetings and to quarterly National Quality Assurance meetings to evaluate the effectiveness of action planning and implementation within the audit cycle. With regard to additional assurances from our subcontracted mental health service, DPT run an annual half day training for all their staff on risk assessment and management plans. This supports staff to evaluate patient risk to self and to others and assess when it is appropriate to open an ACCT. This training was last delivered in May 2021. In addition, DPT complete a qualitative audit of a selection of progress notes weekly. Staff have been instructed that all progress notes following face to face contact with patients must now include the consideration of the ACCT process and the rationale for opening / not opening an ACCT. Feedback from this audit is discussed in staff one to one supervision that occurs at least monthly. DPT audit attendance at both initial and ongoing ACCT reviews on a monthly basis. DPT staff working in Devon prison establishments have been trained in the use of The Connecting with People Suicide Awareness & Suicide Response sessions 1 & 2 (incorporating safety planning for all service users). This training took place in March 2021. All DPT staff who joined the teams prior to the Covid-19 pandemic were trained in ASIST (Applied Suicide Intervention Skills Training). This training has not been delivered during the Covid-19 pandemic, but will be resuming soon and all staff who have not attended will be booked on to this training as soon as dates are published. Two DPT staff working in the Devon prison cluster are trained trainers for delivering Safe Talk training to partner agency staff. This is a shortened version of the ASIST (Applied Suicide Page 4 of 5 Intervention Skills Training). This half day training has been delivered to trainee prison officer’s pre Covid-19, and will be offered to all partner agency staff as Covid-19 restrictions lift. This promotes a whole prison approach to identifying vulnerability and supporting those at risk. In addition, DPT expects all qualified clinicians to attend a Clinical Risk course within their core training. This course covers all aspects of clinical risk and is updated every two years by all qualified staff. Finally, the Head of Healthcare at HMP Dartmoor also attends the Local Quality and Delivery Board (LQDB) with the Governor of the prison to discuss healthcare performance and operational issues requiring a partnership approach. Within the standing agenda items for LQDB there is a section for `Safe Care and Treatment’, where learning from incidents and learning generated as a result of the introduction of new policies is discussed. Our progress against actions identified in this PFD response will be reviewed within LQDB. We hope that the above response provides assurance that Practice Plus Group are committed to providing a high quality healthcare service at HMP Dartmoor. In response to the specific concerns raised in relation to the death of Mr Bonaparte, we will ensure that the lessons learnt are implemented at HMP Dartmoor and are shared across all of our healthcare services in prisons throughout England. We would like to end our response by taking the opportunity of inviting you to visit the healthcare team at HMP Dartmoor should you wish to discuss and review first-hand the improvements described above. Yours faithfully, Director of Nursing & Quality On behalf of Practice Plus Group Page 5 of 5
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Governor HMP Dartmoor
2. Head of Healthcare HMP Dartmoor
1
CORONER
I am Nicholas Leslie Rheinberg, assistant coroner for the coroner area of Exeter and
Greater Devon
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
Following the death on 28th February 2017 of Corin Bonaparte aged 23 an investigation
was opened. The investigation concluded at the end of an inquest on 6th May 2021. The
conclusion of the inquest was that the deceased had died as a result of hanging and that
his death was as a result of an accident.
4
CIRCUMSTANCES OF THE DEATH
Corin Bonaparte was a young man facing his first time in prison. He was suffering from
anxiety and depression. Not long after his move to HMP Dartmoor on 13th January 2017
his partner ended their relationship which Corin had described as the only good thing in
his life. On 28th February 2017 shortly after 4.30 in the afternoon, during the course of a
telephone call with his former partner, his former partner told Corin that she did not want
to maintain further contact with him. Not long afterwards Corin was found hanging in his
cell. Efforts to revive him in the prison and later at Derriford Hospital in Plymouth were
unsuccessful.
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) Addressed to the Head of Healthcare and the Governor, HMP Dartmoor
Corin sought help from the mental health department at HMP Dartmoor. He revealed to
a nurse in the mental health department the fact that he had recently deliberately
harmed himself and made this fact known to other mental health workers. An ACCT was
not opened despite the provisions in Chapter 2 of PSI 64 / 2011 which made the
opening of an ACCT in these circumstances mandatory. In the light of the evidence from
relevant witnesses at the inquest hearing it could not be confidently assumed that their
actions would be any different if similar circumstances were to arise in the future. This
suggested a lack of adequate training.
(2) Addressed to the Governor, HMP Dartmoor
A witness gave convincing evidence to the effect that the ambulance with Corin
1
Bonaparte on board was kept waiting 8 minutes at the main gate while a prisoner escort
was found. Although there was no evidence to suggest that this delay in transporting the
deceased to hospital contributed to Corin Bonaparte’s death, the fact of such a delay
was disturbing and suggested that there were inadequate arrangements in place to
ensure the swift departure of an ambulance from the prison in a blue light emergency.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you 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 5th July 2021 I, 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons namely the family of the deceased, the prison service, Practice Plus Group and
Devon Partnership NHS Trust I have also sent it to HM Inspector of Prisons 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.
9
Dated 7th May 2021 SIGNED N.L.Rheinberg
Assistant Coroner
2
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.
Director General Prisons HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Email: 30 July 2021 Mr Nicholas Leslie Rheinberg Assistant Coroner Room 226 County Hall Topsham Road Exeter Devon EX2 4QD Dear Mr Rheinberg, Thank you for your Regulation 28 report of 7 May 2021 following the inquest into the death of Corin Bonaparte at HMP Dartmoor on 28 February 2017. I am grateful to you for granting an extension to the statutory deadline for my response. I know that you will share a copy of this response with the family of Mr Bonaparte and I would like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. You expressed concern following evidence heard at the inquest that healthcare staff did not open an Assessment Care in Custody and Teamwork (ACCT) and suggested that this may be the result of a lack of training. You also raised a concern that there were inadequate arrangements in place to ensure that ambulances could leave the establishment without delay in a blue light emergency. I am grateful to you for bringing your concerns to my attention and will respond to them in the order in which you have raised them. I understand that a response is also being provided by Practice Plus Group (PPG), the healthcare provider at HMP Dartmoor, so in relation to your first concern I will limit my comments to explaining the recent changes to the ACCT system and the training that HMPPS makes available to healthcare staff. ACCT is a prison service document that assists staff in providing multi-disciplinary care and support to individuals at risk of harm to themselves, in order to minimise that risk. It is to be utilised by all members of staff working within prisons, including healthcare colleagues, and it is important staff feel confident in recognising risk and making the decision to open an ACCT in order to support prisoners through their period of crisis. In July 2021, a new version of ACCT (Version 6, known as “ACCT v6”) was rolled out across the prison estate. The changes made to ACCT are intended to assist staff in providing high quality multi-disciplinary care and support to individuals at risk, focusing on a person centred approach which meets the needs of each individual in order to minimise their risk of harm to self. Training packages have been developed to assist in the understanding and delivery of the new ACCT process and include sessions on understanding self-harm, the ACCT v6 process and supporting individuals who self-harm. Training is currently being delivered at HMP Dartmoor and is available to all staff, including healthcare colleagues. Introduction to Suicide and Self-Harm Prevention (SASH) training is being delivered and healthcare attendance at the monthly sessions has been prioritised in order to support the up-skilling of staff in recognising risks and triggers for self-harm, as well as to build confidence in decision making around the opening of ACCT documents. Your second concern is that there were inadequate arrangements in place to ensure the swift departure of an ambulance from the prison in a blue light emergency. Following the inquest, the Governor ordered a review of the prison’s Local Security Strategy (LSS) and has confirmed that it sets out the action that must be taken in the event of a medical emergency, which include making escort staff available once a medical emergency code has been called and, where necessary in a blue light emergency, dispatching an ambulance before a risk assessment of the prisoner has been completed. In order to ensure that all staff are aware of the requirements in the LSS, and are confident in their decision making in emergency situations, briefing sessions have been delivered and staff have been required to provide written confirmation that they understand the instructions. Duty managers have also been instructed to ensure that at least two officers are identified at the beginning of each shift to assist with escorting duties in the event of an emergency. A Governor’s order has been published to reinforce the expectations of staff responding to emergency situations. When COVID-19 restrictions have been relaxed sufficiently, the prison will be working with the ambulance service on a contingency plan development exercise. This will involve a run through of an emergency situation to check how quickly an ambulance can get through the prison gates and how long it should take for a quick departure without delay. This will also provide an opportunity for both organisations to set out their expectations, and the learning will be used to strengthen the contingency plan for emergency situations. Improved monitoring will be introduced to identify any delays in ambulances departing the prison in future so that swift action can be taken to improve. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters that you have raised. Yours sincerely Director General for Prisons
See every Prevention of Future Deaths report matching State Custody related deaths, 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.